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Is the world ready for audacious face transplants?

Ventura County Star
Monday, 12/05/2005
by Samuel Bern

In the 1997 film, "Face Off," John Travolta takes the war on terror to a new level of personal sacrifice. He arranges for the face of a comatose terrorist (Nicholas Cage) to be transplanted onto his own, allowing him to penetrate Cage's international crime syndicate. The two men exchange faces, families and jobs, leading to a roller coaster of murder, mayhem and mistaken identity. What seemed like an outlandish Hollywood "high concept" has now taken on an aura of reality 80 miles north of Paris.

The week before last, French surgeons transplanted the mid and lower face of a brain-dead woman onto the severely mauled victim of a dog attack. Technically, this seemingly miraculous feat appears successful. But the procedure raises a host of ethical, emotional and medical questions, and like a horde of moviegoers, the critics have begun to weigh in. Let me add a voice of both praise and caution to the discussion of this audacious operation.

For the operation to be a true success, the tiny blood vessels connecting patient to graft need to stay open and the hairsized nerves need to regroup. The skin must match well and the muscles should regain their subtle expression.

Our ability to treat rejection of the new body part is not as advanced as our ability to microsurgically reattach it. White cells will likely see the new face as a foreign invader and attack it. Skin is especially prone to this type of organ rejection. The attempt to suppress this rejection is the most perilous part of the surgery.

Is it ethical to condemn a person to a lifetime of potentially lethal immunosuppressant drugs for a graft that does not sustain life?

How the recipient of the new face will react is also unknown. Can a valid informed consent be obtained from a depressed trauma victim who cannot understand what lies ahead? Should more conventional reconstructive methods have been tried first? All of these are valid questions that need to be explored.

While it is easy to question the value of this daring new procedure, it remains a compelling surgical choice. I have worked in burn centers with children who would certainly benefit from a face transplant. I remember one boy in particular who had been trapped in a burning car, and survived after a year on life support. His face was a mask of scar tissue with no recognizable features.

I do not believe patients like him should be denied the opportunity for a normal life that face transplantation may offer.

Face transplants may someday provide hope for thousands of victims of bums, trauma and cancer. However, the medical community must proceed cautiously.

We must avoid well-publicized, dramatic failures early on, or the procedure will be discredited, and thus not available to those truly in need.

The patient who received the first transplanted hand proved to be psychologically unstable and refused to take his immunosuppressant medication. As a result the chronically rejecting, painful, transplanted hand was eventually amputated.

We must emphasize the development of toxic anti-rejection treatments and evaluate patients carefully, both medically and psychologically. Choosing only those patients who have failed conventional plastic surgery reconstruction will be important in the early stages of the development of this risky procedure.

The 21st century will no doubt bring innovations that read today like a science script. Some will pass the test of time; or will reveal only the hubris of the surgeon who performed them. "Face Off: the movie, was a commercial success as well as an Oscar nomination. The success of "face off," the operation, remains to be seen. Personally, I give the precedure cautious two thumbs up.

—Samuel Bern, M.D., is a leading plastic reconstructive surgeon, practicing at Community Memorial Hospital in Ventura.