Face to Place
Does Frankenstein live? Bits and pieces and Humpty Dumpty are all well and good in bedtime stories, but when confronted face to face with a face newly placed, wonder may cede the field to nightmare. We saw it coming, however. Test tube babies, cloned sheep, and bionic limbs just whet our appetites, in anticipation of the pièce de résistance, the “face-off.” As mankind continues to sashay the so-called high ground, the noble cause received a jumpstart in Lyon, France at the bite of a dog. Dirty work was done to a face, and the men in white tried to “one-up” all the king’s horses and all the king’s men. The lower part of the nose, the lips, and the chin of a torn visage were transplanted, as the world watched in awe. Now China and the U.S. want to hop on the bandwagon, and their target is the entire face. But are we ready for this? Is the technology up to speed for such a complex endeavor? Does the end, indeed, justify the extremely exorbitant means? You be the judge. It becomes much easier for me to present the simple facts.
A complete facial transplant would require ten or more surgeons, take 14-20 hours to complete, mandate a donor with a compatible blood group and matching sex, race, and age, and necessitate sufficiently large areas (1200 cm2) of skin, via autologous skin grafts from the same patient, to cover the entire face, scalp, front of the neck, and ears, should the transplant fail or be rejected. Add an additional $12,000-$24,000 price tag for immunosuppressive drugs to follow an already expensive procedure and prevent rejection, and the almighty healthcare dollar might be stretched to limits paralleling those reached by the rack in a medieval torture chamber. With so many pros and cons at issue, calmer minds must prevail, and we, the public, must weigh and pronounce, with a foot to the gas while finger rides ignition.
To start out with, the operation itself is very difficult technically, not to mention the fact that nerves grow and heal slowly, limiting assessment of sensory and motor function of the transplant to nine months or longer post- procedure. Furthermore, rejection is always an unwelcome visitor lurking in the wings, more than willing to come a knocking at a moment’s notice. Enter the necessity for frequent medical monitoring and immunosuppressants for life, which would hardly curb the estimated 10 percent rejection rate in the first year and 30-50 percent rate during the first two to five years.
So, is it all worth it? Skin and subcutaneous tissue, though not underlying muscle, would be transplanted, and major blood vessels in the neck would be called upon to connect the recipient’s circulation to the newly placed graft. The recipient’s own facial muscles would be enlisted to animate the transplant, restore facial mobility, and allow expression. That’s it in a nutshell, and in theory.
While cosmetic lips and ears, in the absence of facial function, are fine for a Halloween gathering or in the recesses of subterranean Paris, they would hardly constitute success in the light of day. With bugs to iron out and questions lingering, all bets are off right now. Doubts remain regarding adequate blood supply to the graft and connection of the patient’s facial muscles to the transplanted face. If a mask is all you are to end up with, then why go it at all. Even the limited French procedure, while quite impressive in the short term, has yielded deluding results in the weeks thereafter, with marked drooping and paralysis of the patient’s lower lip.
The eventual transplant recipient and family will have to get used to a new hybrid face, combining aspects of both the donor and the recipient. All the exhaustive, preoperative, psychological testing in the world will not prepare for those first few seconds, when the bandages are cut and a new being is hatched. The only thing more traumatic for patient and family might be abortion of the procedure. Once the medical risks, uncertainty of success, and media scrutiny have been digested by the immediately involved, hinging all hopes on an evanescent and uncertain, brain-dead donor, free of cancer and various infections, hooked up to a ventilator, and meeting other stringent requirements, might be hard to stomach and, excuse the pun, to face. The pool of potential donors is small, and one can only imagine the difficulties inherent in obtaining consent for a facial transplant.
Perhaps the final decisions regarding these new and provocative, surgical procedures should be left to the severely disfigured, for they are the ones who stand the most to gain or lose. You will not see them in a neighborhood mall or in a local grocery store. Their legions populate the corridors where The Phantom lives!
© 2006, Albert M. Balesh, M.D. All rights reserved.
A complete facial transplant would require ten or more surgeons, take 14-20 hours to complete, mandate a donor with a compatible blood group and matching sex, race, and age, and necessitate sufficiently large areas (1200 cm2) of skin, via autologous skin grafts from the same patient, to cover the entire face, scalp, front of the neck, and ears, should the transplant fail or be rejected. Add an additional $12,000-$24,000 price tag for immunosuppressive drugs to follow an already expensive procedure and prevent rejection, and the almighty healthcare dollar might be stretched to limits paralleling those reached by the rack in a medieval torture chamber. With so many pros and cons at issue, calmer minds must prevail, and we, the public, must weigh and pronounce, with a foot to the gas while finger rides ignition.
To start out with, the operation itself is very difficult technically, not to mention the fact that nerves grow and heal slowly, limiting assessment of sensory and motor function of the transplant to nine months or longer post- procedure. Furthermore, rejection is always an unwelcome visitor lurking in the wings, more than willing to come a knocking at a moment’s notice. Enter the necessity for frequent medical monitoring and immunosuppressants for life, which would hardly curb the estimated 10 percent rejection rate in the first year and 30-50 percent rate during the first two to five years.
So, is it all worth it? Skin and subcutaneous tissue, though not underlying muscle, would be transplanted, and major blood vessels in the neck would be called upon to connect the recipient’s circulation to the newly placed graft. The recipient’s own facial muscles would be enlisted to animate the transplant, restore facial mobility, and allow expression. That’s it in a nutshell, and in theory.
While cosmetic lips and ears, in the absence of facial function, are fine for a Halloween gathering or in the recesses of subterranean Paris, they would hardly constitute success in the light of day. With bugs to iron out and questions lingering, all bets are off right now. Doubts remain regarding adequate blood supply to the graft and connection of the patient’s facial muscles to the transplanted face. If a mask is all you are to end up with, then why go it at all. Even the limited French procedure, while quite impressive in the short term, has yielded deluding results in the weeks thereafter, with marked drooping and paralysis of the patient’s lower lip.
The eventual transplant recipient and family will have to get used to a new hybrid face, combining aspects of both the donor and the recipient. All the exhaustive, preoperative, psychological testing in the world will not prepare for those first few seconds, when the bandages are cut and a new being is hatched. The only thing more traumatic for patient and family might be abortion of the procedure. Once the medical risks, uncertainty of success, and media scrutiny have been digested by the immediately involved, hinging all hopes on an evanescent and uncertain, brain-dead donor, free of cancer and various infections, hooked up to a ventilator, and meeting other stringent requirements, might be hard to stomach and, excuse the pun, to face. The pool of potential donors is small, and one can only imagine the difficulties inherent in obtaining consent for a facial transplant.
Perhaps the final decisions regarding these new and provocative, surgical procedures should be left to the severely disfigured, for they are the ones who stand the most to gain or lose. You will not see them in a neighborhood mall or in a local grocery store. Their legions populate the corridors where The Phantom lives!
© 2006, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
7/06/2006 08:19:00 AM
2 Comments:
Hey what a great site keep up the work its excellent.
»
By
Anonymous, at Wednesday, July 19, 2006 5:38:00 PM
This comment has been removed by a blog administrator.
By
Anonymous, at Thursday, July 20, 2006 6:54:00 PM
Post a Comment
<< Home