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Cambridge Quarterly of Healthcare Ethics (2019), 28, 463–467.
© Cambridge University Press 2019.
doi:10.1017/S0963180119000380 463
Commentary
A Second Chance at Life
ALEXANDRE G. LELLOUCH and LAURENT A. LANTIERI
History
Vascularized Composite Allotransplantation (VCA) including Facial Transplantation
(FT) emerged as a unique solution for anatomically restoring faces after disfigure-
ment. It became a clinical reality after the first successful face transplantation in
2005.1 VCA is a rapidly growing new field in plastic surgery; and from November
2005 to the time of this writing in September 2018, 44 transplants have been per-
formed worldwide. It is clear that many more transplantations will be performed
in the future. The main concern in VCA remains the risk of chronic rejection2 and
graft loss3 despite life-long immunosuppression. Scientists are actively working on
new strategies to reduce the burden of immunosuppression and prevent immune
rejection. The most promising approach is the development of tolerance protocols
through the induction of mixed chimerism4. Indeed, it is the sole strategy to have
demonstrated long-term tolerance in solid organ transplantation in humans.5
Currently, the gold standard in reconstructive surgery remains the use of autologous
tissue. This strategy is still very useful to replace limited missing body parts (like
mandible) by tissue transfer (for example, osteomyocutaneous flap). However, the
functional sensory organs (mouth, eyes) cannot be restored adequately by these
conventional surgical techniques.
The goal of face transplantation is not only to restore the patient’s appear-
ance but also, to create a new physiognomy that will allow the facially disfig-
ured person to adapt and reintegrate into life. Before the advent of VCA, the
complexity of the face made surgeons unable to reestablish an “acceptable out-
come,” leaving disfigured patients little chance of social rehabilitation. Nowadays
VCA surgery, while offering new hope, represents an important challenge
(even for the top facility) for the surgical6 and medical7 team. First, there must
be a high level of cooperation between the various specialists including surgeons,
anesthesiologists and nephrologists. Secondly, the management of immune
rejection remains a primary on-going concern due to the untreatable chronic
rejection effect.8
Background
Over the last 20 years, our surgical team has been led by Laurent Lantieri.
Numerous articles have been written on the ethical issues9,10,11 pertaining to FT.
In our hospital, European George Pompidou in Paris, the anatomical study on face
transplantation was performed in 200512. In 2007, we performed our first partial
face transplant case13 (the third in the world); the first successful partial face trans-
plant was performed in 2005 in Amiens, France.14 We determined that in the light
of immunosuppressive regimen improvement, it appeared reasonable to consider
VCA as a clinical option, especially for hand and face transplantation.15
The scientific community continues to debate the ethical dilemmas regarding
FT16. Our team already transplanted a patient after shotgun injury.17 Following the
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Alexandre G. Lellouch and Laurent A. Lantieri
464
success of our first face transplant, we decided to go further with the elabora-
tion of the first full face transplant.18 Our first report evaluating the short-term
quality of life was encouraging.19 Regarding types of disfigurements, the most
frequent situations involve the severely disfiguring facial tumors of neurofi-
bromatosis, shotgun injury, dog bites, and burns; but in our experience, burn
patients are not considered the best candidates for receiving VCA due to the
risk of sensitization after care management.20 Furthermore, there is no benefit
to changing the standardized care management of burn patients (using skin
allograft, blood transfusion) due to the high risk of medical complications.21
In our series of VCA/FT patients with more than five years follow-up, we
demonstrated positive outcomes.22 In addition to improvements in immuno-
suppressive strategies, we described our protocol for management of the facial
nerve (one anastomosis at the trunk). The aim was to simplify and improve
surgical outcomes in FT by avoiding dyskinesia.23 Unfortunately, one of our
FT patients rejected his face leading to a total graft loss within a few months.
We published a letter to the editor in the journal Lancet addressing the risk of
face retransplantation.24 Under extremely urgent conditions we pushed forward
in retransplanting the patient.25
Comment
In their paper, McQuinn et al. raise the challenge of human FT post Self-Inflicted
Gunshot Wound (SIGW). The major ethical concern is the potential risk of recur-
rence of such a suicide attempt. According to the manuscript, 25% of the FTs
performed have been in patients identified as survivors of SIGWs, and one
recipient has committed suicide post-transplant.26 This clinical reality has already
been accepted by most VCA surgeons. Interestingly, ballistic trauma patients
have eclipsed burn patients who were initially projected to make up the largest
number of transplants. This confirms the observation that we made in 200427
that ballistic trauma patients can be excellent candidates for FT. Beyond the risk of
suicide, patients’ intellectual ability and their understanding of long-term treatment
is the minimal requisite for suggesting this surgery, and more determinative than
the type of injury itself.
