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Physicians Update


Physicians Update

Spring 2013

Face-Transplant Program Will Help to Restore Devastated Lives

Kodi Azari, MD, FACSUCLA Health is the first center in the western United States to offer facial transplantation to qualified patients who cannot be adequately treated using conventional reconstructive techniques. The UCLA Face Transplant Program is one of only a handful in the nation to offer this still-experimental innovative treatment. Facial transplantation is a complex procedure that is part of the emerging transplant field called vascularized composite allotransplantation (VCA). This is the transplantation of skin, blood vessels, nerves, bone, muscle and other supportive structures from a donor to a candidate. To accomplish this, the UCLA program has assembled an outstanding team of specialists, including those in plastic and reconstructive surgery, head and neck surgery, microvascular surgery, occuloplastic surgery, neurosurgery, oral surgery, dentistry, psychiatry and transplantation medicine. Kodi Azari, MD, FACS, chief of reconstructive transplantation, talks about the program.

How did this program evolve?
UCLA has been involved over the past several years with the U.S. military through Operation Mend, providing reconstructive surgery to service members wounded in Iraq and Afghanistan. Our face-transplant program grew from our desire to do more for our wounded service members. The face is the most exposed body part and is integral to our sense of self. So you can only imagine what it’s like to not have a face. Face transplantation offers the potential to restore the sense of self to persons who have suffered the devastating loss of their face. People with massive facial injuries often have trouble breathing, speaking and eating, as well as depression and social isolation. Early surgeries have demonstrated very promising results in improving both appearance and function. While the program is an outgrowth of our relationship with the military, it will accept both civilians and veterans as candidates.

UCLA Face Transplant Illustration What are the criteria to become an eligible candidate for face transplantation?
The first requirement is that the patient’s facial disfigurement cannot be the result of cancer and, in spite of repeated attempts, cannot adequately be reconstructed by conventional means. We can do amazing things through reconstructive plastic surgery, but there are injuries from trauma or from burns that are just beyond our capabilities to restore. Facial transplantation offers us that capability. Appropriate candidates must be between 18 and 60 years of age, have no serious infections, including hepatitis B or C or HIV, and be in otherwise generally good health. In addition, candidates must commit to extensive rehabilitation, adhere to an immunosuppression medication regimen, and participate in all appointments at the transplant center.

Patients needing an organ transplant can spend years on the waiting list before an appropriate donor is found. What are the challenges of matching an appropriate donor and recipient for this procedure?
Finding the right donor is a challenge, and this is such a new field that there is no streamlined way for finding donors. We would like to push for a national database, like what exists for organ transplantation, to identify and match potential donors and patients. It would be a very important part of accelerating the pace of these procedures. That said, the donor’s tissue must match that of the recipient in terms of blood group, sex, age, skin color and size. Potential donor families are approached with sensitivity to the emotional and ethical issues of donation. Our program also works with James Kelly, DDS, an expert in maxillofacial prosthetics to provide the donor family a facial reconstructive mask to recreate the donor’s visage and allow for an open-casket funeral if that is desired.

Identifying the right candidate for the surgery also is a significant challenge. Because this is a life-altering procedure rather than a life-saving one, an appropriate candidate must not only meet the medical criteria, but must also be psychologically ready for this surgery, and for what it means afterward. While there might be some resemblance, recipients will neither look like themselves nor like the donor. It can be a lot for someone to grasp, even for a patient who up to this point has been living with a badly disfigured face. That is why candidates are screened for psychological issues, including depression and post-traumatic-stress disorder, which would interfere with their ability to accept and recover from the transplant. The program also provides psychiatric care around the time of the procedure as well as long-term follow-up with psychiatric therapy.

In March 2012, Richard Lee Norris, who was injured in a gun accident
In March 2012, Richard Lee Norris, who was injured in a gun accident, received a full face transplant at the University of Maryland Medical Center.Richard Lee Norris seven months after face transplant He is pictured in the second photograph seven months after the procedure. Photos: Courtesy of University of Maryland Medical Center

How is the surgery performed?
Once an appropriate donor is identified, two teams begin work in concert. One team travels to the donor hospital and procures the tissue to be transplanted, taking only the tissue that the recipient will need. A second team prepares the patient, removing damaged tissue and scar tissue down to the healthy, underlying structures. The reconstruction begins by anchoring bone in place and attaching muscle to the facial skeleton. Blood vessels, nerves, ducts and glands are attached to corresponding structures, and then skin is closed. It is a laborious, lengthy procedure than can take more than 20 hours, depending on the case.

Patients will remain in the hospital for the first month following surgery, and will start speech and occupational therapy, which will continue for a year to 18 months. After they are discharged from the hospital, they will spend another two months at nearby UCLA housing, and then they will be seen monthly for the next year, and then with decreasing frequency.

The surgery is very complex and involves many different specialties. How is it being funded?
As one might imagine, this kind of procedure is very expensive — around $600,000. Right now our funding is coming from UCLA Health and private sources. But we are hopeful that the U.S. military may become involved in supporting our program as we move forward. The Pentagon has been very interested in research into such programs as facial transplantation and regenerative medicine to treat wounded veterans, and it has given several million dollars to Brigham and Women’s Hospital in Boston, which has done the majority of face transplants in the U.S.

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