Surgeons Say Recipient of Face Transplant 'Is Doing Well'

Surgeons yesterday provided details of the first face transplant done in the United States, a painstaking 22-hour operation to stitch most of a dead woman's face onto a recipient so horribly disfigured that she was willing to undergo the risky surgery in the hopes of being able to smile, smell, eat and breathe normally again -- and go out in public without frightening children.

In a procedure done sometime in the last two weeks, the 30-member Cleveland Clinic team replaced about 80 percent of the woman's face -- essentially re-creating the entire middle portion, including her lower eyelids, nose, cheeks and upper jaw, along with the supporting bones, muscles, nerves and arteries.

The operation, transferring everything except the upper eyelids, forehead, lower lip and chin, marks the first time the controversial procedure has been performed in North America and the most extensive face transplant yet.

"I'm very proud and emotional today to share with you what we finally did," said Maria Siemionow, the reconstructive surgeon who led the team. "The patient is doing well. . . . I must tell you how happy she was when with both her hands she could go over her face and feel that she has a nose, feel that she has a jaw."

To protect the privacy of donor and patient, no details about either were released, other than a statement from the recipient's family.

"We never thought for a moment that our sister would ever have a chance at a normal life again, after the trauma she endured," the statement said. "There are tears of joy, and tears of pain that it took one to pass for one to have a life."

Several surgeons and bioethicists said many of their early reservations have eased since the first procedure in France three years ago. But thorny questions remain, and some people continued to question the operations, saying it remains far from clear how long the graft will last and whether the benefits outweigh the risks.

Siemionow and her colleagues said the operation was based on more than 20 years of research, including practice on animals and cadavers. Dozens of candidates were carefully screened and subjected to intensive psychiatric testing. The woman finally selected had undergone several reconstructive procedures but remained unable to eat, speak or breathe normally.

The process began about 5:30 p.m. when the donor's family agreed to the donation and doctors determined the arteries and veins in the recipient's neck could receive the transplant. After confirming the two women's tissues were a good match, surgeons carefully started to remove the donor's face at about 8 p.m. and worked for more than nine hours.

In an adjacent room, a second team prepared the recipient. The facial tissue was transferred to her operating room just past 5 o'clock the next morning. For nearly three more hours, surgeons connected the patient's blood vessels to the facial graft to restore circulation. When the tissue turned pink, the surgeons knew they had succeeded. The multidisciplinary team then continued to work in shifts to allow some to rest, sleep and confer, and the operation was completed about 4:30 p.m.

"I think it's the most complex surgical procedure ever performed," said Frank Papay, who was part of the team.

Doctors stressed that the patient has a long, potentially treacherous road ahead. They are carefully monitoring her for any signs of transplant rejection. Assuming no complications occur, doctors expect that the swelling will subside after a couple of months and that feeling will return to her face within about six months. With intensive physical therapy, function should return within about a year. Eventually, the woman's destroyed right eye will be replaced by a prosthesis.

The transplants are controversial because they are aimed at improving a patient's quality of life rather than saving it, raising questions about whether the procedures are worth the risks, which include life-threatening side effects from powerful immune-suppressing drugs the patients need to take for the rest of their lives.

"For a patient who needs a heart transplant, not receiving the transplant is going to be fatal," said Carson Strong, a professor of human values and ethics at the University of Tennessee College of Medicine. "That isn't the case for a patient who needs a face transplant."

Strong added that "a graft loss would leave the patient with an open wound across most of the face. The patient clearly would be worse off than before."

The Cleveland Clinic researchers acknowledged that the procedure poses issues for society, including fears that it would come to be used for purely cosmetic purposes or even to steal someone's identity. "We will do everything in our power to prevent the misuse of this important advance," said Eric Kodish, a bioethicist who was on the team.

When the first partial face transplant was performed in France on a woman who had been mauled by her dog, the news set off an international firestorm. Another face transplant was subsequently performed on a Chinese farmer who had been attacked by a bear, and then another in France on a man disfigured by a genetic condition.

Despite a difficult recovery, the first recipient, Isabelle Dinoire, gradually regained normal skin sensation and control of her facial muscles and has reported that the operation transformed her life.

"I've become convinced a competent team could manage this," said Arthur Caplan, a University of Pennsylvania bioethicist. "I think the microsurgery, the cosmetic surgery, the management of the immunosuppression has gotten to the point where trying this, given the desperation of the patients, makes sense."

But if the transplant "did fail and the face was rejected," he said, "it would be an almost unimaginable situation. Your face would be sloughing off. You can't eat. You can't breathe."

If the Cleveland Clinic patient's graft fails, doctors said, it would be replaced with a skin graft from different parts of her body.

The transplantation of a face could also cause people to reevaluate how they perceive their identity and those of others, some said.

"People have a lot of very deep-seated psychological anxieties related to receiving the face of another," said Carla Bluhm of Allegheny College, who co-authored an upcoming book titled "Someone Else's Face in the Mirror: Identity and the New Science of Face Transplants." She added: "How deeply can it disrupt your sense of who you are? And what are those consequences?"

Another issue is whether people who sign organ donor cards should be advised that in addition to the heart, kidneys and other organs, the face may be used for transplants.

"When I signed my organ donor card, I wasn't thinking about someone taking my face," Caplan said. "I doubt most Americans do. Do you also have to have the family consent? They bear the emotional consequences of seeing their loved one's face on someone else. Even if it looks different, it will remind them of you."

Others said they were reassured that the transplanted tissue does not resemble the donor.

"When we think of face transplants, we think it's going to be someone else's face on another person -- a Frankensteinian kind of thing," said Jeffrey Kahn, a University of Minnesota bioethicist. "In fact, that's not what happens. It's the underlying structure of the recipient that really determines what it's going to look like."

Several surgeons elsewhere praised the operation, saying it was a prelude to many similar surgeries to help thousands of patients mutilated by accidents, tumors and other trauma.

"This is a wonderful advance," said L. Scott Levin of the American Society for Reconstructive Transplantation, noting that hospitals in North Carolina, Massachusetts and Tennessee are planning similar surgeries. "The entire North American reconstructive surgery community is on the precipice of jumping into this in a big way."

"It's very exciting," said Bohdan Pomahac, who is planning a face transplant at Brigham and Women's Hospital in Boston. "It's great for the field."

Siemionow said she hopes the operation will eventually help many others.

"There are so many patients . . . who are hiding from society because they are afraid to go to the grocery store, they are afraid to go to the street because they are called names and they are humiliated," Siemionow said. "You need a face to face the world."