Face transplantation: the view from Birmingham, England.

The news that the world's first partial face transplant had been performed in France on 27th November 2005 was greeted with a mixture of emotion by the medical profession and public alike. On the one hand this was a groundbreaking procedure with the potential to help many people, on the other there was a fear and fascination with a procedure that sounds not far removed from science fiction. (1,2) Part of the problem has been a misunderstanding of the practice and goals of facial transplantation fueled by imagination of this becoming a cosmetic procedure or of a Hollywood "Face Off" style change of appearance. The reality of course is quite different and the potential of facial transplantation to help the severely disfigured is genuine. All the media that have covered the story have commented that there are ethical issues associated with facial transplantation, but what are these issues that have made this procedure so controversial?

When we develop new medical procedures we must balance the potential benefits against the potential risks. In this context it is relatively easy to justify heart transplantation for someone with a life expectancy of weeks or months due to heart failure even if the likelihood of success is small. The problem with face transplantation is two-fold; first, it is not a life saving procedure and second, the risks are largely unknown or can only be estimated based on experience with other composite tissue grafts. However, while it may not be life saving, successful facial transplantation is certainly likely to be life-enhancing. The benefit to the patient is easy to underestimate for the majority of us since our facial appearance is normal, and the idea of having a face transplant is totally alien. Coupled with this is the frequent misconception that the primary function of a partial or total face transplant is aesthetic rather than functional. (2) Some years ago some medical students and I asked members of the public whether, if they had kidney failure, they would accept a xenograft from a transgenic pig. Not surprisingly most individuals said no. Contrast this response with that of patients with chronic renal failure, on long term hemodialysis awaiting renal transplantation who almost universally said they would accept a xe-notransplant. Context is therefore important and for many individuals with severe facial disfigurement due to trauma or burns the prospect of a possibly hazardous facial transplant to give them back something closer to normal facial function and physical appearance is definitely worth the risk.

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It has been argued that informed consent could not be obtained for this procedure because of the experimental nature of facial transplantation and because many facially disfigured patients are desperate for a solution to their functional problems and disfigured appearance. Similarly there has been concern that patients would not fully understand the implications of taking lifelong immunosuppression and would not be able to make a reasoned decision regarding the risks of this. These issues were among the major concerns of the Royal College of Surgeons Working Party which reviewed the ethics of facial transplantation and published a report in 2003 stating that they could not support its inception in the United Kingdom at that time. (3)

It is important to appreciate that facial transplantation has not just come about as a random act, but that teams in the USA, France and Britain have been working for years to develop not only the surgical techniques (4,6) but protocols for immunosuppression, psychological assessment and informed consent. (1,7) Indeed many of the concerns raised by the 2003 Royal College of Surgeons Working Party are being addressed by this fast moving field. The technical success rate for microvascular anastomoses are of the order of 95% or better, and data from hand transplants, which is an immunologically comparable composite tissue allograft, suggest that levels of immunosuppression will be lower than that required for renal allografts. (8) Further work has been done to develop ethical protocols for the assessment of patients for facial transplantation, and the issue of informed consent has received similar attention. (9) In each of the countries involved with facial transplantation the procedure has been subject to rigorous external ethical review and controversy still remains regarding the sanctioning of the procedure. It is likely and entirely apposite that for the time being each case will be reviewed on an individual basis by an appropriate board.

There still remain issues regarding the functional success of facial transplants and the extent to which sensory perception of the skin will be restored, and whether functional aspects such as oral continence in transplants involving the lips will be preserved. There is no easy answer to these questions, and the early patients who undergo these procedures will need to be evaluated on many levels including functional, aesthetic and psychological criteria. A major question from critics of facial transplantation has been what would the consequences be of graft failure? This is something which has not really been adequately addressed by the proponents of facial transplantation although it has been stated that loss of an allograft would not be life threatening. The outcome of the first hand transplant where the patient failed to accept the hand as his own and voluntarily stopped his immunosuppression, which led to graft failure, lives long in the memory and has inevitably colored the perception of the effects and consequences of facial transplantation.

