Costs are comparable for face transplant vs. multiple reconstructions

Face transplantation — at least in the near-term — may not cost much more than the multiple conventional reconstructive surgeries that a complex case would need, according to the team that did the first U.S. face transplant.

That near-total face transplant done in 2008 for a woman injured by a shotgun blast cost $349,959 compared with $353,480 for the 23 separate conventional reconstructions she had done before transplantation.

The post-transplant costs added an extra $115,463, but the overall cost was “similar,” Maria Siemionow, MD, PhD, DSc, the reconstructive surgeon who led the transplant team at the Cleveland Clinic.

Moreover, the piecemeal reconstructions hadn’t offered good results, Siemionow and colleagues reported online in the American Journal of Transplantation.

“Although the cost of facial transplantation is considerable, the alleviation of psychological and physiological suffering, exceptional functional recovery, and fulfillment of long-lasting hope for social reintegration may be priceless,” the group wrote.

The 46-year-old woman had lost her nose and palate in the injury and had been unable to breathe, smell, taste, or eat normally. She remained so disfigured that she reportedly wouldn’t go out in public despite four years of reconstructive surgeries.

The transplant from a dead donor replaced 80% of her face, including the cheeks, lower eyelids, nose, and upper lip as well as cheek and maxillary bone and some upper teeth.

The world’s first partial facial transplant had been done in France in 2005 for a dog attack victim. The success of the French and U.S. cases spurred further facial transplantations, including the world’s first total face transplant in Spain in 2010.

Siemionow’s group had called for consideration of face transplantation as first-line treatment for severe facial trauma.

But, they noted in the journal article, “As face transplantation moves further away from the questions of ‘can we?’ or ‘should we?’, the question of fiscal responsibility will soon move into the forefront and may likely become the central issue of the face transplant debate.”

To address that issue, Siemionow and colleagues detailed the costs for their case.

Inpatient costs were estimated to be 25.5% higher than for the conventional reconstructions the patient had prior to transplant.

The biggest components were surgical costs — 42% for the face transplant and 38.5% for the conventional reconstructions — and nursing costs, 19.7% for the transplant versus 27% for the conventional surgeries.

Pharmacy costs, though, were doubled with face transplantation at $38,574 (16.6% of total costs) compared with $16,581 (8% of total) for reconstruction.

Immunosuppression — required to prevent graft rejection — was the major reason for the difference at a total direct cost of $21,506 for the regimen of antithymocyte immunoglobulin, granulocyte stimulating factor, tacrolimus, mycophenolate mofetil, and steroids for varying durations.

However, these cost comparisons include only the early period, the researchers noted.

Chronic immunosuppression for other transplant types ranges from $10,000 to $20,000 a year, so life-long immunosuppression for the face transplant patient could add up to $370,000 to $518,000.

Although long-term immunosuppression carries risks, the consequences of facial graft failure remain unknown.

Other organs like the kidney can be removed and the patient temporized until retransplantation, but what reconstructive options exist and the possible morbidity and mortality aren’t clear for face transplant, the Cleveland Clinic team acknowledged.

The single-patient case study findings may not generalize to other patients, institutions, or countries, and objective cost comparisons couldn’t be done, making the cost conclusions only speculative, the researchers warned.

But the financial considerations don’t tell the whole story, they added.

“Given the face’s … role in societal acceptance, it is impossible to truly quantify the value of this procedure using monetary means as it has immensely improved our patient’s overall quality of life, thus leading to significant reductions in both psychological and physiological anguish,” they concluded in the paper.

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