In transplants, as in the rest of modern healthcare, the debate also involves the
cost for society. In our institution, the transplantation of a face led to higher costs
than heart or any other solid organ, and represented twice the costs for a liver
transplantation.28 The question is: how much is society willing to expend resources
to help these people? In the case of face transplant (contrary to solid transplanta-
tion indications), there are no face shortages so far.
A close follow-up post-face transplant is crucial for detecting the first signs of
psychological distress. As reported by the authors, mortality from SIGWs can be
as high as 80%. The survivors have important morbidities and lifelong disabilities.
A global assessment of the possibilities of motor and sensitive function restoration
will help address the risk-benefit ratio in FT. A patient with SIGW suffers signifi-
cant psychological pain that must be treated. The decision to perform a VCA is
multidisciplinary, depending of the psychological state, the surgical feasibility,
and the willingness of the patient. We understand and appreciate the importance
of the role of psychiatrists and psychologists for identifying “low-risk patients.”
These professionals need to make the distinction between known psychosocial
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A Second Chance at Life
465
contraindications (active psychoses, amongst them) and SIGW. Our institution
does not exclude patients with SIGW, viewing VCA as a chance to give the patient
a “second chance” at life.
The patient’s ability to make medical decisions for themselves cannot be
overestimated. A prerequisite for the surgery is fully informed consent to all
aspects of the procedure, which becomes a more complex issue as VCA for chil-
dren is explored,29 along with understanding and committing to the extensive
after-care regimen. This point is particularly important since an inability to
adhere to the post-transplant regimen can lead to adverse outcomes, including
rejection and graft failure. But even with treatment compliance, we cannot rule
out the risk of developing chronic rejection.
The authors stated that the general public in the United States supports
solid organ donation but is hesitant about vascularized composite allotrans-
plantation. But looking back at the first heart transplant, when the world
was amazed by Christian Barnard’s case, support was also not immediate
for taking a heart that had only arrested during surgery with cardioplegia.
This reluctance may be traced to insufficient communication, and lack of
information from the VCA center. Inadequate clarification can lead to confu-
sion and misunderstanding, causing relatives of donors to have misconcep-
tions regarding the procedure, and refusing to donate for VCA. Disfigurement
of their diseased loved one is often a major concern. As surgeons, it is imper-
ative that we restore the donor’s face to its original structure. The general
public remains unaware of this part of the procedure, as does much of the
medical community. This is necessary, to show respect to the donor’s family,
and also the donor.
The ethics of face transplantation go far beyond recipient risk-benefit analysis,
and allocation of resources. It involves all the questions regarding the use of body
parts after death raised in the literature by Mary Shelley’s novel, Frankenstein,
written a century ago. For example, are we an amalgamation of organs? If so, is a
part of personality is transferred when organs are transferred—even more so
when it is related to the face? But a human being is a complex system, and a complex
system is not the addition of simple elements. In VCA, we are not transplanting
personality through a face transplant, but restoring faces to rehabilitate patients
and bring them back to a normal life.
Conclusion
FT goes beyond the restoration of the anatomical subject; it is the retrieval of
the self-esteem. The right to have a face goes beyond improving the quality of
life; it is at the core of human dignity. The atrocities performed on concentration
camp prisoners in World War II, under the guise of “scientific experiments,”
demonstrated the ravages of a loss of dignity. We agree with the conclusion of
the authors regarding the absence of justification for rejecting patients with SIGW.
The allocation of health care resources is very important, but the decision to
provide VCA lies at the health policy decision level; physicians have the profes-
sional duty to provide their patients with the best treatment options available.
VCA is the best treatment option available for SIGW, and needs to be considered
in the therapeutic arsenal for treating it. The report of long-term follow-up will
bring new insight to this topic.
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Alexandre G. Lellouch and Laurent A. Lantieri
466
Notes
1. Dubernard J-M, Lengelé B, Morelon E, Testelin S, Badet L, Moure C, et al. Outcomes 18 months
after the first human partial face transplantation. New England Journal of Medicine 2007;
357(24):2451–60.
2. Petruzzo P, Kanitakis J, Testelin S, Pialat J-B, Buron F, Badet L, et al. Clinicopathological findings of
chronic rejection in a face grafted patient. Transplantation 2015;99(12):1–7.
3. Morelon E, Petruzzo P, Kanitakis J, Dakpé S, Thaunat O, Dubois V, et al. Face transplantation:
Partial graft loss of the first case ten years later. American Journal of Transplantation 2017;
17(7):1935–40.
4. Lellouch AG, Ng ZY, Kurtz JM, Cetrulo CL. Mixed chimerism-based regimens in VCA. Current
Transplantation Reports 2016.
5. Kawai T, Sachs DH, Sykes M, Cosimi AB, Immune Tolerance Network. HLA-mismatched renal
transplantation without maintenance immunosuppression. New England Journal of Medicine
2013;368(19):1850–2.
