Facing an uncertain future

The scientific briefing with Luke Boulter

As you amble down Micklegate at 3am with a cold take-away in one hand and the other hand pressed to your forehead trying to convince yourself that you know the way home, what is it that causes someone that you’ve only spoken to once in your life to yell across the street acknowledging you as a friend? Similarly, what is it that causes a loved one to run towards you as you step off the train?

I should like to suggest that, for me, it is my wit and gripping sense of style, but alas it would seem this is not the case! It’s my face. Without doubt, our face is our most defining feature; each one is different and it is the part of us that is most on show. So what if one day this all changed? What if through some accident what you saw in the mirror was no longer the face that you had grown up with?

In the UK alone, it is suggested that 1 million people suffer a facial injury each year; of these injuries 125,000 are classed as serious. Most of these people fall into a similar age group to most undergraduate students. Conventional treatments obviously vary according to the condition, but in most situations the wound is covered up or closed, leaving scarring on the face. In the most severe cases, skin grafts are used in tandem with plastic surgery in an attempt to reconstruct the face. This, however, is often a lengthy and painful procedure with no guarantee of a successful outcome.

So what does this have to do with science? During the final week of November, a revolutionary procedure was performed: an operation on a 38-year-old woman whose lower face (nose, lips and chin) had been savagely mutilated in a dog attack. The plan in this case was to take a triangle of flesh from a recently-deceased donor (which contains nose, lips and chin) and attach it to the recipient. The surgery was performed at a hospital in Amiens, France, and the team was the first ever to carry out this type of procedure. Shortly after completion, a statement was released saying, “the transplant looks normal.”

Face transplants have been theoretically possible for years, ever since microsurgical techniques, required to separate the tiny and delicate capillaries and nerves, were mastered. If nothing else, the operation could be classed as experimental. Surgeons had to weave together a highly complex network of blood vessels and nerves, as well as attaching muscle to bone, in order to prevent the graft moving away from the rest of the face. The patient does not look entirely like the donor or her old self, with bone from the recipient and soft tissue from the donor combining to give an intermediate appearance.

The procedure, however, has not yet been declared a success. It is still early days; the coming days and weeks remain crucial. The microscopic remodelling will have to work as intended, with blood vessels supplying a healthy flow of nutrients to the tissues, and the nerves providing both movement and sensation.

The patient will be required to take anti-rejection drugs for the rest of her life, which will increase her risk of developing some forms of cancer; there are personal decisions to be made. Also, there will always be the very real chance that the body rejects the graft, resulting in the tissues being slowly broken down. If the graft is lost, she might be worse off than she was before the surgery, aesthetically speaking at least.

Now you understand my opening statements, what would the long term psychological effects of this type of surgery be? What would it be like to look in the mirror and see what can best be described as a mask, or at least a partial one. Within just a few months of the injury, the woman was reportedly already on a waiting list for a donor face, well before conventional reconstruction procedures had been tried.

Critics of the French team also note that in most cases transplants are intended to save a life, and that, however much the patient suffered from being mauled, there was no indication that her life was in danger. This procedure should not, however, be moved into the realms of aesthetic surgery, as it is no mere nose-job or face-lift.

In terms of ethics, the question remains of whether it is any less deserving to improve the quality of a life than to save one. Invariably between black and white there is a scale featuring several shades of grey. I imagine that the woman in question will be pleased not to live a life where people stare or politely avert their eyes whenever she leaves the house to do her weekly shop. What’s more, emotional detachment in the light of this decision is undoubtedly beneficial, but is a patient facing death without a new heart or kidney any more capable of this choice than someone confronting a life without a face?

With the ethical conundrum still up for debate, the continuation of these transplants relies solely on one thing: whether by this time next year the French patient can stand by the side of her surgical team and smile for the world’s cameras and can make it comfortably into a supermarket.

If this happens, it is increasingly difficult to claim that these procedures, no-matter how sci-fi and outrageous, are not beneficial and that the French recipient and those similarly injured should not be given the chance to have their face back. For now, a clinic in Ohio has given the go-ahead for a team to conduct a face transplant, and there are similar projects in the pipeline at the Royal Free Hospital in London.
Only time will tell in this face-off (apologies) between nature and the surgeon’s knife.

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