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Face Transplantation

Face Transplantation. Face Transplantation First partial transplant: France, Nov 2005, reported 2007 Subsequent face grafts: China 2006, France 2007; little information available. First in US: Nov 2008, most complicated yet. Ethical Issues Primum non nocere

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Face Transplantation

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  1. Face Transplantation

  2. Face Transplantation First partial transplant: France, Nov 2005, reported 2007 Subsequent face grafts: China 2006, France 2007; little information available. First in US: Nov 2008, most complicated yet.

  3. Ethical Issues Primum non nocere Any procedure, especially new procedures: risks vs. benefits Face transplant different than others: the risk-benefit calculation is more complicated. What if the graft is rejected? Could be worse off. Is it “just cosmetic surgery”? Social consequences of regaining a face include ability to speak, eat, express emotion. Would you be an organ donor? A face donor? Would you allow your loved one’s face to be transplanted? Health care resource allocation

  4. First Partial Face Transplant: Background 38 y.o. female badly bitten by dog, resulting in amputation of distalnose, upper and lower lips, entire chin, and adjacentparts of right and left cheeks. Face graft performed 6 mos. post injury (Nov. 2005, in France). Donor (brain-dead46-year-old woman) and recipient had same blood group(O+) and shared five HLA antigens (out of 6 possible).

  5. Methods “The figure shows vascular anastomoses of the bilateral facial arteries (red) and veins (blue); sutures of the sensory maxillary (V2) and mandibular (V3) nerves (yellow) and the inferior branch of the left facial motor nerve (green cross); and musculomuscular sutures on the levator and zygomatic muscles.” Dubernard et al. (2007), NEJM 357: 2451-2460.

  6. Methods Immunosuppression and infection prevention and control: Various drugs used. Hematopoetic stem cells (bone marrow cells) harvested from donor before transplant and infused into recipient on postop days 4 and 11. Tacrolimus was an immunosuppressive drug initially, changed to sirolimus (also used in drug-eluting stents) at 14 months due to reduced renal function, which has since recovered. Rejection episodes at 18 days and 9 months (characterized by erythema and edema of the graft) were managed. Extracorporeal photochemotherapy (exposure of white blood cells to a photosensitizing agent and UV light, an established procedure for managing graft rejection) has been used prophylactically since month 10. No graft vs. host disease. Physical therapy: Twice daily for first 4 months; once dailythereafter. Training inpassive and active facial exercises, focusedon restoring lip movement and mouth occlusion. Psychological support: Once daily for first4 weeks; twice weekly for next 4 months; once a month or at patient's request since then. Dubernard et al. (2007), NEJM 357: 2451-2460.

  7. Results • Recovery of sensation with time. • Touch • Heat & cold • Sensory function recovered faster than motor. Dubernard et al. (2007), NEJM 357: 2451-2460.

  8. Results • Recovery of lip occlusion. • Passive • Active • Asymmetry in active closure (arrows) due to initial wound asymmetry. Dubernard et al. (2007), NEJM 357: 2451-2460.

  9. Results: Aesthetic and Psychological • Pre-injury. B. 1 yr post-op with makeup. C. 18 mos. post-op, no makeup. • “By the end of the 12th postoperative week, the patient was capable of facing the outside world and gradually resumed a normal social life. The progressive return of expressiveness correlated well with psychological acceptance of the foreign graft. At present, the patient says she is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results.” Dubernard et al. (2007), NEJM 357: 2451-2460.

  10. First Partial Face Transplant: Conclusion “In this patient who underwent the first partialface transplantation, the functional and aesthetic results 18months after transplantation are satisfactory.” Dubernard et al. (2007), NEJM 357: 2451-2460.

  11. First U.S. Face Transplant Nov 2008, reported Dec 2008 but few details More complicated than previous transplants: more tissue and types of tissue transplanted: skin, nerves, muscles, arteries, veins, bones. Patient: female, unable to eat, one eye lost, other functions poorly, required tracheostomy tube to breathe. Lacked nose, palate, underlying bones.

  12. First U.S. Face Transplant About 80% of face (500 cm2 tissue) transplanted. Lower eyelids, nose, nasal sinuses, cheeks back to the ears, upper lip, upper jaw, teeth. Bones (probably): Maxillae, nasals, zygomatics, parts of temporals, ramus of mandible, maybe lacrimals. Nerves Facial (VII): motor to muscles of facial expression (five branches) Trigeminal, mandibular div. (V3): motor to muscles of mastication Trigeminal (V1, V2, V3): sensory to face Arteries & Veins External carotid a. and its branches: facial, maxillary aa. (superficial & deep facial structures, respectively); zygomatico-orbital a. External jugular v. and its tributaries: facial v. and its branches.

  13. First U.S. Face Transplant Harvesting: 9+ hours, careful to preserve vessels & nerves for attachment Simultaneously: remove scar tissue from donor to make a space Then: attach major vessels, 3 hours. Transplant turns pink – it is not being rejected! Continue: 9+ hours attaching bone, nerves, muscles, small vessels, skin. Total: 22 hours. Animation: http://www.clevelandclinic.org/lp/face_transplant/video/transplant_flash.swf

  14. Dr. RisalDjohan, Dr. Maria Seimeionow (team leader), Dr. Daniel Alam. Source: www.clevelandclinic.org

  15. Dr. Robert Lohman, Dr. Daniel Alam. Source: www.clevelandclinic.org

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