Vall d’Hebron performs the world’s first face transplant from a donor who had requested assisted dying

Of all the physical disabilities a person can suffer, facial disfigurement is one of the most devastating. It not only has a profound psychological and social impact on those affected, but also affects essential activities such as speaking, eating and seeing. “Face transplantation is a functional surgery, carried out when a patient has lost areas of the face, such as the orbicular facial muscles and eyes, which cannot be restored through standard Plastic Surgery techniques. These are patients with severe facial disfigurement due to disease, burns, trauma or congenital defects affecting basic vital functions", explains Dr Joan-Pere Barret i Nerín, Head of the Plastic Surgery and Burns Department at Vall d’Hebron University Hospital. Back in 2010, the Vall d’Hebron team led by Dr Barret performed the world’s first full face transplant, five years before a hospital in Amiens (France) carried out the first partial face transplant. The second face transplant at Vall d’Hebron in 2015 also marked the milestone of being the first transplant in the world performed in controlled asystole (Maastricht type III).

Now, Vall d’Hebron has performed the world’s first partial face transplant from a donor who had requested assisted dying. Before her requested assisted dying procedure (PRAM) was carried out, the donor not only decided to donate her organs and tissues but also offered her face for donation. “Donors and their families always perform an immense act of generosity and altruism, but this case also demonstrates a level of maturity that leaves one speechless. Someone who has decided to end their life dedicates one of their last wishes to a stranger and gives them a second chance of this magnitude", says Dr Elisabeth Navas, Medical Coordinator of Donation and Transplants at Vall d’Hebron University Hospital. The recipient required a type I face transplant (central part of the face) after suffering facial tissue necrosis from a bacterial infection.

Face transplantation is evaluated on an individual basis, case by case. Vall d’Hebron has performed three of the six face transplants carried out in Spain; worldwide, there have been a total of 54. Only about 20 centres in the world have the capacity to perform facial transplants, and only seven have performed three or more transplants given the expertise as well as the clinical and laboratory resources required. Around 100 professionals participate in each face transplant, including Plastic and Reconstructive Microsurgery, Transplantation, Immunology, Laboratory services, Psychiatry and Clinical Psychology, Rehabilitation, Intensive Care Unit, and Pathological Anatomy, to name just the main specialities involved. “Vall d’Hebron is a pioneering centre in donation and transplantation in Spain and, in addition to having all the central services, operating rooms, anaesthesia and care services required for these types of interventions, it has the professional expertise to carry out such complex procedures as face transplants. Even so, for each case we develop a specific, tailor-made protocol”, explains Dr Alberto Sandiumenge, Coordinator of Donation and Transplantation Programs at Vall d’Hebron University Hospital. Anesthesiology plays a key role in facial transplantation, ensuring patient stability through advanced monitoring, hemodynamic control, airway management, metabolic resuscitation, and bleeding control. All of this contributes decisively to the safety of the procedure and the success of the transplant.

The donor and recipient must share sex and blood group and have similar anthropometric measurements of the head. First, a biological assessment of both recipient and donor is carried out. The face projects the image that an individual shows to others and is closely linked to personal identity. As part of the recipient evaluation protocol, psychiatry, psychology and social work professionals, led by Dr María Sonsoles Cepeda and Dr Sara Guila Fidel, conduct an assessment that includes an interview with a trusted reference person, who will act as a liaison with the care team throughout the process. “It is assessed whether the candidate for a face transplant meets the criteria for the procedure beyond purely medical ones. Their capacity for adaptation, coping, expectations and adherence to treatment are evaluated. Psychiatric history, social and family support, and cognitive state are also considered", explain Dr Sara Guila Fidel and Dr María Sonsoles Cepeda. With all the reports, the candidate is evaluated by the Care Ethics Committee and the Vall d’Hebron Care Management Committee. If approved, the case is forwarded to Donation and Transplant Coordination at Vall d’Hebron, which elevates it to the Catalan Transplant Organization (OCATT) and the National Transplant Organization (ONT). The ONT performed the technical assessment to inform the Transplant Committee of the CIT-SNS (Spain’s Interterritorial Council of the National Health System, which gave favourable feedback so the procedure could be authorised by the competent regional authority, as required by transplant legislation.

