Disrupted faces, disrupted identities? Embodiment, life stories and acquired facial 'disfigurement'.

Questions about the relationship between faces, 'disfigurement' and identity intensified following the first facial transplant (2005). Over a decade later, empirical research exploring the influence of acquired facial 'disfigurement' on embodied identity disruption and re-formation remains limited. A common strand of thinking assumes identities are contained within faces. Commentators have suggested that identities can be diminished through 'disfigurement' and restored or replaced through reconstruction or transplantation. The authors question this claim and provide a conceptually informed, empirical alternative drawing on the results of a phenomenologically located, narrative study exploring identity shift in British adults following acquired 'disfigurement'. Findings suggest that faces are important to humans and that identities can be disrupted in the aftermath of facial 'disfigurement'. Though, the relationship is not simple and cannot be predicted by the degree of corporeal change. Disrupted, liminal and contradictory strands of identity emerged; pre-existing identities were strengthened, new ones emerged, and other non-related experiences were also influential. Nuanced relationality was at the heart of participant sense-making. Consequently, the authors reject the idea that identities are contained within faces and call for the development of a wider social and relational facial phenomenology to more comprehensively explore this fascinating, multifaceted relationship.

Ethical Issues Posed by Face Transplants.

A face transplant is as challenging a surgical procedure as any patient can undergo. In this introduction I present the medical aspects of this surgery, the profound ethical issues it raises, and optimal interventions that clinicians can pursue to help these patients and their loved ones. I then discuss how to help other kinds of patients and loved ones who confront similar stresses. I end by presenting a goal that author Sharrona Pearl puts forth after she studied many face transplant patients. The efforts she urges should maximize our capacity to see face transplant patients-and anyone-as they are, as opposed to how they look.

Face transplantation-current status and future developments.

More than thirty-five facial allograft transplantations (FAT) have been reported worldwide since the pioneering case performed in France in the year 2005. FAT has received tremendous interest by the medical field and the general public while gaining strong support from multiple disciplines as a solution for reconstructing complex facial defects not amenable/responsive to conventional methods. FAT has expanded the frontiers of reconstructive microsurgery, immunology and transplantation, and established its place in the cross section of multiple disciplines. The procedure introduces complex scientific, ethical, and societal issues. Patients and physicians are called to deal with a variety of-sometimes everlasting-challenges, such as immunosuppression management and psychosocial hurdles. This review reflects on the surgical and scientific advancements in FAT and milestones reached in the last 12 years. It aims to encourage active discussion regarding the current practices and techniques used in FAT and suggest future directions that may allow transitioning into the next phase of FAT, which we describe as safe, reliable, and accessible standard operation for selected patients.

Face transplantation for the blind: more than being blind in a sighted world.

Face transplantation (FT) is a landmark in reconstructive surgery involving vascularised composite allotransplantation. A recent issue of FT for patients who are blind has arisen. Some bioethicists recommend not excluding a patient who is blind, as this may amount to discrimination. From an ethical standpoint, FT for those with blindness is appropriate in selected candidates. This article seeks to add to the clinical evidence supporting FT for those with blindness by detailing a complementary psychosocial perspective. Currently, there is little relevant research about the subjectivity of the blind. This is critical since the arguments against FT for the blind refer to their inability to see their face and to view the reaction of others to their disfigured faces. We begin with a brief look at examples of FT involving blindness and associated arguments. The next part is a multidisciplinary investigation of the experiences of the blind. These are gleaned from a close reading of the literature and drawing inferences, as direct studies are rare. The discussion analyses identity themes of the blind in relation to their faces: as they experience it; the face they wish to show to the world; and how others perceive and react to their face in a saturated environment of imagery and visual communication. Disability and the blind person's experience of faces are well-founded considerations for medical practitioners and ethics boards in the process of FT decision-making.

Pediatric face transplantation: a viable option?

