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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."
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