Once all authorisations are obtained, the suitable donor must be identified, meaning someone without contraindications for donation and with facial anthropometric measurements compatible with the recipient. For the donor study, a CT scan was carried out on both donor and recipient, and the digital information was validated by radiology and engineers from Vall d’Hebron’s 3D Printing Unit. “The 3D Technologies Unit created a digital three-dimensional model from a medical image, a CT scan. This model helps professionals understand how to perform the surgery. We print it so professionals have references when needed before and during the procedure”, explains Laura Escot, biomedical engineer at the 3D Technologies Unit. A semi-rigid silicone mask was also designed and manufactured to apply to the donor’s facial area and reconstruct the surgical site. With engineers from IXOM, bone cutting guides adapted to the donor and recipient were also prepared to achieve a millimetre-perfect fit.

In parallel, the hospital’s plastic surgeons conducted the necessary anatomical studies and final surgical planning in the dissection room of the Anatomy Department at the UAB Faculty of Medicine, with the support of Professor Alfonso Rodríguez Baeza.

Face transplantation should be considered a composite tissue transplant. It is a field that has seen great evolution in recent years within Plastic Surgery, particularly in the development of Vascularised Composite Allotransplantation (VCA) techniques. Its foundation lies in microsurgical vascular and nerve techniques, both for extraction and implantation, to ensure maximum functionality, facial expressivity and sensitivity in the recipient, along with Plastic Surgery techniques, the only speciality accredited to perform facial plastic surgery treatments. In this regard, the Plastic Surgery and Burns Department at Vall d’Hebron University Hospital is a reference not only in Catalonia but also in the Balearic Islands and Andorra. All plastic surgeons involved are experts in reconstructive microsurgery and participate in the transplant programme, with a total of 17 plastic surgeons available and 10 resident doctors in the speciality. 
Skin, adipose tissue, peripheral nerves, facial muscles and facial bone are transplanted. The surgery is extremely complex, as the structures to be anastomosed and reconstructed are small and three-dimensional. Operations can last 15 to 24 hours in total. The goal is to reconnect all structures in the recipient, creating a new facial appearance that is functional and allows the patient to perform vital functions normally. Of the 100 professionals involved throughout the process, around 25 are nurses. “In a face transplant, nursing is present in all phases of the procedure, as in solid organ transplants, even before donation. In this case, two teams were synchronised: the Vall d’Hebron Donation and Transplantation and Plastic Surgery nursing teams”, explains Olga Gabaldà, Nursing Supervisor of the Organ and Tissue Donation and Transplant Programme.

After surgery, the patient was hospitalised for one month, first in the Burn Unit ICU and then on the ward of the Traumatology, Rehabilitation and Burns Hospital. Hospital stays have progressively shortened in the three face transplants carried out at Vall d’Hebron: from three months for the first patient in 2010, to two months for the second transplant in 2015, and one month for this latest case. At the hospital, the patient is stabilised, immunosuppressive medication levels are monitored, and possible complications, such as infections, are controlled. As soon as possible, facial rehabilitation begins to integrate mobility into the transplanted muscles and gradually restore functions such as chewing, gesturing and speaking. “Initially, the patient’s face is in a hypotonic phase, without movement, because the nerve connections are not yet established. We work with the face to stimulate innervation, using tools such as mirrors, different textures, images of the patient to recall movements and visual perception of the face”, explains Dr Daniela Issa, from the Physical Medicine and Rehabilitation Department. It is a daily process that the patient will continue at home and which will extend over time. Their involvement is crucial for functional recovery.

After the procedure, psychological support is offered to the patient in the immediate post-transplant period – to help them process body image changes and the effects of the surgery and medications – and in the second phase, from six months onward, to ensure independence and treatment adherence. The most recent face transplant patient at Vall d’Hebron is now adapting to a second life, made possible by the immense altruism of her donor. “On behalf of the ONT, I want to sincerely congratulate Vall d’Hebron for the excellence demonstrated. Every donation and transplant process is the result of a collective effort. In this case, an exceptional number of professionals from multiple disciplines participated, whose coordinated work ensured the utmost care, respect and support for the donor and her family, as well as a very high level of technical perfection to address a serious health problem in the recipient. Being able to perform procedures of this complexity with these results is a source of pride for the teams involved, the hospital and society as a whole”, says Beatriz Domínguez-Gil, Director General of the ONT.