PURPOSE OF REVIEW: Face transplantation is no longer a young field. Reported outcomes suggest that this life-enhancing transplantation is viable and ethically justified for appropriate patients. Given that pediatric hand transplantation has been performed with promising reported outcomes, it is time to consider how to properly expand the field of face transplantation into pediatric patients. RECENT FINDINGS: Appropriate collaboration between adult and pediatric colleagues can mitigate risks associated with expanding surgical innovation between respective patient demographics. The reported outcomes of the first pediatric hand transplant question the appropriateness of increasing immunosuppression burden to a patient on an existing regimen for prior solid organ allotransplantion. Young donor allografts prove to be more resilient, however, implying that managing rejection episodes is key to long-term viability. Expanding face transplants into a younger population must consider the social functions of the face, and may facilitate healthy personal development given the cultural value appearance has in real life and in social media. SUMMARY: We believe that pediatric face transplantation is not just a viable option, but an ethically reasonable one as long as the field proceeds with cautious optimism.

Ethical issues in pediatric face transplantation.

Facial transplantation has become a reality in adult medicine. Children are subject to congenital craniofacial differences, disease-related, traumatic, or thermochemical craniofacial changes and might be suitable for face transplantation. This manuscript addresses unique ethical issues in considering potential pediatric face transplant. These challenges are operant at the individual, technologic, and psychosocial level for clinicians, investigators, and society.

The miracle of face transplantation after 10 years.

INTRODUCTION: At the 10th year anniversary of the first face transplantation, there are currently 36 patients worldwide, who are the recipients of faces coming from human donors. AREAS OF AGREEMENT: Despite the initial debates and ethical concerns, face transplantation became a clinical reality with satisfactory functional outcomes. AREAS OF CONTROVERSY: The areas of controversy still include the impact of lifelong immunosuppression on otherwise healthy patients as well as the selection process of face transplant candidates. GROWING POINTS: Other concerns include financial support for this new generation of transplants as well as social reintegration and patients return to work after face transplantation. AREAS TIMELY FOR DEVELOPING RESEARCH: Based on over 20 years of research experience in the field of vascularized composite allotransplantation, and clinical experience as a leading surgeon of the US first face transplantation, this review will summarize the well-known facts as well as unexpected outcomes and challenges of face transplantation.

Intraoral features and considerations in face transplantation.

Face transplantation (FT) is a unique and novel addition to the field of reconstructive surgery, which offers new hope to facially disfigured individuals. This review provides an overview of FT, including clinical indications, immunological principles, and functional outcomes, as well as an in-depth characterization of the intraoral hard and soft tissue findings in the six patients transplanted to date at Brigham and Women's Hospital in Boston, MA, USA. Six FT recipients underwent comprehensive clinical and radiographic evaluation to assess their intraoral status, function, and overall health. The extra- and intraoral soft tissue was assessed via quantitative sensory testing. The vitality of the transplanted dental hard tissue was evaluated with clinically available testing methods. Native teeth and prostheses were also assessed. Sensation of transplanted oral mucosa varied based on time elapsed from FT, ranging from minimal at 3 months post-FT, to nearly complete recovery by approximately 24 months. There was mixed success with the integration of donor teeth (Patients 1, 4 and 6), including associated occlusal discrepancies. Mucosal complications included constriction at the donor/recipient interface (Patients 2 and 5) and solitary episodes of mucosal rejection presenting as lichenoid inflammation (Patients 2 and 4). Face transplantation represents a pivotal moment in the history of reconstructive surgery and transplant medicine, providing new optimism to patients with gross facial deformities. This report highlights the successes of FT, but also the challenges of transplanting hard and soft tissues to restore complex stomatognathic function. Further attention directed toward comprehensive oral rehabilitation in FT will contribute to improved outcomes, with the ultimate goal of restoring and optimizing patient quality of life.

Ethical Considerations of Whole-Eye Transplantation.

Whole eye transplantation (WET) remains experimental. Long presumed impossible, recent scientific advances regarding WET suggest that it may become a clinical reality. However, the ethical implications of WET as an experimental therapeutic strategy remain largely unexplored. This article evaluates the ethical considerations surrounding WET as an emerging experimental treatment for vision loss. A thorough review of published literature pertaining to WET was performed; ethical issues were identified during review of the articles.

Ethics of facial transplantation revisited.

