Long-term psychological and functional outcomes after facial transplantation: Lessons from two decades of experience

Facial transplantation (FT), a pioneering vascularized composite allotransplantation procedure since 2005, has transformed reconstructive surgery for severe facial disfigurement caused by trauma, burns, or congenital disabilities. This article synthesizes two decades of global experience, evaluating long-term psychological and functional outcomes from 48 procedures in 46 patients. FT significantly enhances quality of life (QoL), with patients reporting improved self-esteem, reduced depression (e.g., Beck Depression Inventory scores dropping from 16 to 8), and successful social reintegration, including workplace reentry and personal milestones. Functionally, FT restores critical abilities: 100% of cases achieved sensory recovery (thermal/mechanical) within 3–8 months, 76% improved facial expressions, and 93% regained independent breathing. Speech and swallowing often return to near-premorbid levels within 1–2 years. However, challenges persist, including universal acute rejection (reversible), chronic rejection (6% incidence, 14.6% graft loss), and immunosuppression-related risks like infections and malignancies, contributing to 10 patient deaths (21.7%). Ethical debates surround lifelong immunosuppression for a non-life-saving procedure and candidate selection complexities. The absence of FT-specific patient-reported outcome measures (PROMs) hinders standardized assessment. This review underscores the need for refined patient selection, multidisciplinary collaboration, and innovative immunological strategies (e.g., tolerance induction) to minimize risks. Advances in virtual surgical planning and AI-driven monitoring show promise. Continued research and global cooperation are essential to optimize FT’s transformative potential, ensuring sustainable, equitable access to this life-altering intervention.