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CASE NOTES
Tuesday 31 January 2006, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION


RADIO SCIENCE UNIT



CASE NOTES

Programme 4 - Face Transplants



RADIO 4



TUESDAY 31/01/06 2100-2130



PRESENTER:

MARK PORTER



REPORTER: CLAUDIA HAMMOND



CONTRIBUTORS:

PETER BUTLER

KEN LAVERY

BALJIT DHEANSA

FIDELMA MURPHY

ALEX CLARKE

JAMES PARTRIDGE

GUS MCGROUTHER



PRODUCER:
DEBORAH COHEN/PAULA MCGRATH


NOT CHECKED AS BROADCAST





NEWS CLIP

Doctors in France say they've carried out the world's first operation involving a transplant of part of a person's face. Surgeons in Amiens, operated on a 38-year-old woman who was badly disfigured in an attack by a dog. Our health correspondent ...



PORTER

Thirty eight-year-old Isabelle Dinoire catching the world's attention last November when she became the recipient of the first ever face transplant.



Today's programme is all about facial reconstructive surgery and my guest in the studio is Peter Butler, a consultant plastic surgeon at the Royal Free Hospital in London and one of the surgeons pioneering face transplantation here in the UK.



Peter, what's different about Isabelle's operation in France from other major reconstructive procedures that have gone before?



BUTLER
This was the first ever facial or partial facial transplant and reconstructed her defect, which was where she was missing her nose, upper lip, lower lip and chin, with the tissue from another person. And so this is the first time it's ever been done that way.



PORTER
And that's the key - because we've moved tissue around on people's bodies before haven't we but never from a different person. How's she actually doing, do we know?



BUTLER
Interestingly she's actually out and about and been out in public. She had a rocky course following her surgery with an acute rejection episode, which responded to drugs and now she's doing extremely well. She's actually been out in public, no one's staring at her, according to her reports, and so that actually from that point of view it's a good result.



PORTER
And in terms of rejection that's obviously her immune system rejecting the tissues she sees as foreign. Is that something that tends to rear its head in the first phases or could that come back again?



BUTLER
It's called an acute rejection and can occur really in the very early phases but it can occur really at any time. And in the hand transplants which have taken place, which are sort of similar tissue, they've all responded to an increase in medication which then is tailed off and then they actually come back to their normal medication.



PORTER
Well we'll talk about transplants in more detail a little bit later but before we explore what's involved in that type of procedure and the challenges faced by both surgeon and patient I'd like to take a step back and look at the more conventional approaches to correcting facial deformities caused by injury or indeed disease.



And it's not just about aesthetics - the way you look - restoring function is vital too. Vanessa Bryant lost two thirds of her jaw as a result of surgery to remove a malignant tumour. Over the last 15 years she's needed a series of reconstructive operations.



BRYANT
Looking at myself before the operations and then afterwards I felt that I'd improved quite a lot and people didn't stare at me so much in the street, I think that was the main sort of - I think the final arbiter is the person in the street really, if you're stared at constantly then that can be obviously quite demoralising. But that's much less now, I mean I still get some looks but not anything like I used to get. And so I feel now that the position I am in, in that I am able to go out and not be stared at, is really to me what's the most important thing. Function as well, just because you take a face from someone and put it on someone else it doesn't magically mean that that - even if the face doesn't get rejected - it doesn't mean it magically works.



PORTER
Ken Lavery is consultant facio-maxillary surgeon at one of the UK's leading plastic surgery centres - the Queen Victoria Hospital in East Grinstead. And one of the first specialists likely to be called in to see someone with a significant facial injury.



LAVERY
We try to break it down into the first operation being the biggest operation, to try, for instance, if you see a really serious facial injury - we've had a couple of youngsters in recently who've rolled their car and have gone through fence posts and they've lost a lot of tissue. You try and put everything back because the face is a privileged area, it's not like orthopaedic injuries, where the blood supply's not very good, you're worried about infection, the face is really privileged. So the first operation is very much to put back all the anatomy that you've got.



PORTER
And by privileged you mean that it can take quite a lot of insult and recover?



