University of Pittsburgh Medical Center board OKs face transplants

The University of Pittsburgh Medical Center has become the third health system in the United States to win approval to do one of the world’s most dramatic operations — human face transplants.

The Institutional Review Board, which must sign off on all experimental, research-oriented initiatives at the medical center, gave the green light to the face transplant proposal on Thursday.

While UPMC still has many steps to go through before it can do its first face transplant, the program’s endorsement shows just how far the procedure has come since the turn of the century, when face transplants were considered mostly a fantasy.

It is almost impossible to predict when the first face transplant will be done here, said Dr. Joseph Losee, a plastic surgeon at Children’s Hospital of Pittsburgh of UPMC who has headed the face-transplant initiative.

Only now can UPMC begin to evaluate candidates for the surgery, he said. Under the procedures approved by the review board, patients can be considered for the operation if they have a “devastating facial deformity,” either because of congenital malformations like neurofibromatosis or because of trauma such as accidents, burns or gunshots wounds.

Once potential candidates have been approved, there is then the uncertainty of finding an appropriate donor, Losee said.

Not only are there special challenges in getting a family to donate a loved one’s face, he said, but a face-transplant donor must match the recipient in gender, size and skin tone and texture.

One thing UPMC will not have to do is to recruit new surgeons, Losee said.

The center’s plastic surgeons already are highly trained in “free flap” reconstructive surgery, he said, in which tissue is transferred from one part of the body to another. One example: using parts of people’s leg bones to help rebuild their jaws after facial injuries.

Despite the skills that exist within the institution, Losee said, the face-transplant program has been worth pursuing because “our current reconstructive modalities cannot approximate normal human appearance. We cannot make a nose, we cannot make lips, we cannot make eyelids that approximate normal human appearance.”

The other primary motivation is that having a somewhat normal face is vital for basic human interaction.

“Facial expression is key to normal human interaction, and with a devastating facial deformity it is very hard to have normal facial interaction,”he said.

Patients who get successful face transplants will “be able to engage in social functions without being the negative center of attention.”

That was a factor for both of the first two American face-transplant recipients. Connie Culp, who received her new face in December 2008 at the Cleveland Clinic, had lost most of the middle of her face from a gunshot blast. James Maki, who received a face transplant at Brigham and Women’s Hospital in Boston in April 2009, suffered a similar injury after falling onto an electrified train rail.

UPMC also becomes the third program in the nation with approval for face and hand transplants. The Cleveland Clinic and Brigham and Women’s Hospital have had dual approval for some time, but so far have only done a single face transplant each. UPMC has done three hand-transplant surgeries since last year.

A key part of the UPMC program for both types of transplants is keeping the doses of immunosuppressive medications as low as possible using a regimen called the Pittsburgh Protocol.

Transplant recipients must take lifelong medications to prevent their bodies from rejecting the foreign tissue. By giving hand- or face-transplant recipients some of the donor’s bone marrow in the days after the operation, UPMC doctors can help their bodies accept the new tissue and use lower-than-normal doses of anti-rejection drugs.

Face transplants in some cases may improve patients’ functions, such as breathing, eating and swallowing, Losee said, but he feels improving their appearance is justification enough.