French first to perform a partial face transplant; critics raise timing, recipient suitability issues

Jim Warren

The race to perform the world's first partial face transplant was won Nov. 27 by French surgeons when they transplanted a woman who had been severely disfigured after being attacked by her families' dog.

The surgical team, led by transplant pioneer Jean-Michel Dubernard, MD, grafted a nose, chin and lips from a brain dead woman donor, on the face of 38-year-old Isabelle Dinoire The surgery took place in Amiens, a city in northern France. She was later transferred to Edouard-Herriot Hospital in Lyon, where Dubernard works.

The surgery ignited a fierce debate in the worldwide transplant community, with questions ranging from the psychological suitability of the recipient to the timing of being put on the list for a face transplant shortly after receiving her injuries. Critics also raised their eyebrows over Dubernard's plan to give the woman an infusion of stem cells from the donor's bone marrow in an effort to prevent rejection of the new face.

Another complication following the surgery arose when the Sunday Times of London reported that Dinoire had admitted she sustained her injuries during a suicide attempt. The Times said she was mauled by her family's Labrador retriever after she took an overdose of sleeping pills and collapsed. She added that she thought the dog was trying to revive her, not maul her as reported.

Dubernard vigorously denied the Times allegation and has continued to insist that his patient had not tried to commit suicide but the charges continue to raise questions about Dinoire's mental stability to do what's necessary to keep the transplant from rejecting.

"No, no, no!" Dubernard said when asked if his patient had attempted to take her own life, the New York Times reported. He said the patient had taken two sleeping pills for insomnia after a family argument.

In an interview with Le Parisien newspaper, Dinoire said she was "doing very well," but did not address the question of whether she attempted suicide. "I would like to say one thing: I've just been operated on," Dinoire said. "It's beneficial for me to live these moments in peace. At the moment I feel bombarded."

"I just want my family to be left out of it. They didn't ask to be put on a stage," she added.

Further complicating the issue, Olivier Jarde', MD, an orthopedic surgeon at the hospital in Amiens where the transplant was performed, charged that the donor had also committed suicide by hanging herself. However, the family of the donor told the funeral director that handled the burial that her death was accidental, according to the Times.

The Surgeon

It seems fitting that Dubernard, 64, led the transplant team that performed the first face transplant. He is known worldwide as a pioneer who developed techniques to transplant pancreas glands, as well as other tissues, and he organized the surgical team that performed the world's second hand-forearm transplant in 1998 - the first was performed in Ecuador in 1964 before advances in immunosuppression and surgery.

Until now, Dubernard was perhaps best known, however, for leading the team that performed a hand transplant on Clint Hallam in 1998. The case generated enormous publicity in part because the press revealed that Hallam had lost his hand while serving in prison.

In the end Hallam caused a furor when he stopped taking his immunosuppressive drugs to prevent rejection and ultimately demanded that his transplanted hand be amputated.

However, Dubernard's team went on to perform successful hand-forearm transplants on two other patients, one who just celebrated his sixth anniversary of a functioning hand last January.

In a profile in the New York Times, Dubernard admitted he was hesitant about performing the partial face transplant until he saw the severity of the woman's wounds, noting she had difficulty speaking and eating, as food fell from her mouth.

Dubernard is also a politician who is one of the most powerful members of the French National Assembly who commutes to Paris two days a week to attend the French Parliament.

"There's a big brain behind him and a steely will that is willing to confront massive criticism," Thomas Starzl, MD, PhD, a transplant pioneer in his own right, told the Times. Starzl no longer performs surgery but is still engaged in research on tolerance at the University of Pittsburgh Medical Center.

The Patient

A week after the transplant, the Times of London reported Dinoire had signed a deal possibly worth $176,000 for photographs and a film of the face transplant operation. In a deal signed in August, three months before the operation or a donor was found, it was announced she agreed to let British documentary filmmaker Michael Hughes make the film.

Under the deal, Dinoire will keep the profits of the sale of the photographs and the film after deducting Hughes' costs and distribution fees.

Ethical Issues

Many ethicists were critical that the transplant may have been undertaken without adequate ethical preparation. Dubernard denied the charge and said the operation met all French ethical and legal standards and that psychiatrists had examined the patient and found her to be an acceptable patient to receive the transplant.

Others, like Maria Siemionow, MD, director of plastic surgery at the Cleveland Clinic who hopes to perform the first face transplant in the US, were critical of the two protocols - the transplant of the face and infusion of stem cells in hopes of preventing rejection - because they may make it difficult to determine the cause of success or failure of the transplant.

"Ethics aside, it will make it difficult to get clean answers," she told the New York Times. "If it works, why does it work, and if it goes wrong, was it the transplant or the stem cells."

Other critics charged the transplant was performed months after the woman's injury and before conventional reconstructive surgery could be attempted.

What's next?

China announced on December 9 that experts at a military hospital have the ability to perform facial transplants.

Hong Zhijian, director of the plastic surgery section at the General Hospital of Nanjing Military Commands in east China's Jiangsu Province, said many patients are seeking facial transplants but a suitable patient is still being sought.

"When all the conditions are right, we can carry out facial transplants at once," Hong said, according to Chinadaily News.

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