- Email: [email protected]
Disorders of the autism spectrum
Comment
Over the past 3 years, we have been working to clarify what resources and skills WHO needs (and does not need) to carry out its mandate. Those decisions reflect a continuing evolution in WHO. They depend on what our core functions are, and a forecast of the future challenges and opportunities: the global health agenda. WHO’s roles and functions are redefined in this agenda, and the related management reforms and programme budgets take them forward. The repeated themes are of increased accountability, and of adjustment to a functional shape and structure that allows us to work best, providing the right kind of resources promptly. This is work that is relevant beyond WHO, and which we are sharing with others in the UN system to support reform. In the successful completion of the Health Assembly’s agenda, and the flood of messages and support from all sides that followed Dr Lee’s death, the central theme was one of commitment to sustain progress and to deliver. This Health Assembly was a meeting that pressed on with its agenda, and worked out solutions, even when they were on subjects as contentious as intellectual property rights. The position of Director-General is similarly complex, allowing for a range of decisions that are personal, political, and corporate. That is why it matters very much indeed who the next incumbent will be. We will soon know. As a result of the Executive Board’s negotiations, Member States agreed on a process to accelerate the consideration of candidatures, and the election of the new Director-General will be completed on Nov 9, 2006. In one sense, the question of where we are heading is amply answered by looking at the mandates given by our Member States.
This is a fascinating and crucial time for WHO. We have been given the green light on so many issues of pressing public-health significance by our Member States—our constituency. We know that we have their support and motivation to put those plans into action, and we intend to do just that. With my team, I am dedicated to continuing the directions set by Lee Jong-wook, and also to give our full support to the new Director-General so that WHO can go on to play an even more active role in world health. Anders Nordström Acting Director-General, WHO, Geneva 1202, Switzerland [email protected] I declare that I have no conflict of interest. 1 2
3
4 5
6 7
8
9
10
WHO. Application of the international health regulations. 2005: http://www. who.int/gb/ebwha/pdf_files/WHA59/WHA59_2-en.pdf (accessed July 3, 2006). World Health Assembly. Eleventh general programme of work 2006–2015: resolution. May 27, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/ A59_R4-en.pdf (accessed July 3, 2006). WHO. Eleventh general programme of work 2006–2015: foreword. April 24, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_25-en.pdf (accessed July 3, 2006). WHO. The world health report 2006: working together for health. 2006: http://www.who.int/entity/whr/2006/en/index.html (accessed July 3, 2006). WHO. Prevention and control of sexually transmitted infections: draft global strategy. May 18, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/ A59_11-en.pdf (accessed July 3, 2006). WHO. Reproductive health. April 15, 2004: http://www.who.int/gb/ebwha/ pdf_files/WHA57/A57_13-en.pdf (accessed July 3, 2006). WHO. Multi-country study on women’s health and domestic violence: initial results on prevalence, health outcomes and women’s responses. 2005: http://www.who.int/entity/gender/violence/who_multicountry_ study/en/index.html (accessed July 3, 2006). Global Polio Eradication Initiative. Global polio eradication initiative: annual report. May, 2006: http://www.polioeradication.org/content/publications/ Annual Report2005_ENG05.pdf (accessed July 3, 2006). WHO. Resolution WHA 57/9: global strategy on diet, physical activity and health. April 17, 2004: http://www.who.int/gb/ebwha/pdf_files/WHA57/ A57_9-en.pdf (accessed July 3, 2006). WHO. Preventing chronic diseases: a vital investment: WHO global report. 2005: http://www.who.int/chp/chronic_disease_report/en/ (accessed July 3, 2006).
