First U.S. Face Transplant Described

CLEVELAND — Only the upper eyelids, forehead, lower lip and jaw are hers. The rest of her face comes from a cadaver.

In a 22-hour operation, surgeons have given nearly an entire new face to a woman with such severe facial damage she could not eat on her own or breathe without a hole in her windpipe, transplant doctors at the Cleveland Clinic said here on Wednesday.

The highly experimental procedure, performed within the last two weeks, was the world’s fourth face transplant, the United States’ first, and the most extensive and complicated such operation to date. The surgeons, led by Dr. Maria Siemionow, took turns at the operating table so they could rest, sleep and share expertise.

The woman’s identity was not disclosed, nor was the cause of her injury. Doctors would say only that it was from trauma.

At a news conference, clinic doctors said she was expected eventually to be able to eat, speak and breathe normally. Feeling should return to her face in six months, and most facial functions in about a year.

Although the woman passed the first hurdle — there was no rejection of the new face at the time of surgery — she can experience a rejection reaction at any time from the immunosuppressive drugs that she will need to take the rest of her life. Doctors can treat most such reactions by adjusting the drug regimen. The woman is receiving the same kind of antirejection drugs prescribed for other kinds of transplants.

She needed the transplant because of severe functional loss from trauma. Clinic doctors, who have treated the woman for several years, performed “several reconstructive procedures.” But they said no conventional treatment options could restore her facial function.

“This is the largest and most complex face transplant in the world, integrating different functional components such as nose and lower eyelids, as well as different tissue types including skin, muscles, bony structures, arteries, veins and nerves,” the doctors said.

They said about 500 square centimeters (77 square inches) of tissue were transplanted from the donor, whose identity is also being withheld.

Three earlier partial face transplants have been performed — two in France and one in China — since November 2005.

Dr. Siemionow has waited since 2004, when a hospital review board approved the scientific blueprint for experimental facial transplant. One obstacle was finding donor candidates whose sex, race, age and blood type matched that of potential recipients.

The Cleveland face transplant procedure began at 5:30 p.m. one day within the past two weeks, when doctors determined that the arteries and veins in the recipient’s neck could recieve the transplant.

At 8 p.m., surgeons began recovering the donor’s facial tissue, carefully dissecting the arteries, nerves, soft tissue and bones to make sure of a good blood supply. The surgeons also removed scar tissue to make room for the facial graft. That entire effort took 9 hours 10 minutes.

Then they began another nine-hour procedure to attach the facial graft to the recipient’s face. They used microscopes to stitch arteries, veins and nerves from the donor graft to the woman’s head. By 4:30 p.m. she had a new face. Doctors said they do not expect the woman to look like her donor because of diversity in underlying facial structure. Also, they said, “a person’s identity is more than skin and bones, relying on expression, animation and social interaction.”

In her book, “Transplanting a Face: Notes on a Life in Medicine,” Dr. Siemionow wrote that faces are essential for a person’s communication to the world. “No other aspect of our anatomy is capable of even a fraction of the complexity of motion and emotion allowed by the muscles and tissues of the face,” she wrote.

If the transplant fails, the clinic team said it would replace it with a skin graft taken from different parts of the recipient’s body.

Such transplants are experimental and highly controversial.

A main area of concern, critics contend, is the lifelong need to take antirejection drugs. An adverse reaction can come at any time, but can often be managed by adjusting the dose of the drugs. But such fine-tuning involves a balancing act — giving sufficient amounts of the drugs to prevent rejection of the tissue but not enough to lead to infection. What can make a face transplant particularly risky is that, if the drugs fail, surgeons may have little to offer the recipient.

Critics have also raised ethical concerns, including protecting the donor’s identity. Plans for face transplants at a number of medical centers in this country and Europe have been slowed by difficulty in finding donors.

But transplant pioneers say that the psychological effects of facial damage from injuries, birth defects, burns and a number of diseases can be psychologically devastating. Though reconstructive surgery is possible in many cases, proponents say that in other cases, an experimental face transplant could be worth the risks if patients and donors and their families understand them.

Transplant surgery pioneers also point to the apparent success of the three earlier face transplants and a number of hand transplants. Some of these operations — so-called composite transplants — have involved transplanting not only the skin, but also underlying soft tissues.

The first partial face transplant was performed in November 2005 by a team in Amiens, France. The recipient, Isabelle Dinoire, then 38, had been seriously disfigured when she was mauled by her Labrador retriever. The surgeons grafted a nose, lips and chin from a donor who had been declared brain-dead.

In a published report in December 2007, Ms. Dinoire’s doctors said she was satisfied with the aesthetic result. She has since spoken in a news conference.

In 2006, Chinese doctors did a partial face transplant on a farmer who lost much of the right side of his face in a bear attack.

In 2007, a French team performed the third partial facial transplant, on a 29-year-old man. His face had been disfigured by neurofibromatosis, a genetic disorder of the nervous system that causes tumors to grow in tissues around nerves.

By LAWRENCE K. ALTMAN 

NYTIMES