An article published Online First and in a future edition of The Lancet describes the procedures involved in a near-total face transplant. The patient is US citizen Connie Culp. In 2004, she was shot in the face with a shotgun by her husband. The article details her ground-breaking surgery and recovery to date. It is the work of Professor Maria Siemionow, of the Cleveland Clinic, Cleveland, Ohio, USA, and collaborators.

Connie, 46 years old and mother of two, was left with most of the middle part of her face missing after the shooting. She lost her nose, mouth, nerve, skin and other structural damage. She was fortunate to survive the attack, but her face was completely disfigured. She could not drink from a cup and her speech was slurred. She lost her sense of smell as well. From 2004 to 2008, she underwent 23 major reconstructive operations. But unfortunately they failed to restore her disfigured structures and left her feeling humiliated in public. Doctors determined that the final option to allow her to recover facial function and a normal appearance was a full face transplant. Connie was informed of the risk of serious complications. These involved the need for lifelong immunosuppression. She signed the consent form.

A brain-dead woman matching Connie´s age, race, and skin complexion was the donor. In December 2008 the operation was carried-out by an eight-surgeon team, including Professor Siemionow. The surgery lasted twenty-two hours. The donor face covered 80 percent of the area of where Connie’s face had been, and contained various structures including the nose, upper lip, lower eyelids, and the upper jaw including incisor teeth, palate, and various glands. After the bone components of the graft were secure, connections of the arteries and veins were made. Around 2 hours and 40 minutes after the connections were completed, the donor tissue began to pink up. This confirmed the graft’s viability. The facial nerves were then connected.

Immediately following the operation, an assortment of immunosuppressant drugs was given to Connie. She remains on immunosuppressant medication to prevent rejection of her new face. Up to now, she remains negative for cytomegalovirus and other infections. She began physiotherapy and speech therapy 48 hours after the surgery and continued to do so once a day for the first six weeks, then three times per week during follow up. Connie was regularly evaluated on her ability to speak, smell, swallow, make facial expressions, and other muscle control functions in her new face. She also received psychological support once a day during the first six weeks, then three times per week.

There was one occurrence of rejection of the graft lining on day 47, but this was reversed with a 1g dose of methylprednisolone. Facial sensation returned, after 6 months. Motor muscle recovery is slow but progressing. It is assessed by repose (expressionless features), pucker, smile, and pronunciation of vowels. Connie’s upper lip and lower eyelid movements remain imperfect but it is too soon to expect complete recovery in this area. On the other hand, major functions which she had lacked for four years are now restored. Now, she can smell, eat solid foods, drink from a cup, and her speech is intelligible. Before the transplant she felt pain which she rated as 8 out of 10 in severity. It was due to scarring and contracted tissues in the affected area. She now rates the pain as 1 out of 10.The authors write: “Aesthetic outcome will be improved by excision of the redundant skin, which is planned about 1 year after transplantation…Psychologically, she is doing well. She has no symptoms of depression or post-traumatic stress disorder.”

She rated her own appearance as 5 out of 10 three weeks post-transplantation. Then 5 months after the procedure this had improved to 8 out of 10. The authors explain: “Since surgery, she has recovered self-confidence, and looks forward to rebuilding her social life and to helping others who have been similarly disabled by trauma.”

The authors point out that there are ethical challenges remaining for patient selection for future operations, as well as medical support, appreciation of the moral, professional, and financial responsibilities of the patient. All of these factors will be determined by the geographic, cultural, and economic conditions of each particular patient. The authors add: “Nevertheless, in complex physically and functionally disabling cases, the patient’s ethical right to make decisions should be respected, after being informed of the risks and benefits of the procedure and the need for life-long immunosuppression.”

They say in closing: “We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using complete facial allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients.”

Professor Siemionow explains: “The outcome of this particular case supports facial allotransplantation as a means of early intervention for patients with severe facial deformities. It is with great pride that we share the outcome of this surgery; our patient is doing remarkably well and is very pleased with the result.”

In an associated note, Dr Chenggang Yi and Dr Shuzhong Guo,from the Institute of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China, comment: “In our view, all of the problems in human facial transplantation, immunological status, selection of the recipient and donor, surgical technique, and psychological considerations are all important…Technically, Siemionow and colleagues’ surgery was very complex, and the patient gained good functional recovery. So far, total facial transplantation has not been reported. We think the most difficult part of the face transplantation is the aesthetic and functional recovery of the upper eyelids.”

“Some key points in facial transplantation remain intractable. Therefore the objective is to identify potential problems, and develop management strategies to resolve them. The day may not be far when facial transplantation becomes the standard of care for disfigured patients.”

“Near-total human face transplantation for a severely disfigured patient in the USA”
Maria Siemionow, Frank Papay, Daniel Alam, Steven Bernard, Risal Djohan, Chad Gordon, Mark Hendrickson, Robert Lohman, Bijan Eghtesad, Kathy Coffman, Eric Kodish, Carmen Paradis, Robin Avery, John Fung
DOI: 10.1016/S0140-6736(09)61155-7

Written by Stephanie Brunner (B.A.)