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On November 27, 2005, a 38-year-old woman with severe central face deformity from a dog bite underwent an allogenic partial face transplant from a brain-dead donor (same blood type and sharing 5 HLA antigens with the patient). The face graft was used to replace her missing distal nose, upper and lower lips, entire chin, and medial left and right cheeks.
The immunosuppressive induction protocol included antithymocyte globulin, tacrolimus, mycophenolate mofetil, and prednisone. The patient also received hematopoietic stem cell transplantation from the donor prior to surgery. The antirejection protocol included tacrolimus, prednisone, and mycophenolate mofetil. The patient experienced two acute rejection episodes (18 and 214 days after transplantation), confirmed by skin biopsy from both the graft and a separate free flap from the donor placed in the patient’s inframammary region for monitoring. Rejection was manifested by mucosal and skin edema and erythema in the graft that were aborted with high-dose prednisone. Extracorporeal phototherapy was instituted in an attempt to reduce future rejection episodes. Her course was complicated by tacrolimus-induced, partial renal failure that gradually improved after the replacement of tacrolimus with sirolimus. Infectious complications were limited to an episode of herpes labialis and molluscum contagiosum. No graft-versus-host disease has developed.
The patient was able to eat 1 week after surgery, and occasional fluid leakage from the mouth had completely stopped by 12 months. Stenosis of the Stensen duct developed at 8 months and was successfully repaired. Most sensation returned by 6 months. The patient underwent daily physical therapy, with a concentration on recovery of muscle function. Complete lip occlusion was present at 6 months, normal oral movement of food developed by 6 months, contraction of chin and nose muscles was present at 12 months, and smile returned to normal by 18 months, accompanied by other facial expressions of emotion. The patient is very satisfied with the outcome, being comfortable in everyday social situations.
Dubernard J-M et al. Outcomes 18 months after first human partial face transplantation. N Engl J Med 2007 Dec 13; 357:2451.
Comment
Successful facial transplantation is a significant advancement in transplant surgery, as skin is far more immunologically active and antigenic than traditionally transplanted solid organs. The aesthetic and functional results in this case are impressive. Having a face not one’s own did not seem to cause a problem for this patient. This is not too surprising; given the choice of no face or someone else’s face, most would choose the latter.