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Courtesy of the Cleveland Clinic

Graphical representation of first U.S. near-entire face transplant, performed in December 2008 by a team of 25 surgeons. The patient is reconvering and went from missing nose and palate to being able to breathe, eat and drink on her own.

New face, new life

by Tara S. Kerpelman
Feb 13, 2009

Your life has been completely changed by an accident. Most of your face has been destroyed. You are afraid to be seen because your disfigured face is so scary. Daily routines that everyone else does without thinking – eating, drinking, even breathing – are impossible because you no longer have a nose or a palate.

This is what happened to a woman whose identity remains a secret and for privacy reasons, her doctors won't say exactly how the damage occurred. Her last chance at living a normal life was to have a facial transplant, the first U.S. near-total facial transplant. She had the operation in December at the Cleveland Clinic.

The patient is now two months out of surgery that replaced 80 percent of her face, everything but her upper eyelids, forehead, lower lip and chin.

“She can eat [a] hamburger, can smell it and taste it. She can have a cup of coffee, just from the cup, because before the coffee or whatever fluid she had in her mouth was just spilling out,” said Dr. Maria Siemionow, director of Plastic Surgery Research and head of Microsurgery Training at the clinic. “So things we take for granted every day, going to Starbucks, for some people it’s just a part of life. For others….”

Siemionow led the transplant team of almost 45 people in the 22-hour operation and presented her work Friday at a symposium at the American Association for the Advancement of Science annual meeting in Chicago. Siemionow addressed about 50 people on “Origins of the perfect face: Extreme makeovers,” updating the audience on the patient’s recovery.

“You need a face to face the world,” Siemionow said. The face “is very important. It is an expression of beauty, identity and (aids in having a) social life,” she said.

A facial transplant is complicated and is only done as a last resort, Siemionow said, when it is the only way to give a patient a normal existence. Patients are thoroughly evaluated: their support network is looked at and they are assessed psychologically, physically and medically. Siemionow will not perform a transplant “(if the patient) does not have any more skin available in case the face transplant were to fail,” she said. That way, if the patient rejects the new face, the surgeons can still try to patchwork skin from different parts of the patient’s body.

Many people do not fully understand the implications of the surgery, Siemionow said. Factors like scars, the need for lifelong immunosuppressant drugs, along with other consequences of the surgery must be taken into consideration. “Someone with severe acne even called me to request the transplant,” she said. But it is not like ordinary plastic surgery.

Not only are facial transplants themselves difficult surgeries that can last almost 24 hours, but getting a donor and weighing the options for the patient are complicated, too. There are also many ethical implications for face transplants and experts question factors such as whether a person’s core identity will be the same, whether it is better not to go through such an invasive surgery and take medications for the rest of your life.

More than 20 years of research led to the transplant team’s work and Siemionow and her colleagues have published studies on different kinds of facial transplants using rats – partial transplants, with teeth and with tongues. They also did a study for the Cleveland Clinic’s internal ethics review board using cadavers to show that a facial transplant really is necessary. “You need about (470 square inches) of skin to cover a severely burned face,” Siemionow said. “(Or 265 square inches) without the scalp.”

Since the face makes up such a large amount of skin, no other part of the body could provide a graft large enough. The closest the researchers got to the surface area was with skin from the back, which provided only 48 percent of the needed skin: Not even half of what would be necessary for a full transplant.

Other speakers at the AAAS symposium described their research in genetic causes of facial malformations during development. These can include cleft palate, abnormal skull shapes and anomalous spacing of the eyes. Some of the findings are providing insight and the hope that some day there may be cures available for congenital face problems.