LAVERY
Yeah absolute, it can take a real - much more insult than, for instance, a lower limb could or even an arm, it's got a great blood supply and it's got a blood supply which actually even tiny pieces of tissue, critical pieces of tissue, like eyelids will survive, pieces of bone that you wouldn't think about would survive in the leg will survive in the face.



PORTER
So if somebody has part of their mandible jaw bone removed, either because of cancer or because it's horrendously injured in a gun shot wound or something, what are you replacing it with, how are you rebuilding it?



LAVERY
Well we take whatever bone we can. There are various sites we use, we commonly use the fibula, which is a bone ...



PORTER
Shin bone.



LAVERY
... shone bone in the lower leg, it's the sort of small bone opposite the shin bone, not the main shin bone, otherwise you'd fall over. But we can take about between 15 and 18 centimetres of the fibula, provided we leave enough to keep the ankle joint stable. And we can use that, that's a fairly useful piece of bone to replace a mandible.



PORTER
But that's a straight piece of bone, so what ...



LAVERY
It is absolutely. Well we have to be quite clever in doing what's called osteotomies, we have to make - we have to do some sophisticated carpentry.



PORTER
Is this sort of cutting the bone, like taking a wedge out of the bone, and then folding it over?



LAVERY
Absolutely.



PORTER
That must be - that's multiple procedures is it?



LAVERY

Yeah but it's got to be done at the time when you do it because you actually have to cut the bone, do the osteotomies, put the plate on and then offer that up. We very often use, for instance, these models - these are templates - and we will take a template from the model and then the laboratory technicians will tell us ideally what we want.



PORTER
These templates are interesting, I mean looking at this it's a slice through someone's skull effectively and you're making these from 3D CAT scan or MRI scans?



LAVERY
Absolutely, 3D CAT scans.



PORTER
And then some sort of clever modelling.



LAVERY
Yes, they just - they're literally just modelled from a polypropylene material, which in fact is liquid when it's dipped and gradually over the period of time it builds up and you can go from a mandible or you got to a whole maxilla, showing the orbits, or you can just take a piece. This chap here, that we're looking at here, has no upper jaw at all, he has - again it's a post-traumatic case that unfortunately got very infected abroad and he lost his upper jaw effectively. And he requires the whole of his maxilla to be reconstructed. So we use this to try and plan what we're going to do in terms of reconstruction.



PORTER
Baljit Dheansa is a consultant plastic surgeon at the Queen Victoria with a special interest in burns - another common cause of severe facial disfigurement where, once again, early expert intervention is crucial, particularly to prevent contraction or shrinkage of the tissues caused by scarring.



DHEANSA
One of the approaches that certainly most burns surgeons are taking nowadays is to take a very aggressive approach to healing. The quicker a burn heals anywhere the less contracture one's likely to have. If it's possible to get a patient's burns healed within two weeks or so then we know that the amount of contracture associated with that injury is going to be less.



PORTER
When do you make your decision that the skin there isn't going to heal properly on its own and you need to graft, what's the deciding factor there?



DHEANSA
There's clinical appearance, so we know how burns can change in appearance according to their depth. Burns which are quite deep tend to be quite pale and leathery, compared to ones that are going to heal, which are quite red and have lots of blister fluid. And to help us with that we also use something called a laser dopler machine, which uses light that's reflected from the skin to give an estimate of the blood supply within that skin.



PORTER
We've talked about the functional problems of scarring or contraction but what about the aesthetics? One of the things that I would imagine would worry people who've burnt themselves very badly is what they're going to look like at the end and they must ask that fairly early on, how do you talk to them about that?



DHEANSA
At the Queen Victoria Hospital we've got quite a good set up. We know that there's a significant psychological morbidity associated with burns to the face and elsewhere.



PORTER
And by morbidity you mean?



DHEANSA
Anxiety and fear because they don't know what's going to happen. And so we have a psychotherapist and a nurse councillor as well as the nursing and medical staff all working towards assessing this patient and see when they're particularly ready to come to terms with looking at their burn injury and also giving them coping strategies for when they do see their faces or their other burnt areas.



