What to Expect From a Face Transplant

Face transplants represent a dramatic surgery needed to help someone with an often traumatic, disfiguring injury or disease. Face allograft transplantation (FAT) is a surgical procedure used to restore the function and appearance of the face. When facial tissues like skin, muscles, nerves, bone, or cartilage are irreversibly damaged, the corresponding structures from a compatible donor can be used to replace them.

Generally, the donor is brain-dead but still has heart function. The face transplant recipient arrives at the hospital where the donor is being kept and prepares for the surgery. Any planned organ harvesting (including the face donation) is performed at the same time, and the face is preserved in a cold solution.

Self, partial, and complete face transplant surgery are all possible depending on the amount of damage to facial tissue. 

Transplantation techniques and technologies continue to advance making face transplant an attractive reconstructive treatment for severe facial injury or malformity. However, because most face transplants have been performed in the last 10 years, there is no decisive information about long-term outcomes.

Recovering sensation, movement, and function can require several years of therapy, but benefits are seen within the first year in most. Common benefits include improved function affecting:

• Eating or chewing
• Swallowing
• Breathing
• Senses (including smell and taste)
• Speech
• Expression 

Given these potential improvements that affect health and well-being with clear impacts on quality of life, the surgery may be pursued.

Reasons for a Face Transplant

Unlike other organ transplants, a face transplant may not be for life-saving purposes, but it may dramatically enhance an individual’s quality of life through influences on social interactions and sense of self.

After the wounds of a serious facial injury have been immediately treated, a decision can be made about further surgery. Surgeons may attempt to perform facial reconstruction with tissue from elsewhere in the body. This may be adequate for treating shallow injuries, but may not achieve the aesthetic and functional restoration desired.

At this point, either conventional plastic surgery or face allograft transplantation may be considered. This determination is often made in consultation with a team of plastic and transplant surgeons.

The physical interactions between parts of the face are complex even for common functions, such as chewing and breathing. After disfigurement of the face, the physical structures and nerve-muscle connections needed to coordinate movements are damaged and cannot work together properly. A face transplant can attempt to restore normal function, with impacts including being able to taste food or smile.

Face transplant goes beyond cosmetic plastic surgery and uses tissues from the donor’s face to reconstruct the recipient’s face. It may be used to treat disfigurement caused by:

• Severe burns
• Firearm injuries
• Mauling by animals
• Physical trauma
• Side effects of cancer treatment
• Congenital tumors
• Other birth defects

These abnormalities lead to a loss of function. Intact facial tissue from a donor is used to replace or restore the recipient’s face cosmetically, structurally, and most importantly, functionally.

Who Is Not a Good Candidate?

Though there are guidelines used to rate face transplant candidates, there are no universal recipient criteria presently. If someone is being considered for a face transplant, they may be evaluated using the FACES score to assess how useful, maintainable, and safe the procedure would be.

FACES identifies psychosocial wellness, comorbid risks, and how well the recipient could maintain their medication regimen. Pre-existing conditions or certain psychological disorders may worsen the prognosis and comparative benefits of undergoing a face transplant.

The following traits may disqualify someone from being considered for a face transplant:

• Age over 60 years
• Tobacco, alcohol, or illicit drug abuse
• History of HIV, hepatitis C, or other recent infections
• Inability to take immunosuppressive drugs
• History of cancer in the last five years
• Chronic medical conditions affecting the nerves, diabetes, or heart disease
• Unwillingness to postpone pregnancy for one year post-surgery

In addition, if muscles and nerves are too severely damaged, transplantation cannot succeed. There needs to be the potential to heal and regrow connections between the donor and recipient tissues.

Types of Face Transplants

There are two main subtypes of face transplant—partial and full—which are performed depending on the amount and depth of damage to the structure of the face.

Donor Recipient Selection Process

A face donation is a vascularized composite allograft (VCA) organ transplant, meaning multiple kinds of tissue are transplanted at once. Legal classifications and policies related to VCA have recently changed for the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN). 

There are physiological and immunological limitations:

• Blood type
• Tissue type available for transplant
• Presence of cytomegalovirus (CMV)
• Presence of Epstein-Barr virus (EBV)

In addition, there are anatomical limitations:

• Skin color
• Face size
• Age
• Sex

These characteristics are factored into donor-recipient matching. Some viruses, such as the ones listed above, stay in the cells of the body for life. If a recipient has never been infected, they may not be able to receive a transplant from someone who has been infected. due to the heightened risks associated with immunosuppression.

There may be limited availability of compatible VCA donors, which can delay finding a donor match for months to years after a facial injury. It is possible that policy changes surrounding organ donation may affect this wait time.

Types of Donors 

Donors for a face transplant are organ donors who have been designated as brain-dead. Typically, these face transplant donors are concurrently donating other organs such as the heart, lungs, kidneys, or parts of the eye. This is an ethical consideration to avoid wasting the potential life-saving value of a donor by only performing a non-essential transplant like a face transplant.

Before Surgery

Surgeons may want pre-surgical imaging performed to identify structural damage as well as the best blood vessels to use when connecting the donor face. These imaging procedures may include:

• X-rays
• Computed tomography (CT) scans
• Magnetic resonance imaging (MRI) scans
• Angiograms

Such studies also help surgeons recognize whether a donor will be a good fit for structural replacements.

