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Last Updated: Tuesday, 20 September 2005, 11:09 GMT 12:09 UK
Trading faces
By Jonathan Duffy
BBC News Magazine

Face transplant graphic
Not for the first time surgeons are planning to perform the world's first face transplant. The expertise already exists but in the past doctors have shied away, fearing the emotional consequences of this medical taboo.

It took about four years for Denis Chatelier, the world's first double hand transplant patient, to accept the foreign appendages that had been grafted on to the stumps where his hands used to be.

The defining moment, he explained in a newspaper interview in the spring, came about a year ago when, "without realising it, I stopped calling them 'the hands' and started calling them 'my hands'."

The Frenchman's anecdote alludes to the psychological cliff face the recipient of the world's first face transplant would have to scale.

For, as James Partridge, whose face was severely disfigured by burns from a car accident, says "when you look at your hand, you say 'that's mine', whereas the thing about the face is that when you look in the mirror you say 'that's me'."

Previous efforts

From the moment primitive man fashioned his first mask, the issues of taking on someone else's identity have been a source of fascination. And while doctors have grappled with the technicalities of face transplants, crime writers have toyed with its fanciful implications.

Dr James Partridge
The period of adjustment can be long and hard - it took four to five years in my case
Dr James Partridge
The advent of the face transplant has loomed ever closer. In the 1990s doctors in India replanted the skin of a nine-year-old girl who had lost her face and scalp in a threshing machine accident.

There have been partial "face transplants", which actually amount to elaborate skin grafts, and last year doctors in Kentucky signalled their intention to perform such an operation - but are still awaiting permission from an ethics panel.

Doctors in Cleveland, Ohio, have already overcome that hurdle and are about to start screening 12 severely disfigured patients for the first face transplant.

Although the medical world is divided about whether such a procedure is technically possible, rarely has a surgical procedure thrown up such a welter of psychological issues for potential patients and their loved ones.

Traumas magnified

Doctors already know patients who receive a transplanted organ, such as a kidney, face all sorts of possible emotional traumas, such as:

  • fears about whether the organ will work
  • fear for the effects if it doesn't
  • doubts about the effects of the strong drugs that help the body accept the new organ
  • worries about being personally responsible if the organ fails
  • anxieties about how the new organ melds with the existing body image
  • feelings of gratitude and guilt towards the donor and the donor's family

    A report by Britain's top surgeons two years ago suggested that these issues "may be magnified" in the case of a face transplant.

    Clint Hallam
    Clint Hallam eventually asked for his new hand to be removed
    The case of Clint Hallam, who received the world's first hand transplant, looms large. Mr Hallam eventually asked for the hand to be removed. Doctors said he had skimped on his anti-rejection drugs - a charge Mr Hallam denied.

    The experience highlights the need for careful patient selection. But with the face so deeply integral to one's personality, experts see an inherent paradox - those most unhappy with their disfigured features, and therefore most likely to want a new face, will be most emotionally delicate.

    What then, if the transplant starts to go wrong? How will a psychologically vulnerable person cope with their new face sloughing off, especially if more surgery is then required to patch up the old, disfigured face?

    All of which raises the question of whether a patient is mentally fit to put themselves forward for such an operation.

    "If the people seeking this type of procedure are possibly the most vulnerable, how can they give informed consent?" wonders Dr Diana Harcourt, deputy director of the Centre for Appearance Research.

    Supporters of face transplants say patients will get post-operative counselling, which has proved fruitful when helping people accept their disfigured face after an accident.

    SOCIETY'S REACTION
    Society's reaction could further traumatise a transplant patient
    There will be invasive media interest
    Despite anonymity, the press will likely track down the first face transplant patient
    Another issue is the belief a patient would take on the appearance of the dead face donor.

    "Because of the patient's underlying bone structure and eyes what you will really create is a third face," says Dr Alex Clarke, a clinical psychologist in London, and a supporter of face transplants.

    Dr Clarke says the term "face transplant" perhaps over-eggs the procedure, which actually is "moving just a little bit further than the plastic reconstructive surgery" that is common for many burns victims.

    Nevertheless, she agrees the "identity issue is the big one" and favours the more cautious pace of British medics compared to Americans.

    'Face race'

    To emphasise the point Dr James Partridge cites the case of Donald "Dax" Cowart, an American who changed his name after suffering severe facial disfigurement in an explosion.

    Dr Partridge, who runs the Changing Faces charity which helps facially disfigured people, thinks another 10 years' research is needed into transplants to iron out the emotional issues.

    He is scornful of the "face race" to be the first to perform a transplant, and believes strongly that counselling can be "massively effective" in helping people accept a disfigurement, as it was to him.

    "The period of adjustment can be long and hard. It took four to five years in my case to come to terms with my new face, but now I like it and I wouldn't change it."


    Add your comments on this story, using the form below.

