The French position: Comite Consultatif National d'Ethique pour les sciences de la vie et de la sante: "composite tissue allograftransplantation of the face (total or partial graft)"*.

The term "face transplant" is misleading and should not be used: It is composite tissue, rather than an actual face, which is actually grafted. It therefore is necessary to oppose the fantastical images associated with an operation that takes a composite tissue allograft to repair a disfigured or destroyed face: The mere idea of finding the face of one person on that of another belongs to the realm of fantasy. Whereas the primary goal of composite tissue grafts in general is to restore function, that of face transplant is to restore an "acceptable" form. As such, the remaining question concerns the nature of this form. A tissue is not a face: the objective is to return a morphology which has the appearance of a human face. As such, ambiguities exist for both the recipient and the donor. Face transplants are neither organ nor limb transplants, and, unlike organ transplants, face transplants must not be performed until more thorough research underlying the procedures is completed, until the precise risks involved are clearly identified, and until the results are validated.

In the case of an emergency, a positive outcome to reparative surgery depends upon very specialized teams taking charge of the wounded as early as possible, while also relying heavily upon the already validated techniques of autotransplantation. Such circumstances are not in possible in the case of allotransplantation.

In a nonemergency situation, a CTA justifies resectioning grafts which have already been performed. In the case of a failed face transplant, however, the outcome would be worse than the initial situation.

Life-long immunosuppression moves the person from a significantly compromised state to one which is genuinely life threatening. Furthermore, even in situations where the consensus is that the possibilities of self-grafting or of pro-theses have been exhausted, and where the demand for such an operation is very strong, the idea of informed consent for a face allograft remains illusionary. The surgeon cannot promise the results of the restoration, which are always unpredictable, and, in this case, the operation cannot be reversed--such as, for instance, by simply resectioning the hand; failure could further aggravate the situation. Furthermore, even with the assistance of computer imaging, it will be difficult for the patient to envision what his or her face will look like due to the extreme complexity of that which represents him or her: the face. While acceptable in the short-term, the risks of life-long immunosuppression become intolerable in the long-term due to intercurrent illness or aging. What, then, will be the price to pay for the inevitable, relentless and rapid deterioration of this face?

True informed consent can never be possible--even discussions involving psychologists and psychiatrists who are aware of the complexity of such issues deem such consent to be a utopia.

The issue of donors probably remains the main obstacle. Human society has given the face a symbolic force such that one rarely sees such a gift proffered; indeed, the implicit gift associated with organ donation is equally illusionary. Even the idea of rapid cremation, which would make the gift of organs more acceptable, does not entirely overcome the respect due to the body following death. While the dismembering of the body is already understood as an accepted violence in the name of saving others, the removal of a face simply to give hope to a destroyed face has little chance of gaining such acceptance.

Finally, despite all of the precautions that may be taken, such a procedure will be spectacular and will be focused upon in an excessive fashion by the media: this sensationalism will overshadow the surgical aspect.

In conclusion, a full facial CTA does not make sense at present. Nor is the question is a medical or technical one. While the possibility of a partial CTA reconstituting the triangle mouth-nose would return a certain morphologic identity to the face, such a procedure remains in the field of research and high-risk experimentation: It cannot be presented as a forthcoming and ideal solution for the painful difficulties of face alteration. Should the considerations for performing a full facial CTA be envisaged, they should only be considered in the frame of precise, multidisciplinary, multicentered protocols submitted for approval to the Etablissement Francais des Greffes, or to other boards with similar qualifications.

Translated by Conrad C. Daly.

*This was translated by the SMJ and has not been endorsed by the Comite Consultatif National d'Ethique pour les sciences de la vie et de la sante.