Disorders of the autism spectrum In today’s Lancet, Gillian Baird and colleagues1 report a prevalence of pervasive developmental disorders or autism spectrum disorders of 116·1 per 10 000, much higher than previously thought. The researchers base these findings on a total population cohort of 56 946 children aged 9–10 years in 12 districts in southeast Thames, UK, with ICD-10 criteria.2 For subtypes, the prevalence was 38·9 per 10 000 for childhood autism and 77·2 per 10 000 for other pervasive developmental disorders. Nearly 60% of pervasive development www.thelancet.com Vol 368 July 15, 2006
disorders as a whole was atypical autism in accordance with recent UK3 and Swedish4 studies, which reported that about one half of pervasive developmental disorders was a not otherwise specified subtype, a DSM-IV equivalent of atypical autism.5 Baird and colleagues did not give the prevalence of the other three subtypes (ie, Rett’s syndrome, childhood disintegrative disorder, and Asperger’s syndrome), because they found no cases of the first two. The researchers identified seven cases who met Asperger’s syndrome criteria, but classified these
See Articles page 210
179
Comment
Science Photo Library
We do not have the rights to reproduce this image on the web.
cases as childhood autism because the seven cases also satisfied childhood autism criteria. Until the end of the 1980s, the prevalence of infantile autism (the former name of childhood autism) had been reported to be 4–5 per 10 000. In the late 1980s, three epidemiological studies in Japan6–8 reported a high prevalence of infantile autism ranging from 13·0 to 15·5 per 10 000. These rates were the harbinger of the high prevalence of childhood autism reported by European3,4,9 and American10,11 researchers since the end of the 1990s. Those studies found no ethnic difference in the high prevalence of pervasive developmental disorders. Baird and colleagues convincingly present an increased prevalence of pervasive developmental disorders (autism spectrum disorders) and their subtypes in a large child population and with sound methods. What is the cause for the high prevalence of pervasive developmental disorders reported for the past decade? There are two lines of explanation. One explanation is a true rise of the incidence of pervasive developmental disorders. Although genetic factors are the most important part of the cause of childhood autism and other varieties of such disorders, even though responsible genes are still unknown except in Rett’s syndrome, no 180
study has ever clarified the rising prevalence of pervasive developmental disorders from this aspect. Instead, several studies suggested a causal relation of some environmental factors with pervasive developmental disorders. Of those, measles-mumps-rubella vaccine and thimerosal, a mercury-containing vaccine preservative, were two prime suspects. However, among many other compelling lines of evidence, the continuous increase in the incidence of pervasive developmental disorders after cessation of use of measles-mumps-rubella vaccine in a northern district of Yokohama city, Japan,12 and of thimerosal-containing vaccine use in Denmark13 is a strong and overwhelming refutation for any such suspicion. The other explanation is the improvement in case ascertainment for pervasive developmental disorders because of worldwide introduction of ICD-10 and DSM-IV diagnostic criteria of childhood autism and other pervasive developmental disorder subtypes since the early 1990s. These criteria somewhat broadened yet clarified the concept of childhood autism and other subtypes of pervasive developmental disorders. The criteria have helped professionals diagnose the pervasive developmental disorder subtypes more reliably, stimulated establishment of early detection systems for such disorders, and increased public awareness of them. While evidence for the increased incidence of the pervasive developmental disorder remains absent, it is reasonable to attribute the recent surge in the prevalence of disorders to improved ascertainment. Such progress seems to have resulted in the identification of a greater number of high-functioning (intelligence quotient ≥70) pervasive developmental disorders,9,12 which are harder to detect than those disorders with mental retardation because of their milder autistic symptoms, in the past decade that contributed to the increased prevalence of pervasive developmental disorders. Baird and colleagues also show an important way of diagnosing childhood autism and other pervasive developmental disorders. They placed a consensus ICD-10 diagnosis by experienced clinicians on the basis of all available information before the Autism Diagnostic Interview-Revised (ADI-R),14 which identifies childhood autism but no other subtypes of pervasive developmental disorder. This diagnostic procedure is informative for researchers in non-English-speaking countries, where it is virtually impossible to use a local language version of the ADI-R. www.thelancet.com Vol 368 July 15, 2006
Comment
I hope that Baird and colleagues’ study will stimulate work on pervasive developmental disorders to establish service systems for people with such disorders.
6
Hiroshi Kurita
8
Zenkoku Ryoiku Sodan Centre, 2-2-8 Nishiwaseda, Shinjuku-ku, Tokyo 162-0051, Japan [email protected] I declare that I have no conflict of interest. 1
2 3 4
5
Baird G, Simonoff E, Pickles A, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006; 368: 210–15. WHO. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization, 1993. Chakrabarti S, Fombonne E. Pervasive developmental disorders in preschool children. JAMA 2001; 285: 3093–99. Gillberg C, Cederlund M, Lamberg K, Zeijlon L. Brief report: “the autism epidemic”: the registered prevalence of autism in a Swedish urban area. J Autism Dev Disord 2006; 36: 429–35. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn (DSM-IV). Washington, DC: APA, 1994.
