Surgeon screens potential face transplant recipients

"The concept of transplanting tissues other than solid organs such as the heart, kidney or liver is not new," says Dr. Siemionow, director of plastic surgery research and head of microsurgery training in the Cleveland Clinic Foundation's department of plastic surgery. "We already have patients who are living worldwide for as long as seven years with transplants of hands taken from cadaver donors," she says, as well as patients living with transplanted knees. A Cleveland Clinic patient also received the world's first larynx transplant.

For years, Dr. Siemionow has been working on strategies and experimental designs for reducing immunosuppression requirements and inducing donor-specific tolerance without the need for lifelong immunosuppression in models including limb, skin and face transplants. She says the next logical step will involve bringing what she's learned from her research approach into clinical trials.

With more than 15 years' experience in plastic surgery and training in orthopedic, hand and microsurgery, Dr. Siemionow adds, "My primary clinical interest is also microsurgery of peripheral nerves."

While working as a hand surgeon, she treated many children whose burn injuries also scarred their faces.

"Somewhere in the back of my mind, that probably created the idea that at some point I might be able to help not only in treating their hand function, but also their facial function," she says.

While she declines to divulge complete details of her proprietary surgical protocol (much of which she has already published*), it includes transplanting facial skin and soft tissues - but not muscle - from a cadaver donor to a living burn victim yet to be selected.

"It will be a vascularized graft, meaning that the main arteries and veins will be preserved, as will the nerves," she adds.

All told, she expects the procedure to take around 10 to 15 hours. She says it is very difficult to predict because it depends on how long preparation of the donor will take and on the anatomical circumstances of the recipient.

The transplant team will include at least eight to 10 specialists, including consultants with expertise in areas such as infectious diseases. As with any transplant procedure, she says, "We have to have at least two fully equipped teams of specialists ready from the beginning of the surgery."

As to the functionality of the transplanted face, she explains, "We are presuming that the muscles located under the contracted skin graft will be functional - they can be either stimulated or the patient can be rehabilitated through physical therapy. We hope the patient's return of function will be at least better than what the patient had before surgery. The uniformity of the transplanted skin, compared to the patchy look of skin grafts taken from different parts of the body, will also be a definite advantage for the patient."

Selection criteria

Out of concerns for privacy and dignity, Dr. Siemionow says, she won't reveal how many prospective patients her team has already screened. She says she plans to select a patient "when the time is right."

While selection criteria for a similar project at the University of Louisville stipulate that the ideal patient will have undergone relatively few prior reconstructive surgeries, Dr. Siemionow says her team will focus not on the number of surgeries done, but on what tissue remains.

"We have to be sure that we have some of the patient's own skin left on their body for the rescue procedure," should one be required in the event of a transplant failure, she explains.