Why has facial transplantation attracted such enormous public interest? Humans are capable of recognizing hundreds and thousands of different faces; facial expressions are believed to impact the way that babies respond to their parents, and how we interact with each other in business, relationships and socially. In many ways the face is a window into the mind and it is often possible to tell an individual's emotions simply by watching their facial expression. Change of identity is difficult for the individual whose appearance is changed and also for those people who know that person. Potential recipients of face transplants have often had a great deal of change to cope with. First, there is the trauma of their facial injury, be it burns or trauma. There is the healing and scarring response to this. There may be change associated with attempts to repair injury through reconstructive plastic surgery. Individuals who have suffered facial disfigurement often experience or feel that they are being stared at or may even be the subject of comments from the public. (10-11) Indeed this perception of hostility from observers has lead to facial disfigurement being described as "the last bastion of discrimination." (12) Disfigured individuals often experience low self esteem, have difficulty making friends and finding employment, and as a consequence can experience social isolation, depression, anxiety and poor quality of life. (13-14) In this context it could be argued that face transplantation, although not life saving, can offer a significant opportunity for individuals to integrate back into society.

The media in our society has become very intrusive and no subject is safe from its spotlight. It was largely the media that created the "face race," the competition between different centers who were all developing protocols for facial transplantation, to perform the first transplant. A number of individuals involved, notably in the UK group, became extremely uncomfortable with this notion of competitiveness. The reality of course was that the different centers had been developing protocols for technically different procedures and for different groups of patients, thus in a global sense all were developing complementary approaches to facial transplantation. The shadow of the media has now become larger and already details and photographs of the donor who provided the tissue for the first facial transplant have been published in newspaper articles, something which the transplant community would consider highly unethical. There is a very real danger that similar intrusion to recipients and the fixation over what the appearance of a face transplant will be could portray recipients as circus freaks and reinforce any doubts that the individuals had regarding their personal identity or normality. Thus society has a responsibility to respect the privacy of these patients to give them the best opportunity to return successfully to society.

We would do well to remember how the first heart transplant was greeted in 1967. In that case the startled world responded with a mixture of congratulations and vilification with many of the same criticisms that have been applied to facial transplantation, principally of unwarranted human experimentation and medical ego superceding medical ethics. Heart transplantation is now of course a valuable and accepted treatment option. Ultimately the future of facial transplantation will depend on the success and failure of the first handful of cases. The proponents of facial transplantation are some of the strongest advocates for regulation of this treatment modality and such a system of regulation would protect both the interests of patients and practitioners.

References

1. Hettiaratchy S, Butler PE. Face transplantation-fantasy or the future? Lancet 2002;360:5-6.

2. Butler PE, Clarke A, Hettiaratchy S. Facial transplantation. BMJ 2005;331:1349-1350.

3. Morris PJ, Bradley JA, Doyal L, et al. Facial transplantation: a working party report from the Royal College of Surgeons of England. Transplantation 2004;77:330-338.

4. Clarke A, Butler PE. Facial transplantation: adding to the reconstructive options after severe facial injury and disease. Expert Opin Biol Ther 2005;5:1539-1546.

5. Hettiaratchy S, Randolph MA, Petit F, Lee WP, Butler PE. Composite tissue allotransplantation--a new era in plastic surgery? Br J Plast Surg 2004;57:381-391.

6. Unal S, Agaoglu G, Zins J, et al. New surgical approach in facial transplantation extends survival of allograft recipients. Ann Plast Surg 2005;55:297-303.

7. Clarke A, Butler PEM. Face transplantation: psychological assessment and preparation for surgery. Psychol Health Med 2004;9:315-26.

8. Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft: report on first 6 months. Lancet 1999;353:1315-1320.

9. Agich GJ, Siemionow M. Until they have faces: the ethics of facial allograft transplantation. J Med Ethics 2005;31:707-709.

10. Kent G. Understanding the experience of people with disfigurements: an integration of four models of social and psychological functioning. Psychol Health Med 2000;5:117-129.

11. Kish V, Lansdown R. Meeting the psychosocial impact of facial disfigurement: developing a clinical service for children and families. Clin Child Psychol Psychiatry 2000;504:497-512.

12. McGrouther DA. Facial disfigurement: the last bastion of discrimination. Br Med J 1997;314:991.

13. Clarke A. Psychosocial aspects of facial disfigurement: problems, management and the role of a lay-led organization. Psychol Health Med 1999;4:127-142.

14. D'Antonio IL, Zimmerman GJ, Cella DF, Long SA. Quality of life and functional status measures in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 1996;122:482-487.

The more sand that has escaped from the hourglass of our life, the
clearer we should see through it.
--Jean Paul

Stephen J. Wigmore, MD, FRCSED, FRCS 

From the Department of Transplantation Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom.

Reprint requests to Professor S. J. Wigmore, Institute of Biomedical Research Level-5, University of Birmingham, Edgbaston Birmingham B15 2TH, United Kingdom. Email: [e-mail]