Gaining face

The daring team of American hand-transplant surgeons is ready to move on to the body's most personal component within a year.


Jon Bowen
May 19, 1999 8:00PM (UTC)

Nothing in the spectrum of human injury, disease and disfigurement compares to the trauma of losing your face.

"How many people have you seen who are missing part or all of their face?" asks Dr. John Barker, a plastic surgeon at the University of Louisville in Kentucky. "Not many. They're so traumatized, they don't go out on the street."

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Barker wants to change that -- by pioneering the field of human face transplantation. "The first face transplant will probably be done within a year," he says. "It could be done anytime. We have the know-how."

But will disfigured patients be willing to undergo such a drastic procedure? Ashley Allen of Chattanooga, Tenn., was born with Crouzon Syndrome, a hereditary condition that causes extreme cranial and facial malformations. "I had a lack of bone in the face, no eye sockets, large bulging eyes, teeth in my sinus cavity." Now 24, Allen has undergone 22 reconstructive operations to normalize her appearance. If she were back at square one, would she endure a transplant to get a new face? "Oh yeah," she says. "In a minute."

As thousands of transplant surgeons convene in Chicago this week for the annual meetings of the American Society of Transplantation and the American Society of Transplant Surgeons, the topic of face transplantation will be on the tips of a lot of tongues. Will the procedure really work? Is it worth the risk of dosing a patient with immunosuppressive drugs to enhance appearance? Will donors come forward? Is it ethical to graft one human being's face onto the skull of another? Is it taboo?

To begin at the beginning, let's say your face is badly damaged in a fire, or a car wreck, or say some rare disease destroys it, or you destroy it yourself in a botched suicide attempt. Up until now, the options for recovery have been limited to the patchwork restoration done with tissue grafts and reconstructive surgery. The most common procedure for rebuilding shattered faces is known as a "lateral arm flap," a process that involves taking part of the victim's arm -- the bone, muscle, nerves and skin -- and molding it onto what's left of the ruined face. This procedure requires 10 to 16 hours of preliminary surgery, followed by dozens of subsequent operations to make the face resemble a somewhat normal face, aesthetically and functionally.

But with a face transplant you would undergo just one operation, followed by a protracted regimen of drug therapy. And the comparative simplicity of transplant surgery would exponentially boost the surgeon's odds of giving the patient a good-looking end product. As Barker succinctly puts it, "You're making a face into a face, not an arm into a face."

Barker says the medical community has possessed the technical know-how to transplant faces for 20 to 30 years, but until now obstacles associated with immunosuppression have stopped transplant surgeons from attempting multiple tissue grafts.

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Because a hand or face transplant requires grafts of bone, tissue, nerves and skin, doctors must first create a flawlessly balanced prescription of drugs to keep the body's immune system from rejecting all the different types of grafts. For the past three years, Barker and his colleagues at the University of Louisville have been conducting animal research in their quest to find that perfect pharmaceutical recipe.

"The goals of our research," Barker says, "were to maximize immunosuppression, and to minimize systemic toxic side effects." In other words, they had to identify a drug cocktail that would sufficiently suppress the immune system while ensuring tolerable levels of toxicity in the patient.

They mixed together three drugs commonly used in other types of transplants -- FK506, MMF and prednisone -- and the resulting concoction seemed to spell success. Barker's findings were published in the journal "Transplantation," and in early 1998 his team presented its pioneering research at a hand surgery conference in Vancouver. A team of surgeons from France attended that meeting, and, according to Barker -- who hints at a trans-Atlantic rivalry -- it was those surgeons who brought his research to fruition on the arm of a man named Clint Hallam, when they performed the first successful human hand transplant last September. Today, eight months down recovery's road, Clint Hallam and his new hand are doing fine. When asked at a press conference if the new hand felt like his own, Hallam emphatically replied, "Of course it does."

In the months since Hallam's surgery in France, Barker's team at Louisville has also performed a successful hand transplant, and it's the startling triumph of these transplantations that has presented the possibility of a human face transplant. Barker says, "In doing the hand, we've proven that a face will work."

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Barker's team now has permission to do 15 hand transplants. (Permission comes from an Institutional Review Board that weighs ethical issues and ensure the rights and safety of patients.) Once Barker and his team have completed the first five hand transplants they plan to review the status of the recipients. "We'll monitor each one," he says of the hand transplant patients. "If they turn out well, then we'll move forward with the face."

Some critics view cutting-edge surgeons like Barker as the cowboys of the medical community, pushing the transplant frontier out of a narcissistic need to boost their own outsized egos. For example, some skeptics accused Barker of showboating when he held a press conference in July of 1998 to announce his surgical team's plan to perform 15 hand transplants.

"We got a lot of criticism," Barker says, but he claims that his intentions were altruistic. "We did it to educate the donor pool. We have to go out there now [to the families of potential donors] and say, 'We're going to ask for the hand of your loved one.' Before the press conference, we had ten donors to choose from. Two weeks after the press conference, we had 100 donors."