PURPOSE OF REVIEW: There have been 26 cases of facial transplantation reported, and three deaths, 11.5%. Mortality raises the issue of risk versus benefit for face transplantation, a procedure intended to improve quality of life, rather than saving life. Thus, one of the most innovative surgical procedures has opened the debate on the ethical, legal, and philosophical aspects of face transplantation. RECENT FINDINGS: Morbidity in face transplant recipients includes infections and metabolic consequences. No graft loss caused by technical failure, hyperacute, or chronic graft rejection or graft-versus-host disease has been reported. One case of posttransplant lymphoproliferative disorder, 3.45% and one case of lymphoma in an HIV-positive recipient were reported. Psychological issues in candidates can include chronic pain, mood disorders, preexisting psychotic disorders, post-traumatic stress disorder (PTSD), and substance abuse. SUMMARY: Early publications on ethical aspects of face transplantation focused mainly on informed consent. Many other ethical issues have been identified, including lack of coercion, donor family consent and confidentiality, respect for the integrity of the donor's body, and financial promotion of the recipient and transplant team, as well as the cost to society for such a highly technical procedure, requiring lifelong immunosuppression.

Face transplantation: psychological outcomes at three-year follow-up.

BACKGROUND: The advent of face transplantation has raised both ethical and psychological issues. Mortality of 18 existing face transplant recipients is 11.1% (2/18) through 2011. OBJECTIVE: Psychological outcomes are as important in face transplantation as is restoring the face physically. Little quantitative information has been published this area. METHODS: Data was systematically collected over 3 years with a face transplant recipient, including appearance self-rating, body image, mood changes, pain rating, perception of teasing, quality of life, self-esteem, and social reintegration. We identified a significant gap in rating instruments for use in the field, so we developed the Perception of Teasing-FACES, Facial Anxiety Scale-State, and the Cleveland Clinic FACES score, analogous to the model for end-stage liver disease (MELD) score for prioritizing patients for a face transplant registry. RESULTS: Appearance self-rating rose from 3/10 prior to transplantation to 7/10 now. Anxiety about body image and the Facial Anxiety score were halved by the end of the third year. Beck Depression Inventory fell from 16 (prior to transplant) to 8. Chronic daily pain was 6-7/10 prior to transplant and 0/10 by day 50. Perception of Teasing-FACES scores fell from 25 to 9 by the end of year 3. Quality of life improved on the Social Environment Domain of the psychological adjustment to illness scale-self-rated (PAIS-SR), where the score dropped from 15 to 1 by the end of year 3, indicating marked improvement in social reintegration. CONCLUSIONS: Standardized data collection may help quantify psychological outcomes with facial transplantation to determine whether the risks of immunosuppression over time are offset by improved quality of life for recipients.

Experiences of healthcare team members involved in facial transplant surgery and patient care.

BACKGROUND: Situations that highlight the healthcare team member vulnerability, present ethically laden questions, or are innovative in nature may have a long-term personal and professional impact on caregivers and, consequently, directly or indirectly affect patient care. The ethical experiences and perceptions of the healthcare team members involved in facial transplantation procedures and patient care have not been explored. OBJECTIVE: The objective of this study was to explore healthcare team member experiences of caring for facial transplantation patients, using an ethical framework. METHODS: This study used a qualitative descriptive design to explore the experiences of 26 multidisciplinary healthcare team members, including professional, ancillary, and support staff who have participated in facial transplantation procedures and patient care. Individual, private, semistructured interviews were conducted. RESULTS: Two main themes emerged: individual sense of purpose and esprit de corps. Individual sense of purpose describes the meaning of the experience that involvement in facial transplantation had for the participants and comprises three subthemes: "getting it right, "transforming a life," and "spirituality." The theme esprit de corps conveys the morale of the healthcare team members involved in facial transplantation and was expressed through three subthemes: "leadership," "teamwork," and "environment." DISCUSSION: Many potential ethical dilemmas were mitigated by an overwhelming sense of moral obligation to help patients with complex cosmetic, functional, and mechanical facial deficits. Participants in this study unanimously believed that the risk-benefit ratio of the procedure and subsequent treatment supported its implementation.

Would you be a face transplant donor? A survey of the Turkish population about face allotransplantation.

With the technical advancement in face allotransplantation, we decided to survey the Turkish population to gain perspective into their thoughts and reactions toward face transplantation. A questionnaire was given to 1000 volunteers, regarding data about demographics, educational status, religious, and behavioral preferences. Their attitudes about donating their faces, knowledge about the pros and cons of this procedure, and personal desire for face transplantation if needed were inquired.The results of the survey demonstrated that knowing more about the procedure increases its acceptance but even so, the majority would rather undergo multiple operations with self-tissues before getting a facial transplantation (FT). When the risks of immunosuppression were exposed, less people agreed to FT, thinking it was not worth the risks.The cultural, ethnical, religious, and social background of different societies may influence the way FT is perceived and accepted. As this procedure is thought to challenge many ethical, physiological, and social points of views, we believe that it is important for a surgical team to have insight into their population's perception and general thoughts concerning the issue.

