The Technology and Ethics of Face Transplants A French woman says she is feeling well after doctors transplanted the mouth, lips and chin of a brain-dead organ donor onto her face last month. Physicians performed the procedure to change her appearance -- rather than save her life -- raising ethical and technical questions about how and when such a transplant should be done.
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The Technology and Ethics of Face Transplants

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The Technology and Ethics of Face Transplants

The Technology and Ethics of Face Transplants

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A Frenchwoman says she is feeling well after doctors transplanted the mouth, lips and chin of a brain-dead organ donor, transplanted those parts onto her face last month. The operation was not done to save her life but, instead, to change her appearance. The procedure has raised ethical questions about when such a transplant should be done, and scientific questions about how it should be done.

What technology made the operation a success? Could the so-called transplant have been done in this country? Should it? That's what we'll be talking about this hour. If you'd like to get in on our conversation, I invite you to give us a call. Our number is 1 (800) 989-8255; 1 (800) 989-TALK.

Dr. L. Scott Levin is the chief of plastic and reconstructive surgery at Duke University Medical Center in Durham, North Carolina. He's with us on the phone.

Thanks for talking with us today, Dr. Levin.

Dr. L. SCOTT LEVIN (Duke University Medical Center): It's my pleasure, Ira. How are you?

FLATOW: Tell us what you know about the transplant. Was it a surprise to most people that it actually occurred?

Dr. LEVIN: Well, the comment I would make is it was only surprising in that a partial face was transplanted. As your listeners may know--and, first of all, my information, of course, comes from the media.

FLATOW: Right.

Dr. LEVIN: I haven't spoken with Dr. du Bernard. I don't know that team, per se. I'm very familiar with many of the people around the world who do what we call composite tissue allotransplantation, which means taking tissue with its blood supply, an artery and a vein, and transplanting it, like you alluded to; we would do a kidney or a heart or a liver, only these are other body parts. And this was a partial face transplant. The efforts in North America and other places around the world have been really directed towards the total face patient. And it also surprised me very much that this woman was not offered a standard reconstructive surgery to address her deformity issues before this very, very radical step was taken by the French team.

FLATOW: You mean they could have tried lesser methods of reconstructing faces.

Dr. LEVIN: Yes. I mean, there's no question that the power of a tissue transplant is a very potentially powerful tool, and as I want to say to your listeners--and many of us around the world hope and want our reconstructive efforts to go in this direction. But this has to be done with solid ethics, good science, patient safety like we practice here at Duke. But that's the hallmark of good care. And I have concerns about a partial face being done on this particular lady, who was not offered conventional reconstructive surgery.

FLATOW: So this kind of operation could not have been done in this country.

Dr. LEVIN: No. I don't think that there's any institutional review board, whether it's here or in Louisville--or even Dr. Maria Siemionow's team at the Cleveland Clinic has a much more stringent inclusion criterion for doing a face. First of all, it's a total face. Second of all, it's a patient that is stable psychologically. And there are many people--even the French ethicists question the psychological stability of this patient in France. And again, I'm going by what I've read from the media...

FLATOW: Right.

Dr. LEVIN: ...all over the world. And third of all, this woman, again, was not offered any conventional attempts, which can be quite sophisticated, at doing reconstruction. So I think if we looked at the Cleveland Clinic protocol, championed by Dr. Siemionow, others around the world, the inclusion criterion for us to even think about this in the United States, which is your question--the criterion would not have been met.

FLATOW: Mm-hmm. But you do say that the world is heading in this direction.

Dr. LEVIN: There's no question about it. I mean, most of the basic science research--we're working with our immunology colleagues, our solid organ transplant colleagues; we're trying to develop models and go, as we say in medicine, from the bench to the bedside. We have to have scientifically valid data and experiments, and true animal models that will allow us to make the foray into human efforts. And we have to go very, very slowly. Again, there are multiple issues. There are ethical issues; there are issues based on just the type of immunosuppression or how we handle the recipient's immune system that still--there are many unanswered questions, I would say, and that's the position of myself. It's the position of the American Society for Reconstructive Microsurgery, of which I'm a member and will be president this next year. We have, actually, a position paper on this, and if your readers--listeners wanted to go to the Web,, it goes into much detail about the pros and cons of this. But suffice it to say, I don't think we're ready to do the kind of case that was done in France, for sure.

FLATOW: Yeah. And at what point would you be ready? You said animal models would have to be experimented on first; other issues here?

Dr. LEVIN: I think that what we would have to do, at least from the scientific standpoint, would be able to demonstrate the risk-benefit of certain immunosuppressive protocols. For example, a heart, a lung--these are, as you said in your introduction, Ira, life-saving transplants. And patients, to sustain life, are appropriately willing to undergo the risk of these immunosuppressive agents. And the risks include, for your listeners, the possibility of developing lung disease, drug toxicity on the lungs, on the kidneys, on the blood system, giving patients diabetes; the risk of even secondary cancers can form in patients that are on long-term immunosuppression. This is a young woman. And we have--many of, for example, our kidney or heart or lung transplant patients that have been on immunosuppressive drugs for a long time are getting skin cancers and the ravages of secondary malignancies related to their immunosuppression.

