Replacing the Face?

When plastic surgery comes to mind, people normally think of some minor improvements in the overall appearance. We recognize that the surgeon can improve the shape of our nose, and make our face look better.  However, in more serious situations when the face has been badly deformed as a result of illness or accident, the plastic surgery quickly reaches its limits.  Apparently, the skin that covers our face differs from the skin that covers other parts of our body. The skin on our face is much more elastic, it lends itself to all sorts of stretches by all sorts of facial muscles that are responsible for very diverse functions such as eating, talking, and eye blinking, or mimicking to express emotions.  Transplants of skin from other parts of the body may result in immovability or twitch of that part of the face. With respect to the eye or mouth areas such impediment poses not only an esthetic problem, but also a health hazard.  Thus, a question arises whether skin from another person’s face can be transplanted?Today medical science deals with instances when a heart or kidneys stop functioning and the life can be saved only by transplanting such organs from another person.  In the case of a heart transplant, only a dead person can become a donor.  Every time another person becomes an organ donor, medical science must deal with the natural tendency to reject the transplant by the receiving organism. The immune system is designed to destroy all „foreign bodies” in our organism, thereby protecting us against all sorts of diseases and infections. That is why after the transplant, the recipient of a new organ must take medications that restrain the immune system and protect the transplant against rejection.

Recently, I spoke about the facial transplant with Doctor Maria Siemionow. Thanks to an article in the July issue of the New York Times and recently in Gazeta Wyborcza, her name became known worldwide. Doctor Siemionow heads an experimental plastic surgery group at the Cleveland Clinic, where she perfected microsurgical methods and immunosuppressant techniques that made it possible for the first time ever to plan and prepare a facial skin transplant in a human.
For this interview, I met with doctor Siemionow in a coffee shop at the Museum of Art in the University Circle.  From the outset it became obvious that I met a person who speaks about her life’s passion, about overcoming obstacles, about people that need her help, about authorities that need to be convinced, and about the precision and focus that her work requires. I learned that the skin is the most immunogenic tissue in the organism, as it becomes the first barrier defending our organism against infection. How do we know, then, that skin transplant is possible?  Apparently, there are already several successful cases of transplanting the entire hand from a dead person. Clearly, such transplants also mean the successful transplant of the skin on that hand.  It follows that the acceptance by the recipient body of this type of a transplant proves that the skin transplant is possible.

From the scientific standpoint, there are two types of skin transplant:  skin tissue with blood vessels and skin flaps with no blood vessels. With respect to the facial skin transplant, the transplant that doctor Siemianow plans to perform will include some blood vessels.  The chances for the survival of the transplanted tissue cells increase when such cells are supplied with more nourishment and oxygen thank to the blood vessels.  Prof. Siemianow already conducted a number of experiments on rats, transplanting skin tissue with blood vessels from the eye and face areas including ears. The results have been very promising.

And so, step by step Prof. Siemianow led me through the arcana of her experiments.

I learned that the thread she uses to stitch blood vessels is thinner than a hair, and that she performs most of the surgeries by herself under the microscope.  Also, I looked through articles about her work in a German magazine, with a photo of Prof. Siemianow always with her primary tool – the microscope.

Doctor Siemionow‘s exceptional microsurgery skills are evident. However, after listening to her explanation of transplants and upon glancing over her publications it became clear that she is also among world leading specialists in the immunology and immuno-suppression sciences. She also specializes in peripheral nerve injuries.  Her standing in the scientific world has been recently acknowledged by her election to the Chairmanship position of the American Association of Peripheral Nerves.

My next question was about the desire to help others.  This motivation, to help others, became the driving force for doctor Siemionow over the course of twenty years of her hard experimental work.   The press frequently mentions her early experience when as a young resident in Finland she participated in a hand transplant surgery. It was precisely this “miracle” that seriously impacted her future interest.

