The Story of the Face Transplant

Today, facial transplants are accepted by both the medical community and the public as financially and medically viable solutions that enable the severely disfigured to re-integrate into society. Face transplantation has evolved greatly over the last ten years, and in that time it has made a radical transformation from something that was once feared "science fiction" to something that is now a realistic life altering opportunity for those who need it. The last decade has seen the most progress for the procedure, but the idea is not a new one. In the 1970s scientists were already aware of it as a possibility. However, the world was not ready to accept it as a reality. The first scientist who spoke publicly about the procedure at the time caused an uproar. The outrage went so far that the he received a barrage of hate mail and even death threats.

Why were people so upset about the possibility of face transplantation only forty years ago, whereas today it is viewed as acceptable? Back then, they had the technology to perform transplants on numerous organs. From a medical standpoint the face can be seen as “just another organ”. The technology at the time was a bit rudimentary for some aspects of the delicate and complicated procedure, but it was not unimaginably far off the mark. From a technical standpoint, the face transplant was a potential reality even in the 1970s. So why did it take until 2005 for the first procedure to actually be performed? Later, we will further discuss the intricacies of bringing facial transplantation into mainstream acceptance. It is important to understand that the biggest obstacle in the evolution of the facial transplant is not technology so much as it is ethics. Today, there is still much to consider from an ethical standpoint about the procedure. However, the particular issues have changed drastically.

Of course, the procedure is not without risk. After over a decade of doing this procedure, only about 30 facial transplants have been performed to date. Having an understanding of the basic technology and techniques involved in the procedure can help one to understand why the procedure has a relatively high success rate, and to demystify an operation which may at first sound alien. Understanding the technicalities of the procedure can also help us to understand what risks are present and why, while clarifying the ethical questions medical professionals need to review before going ahead with a facial transplant.

By discussing the stories of real people who have gone through the procedure, we can understand the true benefits that facial transplantation can bring and why it is so important that we continue research in the field. Some case stories tell a cautionary tale, and illustrate the considerations that need to be made before going ahead with the process.

Over the course of only the last 10 years the debate has changed greatly. Originally, the fear was that it is somehow equivalent to a Frankenstein procedure. People were incensed at the idea of taking a person's face and putting it onto another person's face. At the time, the biggest issue was that the face was somehow 'sacred'. While a kidney or a liver is an internal organ, the face carries the identity of an individual. People were genuinely concerned that when a face was transplanted that the donors face would become the recipients face, and this would most likely cause an identity crisis for the recipient. Also, it was feared that if the donors family saw the recipient, it would be as if their face was suddenly on someone else. The entire thing was thought to be preposterous in every moral sense of the word. This debate kept face transplants from evolving much between the 70s when the idea was first introduced, all the way up to 2005 when the first face transplant successfully took place. Fortunately, in that time there were dedicated surgeons and medical professionals who researched the possibility extensively by practicing on cadavers. When the first one was actually performed on a live person, it was a success.

However, did the original outrage have good reason? The truth is that no, it did not. When a face is transplanted, the look that the recipient acquires is a combination of their original face and the donor's face. While the donor's face will obviously make up the skin structure, the bone structure beneath is what determines the look of the face to a greater extent. Also, most of the people who receive a successful face transplant are psychologically impacted positively. The original ethical concerns of identity confusion and looking exactly like the donor have quieted. There was a time only 15 years ago when most published information on facial transplantation focused solely on this issue. However, the debate has shifted over time into one of more pragmatic and modern ethical concerns.

Today, ethical questions still surround the procedure, but they relate more to who is most suited to have the procedure from a psychological and physiological point of view. A person who undergoes a facial transplant, should be psychologically prepared to deal with it. As mentioned earlier, most recipients have an overwhelmingly positive psychological effect, because they were maimed and disfigured to the point that they could not properly integrate into society any longer. Thus, a veil of isolation is lifted and they can resume life again. However, that person also needs to be prepared for a lifetime of immune-suppressants and follow up medical care. The medication to suppress the immune system is very hard on the body, patients who fail to stay on course can die, and this actually happened to one recipient. The recipient also needs to be prepared for a life in which they may be the focus of research, medical attention and even media attention.