Face transplantation: outcomes, concerns, controversies, and future directions.

BACKGROUND: Since 2005, 17 facial allotransplantations have been performed worldwide. The brief summary of current cases with ongoing concerns is presented in this article. METHODS: Fifteen publications were reported for 10 facial allotransplantations. For the remaining 7 transplantations, information was gathered from scientific meeting presentations and media releases. The summary of current cases in terms of etiology, indications, results, complications, and outcomes are based on these data. The discussion of ongoing concerns, controversies, and overview of future implications is accomplished by reviewing the literature of ethical debates, experimental studies, clinical studies, and personal opinion. RESULTS: Two of the 17 face transplant recipients died. Overall survival rate was 88%. No early graft loss due to technical failure was reported. All reported cases that have more than 1-year follow-up had at least 1 acute rejection episode, which was reversible with treatment. Opportunistic infections and metabolic complications were observed as adverse effects. Motor recoveries were slower than the sensorial recoveries, as expected. Functional and aesthetic outcomes were satisfactory. Concerns and controversies about concomitant face and hand transplantation, recipient blindness, recipient age, primary reconstruction option in facial trauma cases, funding, graft failure risks, and future treatment options are discussed. CONCLUSIONS: Because of uncertainty about long-term outcomes, immunosuppression-related concerns and ethical debates limit worldwide application of facial allotransplantation. However, in selected group of patients, it is a unique reconstruction method with promising outcomes. Further research and investigation in transplant immunology and treatment hold the key to advance this treatment option.

Face transplant: a paradigm change in facial reconstruction.

Face transplantation is a new surgical technique that could be considered as a paradigm change in facial reconstruction. In recent years, 17 cases have been realized around the world. The author reviews these cases enlightened by his personal 7 cases.

Human facial allotransplantation: patient selection and pertinent considerations.

Devastating facial deformities can cause significant functional and psychosocial injury. Significant facial disfigurement can preclude meaningful human interaction. Allotransplantation of facial tissues for reconstruction of devastating deformities has become a clinical reality, with 15 transplants performed at various centers around the world. Restoration of aesthetics and functionality has been superior to that achieved by conventional reconstruction, without the morbidity of multiple surgeries. Unlike solid organ transplantation which can be life saving, facial transplantation is considered by many to be life enhancing, highlighting the ethical argument against justification of these procedures given the risks of lifelong immunosuppression. Meticulous patient selection is mandatory, and a multidisciplinary team approach is key for the program's success. The overriding goal of screening for candidacy is to identify and select subjects who have the best chance for a positive immunologic, functional, and quality-of-life outcome. This article reviews the pertinent considerations and screening approach for appropriate patient selection in facial tissue transplantation.

A historical, clinical, and ethical overview of the emerging science of facial transplantation.

In the past 5 years, a total of 16 facial transplantation surgeries have been performed in France, China, Spain, and the United States. Facial transplantation has become a surgical option in clinical situations in which soft tissue and bone loss is accompanied by severe cosmetic, sensory, and functional deficiencies due to disease, trauma, or congenital malformations. With the introduction of facial tissue transplantation surgery came complex clinical, technological, and ethical patient care issues. These complex issues included determining patient selection criteria, refining donor tissue procurement techniques, predicting expected functional outcomes, appreciating the limitations of obtaining a fully informed consent for an innovative procedure, and deliberating the immunological response and postoperative immunosuppressant requirements of the recipient. In addition, psychological implications for the patient, societal consequences, and ethical concerns have been discussed. The short-term results have been positive. Results to date indicate that the clinical, technical, and immunological patient care issues in this emerging science appear to mirror those of other reconstructive and organ transplantation procedures. The long-term physical, emotional, and psychological effects on the recipient patient, as well as long-term consequences to the donor's family, are yet to be validated.

Near-total human face transplantation for a severely disfigured patient in the USA.

BACKGROUND: Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results. METHODS: On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society. FINDINGS: After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup. INTERPRETATION: We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients. FUNDING: None.