Three successful full face transplants: Brigham and Women’s report

By Dr. Ananya Mandal, MDDec 29 2011

A team of Brigham and Women’s surgeons performed three full face transplants at the hospital this year and have published a detailed account of the procedures in the New England Journal of Medicine.
The authors outline the three cases with before and after photos and explanations of how the patients - Dallas Wiens, Mitch Hunter, and Charla Nash - fared in the aftermath of surgery. While all three had infections and two had episodes of rejection, all were successfully treated.

The lead author on the report is Dr. Bohdan Pomahac, who led the face transplant program, now second busiest center of its kind in the world. One of the most striking details is about how the faces have changed. Authors wrote, “We expected major immediate and gradual changes in facial appearance in these patients. We anticipated that the underlying skeleton and facial volume would shape the final facial appearance, making resemblance to the donors unlikely. It is our subjective opinion, as well as that of two of the donor families, that the patients do not look like their donors (the remaining donor family has chosen to remain unknown).”

“I think it's important for people to realize this is becoming a reproducible technique,” said Pomahac. Pomahac recalled feeling uncertain about the procedure when he received the file of his first patient in need of a full face transplant. Dallas Weins, 25, a construction worker from Dallas, Texas suffered severe burns to his face two and a half years ago when the boom lift he was operating drifted into a high voltage power line. After 22 surgeries, Wiens was left with a face void of features, except for a lipless mouth and a goatee. Even his eye sockets were smoothed over with skin taken from other parts of his body. Pohomac looked at the chart of the potential face transplant recipient and thought the risks were high.

“I was worried the defect was too extensive,” said Pomahac. “I was worried that his nerves were damaged to the point that we wouldn't be able to reconnect them.” But Wiens was young, and his face could be repaired back to the way it was should something go wrong. “We don't want patients to end up with worse deformity than before if the face is rejected,” said Pomahac.

“In conclusion, on the basis of our experience with three patients who had severe facial deformities resulting from various injuries, we have shown that it is feasible to perform face transplantation with the use of a consistent, complex protocol. Despite important adverse events and a short follow-up, this study provides further support for the concept that full-face transplantation is able to restore functional defects and to resurface major deficits with the use of conventional immunosuppression and early glucocorticoid withdrawal. We will continue to assess functional reintegration, as measured by standardized restoration of motor and sensory function, over time,” they wrote.

Since 2005, 18 patients have received facial transplants, most of them designed to restore partial face defects. But Weins' case became the first procedure out of three Pomahac performed this year to replace a full face. Pomahac called the novel technique a “unique way to simplify anatomy.” Facial tissues are extracted from the donor as one block, including the skin and underlying muscles and nerves and reconnected to the recipient.

“We can do it now so much better than the first cases,” said Pomahac. “The extent of how it will be used is undetermined, but it's here to stay.”