Recognizing the Man in the Mirrorby Maria Goddard, MD | December 27, 2008
Three short years ago, the first partial face transplantation was performed in France and recently the first of these procedures to be conducted in the United States was successfully accomplished. This was only the fourth operation of its type but experts estimate that perhaps as early as next year the first complete face transplant will be attempted.
It is one thing to receive a donation of an organ such as a heart or liver, which is inside of one’s body and never seen, but quite another to look into the mirror everyday and see someone else’s face. While the underlying bone structure of the affected patient will largely determine the facial construct, the knowledge of the organ’s origins may be too much for some to bear psychologically. In addition, there may be some difficulty convincing the family members to allow the use of their loved one’s face for transplantation purposes. Herein lays the ethical dilemma of this groundbreaking procedure. Faces are considered to be individualistic; they express feelings and show personalities. However, this must be balanced by imaging the psychological consequences of the patient going through life with a disfigured face. Whether we care to admit it or not, humans are judged on their appearance, so being able to interact with society and continue normal daily activities and conduct their everyday life is essential. Some may even argue that the damaged face is not theirs either and transplantation offers them the chance at a normal life.
In December 2007, the 18 month follow-up of the index transplantation patient in France was reported in the New England Journal of Medicine with good medical results. Psychological support was given at regularly scheduled intervals as part of her recovery protocol. Although no formal psychological testing was conducted, she reported being pleased with the aesthetics and felt comfortable interacting with other people.
Reading about these advances also reminded me of a medical condition called prosopagnosia or “face blindness”. This is a neurological condition where affected persons do not recognize faces, sometimes including their own. It can be caused by brain damage to the occipital and temporal lobes and there is some evidence of a congenital form of the disease. Studies have shown that patients have great anxiety in social situations and may become reclusive as a result. What happens when the face is not actually your own?
Organ transplantation is already a difficult procedure medically, requiring the patient to take lifelong immunosuppressive drugs. Combine this with the many unanswered ethical questions and facial transplantation becomes even more complicated. Therefore patient selection for this surgery must focus not only on organ compatibility but also on the emotional and mental capacity of the individual.
J.-M. Dubernard, B. Lengele, E. Morelon, S. Testelin, L. Badet, C. Moure, J.-L. Beziat, S. Dakpe, J. Kanitakis, C. D’Hauthuille, A. El Jaafari, P. Petruzzo, N. Lefrancois, F. Taha, A. Sirigu, G. Di Marco, E. Carmi, D. Bachmann, S. Cremades, P. Giraux, G. Burloux, O. Hequet, N. Parquet, C. Frances, M. Michallet, X. Martin, B. Devauchelle (2007). Outcomes 18 Months after the First Human Partial Face Transplantation New England Journal of Medicine, 357 (24), 2451-2460 DOI: 10.1056/NEJMoa072828
L YARDLEY, L MCDERMOTT, S PISARSKI, B DUCHAINE, K NAKAYAMA (2008). Psychosocial consequences of developmental prosopagnosia: A problem of recognition Journal of Psychosomatic Research, 65 (5), 445-451 DOI: 10.1016/j.jpsychores.2008.03.013
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