Facial Transplant Surgery: On the Edge of Shaping Medicine

Reviewed by Daniel Alam, MD

Face transplant is a relatively new, experimental reconstructive plastic surgery procedure for people who have been severely disfigured by trauma or illness.

Connie Culp (pictured below), the first US facial transplant recipient, underwent face transplant surgery after her husband shot her in the face, leaving nothing intact except for her eyes, chin and forehead.

Today, Ms. Culp is doing well. In fact, she recently appeared on the Oprah Winfrey show to discuss her face transplant surgery and the emotional and physical recovery process that it entailed. There have now been seven other face transplants performed.

Free Tissue Transfer vs. Face Transplant

A free tissue transfer is the relocation of tissue (and possibly underlying fat, nerves and blood vessels) from one area of a person's body to another. This type of surgery involves the use of one's own tissue. As a result, there are no rejection issues. In contrast, facial transplantation involves taking healthy tissue from a brain-dead donor, and surgically transferring it to a recipient. This presents unique immunological challenges. For example, there is a risk of chronic rejection and the need for lifelong immunosuppression. Immunosuppressant drugs come with high risks, including certain cancers and kidney failure. This issue is not given as much weight in solid organ transplant because the organ transplant is done to save a person's life. Face transplants are performed to improve the quality of person's life.

During a face transplant, the healthy tissue is procured from the donor and the recipient is prepared for transplantation by removing any non-viable injured tissue. Doctors must restore blood flow, reattach nerves, muscles and bony structures, and reconnect each layer of the new face to that of the recipient. Face transplant patients may require other follow-up surgeries at a later date.

Images courtesy of the Cleveland Clinic

Many Issues Remain With Facial Transplantation

While there are many technical issues that need to be worked out by reconstructive surgeons before face transplants become more commonplace, there are ethical considerations as well. Understanding and considering the nuances of the complex ethical milieu of this field is critical. At this time, the surgery should be reserved for restoring function in people who are severely disfigured. While this may be associated with a dramatic improvement in appearance, that should not be the primary indication for a face transplant. There are also complex psychological and identity issues that arise from having a new face stare back at you in the mirror. A common misconception is that there is an identity transfer that occurs with this operation with the recipient "looking like the donor" after the surgery. The final result is more of a hybrid.

To even be considered, candidates must undergo three years of psychological testing to determine if they are emotionally healthy enough to undergo this radical plastic surgery.

As with any surgery, facial transplantation does come with risks, and appreciating these risks is also critical. A face transplant requires lifelong use of immunosuppressant drugs, which may increase the long-term risk of cancer, infection and end-organ failure. Other potential complications that may arise include:

  • Rejection of the new face, either acutely or in a chronic fashion
  • Reduced sensation or movement in the transplant, which can be permanent
  • Acute or chronic facial flap failure, meaning that the tissue transfer in one or more areas did not adhere to the healthy surrounding tissue

It's important to remember that a face transplant is a long, complicated operation. Cleveland Clinic surgeons spent 22 hours transplanting Ms. Culp's face. And the transplant was not the first operation that she underwent; far from it. She had 23 other facial surgeries before the headline-grabbing transplant, and she still isn't done. Ms. Culp will likely undergo future revision surgeries to excise some of the extra glandular tissue around her neck. The good news is that she has experienced no long-term rejection and has regained her senses of smell and taste.

About the Reviewer of This Article

A key member of the first US transplant surgical team, Daniel Alam, MD, is the head of the section of facial aesthetic and reconstructive surgery in the Head and Neck Institute of the Cleveland Clinic in Ohio. He graduated from Johns Hopkins University School of Medicine as valedictorian in 1996. Dr. Alam completed an internship in general surgery at the Massachusetts General Hospital, and completed his residency through the Harvard Medical School Program in otolaryngology/head and neck surgery. He later completed a fellowship in facial plastic and reconstructive surgery at UCLA Medical Center and served on the faculty as a clinical instructor in facial plastic surgery.

Dr. Alam joined the Staff of Cleveland Clinic in 2002. He is board certified in otolaryngology and facial plastic and reconstructive surgery.