Nip, Tuck, Transplant: The Ethics Firestorm
Feb. 6, 2006 — -- When a face transplant was the focus of an episode of the television drama "Nip/Tuck" last year, viewers might have thought that was the closest they would get to seeing such a procedure take place. Today, however, the world got a sense of the real version's results.
After hearing -- and seeing -- French facial transplant recipient Isabelle Dinoire for the first time at a news conference aired around the world, doctors are impressed by the first-ever operation, but also still guarded about the outcome.
"The jury is now in. This was a profound success compared to all other standard methods of reconstruction that could have been offered to this patient," said Dr. Peter D. Costantino, director of the Center for Facial Reconstruction and Restoration at Roosevelt Hospital in New York. He called the transplant "very appropriate" for the French woman who had been mauled by her pet dog.
However, other surgeons emphasized that Dinoire would never be as normal as she hoped. There is a persistent risk that Dinoire, along with any future face transplantees, could experience an immune system-activated rejection of the new face.
On top of that, doctors admit the results are less than perfect.
"The results on video are exactly what I expected," said Dr. Brendan C. Stack, Jr., chief of Head and Neck Surgery at the University of Arkansas. "She has a paralyzed face where all movement comes from moving the jaw. The mouth remains open -- which is from paralysis of the mouth -- and would thicken speech, promote drooling, and interfere with eating."
Most doctors agree that face transplants will not be as common as Botox or rhinoplasty, but Dinoire's transplant has brought hope for those with disfigured appearances and has put the focus on other more studied options.
Some plastic surgeons prefer the less risky alternative of a removable silicone prosthesis, which is more commonly used in the United States when patients need extensive facial reconstruction.
"Emotionally, there is something more appealing about not having to wake up and put something on, but you are trading a non-life-threatening condition, for a life-threatening condition," said Dr. Laxmeesh Nayak, director of Facial Plastic and Reconstructive Surgery at St. Louis University School of Medicine. Nayak worries that Dinoire has more doctor's visits in her future than one should have to endure.
Another alternative involves removing skin from the patient's own back, thighs or buttocks. This tissue is then re-applied to the patient's face in an attempt to regain some function. However, patients can face as many as 50 operations to complete the task.
Besides the physical hurdles, there also are complex emotional and ethical concerns. Already there is little psychological evaluation for those who choose other types of plastic surgery. It is often a matter of choice and money. Should face transplants be different?
Nayak said that most decisions like those were left up to surgeons, but admitted that it would help if there were psychological screenings to ensure recipients had the emotional wherewithal and understood the choice they were making.
"This isn't like a heart transplant. There is no urgency, and you can sit back and take six months to a year to determine if this is a good candidate," Nayak said.
In the United States, where more than 40 million are without health insurance, most realize that plastic surgery often comes down to a stash of cash. A face transplant might not be any different.
"Most insurers are going to pick the most cost-effective option. Most likely [face transplants] are going to only be an option to those who are paying cash," Nayak said. "But that applies to all of medicine. Who can get a cochlear implant? Does it come down to if they can pay for it?"
With nearly 12 million cosmetic procedures performed in the United States in 2004 alone, these types of questions will likely be on the operating table for some time to come.