PORTER
There's obviously tremendous individual variation but when would you think about showing them?



DHEANSA
Really when most of the areas are healed. They'll often have dressings on their face for a long time, when they're skin grafted they'll often have dressings to protect the skin grafts. So it's really at the stage when the skin graft's mostly stuck that they will have an opportunity to see their face and it's at that point that we really talk through with them as to what they would like to do and when they would like to do it because it's a big step for them, they have had a long time to think about what sort of appearance they're going to have and they will have also seen the reactions of their relatives and loved ones to how they are seen.



PORTER
Surgeons Ken Lavery and Baljit Dheansa talking to me in East Grinstead about existing plastic surgery approaches to managing facial injury.



This is Case Notes, I'm Dr Mark Porter and I am discussing face transplants with my guest plastic surgeon Peter Butler.



Peter, surgeons have been using flaps of tissue from patients, I mean I'm thinking of things like taking a flap of muscle or skin from the chest and swinging it up on to the side of the face as a way of repairing nasty injuries to the face. What's different about a transplant I presume is that the tissue that you're putting there is designed to work as a face?



BUTLER
Well the face is a very specialised structure and at the moment what we borrow - we borrow tissue from elsewhere in the body like the thigh or the back or some other region which it produces a facsimile but not a wonderful facsimile for the facial tissues it's supposed to be replacing. So it doesn't really function like a face and the idea for facial transplantation is actually to replace what's missing, which is really facial skin tissue. The eyelid skin is very thin in comparison to say the cheek skin, so has very different types of function. So if all the face is destroyed or damaged following an injury it's very difficult to reconstruct it in a way that functions like a normal face with tissue from the rest of the body.



PORTER
And forgetting function for a moment, just looking at the way things look, the aesthetics. Skin from another part of the body looks very different as well, doesn't it, and that's why it's often quite obvious when you see people who've had skin grafts or bits of tissue stuck on, it does look different from a normal face.



BUTLER
It does, it is improving all the time, we are getting better at matching but the skin, say, of the abdomen will tan slightly differently, will have different hair follicle distribution, so will always be slightly different than the rest of the face.



PORTER
What sort of injuries do you think are particularly suited to face transplantation?



BUTLER
We're talking about people with severe facial injury, somebody following a burn or similar injury where all of the face has been affected by the injury and the patient has undergone a reconstructive process. And so we're looking for somebody that's two to three years following that, the end of the reconstructive process, so they're fairly stable. And we're looking for people that may have a functional problem - whose eyelids don't work very well or mouth doesn't work well - and the idea would be is to replace the scar tissue and reconstructive tissue that doesn't allow the face to function as well as it should with what's missing, which is facial tissue.



PORTER
So is that the first stage, I mean let's look at the steps you have to go through as a surgeon, is the first stage to prepare the patient for the new "face"?



BUTLER
In the operative procedure it would first of all you'd have to remove the old scar tissue that's impairing the muscles of facial movement as well as the previous reconstruction to remove this tissue to allow then - to free up the muscles that have been impaired by that previous reconstruction. Then take a face off a donor, with its blood supply, and then that is then transferred onto the recipient and the blood vessels are joined back up with a microscope to re-establish the blood supply to that skin envelope that's replacing the scar tissue.



PORTER
You mentioned the blood supply but what about the nerve supply as well, because presumably if you're shifting muscle across that that requires nerves and sensation - you want to be able to feel your face?



BUTLER
We plan to take some of the sensory nerves with the skin envelope but actually because we're freeing up the muscle of the actual recipient, we're not actually transplanting muscle with the graft.



PORTER
So the architecture of their face would remain underneath so they'd be able to move their face as per normal, that's their existing muscles, it's just that the top - the upper layers that you're putting back on.



BUTLER
That's correct.



PORTER
And by reconnecting the nerves how good a sensation would you get from that?



BUTLER
Sensory recovery is actually pretty reasonable. The reason we've steered away from motor and motor nerves, those are the nerves that cause the muscles to move, is that their recovery may be unpredictable and sometimes not very good in cases of certain types of the nerves that are in the face. So that's why we've avoided that approach.



