Third Face Transplant Signals Advancements, Acceptance

Jan. 23, 2007 — -- With the world's third face transplant patient resting in the recovery room, surgeons have once again shown that the operation is viable.

But the third success begs the question: Will the procedure ever become commonplace?

"Used to be, it was a curiosity," said Dr. Peter Costantino in an interview with ABC Medical Editor Dr. Tim Johnson on the ABC News Now "Healthy Life" program.

"Now we're seeing several centers developing capabilities, of which we hope to be one," he said. "You're going to see in major centers around the world the opportunity to have parts or significant amounts of the face replaced depending on the needs of the patient."

But while there may be more of these procedures in the years to come, each case still comes with its own set of special considerations.

"These are very specific cases," said Dr. Scott Levin, professor and chief of plastic and reconstructive surgery at Duke University Medical Center. "They are not mainstream by any stretch of the imagination."

Doctors Say Surgery a Success…So Far

Surgeons in France announced the completion of the partial transplant procedure on Tuesday. The 29-year-old patient's face was disfigured by a genetic disorder known as neurofibromatosis -- a condition that causes large but benign tumors to form on the nerves. It is sometimes referred to as the "Elephant Man disease" after James Merrick, who suffered from the disease in the 1800s.

"The lower part of the face was completely destroyed by this benign tumor, and we had to remove everything," said Dr. Laurent Lantieri, lead surgeon and head of plastic and reconstructive surgery at Henri Mondor Hospital in the Paris suburb of Creteil, during a press conference Tuesday.

"As we removed all this part of the face, which are the lips, the nose and part of the cheeks, the only way we could reconstruct it correctly was to do a face transplant."

By the end of the 16-hour procedure, surgeons said the patient was recovering well. However, doctors will only be able to know for certain whether the operation was a success in the days to come.

"We have to wait to see if the nerves will grow, and we have to wait to see if the face will move, and finally we have to wait to see if the patient will be able to go back to a normal social life," Lantieri said.

The case differs from the two previous face transplants in that it was performed to correct disfigurement from a genetic condition rather than from an accident.

Frenchwoman Isabelle Dinoire, who was the first face transplant recipient, required the surgery in 2005 after her dog attacked her.

The second patient, a Chinese farmer, received a partial transplant following a bear attack that disfigured his face.

Costantino said this third procedure is a step forward in making face transplant surgery a reality in multiple surgical centers around the world.

"The big change is that the French surgeons have been able to put it together as a single operation, work out logistics of getting the donor and the recipient together, and they've really advanced the field based on techniques that already existed," Costantino said.

"That means that we're going to see this in many places around the world in the next several years."

Challenges Still Exist

But before this happens, surgeons will have to find better ways to deal with many of the complications that come with face transplants -- and the issue of tissue rejection tops the list.

Levin said there are various centers around the world that have the capability to pull off a face transplant; the technical particulars of the surgery are becoming more widely understood.

But he also said that how doctors ensure that the patients' bodies do not reject the transplanted tissue after the operation is crucial.

Case in point is face transplant recipient Dinoire, who has already suffered several bouts of what doctors call "subacute rejection" -- complications that result from the patient's immune system attempting to reject the transplant.

"The patients are far from out of the woods after the surgery is over," Levin said.

In order to prevent this rejection from occurring, patients must take a cocktail of drugs designed to suppress their immune systems. But Costantino said the use of these drugs restricts certain patients from consideration for these procedures.

In particular, cancer patients who have been disfigured by the disease would not be able to take advantage of this option because of the necessity for immunosuppressive therapy.

"If the patient had a cancer, it's really not appropriate," he said. "We're not really anywhere near doing this in cancer patients because of the immunosuppressive effect on the cancer maybe coming back."

Other challenges come naturally in dealing with the face -- a remarkably complex part of the body that is the site of dozens of delicate muscles and nerves.

Costantino said eyelids are a particularly difficult area where transplant is concerned.

"That's why you're seeing these face transplants focus on nose, mouth and chin," he said. "Right now I think that the partial face transplant really is the face transplant."

And then there is the question of public acceptance. While people may be more accustomed to the idea of a face transplant than they were in 2005, many would still balk at the idea of donating their own face for transplant.

As more face transplants are performed, this hesitance could even spell a problem for organ donation in general. Levin said that the public could fall prey to the misconception that becoming an organ donor would mean that the face is also up for grabs.

"If the public perceives that this is a possibility, they may balk and say that they don't want to donate their organs at all," Levin said. "The last thing that we want to do is make organs harder to procure."

The Future of Face Transplants

Despite the challenges facing this procedure, surgeons are hopeful that face transplants will be beneficial to many patients once these issues are solved.

The applications of this procedure will "absolutely explode exponentially," Levin said. "This is what all of us involved with the ravages of cancer, traumatic accidents and congenital diseases are all waiting for."

And these surgeons may not have to wait much longer. Doctors in Britain and the United States are currently working toward their countries' first face transplants.

"There are many complex issues here, but there is an entire cadre of surgeons such as myself who want to see this go forward," Levin said. "I think things are advancing at a pretty rapid clip, and I hope that in the next couple of years we'll see some major breakthroughs.

"I truly believe that when the scientific aspects of transplant immunology are solved, this will become a clinical reality," he said.