Acute rejection episodes occur in at least half of the patients who undergo the procedure. This means that the face becomes necrotic or partially deformed with nodules etc. To date, all of these episodes were manageable, but its a difficult situation to deal with, and it requires intensive medical intervention. Considering that patients who are eligible for the procedure have gone through great trauma to begin with, their psychological state is always taken into account when they are considered for the procedure.

A face transplant can be a blessing for most patients, but if they are not physically and psychologically a good candidate, it can be traumatic and even deadly.

The question is, “Who is fit to deal with what follows?” Some experts also wonder if the people who cope the best actually need the transplant the least, because they are dealing well with their situation. Do the people who cope poorly need it the most? And would those people make good psychological candidates?

Also important to consider is the high cost of the transplant, which is upwards of $300,000. People who go through this procedure not only need an extremely expensive transplant operation, but they will be under medical supervision for the rest of their lives.

Are the benefits that the transplant brings worth the risk? Also, what happens if the transplant is chronically rejected? Fortunately, this has not happened to date, but results could be devastating. To put a new face on, the recipients previous facial structure is completely removed. If a recipient faces chronic rejection episodes and loses the transplant, this means that they no longer have a face at all. Also, chronic rejection would result in a chronic necrotic state of the transplant, which would be psychologically devastating and traumatic for the patient involved. Other questions that are asked today are whether or not children should be eligible for face transplantation. Also the ethnicity and age of patients is taken into account. What if a person of dark skin needs a transplant badly, and the only eligible donor has lighter skin, or is 15 years older? Facial transplant donor matches are not easy to come across, so at what point do you accept a new face as the right donor? Where do you draw the line pertaining to the visual compatibility of the donor? What if a potential recipient loses their original face to cancer, is it ethical to give a new transplant knowing that it could be destroyed by spreading malignancy? What if a patient has a life shortening or immune issue, such as HIV?

These are just some of the major questions that are raised when considering face transplantation as an option. The debate has come very far now that face transplants are actually performed. However, the procedure is still surrounded by questions.

Isabel Denoir was the recipient of the first facial transplant. As is the case with many of the actual patients who have received facial transplants, her story is both tragic and uplifting. Obviously, the people who come into a position where they are eligible for the procedure have gone through great trauma. Some of the case studies can be unsettling and sad to learn about, because they always tell the tale of a person who truly suffered. However, most of the stories end in hope and are about people who beat the odds, made great contributions to medicine and who learn to live again.

In 2002, Isabel was living in France and had been suffering from recurrent bouts of depression for much of her life. One day, she decided to end her life by taking sleeping pills. She passed out onto the floor, and does not remember anything. She woke up some hours later, and could see that she was surrounded by blood. She told a story of trying to light a cigarette, and simply noticing that it would not light no matter what she did. When she looked in the mirror, she saw that her lips nose and chin were all missing. It turned out that the family labrador had been most likely trying to wake her up by clawing desperately at her face to the point that the flesh was clawed off.

When doctors examined her, they knew that there was nothing that could be done with conventional surgery techniques. Up until that point skin grafting was the only way to deal with facial injuries of this sort. The benefit of grafting is that the grafts come from the person who receives them. For example, skin might be removed from the groin in order to make a patch on the cheek. Thus, there are not so many ethical questions, and there is not an issue of rejection due to genetic incompatibility. However, grafting on the face in particular is extremely limited. This mostly relates to the fact that facial skin is highly specialized. As you move down the face you go through six different thicknesses in the skin, and this skin is not found elsewhere on the body. Using skin from other body parts may be able to literally patch up a hole, but it will never look “ok”. Also, when a person has extensive facial damage they require numerous grafts from different parts of the body, and it never looks right once these are all patched together. Isabel's damage was so that surgeons knew that her only option would be to actually have a face transplant. However at the time, this was an extremely controversial procedure that had never been done before. The medical community and the public both feared the implications of the procedure. Getting the go ahead from an ethical committee was ground breaking.

