The object of this face-changing operation in the United States is a 25-year-old man named Dallas Wiens. Three years ago, as a construction worker, he was unfortunately electrocuted at work, resulting in serious damage to facial skin, lips, nose and eyebrows below the forehead, blindness and loss of facial touch and smell. Since the injury, what wiens longed for most was to smell his three-year-old daughter and feel her kiss one day. However, dozens of previous plastic surgery failed to help him realize this wish. Earlier this month, this Boston hospital performed the first full face transplant for wiens in the United States. The operation lasted 15 hours, and more than 30 medical staff worked together to successfully transplant nose, lips, skin, muscle and nerve tissue for wiens. Due to some serious nerve injuries, some of his cheeks and forehead still can't regain their sense of touch after the operation, but according to wiens's grandfather, he has been able to talk to his family on the phone, at least in a short time, and the operation has been successful. The cost of the operation is funded by the US Department of Defense, hoping to accumulate experience and help soldiers with serious facial injuries in the future. Wiens was chosen among thousands of candidates. The doctor said that wiens was chosen because the test showed that wiens was a determined person with a positive attitude and a correct understanding of the operation.
On May 9, wiens, who appeared publicly after the operation, was with her daughter.
From the case of "face-changing" surgery in the United States, we can see that the so-called full-face transplantation in modern medicine is actually very different from the situation in the movie "FACE/OFF". The former is only applicable to patients with severe facial damage caused by illness or trauma, and is not implemented because of cosmetic needs. Face transplantation has strict requirements in patient selection and operation execution. In addition, the psychological and ethical problems accompanying this operation can not be ignored. In fact, whole face transplantation has always been controversial. In a survey of burn plastic surgeons in 2007, although 78.7% doctors admitted that the existing medical technology could not meet the needs of all patients with facial injuries, only 26.2% doctors agreed to perform CTA (Composite Tissue Allograft) on the basis of immunosuppression. More 10% doctors are against all CTA. Why is this?
CTA is a general term for a kind of operation, including hand transplantation, abdominal wall transplantation and face transplantation. Compared with traditional organ transplantation (such as liver transplantation and kidney transplantation), CTA is unique in that the tissue type of the graft is more complex, involving more functions, more difficult to operate and less experience. Among them, facial transplantation is particularly prominent. Face involves not only appearance, but also expression, vision, breathing, chewing, feeling (smell, touch) and other functions. Facial disfigurement will not only bring the above obstacles, but also have a great impact on patients' social interaction and mental health. For a long time, despite the continuous progress of plastic surgery technology, it still can not meet the needs of some critically ill patients to reconstruct their faces. In this case, "face transplantation" has become the final choice for such patients.
Face transplant is a good idea, but it won't happen overnight. 1963, a group of Ecuadorian surgeons first tried hand transplantation. The importance of hands is self-evident. If hand transplantation is feasible, it will undoubtedly be a great encouragement for those patients who have lost their ability to work. However, the result of this adventure was disappointing: due to the lack of powerful immunosuppressants, the transplanted hand had a strong rejection reaction three weeks after operation and had to be removed. The appearance of 1976 cyclosporine A once again aroused people's interest in hand transplantation. The transplanted hand lasted for 300 days, but the strong skin rejection failed the operation. Until the end of 1990s, the appearance of combined immunosuppressive drugs greatly improved the anti-rejection effect, and three groups of medical staff in France, the United States and China finally achieved successful hand transplantation respectively. Because the tissue structure of the hand is similar to the face (such as muscles, bones, motor and sensory nerves, small blood vessels, etc.). ), the success of hand transplantation has aroused people's enthusiasm for face transplantation.
However, facial transplantation was questioned a lot from the beginning. So far, there are only about ten cases of total transplantation in the world. The reason why this happens is that there is widespread controversy in the medical field about CTA for facial transplantation. Different from the life-saving purpose of solid organ transplantation such as liver and kidney transplantation, facial transplantation can be said to be an operation with the main purpose of improving the quality of life, but its risk and difficulty are no less than those of traditional organ transplantation. Last year, a full face transplant in Spain took 30 medical staff and took 24 hours. It was a marathon operation. In 2009, a full face transplant in France took 30 hours. Such a long period of anesthesia and medical operation is a difficult test for patients and doctors. Postoperative patients have to face strong rejection, especially the rejection of skin tissue, which requires long-term and high-dose anti-rejection drugs. Excessive rejection will nullify the pre-operative work, large doses of drugs will test the immune system of the body, and the chances of serious infection, organ failure and malignant tumor will greatly increase. Therefore, the risks and benefits of facial transplantation and other operations are still unknown. Perhaps the patient can recover some facial functions after surgery, but whether this improvement in quality of life is worth exchanging with such high-risk surgery, lifelong medication and cancer risk remains to be discussed.
