Facial transplantation can be a useful treatment for severe disfigurement, although it is not without risks, according to two case reports involving facial damage caused by a bear attack and by growth of a rare aggressive tumor. Both reports appear in the August 23rd issue of The Lancet.
In the first report, Dr. Shuzhong Guo and colleagues from the Fourth Military Medical University in Xian, China, describe the 2-year outcomes of a 30-year-old man on whom they performed a partial facial allotransplantation in 2006.
In October 2004, the man was attacked by a bear, causing severe damage to the right side of his face. Debridement and wound repair with a forearm pedicle flap was performed at the time, but the injury did not heal. The patient presented to the authors' center in March 2006 for evaluation and further treatment.
The transplantation, which was performed in April 2006, involved anastomoses of the right mandibular artery, anterior facial vein, and facial nerve as well as whole repair of the nose, upper lip, parotid gland, zygomatic bone, frontal wall of the maxillary sinus, and part of the infraorbital wall. The graft came from a 25-year-old man who had died in a car accident.
The subject's immunomodulatory regimen included tacrolimus, mycophenolate mofetil, corticosteroids, and humanized IL-2 receptor monoclonal antibody.
Good survival of the tissue flap was seen, although acute rejection episodes occurred at 3, 5, and 17 months following surgery. All of these episodes were effectively controlled with adjustments in the immunomodulatory regimen. The patient had no impairments in renal or hepatic function and no infections arose.
Hyperglycemia occurred soon after surgery and then reappeared 3 months later. After being effectively treated with insulin therapy, the patient successfully switched to oral agents.
Although the facial nerve was not fully functional, the patient was able to speak, eat, and drink normally, the report indicates.
The second report describes the 1-year results of a 29-year-old man who underwent facial transplantation for damage caused by massive plexiform neurofibroma. Resection of the tumor, which diffusely infiltrated the patient's middle and lower face, and composite tissue allotransplantation took place in January 2007.
According to lead author Dr. Laurent Lantieri from CHU Henri Mondor in Creteil, France, and colleagues, the main goal of the operation was to restore the cutaneous appearance and function of the face, with a particular focus on contraction of the orbicularis oculi and oris muscles. The graft came from a brain-dead, beating-heart donor.
The patient's immunosuppressive regimen included antilymphocyte serum, tacrolimus, mycophenolate mofetil, and prednisone.
Following an uneventful immediate postoperative course, the patient experienced rejection episodes 28 and 64 days after surgery, the latter of which was complicated by cytomegalovirus infection. Both episodes, however, resolved without any further evidence of rejection and the patient's immunosuppressive regimen was able to be reduced.
At 1 year, the functional results were very good, the authors state, and both sensory and motor reinnervation of the graft were noted. Psychological recovery, they add, has been excellent, the patient's social life has improved, and he now holds a full-time job.
"Important contributions of the teams from Xi'an and Paris in addressing the issues of face transplantations have shown the need for progress in three directions: surgery, immunology, and psychology," French physicians comment in a related editorial.
Dr. Jean-Michel Dubernard, from University Lyon I Hospital, and Dr. Bernard Devauchelle, from Amiens-Nord University Hospital, note that cooperation among teams will be needed "to answer the many technical, functional, immunological, and psychological questions raised by face transplantation."
Lancet 2008;372:603-604,631-645.
Reviewed by Ramaz Mitaishvili, MD
