Correspondence

Outcomes 18 Months after the First Human Partial Face Transplantation

N Engl J Med 2008; 358:2179-2180May 15, 2008

Article

To the Editor:

The acceptance of a partial face allograft as a promising procedure for patients with facial disfigurement will depend on long-term functional results. An impressive recovery of sensory function was reported by Dubernard et al. (Dec. 13 issue).1 This recovery of sensory function is understandable, given that the maxillary and mandibular nerves were resutured in the recipient's face. The recovery of motor function, however, remains a mystery, since only a single branch of the facial nerve (described by Dubernard et al. as “the inferior branch of the left facial motor nerve”) was resutured. Such a nerve branch does not exist in the human facial nerve. Moreover, the authors do not explain why a circumscribed reanimation on the left side of the lower face would lead to recovery of motor function on both sides of the midface as well as the right side of the lower face. The video does not provide a convincing explanation. Perhaps what we see in the video is just passive movement in the transplanted tissue due to the sutures holding the graft muscles to the conserved muscles of the recipient. The authors should present electromyographic data to document active movement in the graft. Without an active nerve supply, the graft musculature will undergo progressive atrophy.

Orlando Guntinas-Lichius, M.D.
Friedrich Schiller University Jena, D-07740 Jena, Germany
orlando.guntinas@med.uni-jena.de

1 References

1. 1

   Dubernard J-M, Lengele B, Morelon E, et al. Outcomes 18 months after the first human partial face transplantation. N Engl J Med 2007;357:2451-2460
   Full Text | Web of Science | Medline

Author/Editor Response

We surmise that the recovery of muscle function inside the face graft occurred mostly through a phenomenon of intramuscular innervation along the multiple bilateral sites of muscular anastomoses and not through axonal regeneration arising from the single, small nerve anastomosis that was performed on the lower left part of the transplant. All depressor muscles on the lower face had been avulsed completely, along with the right and left mandibular (or inferior marginal) branches of the facial nerves. We repaired the nerves on the left side of the face with the aim of reanimating the lower lip and the chin but could not do the same on the right side because the thin corresponding nerve was absent in the graft.1 Early in the postoperative period, dynamic motions in the face graft were apparently due to contractions arising from the recipient's remaining muscle bellies, transmitted to the homologous allogeneic muscles to which they were connected. We speculate that as intramuscular innervation progressed, motor-nerve ingrowth through anastomoses of the levator muscles resulted in secondary dynamic expressive motions, involving the midface muscle segments from the donor. Restoration of complete lip occlusion probably occurred as a result of both intramuscular innervation of the upper part of the orbicularis oris muscle and intraneural axonal regeneration inside its lower sling.

We also wish to clarify our statement in the Methods section regarding consent. We noted that the patient gave her consent for the face transplantation; we wish to add that she also gave her consent for publication of the manuscript and for development and release of the accompanying video.

Jean-Michel Dubernard, M.D., Ph.D.
Université Lyon 1, 69473 Lyon, France

Benoit Lengelé, M.D., Ph.D.
Université Catholique de Louvain, B 200 Brussels, Belgium

Bernard Devauchelle, M.D.
Amiens Nord University Hospital, 80054 Amiens, France

1 References

1. 1

   Devauchelle B, Badet L, Lengele B, et al. First human face allograft: early report. Lancet 2006;368:203-209
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Dalibor Vasilic, John H. Barker, Ross Blagg, Iain Whitaker, Moshe Kon, M Douglas Gossman. (2010) Facial Transplantation: An Anatomic and Surgical Analysis of the Periorbital Functional Unit. Plastic and Reconstructive Surgery 125:1, 125-134
   CrossRef

2. 2

   Chenggang Yi, Shuzhong Guo. (2009) Facial transplantation: lessons so far. The Lancet 374:9685, 177-178
   CrossRef