Face Transplants Are Possible, but Rare and Highly Complicated

Surgeons have fancy names to describe the process that most of us just call face transplantation: vascularized composite allotransplantation (VCA), facial composite tissue allotransplantation, and human craniomaxillofacial allotransplantation. These all refer to the very complex series of actions that must be undertaken to transplant a face from a donor onto a recipient.

Technically, VCA refers to the transplantation of multiple tissues, such as muscle, skin, tendons, nerves, and bones — as is required by a face transplant. It can refer to a face transplant, but it can also refer to other types of transplants that aren’t solid-organ transplants, like a hand transplant.

Traumatic injuries can cause catastrophic damage to a person’s face. This might include injuries from burns, gunshot wounds, and others.

As a result of tissue and bone loss and damage, a person may lose certain essential functions, including speaking and the ability to chew and swallow food. These injuries can also create severe psychological distress.

A face transplant can repair the damage and restore basic functions so that they can regain some of the quality of life that was taken from them. It can also help them feel less self-conscious about their appearance in front of other people, which can have a positive impact on their mental health.

Surgeons performed the very first partial face transplant in 2005. The recipient was a French woman named Isabelle Dinoire, whose face had been mauled by a dog. The transplant was considered successful and Dinoire later died of cancer, 11 years after undergoing the procedure.

After the first few surgeries, other countries would strive to make the procedure available:

• Between 2009 and 2013, a total of 27 face transplants were conducted in 21 hospitals in 11 countries.
• By 2020, 48 face transplants had been performed worldwide on 46 people (two of the procedures were actually retransplants).
• The majority of the surgeries were conducted in just three countries: France, the United States, and Turkey.
• Most of the people who received facial transplants are still living today. A 2021 study noted that 81.2% of face transplant recipients were still alive, while eight of those people had died (the study doesn’t indicate any reason for those deaths or explain whether they were related to the face transplant).

Face transplantation procedures are very lengthy surgeries. They’re intensive and time-consuming by necessity, as surgeons must painstakingly connect bones, blood vessels, and nerves.

Many recipients of face transplants have also already undergone multiple surgeries beforehand.

Planning for surgery

Before a person can undergo surgery, the transplant team will consider and review a multitude of factors that can affect outcomes.

They’ll painstakingly review the person’s medical history, including their overall physical health and their history of blood transfusions, skin grafts, and immunological responses.

A person’s mental health is also a critical factor to consider to make sure they’re psychologically prepared and well suited for this type of life changing surgery. Research suggests that a comprehensive psychological evaluation should be conducted before a person undergoes surgery.

Because every person is unique, surgeons must create a plan to meet a recipient’s specific needs.

As a 2021 review of face transplantation procedures explained, surgeons are also now using computerized surgical planning (CSP) and computer-aided design and manufacturing (CAD/CAM) of person-specific devices to aid them in creating customized approaches for each transplant recipient.

When a donor is identified, it’s important to make sure the donor’s blood and tissue type match up with the recipient’s to ensure the best chance of success.

The donor’s age, face size, skin tone, and biological sex are also factors that must be considered.

However, some research suggests that cross-sex face transplantation, or CSFT, may be possible in the future, which might open up more possibilities.

Procedure

This type of surgery can last anywhere from 12 to 36 hours, depending on factors such as how much of the transplant recipient’s face is being restored.

1. Surgeons must first remove the donor’s face, which includes skin, muscles, nerves, cartilage, fat, and blood vessels.
2. Then surgeons must carefully prepare the recipient’s face, which may entail removing damaged tissues.
3. When it’s time to place the donor’s face on the recipient’s head, the surgical team must painstakingly connect blood vessels to make sure that blood flow is restored.
4. Then they’ll connect the muscles and nerves, as well as bones and cartilage, to create the structure of the face.
5. Finally, they’ll finish suturing the tissues and skin together to complete the transplant.

After surgery

After surgery, a face transplant recipient will remain in the hospital under careful monitoring to detect signs of side effects or rejection.