In the doctor's eyes, the patient who underwent the operation is still a healthy person although his face was destroyed. But acute rejection after operation is almost inevitable. Most patients who have received face transplantation have experienced many acute rejection reactions, and some patients even died of it. This will make the operation face an ethical dilemma-even if the operation is carried out at the patient's strong request. The medical profession has even formulated eight ethical standards for this kind of surgery, including innovative scientific background, skilled and experienced team, open process, evaluation by experts and the public, reliable institutional ethical atmosphere, sufficient animal experimental research foundation, informed consent of patients, necessary surgical premise, and acceptance of regulatory review by relevant institutions.
According to the survey, doctors mainly tend to use transplantation for patients with repeated facial reconstruction failures, extensive facial burns and serious facial tissue defects. The donor of the operation is also a big problem: it is necessary to ensure that the donor's blood type, sex, age, skin color and skin quality match the recipient, and the three-dimensional size of the transplanted tissue, especially the three-dimensional size of the maxillofacial bone, is also required to match the recipient. After these requirements are met, people find that the requirements of facial transplantation are much higher than those of solid organ transplantation. In China, because the concept of brain death has not been widely accepted, the source of donors is even scarcer. Even abroad, few people are willing to donate and agree to donate the faces of relatives and friends for transplantation.
Postoperative patient compliance is also a part to be considered. In the CTA that has been carried out, there are cases in which patients do not follow the doctor's advice and lead to death. There is also a face transplant in China: the patient's face was bitten by a bear and recovered well after operation. However, due to the remote residence of the patient, under the persuasion of "witch doctor", he stopped using anti-rejection drugs two years after operation and eventually died of organ failure. Considering that facial transplantation itself is only an operation to improve the quality of life, it is more necessary to consider the patient's compliance when choosing the surgical object, otherwise the harm brought by the operation will far outweigh the benefits. Before the operation, the patient's mental state should be evaluated and patient and meticulous education should be carried out. Many patients have high expectations for the effect of the operation. Once such patients find that the effect is not as good as expected after operation, they will have great negative emotions, which will lead to a rapid decline in compliance and eventually endanger themselves. There are also some patients who rely too much on the psychological comfort brought by the graft, so that when they have to take out the graft due to serious rejection, they adopt an irrational and uncooperative attitude. They would rather take medicine desperately than keep the graft, which will also do harm to themselves. These conditions are not uncommon in patients receiving transplantation. This kind of psychological evaluation is even more important for face transplantation. Doctors should not only fully inform patients of the purpose of operation, complications and the prospect of functional recovery after operation, but also ensure that patients can understand and accept everything brought by operation. Judging from the current records, patients who have received full face transplantation are often easy to identify with their new faces in the short term, but the long-term identification needs to be observed; Patients will reintegrate into society after operation, and the influence of social environment on patients' psychology will gradually appear. These are all areas that need to be evaluated.
A very important part of the controversy about facial transplantation is about the recovery of facial function after operation. Some people think that facial transplantation can't bring about the functional recovery of the face, "even partial recovery is impossible". However, from the current situation, the functional recovery brought by facial transplantation is still remarkable. The 2009 Yearbook of Plastic Surgery reviewed 7 cases of facial transplantation up to that year, among which several patients recovered their sense of touch of skin and mucosa, possessed some facial motor ability and language ability, and 1 patient even returned to work. This result is undoubtedly a great encouragement to the surgeon and his supporters. Last year, patients who underwent full face transplantation in Spain could not close their eyes and lips, but at least they could eat a liquid diet and speak simply. With the improvement of surgical techniques, the improvement brought by facial transplantation is still worth looking forward to.
Today, facial transplantation is still the ultimate means of facial reconstruction in controversy. The magical "face changing" in science fiction stories is far from being realized in medical practice, and its main obstacle is similar to other transplant operations: rejection caused by foreign bodies. To overcome this obstacle, only major breakthroughs such as artificial organs in basic medical research can be expected to be solved. Before that, what doctors can do is to constantly improve their surgical skills. First, they can achieve good facial reconstruction without transplantation. Secondly, I hope that once face transplantation is adopted, the facial function after transplantation can be better restored through technology.
Source: Eight Claws Author: Zhao Chengyuan (partially deleted)