7
9
10
11 12 13
14
Matsuishi T, Shiotsuki Y, Yoshimura K, Shoji H, Imuta F, Yamashita F. High prevalence of infantile autism in Kurume City, Japan. J Child Neurol 1987; 2: 268–71. Tanoue Y, Oda S, Asano F, Kawashima K. Epidemiology of infantile autism in southern Ibaraki, Japan: differences in prevalence in birth cohorts. J Autism Dev Disord 1988; 18: 155–66. Sugiyama T, Abe T. The prevalence of autism in Nagoya, Japan: a total population study. J Autism Dev Disord 1989; 19: 87–96. Baird G, Charman T, Baron-Cohen S, et al. A screening instrument for autism at 18 months of age: a 6-year follow-up study. J Am Acad Child Adolesc Psychiatry 2000; 39: 694–702. Bertrand J, Mars A, Boyle C, Bove F, Yeargin-Allsopp M, Decoufle P. Prevalence of autism in a United States population: the Brick Township, New Jersey, investigation. Pediatrics 2001; 108: 1155–61. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of autism in a US metropolitan area. JAMA 2003; 289: 49–55. Honda H, Shimizu Y, Rutter M. No effect of MMR withdrawal on the incidence of autism: a total population study. J Child Psychol Psychiatry 2005; 46: 572–79. Madsen KM, Lauritsen MB, Pedersen CB, et al. Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data. Pediatrics 2003; 112: 604–06. Lord C, Rutter M, Le Couteur A. Autism Diagnostic Interview-Revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J Autism Dev Disord 1994; 24: 659–85.
Repair of a human face by allotransplantation The reconstruction of the body is a challenging task in medicine, especially when pioneering surgeons push technical frontiers forward to reach their vision for the benefit of humanity. Human nature reveals that individual steps are met with criticism which emphasises the status quo (or that which we feel safe in knowing). Bernard Devauchelle and colleagues have reached a new milestone by repairing a severely damaged face with a face allograft, as described in today’s Lancet.1 The aesthetic outcome of the procedure, although not perfect, has proved better than that of conventional methods. Established techniques for repairing the human face use autologous local cutaneous tissue-flaps and free-flap autografts, which allow the transfer of more complex components such as skin, bone, and muscle. Local flaps, such as bilobed, nasolabial, or forehead skin-flaps, often produce good results in the face.2 But to reconstruct the face of the woman presented by Devauchelle and colleagues would have proved a major challenge to any surgeon. It is difficult to conceive that the same degree of success in the restoration of her complex perioral structures—including lips, nerves, and functioning mimic muscles—would have been possible with existing techniques. Another advantage in the technique presented is that the need to harvest autologous flaps is www.thelancet.com Vol 368 July 15, 2006
avoided; such harvesting produces secondary defects that might compromise the donor site severely. Devauchelle and colleagues have circumvented the disadvantages posed by established reconstructive techniques in the same way as for any other organ transplant: they harvested all the tissue required for reconstruction of this intricate area from an HLA-matched donor. The success of their procedure is evident not only in the acceptable cosmetic outcome, but also because the patient regained masticatory function and an improved ability to speak. Despite her lack of functioning mimic muscles, this reconstruction restored sufficient selfconfidence that the patient was willing to show her face in public again—in the popular media no less. Despite the success of this technique, there remains a major disadvantage. Unlike other commonly transplanted organs, such as the heart or liver, musculocutaneous grafts like facial structures are histologically heterogeneous and contain tissue components that express different degrees of antigenicity (such as epithelium or glands).3 The allotransplantation technique of Devauchelle and colleagues mandates substantial lifelong immunosuppression to prevent rejection. Failure of the regimen chosen could prove devastating, with the possible loss of the transplanted face at any time. Chronic rejection is also a concern, given the visibility of the transplant.