In addition, further blood tests and assessments of physical health, such as an EKG or echocardiogram to evaluate heart function, may be required.

Beyond these measures, it is important to assess mental health to understand expectations, coping skills, and communication abilities. A social worker may evaluate the network of family and social support that will be required to enhance recovery. In some cases, a financial assessment is also included to ensure post-surgical stability.

Surgical Process

The surgical process for face transplant varies from patient to patient as every face and facial injury is different. Nevertheless, there are some techniques that would be commonly employed. The procedure may take from 10 to 30 hours to complete and involves a team of surgeons, anesthesiologists, nurses, technicians, and operating room staff.

Initially, the graft tissue composing the face of the donor—including the skin, fat, cartilage, blood vessels, muscles, tendons, and nerves—must be removed. In some cases, depending on the nature of the injury repair, underlying hard or connective tissue such as the nasal bone, maxilla, or mandible may be included. Once removed, the tissues must be briefly preserved to prevent the effects of ischemia (reduced blood flow).

The recipient may undergo a preparatory surgery, such as removal of a tumor or scar tissue.

The tissues of the donor and recipient then must be connected via a grafting procedure. This may involve suturing together like tissues. Bones and cartilage may be connected and stabilized with screws and metal anchor plates.

Multiple large and smaller blood vessels of the donor and recipient are connected through microvascular surgery to allow blood flow to the donor tissues. The facial and trigeminal nerves are connected using microsutures or grafting.

A skin graft from the donor’s arm is attached to the recipient’s chest or abdomen. This allows for periodic, non-invasive biopsies of the tissue. Doctors can check for indications that the donor tissue is being rejected without removing tissue samples from the face.

After the surgery, the recipient would be observed in an intensive care unit (ICU) during the initial recovery period. Once breathing and facial swelling are normalized, transition to a standard hospital room and rehabilitation center may occur. This would likely unfold over multiple weeks.

Complications 

Trauma and extensive surgery involving the face may affect eating and breathing and involve a lengthy hospitalization, with potentially life-threatening consequences. Conventional solutions (i.e., feeding tubes and tracheostomy) also have long-term risks. Some potential complications of a face transplant include:

• Infection
• Tissue rejection
• Bleeding
• Incomplete revascularization causing tissue death (necrosis)
• Numbness
• Facial paralysis
• Difficulty speaking
• Difficulty chewing or swallowing
• Pneumonia
• Psychological sequelae
• Mortality (death)

There are also lifelong risks, including those associated with immunosuppression. Rejection may occur if a recipient stops using immunosuppressants, so these must be continued or risk losing the face transplant.

After Surgery

Post-surgery assessment and recovery in the hospital usually last for a week or two. Initially, it may be necessary to have breathing supported with a ventilator and feeding done through a tube. Pain medication will be given. After several days of recovery, once sedation is lightened, a physical therapist begins work to restore facial mobility. Later, a psychologist helps to navigate lifestyle adjustments that come with this type of transplantation.

Subsequent physical therapy may involve four to six months of rehabilitation, though the duration and timing of milestones in recovery vary. Rehabilitation therapy involves retraining the nerves and muscles of the face through intentional, repeated actions. 

The immediate goals include promoting both sensory and motor functions of the face. Not everyone regains the ability to feel a light touch. It is possible for the sense of smell and taste to improve. Over the early months of therapy, additional mechanical skills are developed. These enhance the ability to eat, chew, drink, swallow, talk, blink, smile, and make other facial expressions.

Finally, communication skills including facial expressions and speech are refined. Recovery of motor skills varies greatly between individuals and may be incomplete in many.

The immunosuppressant regimen begins soon after surgery. Possible immunosuppressant medications include:

• Basiliximab
• Daclizumab
• Mycophenolatemofetil
• Tacrolimus
• Prednisolone 

Stem cell treatments may also be used to reduce the immune response to donated tissues.

Early indications of an adverse immune response to the donor tissue include painless, spotty, patchy rashes on the face. Immunosuppressant drugs should be taken as prescribed and must be continued for life. Currently, the only case of rejection has occurred due to going off the immunosuppressive regimen. 

Depending on the severity of immunosuppression, it may be necessary to wear a mask in public, to avoid social situations that may involve contact with contagious people, and to be cautious of environmental exposure to certain pathogens.

Prognosis

Of the roughly 40 face transplants that have been performed, 86% have survived. Surgical complications, infection, and failure to keep taking immunosuppressants represent additional risks on top of relevant morbidities from the baseline injury. Many of these potential risks can be mitigated by adhering to treatment recommendations, including proper medication use.

Support and Coping

Physical therapy is integral to making the most of a face transplant. It is a long, intensive process that requires dedication and may benefit from a strong emotional support system.

Many individuals who have received a face transplant ultimately find they have better body image, mental health, and ability to socialize.

A Word From Verywell

For those who are presented with the need to undergo a face transplant, a significant traumatic injury or disfiguring disease process has already occurred. It is a procedure that may offer hope to restore a life that may have been lost. Careful consideration prior to the surgery and a commitment to a long recovery course and lifelong immunotherapy is important. The benefits to those in need, extending from a recovered sense of self to normalized social interactions, cannot be overstated.