Full face transplant coming next

Within the next 12 months, the world might see its first totally transplanted face. Peter Butler and his team at London's Royal Free Hospital have been working on the project for over a dozen years now. They have seen all the successful cases of partial and near total face transplants through the years making big news.

Alex Clarke, chief psychologist in Butler's team from the hospital's plastic and reconstructive surgery department says a lot of interest has been generated in the 'total face transplant' project since plastic surgery has 'this magic, mythical public perception'. The team has been granted ethical permission for a research programme of four facial transplants.

"The issue of a total face transplant has evoked tremendous interest, not simply in the medical community but among people who think they might qualify to get a transplant. We have to tell hundreds of callers every day that this is not just a cosmetic affair. Only severely deformed cases can be considered for a transplant," she said.

Is the team fuelled by competition to perform the world's first full face transplant? "We have been working on the tolerance models and laboratory-based work for over 14 years. Certainly we are not at the stage where we would rush it all to jeopardise the hard work. The French helped us enormously by carrying out the first partial face transplant. The Americans near total transplant has proven that the technical and psychological difficulties can be overcome. We are not in a race. We just want to do it well."

"All sorts of people call up and put queries on our website. Some of them have severe injuries. Some have appearance-related concerns that are not serious enough." Clarke says they know it's not going to be a bed of roses. "We are prepared for glitches. Someone might be willing and by the end of the preparatory process might just say 'no'. It could be very frustrating."

Their announcement in 2005 had raised questions on ethics. The Royal College of Surgeons soon came out with a working party report urging caution. It laid out 15 minimal standards that the face transplant team must meet before even thinking of getting started. Prof. Sir Peter Morris, chairman of the working party, said, "The greatest risk is the rejection of the new face. There's a 10 per cent risk of acute rejection within two or three months and up to 50 per cent chance of chronic rejection later. The skin is top of the league when it comes to tissue or organ rejection."

Then there is the critical threat of the patient having to be on a lifetime of immuno-suppressant drugs or steroids to prevent rejection and failure of the grafted organ or tissue. This therapy has well known side effects — hypertension, renal toxicity, diabetes, viral infections and cancer, conditions that shorten life.

Working party member Nichola Rumsey also raised concern that the recipient might end up getting a "mask-like" face whereas humans have to make minute facial changes to express emotions. "And what happens in case of a rejection where the patient will be left with a raw face and has to undergo conventional reconstruction," she asked.

Changing Faces, a charity that provides aid for people with disfigurement, has been extremely vocal about the issue. "It is the responsibility of the research ethics committee to maintain the highest ethical standards," said James Patridge, CEO of the charity, who was himself severely disfigured in a car fire as an 18-year-old.

Clarke, who worked for Changing Faces earlier, says her team is undeterred by such presumptions. "We meet all the 15 standards set out by the Royal College. In fact, we exceed them in some. We don't anticipate any problems with that. We don't actually start taking people through an assessment process unless absolutely sure that we've dotted all the 'i's and crossed all the 't's."

Indeed, the team has a Plan B in case of a graft failure. "Reconstructive surgeons always work in terms of Plan A, Plan B, Plan C. Those who are criticising us just don't understand how plastic surgeons work." To back this up, Clarke, Butler and Simon Brill co-authored a paper with David Veale of the Institute of Psychiatry at London's Kings College in the March issue of the journal Body Image, discussing in detail the psychological management of facial transplant. "We have a robust plan ready… and we are not taking it lightly at all."

As a clinical psychologist, Clarke set out with public engagement exercises to begin with. "The first question to answer was whether people are willing to donate facial tissue to somebody in their family. Another early concern was the idea of compromised identity." The team found that it was unlikely that the identity of the recipient would be compromised in a way people perceived it to be. "They were taking the 'face-off' image from the Hollywood film and imagining that there would be a direct swap of faces."

To allay such fears, Clarke and Butler produced some computer-generated images of their own faces and swapped them. And what they got was a third face. "When the French did the transplant, we made those images available… it was very clear at the outset that the new face would be somewhere in between those of the donor and the recipient. That was a real advance," says Clarke.

Donors are coming forward after the French and American transplants since the phenomenon is better accepted and understood now.