Friday, December 19, 2008


So Dr. Siemionow at the Cleveland Clinic Foundation performed the first face transplant in the United States this week. I say good for her. Good for the patient. Let's just hope that it works.

Transplant surgery is an incredibly complicated amalgam of immunologic manipulation and technical expertise. Successful outcomes depend on two things: flawless surgical technique and tricking the body's defenses into thinking that a foreign protein (the donor organ) is not a threat. The surgical aspect requires meticulous dissection and the creation of tenuous anastomoses (bowel, vessels, nerves, etc) in patients who are high risk and exceedingly fragile. The immunomodulatory issues, however, are a lifetime challenge. Rejection is a constant threat requiring vigilant montioring. T-cell mediated rejection afflicts 30-50% of new liver transplants within the first 6 months. Most of these can be managed with high dose steroid pulses but a small percentage progress to chronic rejection despite all best efforts.

If your kidney graft starts to fail, a patient can go back on dialysis until another one becomes available. When a liver graft fails a patient will often end up back on the top of the recipient list because of a high MELD score. But what happens when your face graft fails? You can't just slap on another one from the donor list. You basically get one shot at it. The graft is removed and the defect is covered with skin auto-transplanted from your thigh or buttocks. Once again, the patient is ostracized from the rest of humankind by his/her deformity.

Self identity is what we feel we project onto others. The way we smile, an arched eyebrow, the way we tilt our heads when asked a question, these subtle gestures and tics are the tools we use to hint at what's going on in the depths of our heretofore unfathomable consciousnesses. Without the face, we are, in many ways, sundered from our fellow man. The ability to project ourselves, to communicate the inarticulable, is crippled without it. Too often, the Other is too lazy to look beyond the superficial reality of what presents itself; a face, a body, a skin color. The despair of not being able to express yourself because of a "defect" in physicality must be indescribable. And so this concept of "face transplantation" is a noble endeavour. But I worry about the long term results. Can you imagine living in social isolation for years after an injury/accident, then being given a new face, a new identity via a graft which allows you to re-enter society and present yourself as a complete physical human being, just like everyone else, only to have that torn away from you after a couple years because of rejection issues? I can't imagine...

The ultimate solution likely is going to come from advances in stem cell research. Instead of using cadaveric or live donor grafts and subsequently engaging in a life long battle to outwit our immune system, we could grow tissues from our our own cells, avoiding the problem of rejection altogether.

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