French Patient Calls Partial Face Transplant Very Satisfactory

Michael Smith
LYON, France, Dec. 12 -- Eighteen months after a partial face transplant, the patient is doing well and is "very satisfied" with the results of the surgery, researchers here said.Isabelle Dinoire now has "an almost normal appearance" and nearly complete function, according to Jean-Michel Dubernard, M.D., Ph.D., of the University of Lyon, and colleagues.
Action Points --->
Explain to interested patients that French surgeons performed a partial face transplant in 2005 on a woman who had been disfigured by a dog.
Note that this study says that results 18 months after the surgery were good and the patient is satisfied, but add that side effects were occasionally severe.
"The patient says she is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results," Dr. Dubernard and colleagues reported in the Dec. 13 issue of the New England Journal of Medicine.
A video posted with the report shows her speaking clearly in French, contracting the muscles of the transplant, and smiling.
The transplant was regarded a technical tour-de-force when it was performed in 2005, although questions were raised about the ethics of the surgery.But "the encouraging 18-month outcomes of face transplantation in our patient suggest that this procedure can offer hope for some patients with severe disfigurement," Dr. Dubernard and colleagues concluded.
The patients had two episodes of rejection, at 18 and 214 days after the surgery, characterized by the gradual development of erythema and edema.
The first was controlled with increases in the doses of oral prednisone, tacrolimus, and mycophenolate mofetil, as well as clobetasol ointment and prednisone mouthwashes, coupled with three 1,000-mg intravenous boluses of methylprednisolone.
The second was met with three 750-mg boluses of intravenous methylprednisolone, combined with prednisone mouthwashes and local applications of clobetasol and tacrolimus ointments. The oral corticosteroid dose was increased to 50 mg daily and tapered to 5 mg a day over eight weeks.
Dinoire had a progressive decrease in renal function, which her physicians attributed to the tacrolimus. When the drug was replaced with sirolimus, her renal function gradually improved, they said.
The surgery provided "a reasonable functional outcome," commented transplant specialist Maria Siemionow, M.D., Ph.D., D.Sc., of the Cleveland Clinic, but with "quite severe side effects," including two episodes of rejection and a decrease in renal function.
Because of the potential side effects, Dr. Siemionow said, she still considers such surgery should be a "last chance" that is considered only when all other options are exhausted.
Two other partial face transplants have been performed -- one in March 2006 in China and the other in January 2007 in France -- but no reports have been published on those cases, the researchers said.
"It should be almost a life-saving procedure" that allows a patient to resume a place in society, Dr. Siemionow said.
"You cannot walk on the street without a face," Dr. Siemionow said, and for that reason there are "patients who have severe deformity or after severe trauma who will be candidates."
But the selection of such patients has to be done "very carefully," she said.
Dinoire became a candidate for the surgery after her dog chewed her face, amputating the distal portion of her nose, both lips, chin, and adjacent parts of the cheeks.
Her doctors concluded at the time that conventional plastic surgery techniques would not work.
The donor was a brain-dead 46-year-old woman who had the same blood group as Dinoire. The two women also shared five HLA antigens.
Dinoire was able to eat and drink almost normally a week after surgery, the researchers reported, and sensation on the transplanted part of her face was normal by six months.
Functional recovery was slower, however. Dinoire started to regain control of the upper lip by 12 weeks after surgery and the lower lip by the end of the fourth month. She was able to close the lips by six months.
After a year, she could contract the chin muscles and the nose pyramidal muscles. Her smile was asymmetric for the first 10 months, but was "nearly normal at 14 months and normal at 18 months," the researchers said.
The study was supported by the university hospitals of Amiens and Lyon. The researchers reported no potential conflicts.
Primary source: New England Journal of MedicineSource reference:Dubernard J-M, et al "Outcomes 18 Months after the first human partial face transplantation" N Engl J Med 2007; 357: 2451-60.