How Face Transplants Work

Scientists have long thought about the idea of replacing a diseased organ with a healthy one from a donor. The problem at first was that the human body is not particularly receptive to foreign tissue. The immune system is like an army, constantly on guard against any invasion of bacteria, viruses or other potentially dangerous substances. When tissue from a donor is placed inside the body, this immune army sees it as a foreign invader and goes into battle mode. White blood cells attack and destroy the unknown tissue in a process known as rejection.

Eventually, scientists realized that the problem of rejection didn't occur when the organ donor and recipient were identical twins. The genetic similarity appeared to prevent the immune response. Massachusetts surgeon Joseph E. Murray used this concept to his advantage in 1954, when he accomplished the first successful kidney transplant between identical twins at Brigham and Women's Hospital in Boston.

Dr. Murray's surgery was a major breakthrough, but it wasn't a solution. After all, very few people have an identical twin they can rely on for organ donation. In the late 1960s, doctors figured out a way to perform transplants between nonrelatives by suppressing the recipient's immune response with drugs like cyclosporine. The trouble was that the drugs themselves were highly toxic. Between the risks of infection and those of the immunosuppressant drugs, most transplant patients didn't live long after their operation.

By the 1980s, anti-rejection drugs had improved to the point where transplantation surgery became pretty routine and far less risky than it had been a few decades earlier. Survival rates rose. Once surgeons had streamlined the process of transplanting essential organs -- heart, kidneys, liver and lungs -- they turned their focus to "nonessential" parts of the body. In the late 1990s, surgeons in Lyon, France, and New Zealand performed the first successful hand transplants. The next step was to attempt a face transplant.

The first step to face transplant surgery was reattachment of a patient's own face. In 1994, 9-year-old Sandeep Kaur was chopping grass to feed the family buffalo at her home in northern India when her hair became caught in the threshing machine. Her entire face -- scalp and hair included -- was torn off. Sandeep's family put her face in a bag and drove the child by moped to the nearest major medical center, which was three and a half hours away. When surgeons assessed Sandeep, they decided that skin grafts would still leave her so disfigured that she'd never have a normal appearance. Instead, they performed surgery to reattach her face and scalp.

Sandeep's doctors made history by performing what was in essence the first human face transplant. Sandeep was left with some scars, and she's never regained full mobility in her face, but she has been able to lead a normal life since her operation. A handful of other successful face reattachment surgeries followed, including an operation at Massachusetts General Hospital on a man who'd gotten his hair caught in a conveyer belt at work.

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The next step was transplanting part of a face from a donor. The recipient of the world's first partial face transplant was a 38-year-old Frenchwoman named Isabelle Dinoire. In May 2005, Dinoire took sleeping pills and passed out on her couch. When she awoke and tried to light a cigarette, she was surprised to find that it would not stay between her lips. A glance in the mirror revealed a horrible sight -- Dinoire's black Labrador had chewed off the lower part of her face, including her chin, lips and much of her nose, leaving her teeth and gums completely exposed. "I couldn't believe what I was seeing -- it was too horrible," she told reporters [source: New York Times]. After the incident, Dinoire was forced to eat pureed food and wear a surgical mask to hide her disfigured face.

Doctors could have taken tissue from Dinoire's chest to repair the damage to her face, but that would have left her with very little movement. Instead, surgeons Bernard Devauchelle and Jean-Michael Dubernard (who had performed the first hand transplant surgery in 1998) stepped in and agreed to give Dinoire a new face. The donor was a 46-year-old woman who had been left brain dead from a suicide attempt.

In November 2005, two medical teams consisting of about 50 professionals gathered to perform the surgery at a hospital in Amiens, France. They removed the donor's face at 10:30 p.m. on a Saturday and finished attaching the graft to Dinoire at about 4 p.m. the next day. Within a week, Dinoire could speak, eat and drink, but doctors said it would likely be several months before she gained sensitivity in her new skin.

In 2006, doctors in China were confronted with an even more challenging case than Dinoire's. Three years earlier, a farmer named Li Guoxing had been trying to shoo a black bear away from his cows when it attacked him. The bear ripped away most of the right side of Guoxing's face. Not only was his skin missing, but also part of the bone in his nose and cheek.

In a surgery that lasted some 15 hours, a team of 18 doctors led by Guo Shuzhong gave Guoxing a new nose, upper lip, cheek and eyebrow from a brain-dead donor. The surgery went without a hitch, and Guoxing's new skin even sprouted facial hair and acne within days of the procedure.

Then in 2007, French doctors performed a third partial face transplant on a 29-year-old man with neurofibromatosis, a disease that causes tumors to grow on nerves throughout the body. Although the man had already undergone more than 30 operations, his face was still so disfigured that he was unable to speak or eat. During the 15-hour operation, doctors gave the man a new nose, mouth, chin and cheeks.

