Face transplants: is the genie out of the bottle?

In November 2005 a new world of reconstructive possibility opened up for people with severe facial disfigurement when oral and maxillofacial surgeon Bernard Devauchelle teamed up with Jean-Michel Dubenard to perform the first composite tissue allotransplant taking facial tissue from a brain dead donor and transferring it to a French woman whose face was destroyed by a dog biting off her nose and lips.

Their breakthrough captured the public imagination, not only because of the awe that medical advance so often generates, but because the idea of swapping faces contains such mysterious possibilities. The public reaction was one of excitement, fascination and occasional revulsion at the thought of one person's face being transposed onto another. It not only evoked ideas that the recipient would take on the appearance of the donor but also that they might take on the donor's personality--"our faces are the mirror of our souls."

This was an operation waiting to happen. Surgeons in Louisville, Kentucky, London (UK) and, latterly, the Cleveland Clinic have been talking up the possibility of face transplants over the past decade. Although some of the protagonists initially proposed transplantation of facial bone, cartilage, muscle, mucosa and skin the consensus now seems to be to use this operation to replace skin and subcutaneous fat alone. The skin would be draped over the underlying bones, teeth, and eyes of the recipient.

The surgical technology and medical therapy required for this operation have been available for many years. For example, the face lift operation and the anatomy of the face are both well known while the microsurgical techniques necessary for the blood vessel and nerve anastomoses essential to the survival and functioning of the transplant have been common currency for 2 decades. The immunosuppressant drugs necessary to minimize rejection have been used on tens of thousands of heart, liver and kidney transplant patients around the world and their effectiveness and morbidity are well documented.

The face is anatomically complex with wafer thin bones hollowed out by air spaces such as the sinuses and specialized irreplaceable structures such as eyes, teeth and tongue. Overall this is draped skin whose suppleness and texture is unlike skin anywhere else in the body. Furthermore there is the pattern of hair growth which spares certain areas but is vital in others. The three dimensionally complicated shape of the nose, eyelids and lips is compounded by the subtle and ever changing pattern of facial expression.

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Despite all this complexity, it is often possible to achieve excellent aesthetic results when reconstructing defects in the facial skeleton, the oral cavity and pharynx using autogenous tissue and alloplastic material. However, skin transferred from other parts of the body does not effectively mimic facial skin and certainly cannot reproduce the intricate detail of the eyelids, lips and nose and the hair bearing areas.

It is therefore clear that in at least one clinical situation involving burn victims, our current reconstructive techniques cannot offer patients a return to their premorbid appearance.

So why has this operation not been performed before now? The Royal College of Surgeons of England working party (RCS) report from 2003 illustrated the main obstacles to the operation which revolve around uncertainty about the physical and psychological outcomes of face transplantation. (1)

Before any face transplant, the prospective patient will have undergone current "gold standard" reconstruction transferring tissue from other parts of their body, possibly involving several long and difficult operations. These tried and tested "autograft" techniques satisfactorily replace the deeper tissues of the face, such as bone, achieve skin cover and carry no risk of rejection. If the patient opts for facial transplantation, all this previous reconstruction will have to be removed to make way for the face transplant.

Unfortunately, the transplantation process carries significant practical risks for its recipients. In the first few days after the operation the transplant is at risk of failure if the arterial or venous microsurgical anastomoses between the donor and recipient's vessels block with clot, and this situation cannot be salvaged. There is a 5 to 10% chance of this happening. Secondly, the immunosuppressant drugs may not prevent acute rejection. The RCS working party estimated that there would be a 10% chance of this happening within the first year after transplantation. (1) In both these situations the transplant would be totally lost. The patient would be back to "square one," where they were at the time of injury before any reconstruction had been undertaken!

Although the acute rejection process can often be reversed with steroids chronic rejection is less amenable to drug therapy, (1) quoted the risk of this to be as high as 50% in the first 5 years post transplantation.

The recipient will have to take immunosuppressant drugs for the rest of their life. These drugs cause coarsening and blemishes in the patient's own skin. They also increase the risk of chronic disease, (2) viral and fungal infections and tumors such as lymphoma (3) and skin cancer. (4)

The transplantation of hearts, lungs and livers saves lives so that these practical risks are offset by the extension to life produced by the surgery. In facial transplantation lives would not be saved--it is a "quality of life" transplant--so the risk benefit ratio of the surgery is less clear and certainly unpredictable.

Our face does, however, play a significant role in our self-esteem and how we are perceived and judged by others. Any facial abnormality, no matter how minor, may provoke an emotional crisis in its owner, while definite disfigurement often stimulates hostile behavior from the public. The impact of facial disfigurement is not trivial. The facial transplant may improve the lives of its recipients. Its advocates justify it on these grounds but the potential benefits must be carefully balanced against the serious risks.

