What happens if a face transplant is rejected?: A Comprehensive Guide

September 21, 2025 •

4 min read

According to a 2024 JAMA Surgery study, despite significant risk, face transplant survival rates are encouraging, but the possibility of rejection remains a critical challenge. So, what happens if a face transplant is rejected? This article explains the clinical journey and outcomes.

Quick Summary

A face transplant rejection triggers an immune response with symptoms like swelling and redness, which doctors manage intensively with escalated immunosuppressive medication. If treatment fails, the transplant may need to be removed, requiring reconstructive surgery or, rarely, a second transplant.

Key Points

Early Detection is Key: Vigilant monitoring for signs like swelling, redness, and rash allows for prompt, effective treatment of rejection episodes.
Intensive Medication is Standard: Acute rejection is often managed by temporarily escalating doses of immunosuppressive drugs to control the immune response.
Irreversible Rejection is Possible: If medical interventions fail, the face transplant may need to be removed, requiring further reconstructive surgery.
Lifelong Commitment Required: Patients must take immunosuppressants indefinitely, which carries significant long-term health risks like increased susceptibility to infection and certain cancers.
Psychological Support is Crucial: The emotional and mental toll of a potential or actual rejection is immense, highlighting the need for dedicated psychological care throughout the process.
Chronic Rejection Causes Slow Damage: Unlike acute episodes, chronic rejection is a slow process that can lead to fibrosis, thinning skin, and other degenerative changes over time.
Sentinel Flaps Aid Monitoring: Surgeons often transplant a small, hidden piece of donor skin to help monitor for rejection without needing to biopsy the facial tissue.

The Immune Response to a Transplanted Face

The human body's immune system is designed to identify and destroy foreign invaders like bacteria and viruses. In the case of a face transplant, the immune system recognizes the donor tissue as foreign and mounts an attack against it, a process known as rejection. This is an unavoidable biological reality that all transplant recipients must face and manage for the rest of their lives through immunosuppressive medication. Rejection episodes can be acute, occurring suddenly, or chronic, developing slowly over years.

Acute Rejection: Early and Treatable Episodes

Acute rejection can occur at any time, but is most common in the first year following the surgery. It involves a swift and aggressive immune attack on the new tissue. Symptoms often include visual changes that can be detected through regular monitoring, such as:

Redness or a patchy, blotchy rash on the face
Swelling and puffiness
Changes in skin color
Dryness or skin thinning

To aid in monitoring, a small section of donor skin, known as a sentinel skin flap, is often transplanted to a less visible area of the body. If rejection begins, it will typically affect both the face and this flap, allowing for biopsies to be taken from the inconspicuous area instead of the face itself. Early detection is paramount, as acute rejection can often be reversed with prompt treatment.

Chronic Rejection: The Long-Term Threat

Chronic rejection is a more insidious and long-term process. It involves a continuous, low-grade immune attack that slowly damages the transplanted tissue over time. This can lead to fibrosis (thickening and scarring of the tissue), atrophy (wasting away of tissue), and gradual changes to the face's appearance and function. In some documented cases, chronic rejection has manifested as premature aging, tightening of the skin, or distinct discolorations. Chronic rejection is a primary cause of graft loss in the long run.

Medical Intervention for Rejection

When a rejection episode is suspected, the transplant team acts quickly. Diagnosis is often confirmed with a biopsy, and treatment is immediately initiated to suppress the immune system and halt the attack.

Standard Treatment Protocol:

Escalated Medication: For an acute episode, doctors will typically administer high-dose intravenous steroids to quickly reduce the immune response.
Drug Adjustment: The long-term maintenance immunosuppression regimen may be modified, with different combinations or dosages of medication used to better control the body's immune reaction.
Hospitalization: Patients may be admitted to the hospital for intensive IV drug therapy and close monitoring during severe rejection episodes.

The Dire Outcome: Irreversible Rejection and Removal

Unfortunately, not all rejection episodes can be reversed. If the immune attack is too severe or does not respond to intensive treatment, the rejection is deemed irreversible. In this rare but serious scenario, the transplant must be removed to prevent further complications. This decision is made by the transplant team in collaboration with the patient, and it represents a difficult and emotionally challenging moment for everyone involved.

