Face transplantation: a brave or maverick surgery?

On November 27, 2005 two French surgeons and their teams dropped a bombshell: they performed a partial face transplant on a 38-year old female patient whose face had been mauled by a dog in May of that year. Worldwide several teams had been working on the various technical, scientific and ethical issues associated with face transplantation. Many experts and several scientific organizations in a number of countries had recommended caution and restraint and actually discouraged face transplantation at the present time.

We contacted several reputable centers and were delighted that so many experts agreed to write their views which we are proud to publish in this issue of the Journal. We are deeply indebted to all these experts. We are also happy to have received permission to reprint the Position Papers of the American Society for Reconstructive Microsurgery, the Royal College of Surgeons of England and France's Comite Consultatif National d'Ethique pour les sciences de la vie et de la sante. We also attempted to contact the surgeons: Professors Bernard Devauchelle and Jean-Michel Dubernard, who performed the surgery to ask them to write their views. Unfortunately, however, despite repeated attempts we were not able to reach them. We still would welcome their views and would be happy to publish them should they be interested in sharing them with us and our readers.

The surgery, the publicity and the reaction from professionals and lay public are reminiscent of the first cardiac transplant performed in 1967 in South Africa. At that time too, several centers had been working on the technical, scientific and ethical issues involved in organ transplantation, including cardiac transplantation, and the consensus at that time was that the world was not yet quite ready for this milestone. A surgeon, Christian Barnard, however, took the bold and possibly maverick step in 1967 and performed the first recorded successful human heart transplant. This was a thunderbolt that energized many centers throughout the world. Now, less than forty years later, cardiac transplantation, and transplantation of several organs are routinely performed. So what is the issue with face transplantation?

Experts agree that the technology to successfully perform a facial transplantation is available and is not an issue. Immunosuppression, on the other hand, is more problematic and more difficult to achieve and especially maintain in cases of facial transplantation than other organ transplantation because of the increased susceptibility to skin rejection. The relatively young age of the patient is another concern: would it be possible to successfully immunosuppress her for about 40 years and avoid the associated complications? The cost alone is astronomical. The main issue with face transplant, however, is neither in the scientific, nor economic arena, but in the ethical one.

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A main difference between facial and organ transplantation is that the latter is performed as a life saving measure. There are concerns about the former being performed essentially for aesthetic reasons. No one would question a liver transplant in a patient with liver failure: the successful transplant essentially saves the patient's life: without the transplant the patient would die. In that case the choice is fairly straight forward: transplantation or imminent death.

Face transplants on the other hand are not performed to save the patient's life, but rather to improve aesthetic appearance, and acceptance by oneself and by society. As such therefore they could be frowned upon. But should they? When the World Health Organization was instituted in 1948, it defined health as a "state of physical, mental and social well-being and not merely the absence of disease." By this definition, a person with a grossly deformed, malfunctioning face, who feels marginalized by society, is not healthy and could benefit from medical attention. The only difference between the patient with a disfigured face and one with liver failure is therefore essentially a matter of degrees. Neither is "healthy," and both may benefit from medical help. In fact, the goal of plastic surgery is not so much to save physical lives, but to enhance the quality of life by improving the patient's appearance and subsequently mental and social wellbeing. Various cosmetic procedures are accepted, so what is wrong with face transplant?

An important issue is that of potential failure and complications of face transplant. Given our present state of knowledge, most experts believe that the question is not whether the face transplant will fail, but when will it fail? The issue of rejection is pivotal and radically different in facial than in other organ transplants. If, for instance, a liver transplant fails, the patient will not be much worse than before the transplant and hopefully another one may be done. In other words, performing the liver transplant would be an act of beneficence and if the transplant were not successful such would not be an act of malfeasance, but merely an unfortunate complication to be corrected.

Not much is known about unsuccessful face transplant. It is, however, very probable that the patient will be worse, probably much worse, after the unsuccessful transplant than before the surgery. Here the 2 principles of nonmaleficence and beneficence become closely intertwined. The beneficence of the surgery could very easily become the malfeasance of the failure or rejection of the transplant.

Another important issue is that one's face is so unique, individual and characteristic of one's self. The psychological impact of having someone else's face instead of one's face must be tremendous and should be thoroughly assessed before the surgery.

This brings on the issue of informed consent. It is comforting to read that the patient who underwent the face transplant had been extensively counseled before her operation. One wonders, however, how can the consent be truly "informed" if the potential sequelae, not only physical, but especially emotional are not known? The patient's informed consent is further clouded by her psychological background.

Before rushing in and performing the surgery should the two French surgeons have waited for most of the issues concerning face transplant to be solved, not only the technical ones, but especially the ethical and moral ones? Looking back at the history of medicine, boldness was often the catalyst to the introduction of new methodologies. It is doubtful that all the issues concerning anesthesia had been worked out before it was first administered. Similarly none of the issues pertaining to antibiotic therapy had been sorted out before penicillin was first administered. Indeed there was not even enough medication to last more than 5 days. And yet, although the patient did not survive, his temporary, but remarkable improvement ushered in the era of antibiotics. In a way it is regrettable that the use of penicillin had to be delayed by more than a decade because Sir Alexander Fleming who first discovered it in 1928 felt that its toxicity may outweigh its potential benefits. Could the same be said about face transplantation?

It is worrisome that virtually all the world experts and scientific organizations at the present time condemn face transplantation on scientific and ethical grounds. They are concerned that not only is the time not ripe for this procedure, but, given our present state of knowledge, this procedure may put at risk the patient's wellbeing, undermine the painstaking efforts of several dedicated groups and jeopardize the future of face transplantation.

Are the two French surgeons bold pioneers, or maverick opportunists? They took a daring leap forward against the consensus of many of their peers. Only time will determine whether this will be a small step for the two brave surgeons and a giant one for mankind or whether it will be a pathetic leap for the two surgeons, and a regrettable step backward for mankind. As always, we welcome input from our readers.

Whenever I climb I am followed by a dog called 'Ego'
--Friedrich Nietzsche

Ronald C. Hamdy, MD, FRCP, FACP 

Editor-in-chief