The New Face of Transplant Surgery

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No surgery quite crosses the existential line the way transplant surgery does. Create a single chimeric human with the tissues of another and the very sense of self goes wobbly. In most cases, the donor organ is at least tucked safely out of sight—a heart hidden into the chest cavity, a kidney slipped under back muscle. Yesterday however, French surgeons announced that they had completed the least concealable surgical graft of all, successfully performing the world's first face transplant.

The patient in the landmark operation was a 38-year-old woman—who has insisted on anonymity—whose nose, lips and chin were savagely mauled in a dog attack last May. The donor was a woman who had been declared brain dead and whose family consented to her face and other tissues being used for transplants. The surgery was performed at a hospital in Amiens, France, with in-house surgeons and others from a hospital in Lyons participating in the procedure. Officials from both facilities were studiedly subdued in their joint statement to the press. "The patient is in an excellent state," the formal release read, "and the transplant looks normal." But those spare words don't begin to touch the enormous implications of either the medical achievement—assuming the transplant holds—or the ethical unease raised by the surgery.

Face transplants have been theoretically possible for years now—ever since the microsurgical techniques necessary to splice tiny, thready capillaries and nerves were mastered. Scalp and ear transplants had already been performed, but it was only last year that a medical ethics committee in France gave the green light for a partial face transplant, cautioning that the procedure remained "high-risk experimentation."

By any measure the operation just performed was experimental indeed. Surgeons not only had to weave together the webwork of nerves and vessels, but also had to fit and anchor muscle and skin to the underlying bone. The patient will neither look entirely like the donor nor entirely like her old self, with bone and soft tissue combining to form a third face entirely.

But that's assuming all the hurdles can be overcome—and they're decidedly high. The microscopic plumbing and neural wiring will have to work as intended, with the circulatory system nourishing the new tissue and the nerves providing it both movement and sensation. Vascular blockages could damage or kill the graft. Anti-rejection drugs the patient will have to take for the rest of her life will increase the risk of cancer. And even if the graft is sound and the woman tolerates the drugs, transplants in general pose a 10% risk of rejection in the first year and a 30% to 50% risk in the next three to five years. If the graft is lost, she might be worse off than she was before the surgery, aesthetically at least. None of this begins to address the psychological issues that come with any transplant surgery—never mind one that carries the psychic dislocation of looking in the mirror and seeing an entirely different person looking back.

For that reason, some critics argue that the French doctors moved too fast. 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 could have been tried and exhausted. Whether a patient who had just suffered such primal trauma could even have granted the informed consent necessary for surgery is questionable. What’s more, transplants are generally seen as life-saving procedures, and however cruelly the patient may have been suffering her disfigurement, there is no indication that her life was in danger.

Of course, somewhere along the continuum between saving a life and improving a life the line goes fuzzy, and people who must bear the stares or averted eyes of others every time they step onto the street might argue that their desire for surgery was a good deal more than cosmetic whim. What's more, informed consent may be a tidy legal concept, but it's arguable that a patient facing death without a new heart or kidney is no more capable of cool deliberation than someone confronting a life without a face.

For now, the ethical arguments will turn at least in part on how the French patient fares. If she stands prettily before cameras in six months' time, ready to resume her life, it will be hard to argue that she should not have been given her chance. If the surgery fails and her lot is made worse, the future of such transplants will grow darker too. The Cleveland Clinic in Ohio—which has already given the thumbs-up to one of its surgeons to perform a full facial transplant sometime in the future—is surely awaiting those results, as are ethics boards in the United Kingdom, where full facial transplants have been forbidden for the time being. But all of those players are merely peripheral. At the moment, the patient herself—both nameless and, for now, faceless—is the only one who truly counts.