PORTER
We mentioned a little earlier the concept of rejection, this is foreign tissue to the people who are receiving it, their immune system tries to get rid of it. We suppress that with drugs. Is that likely to be successful, presumably we've learnt quite a lot by organ transplantation which has been going on for many years?



BUTLER
Yes we've learnt a lot from not only organ transplant but also the hand transplants that have taken place - there have been 24 hands in 18 patients world wide. None have been lost because of problems with immuno-suppression. So it looks very good in regards to the survival data from hand transplant which is really the best analogy to a face transplant because of similar tissue.



PORTER
And what about the degree of function that you hope to get? You talked about eyelids, I mean that's a very complicated, very delicate movement the eyes. Do you expect these people to have normal eyelid function or close to?



BUTLER
Well it depends obviously where we start from. If we start where the eyelashes and some of the muscle underneath is still intact then when we resurface with the skin of the eyelid that actually should return good function. In regards to how the rest of the face will function, the only really group that we have that will give us a good idea of what'll happen is the faces that have been replanted, faces where they have been [indistinct word] removed because of accident.



PORTER
So putting the person's own face back on.



BUTLER
Own face back on, yes. And so looking at - there's only been four in the world and three really available for follow up and they get about a 70-80% return of function, so that's what we can presume would be the functional recovery following this type of transplant.



PORTER
Well face transplantation may be technically possible, but it can't go ahead unless people are prepared to include their face in the list of organs and body parts they are willing to donate after their death.



A shortage of donor organs is already the main limiting factor in more established forms of transplant surgery so will people really be willing to donate their face? Claudia Hammond went to find out.



PHONE RINGING
Hello transplant coordinators, Rebecca speaking. You have a referral of a patient. Okay, which intensive care unit are you in? And have you spoken to the family about organ donation?



HAMMOND
At the West London Transplant Centre, the staff have the task of matching up those in desperate need of organs with suitable donors. Anyone who carries a donor card or joins the register online is free to decide which parts of their body they'd be prepared to donate in the event of their death.



VOX POPS
I do have a donor card and I've thought quite a lot about it actually and I don't think I would really mind what they take of mine because by that stage it wouldn't be any use to me and if it can help somebody else I really wouldn't mind what part of my body they took.



I had one once, 10 years ago, but not since then no. I think losing the card in the first place, I don't know whether it's conscious or subconscious, but I do think there was an element of - it wasn't something that's very nice to have in your wallet. Any time you pull out a tenner and you've got this card there, it makes you feel a bit edgy.



As far as I'm concerned once I'm dead I'm happy to donate any of my parts if they're useful to anybody.



HAMMOND
Fidelma Murphy is the leader of the North West Thames Regional Transplant Coordinator's team.



MURPHY
As you can see from the cards there's an A and a B. A is where it says any of my organs or tissues. Or B you actually can take kidneys, lungs, corneas, liver, heart, pancreas and so you can choose whichever you would prefer.



HAMMOND
And what do you find that most people do?



MURPHY
Some people attach different emotional thoughts to different parts of their body. For example, obviously the heart is quite an emotive organ so some people feel strongly that they prefer not to donate that. Other times you find people who fill out organ donor cards don't have problems about internal organs but actually when you discuss tissues, such as corneas or skin and bone etc., they prefer not to go down that avenue and say no.



HAMMOND
And do you think that's because they haven't seen what's internal, so we don't really know ...



MURPHY
Yes I think so, there's no emotion to it is there, we don't know what it looks like. But you will have other people who think that if they believe in an afterlife maybe that if they donate the corneas of their eyes that they won't be able to see afterwards. I can remember a lady saying to me that her husband was a pilot and his eyes were his living and it was his eyes that she fell in love with in the first instance, so she didn't mind donating everything else but she wanted to keep the eyes.



HAMMOND
There are concerns that if face transplants become more common it might put some people off carrying donor cards. Alex Clarke is consultant clinical psychologist in plastic and reconstructive surgery at the Royal Free Hospital in London.



