Hospital May Have Sidestepped Prior Rules for Face Transplant

Photo: New Englands first partial face transplant performed at Brigham and Womens Hospital

A Boston hospital may have bent its own rules to offer a disfigured patient a facial transplant -- but doctors and ethicists say the move was likely justified.

The surgery, which took place Thursday at Brigham and Women's Hospital in Boston, is the second face transplant operation performed in the United States and the seventh in the world.

A team of seven plastic surgeons and one ear, nose and throat surgeon led by Dr. Bohdan Pomahac took 17 hours to complete the surgery, according to a hospital press release. The release further indicated that the nose, hard palate, upper lip, facial skin, muscles of facial animation and the nerves that power them and provide sensation were transferred to the recipient from a deceased donor.

The patient was a man who required facial reconstruction after injuries he suffered in a severe traumatic accident, Kevin Myron, manager of media relations for Brigham and Women's Hospital, said.

At a Friday press conference, Pomahac acknowledged that the patient had not undergone immunosuppressant therapy before the operation -- a deviation from the hospital's previously stated policy on facial transplantation.

Immunosuppressant therapy -- a course of medication designed to ratchet down a patient's immune response -- is necessary in such operations to prevent the patient's body from rejecting the organs or tissues of the donor. Such therapy is crucial to the patient's survival, but it also comes with serious side effects, including an increased risk of infections.

At Friday's press conference, Pomahac said that the hospital has obtained approval from an institutional review board -- a committee that reviews the ethics of medical procedures -- for performing the operation on patients not on immunosuppressants. He said that the hospital made the decision to liberalize the rule in order to help more patients in need.

"We felt it was a natural progression of the program to extend [the operation] to the patient who is not on immunosuppressants."

Still, immunosuppressant therapy is a significant commitment. Dr. Joseph McCarthy, director of the Institute of Reconstructive Plastic Surgery at New York University's Langone Medical Center, said that the side effects of immunosuppression may be an even weightier consideration than the surgery itself.

"You are really committing the patient to a lifetime of treatment to prevent rejection," he said. "You have to be absolutely convinced that no existing traditional surgery or techniques would give these patients the quality of life they need, and therefore you can justify starting a course of immunosuppressant medications."

Pomahac said that the patient is now on immunosuppressants, and likely will be for the forseeable future.

"The patient is now expected to take immunosuppressant medication for the rest of his life," he said. "There is nothing on the horizon, no major medical breakthrough that would suggest otherwise."

But he noted that the doses would likely be reduced as time progresses, which would likely come hand-in-hand with a reduction in side effects.

Implications of Immunosuppression After Face Transplant

The importance of such side effects was not lost on Brigham and Women's. A 2007 article in a hospital newsletter and a 2008 article in the journal Transplantation suggest that Brigham and Women's had a policy in place not to perform such a surgery on any patient who did not already have a suppressed immune system.

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