Since 2005, only 50 face transplants have been performed worldwide—10 of them by Bohdan Pomahac, MD, Frank F. Kanthak Professor of Surgery (Plastics) and chief of plastic and reconstructive surgery at Yale School of Medicine. With very few procedures being done every year and fewer than 20 surgeons around the world with the expertise to perform these transplants, the field to date has been somewhat fragmented, Pomahac said.
That’s now starting to change—for the first time, Pomahac and his counterparts have come together to share data and compare notes. In a recently published article in the journal JAMA Surgery, they describe how the world’s first 50 face transplants (performed on 48 patients) have fared. These 50 transplants occurred in 11 countries in North America, Europe, and Asia.
“There’s great promise in people coming together to synthesize our knowledge,” Pomahac said. “We’re getting to the point where it’s critical to build consensus in the field.”
The authors describe outcomes among recipients of this very complex form of transplant surgery. Face transplants are typically performed after major trauma to the face (often from burns or gunshot wounds) that affects the central features — nose, lips, and eyelids. Despite the difficulty of the procedure and the significant injuries that necessitate it, the patients, overall, have fared well.
After five years, 85% of transplant recipients were alive and had retained their transplant. The other 15% had either died or experienced permanent rejection of the transplant; two patients needed to have a second transplant. By 10 years after surgery, the success rate of the 48 patients in the study was 74%. Even though transplants involving skin are notoriously difficult — the skin is rich in immune cells and more prone to rejecting foreign tissue than are internal transplants — these rates are similar to — or better than — those seen in solid organ transplants, Pomahac said. Patients transplanted more recently had better outcomes than those who received the earlier transplants.
Lifelong immune suppression
Face transplant recipients must be closely monitored due to the skin’s tendency toward rejection. Like all transplant recipients, these patients need to take medication that mildly suppresses their immune system for the rest of their lives. Face transplant patients experience a heightened threat of rejection during the first year after surgery; if this happens, patients must temporarily take stronger immune-suppressing medication to avoid permanent rejection of the transplant.
There’s great promise in people coming together to synthesize our knowledge. We’re getting to the point where it’s critical to build consensus in the field.
Bohdan Pomahac, MD
In part because of the continuing immune suppression, figuring out when to perform a face transplant is never easy, Pomahac said. Most recipients are relatively young and healthy, aside from the trauma that necessitated the transplant.
“There’s no question that we improve the quality of life of the patients immensely,” he said. “On the other hand, we convert young and relatively healthy patients into someone who’s slightly chronically ill. Their immune response is not completely normal; they are a bit more susceptible to infections.”
Returning movement and sensation to the face
In ongoing work, through a study funded by the U.S. Department of Defense, Pomahac and colleagues are looking further into face transplant patient outcomes with the goal of developing standard guidelines for the field to follow. They’re studying not only transplant rejection, but more fine-level outcomes, including how well patients regain movement and sensation in their transplanted faces. Surgeons carefully reconnect as many of the delicate branches of the facial nerve to the new face as they can, but this can be challenging because sometimes this tissue is significantly damaged from the original injury.
All the 10 patients whose face transplants were performed by Pomahac (all his face transplant surgeries were performed at Brigham and Women’s Hospital in Boston, before he joined YSM in 2021), see a return of motor function at around 50 to 60% of normal levels, he said. By and large, these patients can now express emotions through their face, for example by smiling, although they may only manage a half smile, and their speech has improved from deficits to the mouth and jaw that resulted from the original trauma. Return of feeling to the new face seems more variable. Some of his patients have full sensation in their new faces while some have almost none, Pomahac said.
While the field of face transplantation surgery continues to improve, especially as the providers work more closely together, Pomahac hopes that the greatest advances may come from improvements to immune-suppressing medication, an active area of research. If medications could be developed that allow patients to successfully retain their transplants without causing chronic immune suppression, “there’s huge potential that the techniques we have developed could be broadly applicable to vast numbers of patients, especially for transplantation of facial subunits,” Pomahac said.