What You Should Know About Face Transplants

Disfiguring facial injuries from burns, animal attacks and other trauma may not be life-threatening but they can forever change someone's life. For some people, adjusting to a badly scarred and disfigured appearance could bring on deep depression and social seclusion. In the most severe cases, traditional reconstructive surgery isn't enough. For a select few patients, receiving a face transplant from a deceased donor is a rare but potential option. Below are some fundamentals from the complex world of face transplantation.

By the numbers. Since July 2014, four face transplants and one scalp transplant have been performed in the U.S., according to the United Network for Organ Sharing, or UNOS, the nation's transplant system. Eight U.S. face transplants were done before UNOS became involved in their oversight. Worldwide, an estimated 30 people have had the procedure. As of March 10, 2017, three candidates were on the UNOS waiting list for face transplants. The first full face transplant reported in the U.S. was performed by the Brigham and Women's Hospital surgical team in Boston in March 2011.

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Public faces of transplant. For some transplant recipients, adjusting to a new face is a private process. Others, however, have shared their transformations with the world. Transplant centers at the University of Maryland Medical Center, Brigham and Women's Hospital, NYU Langone Medical Center and Mayo Clinic detail the before-and-after experiences of these pioneering patients on their websites (click on links to learn more).

Extraordinary transplants. Face transplants fall into a special category called "vascular composite allografts." Unlike a kidney transplant, for instance, VCA transplants involve multiple body structures such as skin, bone, blood vessels, nerves, muscles and cartilage. Other VCA types include hand, abdominal wall and genitourinary transplants -- like the penis transplant done at Massachusetts General Hospital in May 2016.

Remove and replace. Face transplants involve reconstruction that goes beyond the limits of conventional plastic surgery, when damage to a person's original nose, lips and surrounding skin is profound and irreparable. The scalp, skull, jaw and chin may also need to be replaced to restore appearance and function, all with great skill. "At some point, it's not sculpting a face; it's not injecting fat or doing a facelift," says Dr. Rolf Barth, head of the transplantation division and an associate professor of surgery at the University of Maryland School of Medicine. "It's really attaching a [similar] segment of tissue, and removing and replacing a diseased segment with a normal segment." Work of this scope requires a highly skilled team of transplant and reconstructive surgeons, organ recovery specialists and many others.

Finding a match. "When somebody needs a transplant, they're evaluated by the transplant center," says Anne Paschke, a media relations specialist with UNOS. If the center's team determines that someone is a good transplant candidate, it puts his or her information into the UNOS computer database. On the other end, one of the 58 U.S. organ procurement organizations, also known as organ banks, determines that a deceased person is a suitable donor whose organs can be used for transplant. "They also access our database and put in information about that person," Paschke explains. "And then they use our system to run a match for each of the organs." From those results, the organ bank offers the appropriate organs to the transplant centers involved with people at the top of the list.

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Appearance matters. Face transplantation requires an added dimension when matching recipients to donors. Beyond the donor's medical history, blood-type compatibility and cross-matching to determine the likelihood of graft rejection, appearance also matters in face or hand transplants. Skin tone is a consideration with faces, unlike hidden organs such as kidneys or livers, says Chris Curran, director of organ operations and surgical recovery with New England Donor Services. Gender is another consideration, he says, although gender matches aren't always made. "And for a face transplant, what's the acceptable donor age for that recipient?" he adds. "If they're 25 years old, would they take a face up to 55 years old? That's candidate-specific."

Special consent. If you agree to become an organ donor through your state's donor registry or department of motor vehicles, that consent doesn't apply to face, hand or other VCA transplants. "If I were to go to an online donor registry and say I wanted to be an organ donor, and then I also wrote that I wanted to donate my face or hands, it's acceptable for first-person consent," Curran says. "But most people don't do that in the general public. So we're going to their families and asking for permission." Many donor families in the midst of tragedy don't realize face transplant is even possible, he says. "People are extremely generous," he adds. "Even in circumstances where they say no, they genuinely consider it because they know it can help another patient." For individual donors, the likelihood of being part of the face transplant story is low. However, Paschke points out, with more than 118,000 people waiting for some form of lifesaving transplant, donors are always needed.

Emotional side. It's unlikely that the person who receives the face will closely resemble the person who died. "There have been studies that demonstrate that if you're only transplanting the soft tissue, and not skeletal components, that the tissue doesn't really look like the donor," Barth says. "They adapt to the skeletal characteristics of the donor." Contrary to what others might expect, he says, issues of "Am I me or am I them?" aren't usually present for recipients. Rather, psychological issues may arise from post-traumatic stress stemming from their traumatic injury. "Mostly," he says, "they're extremely grateful and appreciative of their second chance."

Fending off rejection. The risk that the transplant recipient's body will reject the donor's facial graft is higher early on, Barth says. Research his center has been conducting for years on immune-system suppression to protect skin-based transplants can be applied to facial transplants as these procedures continue to be refined. "While the short-term rejection risks of transplant are increased in hand and face [procedures],' he says, "it looks like the long-term results are really quite good."

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Future and now. Lack of funding threatens to stall the promise of facial, hand and other VCA transplants, says Dr. L. Scott Levin, the chair of orthopedic surgery and a professor of plastic surgery in the Perelman School of Medicine at the University of Pennsylvania. Unlike kidney or lung transplants, insurance does not cover the costs of the newer procedures, including face transplants, which, he says, are comparable to the costs of traditional organ transplants. What's needed are more health facilities that are prepared to treat these patients, as well as greater medical education and awareness, says Levin, who is also past president of the American Society for Reconstructive Transplantation. "This is the future of reconstructive and restorative surgery," he says. "There's no turning back."

Lisa Esposito is a Patient Advice reporter at U.S. News. She covers health conditions, drawing on experience as an RN in oncology and other areas and as a research coordinator at the National Institutes of Health. Esposito previously reported on health care with Gannett, and she received her journalism master's degree at Georgetown University. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.