The “Face Race” had been on for over a decade, and numerous teams of doctors in France, Britain and the US were all ready to do the first facial transplant. While these medical professionals had been preparing for years to perform a procedure it had never been accepted by ethical committees up until this point, and that is what had been standing in the way of making progress. When Isabel's case was approved, it revolutionized facial transplantation. Up until that point in time, it had only been seen as theoretical, and it had frightened a lot of people. Doctors were successful in transplanting the lower half of a donor's face onto Isabel's, and this showed the world that the procedure was possible. Knowing Isabel's story also helped people to see the positive aspects of a facial transplant. Before the transplant, Isabel was confined to her house and was afraid of associating with people. By having a new face, she was able to live again and could take part in the world. The case was a media sensation.

One of the major questions that the public asked at the time was, “Why did Isabel receive a face transplant? Was there no other option?” The answer is that no, there was not. It was clear that she was not able to function in society with her disfigurement, and that traditional reconstructive surgery was too limited to give her a satisfying result. A face transplant was the only thing that could really give Isabel her life back, and that is what made her a perfect candidate.

Richard Lee Norris is another well known face transplant patient who now has a presence in the media and has become an advocate for the procedure. In 1997, he shot his own face off with a shotgun while drunkenly arguing with his mother. He lived like a hermit for the next 16 years and was completely unable to function in society due to the extent of his disfigurement. After years of conventional surgery He received the most extensive face transplant that had ever been performed. While many face transplants have been partial, like Isabel's, his required that his entire face be removed. His case is interesting, because he has accepted stepping into the spotlight and he is proud of being a part of medical research for the rest of his life. Also, the quality of his face transplant is very good in that his face is somewhat realistic looking, and probably the most advanced and lifelike result of the procedure to date. Richard illustrates how this life altering procedure can be life saving.

On one hand, some might argue that a procedure which does not save a patients life should not carry so much risk. Richard's extensive transplant actually put him at a 50% risk for death. However, he was willing to accept this because the life he was living did not feel like a real life to him. If a patient is forced to live a life of hiding in their house, as many of these patients are, and they can be offered a shot at being able to step out into the world and have interests, friends, hobbies and lovers again, is it a poor trade off for the fact that the operation puts them at so much risk? How do you really define saving a life, and is that not one way to save one?

Facial transplantation is an extremely delicate and complex operation. It draws on the techniques of microsurgery and basic organ transplantation. This article will not get into the finer details of what is obviously a very technical procedure. However, having a basic understanding of how the operation is performed gives an idea as to the results and risks that can be expected.

First, tissue must be quickly harvested from a brain dead patient and quickly transplanted onto the recipient while the tissue is still alive. You can imagine that this in itself has many implications. Not only does the doner need to be compatible with the recipient aesthetically, but their family also has to be OK with allowing the transplant to take place. The face is not like a kidney, and for many relatives the idea of giving up the face of a loved one is a heavy emotional burden. Also, one issue that many recipients have to face is the fact that they are essentially waiting for someone to die. This is something that Isabel Denoir spoke of in an interview. On one hand, she desperately wanted to have a new face, but on the other hand every time she heard an ambulance she imagined that a woman may have died in order to save her. In Isabel's case, the transplant that she received was from a mother, not far from her own age, who had taken her own life. There are obviously many parallels in that story and facial transplant patients often feel a connection to their donor. Isabel said that every morning she wakes up, and sees the wonderful gift that this woman gave her, and so she is thankful and ever reminded. Some of the biggest impacts of this procedure, are the psychological ones.

What happens when a donor's face is removed? Many people do worry about defiling the face of a dead person, and this is taken into account. Once the face is removed, it is replaced by a wax cast of the person's original face as an attempt at giving the body some last dignity. How is a donor selected? Facial transplants are performed on an individual basis. Since they do not occur very often, there is not a bank of donor faces as there is for other more common transplants. Instead, each case is approved individually and once approval occurs, the patient literally has to wait for 'the perfect person' to die.

Although the procedure is dangerous and complicated, there have actually been zero surgical failures to date. This is probably because the teams who perform transplants are extremely skilled. Also, despite the fact that the face is complex, there are relatively few vascular hook ups that need to be made so that the face reattaches properly and has functioning blood supply. There is only one main artery that connects the entire face and maxilla. In the technical sense, the procedure is actually a set up for a promising success rate. Of course, appropriate nerve endings must be attached. It is said that feeling in the new face usually comes within about six months, and that motor functions should be fully restored within about a year. Basically, if the surgeons are skilled and can make all of the crucial hook ups in the beginning with the vascular and neural passage ways, then nature will take over from there and restore proper functioning to the face over the course of the next year.