Eventually, the recipient will be discharged to return home, but they can anticipate many follow-up visits. They’ll also likely need physical therapy to begin learning how to adapt to the new face.

In 2019, the New England Journal of Medicine (NEJM) published the results of a study that followed six face transplant recipients for 5 years after their transplantation surgeries.

According to the results, the recipients experienced improvements in their ability to distinguish between hot and cold stimuli on their skin and significant improvements in motor function after their surgery, “reaching a mean of 60% of maximal motor function at 5 years of follow-up.”

However, the NEJM study noted that each of the six people in the study experienced between two and seven acute rejection episodes that required treatment. Acute rejection is one of the most common side effects of a face transplant and has some of the most severe consequences for the recipient.

Rejection was the reason for two failed transplants that eventually led to retransplants. The recipients included:

• Jerome Hamon, a recipient in France who was the first person to undergo a retransplant but began experiencing transplant rejection
• Carmen Tarleton, a recipient in the United States whose body began to reject her first face transplant after 6 years and who received a second face transplant

According to a 2020 study, signs of acute rejection can include:

• atypical skin redness (erythema)
• edema
• an eruptive skin rash (exanthema)
• erythema alongside stitches
• wounds of the skin within the nose and mouth (mucosal lesions).

The likelihood of acute rejection is highest in the first few months after transplant.

The signs get harder to identify over time. However, the study suggests that biomarkers may be used in the future to better identify and diagnose transplant rejection.

Even if the surgery is successful, the recovery process is lengthy.

It can take many months for nerves to grow and restore sensation and function.

Transplant recipients must undergo physical therapy to help them learn to use their new faces.

Some recipients also need follow-up surgeries, or revisions, to further refine and improve their appearance.

Just as you’d need to take immunosuppressant drugs after undergoing a heart transplant or any type of organ transplant, you’ll need to take immunosuppressant medications after a face transplant procedure.

Otherwise, your body’s immune system won’t recognize the transplanted tissues as your own, so it will attack the transplant. These drugs work by suppressing your immune system’s natural reaction to foreign tissue, preventing your body from attacking that new tissue.

However, immunosuppressants aren’t something to be taken lightly. Research suggests that the side effects of these medications can be severe.

For example, transplant recipient Richard Norris underwent a kidney transplant a few years after receiving his face transplant after one of his immunosuppressive medications damaged his kidneys.

Also, the drugs can’t prevent the body from rejecting a transplant. In fact, preventing rejection is an ongoing challenge. As a 2020 review of facial transplantations noted, “Immunosuppressive management has improved, but significant adverse events continue to be reported.”

Here are a few interesting facts about face transplants that you might not know.

How many face transplant surgeries have there been?

There have been a total of 48 transplants on 46 recipients since the first one in 2005.

Is the face transplant on Grey’s Anatomy real?

In 2009, the popular TV drama “Grey’s Anatomy” featured a storyline about a man who lost most of his face, including his lips and his nose. This was the result of a car accident caused by a drunk driver. A team of surgeons, led by one of the then-stars of the TV program, performed a face transplant.

While the storyline was inspired by early face transplantation surgeries, it’s important to remember this was a fictional story.

The very first face transplant in the United States wasn’t conducted until 2008 at the Cleveland Clinic, just a year prior to the “Grey’s Anatomy” storyline. Even a decade later, very few institutions in the country have attempted such procedures.

Can you get a double hand and face transplant?

Yes, but only one person has actually undergone this combination of surgeries. Joe DiMeo received both a face transplant and a double hand transplant in 2020.

Even though 17 years have passed since the first facial transplant surgery was performed, it’s still a fairly rare procedure — and most still consider it to be an experimental type of procedure. Consider that more than 40,000 organ transplants were performed in the United States in 2021 alone, while the total number of face transplants worldwide still hovers under 50.

However, research on face transplantation continues at institutions like NYU Langone Health, as researchers look for ways to improve techniques and hopefully increase the success rate of these transplants.