Specialists in Toronto are gearing up to perform Canada's first face and limb transplants, experimental procedures that push the boundaries of accepted surgical practice and can bolster the reputations of the doctors and institutions that perform them.
Provided they receive approval from hospital administrators, surgeons at the University Health Network and the Hospital for Sick Children hope to perform the first surgeries early next year and then do about five face transplants and up to 25 upper limb transplants a year.
The techniques are still risky and highly controversial. But doctors in Toronto say the surgeries are now far enough advanced that they believe they can go ahead with them safely. At the same time, the area is still so young they can position themselves as leaders in a rapidly growing field.
"That's what we're here for is to explore new techniques," said Ron Zuker, a plastic surgeon at the Hospital for Sick Children and co-director of the face and limb transplant program. "I think anybody who does it almost automatically is a leader."
Just 17 face transplants have been performed in France, Spain, China and the United States since the first successful partial transplant in France in 2005. Doctors in those same countries have replaced about 60 hands and one foot.
Face transplants are especially controversial because of the connection between a person's face and his or her identity. They also raise questions about whether it is ethical to perform risky, life-threatening surgery on patients who do not suffer from a deadly illness. To prevent rejection, patients must commit to a lifelong drug regimen that can cause severe side effects such as diabetes, lymphoma, depression and liver and kidney damage.
Even with the drugs, every face transplant recipient so far has had complications and two have died – one from a severe infection and another after he stopped taking anti-rejection treatment. Although limb-transplant patients have experienced fewer complications, there is early evidence that the limbs may be functional for only a few years, Dr. Zuker said.
"Everybody is making mistakes because this is new territory," he said.
The surgeries are expensive and resource-intensive. A face transplant costs about $400,000 and a hand about $250,000, far more than any other transplant surgery, said Gary Levy, director of the UHN Multi-Organ Transplant Unit.
Even so, Dr. Zuker said the surgery is worth doing for a limited number of people with severe deformities that cannot be fixed with conventional reconstructive surgery and that prevent people from leading normal lives.
"We are not doing this to make people pretty. We are doing it to make them function," he said, adding that the surgery could end up costing less than it would to do multiple procedures to try to reconstruct a face.
Dr. Levy said patients who might be candidates for the procedures will have to follow a strict protocol before they are accepted. It will include intensive psychological screening to be sure they are mentally fit enough to accept having a new face or limb. A team of at least 18 surgeons, ethicists, lawyers, psychologists, social workers and physical therapists will work on each case. After the surgery is performed, the patients will undergo an intensive program of physical and occupational therapy for at least a year and live near the hospital so they can get there quickly in case their body starts to reject the transplant.
Facial transplantation is becoming more widely accepted since doctors in Amiens, France, successfully replaced part of Isabel Dinoire's face after the mother of two was injured by her Labrador retriever. In the United States, the Defence Department funds the surgery for veterans who have come home from Iraq or Afghanistan with severe facial injuries.
Making new advances in leading-edge surgery can help to make or seal the reputations of those performing them. Surgeons involved in face and limb transplants have raced to see who can make the next advance the soonest, with competing teams trumpeting their latest success.
"It definitely brings recognition, and in keeping your place in the first tier of medical institutions, it definitely supports that," said Maria Siemionow, who performed the first full face transplant at the Cleveland Clinic three years ago.
Anna Pileggi, executive director of About Face, a support group for people with "facial differences," said she welcomes the possibility the treatment will be available in Canada but said she hopes scientists will tread carefully.
"This is not without consequence so we have to keep in mind why are we doing this and to whose benefit," she said. "It's the next level in science, it's the next level in medicine and you can get caught up in the potential, 'If I can be the one to drive that, wow, that's pretty big.' But is has to be the patients driving it and we have to be sure it's in the patients' best interests."