While the procedure has been overwhelmingly successful in the operating room, most of the recorded dangers to date have come in the aftermath of a seemingly successful operation.

The most significant concern, and most commonly occurring problem, is that of organ rejection due to recipient/donor genetic incompatibility. What would happen if a face transplant was rejected? Since the original transplant operation involves removing the recipient's damaged face, if their transplant is rejected this could put them at risk for having no face at all. Because of this all patients are required to have enough skin so that if something does go wrong like this, then they could use the recipients own skin to make a new emergency face. While this would save their life, there is a good chance that they would end up even more disfigured than they were to being with.

Another considerable risk is that of infection. Due to lowered immunity, facial transplants are often prone to viral infection, or to bacterial infection from the surgery itself. Something simple like the common cold sore virus could be devastating for a facial transplant patient. Since patients need to be on immune suppressants for the rest of their lives, this means that their immune systems will never work at full potential. This leaves patients who have undergone a major surgery which exposes them to all sorts of bacterial and viral risks, who also have lowered immune systems to boot. Fortunately, these episodes have usually proven to be manageable, but they are one of the most considerable risks that many patients need to deal with. Also, wound healing disorders can be common.

Organ rejection is the greatest risk that patients face, and so it should be discussed in further detail to understand its implications. Organ rejection therapy is something that patients will have to deal with for the rest of their lives. Whenever an organ from another person is transplanted, there will be an issue with genetic compatibility. The body always sees that transplanted body part as a foreigner and something that it should attack in an immune response. This can be compared to a foreign body like a bacteria. The body recognizes the bacteria as something that does not belong, and in an act of self defense it attacks it. Unfortunately, in the case of transplants, the transplant is always the outsider and so without immune suppressive therapy the transplant will always be under attack. Skin is highly antigenic, which means that it has this propensity to attack outsiders even more than other body parts, so a facial transplant requires extra heavy medication and vigilance to keep it healthy. While at least half of patients face acute rejection episodes, there are no cases of chronic rejection to date. One important fact to consider is that the transplants are a somewhat new technology, and we have no data on long term affects or outcomes. The oldest face transplant at this point is only about ten years old. What will happen after 20, 30 or 40 years? The fact is that right now we do not know. So far, all acute rejection episodes have been manageable by changing the dose of immune suppressant drugs, but no one knows exactly what the future will look like. These drugs are very hard on the body. It is estimated that the drugs alone shorten lifespan by about 10 years. Numerous patients end up having some form of cancer on their implant or on some other part of the body because the drugs are carcinogenic. Alternatives to modern immune suppressants are being studied and include T cell transplantation and stem cell therapy, but the technology isn't there yet. When the future presents a more realistic and less taxing option, transplant patients everywhere will be able to enjoy healthier lives. Until that happens, a life on immune suppressants is a reality that all patients have to live with.

What kinds of psychological impacts can be expected in the aftermath of this procedure? The original debate revolved around the concept that recipients would go through an identity crisis. It was thought that suddenly having someone else's face would have unforeseen consequences and could cause deep psychological disturbances. There have been three studies conducted to date that were concerned with these psychological effects, and all of them found that recipients were doing overwhelmingly well psychologically. The fact that many people were able to join the world again and could be released from the shame and isolation they felt outweighed any aspects of an identity crisis, which has not proven to be a notable side effect. Not only were patients found to be able to accept their new appearances, but a speedy integration back into society was the most notable benefit. In this sense, the procedure really has saved quite a few lives.

While the procedure has often been successful, there have been three deaths that occured as a direct or indirect result of a face transplant. Each case tells a specific cautionary tale that illustrates the kind of considerations that need to be made when selecting a patient.