There are also unknown psychological consequences resulting from this surgery. We know that the psychological impact of facial injury or disease and its subsequent treatment is unpredictable even with common problems--simply making a face normal does not necessarily equate with happiness for the patient. There are many patients who have virtually invisible scars following trauma or other facial surgery who are emotionally crippled by what only they can see in the mirror. Conversely, there are patients with significant scarring and disfigurement following trauma or cancer surgery who lead normal and fulfilled lives. So how will facial transplant recipients cope with this revolutionary treatment? What will they feel when they see their new face? How will they feel having somebody else's skin on their face? Will they want to know about the donor's life?

Furthermore, how will family and friends adapt to the patient's new appearance? Although the patient's own facial shape should only be slightly modified by the transplant, their skin texture and color will be altered. Their face should still be recognizable but is likely to be a hybrid of donor and patient.

The effects on the donor's family must also be considered and studied. In many religions and cultures the dead relative lies in an open coffin for all to see. Relatives often desire physical contact with the deceased loved one as part of the grieving process. Although this is possible if thoracic and abdominal organs have been harvested, removal of the face will seriously interfere with these actions. It is therefore unlikely that many people or their relatives will donate faces. This is likely to be a factor from preventing this operation becoming as common as other transplants. In cases where a family has consented to "face harvest," the long term effect on the family's attitude to their lost relative's face residing on another person who may be in the public eye is uncertain.

There is also the intrusive and often imprecise media response which cannot be helpful to patient and donor families alike. In the case of the French woman, the media response changed from initial applause, wonder and excitement to raising questions about the suitability of this particular patient for face transplantation, whether the surgeons had overstepped the limits imposed by France's ethical approval committee and the nature of the donor's death. The ethics and morals of whether patients are "deserving" of treatment if they develop problems related to disease-inducing habits such as smoking and drinking alcohol is a huge debate in itself. It was clearly unhelpful of the media to conduct that debate around the bodies of 2 unfortunate people at a time of great stress for the patient and donor families.

Innovation is as essential to surgery as it is to any other branch of medicine or science. Society needs doctors and scientists who are brave and prepared to take risks to allow scientific advance. We should applaud the courage of the French surgeons and that of the patient and donor family in the French case for taking this plunge into the unknown.

However, with innovation comes increased responsibility, especially with surgery, as the surgical act is irreversible. Innovation is not always successful and it is even more vital to report failure, in order to assist future advances and to prevent repetition of error. Our excitement at the surgeons' achievement must be tempered with caution. The effect of this experiment on the patient and her family must be scrupulously monitored for her lifetime and the effect on the donor's family for a lengthy period, too. The best reason for this comes from Professor Dubenard himself. He was involved with the first hand transplant in 1998. Unfortunately, 2 years after the operation, this hand was removed.

These operations create huge media and public interest. We have a responsibility to dampen down the public's heightened expectations. We have to explain away their fantasies of face transplants for witnesses in police protection programs, gangsters escaping arrest or wealthy elders who want to replace their facial skin with a younger version. These are not going to happen because of all the risks and side effects. The hand transplant illustrates the media's failure to keep the public informed and the increased onus on the surgical profession to present realistic scenarios for our surgical experiments. The hand operation was met with huge media interest at the time, but they failed to follow-up the first patient's progress so the public was not aware that this operation could fail as well as succeed.

Facial transplantation is an experimental procedure with serious physical risks and unknown psychological outcomes. Informed consent is difficult to obtain. It is imperative to explain the research aspect and uncertain nature of the surgery to the patient as part of the consent process. (5) The patient must have extensive psychological assessment to ensure that they can cope with all possible outcomes. The genie is out of the bottle and more facial transplants will follow, but surgeons and society must learn from the French experience in a controlled scientific manner before we open the floodgates to face transplants. We must also restrain the public's excitement and imagination and present to them a realistic picture of the indications and outcomes of facial transplantation.

References

1. Facial Transplantation Working Party Report. The Royal College of Surgeons of England. London UK, 2003.

2. Miller LW. Cardiovascular toxicities of immunosuppressive agents. Am J Transplant 2002;2:807-818.

3. Gao SZ, Chaparro SV, Perlroth M, et al. Post-transplantation lymphoprolif-erative disease in heart and heart-lung transplant recipients: 30-year experience at Stanford University. J Heart Lung Transplant 2003;22:505-514.

4. Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. New Engl J Med 2003;348:1681-1691.

5. Kennedy I, Grubb A. Medical Law: texts with materials. London, But-terworths, 1994, pp 1042-1067.

Inspiration usually comes during work, rather than before it.
--Madeleine L'Engle

Iain Hutchison, FSRF 

From St. Bartholomew's Hospital, London, United Kingdom.

Reprint requests to Iain Hutchison, FSRF, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE United Kingdom. Email: [e-mail]