Facial transplantation : from the early trials to ethical and clinical guidelines

Organ transplantation is one of the most important medical developments to have taken place in recent decades. The number of individuals who benefit from this therapeutic resource every year continues to rise. For a number of years now, in addition to organ transplants, multi-tissue transplants have also been possible. In these procedures, a number of tissues are harvested from a donor cadaver and used to reconstruct parts of the recipient’s body. Although multi-tissue transplants are not life-saving procedures, they can allow huge improvements in the recipient’s quality of life. The first multi-tissue transplant was performed on 23 September 1998 when, at the Édouard-Herriot Hospital in Lyon, a team led by Jean-Michel Dubernard transplanted the right hand (harvested from a deceased forty-one-year-old man) on to forty-eight-year-old New Zealander Clint Hallam, who had undergone an amputation. Dozens of hand, upper limb and even lower limb transplants have been performed since. Of the various types of multi-tissue transplants, facial transplants are particularly complex from a technical standpoint and, above all, raise important ethical questions [1]. Those who are eligible for face transplants are carefully-selected individuals who have severe facial disfigurations for various reasons and for whom there are no longer any alternative conventional plastic surgery or reconstruction options [2]. These individuals have severe limitations when expressing themselves, in their interpersonal relationships and when breathing and eating. So far, a few dozen face transplants have been conducted around the world. In most cases, the transplant regards a limited part of the face below the eyes, including the cheeks down to the chin. All those cases approved for facial transplantation had extremely serious lesions, for which there were no reconstruction options. The first face transplant was performed in France at Amiens university hospital on 27 November 2005 by two teams (led by surgeons Jean-Michel Dubernard and Bernard Devauchelle). The patient (Isabelle Dinoire, a 38-year-old mother-of-two whose face had been mauled by her Labrador) was transplanted the tip of a nose, lips and chin [3, 4]. The second face transplant was performed on 14 April 2006 at Xijing military hospital in the city of Xian, in northern China, on a thirty-year-old patient, Li Guoxing, who had been attacked by a bear in 2004 [5]. This case was more complex than the previous transplant performed in France: two-thirds of the patient’s face were completely disfigured and the transplant involved a cheek, upper lip, nose and one eyebrow. The patient was discharged on 30 July 2006. Although the techniques used have improved over time, facial transplantation is still a highly complex procedure. Suffice to think that for the first facial transplant performed in Canada (in spring 2018 by surgeon Daniel Borsuk on a patient who had lost his nose and upper jaw in a hunting accident), it took 12 hours to harvest the tissues from the donor, 16 hours to prepare the recipient and 18 hours for the transplant. From a clinical standpoint, the issues connected with a highly complex procedure are obvious: “Facial allografts could fail in the short or the long term. Technical failure, immunological problems, and poor selection of patients are significant risks” [6].