French, in first, use a transplant to repair face
By LAWRENCE K. ALTMAN (The New York Times)
Updated: 2005-12-01 16:58

Surgeons in France have for the first time performed a partial face transplant, a surgeon who led one of the two teams that performed the operation said yesterday.

Dr. Jean-Michel Dubernard of Lyon, who led one of two teams of surgeons that performed a partial face transplant on Sunday. [AP]

The recipient of the transplant was a 38-year-old woman who had been severely disfigured in an attack by a dog, said the surgeon, Dr. Jean-Michel Dubernard of Lyon. The operation was carried out in Amiens on Sunday.

In a brief telephone interview, Dr. Dubernard said the two surgical teams had grafted a nose, lips and chin from a donor who had been declared brain dead onto the woman's face.

Hospital officials said the woman who received the transplant did not wish to be identified. They gave no details about what measures, if any, had been taken to reconstruct her face short of a transplant. "The patient is well and fine, and the graft is O.K.," Dr. Dubernard said. He said a news conference would be held tomorrow in Lyon to discuss the case.

The surgery represents the first foray into a much-debated realm of medicine. A number of other surgical teams in the United States, France and the Netherlands have announced plans to perform various types of face transplants. But none are known to have performed the procedure. Face transplants are among the most disputed frontiers in transplantation science because they are so risky and no one can say what a patient will look like afterward.

Ethics committees in France and England have rejected proposals to perform full face transplants until more research is done. The committees were concerned about the unknown risks of the long-term use of large doses of immunosuppressive drugs for a procedure that does not save lives. The aim of face transplants is to improve the quality of life for patients who have suffered severe injuries from burns, accidents and shootings, for example.

The French committee did approve partial face transplants of the type performed on the woman in Amiens. But the committee cautioned in a report last year that even a partial transplant - the mouth and the nose, for example - was "high-risk experimentation."

In the United States, an institutional review board that oversees the safety of human experiments at the Cleveland Clinic last year became the first such body to approve a full face transplant. Full and partial face transplants can involve the transfer of attached muscles, blood vessels, nerves and other tissues. The tissues are needed to help restore an acceptable appearance for the recipient.

Among the risks of either type are the chance that the graft will be rejected, leaving a patient in a worse condition than before the operation, the development of cancer from the immunity suppressing drugs given to prevent organ rejection, and the chance that a patient will suffer psychological problems in adjusting to a new identity and appearance.

The woman who received the transplant on Sunday had been attacked by a dog last May. Dr. Dubernard said she was transferred on Tuesday from Amiens to the Edouard-Herriot Hospital in Lyon, where Dr. Dubernard works, for long-term monitoring of the immunosuppressive therapy that she will need. The transfer was according to a scientific blueprint that Dr. Dubernard said he and Dr. Bernard Devauchelle of Amiens had agreed on before the operation. He said Dr. Devauchelle's team was "very well trained for this type of surgery."

In 1998, Dr. Dubernard headed the team that performed the first hand-forearm transplant. He is also a politician and member of the French Parliament.

Outside experts said it was difficult to know whether the partial transplant was as difficult to perform as a full face transplant. For example, it is not known how badly injured the woman was, or how much of the donor's face and underlying muscle, blood vessels and tissue were transplanted Sunday. Also, the experts said they could not determine how well the French team had informed and prepared the woman psychologically for the transplant.

The relatively short interval of about six months between the dog bite and the surgery raised questions among some experts about what, if any, efforts had been made to perform reconstructive surgery first. "The major question is: what were the indications" for the transplant, said Dr. Maria Siemionow, a surgeon at the Cleveland Clinic who plans to perform a full face transplant.

Questions about the timing of the French surgery are relevant because the first patient to receive a hand transplant, Clint Hallam, did not comply in taking his prescribed antirejection therapy. He had his transplanted hand amputated in 2001, three years after receiving it.

Dr. Laurent Lantieri, a surgeon who was not directly connected with the French woman's surgery but who has reviewed some of her records, said he was puzzled about why she was put on the list for a face transplant in June or July, so soon after she received her injuries. Dr. Lantieri has published articles about his intention to perform partial face transplants, and was a consultant to the ethics committee in France that approves such procedures.

Face transplants, the committee said, should not be performed on an emergency basis. One reason, it said, is because "the very notion of informed consent is an illusion," even if all standard techniques have been exhausted, a candidate patient insists on receiving the transplant and a donor is available. "The surgeon cannot make any promises regarding the results of his restorative efforts, which are always dubious," the committee said. The report continued, "Authentic consent, therefore, will never exist."

The national committee was intended only to give advice and not to approve individual cases, Dr. Lantieri said in a telephone interview. French surgeons are supposed to have their experimental protocol reviewed by an independent committee of experts before carrying out a partial face transplant, he said.

Dr. Lantieri said he had reviewed a summary of the woman's medical record and examined a photograph of her damaged face. The woman's type of injury seemed consistent with proposals to do a partial facial transplant, he said. "She had very strong psychological problems," Dr. Lantieri said. "I said I would not go further if I did not have more examinations by additional psychiatrists to know that she would be able to pursue lifelong immunosuppression therapy." Dr. Lantieri said he believed that Dr. Dubernard "wanted to be first" to do a face transplant, as he had done a hand transplant.

Dr. Dubernard said his team planned to do another transplant - of bone marrow - on the woman while she was in the hospital in Lyon. Although bone narrow transplants are a standard treatment for some conditions, in this case the hope would be that it would increase the patient's tolerance to a graft.

Dr. Lantieri said if a bone marrow transplant was carried out on the patient it would mean that she would be undergoing two experiments at the same time. The extra experiment would be unethical, Dr. Lantieri said, because "every ethical committee says that only one experiment should be carried out at a time. That is a basic rule of clinical research."

But, he added, "I really hope the partial face transplant will work."