CLARKE
What we did was to ask people in two different studies about how likely it was that they would donate a face. But also how likely it was that they would donate or receive any other kind of tissue as well. And what we found was that the highest level of donation was for things that people are very familiar with like kidney and then you could draw a curve. The thing that was - people had the most questions about were things that they were less familiar with and that was hands and faces, also corneas, which was quite interesting. We were very pleased to find that when we explained properly what was planned and when we dealt with people's concerns about the issue most people could see that this was a perfectly reasonable thing to do. And our levels in the populations that we sampled were something like 70% in favour of donating and receiving a face and happy to do so, given the right circumstances.



MURPHY
If you're from a cultural background or a religious background who has open caskets or who view the body afterwards they're more likely to say no obviously to external body tissues because they feel that it may upset some of the people involved in the funeral. Whereas within other cultures who choose cremation they seem to be less worried.



VOX POPS
If that can help someone I'll be quite happy to do it. As long as my relatives don't see me, you know.



HAMMOND
Would you be worried about the person with the transplant looking like you?



VOX POPS
Oh no, no, no I think she would be a very happy person to have a very good looking face.



If it included my face? I don't think I would mind that because from what I know I don't think the recipient would look like me and I think it is just a matter of needing the tissue and the bits and bobs from my face, rather than actually taking off a mask and putting it on somebody else.



I think it would be another box I wouldn't check, yeah, I think I'd just find it a bit disgusting to be honest. But I think also there is an element of the aesthetic, that it's me, my face is kind of who I am.



HAMMOND
In Alex Clarke's study the issue of identity was the biggest concern amongst those who weren't keen on the idea of face transplants.



CLARKE
They were worried about the concept of someone walking down the street and seeing the face of some - a loved one on somebody else, kind of nightmarish idea, so I mean it would be dreadful to think that your children had just seen their father walking down the street weeks after he'd died, what an awful thought. So what we then moved on was to do some modelling using computer images to try and demonstrate just how much of identity was passed on.



HAMMOND
And you've got a couple of these pictures here. Let's have a look at these. So what we have here is a picture of a woman, which happens to be you, and a picture of a man, which is your colleague. These presumably are the before pictures. And then what are the after pictures?



CLARKE
What we've done is used a laser scanner to scan in the faces of both of us and then we've put the superficial skin envelope of each of us on to the bony skeleton of the other, so the pictures you're looking at are a picture of me with Peter's face and a picture of Peter with my face.



HAMMOND
Certainly with these pictures there'd be no chance of recognising this picture is you in the street.



CLARKE
What they show actually is that you create something of a third face.



PORTER
Claudia Hammond reporting there.



James Partridge underwent five years of reconstructive surgery to his face after he was badly burnt in an accident over 35 years ago. He is the founder of Changing Faces - a charity that supports and represents people with facial disfigurement - whatever the cause.



James, you've been quoted in the past as being scornful, I put this in inverted commas, scornful of the "face race" - the race to be the first person or team to perform a face transplant. What worries you about the technique?



PARTRIDGE
I think the idea of a race is something that I [indistinct word] and I still hold considerable reservations about. These are very, very important developments.



PORTER
Is that something that the media - is the face race a term that the media have come up with, is it actually a race or is that how it's perceived?



PARTRIDGE
I think it's been perceived in the media as a race. We were very keen for the Royal College of Surgeons to come up with an authoritative view because many of the people that were contacting Changing Faces were asking - so what view should we take on this? Clearly many of them are seeking advice on what sort of surgery to undertake and they are wanting the very best information that they can possibly get. And when a new development like this comes up people say well hey is this possible and if so what are the risks, how should I, as a potential recipient of this, look at it? And so we were very from the outset really concerned that realistic expectations about this new surgery was spread, not just to potential recipients like myself but to the wider public too. So that there would be no misunderstandings.



PORTER
Do you think it's been misrepresented?



PARTRIDGE
I think the whole link with Hollywood movies and so on is unfortunate because I think this ...



PORTER
You're referring to the John Travolta film where basically his character swapped faces completely with somebody which is utter nonsense obviously.



