Iain Hutchison: The crossing of a dangerous medical frontiers

We must learn in a controlled way before opening the floodgates to face transplants
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The Independent Online

A new world of reconstructive possibility appeared to open up for people with severe facial disfigurement when oral and maxillofacial surgeons performed the first face transplant onto a French woman two weeks ago.

Their breakthrough captured the public imagination because the idea of swapping faces contains such mysterious possibilities. The reaction has been one of excitement, fascination and occasional revulsion. It has evoked ideas that the recipient will take on the appearance and personality of the donor. Our faces are, after all, supposed to be the mirrors of our souls.

This operation is actually not a transplant of the whole face - only the skin and subcutaneous fat of the donor have been used to drape over the underlying skeleton. The woman's face will not look the same as that of the donor.

Prior to her face transplant, she will have undergone surgery transferring tissue from other parts of her own body to reconstruct her face. Unlike the pioneering operation just completed, these existing surgical techniques carry no risk of rejection. The trouble is that skin from other parts of the body will not match the suppleness and texture of facial skin.

This is why some surgeons have for the past decade been pushing to carry out face transplants to improve this reconstruction of facial skin.

Other surgeons, myself included, will continue to urge caution because the transplantation process carries significant practical risks. All previous reconstruction will have had to be removed to make way for the face transplant. In the first few days, the transplant is at risk of failure if the surgical junctions that pump blood from the patient's artery into the transplanted skin block with clot.

Immunosuppressant drugs may fail to prevent her body rejecting the transplant. This can happen many months after the transplant. The French woman will have to take the immunosuppressant drugs for the rest of her life and these drugs increase the risk of tumours such as lymphoma and skin cancer.

But it is the unpredictability of the psychological outcome of this surgery that has prevented face transplantation occurring before now. We know that the psychological impact of facial injury or disease is uncertain 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 quite marked disfigurement following trauma or cancer surgery who lead normal and fulfilled lives.

So how will this woman cope with this revolutionary treatment? How will she feel having somebody else's skin on her face? Will she want to know about the donor's life?

Yet our face is so fundamental to our self-esteem that we must all have felt immense sympathy for this French woman who eloquently described how her facial appearance socially isolated her. While the facial transplant does not save lives, it does have the potential to transform them. On these grounds, I believe it may be justified in certain conditions.

Those who would certainly benefit include burns victims. Bangladeshi girls whose rejected suitors pour acid over them immediately spring to mind. Their lives are destroyed in a moment by the outrageous behaviour of callous men while they are still teenagers, and in some cases they might choose this surgical option.

The fantasy scenario of face transplants for witnesses in police protection programmes, gangsters escaping arrest or wealthy elders is not going to happen because of all the risks. Nor is it clear how many people or their grieving relatives would be prepared to donate faces. Society needs surgeons who are brave and prepared to take risks. Without them, innovation will not occur. We should applaud their courage and that of the patient and the donor's family for taking this plunge into the unknown.

However, our excitement at the French surgeons' achievement must be tempered with caution. We must monitor this experiment and its effect on the patient and her family for her lifetime and the effect on the donor's family for a lengthy period, too. It is vital that surgeons and society learn from the experience in a controlled scientific manner before we open the floodgates to face transplants.

Professor Bernard Devauchelle's operation has broken through society's emotional and psychological reservations about the face and identity. This has aroused much anticipation, but it must only be repeated in very few centres and on very few patients until we can be sure about the long-term results. Failure to observe this caution could be dangerous to patients and surgeons alike.

The writer is a consultant oral and maxillofacial surgeon at Barts and The London. He is also the unpaid chief executive of the facial surgery research charity, Saving Faces