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For transplants, 'God in details'

Swerving ethical pitfalls, Czech doctor to conduct controversial face surgery

By Paul Voosen
Staff Writer, The Prague Post
February 20th, 2008 issue

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COURTESY PHOTO

Pomahac will be one of the first to perform a face transplant.

Stages of a transplant

Locating potential patients will not be easy for Pomahac, since he requires them to already be on immunosuppressant drugs
Face donors will only come from families who say "take anything" from their deceased; "regular" donors will not be touched
Once a match is made between donor and patient, the face must be harvested and transplanted within four hours
Recovering patients should be able to leave the hospital after a week, but will require regular physical and psychological therapy

Isabelle Dinoire is thrilled with her new face.

It has been more than two years since Dinoire became the recipient of the world’s first partial face transplant in France, after her original mouth and nose were gnawed off by a pet dog concerned by her overdose on sleeping pills. She can now feel the graze of a filament across her cheek and her drooling is under control.

Dinoire’s replaced face is well on its way to being a success story, but it did not come without sacrifice or controversy. Twice her body came close to rejecting the foreign skin, which could have led to the face sloughing off. To prevent such rejection, she must take debilitating drugs for the rest of her life.

Since Dinoire’s surgery, only two similar transplants have taken place, one in China and the other also in France. Many surgeons are deterred by the logistical and ethical layers enfolding the operation, leaving the field open to a select group of trailblazing doctors who are looking to push the limits of medicine.

One of those surgeons is Bohdan Pomahac, a Czech national working at Brigham & Women’s Hospital in Boston, Massachusetts. Pomahac, who directs the hospital’s burn unit, is setting up a surgical unit to conduct face transplants, and he could soon become the first to lead the surgery in the United States.

“The bottom line is that the risk [of face transplants] isn’t as significant as surgeons thought,” Pomahac says.

More than any kind of surgery, facial reconstruction fascinates Pomahac, a point that became clear in a series of phone interviews.

“God is in the details” in face work, he says. “You can really change someone’s life.”

Saving face

The face is the crux of human interaction, its variations and symmetries tied into our notions of self, other and beauty. Should our face be sheered from the latticework of muscle and sinew on which it balances, souls could be set adrift. But, thanks to modern medicine, you could live. Losing face does not mean losing life.

Face transplants, unlike life-saving kidney or heart transplants, are termed “non-life-threatening” by doctors — they’re essentially optional. That is the challenge confronting Pomahac.

While the two types of surgeries differ in perceived need, they’re identical in treatment: Both require patients to take cocktails of immunosuppressant drugs for the rest of their lives. Immunosuppressants, as you may expect, reduce the effectiveness of the immune system.

The drugs are a necessary evil. Without them, white blood cells would attack transplanted organs in the body’s misguided attempt to defend itself. Sacrificing these defenses, though, means that recipients of organ transplants face increased risks of infection and cancer, potentially shortening their lives by decades, Pomahac says.

The controversy surrounding the first three recipients of face transplants is that, except for their disfigurements, they had healthy immune systems. Now Dinoire, “although she looks great, [will] probably be in the hospital once or twice a year,” Pomahac says. People don’t quite get “how significant the side effects are,” he adds.

With these side effects in mind, many have questioned the ethics of conducting face transplants. Does exposing healthy patients to immunosuppressants violate the bedrock medical principle of primum non nocere — first, do no harm?

“What is the whole world going to say when you start changing people’s faces?” says John Barker, a surgeon at the University of Louisville who has conducted similarly optional hand transplants. “What risks would people accept to get one of these non-life-saving procedures?”

To help answer these questions, Barker led a team that conducted a survey of 400 people wrestling with these questions from various approaches: transplant surgeons, plastic surgeons, the facially disfigured, hand amputees.

“[We asked] basic questions like, how much risk would you accept to get a face transplant?” Barker says. The responses were revelatory. “All of them would risk the most to get a face transplant. They would risk more to get a face than a kidney.”

People want to look human. And skin grafts and other forms of plastic surgery used for facial reconstruction just can’t produce the same results as transplants, Pomahac says.

In the run-up to Dinoire’s surgery, the medical community split on the face transplant question. England’s Royal College of Surgeons published a report saying it was “unwise” to proceed with such transplants pending more research. The French went ahead anyway. Last December, they published an update on Dinoire in the New England Journal of Medicine, which Pomahac found heartening.

“I don’t think there is any way you could achieve this result with conventional means,” he says. “Isabelle has the ability to carry on a normal life and you can’t say that would be the case for patients with conventionally reconstructed faces.”

As he prepares his team to conduct a surgery, Pomahac has worked to address every possible contingency. But there are questions lingering about the operation, he admits:

“Some answers you just won’t get unless you do it.”

An elegant solution

The transplant system designed by Pomahac will allow more of these surgeries to take place, while artfully sidestepping many ethical qualms. Most notably, Pomahac will only target patients who are already on immunosuppressants — an elegant solution, Barker says.