PARTRIDGE
This is a technique that may well have value for people with very severe disfigurements when all other conventional surgery has proved difficult or problematic in whatever way. And our issues are really about making sure that the best possible fully informed consent is given to the patient and the family, so that they know exactly what they're going in to.



PORTER
Do you see it as a welcome addition to the options that are available to people with the severest type of disfigurement?



PARTRIDGE
Yes it is. But I don't think it's something that will be available for very many people - there are 400,000 people with different disfigurements of one sort or another and I think the selection of who those potential recipients is very, very problematic and it's certainly not going to be the panacea, the fix it.



PORTER
James Partridge from Changing Faces, thank you very much.



Gus McGrouther is Professor of Plastic and Reconstructive Surgery at the University of Manchester and I asked him for an insider's view on how facial transplantation had been received within the profession.



MCGROUTHER
I think doctors are a microcosm of society. There are people who are very much for it and those who are violently against. And there's a happy mean.



PORTER
They're obviously a major advance, this sort of operation's obviously a major advance in treating some cases of severe facial injuries but does its introduction suggest that we've perhaps exhausted other avenues of development?



MCGROUTHER
No I think we're working on other avenues. This is obviously for certain selected cases, very severe cases. If a patient has no face then they don't have many choices open to them. And people can lose their face from cancer, severe injury, animal bites, accidents of various sorts, severe burns. So for the patient who has really no other option this is a good opportunity.



PORTER
Looking back over your own case load over the last 10 years there must have been an awful lot of people who really didn't have another option but of course face transplantation wasn't available, so what was being offered to these people?



MCGROUTHER
Well there are patients who are hidden away around the world. I receive letters from Africa and China, from patients with terrible deformities, patients who are so deformed that they will never go out of their home. And there are patients out there who do need this sort of very radical approach to solve their problem.



PORTER
So there might be people that you yourself have met that you perhaps might consider in future putting forward for this sort of operation?



MCGROUTHER
Yes, I can recall cases - early in my career I saw a girl who had been scalped in an agricultural machine, she'd lost her entire skull and her forehead and for a case like that where a transplant would give really very good function - it would give hair growth - then I think that sort of case it would be justifiable.



PORTER
Professor Gus McGrouther talking to me earlier. Peter Butler, one of the pioneers of facial transplantation in the UK, is with me in the studio.



Peter, we've discussed the medical and surgical challenges involved or some of them but what about the psychological effects of living with effectively somebody else's face?



BUTLER
That is obviously a significant issue and the key to that really would be in the patient's selection process because what we're looking for is psychological robustness in how to deal with a facial transplant which will be a change in identity yet again. So of the indicators - some of the things that give us a clue to how they might challenge - our faces challenge - will be how they have faced the challenge in the past.



PORTER
And can you - can you predict who might do well psychologically, based on certain psychological criteria?



BUTLER
There are a number of key issues, I mean one is around say the issue of compliance which is how will you take your medications and deal with taking drugs - immuno-suppression drugs - and there are some risk factors in regards to that. The young patient doesn't do too well from the renal transplant data and so that's another issue about how we might select the patient. Sometimes females don't do as well as males and so there's issues around other endeavours that have taken place before to give us indication.



PORTER
Briefly where are we now, can we expect the first transplantation here in the UK this year?



BUTLER
We have got ethical committee approval to start selection and we have worked out psychological and surgical screening selection criteria for people seeking facial transplantations, so that's the stage we're at now. And we're at the moment reviewing patients that have come forward to ask to be reviewed for facial transplantation. The next step is an educational one, following that then they will then be presented as a panel to the ethical committee at the Royal Free and following that we may or may not do a facial transplant. But that has yet to be understood.



PORTER
We have to end it there. Peter Butler thank you very much.



Don't forget you can listen to any part of the programme again by visiting the website at bbc.co.uk/radio4.



Next week I'll be finding out about recent advances in preventing and treating strokes - including a sea change in attitude that means a stroke should now be regarded as a medical emergency and treated with the same urgency as a suspected heart attack.


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