The idea to transplant the face skin has been discussed some time ago in England and France.  However, the medical establishment decided against pursuing this type of experiment.  Documentation submitted back then as well as issues raised did not convince the leaders of the profession that the risks involved are worth taking.  Years later, the work, documentation, and solid argumentation that such operation is medically and ethically justified presented by doctor Siemionow broke a new ground.  Her expertise and dedication gave the Committee on Clinical Studies at the Cleveland Clinic enough assurance for success to issue the first in the world permission for such experimental work on the human. That is how doctor Siemionow, dedicated advocate of her patients, broke through yet another barrier in medical science.

The search for the first patient is under way.  Many hurdles still exist however.  The patient must understand the risk of the transplant; such risk is estimated at about 50 percent.  The patient must be mentally healthy, with no history of drug dependency to assure that the organism can handle difficult immunological treatment.  It has been proven that even two-day interruption in the immunological treatment results in the rejection of the transplant. Also, the size of the damaged skin is important to the prospects of success. An option to transplant patient’s own skin in the event of transplant rejection must be available.  That is why only those with no prior skin transplant experience can be considered. Furthermore, the patient must have strong family support because diligent care and cooperation with caretakers is critical in the post-transplant period.  An expert named Life Bank who matches donors with recipients of transplant organs will decide who will be selected for the groundbreaking transplant of the face.

The patient must be informed that the immunosuppressant therapy is dangerous, must understand that in certain circumstances this therapy may become life threatening. In practice, however, the greatest problem is the rejection of the transplant rather than the side effects of the immunological therapy.

The face transplant was held back by the medical scientific community because of one main reason. By definition, this procedure does not save life but only improves its quality.

Professor Siemionow views this ethical problem from a different perspective and raises a different question. Who is in a better position to judge what is in the best interest of the patient: doctor or patient?  She told me stories of her patients who hide in their homes, whose face is so devastated that they cannot close their eyes, and all sorts of transplanted patches of skin create a mosaic that makes their contact with the outside world impossible.  Even doctors themselves with difficulty look at these faces. And yet, they reserve the right to agree or disagree for the treatment that could help those people.  It is precisely this issue that according to professor Siemionow is ethically questionable. Professor Siemionow earned the right to stand up in this debate.  With her knowledge and experience, she knows she can help these people.

Many have a negative reaction to the concept of „face transplant.” This idea rather reminds us of a movie Without Face than of a real problem of the ordinary people. Doctor Siemionow does not have much patience for this kind of thinking. She is too busy dealing with heavy problems of her patients to have any time for movies. She watched the movie only after others kept referring to it, while discussing her work.

Other objections with respect to her procedure deal with the word „face.”  Recommendations were made to transplant just smaller fragments of the face. Doctor Siemionow points out, however, that the immunological therapy is the same for the smaller or larger transplants.  From that standpoint, there is no reason to limit the procedure.  “If only to avoid the word “face,” it doesn’t make sense,” she adds. Other objections deal with the issue of identity with respect to both recipients and donors.  Such discussions will continue. To this day, people debate the identity problem with respect to heart transplants.  Staying within the movie realm, we can point out Return to Me with Minnie Driver and David Duchovny.

Professor Siemionow learned her craft in the Poznań Academy of Medical Sciences where she was promoted to the professorship position at the Surgery Department.  Prof. Siemionow believes that she found the courage to break through the barrier that had restrained her from helping others thanks to her frequent travels and cooperation with exceptional scientists from all over the world.  Her cooperation with Poland and her Alma Mater is of particularly importance to her.  She was the lead advisor on two doctoral dissertations there. Among her close associates and graduate students at the Cleveland Clinic are ten people from Poland. Through exchange and cooperation, she was able to bring on board young specialists who possibly will follow in her footsteps.   Professor Siemionow also became interested in the Polish-American Center that promotes Polish culture and serves Polonia. That is how I met this remarkable scientist who bravely pushes forward medical frontiers, this exceptional ambassador of Polish science of the highest order.

By Dr. Ryszard Romaniuk
Translated by Maria Szonert-Binienda

Forum, 10/2005