­The success of these three partial face transplants has prompted doctors to attempt the first full-face transplant, which would include an entire face, as well as the ears and hair. In 2004, the Institutional Review Board at the Cleveland Clinic gave doctors there the go-ahead to proceed with the operation. As of 2007, all that was left to do was find the right candidate.­

Before face transplant surgery can be performed, doctors need to find the right donor and recipient. Candidates must be physically healthy enough to undergo surgery, and psychologically prepared to handle the emotional stress of undergoing such a huge physical transformation.

The donor also must be carefully chosen. Because the tissues must still be connected to an active blood source, the donor has to be alive on life support, but brain dead with no hope of recovering. Doctors try to match recipients with a donor of a similar age and skin tone. More important is matching the blood and tissue, because a poor match will end in the recipient rejecting the new tissues.

To find a good match, doctors use a test called HLA typing, which looks for proteins called antigens on the surface of tissues. Antigens are what stimulate the body's immune system to launch an attack and reject foreign tissue. Tissue type is based on a pattern of antigens. Everyone has a different pattern, with the exception of identical twins, who share the same pattern (which is why organ donation is a relatively smooth process in twins). The closer the antigens match, the less likely that the recipient will reject the transplanted tissue. (In Isabelle Dinoire's case, doctors actually went a bit further -- they gave her an infusion of bone marrow stem cells from the donor to prepare her immune system and reduce the odds of rejection.)

During the surgery, doctors first cut and peel away the donor's face. How much of the face is removed and transplanted is based on whether the procedure is a partial or full face transplant (as of 2007, only partial face transplants have been performed). Depending on the extent of the damage to the recipient's face, the surgeons will take not only the skin but also the underlying fat, muscle, cartilage, nerves, arteries and veins. Some patients (like Li Guoxing in China) will need replacement bone as well.

Once the face is removed from the donor, a medical team will transport it on ice to the recipient waiting in another hospital operating room. Before the transplant tissue arrives, doctors will have removed the remaining damaged skin and muscle from the recipient's face to make way for the new tissue.

Using microscopic needles and thread, surgeons will first connect arteries and veins to the new tissue to supply it with the oxygen-rich blood it needs to live. They don't need to connect all of the arteries and veins -- just a few will ensure that enough blood flows to the face. The surgeons will also connect the nerves and muscles so that the patient has feeling and movement in his or her face. Doctors will drape the donor's face over the recipient's skull, adjust it to fit and sew it into place. The recipient will have to take immunosuppressant drugs for the rest of his or her life to prevent tissue rejection.

On the next page, we'll learn about the many risks and controversies surrounding face transplant surgery.

One big question everyone asks is: Will the face transplant recipient look exactly like the donor? The answer is no. Your looks are not defined solely by your skin -- the underlying bone structure also is an important factor. After the procedure, the patient will actually look like a combination of him- or herself and the donor.

Any type of surgery comes with risks, and particularly one that is as complicated as the face transplant. As with any other surgical procedure, the main risks are excess bleeding and infection. Also, a blood clot can form in one of the reattached blood vessels, blocking the blood supply to the new face and killing the tissue.

Because the face is coming from another person, rejection is always a worry, even if the tissue types closely match. The drugs used to prevent rejection come with their own risks because they suppress the immune system and lower its ability to fight off infection. People who take immunosuppressive drugs are more likely to develop diabetes, kidney disease, infections and cancer.

Patients have to endure these potential side effects and take their medicines religiously in order for the surgery to be successful. They also need to follow all of their doctors' recommendations. One hand transplant patient had to have the appendage removed when he stopped taking his anti-rejection medications. Isabelle Dinoire ignored her doctors' advice to stop smoking, which could affect the circulation to her new face [source: New York Times].

In addition to the many potential physical complications of having a face transplant, there are a number of psychological issues. Having someone else's face in place of your own is understandably traumatic, and people who undergo this operation may need counseling to regain some normalcy in their lives.

All three of the partial face transplants performed so far have been successful, but there is still a high possibility that future surgeries will fail. If that happens, doctors have one of three options: They can remove the face and perform another transplant from a new donor, resurface the face with artificial skin or cover the space with grafts of real skin.

The Controversies

Although the technology to perform face transplants has been around for many years, doctors didn't attempt the procedures until recently, mainly because of ethical concerns. The first concern is over the donor, whose family must be willing to turn off life-support machines while the person is still technically alive. Other ethicists are concerned about patients assuming the risks of major surgery when their lives are not technically in danger. Might there come a day, some have speculated, when the ultrarich will opt for face transplants simply to look prettier or younger?

In 2003, the Royal College of Surgeons in the United Kingdom issued a paper in which it warned doctors not to perform face transplants until they knew more about the risks and ethical implications of doing such a surgery. A year later, the French National Ethics Advisory Committee issued its own warning against performing the procedure. Yet despite the concerns, in just a few years doctors started performing partial face transplants -- and began gearing up to do a full face transplant. How the technology, and the debate, evolves will become clearer in the coming years.

For more information about face transplants, check out the links on the next page.