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Whether Barker is a caretaker of the afflicted or a limelight lover, the result is what matters most -- to patients, anyway. As stated in a New Scientist magazine editorial, "Without patients who are willing to take a chance and surgeons egotistical enough to stick their necks out, transplant medicine would be stuck in a rut."

One of the stronger arguments against hand and face transplantation says that it's irresponsible to dose patients with such an excessive level of immunosuppressive drugs for anything other than a life-saving procedure. Because these drugs stifle the immune system, they heighten the risk of infection and expose the body to a universe of other diseases.

Dr. Matthew Tomaino, chief of microsurgery for the University of Pittsburgh's orthopedic surgery department, has been one of Barker's more outspoken opponents. Last July, when Barker's team was granted approval to do hand transplants, Tomaino told the Associated Press, "It's very, very risky and I think they're pressing the envelope with this. The risks from taking these drugs, which the recipients will have to take for the rest of their lives, have not warranted the transplant of a non-vital organ."

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But now, when asked to comment on the prospect of face transplants, Tomaino takes a more charitable view. "This is a different situation than the hand. The goal is very reasonable. And it's definitely feasible." Tomaino says that for patients with destroyed faces the potential improvement in quality of life warrants the risk of taking the drugs.

Allen agrees: "I don't see why people wouldn't be willing" to receive a transplant. "I've got substances in my face that aren't human -- implants, false cartilage. To take donor [material] would be better," than undergoing the "massive series" of operations that Allen had.

Dr. Linda Hogle, a medical anthropologist and senior fellow at the Stanford Center for Biomedical Ethics, says, "If you have someone who's unable to work or have a social life, [the transplant] would make a dramatic change. You have to ask, is it enhancement or is it something that would dramatically change a life?"

And what about donors -- will they come forward? Numerous and monstrous are the implications of taking the face from a cadaver and grafting it onto the skull of a living human being. Hogle has done extensive research on organ procurement and issues related to allocation. She poses the question this way: "We donate our organs to save lives, but will people be willing to donate to improve someone's appearance?"

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One potential hindrance to donation is the tight time frame that's essential to transplant surgery. When a person dies, the body instantly begins to deteriorate. Fluid drains out of the cells. The cell walls collapse. The tissue becomes rigid. In order to preserve the structural integrity of the donor's face, the transplant would likely need to take place soon after the donor's death -- preferably within 24 hours. And the necessity of harvesting the material so quickly would cut short the family's grieving process. "They want to see the body -- have a viewing," Hogle says. "It would disrupt the normal grieving rituals. It could be a barrier to donation."

Even Barker flatly admits, "It'll be difficult to get families to donate the faces of their loved ones."

Assuming the donors do come forth, and supposing the first transplants take place, a whole new set of quandaries arises. In a face transplant, surgeons might use all of the donor's face, or just parts of it -- the jaw, the skin -- depending on the type of damage done to the victim. So, when the surgery is completed, will the recipient's face then resemble the donor's face? "It depends," Barker says. "If we only transplanted the skin, it wouldn't because you're just draping the skin over the underlying bone structure. But if you used, for instance, a whole jaw, then, yes," it would look like the donor's lower face.

Hogle sees beyond the medical concerns to the metaphysical: "You're really transplanting more than the tissue itself. You're bringing someone else's identity and overlaying it on the recipient's body."

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And what about the recipients -- how would they feel, waking up each morning to a face in the mirror that is not, in the strictest sense, their own? Allen says "There would be massive psychological side effects. But it all depends on the person -- how comfortable they are. Their self-esteem."

"The face is the most intimate, most individual characteristic of your body. It's who you are," Hogle says. "The recipient has already had one identity shift with the disfiguring injury, and now a second shift would come with the repair process. And remember: This is not an artificially molded face, this is someone else's material. There will be cultural issues about what it means to have someone else's face."

The issues keep rising, and they drift into Hollywoodish absurdity. Will the famous faces of celebrity donors become available? Will crazed fans deliberately deface themselves on the slim hope of getting their idol's face? Could there come a day when the wizened wealthy are able to barter for a youthful face? "I don't see that happening," Barker says. "This is to help people who are suffering."

Even when it's put forth as a purely humanitarian endeavor, face transplantation is likely to trigger heated discussion in the medical world and beyond. "When it comes to using parts of the dead for the good of the living, there is no consensus on the way people view these things," Hogle says. "Face transplantation -- it seems sort of taboo. Some will say, 'This is wonderful.' Some will say, 'This is horrible.'"

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To transplant, or not to transplant? The only person who can answer that question -- maybe the only one who really deserves to answer it -- is someone like Allen.


Jon Bowen

Jon Bowen is a frequent contributor to Salon.

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