TUCSON, Ariz. Jan. 19 - The French woman who received the world's first face transplant is reportedly doing well, but her surgeons are concerned that all their preparation and hard work could go up in smoke.
The 38-year old woman, identified as Isabelle Dinoire, has renewed her smoking habit, which could interfere with her recovery, and might even jeopardize the integrity of her transplant, surgeons reported at the 6th Annual International Symposium on Composite Tissue Allotransplantation here.
In the pioneering procedure performed last November in Amiens, France, Dinoire received a nose, chin and lips from a brain-dead donor to repair facial disfigurement she suffered after being mauled by her dog about seven months earlier.
The mauling occurred when the woman was reportedly heavily sedated after taking sleeping pills, in what may have been a suicide attempt, although Jean Michel Dubernard, M.D., the transplant-team leader, has denied this.
Although the tissue grafts appear to have taken well, and the patient is said to be pleased that she can once again go out in public without attracting undue attention from her appearance, she still has little sensation in the transplant area, and is unable to smile or fully control her facial muscles, the surgeons acknowledged.
Maria Siemionow, M.D., director of plastic surgery research at the Cleveland Clinic, who is planning to perform a similar procedure in the near future, said that it may be a year or longer before its known whether the patient's facial muscles will work again.
Both critics and supporters of facial transplant surgery agree that cigarette smoking can significantly impair tissue healing through a variety of mechanisms, including constriction of blood vessels and decrease in circulating oxygen levels.
"The main problems with chronic smoking during wound healing are an increased rate of infection and increased rate of flap failure," said Victor Neel, M.D., Ph.D., director of dermatologic surgery at Massachusetts Genera; Hospital in Boston, in an interview.
"Some surgical closures require a very delicate procedure - and of course a face transplant is the ultimate high-risk procedure - where the blood supply is compromised," Dr. Neel said. "Light-to-heavy smokers have something like a six- to tenfold increased risk of the skin flap dying. Smoking also decreases immune surveillance, so if the wound is contaminated, the body has less ability to fight if off,."
Dermatologists have a term for the effects of tobacco on skin: "smoker's face," defined as premature deep wrinkling and discoloration of facial skin. According to the American Academy of Dermatology, white women such as Dinoire are particularly susceptible to premature skin aging from smoking.
The woman also faces the risk of tissue rejection and a lifetime of immunosuppressant therapy. She had an episode of acute rejection in December that was treated with increased doses of immunosuppressants, and is now doing well, her doctors said.
The apparent clinical success of the face transplant procedure appears to have taken the edge off some of the criticism directed at the French transplant team. Dr. Dubernard and colleagues had been accused of rushing headlong into the procedure, without sufficient regard for the ethical questions surrounding the procedure or for the mental health of the recipient.
At a session Wednesday night announcing preliminary results of the surgery and discussing the patient's progress, several prominent transplant surgeons and immunologists rose to defend the French team, saying that it had proceeded cautiously and adhered to standards of reconstructive surgery.
The face-transplant surgeons had also been criticized for giving to Dinoire bone marrow from her tissue donor in an attempt to dampen the recipient's immune response to foreign tissues.
Immunologist Suzanne T. Ildstad, M.D., director of the Institute for Cellular Therapeutics at the University of Louisville, told the New York Times that the addition of a bone marrow graft was appropriate because other transplant teams had used it, some with encouraging results.