ace transplantation, once a headline-inspiring medical treatment, is slowly moving toward mainstream medicine. Since the first such transplant in 2005, more than 40 of these procedures have been performed in more than 15 centers in nine countries. To acknowledge and support this shift, it’s time for insurers to step up and cover the cost.
For years, the standard treatment for devastating facial injuries and congenital defects was reconstructive surgery using tissue from other parts of the body. Surgeons aim to maximize the patient’s ability to breathe, eat, and see, while also restoring the natural, aesthetic appeal of the face. This approach includes numerous visits to the operating room, each of marginal benefit. The results are often suboptimal and may limit the individual’s ability to reintegrate into society.
Face transplantation, by comparison, restores the shape and composition of the face, returns motor and sensory functions, and makes possible the facial expression of emotion. The ability to restore facial form and function in one major operation is an improvement over conventional reconstruction. Face transplantation helps promote societal reintegration, improves the sense of self with psychological benefits, and increases quality of life.
Recipients of the procedure have been able to resume work, enjoy sharing meals in public, and partake in both recreational and leisure activities. But until it is covered by medical insurance, many people who need the procedure won’t be able to get access to it.
A face transplant is a lengthy and demanding operation with many potential risks and barriers. These include the operative and anesthetic risks of a longer than 20-hour surgery and mandatory lifelong immunosuppressive therapy, which increases the risk of developing diabetes, cancer, and serious infections.
An equally substantial barrier is the financial cost. One case study determined the immediate costs to be around $465,000 without including immunosuppressive therapy, which could match that figure over the recipient’s lifetime. Insurance companies will not entirely pay the cost because face transplant is still considered an investigative procedure. Private institutions and the government, through research grant money, have partially covered the expenses of the 14 face transplants in the United States. The recipients relied on personal savings and crowdfunding to cover the remainder.
What happens when the entire burden of payment falls onto the patients?
Almost $1 million is a lot to pay for a new face. It’s more than the cost of conventional face reconstruction, at least until gains in efficiency and experience lower the cost of transplantation. Yet a study done by transplant physicians at Brigham and Women’s Hospital in Boston, where more face transplants have been performed than in any other U.S. medical center, found that the cost profiles for both face transplantation and face reconstruction were similar after adjusting for the severity of the case.
The feasibility of insurance coverage for face transplants is increasing with recent changes in U.S. health policy.
Steps are being taken at a national level to standardize the practice of vascularized composite allotransplantation. This refers to the transfer of a body part containing multiple tissue types (skin, muscle, bone, nerves, and blood vessels) as a structural unit from a human donor to a human recipient. The U.S. follows the UNOS policy on vascularized composite allotransplantation that defined the face, limbs, abdominal wall, and genitourinary structures like the penis and uterus as transplantable organs under federal regulation and legislation.
New policies are being proposed to address barriers to vascularized composite allotransplantation donation, standardize accreditation for reconstructive transplant surgeons, and ensure patient safety. These are set to go into effect in September 2018.
At the local level, investigational procedures like face transplantation must abide by U.S. health policy and institutional ethical standards. But these don’t always overlap. An instance of this happened at Brigham and Women’s that complicated and prolonged the listing process for face transplant patients. During this time, a potential donor was found for one of the candidates but the donation could not be accepted. Insurance coverage for face transplant would allow for the listing process to be similar to common kidney transplants. This would remove additional steps that unwittingly limit patient access. Because what good is this process if a patient is left waiting as a donated organ goes unused?
Face transplantation should be recognized as meriting an increase in private and public funding to open up access to it. A leading surgeon in the field, Dr. Frank Papay, chair of the Cleveland Clinic’s Dermatology and Plastic Surgery Institute, believes that insurers don’t have enough data to assess how much of the total cost of a face transplant they should cover. But more data requires more face transplants, which is difficult with the current limits on patient access.
If insurers were to cover the cost at centers that have demonstrated expertise with face transplantion and its pre- and post-surgery management, they could help patients in need. This could ensure future patients a higher acceptance rate of donor organ matches. In return, increased access to care would yield more outcomes data for future expansion of coverage.
Face transplants should be an insurable option for the treatment of facial disfigurement. Just as there’s no question that kidney, heart, and other solid organ transplants — which insurance covers — can extend life, we should appreciate that transplants of the face can enhance life.
Miguel I. Dorante is a bioethicist and fourth-year medical student at Boston University School of Medicine who plans to pursue a career in plastic and reconstructive surgery and health policy. He has worked as an unpaid research trainee with the Center for Reconstructive and Restorative Surgery at Brigham and Women’s Hospital since June 2017.
Editor’s note: This article was revised to clarify the role of institutional review boards in the face transplant process.