Face transplants: Moving forward?

Cleveland - Facial transplantation, a controversial procedure, has moved one step closer to clinical practice, following approval of a protocol late last year by the Cleveland Clinic's internal review board. However, no one can say when the first facial transplant will take place.

Leading experts in the field do not question the ability of skilled plastic and reconstructive surgeons to remove and reattach donor tissue. And today's immunosuppression strategies - while they could be improved - are effective enough to offer a good chance for graft survival, provided patients adhere to the prescribed regimen.

Some of the biggest hurdles that remain, proponents say, are ethical and psychological. And of prime importance right now is the selection process: picking patients who not only have suffered truly debilitating disfigurement, but are also psychologically stable and truly understand the risks of the procedure.

However, others say it is time to move facial transplantation into the clinical arena.

"If we had waited longer before going to the moon, yes, it would have been safer ... but from all that we learned going to the moon, we are ready to go to Mars," says John Barker, M.D., Ph.D., a University of Louisville researcher who helped lay the groundwork for human hand transplantation. He now leads a team studying the immunologic, psychosocial and ethical hurdles to human facial transplantation.

"For us, the moon was the hand transplant, and now we are ready to go to Mars, and we sure are glad we went to the moon. We answered a lot of questions because we took that risk," he says.

Dr. Barker tells Dermatology Times that he feels more confident in the prospects of face transplantation than he did when his team was ready to do its first hand transplants.

"Before the first hand transplant, there was rat, rabbit and pig research saying it should work. Now, there have been 24 hands transplanted in 18 human beings, some out five years post-transplant," he says. "We could wait, and it will get safer, but we don't feel doing more animal research will add anything to this field at this point."

First steps Since not everyone is convinced that facial transplantation is in the best interest of the patient, experts have spent a lot of time educating the public - and colleagues - on a variety of issues, from the nature of human identity to the realistic limits of what reconstructive surgery can and can't achieve.

Efforts are certainly under way to at least put the issue on the table. The Cleveland Clinic's internal review board (IRB) decision, made after 10 months of deliberation, was highlighted in an announcement on the front page of that institution's Web site.

"I think this is the most ethical way we can do it," says Maria Siemionow, M.D., Ph.D., D.Sc., a hand and micro-surgeon who has spent nearly 20 years researching transplantation and immunosuppression strategies. "Patients who are really interested can call us ... They may not be candidates for transplant, but at least we will be able to educate them better - and educate our society on who the patients are, how they feel, why they would decide to go through the procedure."

The Cleveland Clinic is one of at least five centers worldwide committed to researching the science behind the procedure or the ethics surrounding its application. It is believed to be the only center, so far, to have an approval in place that would facilitate bringing the procedure closer to clinical application.

Dr. Barker and his colleagues at the university of Louisville and the University of Utrecht in the Netherlands are submitting their protocol for IRB approval, first in the Netherlands, where their first procedure will be done, and then in Louisville.