    I had maxillofacial surgery 3 years ago to correct my underbite. The result was that my face was unrecognisable as my own and I am still coming to terms with it. I have no regrets about choosing to undertake the treatment but it is a very complex psychological process learning to first recognise and then like your new face especially when the people who are closest to you are treating you like a stranger and requiring reassurance that you are still the same person inside. I still find it difficult to look at photographs of myself taken before my treatment as they look like a different person to what I look like now but at the same time they are so familiar.
    Lucy Saunders, London

    Having had a skin graft on my right leg after I suffered full skin loss due to a serious accident 4 years ago, it still hurts me to see it, knowing my poor legs will never be the same again. I can only barely imagine losing my face, but I feel that NOT having a transplant would be worse as it is more likely to look "normal" after a graft than just leaving it. Looking at my leg I know it would have been a lot worse not having the graft as I did not have a graft everywhere I lost skin. Either way, the image staring back at you from the mirror, with or without the graft/transplant, will never again be what it used to be.
    R, Suffolk

    What's not mentioned here is the psychological effect of having a dead person as part of your own body. Clint Hallam effectively had taken a part of a dead persons body and attached it to his own. It seems like something out of a Frankenstein story and I can understand why he chose to have it removed.
    Scott Bowler, London, UK

    This is the plot of Desmond Bagley's 1973 novel "The Tightrope Men", which opens with the protagonist waking up in a hotel room (in Oslo) and seeing a strange face in the mirror. It's a quite frightening opening to a good tale well told.
    Alan, London Uk

    It seems our society is so image-obsessed that we can no longer accept people who look a little different! Instead of developing 'face transplants', shouldn't we be teaching ourselves to be more accepting and affirming of those who have been through traumatic experiences?
    G, London

    Never say never. We won't know the outcome until it's done on a carefully selected individual. Only time will tell.
    Tina, London

    It is now 9 years since I first shaved my head, when I began to go bald. Yet, in my dreams, I still have hair. How strange that a residual self-image should remain in my subconscious for so long... if such a simple change to my appearance can have such ramifications, what it must be like for someone to get a new face I cannot imagine. That said, any face must be preferable to disfigurement, and surely it is worth it in the long run.
    Rob, London, UK

    In 2002 my own face has changed dramatically through surgery. No transplant was involved, but the aim was to change my appearance. I believe that most people who'd be up for it presumably have an issue with how they look. In my case the issues were dental and medical and the treatment was initiated by dental and medical experts - all I had to do was agree to undergo it. I still attend regular post op meetings with the surgeons, but I've not been offered, or felt the need for, any kind of counselling. I'm very happy now with my appearance!
    Stephen Dale, London, UK

    As harrowing as it must be to be severely disfigured, I am very unsure that face transplants are the right thing to do. Surely the investment could be put into curing serious illnesses eg. cancer, motor neurone disease to mention but two.
    Sue, Halesowen, West Mids, UK

    I think that the bone structure and eyes of a persons face give the fundamental shape and identity of a person. Everyone's exterior skin changes through the aging process but the essential shape stays the same. For example my wonderful grandmother is 95 but her face still exhibits her sculpted cheekbones and her sparking blue eyes. That's her facial identity, those features that people recognise her by, not her skin.
    B, UK

    I strongly agree that these patients need counselling sessions even before they are transplanted with a new body part. As a nurse, I have seen patient grieving for having scar marks on their body, which were unbearable for them, whereas changing a face would be more painful. The article was very stimulating and mind provoking!
    farzana.mukhi, Dar-es-salaam, Tanzania

    What about the potential donors? I'm not sure many people would wish for their face to be removed at death in order for someone else to receive it. And what about the relatives left behind? What if they bumped in to the receiver of the donor?
    ,

    Surely if face transplants go ahead, the whole family of the patient will need counselling to come to terms with, and accept the patients new appearance, not just the patient?
    Amanda Woodfield, Brentwood USA

    Plenty of people have cosmetic surgery that completely changes their appearance so I'm confused by the idea everyone will freak out at wearing a donor face. And of course our faces change with age, from childhood to adulthood then again in later years. My concerns are that the person will be on immuno-suppressant drugs for life, and that finding donors - especially child donors - will be incredibly hard. I doubt anyone will undergo this unless the need is desperate so good luck to anyone who needs it.
    Chandra, England

    I had a breast reconstruction operation and it was the best thing I ever did following a mastectomy seven years before. I often feel I am so lucky because if I lost an arm or a leg I couldn't have another one. But hopefully that will become possible. It is never the same as what you started out life with but to have a body and body shape that is "normal" to have frees you to be all that you can be in future.
    Ali, Newcastle upon Tyne

    I don't feel this is something we should rush into but if the technology is there and we have the ability to make it possible for people with disfigurements to undergo this treatment then they should have the option.
    Jo, Edinburgh

    I pick up on the point about underlying bone structure, how much remains intact and how much reconstruction work may already have been performed to match the patients' natural features. Therefore, superficial facial transplantation cannot completely mirror the donor and is probably more likely to resemble the patient, especially if the eyes remain unchanged. I wonder if there are any strong differences between male and female patients on this subject?
    Judi Lang, Lichfield, Staffordshire, UK

    The assumption here is that your face is static, when in fact it changes over the years. That means we go through a constant process of adaption to what we look like.
    John Airey, Peterborough, UK

    I have no problem with the concept of face transplants any more than heart transplants - which raised similar ethical issues. What bothers me is that this is being done primarily for the surgeons benefit and not the patients.
    Ian, coventry

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