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Rapid Responses: Rapid Responses published:
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Problem of rejection?
- Peter J Allmark (9 December 2005)
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Facial Transplantation
- Philip M. Gilbert, Holtye Road, East Grinstead, RH19 1RS (11 December 2005)
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Re: Problem of rejection?
- Shehan Hettiaratchy (19 December 2005)
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Facial Transplantation
- Nichola Rumsey, Diana Harcourt and Nina Yearsley (21 December 2005)
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Peter J Allmark, Senior Lecturer Sheffield University
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Butler et al's article on face transplantation is reassuring in relation to one key problem, that of immunosuppression. The other problems, such as fears about identity, seem to me fairly minor. I'd like to hear their thoughts on rejection. A rejected hand or kidney transplant can be removed. What happens when a face transplant is rejected? Competing interests: None declared |
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Philip M. Gilbert, Consultant Plastic & Burns Surgeon Queen Victoria Hospital, Holtye Road, East Grinstead, RH19 1RS
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When considering face transplants the ethics of the procedure are really no different than any other surgery.As long as a patient is fully informed about the benefits and risks of the procedure,then they are in a position to give informed consent. The real problem is that nobody knows what the outcome will be, and so the procedure is experimental.Apart from tissue rejection there are many potential problems. The microvascular anastomoses should be the least of the problems.Success rates of such anastomoses in other free tissue tranfers is over 95% patency in many units. Attaching small muscles to firm skeletal anchors,at the right level of tension to function,is more difficult. Sensory nerve anastomoses usually produce protective sensation with reduced 2-point discrimination.This should be sufficient for reasonable function. The most difficult problem is the growth of motor nerves so that the muscles of the face can function normally.When the facial nerve trunk is divided by trauma suturing of the cut ends rarely results in perfect function.Interposed nerve grafts as used in facial reanimation also give less than perfect results.Functional muscle recovery following face transplants is unlikely to be as good as these. The donor and recipient nerve ends have different configurations and so many growing axons will never reach their target motor-end plates,and recipient muscle fibres may well have atrophied before they do. The result therefore is that patients will have lips with reduced sensation and with the addition of poor or absent muscle tone. It is then likely that oral continence will not be complete resulting in dribbling,rather like stroke patients who have lost oral control. Attendees at International Burn Meetings in the last few years have seen major advances in facial reconstruction using combinations of various skin flaps,tissue expansion,and dermal substitutes, producing results that were not thought to be possible. At the end of the day,will the transplanted face provide a better aesthetic and fuctional result than the best of existing reonstructions? It must be remembered that the results of conventional reconstruction get better as the years go by.This is well seen in the surviving 'guinea pigs'treated by McIndoe after the second World War.Transplanted tissue always has a risk of rejection,and there is an increased incidence of malignancy associated with immunosuppression. The results of just a few cases of facial tranplantation will need to be carefully monitored over many years to truly assess its usefulness. Competing interests: None declared |
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Shehan Hettiaratchy, Specialist Registrar Department of Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead
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Rejection is a major concern and all transplants should have an exit strategy. For hand transplants it is simple; amputation of the allograft. Face transplants are more challenging. Our current thoughts, guided by the burn surgeons in the team, is to use integra, an artifical dermis, to resurface the face if retransplant is not an immediate option. Competing interests: None declared |
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Nichola Rumsey, Director of Research Centre for Appearance Research, University of the West of England, Bristol, BS16 1QY, UK, Diana Harcourt and Nina Yearsley
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We read the recent editorial on facial transplantation(1) with great interest. We welcome the authors’ clear statement of the importance of careful selection of potential recipients, tailored information provision and the need for informed consent and appropriate psychological management in both the short and long term. Facial transplantation is now a reality, but debate on this topic is likely to continue and we are keen to ensure that the views and opinions held by individuals with a facial disfigurement are included in such discussions. We recently conducted a study on this topic with adults with a disfigurement(2). Participants expressed concern that the availability of facial transplantation might increase societal pressure for them to undergo any surgical procedure that might “improve” their appearance. There was considerable concern that such pressures are likely to be influenced by media involvement and coverage of these procedures which are likely to be portrayed as “heroic surgery”. We hope that facial transplant procedures meet patients’ expectations, but also hope that there is widespread acknowledgement that people with a facial disfigurement can have a very good quality of life without undergoing such drastic surgery. We hope that in contrast to the recent media coverage, future reporting will also promote tolerance of diversity in appearance rather than an emphasis which increases the pressures on those living with a visible difference. 1. Butler, P.E.M., Clarke, A., Hettiaratchy, S. Facial Transplantation. BMJ 2005; 331, 349-1350. 2. Yearsley, N. Facial Transplantation: Beliefs Held by Individuals with a Visible Difference. Unpublished Dissertation 2005; University of Bath. Competing interests: None declared |
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