Published Online July 4, 2006 DOI:10.1016/S01406736(06)68937-X See Comment page 183 See Articles page 203
181
Over the past 3 years, we have been working to clarify what resources and skills WHO needs (and does not need) to carry out its mandate. Those decisions reflect a continuing evolution in WHO. They depend on what our core functions are, and a forecast of the future challenges and opportunities: the global health agenda. WHO’s roles and functions are redefined in this agenda, and the related management reforms and programme budgets take them forward. The repeated themes are of increased accountability, and of adjustment to a functional shape and structure that allows us to work best, providing the right kind of resources promptly. This is work that is relevant beyond WHO, and which we are sharing with others in the UN system to support reform. In the successful completion of the Health Assembly’s agenda, and the flood of messages and support from all sides that followed Dr Lee’s death, the central theme was one of commitment to sustain progress and to deliver. This Health Assembly was a meeting that pressed on with its agenda, and worked out solutions, even when they were on subjects as contentious as intellectual property rights. The position of Director-General is similarly complex, allowing for a range of decisions that are personal, political, and corporate. That is why it matters very much indeed who the next incumbent will be. We will soon know. As a result of the Executive Board’s negotiations, Member States agreed on a process to accelerate the consideration of candidatures, and the election of the new Director-General will be completed on Nov 9, 2006. In one sense, the question of where we are heading is amply answered by looking at the mandates given by our Member States.
This is a fascinating and crucial time for WHO. We have been given the green light on so many issues of pressing public-health significance by our Member States—our constituency. We know that we have their support and motivation to put those plans into action, and we intend to do just that. With my team, I am dedicated to continuing the directions set by Lee Jong-wook, and also to give our full support to the new Director-General so that WHO can go on to play an even more active role in world health. Anders Nordström Acting Director-General, WHO, Geneva 1202, Switzerland [email protected] I declare that I have no conflict of interest. 1 2
3
4 5
6 7
8
9
10
WHO. Application of the international health regulations. 2005: http://www. who.int/gb/ebwha/pdf_files/WHA59/WHA59_2-en.pdf (accessed July 3, 2006). World Health Assembly. Eleventh general programme of work 2006–2015: resolution. May 27, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/ A59_R4-en.pdf (accessed July 3, 2006). WHO. Eleventh general programme of work 2006–2015: foreword. April 24, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/A59_25-en.pdf (accessed July 3, 2006). WHO. The world health report 2006: working together for health. 2006: http://www.who.int/entity/whr/2006/en/index.html (accessed July 3, 2006). WHO. Prevention and control of sexually transmitted infections: draft global strategy. May 18, 2006: http://www.who.int/gb/ebwha/pdf_files/WHA59/ A59_11-en.pdf (accessed July 3, 2006). WHO. Reproductive health. April 15, 2004: http://www.who.int/gb/ebwha/ pdf_files/WHA57/A57_13-en.pdf (accessed July 3, 2006). WHO. Multi-country study on women’s health and domestic violence: initial results on prevalence, health outcomes and women’s responses. 2005: http://www.who.int/entity/gender/violence/who_multicountry_ study/en/index.html (accessed July 3, 2006). Global Polio Eradication Initiative. Global polio eradication initiative: annual report. May, 2006: http://www.polioeradication.org/content/publications/ Annual Report2005_ENG05.pdf (accessed July 3, 2006). WHO. Resolution WHA 57/9: global strategy on diet, physical activity and health. April 17, 2004: http://www.who.int/gb/ebwha/pdf_files/WHA57/ A57_9-en.pdf (accessed July 3, 2006). WHO. Preventing chronic diseases: a vital investment: WHO global report. 2005: http://www.who.int/chp/chronic_disease_report/en/ (accessed July 3, 2006).
