Three people received full-face transplants at Brigham and Women’s Hospital in Boston this year. Now, physicians are reporting the details of the extensive procedures — which include grafting not only the skin, but also nerves, muscles, blood vessels, and structures like the nose. The report appears in the New England Journal of Medicine. We’ve covered some of the medical developments in those cases: the first patient in the U.S. to undergo the extensive operation , Dallas Wiens, reported regaining his sense of smell just a few days after surgery. He was injured in 2008 when he came into contact with a power line. The second patient also experienced a severe electrical burn. The third patient to undergo a full-face transplant, Charla Nash, was a victim of a chimpanzee attack in 2009. She underwent surgery in May and the hospital released a photo (see above) in August. Bohdan Pomahac , director of the plastic surgery transplantation program at Brigham and Women’s, is the lead author of the report describing the three cases. He says the chief obstacle to the surgery had been the belief that you’d need to connect four arteries and a corresponding number of veins in order to provide enough blood flow to the transplanted tissues. “If that were the case, it would be extremely complicated,” he says. But the team at the hospital used a simplified method, connecting just one artery and one vein on each side of the face. The team also connected all the main available motor and sensory nerves, in an attempt to restore function to the face. “When the patient wants to blink,” he can do so, says Pomahac. He says patients can expect to get back between 75% to 90% of facial function. That may take time, however; Nash, for example, experienced a return of sensation, but not yet motor

function, at the three-month mark, the report says. The chief complication experienced by the patients was infection, due to the immunosuppressive drugs they took to prevent rejection of the transplanted tissues. All of them recovered. And, says Pomahac, over time their drug regimen has been tapered down from four drugs to two, to minimize the chance of side effects. It’s possible that could be reduced even further, to lower doses of two drugs or even to one drug, he says. Vascular clotting is another potential complication right after surgery, though it hasn’t been a problem for the patients, Pomahac says. The hospital has a Defense Department grant to fund these transplants in civilians and veterans. Potential candidates must meet certain requirements , including the loss of at least 25% of the facial tissue or a major, irreplaceable part of the face such as the nose or the lips. Candidates are also screened to be sure they’re sufficiently medically and psychologically fit for the procedure. Patients also receive counseling, particularly in the three months after the surgery. “We want them to cope well with what they’ve been through,” says Pomahac. All three have easily gotten used to their new faces — which resemble neither their own pre-accident faces nor those of the donors. “They look like someone completely new,” Pomahac says, though because their body language and speech is the same, it’s “remarkably easy” to identify them. The patients will be followed over time to keep tabs on the return of their motor and sensory function. In 2008, the Cleveland Clinic performed the first partial face transplant in the U.S., replacing 80% of a woman’s face. Here’s more on face transplants from the medical literature, if you’re intrigued. Photo: Lightchaser Photography/Brigham and Women’s Hospital

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Hospital Reports Details of Three Full-Face Transplants