Composite tissue allotransplantation is a microsurgical technique where tissue from a donor is transplanted to a patient. Essentially, it is a combination of transplant and reconstructive surgery. Distinctly, these operations are primarily for quality of life, often in trauma or tumor patients, not necessarily for prolongment. At first, this was completed with hand transplants in France, 1998. However, facial transplantation is a new example and is used for both functional and aesthetic purposes. This technique is still rare, with only 11 human face transplants having been performed between 2005 and 2011. Moreover, these transplants are often partial .
In general, facial transplants and composite tissue allotransplantation have had issues with rejection, not dislike solid organ transplants. The immune system is alerted by organ antigens and proceeds to attack it. Most surprisingly, some patients experience split tolerance, in which different tissues from the same donor cause varying responses, possibly due to organ-specific antigens. The first composite tissue allotransplantation corroborated this. The skin of the donor hand was rejected, though the joints were spared. In addition, there are chronic rejection issues with maintaining blood vessels, which progressively narrow as the body rejects the organ. This can lead to thrombosis, then cell death. Infection may contribute to both of the aforementioned issues .
Nonetheless, there are solutions. In 2010, a full face transplant was performed on a 30-year-old male with a severe facial deformity from ballistic trauma. Unlike previous transplants, this included all facial units (forehead, nose, eyelids, cheeks, lips and chin). There were no intraoperative complications, but postoperative complications included acute rejection episodes and venous thrombosis. As a result, the immunotherapy treatment needed to be adjusted. Originally, the immunotherapy course consisted of thymoglobulin, prednisone, tacrolimus, and mycophenolate mofetil. The prednisone was tapered, but acute rejection occurred and they required a bolus of prednisone. Additionally, mycophenolate mofetil was replaced with Sirolimus. For the venous thrombosis, the patient’s anastomoses needed to be adjusted. From then on, the patient experienced few psychological issues, which facial transplants can be associated with. 
Another 45-year-old woman received a face transplant after a gunshot wound. Prior to the transplant, the patient experienced social issues, with some strangers screaming and running away when they saw her face. In addition, she had difficulty eating and anosmia. As a result, past psychiatric history included treatment for depression and post-traumatic stress disorder. After treatment, the patient reported receiving more positive affirmations than before. Other factors in bolstering her self-esteem included social assimilation. Family members reaffirmed family ties by finding similarities between the new face and family traits. Notably, this patient reported a strong support system, which was found to be less common in patients with psychological issues .
Finally, a 28-year-old female qualified for a facial transplant in 2013 for aesthetic, psychological, and medical purposes. Specifically, this patient experiences neurofibromatosis, a genetic disorder causing tumors. The condition caused malformations in facial appearance and quality of life issues. Additionally, they resulted in psychological problems. However, the transplant was soon integrated into the patient’s quality of life .
Despite high risk and rejection issues, facial transplant patients appear satisfied with their quality of life. As a result, it is of importance that not only critical procedures are provided for by insurance or the government, but quality of life procedures are beneficial as well. In addition, psychological issues are a genuine concern for face transplants, especially with a body part as personal as the face. However, this level of psychiatric care may need to be extended to other procedures as well, especially ones affecting quality of life as this one does. While the healthcare system is designed to treat illnesses and issues, home life is often outside of its hands. Physicians take a social history to view factors that may impact treatment, but further research must be conducted into the management of resulting psychiatric issues. Based on the case reports, there was prior pharmacological management, but social integration was the greatest contributor to mental health. So, healthcare management research must open up to bolster clinical treatment.
Surgical techniques continue to advance as healthcare aims to both, prolong life and improve it. However, this includes further cooperation between specialties. In this case, that includes transplant surgery, reconstructive surgery, and even psychiatry. The field of composite tissue allotransplantation along with facial transplantation will hopefully continue as a higher case loader is needed to tease out further complications. Nonetheless, past cases have conveyed the ability to ameliorate rejection and psychiatric issues.
Aleicia Zhu, Youth Medical Journal 2020
- Barret, J. P., Gavaldà, J., et al. (2011). Full Face Transplant. Annals of Surgery, 254(2), 252-256. doi:10.1097/sla.0b013e318226a607
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