In one instance a patient's transplant acquired a form of antibiotic resistant bacteria. Despite doctors efforts to save the unidentified 30 year old man through extensive therapy, the patient later died of heart failure during an operation to keep the bacterial infection under control. Doctors were not able to directly link the infection to to the transplant, and to this day do not completely understand what went wrong. This particular patient had received both a face and double hand transplant, and there are implications that both of these transplants in one person may have been too much for the patient's body to handle. The patient did not suffer from rejection or a vascular issue. While it is possible that it is coincidental that the man contracted the untreatable infection, it also needs to be asked if the infection was due to an inevitably compromised immune system due to extensive suppressive therapy. This man was the sixth person in the world to receive a face transplant, and his case kept the medical community and the public weary of the dangers and implications of such an extensive therapy. Again, if a procedure is life altering, but not life saving, where do we draw the line and say that the risks are outweighed by the potential benefits?

Li died in 2008 after a partial face transplant. He had been mauled by a black bear which he had been attempting to fend off from his sheep. Li's death was due to the fact that he stopped taking his immune suppressive therapy in exchange for traditional Chinese herbal medicine. Obviously, results were deadly. This case raises the point that some patients may not be psychologically prepared to be on this therapy for the rest of their lives. This is why it is particularly important to select patients carefully, and why psychological fitness is just as important as physical fitness when it comes to facial transplantation. Even more troubling is this; Even if a patient seems to be ready to take the medications, can they ever really know what it is like to be on such heavy medication until they do it? A few years earlier, the man who had received the world's first successful hand transplant asked for his hand to be removed because he could not stand the therapy any longer. One thing to keep in mind is that these people are not simply lazy or noncommittal, but that the effects of this therapy can be so extreme and painful that it may just be too much for some people to realistically handle.

Another patient who died after his face transplant had HIV as well as cancer. This case shines light on a couple of important considerations when it comes to donor selection. Should a person with a history of cancer, who also has HIV receive a face transplant to begin with? On one hand, the main purpose of the transplant is that it can help a person lead a somewhat normal life again and ease the suffering of having a severely disfigured face. Of course you would want to give everyone a shot at this. However, the procedure is life transforming and not life saving. We know the serious risks involved in taking immune suppressants for the rest of a transplant patient's life. When a patient ALSO has HIV, is it responsible to give them a transplant that will require them to seriously suppress their immune system further? The patient also had a history of cancer of the face, and it is known that immune suppressants encourage malignancy. The patient did ultimately die of aggressive cancer of the jaw and tongue, which is exactly where the transplant was. Pedro's face transplant was the first to occur in Spain, and it makes you wonder if doctors had been trying to achieve fame and recognition in The face Race more than they had the actual best interests of their patient in mind. After everything that has been covered about the ethical controversies surrounding modern face transplants, this case sticks out as one that may have been irresponsible.

Facial transplantation is very complex and there are many intricacies to consider when choosing candidates. However, at this point in time they are accepted as a feasible option for people who are severely disfigured. The technology and surgical techniques are very good to perform face transplants, and most patients have a good prognosis of getting through surgery with success. While they can present many risks, most of those risks have proven to be manageable with proper medical attention. In the cases where people have died, it was because the patient was either poorly selected for such a risky procedure or ultimately unfit to stay on their medication regiment. Patient selection is one of the most important aspects to consider. Is the person healthy enough to have the transplant? Is the person psychologically prepared to be on medication for the rest of their life? Will the person seek immediate and regular medical attention every time that it is necessary?

One of the greatest mysteries surrounding the procedure is that we do not have data on any long term psychological or medical effects. The first transplant was only performed ten years ago, and during the last decade less than thirty have been performed. While the prognosis is currently good for most patients, we can hardly call this a routine procedure nor can we say that the longterm risks and outcomes are clear to us.

What is clear is that all current information we have on the procedure shows that it can truly benefit the people who receive it. Many of the patients who have had the procedure went from a life in hiding to a life where they were able to join the world and socialize again. This possibility is a wonderful gift.

It's interesting to note that just ten years ago so many people were outraged about the ethics of having a different person's face, and that the real barrier in making progress with the procedure was not so much one of surgical advancement, but one of ethics. Society was afraid of this procedure, and the brave patients and hard working doctors who have gone ahead with it have changed that perception over time. Facial transplantation could one day become a more standard procedure, and there are many people in the world who could greatly benefit from it. Right now, the best course of action is to continue embracing the procedure and performing it on the right candidates, so that it can advance into a future where it is known to be a safe life altering procedure for people who truly need it.

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