6. Meningaud J-P, Hivelin M, Benjoar M-D, Toure G, Hermeziu O, Lantieri L. The procurement of
allotransplants for ballistic trauma: A preclinical study and a report of two clinical cases. Plastic and
Reconstructive Surgery 2011;127(5):1892–900.
7. Sedaghati-nia A, Gilton A, Liger C, Binhas M, Cook F, Ait-Mammar B, et al. Anaesthesia and
intensive care management of face transplantation. British Journal of Anaesthesia 2013;111(4):
600–6.
8. See note 2, Petruzzo et al. 2015.
9. Petit F, Paraskevas A, Minns AB, Lee WPA, Lantieri LA. Face transplantation: Where do we stand?
Plastic and Reconstructive Surgery 2004;113(5):1429–33.
10. Petit F, Paraskevas A, Garrido I, Lantiéri L. [Could (allo)transplantation be the future of microsur-
gery?] Annales de Chirurgie Plastique et Esthétique 2005;50(1):76–9.
11. Lantieri LA. Face transplantation: The view from Paris, France. Southern Medical Journal 2006;
99(4):421–3.
12. Paraskevas A, Ingallina F, Meningaud J-P, Lantiéri L. [Face allotransplantation: anatomical study,
potential partial and total facial allografts harvesting and clinical application]. Annales de Chirurgie
Plastique et Esthétique 2007;52(5):485–93.
13. Lantieri L, Meningaud J-P, Grimbert P, Bellivier F, Lefaucheur J-P, Ortonne N, et al. Repair of the
lower and middle parts of the face by composite tissue allotransplantation in a patient with
massive plexiform neurofibroma: A 1-year follow-up study. Lancet (London, England) 2008;
372(9639):639–45.
14. See note 1, Dubernard et al. 2007.
15. Lantieri L. [Composite allotransplantation in the upper extremity: From research to clinical reality].
Chirugie de la Main 2009;28(2):67–73.
16. Gordon CR, Siemionow M, Papay F, Pryor L, Gatherwright J, Kodish E, et al. The world’s expe-
rience with facial transplantation: What have we learned thus far? Annals of Plastic Surgery
2009;63(5):572–8.
17. See note 6, Meningaud et al. 2011.
18. Meningaud J-P, Benjoar M-D, Hivelin M, Hermeziu O, Toure G, Lantieri L. Procurement of total
human face graft for allotransplantation: A preclinical study and the first clinical case. Plastic
and Reconstructive Surgery 2010;126(4):1181–90.
19. Lantieri L, Hivelin M, Audard V, Benjoar MD, Meningaud JP, Bellivier F, et al. Feasibility, reproduc-
ibility, risks and benefits of face transplantation: A prospective study of outcomes. American Journal
of Transplantation 2011;11(1):367–78.
20. Duhamel P, Suberbielle C, Grimbert P, Leclerc T, Jacquelinet C, Audry B, et al. Extensively burned
patients still need blood transfusions and skin allografts: Unavoidable HLA sensitization requires
optimization of VCA access. Transplant International 2015;28(10):1229–30.
21. Ng ZY, Lellouch AG, Drijkoningen T, Chang IA, Sachs DH, Cetrulo CL. Vascularized composite
Allotransplantation—An emerging concept for burn reconstruction. Journal of Burn Care & Research
2017;38(6):371–8. doi: 10.1097/BCR.0000000000000532.
22. Lantieri L, Grimbert P, Ortonne N, Suberbielle C, Bories D, Gil-Vernet S, et al. Face transplant: Long-
term follow-up and results of a prospective open study. Lancet (London, England) 2016;
388(10052):1398–407.
23. Swanson JW, Yu JW, Taylor JA, Kovach S, Kanchwala S, Lantieri L. The retroauricular approach to
the facial nerve trunk. Journal of Craniofacial Surgery 2017;28(2):347–51.
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A Second Chance at Life
467
24. Lantieri L, Grimbert P, Ortonne N, Lemogne C, Wolkenstein P, Hivelin M. Facial transplantation:
Facing the limits, planning the future. Lancet (London, England) 2017;389(10076):1293–4.
25. Breaking news, CNN 19 Apr. Available at https://www.nytimes.com/2018/04/19/world/
europe/jerome-hamon-face-transplant-france.html (last accessed 25 Mar 2019).
26. See note 22, Lantieri et al. 2016.
27. See note 9, Petit et al. 2004.
28. Rüegg EM, Hivelin M, Hemery F, Maciver C, Benjoar MD, Meningaud JP, et al. Face transplanta-
tion program in France: A cost analysis of five patients. Transplantation 2012;93(11):1166–72.
29. Marchac A, Kuschner T, Paris J, Picard A, Vazquez MP, Lantieri L. Ethical issues in pediatric face
transplantation: Should we perform face transplantation in children? Plastic and Reconstructive
Surgery 2016;138(2):449–54.
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