Two years after French doctors stunned the world with the first partial face transplant, other doctors remain cautious about pursuing the surgery.
The French patient, Isabelle Dinoire, has a new face that resembles and moves like the one she was born with. Her doctors celebrate how far she's come in an article this week in the New England Journal of Medicine.
"She's perfect,'' said Dr. Jean-Michel Dubernard, the lead surgeon on the operation, in an interview.
Her recovery has been remarkable but difficult. Dinoire's post-transplant life has been full of complications, including kidney failure and two episodes in which her body's immune system tried to reject the new skin.
At the two U.S. hospitals planning face transplants, doctors say it's hard to judge how well some treatments used by the French would work on other patients. They also questioned whether Dinoire can be depended upon to keep taking immune-suppressing drugs the rest of her life.
Failure to do so could lead to the face sloughing away. "It could lead to a disaster,'' said Dr. Bohdan Pomahac, a plastic surgeon at Brigham and Women's Hospital in Boston.
Dinoire had the transplant in November 2005, in an operation performed in Amiens, France. She was horribly disfigured six months earlier, when her pet Labrador chewed her face while she was passed out from an overdose of sleeping pills.
She lost the end of her nose, lips, chin and parts of her cheeks. "She was unable to speak, unable to eat. She was fed by a gastric tube,'' Dubernard said.
The donor was a brain-dead, 46-year-old woman. Doctors took not only her face but also bone marrow cells, which they injected into Dinoire shortly after the operation.
Skin transplants are highly susceptible to rejection, and it was clear Dinoire would need powerful doses of anti-rejection drugs. But the physicians hoped the donor bone marrow cells would help Dinoire's immune system accept the transplant.
Dinoire still suffered rejection symptoms twice: once a month after her surgery and again in June 2006. After the second episode, doctors started a treatment that exposed her white blood cells to ultraviolet radiation to weaken the immune response.
Meanwhile, her kidney function deteriorated, until one of the immune-suppressing drugs was replaced in the fall of 2006 and she improved.
She's also had a couple of small infections, including a cold sore on her new lip and tiny white pox across her cheeks.
Since Dinoire, two other partial face transplants have been reported.
Last year, a Chinese farmer received one after he was disfigured in a bear attack. In January, French doctors performed one on a man disfigured by a genetic condition. Dubernard said he was not involved in those operations.
Brigham and Women's Hospital is one of the U.S. hospitals gearing up to do face transplants. In May, doctors there won approval from the institutional review board, the hospital's gatekeeper for research projects. The program is working with an organ bank and expects to enroll patients next year, said Pomahac, who runs the Brigham program.
The Cleveland Clinic won approval from its in-house review board in 2004 and has been developing donor consent procedures and identifying patients who are most physically in need and most mentally capable of dealing with a transplant.
Alluding to reports that Dinoire's overdose was a suicide attempt, Siemionow called her "psychologically questionable as a candidate'' for a face transplant.
Siemionow declined to predict when the first transplant at her own hospital might occur.
Still, U.S. doctors marvel at the reported improvements in Dinoire's ability to eat and drink, feel sensations on her face, and talk and smile.
"This has been a very successful surgical exercise,'' said Dr. W.P. Andrew Lee, chief of plastic surgery at the University of Pittsburgh School of Medicine.
