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The face as frontier

Burn victims could soon have another treatment option -- a facial transplant. Some surgeons fear the risks.

February 02, 2004|Shari Roan | Times Staff Writer

Society may not be quite ready for the day when a dead person's face is recycled for the living -- but that day is coming nonetheless.

Such an operation would give new life to someone severely disfigured by burns, cancer or an accident, allowing the person to exist free of the stares and shock their appearances often evoke. The procedure would be more straightforward than the many reconstructive surgeries such victims usually must endure.

Already, doctors at the University of Louisville in Kentucky say they hope to soon select a candidate for the operation, possibly within the year. The same team performed the first U.S. hand transplant (and second in the world) in 1999. Surgeons in other countries are pursuing the possibility of a face transplant as well. All agree it's just a matter of time until the world's first face transplant.

The technical skills needed for the surgery are well-established. Organs are routinely transplanted from one person to another, and even some limb transplants have been successful. Those operations, once remarkable, have become almost commonplace.

But an internal organ, or even a hand, is dramatically different from the wholesale appearance change that surgeons are now considering, the Louisville surgeons acknowledge.

Faces are the most visible portion of human identities. They're how we think of ourselves, how others recognize us. The possibility of altering that identity so radically -- a science fiction plot device made real -- could make people recoil, perhaps eroding support needed for the operation.

In Britain, reservations from the medical community have indefinitely stalled plans there for a facial transplant. Aware of the sensitive nature of such surgery, the doctors in Kentucky are treading carefully. The team is exploring ethical arguments for and against the procedure, using studies and surveys to gauge likely public reaction.

If the results are favorable, the surgeons are prepared to proceed. Even if the reaction is an unexpected negative, the surgeons say the notion eventually will become accepted.

"As for surgical technique, a face transplant could have been done 10 years ago," said Dr. John Barker, director of research for the surgeons' group. "And now with the preliminary results we have in our ethics studies, we think it's time."

The group is evaluating potential transplant recipients, as is a group of collaborating physicians in the Netherlands, he said. French surgeons also are said to be considering the operation.

Public acceptance is not the only roadblock, however. Many doctors remain unconvinced of the medical need for the operation, questioning whether the risks of the surgery outweigh its potential value. A face recipient would need to take powerful medications for the remainder of his or her life to prevent rejection by the body. He or she also would face the possibility that the transplant would fail -- and the unknown psychological effect of having one's cardinal form of identity, even if disfigured, so wholly transformed.

"Faces," said a British advisory panel in a published report, "help us understand who we are and where we come from."

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A unique appearance

A face transplant would rely on microsurgery -- the connection of very small nerves and blood vessels. In the first such surgeries, doctors probably would remove a layer of donor skin containing muscle, nerves, tendons and blood vessels. The recipient's disfigured face would be removed down to the bone and cartilage, and the donor face draped across it, fitted and reattached.

The result would be a hybrid face, with features from both donor and recipient, Barker said. The team has tried to anticipate the cosmetic result by experimenting on cadavers. The result is a face that resembles both donor and recipient, perhaps similar to a relative of one or the other.

"It's surprising how different the recipients look" from the donors, he said. "If you transplanted the entire bone structure, however, they would look exactly like the donor." (That, however, is not currently possible.)

The groundwork for face transplantation was laid about five years ago when French surgeons transplanted a hand. Since then, more than 20 hand transplant surgeries have been completed worldwide, Barker said.

Surgeons also have become adept at reattaching hands, scalps and large parts of faces that have been torn off in accidents. In many of those cases, the tissues being reconnected are mangled and unclean, requiring herculean surgical efforts in an emergency setting. Reconstructive surgeons also routinely remove tissue from other parts of the body and reshape and attach the grafts to the faces of trauma patients.

"Technically, what our reconstructive surgeons do to reconstruct a face is probably harder than doing a face transplant," Barker said. "A donor is in pristine condition. Everything is planned. You remove all the tissue you need from the donor -- even more than you need. You cut away the excess you don't need."

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