Facial transplantation

The world's first facial transplant has been reported in France (see News p 1359), but whether this signals the opening of a new frontier in reconstructive surgery depends on clinical outcome. Facial transplantation has long been recognised as technically challenging but clinically possible.¹ The key area of debate is whether the benefit of this procedure to someone with severe facial deformity—in terms of improvement of function, aesthetics, and psychology—outweighs the risk of long term immunosuppression.

Two years ago the Royal College of Surgeons identified the key issues as patient selection, immunosuppressive risk, informed consent for an untried procedure, and psychological issues (notably altered identity).² In the two years that have followed the college's report, considerable progress has been made in answering the questions it raised.

Selecting the right patients is paramount. The overall aim of this form of transplant surgery is twofold, as with any facial reconstruction: to facilitate social interaction (a shared goal for both surgical and psychological interventions), and to re-establish basic facial function such as blinking, mouth closure, and facial expression. The three main facial transplant groups (in France, the United Kingdom, and the United States) have developed different technical approaches and therefore target different groups of patients. The French have adopted central facial transplantation, namely of the nose, lips, and chin. These elements are very difficult, if not impossible, to reconstruct adequately using conventional methods. The UK team has focused on reconstruction in panfacial burn injuries. The US group originally included craniofacial reconstruction but now has a similar approach to the UK team. Despite differences in patient groups and surgical preferences a robust process for selecting patients is essential to avoid long term problems, such as those that arose after the first hand transplant.³

One of the main areas of concern has been the risk to patients from the side effects of long term immunosuppression.¹ To date, many of these fears have not been realised. The current cohorts of hand transplant recipients—the group of patients who are the most comparable because their operations also required complex and intricate reconstruction of several tissue types—have not experienced any serious complications during a maximum of six years' follow-up.⁴ Minor complications have been tolerated by patients and have not led to any change in treatment. The level of immunosuppression required by these patients is similar to and in some cases lower than that needed by renal allograft recipients,³,⁴ and a patient having a facial transplant would probably require a similar level of immunosuppression. One of the main justifications for renal transplantation is improvement in quality of life, and the same argument should apply to facial transplant.

Clarke and Butler have proposed a model for informed consent before facial transplantation.⁵ The model is derived from Marteau et al⁶ and is based on a well validated model of health related behaviour. It puts the individual's current beliefs and attitudes at the centre of the process and builds around this framework, challenging incorrect assumptions and adding missing information in a form that is consistent with the patient's level of understanding, attitude to risk, and clear expectation of outcome. Evidence from the many previous episodes of treatment which people needing facial transplantation will have had provides the source for much of the information required. The consent process is therefore unique to each individual and is dynamic because it is informed by ongoing research.

A psychological change is not necessarily a psychological problem. When reading about the potential psychological effects of facial transplant it is easy to lose sight of the fact that facial transplantation is being proposed as a potential benefit for a patient with combined functional, aesthetic, and psychological impairment. Building on evidence from analogous groups (such as those with head and neck cancer and those having solid organ transplantation and hand transplantation), we have set out a detailed review of expected psychological change and strategies for intervention.⁵ Our premise is that the psychological impact of facial transplant can be anticipated, planned for, and managed, and we have developed a protocol for doing so over the short and long term.

Members of the lay public often worry that the donor's identity will be transferred to the recipient through facial transplantation.⁷ But modelling of the change in appearance, using laser scanning and photography, shows that such transfer does not occur after facial transplantation. Indeed, preoccupation with altered identity risks becoming too much of a distraction from the important issue of managing immunosuppression.

Now that research has made the concept of facial transplant a reality, concerns about long term immunosuppression do remain. But, instead of considering why facial transplantation cannot be justified, we may find it hard to justify why it should not be done.