So these are some of the issues that have very grave implications for a transplant that's done for quality-of-life issues; not life-saving issues, but quality-of-life issues. We in plastic and reconstructive surgery, enhanced surgery and orthopedics are keenly interesting in improving the quality of our patients' lives, but it has to be done safely, ethically and with very strong scientific background that'll enable us to give some assurance that this is going to be a long-lasting and safe technique.

FLATOW: The fact that it was done in France, and if it turns out to be successful, at least over the short run, would you think that people might be heading to France if they want to, you know, get plastic surgery, sort of? The pati...

Dr. LEVIN: I'd say that that is--you know, it's sort of a marketplace mentality. I would say that what I've told you and your listeners today, that myself and my colleagues would maintain that they might do lots of these patients in France, but, again, this is one case. We have to always follow our patients long term, and I'm talking about over several years. Yes, somebody has to do the first step, but I don't think that the French transplant is pulling us any closer, quote, unquote, to "get into a race" or a competition. We want to maintain proper ethics, proper guidelines, proper patient selection and, again, have advanced science that substantiates doing this in a safe manner.

So I might be the last guy in the, quote, unquote, "world race" to do it, but I can assure that when I enter into this, which I want to do, and many of my colleagues here at Duke Medical Center want to do, that we're going to be able to offer patients a realistic risk-benefit ratio that's well-documented both in the research laboratory and with other investigations and with our ethicists on board and so forth.

FLATOW: From a purely technical standpoint, how difficult is it? And what is involved in the transplant?

Dr. LEVIN: Ira, that's an excellent question. Just so your listeners are aware, we've been doing what we call autologous tissue transplant for 25 years, and that means--for example, take a woman who has a mastectomy for breast cancer, and she wants her breast reconstructed. We have for 25 years or longer been able to move tissue from one place in the body to another place. Just this week, I moved a patient's leg bone, the fibula, with skin, and reconstructed an entire jaw that was resected because the patient had cancer. We used the operating microscope. The tissue parts that are transplanted, usually from a person's own body in the autogenous or self-transplant--the surgeons in France, of course, used a donor. And there are small blood vessels, maybe a millimeter or two, an artery that goes into the tissue, a vein that comes out, the blood supply that goes in and out, and we hook these blood vessels up under the operating microscope; so-called microsurgery. And we've been doing tissue transfers like this for a very long time.

So to answer your question directly, the technical aspects of actually doing the surgery have been well solved. This is not anything new, by any standard, OK? It's just where the tissue comes from is different.

FLATOW: So it's the ethical problems that you...

Dr. LEVIN: Pardon?

FLATOW: You're talking about, then, the ethical issues that have not been resolved.

Dr. LEVIN: Well, they have not. The psychological impact of a patient not recognizing self as self, the issue of how this new person is going to appear to friends and family, to children--there are absolute indications, I think, to do this. For example, ethically, if you had, say, a young child that was burned over 70 or 80 percent of the body and had a horribly deformed face--no eyes, no lips, no ears--a horribly ghoulish face, and if you were the parent of that child, you would be searching for a solution to this. Ethics come into play here. Are we going to commit that child to a lifetime of immunosuppression? The answer might be yes. If it was my ch--I want that child to be able to go out and circulate in public and make friends and look, quote, unquote, "normal." That's a different issue than a partial face transplant in a patient that was never offered any standard reconstructive surgery. So I think those are, for example, ethical issues in my mind that I think are in the minds of lots of others around the world.

FLATOW: And I imagine that you're all talking about it now.

Dr. LEVIN: We are. We're communicating. There's actually a meeting that's going to take place in January of people around the world, the solid organ transplant people, the folks--Dr. Breidenbach from Louisville, Kentucky, is actually the president of the Composite Tissue Allotransplantation Society that's meeting in Tucson in January, and he, as you and your listeners may know, did the first hand transplant done here in the United States several years ago. So there's a group of us who are keenly interested in moving this science forward, of making this a safe and effective therapeutic modality. Do I believe it's going to happen in my lifetime? Yes, I do. But I also believe that we have a long way to go in terms of addressing the science and the ethics of this and, again, identifying patients that are psychologically stable enough and have enough support to undergo this kind of procedure.

FLATOW: Dr. Levin, I want to thank you for taking time with us, and good luck in your research.

Dr. LEVIN: It's been my pleasure. Thank you, Ira.

FLATOW: You're welcome.

Dr. L. Scott Levin is the director of plastic and reconstructive surgery at Duke University in Durham, North Carolina.

We're going to take a short break, change gears and talk about the scientific breakthroughs of the 20th century. What do you think are the greatest ones? Well, we have with us coming up Alan Lightman, who has put together a terrific book that--he's collected 25 best ones. Let's see if they match up with yours. What do you think? And not only has he put them in a book, but he's actually put the papers themselves there so you can see them. Stay with us. We'll be right back with Dr. Lightman after this short break.

I'm Ira Flatow. This is TALK OF THE NATION/SCIENCE FRIDAY from NPR News.

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