Disorders of the autism spectrum In today’s Lancet, Gillian Baird and colleagues1 report a prevalence of pervasive developmental disorders or autism spectrum disorders of 116·1 per 10 000, much higher than previously thought. The researchers base these findings on a total population cohort of 56 946 children aged 9–10 years in 12 districts in southeast Thames, UK, with ICD-10 criteria.2 For subtypes, the prevalence was 38·9 per 10 000 for childhood autism and 77·2 per 10 000 for other pervasive developmental disorders. Nearly 60% of pervasive development www.thelancet.com Vol 368 July 15, 2006
disorders as a whole was atypical autism in accordance with recent UK3 and Swedish4 studies, which reported that about one half of pervasive developmental disorders was a not otherwise specified subtype, a DSM-IV equivalent of atypical autism.5 Baird and colleagues did not give the prevalence of the other three subtypes (ie, Rett’s syndrome, childhood disintegrative disorder, and Asperger’s syndrome), because they found no cases of the first two. The researchers identified seven cases who met Asperger’s syndrome criteria, but classified these
See Articles page 210
179
Comment
Science Photo Library
We do not have the rights to reproduce this image on the web.
cases as childhood autism because the seven cases also satisfied childhood autism criteria. Until the end of the 1980s, the prevalence of infantile autism (the former name of childhood autism) had been reported to be 4–5 per 10 000. In the late 1980s, three epidemiological studies in Japan6–8 reported a high prevalence of infantile autism ranging from 13·0 to 15·5 per 10 000. These rates were the harbinger of the high prevalence of childhood autism reported by European3,4,9 and American10,11 researchers since the end of the 1990s. Those studies found no ethnic difference in the high prevalence of pervasive developmental disorders. Baird and colleagues convincingly present an increased prevalence of pervasive developmental disorders (autism spectrum disorders) and their subtypes in a large child population and with sound methods. What is the cause for the high prevalence of pervasive developmental disorders reported for the past decade? There are two lines of explanation. One explanation is a true rise of the incidence of pervasive developmental disorders. Although genetic factors are the most important part of the cause of childhood autism and other varieties of such disorders, even though responsible genes are still unknown except in Rett’s syndrome, no 180
study has ever clarified the rising prevalence of pervasive developmental disorders from this aspect. Instead, several studies suggested a causal relation of some environmental factors with pervasive developmental disorders. Of those, measles-mumps-rubella vaccine and thimerosal, a mercury-containing vaccine preservative, were two prime suspects. However, among many other compelling lines of evidence, the continuous increase in the incidence of pervasive developmental disorders after cessation of use of measles-mumps-rubella vaccine in a northern district of Yokohama city, Japan,12 and of thimerosal-containing vaccine use in Denmark13 is a strong and overwhelming refutation for any such suspicion. The other explanation is the improvement in case ascertainment for pervasive developmental disorders because of worldwide introduction of ICD-10 and DSM-IV diagnostic criteria of childhood autism and other pervasive developmental disorder subtypes since the early 1990s. These criteria somewhat broadened yet clarified the concept of childhood autism and other subtypes of pervasive developmental disorders. The criteria have helped professionals diagnose the pervasive developmental disorder subtypes more reliably, stimulated establishment of early detection systems for such disorders, and increased public awareness of them. While evidence for the increased incidence of the pervasive developmental disorder remains absent, it is reasonable to attribute the recent surge in the prevalence of disorders to improved ascertainment. Such progress seems to have resulted in the identification of a greater number of high-functioning (intelligence quotient ≥70) pervasive developmental disorders,9,12 which are harder to detect than those disorders with mental retardation because of their milder autistic symptoms, in the past decade that contributed to the increased prevalence of pervasive developmental disorders. Baird and colleagues also show an important way of diagnosing childhood autism and other pervasive developmental disorders. They placed a consensus ICD-10 diagnosis by experienced clinicians on the basis of all available information before the Autism Diagnostic Interview-Revised (ADI-R),14 which identifies childhood autism but no other subtypes of pervasive developmental disorder. This diagnostic procedure is informative for researchers in non-English-speaking countries, where it is virtually impossible to use a local language version of the ADI-R. www.thelancet.com Vol 368 July 15, 2006
Comment
I hope that Baird and colleagues’ study will stimulate work on pervasive developmental disorders to establish service systems for people with such disorders.
6
Hiroshi Kurita
8
Zenkoku Ryoiku Sodan Centre, 2-2-8 Nishiwaseda, Shinjuku-ku, Tokyo 162-0051, Japan [email protected] I declare that I have no conflict of interest. 1
2 3 4
5
Baird G, Simonoff E, Pickles A, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006; 368: 210–15. WHO. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva: World Health Organization, 1993. Chakrabarti S, Fombonne E. Pervasive developmental disorders in preschool children. JAMA 2001; 285: 3093–99. Gillberg C, Cederlund M, Lamberg K, Zeijlon L. Brief report: “the autism epidemic”: the registered prevalence of autism in a Swedish urban area. J Autism Dev Disord 2006; 36: 429–35. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn (DSM-IV). Washington, DC: APA, 1994.
