Facial transplantation and immunosuppressed patients: a new frontier in reconstructive surgery

Composite tissue transplantation in reconstructing complex facial defects has developed tremendous interest over the recent years, since the first report of partial face transplantation performed in France in 2005. However, the controversy over the ethical, immunological, and psychological issues remains. Recently, we obtained IRB approval to perform partial face transplantation at Brigham & Women's Hospital, Boston. Here we present the rationale and IRB application process of our unique approach to this highly controversial procedure, which focuses on partial face transplantation on patients currently on immunosuppressants due to previous transplanted organ. 'Patient selection criteria', selection process, technical and immunological protocols are discussed. We currently share the concern that life-long immunosuppression associated with facial transplantation may not outweigh its benefits as compared to the alternative reconstructive methods. We asked ourselves the question of which patient population would risk less and overall benefit more from undergoing face transplantation, and identified those currently on immunosuppressive therapy the most suitable candidates. Organ transplant recipients are at increased risk of malignancy, particularly skin cancer commonly located in the facial region, necessitating surgical resection and facial reconstruction. They also have to take immunosuppressants to prevent rejection of their primary transplanted organ, which will minimize the need for additional immunosuppression associated with facial allograft. Being a previous organ recipient also diminishes the difficulty of complying with the strict postoperative immunosuppressive regimen, commonly encountered by organ transplant recipients. This approach could be very beneficial for previously immunosuppressed patients and perhaps take its place in our reconstructive ladder options.