By Rick Weiss
Washington Post Staff Writer
Thursday, December 13, 2007
A French woman who two years ago became the first person to receive a face transplant has recovered with remarkably good aesthetic results and has gradually regained normal skin sensation and control of her facial muscles, doctors reported yesterday in the first detailed account of her progress.
Isabelle Dinoire, who at age 38 lost her lips, cheeks, chin and most of her nose when she was mauled by her dog, now blends into crowds and attends parties comfortably with the face she got from a 46-year-old brain-dead donor. Surgeons attached the face like a mask in a landmark 15-hour surgery.
Her recovery, however, has at times been harrowing, her surgeon, Jean-Michel Dubernard, acknowledged. Twice her immune system has mounted violent reactions against the new tissue, one of several anticipated risks that had led some experts to question the wisdom of the surgery. The immune-suppressing drugs she must take for the rest of her life have also wreaked havoc, causing infections and, at one point, kidney failure.
But Dinoire is "very satisfied" with the outcome, the medical team reports in today's issue of the New England Journal of Medicine. And although some experts remain uncomfortable with the experiment, including its lack of psychological follow-up, some who were initially critical of the attempt said they are impressed.
"They proved me wrong," said Peter Butler of the Royal Free Hospital in London, who has been organizing a slower-paced effort to transplant faces in England. "Her neuromuscular recovery looks good. She's done extremely well."
The circumstances of Dinoire's injury remain mysterious. She was unconscious when her dog chewed off much of her face on May 28, 2005. Some have suggested she had tried to take her own life, though Dubernard, of Lyon University, has said she merely took a sleeping pill and may have stumbled and startled the animal.
Whatever the cause, the injury was devastating. Lipless and lacking key muscles, Dinoire could not speak and was fed through a tube.
At the time, teams in several countries were developing controversial plans to transplant faces, raising concerns among ethicists and others that a race to be first was underway. Critics said the risks -- including the possibility of total rejection, leaving the person worse off than before -- were not justified to fix a non-life-threatening injury. Others wondered about the psychological impact of wearing another's visage, given the personal and cultural import of the face as a core element of identity.
But with Dinoire's consent, much of the donor's face -- a triangular swatch of skin, including lips, muscles, nerves and blood vessels -- was microsurgically attached on Nov. 27, 2005. The new report covers the first 18 months of recovery.
In one clear failure, an experimental infusion of bone marrow stem cells from the donor failed to make Dinoire's immune system tolerant of the graft. Despite immune-suppressing drugs, rejection reactions developed 18 days after transplant and again six months later. That necessitated use of more potent suppressant drugs, which led to herpes and pox virus infections.
The infections responded to medications, but the drugs led to blood problems and kidney failure, which required other treatment changes. She is now getting an experimental therapy in the hope of preventing further rejection.
Meanwhile, Dinoire learned to make expressions, eat and drink and enunciate. A video shows her progress, and photos show that with makeup, there is virtually no evidence of the trauma.
"It is a success," Dubernard said. "It gives hope to patients with total disfigurement."
Two other face transplants have since been performed, in China and in France by a different team. Neither has described the results, but the new report suggests that the field has a future, said Warren C. Breidenbach, a member of Kleinert Kutz and Associates, a surgical team developing methods for face and other complex transplants at the University of Louisville and the Jewish Hospital there.
"This is a better reconstruction than you could obtain from conventional methods," such as using small skin patches from the patient's body, said Breidenbach, who in 1999 helped perform the first successful U.S. hand transplant. That procedure also drew criticism because it was not crucial for survival, but it has now been done dozens of times around the world.
Studies indicate that most people with severely deforming facial injuries would risk kidney failure to get a new face. Nonetheless, Breidenbach said, Dinoire's difficult course is sure to feed the debate about what constitutes a successful face transplant and who should decide if the risks are worth it.
Several experts said they still have concerns.
Maria Siemionow, director of plastic surgery research and training at the Cleveland Clinic, which has been planning to do face transplants, expressed concern about Dinoire's "unexpectedly aggressive immune response." Scientists need better ways to prevent rejection of large, complex tissues such as faces, she said.
Even more problematic, she and others said, was that Dinoire has not undergone a formal psychological evaluation since her transplant.
"A thorough evaluation would give a lot more information about whether the patient is accepting it or is thinking, 'Maybe I should never have done this,' " Siemionow said.
The lack of psychological follow-up reflects a disturbing pattern with tests of new surgical techniques, said Karen Maschke of the Hastings Center, a bioethics think tank in Garrison, N.Y. Instead of running them as medical experiments, with careful collection of data, they are promulgated as "innovations," often without proper consent in advance or analysis after, she said.
"Research protocols have endpoints by which success can be measured. But where is the protocol? What kind of testing was supposed to be done? Is it still a success if she has total kidney failure four months from now?" Maschke asked. "This is not the end of the discussion on face transplants."