Facial transplantation in a new era: what are the ethical implications?

The Ethics of Facial Allotransplantation: A Systematic Review

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Currently, there are more than 40 cases of facial allotransplantation performed by 13 different groups in 10 countries. Although it has become a potential option to reconstruct and restore the function and appearance of severely facially disfigured individuals, the ethical concerns of facial allotransplantation remain unsolved. We conducted a systematic review to better understand the ethical concerns on facial allotransplantation and the changing trends of the ethical debate over time.

Analysis of factors involved in brain-death donor processing for face transplantation in Korea: How much time is available from brain death to transplantation?

Background

Face transplantation has naturally evolved from reconstructive procedures. However, few institutions perform face transplantations, because it is time-consuming and it is necessary to justify non-vital organ transplantation. We investigated the process of organ donation from brain-dead patients and the possibility of incorporating face transplantation into the donation process.

Methods

A retrospective review was performed of 1,074 brain-dead patients from January 2015 to December 2016 in Korea. We analyzed the time intervals from admission to brain death decisions (first, second, and final), the causes of brain death, and the state of the transplanted organs.

Results

The patient base (n=1,074) was composed of 747 males and 327 females. The average period between admission to the first brain death decision was 8.5 days (±15.3). The average time intervals between the first brain death decision and medical confirmation using electroencephalography and between the first brain death decision and the final determination of brain death were 16 hours 58 minutes (±14 hours 50 minutes) and 22 hours 57 minutes (±16 hours 16 minutes), respectively. The most common cause of brain death was cerebral hemorrhage/stroke (42.3%), followed by hypoxia (30.1%), and head trauma (25.2%).

Conclusions

When face transplantation is performed, the transplantation team has 22 hours 57 minutes on average to prepare after the first brain death decision. The cause of brain death was head trauma in approximately one-fourth of cases. Although head trauma does not always imply facial trauma, surgeons should be aware that the facial tissue may be compromised in such cases.

Facial transplantation: historical developments and future directions

Objective:

To present the clinical outcomes obtained by the first facial transplant teams worldwide, reviewing current practice and addressing controversies.

Methods:

A bibliographic search of Medline and Embase databases was performed, and a comparative analysis of all articles published from 1980 to the present was conducted. Two independent investigators screened the manuscripts in accordance with pre-defined criteria.

Results:

A total of 12 partial and 5 full facial transplants were recorded in the literature. Procedures included partial and near-total facial myocutaneous flaps, and complex osteomyocutaneous grafts. Fifteen patients had fully vascularised grafts, and two patients died of transplant-related and infectious complications.

Conclusion:

Facial transplantation can restore quality of life and enable the social re-integration of recipients. Results published by the first facial transplant teams are promising. However, long-term reports of aesthetic and functional outcomes are needed to more precisely define outcomes. In addition, significant technical, medical and ethical issues remain to be solved.

Recent advances in reconstructive oral and maxillofacial surgery

Reconstruction within the head and neck is challenging. Defects can be anatomically complex and may already be compromised by scarring, inflammation, and infection. Tissue grafts and vascularised flaps (either pedicled or free) bring healthy tissue to a compromised wound for optimal healing and are the current gold standard for the repair of such defects, but disadvantages are their limited availability, the difficulty of shaping the flap to fit the defect and, most importantly, donor site morbidity. The importance of function and aesthetics has driven advances in the accuracy of surgical techniques. We discuss current advances in reconstruction within oral and maxillofacial surgery. Developments in navigation, three-dimensional imaging, stereolithographic models, and the use of custom-made implants can aid and improve the accuracy of existing reconstructive methods. Robotic surgery, which does not modify existing techniques of reconstruction, allows access, resection of tumours, and reconstruction with conventional free flap techniques in the oropharynx without the need for mandibulotomy. Tissue engineering and distraction osteogenesis avoid the need for autologous tissue transfer and can therefore be seen as more conservative methods of reconstruction. Recently, facial allotransplantation has allowed whole anatomical facial units to be replaced with the possibility of sensory recovery and reanimation being completed in a single procedure. However, patients who have facial allotransplants are subject to life-long immunosuppression so this method of reconstruction should be limited to selected cases.