To help people understand the special circumstances surrounding face transplant surgery, orthopedic and plastic surgeon L. Scott Levin has one question:
Would you donate your face for a transplant?
The face arguably is more personal to us than our kidneys and lungs. So, a face transplant makes doctors, ethicists and researchers stop to ponder: Who would be willing to part with it at the end of his or her life? And even if the donor gave previous explicit permission, would family members allow their loved one to be disfigured after death? Would the family worry that the recipient might resemble the donor? Or even that their loved one might meet the afterlife faceless?
"Families, societies and religious leaders are going to have to decide whether donating a face or part of a face is a noble thing," said Levin, of Duke University Medical Center in North Carolina.
Finding the Donor
As highlighted by the partial face transplant performed in France on Nov. 27, surgeons have overcome many of the technical obstacles to facial transplantation, with the exception of any long-term unknowns.
However, public opinion could advance or slow the establishment of face transplant surgery centers. Even if the science is up to speed, as Levin notes, transplant surgery is not possible without willing donors.
It has not been disclosed how the French team of doctors who performed the world's first partial face transplant located a suitable brain-dead donor. The New York Times reported that the donor, a French woman in her 40s, likely hanged herself. The recipient was 38-year-old Isabelle Dinoire, whose face was mauled by her dog after she passed out from taking sleep medication.
Since the operation, a team of doctors in London has announced that it hopes to complete a similar surgery next year. Doctors in China also have indicated they may try the procedure on a severely burned 11-year-old girl.
In the United States, however, development is slower. Two institutions, the Cleveland Clinic in Ohio and the University of Louisville in Kentucky, have both extensively researched the procedure but do not appear to be planning to try the surgery soon.
Dr. Maria Siemionow, at Cleveland Clinic, would likely be the first to try. She has her hospital's approval to look for potential recipients, but has not announced any forthcoming surgeries or how she will find donors.
Ethicists are closely watching the development of this surgery because of its uniqueness. On one hand, most people would agree that the severely disfigured should have access to any technology that would make them look and feel better.
On the other hand, face transplantation is an enormously costly, intricate procedure that does not prevent imminent death, which is the justification for most other organ transplants. It is also not known whether a face transplant will restore much function to the recipient's face.
"The first cases that will be done are going to be purposely under intense institutional review to make sure the ethical, legal and medical standards are met," Levin said. "How we go about it and how we take the first steps are very important."
This careful, slow approach may help make people more agreeable to the notion of being a face donor, said Dr. Thomas A. Bledsoe, the interim director of the Center for Biomedical Ethics at Brown Medical School in Providence, R.I.
"Open, public, ethical deliberation sometimes will allow development of a consensus that allows the new technology to be used with some safeguards or strictures, as opposed to an outright ban," he said.
The same controversy surrounded heart transplants several decades ago, when some worried that the procedure might somehow transplant the donor's personality or emotion. But a heart is an internal organ, which made it easier for people to accept. The face, however, is intensely personal and unique.
An era when face transplants are done fairly frequently is difficult to imagine, partly because it's so dependent on willing donors, said Dr. Raffi Der Sarkissian, of Boston Facial Plastic Surgery. Der Sarkissian is also an assistant clinical professor at the Boston University School of Medicine.
"I think it will be a huge challenge to find a donor, unless you get into a situation where a person wants to perpetuate their person after death," he said.
But, because it offers advances over current methods, Der Sarkissian said, the technology should be available. So, he recommends that surgeons instead focus their efforts on partial transplants, like noses or eyelids, paired with more traditional methods like skin grafting.
"If it can restore function to the central part of the face, or ears, so someone can wear sunglasses or have eyelids so they have a blink function to maintain function, that takes a lot of the mystique out of [full face transplants]," he said.