7
9
10
11 12 13
14
Matsuishi T, Shiotsuki Y, Yoshimura K, Shoji H, Imuta F, Yamashita F. High prevalence of infantile autism in Kurume City, Japan. J Child Neurol 1987; 2: 268–71. Tanoue Y, Oda S, Asano F, Kawashima K. Epidemiology of infantile autism in southern Ibaraki, Japan: differences in prevalence in birth cohorts. J Autism Dev Disord 1988; 18: 155–66. Sugiyama T, Abe T. The prevalence of autism in Nagoya, Japan: a total population study. J Autism Dev Disord 1989; 19: 87–96. Baird G, Charman T, Baron-Cohen S, et al. A screening instrument for autism at 18 months of age: a 6-year follow-up study. J Am Acad Child Adolesc Psychiatry 2000; 39: 694–702. Bertrand J, Mars A, Boyle C, Bove F, Yeargin-Allsopp M, Decoufle P. Prevalence of autism in a United States population: the Brick Township, New Jersey, investigation. Pediatrics 2001; 108: 1155–61. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of autism in a US metropolitan area. JAMA 2003; 289: 49–55. Honda H, Shimizu Y, Rutter M. No effect of MMR withdrawal on the incidence of autism: a total population study. J Child Psychol Psychiatry 2005; 46: 572–79. Madsen KM, Lauritsen MB, Pedersen CB, et al. Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data. Pediatrics 2003; 112: 604–06. Lord C, Rutter M, Le Couteur A. Autism Diagnostic Interview-Revised: a revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. J Autism Dev Disord 1994; 24: 659–85.
Repair of a human face by allotransplantation The reconstruction of the body is a challenging task in medicine, especially when pioneering surgeons push technical frontiers forward to reach their vision for the benefit of humanity. Human nature reveals that individual steps are met with criticism which emphasises the status quo (or that which we feel safe in knowing). Bernard Devauchelle and colleagues have reached a new milestone by repairing a severely damaged face with a face allograft, as described in today’s Lancet.1 The aesthetic outcome of the procedure, although not perfect, has proved better than that of conventional methods. Established techniques for repairing the human face use autologous local cutaneous tissue-flaps and free-flap autografts, which allow the transfer of more complex components such as skin, bone, and muscle. Local flaps, such as bilobed, nasolabial, or forehead skin-flaps, often produce good results in the face.2 But to reconstruct the face of the woman presented by Devauchelle and colleagues would have proved a major challenge to any surgeon. It is difficult to conceive that the same degree of success in the restoration of her complex perioral structures—including lips, nerves, and functioning mimic muscles—would have been possible with existing techniques. Another advantage in the technique presented is that the need to harvest autologous flaps is www.thelancet.com Vol 368 July 15, 2006
avoided; such harvesting produces secondary defects that might compromise the donor site severely. Devauchelle and colleagues have circumvented the disadvantages posed by established reconstructive techniques in the same way as for any other organ transplant: they harvested all the tissue required for reconstruction of this intricate area from an HLA-matched donor. The success of their procedure is evident not only in the acceptable cosmetic outcome, but also because the patient regained masticatory function and an improved ability to speak. Despite her lack of functioning mimic muscles, this reconstruction restored sufficient selfconfidence that the patient was willing to show her face in public again—in the popular media no less. Despite the success of this technique, there remains a major disadvantage. Unlike other commonly transplanted organs, such as the heart or liver, musculocutaneous grafts like facial structures are histologically heterogeneous and contain tissue components that express different degrees of antigenicity (such as epithelium or glands).3 The allotransplantation technique of Devauchelle and colleagues mandates substantial lifelong immunosuppression to prevent rejection. Failure of the regimen chosen could prove devastating, with the possible loss of the transplanted face at any time. Chronic rejection is also a concern, given the visibility of the transplant.
Published Online July 4, 2006 DOI:10.1016/S01406736(06)68937-X See Comment page 183 See Articles page 203
181