A New Phase In Face Transplant

The future of full-face transplant surgery has taken a new form with a team of British surgeons given the official go-ahead to perform the world's first full-face transplant. Is India ready for this significant development which will boost plastic surgery worldwide? Sonal Shukla explores

After partial face transplant, now it's the time for full-face transplant to knock the doors of reality. In December 2005, a French surgeon carried out the world's first partial face transplant on a 38-year-old woman who had been savaged by a dog. This operation was designed to replace her nose, lips and chin. Now, the face transplantation team of the Royal Free Hospital in Britain has received a go-ahead from the research ethics committee of the hospital to conduct a full-face transplant.

Considered the 'Holy-Grail of surgery', this procedure has sparked debate around the world. The operation involves taking the muscles, arteries, veins and the skin of a brain-dead patient and attaching them to another person who has suffered facial trauma or burns.

The Risk Factor

"Surgeons who do face transplants need to have a lot of experience and can start that experiment on animals and then go on to human beings" - Dr Narendra Pandya Plastic Surgeon Jaslok Hospital Mumbai

With this significant breakthrough, the Indian fraternity of plastic surgeons is curious, but still skeptical about its success. According to Dr Anup Dhir, Plastic Surgeon, Indraprastha Apollo Hospital, New Delhi, “The surgery may fail in the first few hours due to blockage of blood vessels. The new face may be rejected after initial phase due to failure of immunosuppression with 10 per cent chances in first year and 30-50 per cent in the next three to five years. If rejected, the patient’s condition may become worse.” In the long term, there is an increased risk of cancer due to immunosuppressive drugs. The risks involved in the procedure range from total failure of the operation in case the vessels get blocked due to the perils associated with immunosuppressants, which can also lead to the rejection of the graft. "When a tissue transplant is done from one body to another, especially if these two bodies are not genetically matching, problems like mismatch or antigen antibody reaction could arise which need to be addressed. The antigen antibody reaction will pose a major challenge where rejection is concerned," explains Dr Narendra Pandya, Plastic Surgeon, Jaslok Hospital, Mumbai. A kidney or heart is a vital organ and the medication given to control the rejection becomes crucial for the life of the patient. However, a face transplant cannot be categorised as a vital organ for life and needs strong medication which could be harmful in the long run. According to Dr Pandya, “This is one of the important reasons why face transplant has not been tried in the past as it is not life-threatening and the life of the person is not in danger.” As the procedure is new, there is no available data on the effect on facial expression and other long-term implications. Doctors are also doubtful whether the operated patient will have any facial expression at all. Hence, the challenge is to find a suitable patient for this surgery who consents to all risk factors.

All Set?

"This will be like any other microvascular free tissue transfer, which is routinely done in major centres and will require a good team" - Dr YN Anantheswar Senior Consultant and HOD Dept of Plastic Surgery Manipal Hospital Bangalore

Do Indian plastic surgeons have the expertise to pull off a face transplant? "Technically, this will be like any other microvascular free tissue transfer which is routinely done in major centres in our country and will require a good team comprising plastic surgeon, psychiatrist and transplant physician (routinely nephrologist/hepatologist)," says Dr YN Anantheswar, Senior Consultant and HOD-Plastic and Craniofacial Surgery, Manipal Hospital, Bangalore.

Indian plastic surgeons insist that many centres in India have the expertise to conduct this kind of surgery and no new investments may be needed in well-equipped centres. According to experts, the surgery may cost anywhere from Rs 15 lakh to Rs 1 crore or more, besides lifelong recurring costs of medicaiton.

Experts opine that though Indian plastic surgeons have the skill, they lack experience. "Indian doctors have to get experience, which can be available through cadavers. Any dedicated person who is intending to do a face transplant must have enough experience on cadavers. Surgeons who do face transplants need to have a lot of experience and can start that experiment on animals and then go on to human beings," opines Dr Pandya.

Surgical Criteria

"At Cleveland Clinic in the US, the ethics committee has given sanction for this procedure but they have not been able to find a patient" - Dr Anup Dhir Plastic Surgeon Indraprastha Apollo Hospital New Delhi

Face transplants are not an elective procedure owing to the associated risks and ethical concerns; they are only carried out in case of extreme facial disfigurement by severe burn or trauma. "At Cleveland Clinic in the US, the ethics committee has given sanction for this procedure but they have not been able to find a patient. Similar situations can arise in the UK," says Dr Dhir. According to Dr Anantheswar, patients with acid burns on their face, who have reached a stage where no more reconstructive surgery is possible, are ideal candidates for this full-face transplant surgery.

Ethical Debate

There has been a moral and an ethical debate surrounding this procedure in Western countries. These concerns along with the possible psychological impact on the patient have to be taken into account and carefully evaluated before carrying out the operation. In the Indian context, Dr Dhir says, “It is difficult to find brain-dead ventilated donors even for life-saving transplants like kidney and liver and will be more difficult for a non-life saving procedure like this.” The issues involved are many, like social acceptance of changed face of the patient by his friends, relatives and others, availability of suitable histo-compatible brain-dead cadaver donor certified by ethics committee and also financial considerations. In India, with huge populous and ethnic differences, the issue of selection of right face can become even more complex. "While identifying and selecting right donors for this surgery in India, aspects like ethnicity, age criteria, colour will also have to be taken into consideration," opines Dr Pandya. Psychological selection criteria need to notice whether the person (recipient) is genuinely desirous of surgery to have his face removed and replaced.

A patient who understands the procedure, is ready to undertake the risks and in whom lesser procedures have not given desired results should be the ideal candidate for this surgery.

"This is the first transplant which is not life-saving. Hence, till the ethical issues involved are resolved, it may not be proper to attempt it. Maybe in future the techniques may become better with fewer side-effects, ethical issues resolved and brain-dead donors available, but at present it is still experimental," concludes Dr Dhir.

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