“It’s a unique situation to have someone who already has immunosuppressants,” he says. “There isn’t the argument of risk versus benefit.”

Boston alone has about 500 kidney transplant patients a year. Pomahac knows that over the past three years several of these patients developed face cancer as a side effect of their immunosuppressant drugs, suffering serious disfigurement. These twice-bitten cancer victims constitute Pomahac’s ideal patient.

Unfortunately, Pomahac’s criteria make this Platonic patient difficult to find. Since receiving the go-ahead from Brigham & Women’s to conduct the surgery late last summer, Pomahac has not found a single patient, he says, partially because such surgeries were not yet ready to move forward.

According to Barker, Pomahac will have difficulty locating patients.

“The key thing there is, where do you find these patients? It’s going to be a needle in a haystack,” he says. “[But] if they’ve got them, that’s a great opportunity. … The more of these cases are done, the better it is for everyone.”

Once he has a list of patients, Pomahac has the rest of his plans prepared. When the call comes from an organ bank with a donor, several teams will go into action. One will “harvest” the face from the donor, who, creepily enough, must still have a heartbeat. Soft tissues are sensitive to loss of blood flow and will die in four hours without blood, Pomahac says.

After being cut from the donor, the face would then be whisked to the waiting patient, where Pomahac would connect, one after another, the face’s arteries, veins and muscles to the patient. (The surgery, for all its aura, is not groundbreaking. The technical skills for it have existed for 20 years, Barker says.) At the same time, a second team will graft a piece of the donor’s skin to the patient’s chest, which will be used for future biopsies. The patient could likely go home after a week, Pomahac says.

When describing the process, Pomahac sounds like the stereotype of detached, surgical precision. He wanted to be a surgeon since entering medical school in Moravia, and he knew that finding emotional disconnection comes with the work. It’s necessary. If he saw one of his patients on the street, Pomahac says, he might also say, “My god, that’s horrifying. … Sometimes it is heartbreaking.”

Pomahac’s surgeries, like most bleeding-edge operations, won’t come without risk. The looming question, says Arthur Caplan, a bioethicist at the University of Pennsylvania, is “what will you do if the experiment fails?” If the face is literally rejected, “would you let someone die under those circumstances?”

Donor watch

Perhaps the largest challenge facing Pomahac, more so than finding patients, is finding donors. To most people, organs like the kidney and heart are abstractions, the stuff of high-school anatomy courses and jars of formaldehyde. The face is different. The face is personal.

Typically, each year there are “at least one or two families who say take anything [from the organ donor] that may possibly help,” Pomahac says. He is currently ironing out the regulations overseeing such donations with the New England Organ Bank that he expects the bank board to approve this month.

Pomahac stresses that the families of recently deceased organ donors — the United States has an opt-in system, typically identified on driver’s licenses — will not find the face of their loved one surreptitiously harvested for a transplant. Rather, potential donors would have to specifically sign up for the program.

The restricted nature of donors is a vital point and must be widely disseminated, says Caplan.

“You can kill people if you’re not careful how you do this,” he says.

Fearful of the unknown or reluctant to sacrifice that last visual connection, “you might get people tearing up their organ donor cards,” which would prevent life-saving organs like the kidney from being used.

Perceptions about face transplants could change over time. Pomahac works with the legendary surgeon Joe Murray, who won the Nobel Prize for conducting the first kidney transplant. Murray told Pomahac that he sees many parallels between the two projects. There was public wariness about kidney transplants, but now the procedure is commonplace. If you can give the heart and the liver, why not the face?

It changes when talking about full face transplants, which doctors in London and Cincinnati are pursuing. Surgeons know that, with partial transplants, there is little chance the patient will resemble the donor. But, with a full transplant, if the two had similar bone structures, the donor could appear as a walking, talking death mask.

Even for full transplants where this is not the case, the psychological impact would be enormous.

“Seeing a loved one coming back home with a different face would provoke reactions not only from the patient but also the social circle and family,” Pomahac says.

Any transplant program would require rigorous psychological screening and social support for donor families and patients, Caplan says. Brigham & Women’s will provide such supports, Pomahac says, and, since the program will work with existing patients, the hospital will already know much about their composure.

Both Pomahac and Barker look ahead to a time when the side effects of immunosuppressants are minimal. The drugs have already improved over the decades, and Barker thinks their impact on healthy patients has been exaggerated by dominant medical studies.

Pomahac is more skeptical of this view but remains adamant that transplants represent the future of facial reconstruction. It is the way forward, he says, because the alternatives, like tissue engineering — growing a nose or ear in a dish — are far from reality.

It may bring a yuck factor, but faces can be transplanted now. The surgery will allow disfigured patients to look in the mirror once again, the muscles of their restored mouth pulling their lips upward in the ghost of a smile.

Paul Voosen can be reached at pvoosen@praguepost.com

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