Comparison of Acute and Chronic Rejection


Feature	Acute Rejection	Chronic Rejection
Onset	Sudden, often within the first year	Gradual, occurs over months or years
Mechanism	Vigorous immune attack on new tissue	Slow, ongoing immune-mediated damage
Symptoms	Redness, swelling, rash, tenderness	Fibrosis, skin thinning, premature aging, loss of function
Treatment	Intensive IV steroids, medication changes	Medication management to slow progression
Outcome	Often reversible with prompt treatment	Often irreversible; can lead to graft loss

Lifelong Immunosuppression and Its Risks

To prevent rejection, face transplant recipients must adhere to a strict, lifelong regimen of immunosuppressive medication. While these drugs are essential for graft survival, they also come with significant side effects because they weaken the body's natural defenses. These risks include:

Increased Infection Risk: A suppressed immune system makes the patient more susceptible to all types of infections, from common colds to more serious fungal or bacterial infections.
Kidney Damage: Long-term use of certain immunosuppressants can lead to kidney problems or failure.
Increased Cancer Risk: Immunosuppression is linked to a higher risk of developing certain types of cancer.
Metabolic Issues: These drugs can contribute to conditions like diabetes and heart disease.

The Emotional and Psychological Impact of Rejection

A face transplant is an intensely personal and life-changing procedure, and rejection adds another layer of profound psychological stress. Beyond the physical symptoms, patients may experience feelings of anxiety, depression, and grief over the potential loss of their new face. The emotional toll of a failed transplant can be immense, reinforcing the importance of comprehensive psychological support for patients and their families throughout the entire process.

Life After Graft Removal

If the transplant is removed due to irreversible rejection, the patient must again face extensive facial reconstructive surgery. Surgical options at this stage can include utilizing skin grafts and other tissues from different areas of the body, following a pre-planned reconstructive strategy. In extremely rare cases, a second face transplant may be considered, depending on the patient's health and the reason for the initial rejection.

For a detailed overview of the procedure and risks, you can visit the official Mayo Clinic page on face transplants.

Conclusion: Managing a Complex Medical Reality

What happens if a face transplant is rejected is a multifaceted medical challenge. While rejection is a constant risk that requires lifelong monitoring and medication, it is often treatable with prompt and aggressive medical intervention. However, in cases of irreversible rejection, the potential for graft loss and a return to conventional reconstructive procedures is a stark reality. The journey is not only a physical one but also a significant emotional and psychological one, highlighting the complexity and dedication required from both the patient and the medical team.

Frequently Asked Questions

Early signs of rejection can include redness, swelling, tenderness, and a rash-like appearance on the transplanted tissue. These symptoms should be reported immediately to the transplant team for evaluation.

Acute rejection episodes are relatively common, particularly within the first year after surgery. However, they are often manageable with medication adjustments. Irreversible chronic rejection leading to graft loss is less common but is a significant long-term risk.

Many rejection episodes can be successfully treated and reversed with prompt, intensive medical management, such as higher doses of immunosuppressive medication. The outcome depends on the severity and timeliness of the intervention.

If a transplant is irreversibly rejected, the tissue must be removed. The patient would then undergo conventional facial reconstructive surgery according to a pre-planned backup strategy or, in rare cases, receive a second transplant if eligible.

Treatment involves using higher, more potent doses of immunosuppressive drugs. This can heighten the patient's risk of infection and other medication side effects, necessitating close medical supervision.

Acute rejection is a sudden, more aggressive immune reaction that can occur at any time. Chronic rejection is a slow, ongoing process of low-grade damage to the transplanted tissue that develops over a longer period.

While the visual symptoms are often most apparent, patients may experience swelling, tenderness, or discomfort in the affected area. Any new or unusual physical sensation should be communicated to the medical team.

The emotional impact can be severe, leading to anxiety, depression, and grief. Patients invest significant emotional energy into the transplant, and rejection can feel like a profound loss, underscoring the importance of psychological support.