Dr. Risal Djohan, Dr. Maria Siemionow and Dr. Daniel Alam operate during the near-total face transplant.
A severely disfigured American woman is the first recipient of a nearly total new face. Surgeons at the Cleveland Clinic in Ohio performed the procedure — the first in the United States — about two weeks ago.
While face transplants have been done in other countries, the transplant at the Cleveland Clinic is the most complete, doctors say.
Although surgeons are not releasing the patient's name or details of how she sustained her injuries at her family's request, hospital officials do say the woman suffered severe trauma and had extensive reconstructive surgery over several years.
Most of that was unsuccessful, however. The patient was missing her right eye, her nose and her upper jaw. She could not smell or taste, had trouble speaking and, according to doctors, children would shriek and run away from her when they saw her in public.
'To Smile Again'
Plastic surgeon Frank Papay, chief of dermatology and plastic surgery for the Cleveland Clinic, was part of the 12-member surgery team and described the operation.
"We transferred the skin ... all the facial muscles in the upper face and mid face; the upper lip; all of the nose; most of the sinuses around the nose; the upper jaw, including some teeth; the facial nerve — and the facial nerve is important in the sense that that's what gives us, once it's connected, the ability to smile and to blink our eyes," Papay said.
"So, our hopes are that, once it's connected and the new facial nerve grows through, that she'll be able to smile again," he said.
The "new" face will not look just like the dead donor's face, doctors say. It will be a sort of third face, a combination of the patient's own muscle and bone structure along with the overlay of the donor's face.
Dr. Maria Siemionow, director of plastic surgery research and head of microsurgery training, led the transplant surgery team.
"The surgery took 22 hours," Siemionow said. "The preparation to the surgery took over 20 years of work in the field of composite tissue transplantation."
Previous Face Transplants
Three years ago, a partial transplant was performed on a French woman who had been mauled by her dog. Similar transplants were done in China, on a farmer who had been attacked by a bear, and elsewhere in Europe, on a man who was disfigured by a genetic condition.
But Siemionow says the Cleveland Clinic transplant is the most extensive, a "near total" face transplant.
"This patient exhausted all conventional means of reconstruction and is the right patient," she said.
The hospital's ethics committee approved facial transplantation three years ago, and since then Siemionow and her team have searched for an appropriate candidate.
"Only patients who are the most disfigured and exhausted already all existing procedures, which are conventional procedures, will be the potential candidates," she said.
Siemionow says the patient viewed her life as grim enough to warrant the risky transplant along with the also risky anti-rejection drugs that must be taken for the rest of her life.
Ethics Of Procedure
Dr. Eric Kodish, director of the bioethics department at Cleveland Clinic, said, "We want to reinforce the fact that we did this [transplant] under IRB [investigational review board] protocol."
The patient and her family took part in extensive screening and interviews, meeting with "surgeons, ethicists, mental health professionals," he noted.
"We all met with the patient, and she has a clear understanding of the risks of transplant rejection and of immunosuppression drugs, including cancer and infection," Kodish said. "She agreed to proceed, with the hope this will help her and others in the future."
While a face transplant may be viewed as life-enhancing, many medical ethicists worry that patients must completely understand that they are putting themselves at great risk for surgery that is not life-saving.
"If I have kidney failure and the prognosis is that I will die in a few years, then the organ transplant becomes life-saving. It means I have a bargain," said ethicist Karen Maschke with the Hastings Center. "I get the organ that may keep me alive, but I have to take drugs that can also cause damage to my body.
"There are risks to those drugs that keep that organ in my body and keep me healthy, but I know that's the bargain I have made to stay alive," she said.
In a context where a transplant does not involve a bargain to stay alive, but to improve the quality of life, then "the risks of the surgery and the risks of the lifetime drugs become more magnified, and that's where we start to look at more carefully, are those risks justifiable in a context that is not life-threatening?" Maschke says.
Doctors at the Cleveland Clinic say the patient and her family were absolutely certain they wanted to take those risks.
It will be at least six months before the patient regains any feeling in her face, doctors say, and she should regain her sense of smell, taste and most facial function within a year. For now, they say, she is extremely happy just to be able to take both her hands "and go over her face and feel that she has a nose, feel that she has a jaw."