THE race to be the first to conduct a partial face transplant was won in the end by a French team, ahead of rivals in the US and the UK. But were the surgeons right to give 38-year-old Isabelle Dinoire a triangular flap of facial tissue containing the nose, lips and chin of a dead woman?
Dinoire, who had been savaged by her dog, was obviously grateful, thanking her surgeons after waking from the 4-hour operation at a hospital in Amiens on 27 November. But some doctors and medical ethicists have questioned whether the team, led by Bernard Devauchelle and Jean-Michel Dubernard, should have delayed the procedure until they had first tried repairing the wounds using conventional reconstructive surgery.
The French team has the support of its rivals, however. The key justification, they say, is that the transplant offered the only hope of giving the woman a functioning 鈥� and cosmetically normal 鈥� pair of lips. Indeed, the potential to restore function could become a deciding factor for other teams contemplating face transplants. But whether Dinoire will in fact be able to move her lips won鈥檛 become clear for months, because it will take time for essential nerve connections to be forged.
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鈥淚f there is total amputation of both lips, I would dispute that there鈥檚 any conventional surgery that could correct that,鈥� says Gordon Tobin of the University of Louisville in Kentucky, whose team is also planning to perform face transplants. 鈥淪o I would agree with the French team doing the procedure.鈥� Peter Barker, who heads another rival team at London鈥檚 Royal Free Hospital, echoed this view at a briefing last week. And at a press conference on 2 December at Edouard Herriot Hospital in Lyon, where Dubernard is based, the French surgeons confirmed that this was their reasoning.
The dog had bitten off Dinoire鈥檚 lips, chin and the tip of her nose after she had taken sleeping pills following a family argument. Since then, she had been unable to speak or eat properly.
The difficulty with lips is that, like eyelids, they are virtually useless unless they move. 鈥淵ou could have rebuilt a nice nose from forehead skin,鈥� Tobin told New Scientist. 鈥淏ut with the lips, the only option would have been to put up flaps of tissue from the chest. She would have had a poor cosmetic result, and virtually no functional capabilities. She would have been able to chew, but she wouldn鈥檛 have been able to speak or show any emotional expression,鈥� he says
鈥淵ou could rebuild a nose from forehead skin, but the difficulty with lips is that they are virtually useless unless they move鈥�
Dubernard and Devauchelle tackled this problem using a triangular graft taken from a brain-dead donor in Lille while she was still on a life-support machine. As well as skin and fat, the graft also contained a multitude of nerves, muscles, arteries and veins (see Diagram).
During the operation, the surgeons stitched the arteries and veins to the corresponding vessels in the patient鈥檚 face, successfully restoring blood flow to the graft. They then joined together the complex networks of facial nerves and muscles needed to restore lip movement.
Dinoire will now be given rehabilitation therapy to relearn how to speak and eat 鈥� she has reportedly already eaten strawberries and chocolate. But she will have to wait to see if full movement returns.
Not everyone is convinced that restoring lip function using existing techniques is impossible. Iain Hutchison, an oral and facial surgeon at St Bartholomew鈥檚 Hospital in London, claims some movement can be restored. But he concedes that a transplant probably gives a better cosmetic result. 鈥淚n terms of quality of life, it鈥檚 a lot better to have lips that look like lips,鈥� he says.
Of the other teams hoping to perform face transplants, the closest to going ahead appears to be Maria Siemionow鈥檚 at the Cleveland Clinic Foundation in Ohio. Siemionow won approval from the clinic鈥檚 institutional review board a year ago, and is now screening for suitable patients.
Each team is conducting detailed preparatory studies ranging from anatomical investigations on human cadavers to ethical and psychological analyses. This is seen as important to help select patients who will be able to cope with the potential identity crisis associated with having someone else鈥檚 face (New Scientist, 29 May 2004, p 32).
