Face Transplants Face Reality

Experts are wary as some surgeons seek to attempt a face transplant -- a procedure that probably isn't what you think it is.

Face transplants soon will be a reality. But they aren't what you think they are.

In the movies, a character goes to the doctor and emerges the next day with someone else's face. This leads to complications. Real-life face transplants won't be anything like this. And the real-life risks may be far more serious, says Steven J. Pearlman, MD, president-elect of the American Academy of Facial, Plastic, and Reconstructive Surgery.

"This is nothing at all like the illusion -- or delusion -- of swapping a face with someone else's," Pearlman tells WebMD. "It will never be a cosmetic procedure. The operation itself is a potentially fatal procedure because of the risk of rejection, life-long immune suppression, and the potential for life-threatening infections even if there is no graft rejection."

Face Transplant: The Reality

Face transplants would work much like other organ transplants. The family of a deceased person would donate that person's face to a needy patient. But after the transplant, the recipient would not look like the donor.

Why? The transplanted material would be a kind of a soft mask made of skin and soft tissue. Its final shape would depend on the bone structure of the recipient. That means that the person who got the transplant would have a brand-new face. It would not look like the face of the donor. It would not look like the recipient's old face, either.

"The recipient will not look like the donor or like themselves," Pearlman says. "We are not transplanting the underlying skeleton. So there will be no resemblance whatever. They will look more like someone with reconstruction of a severe burn or devastating cancer. These are people who are not going to be that visibly attractive. Like when a toe is used to replace the thumb. It is not a terribly attractive digit, but it works."

The new face would look better than the skin grafts now used to heal the wounds of people who suffer devastating facial burns or traumas -- if all went well. But there would still be big scars. The new face would not move like a person's original face, says Ira D. Papel, MD, an officer of the American Board of Facial, Plastic, and Reconstructive Surgery Inc. and associate professor at Johns Hopkins University School of Medicine.

"We have a long way to go," Papel says. "It is not just appearance but function: motion, integrating the movement of the skin with movement of the nose, mouth, and eyes. All the senses will be affected - and we have no way of hooking up nerves in a reliable fashion. To try to get normal facial function, it is a wish at this point. Maybe someday it will all be possible. But not yet."

Face Transplants: Serious Surgery for Serious Situations

"The risks are just awesome," Papel tells WebMD. "If a kidney transplant is rejected, you go back on dialysis. If all the skin on your face is rejected, what do you do? If it just sloughs off, what are you left with? That's a horror-movie situation."

There's about a 10% risk that a transplant won't take. Over the next two to five years, the risk of rejection is much higher. Historically, one-third to one-half of transplants eventually are rejected.

That's too much of a risk, says Douglas Hanto, MD, chief of the division of transplantation at Boston's Beth Israel Deaconess Hospital.

"The real question is whether the benefits and expected success rate are worth the long-term immune suppression," Hanto tells WebMD. "Clearly these patients will require life-long immune suppression. If the outcome is not much better than a 30% rejection rate, it will be hard to justify."

There are situations in which face transplants could save lives.

For example, Pearlman suggests, what if some hypothetical child suffered a terrible, slow-spreading cancer of the face? By the time that child became a teen, the tumor would not only have destroyed the face, but would also be life threatening. If, however, a surgeon had the chance to cut away the tumor -- and replace the face -- recovery might be possible.

It's for cases such as this that doctors around the world are honing their skills. In December 2002, U.K. surgeon Peter Butler, MD, announced that medical science had advanced to the point where a face transplant might be attempted. But in November 2003, the Royal College of Surgeons of England issued a report saying that the technique was not ready for prime time.

Last month, John Barker, MD, director of plastic surgery research at the University of Louisville, Ky., announced that he is seeking a green light from his ethics panel to prepare for a face transplant. Experts in the field tell WebMD that surgeons at other institutions are also seeking approval to begin planning the operation.

To date, no such approval is known to have been granted.

But Barker may have opened a can of worms with statements that the technique might be appropriate for burn victims. Many burn victims have their entire faces destroyed. Skin grafts save their lives. But even multiple operations leave them with such a distorted appearance that many patients feel unable to leave home.

"There are burn patients that have lost all the skin on their faces," Papel says. "But at this point, they are probably better off with skin grafts."

Pearlman agrees that face transplants should be reserved only for people with fatal conditions.

"The first candidate should be one of those patients with no other alternatives," he says. "Especially those with cranial facial cancer or severe craniofacial deformity where there is no other surgical procedure that could cure them."

Pearlman says that he and others in the American Academy of Facial, Plastic, and Reconstructive Surgery are developing guidelines for experimental face transplants.

For the time being, the only guidelines are those of the Royal College of Surgeons.

"Until there is further research and the prospect of better control of these complications, it would be unwise to proceed with human facial transplantation," they state. "This conclusion is not adverse to facial transplantation. Indeed, it acknowledges the need to recognize it as a possible future treatment. It simply means that the work should take a much more incremental approach than some of the current hype surrounding it has suggested."

Show Sources

Published June 2, 2004.

SOURCES: Facial Transplantation: Working Party Report, The Royal College of Surgeons of England, November 2003. News release, University of Louisville, Ky. Ira D. Papel, MD, associate professor, Johns Hopkins University School of Medicine and treasurer, American Board of Facial Plastic and Reproductive Surgery Inc. Steven J. Pearlman, MD, president-elect American Academy of Facial, Plastic, and Reconstructive Surgery and associate professor, Columbia University School of Medicine. Douglas Hanto, MD, chief of division of transplantation at Beth Israel Deaconess Hospital, Boston, and professor of surgery, Harvard University.

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