How is a Face Transplant Performed?

What is a face transplant?

A face transplant is a medical operation that involves the replacement of all or specific parts of the face using the facial tissue of another person (donor). A portion of the area called Vascularized Composite Tissue Allotransplantation (VCA) includes transplants of the skin of the face, the structure of the nose, lips, facial muscles used for expression, nerves that provide sensation, and bones that support the face.

A complete facial transplant makes it possible to transplant to another person absolutely all tissues, muscles, as well as several elements of the facial skeleton, vascular, and nerve fibers. However, the recipient of the face transplant will take lifelong medications to suppress the immune system and fight rejection.

Image Credit: David Tadevosian/Shutterstock.com

When can face transplants be performed?

Face transplants (transplantations) are performed only in exceptional circumstances where there the patient is facing serious anatomical and aesthetic problems. Even though by 2021 more than 45 such operations have already been performed (PRS, 2021), face transplantation is still regarded as an experimental medical operation.

Under a complete face transplant, doctors and specialists transplant all tissues, muscles, nerves, and vascular fibers, as well as several elements of the facial skeleton to another person. The first complete face transplant was performed in 2010 in Spain: the patient received skin, nose, cheekbones, jaw with teeth, and throat transplants in the face of a gunshot wound.

The indications for this most complex surgical intervention are severe damage to the tissues and bone structures of the face, resulting from various disorders. Sometimes it can be a genetic disorder, for example, neurofibromatosis, in which multiple tumor foci are involved in the face. But more often it is mechanical damage.

Statistically, 90% of all patients that underwent a face transplant had a terrible event happen to them. People have lost not just some separate parts (lips, nose, or cheeks), but have lost their normal appearance entirely. Therefore, ordinary plastic surgery was indispensable, and only a face transplant could “save” them.

The main difficulty of any organ transplant is the risk of the body rejecting it. Our immune system naturally does not accept new cells and tissues and begins to actively attack them with antibodies, lymphocytes, and macrophages. In the best case scenario, the patient will be very ill and take medication. Worst case scenario, necrosis, and death will occur. Unfortunately, more than half of all face transplants are fatal.

A face transplant is more than just removing the "mask" from the donor (giving organ) and applying it to the recipient (receiving organ). This is the most complex of manipulations, including the transfer of muscles, blood vessels, and, most importantly, nerve endings.

Facial transplant methodology

Firstly, preparations for the operation begin. The patient has their skin, adipose, muscle tissue, and potentially cartilage of the ears and nose removed. The donor material is then gradually transferred to the face. Medical thread only sutures the nerves – the rest is glued together or processed with a special green laser to prevent the formation of scars and the development of inflammation. Because of this, it is impossible to fully restore facial expressions.

If we omit all the surgical features of such an operation, then its essence lies in the transfer of certain areas of the face to the recipient. The donor material can be connected to the patient's tissues in one of several ways:

• Sewing on (the finest surgical absorbable sutures are used)
• Bonding with medical polymer adhesives
• Bonding with a laser beam that seals fabrics

The connection method is not preselected. It is determined during the operation for the transplantation of areas of the face. Combined techniques are usually used because all types of fabrics connect in different ways. For example, it is better to suture nerve endings with suture material. And the muscles are usually soldered with a laser.

A face transplant operation can last more than a day, so several specialists in the team replace each other. First, veins and arteries are sutured so that the transplanted person is immediately nourished. By the pinkish color of the skin, doctors determine that everything is going well, and can begin to combine other elements.

Post-operation of a face transplant

Rehabilitation does not end after discharge. After surgery has been carried out, the patient is prescribed immunosuppressive therapy to help stop the immune system from rejecting new tissue. To avoid all types of suppurations and infections, the patient is prescribed several antibiotics.

If the operation is performed according to plan, provided that the causes of the development of necrosis and trophic ulcers are eliminated, then the results of skin grafting are very good. Correctly performed surgery ends with success in 95% of cases. In the postoperative period, the transplanted skin is gradually replaced by its epidermis, which manifests itself in the appearance of small crusts, under which young skin is noticeable.

Auto-dermoplasty can be the definitive method of wound closure if the wound is not located on the supporting surface or ​​a large joint. In such places, young skin can be damaged by stress with the formation of trophic ulcers. For supporting and bony surfaces, it is better to use full-thickness dermal grafting with vascular pedicle flaps.

Post-treatment follow-up

The operating surgeon should observe the patient until the complete epithelialization of the trophic ulcer or the wound on which the skin has been transplanted.

The outcome of the skin grafting operation depends on the course of the vascular disease, which caused the formation of a trophic ulcer or necrotic wound. Therefore, the main observation is carried out on the results of the vascular stage of treatment.

References:

• G. Diep., et al. (May 2021) The 2020 Facial Transplantation Update: A 15-Year Compendium. Global Open: May 2021 – Volume 9 – Issue 5
• Devauchelle B, Badet L, Lengelé B, et al. (2006) First human face allograft: Early report. Lancet.
• Shiffman, Melvin (September 2012). Cosmetic Surgery: Art and Techniques. Springer
• Alberti, Faye Bound (April 2020). Facial transplantation as a surgery and psychosocial process
• Alberti, Fay Bound; Hoyle, Victoria. (February 2021). "First US face transplant recipient dies, leaving an important legacy". The Conversation. ]]
• Chambers JA, Ray PD (November 2009). Achieving growth and excellence in medicine: the case history of armed conflict and modern reconstructive surgery.

Further Reading

• All Transplant Content
• Transplant Surgery
• Pulmonary Transplant (Lung Transplant)
• Types of liver transplant
• What is a kidney transplant?

Written by

Dmitry Dorofeev

After completing his bachelor’s degree in market research and psychology in 2019 in New Zealand and Germany, Dmitry moved to London to pursue a career within the healthcare sector to oversee research projects in science and medicine, with a focus on how innovative technologies help drive and shape this industry.