Face Transplantation: A Review of the Technical, Immunological, Psychological and Clinical Issues with Recommendations for Good Practice

Abstract

Three years ago, the Working Party on Facial Transplantation concluded that until there was more information available about risks any potential patient would be exposed to, it would be unwise to proceed with transplantation of the human face. Over the last three years, there has been a deepening understanding of the potential psychological problems of facial transplantation as well as a very considerable debate on the ethical aspects of the procedure. Further data on experimental work in animal models of facial transplantation as well as medium-term follow-up data from 24 hand and forearm transplants in 18 patients has now become available. Furthermore, a partial facial transplantation has been performed in France and a second one in China. In this second edition of the report, the technical, immunological, psychological, and ethical issues are discussed again in the light of this developing knowledge. In particular, there has been a major expansion of the sections on the psychological and societal issues, as well as the ethical and legal problems of facial transplantation. The working party still has considerable reservations about facial transplantation. Although it accepts that on balance the risks cannot be precisely quantified, they remain substantial. Therefore, if patients are allowed to make an informed choice to proceed, they must be very carefully selected and protected in the process, along with the families of both the donors and the recipients. To achieve this, the working party insists that 15 minimum requirements, described at the end of this report, must be fulfilled before it would be appropriate for a research ethics committee/institutional review board to approve of a proposal to undertake facial transplantation.

The Psychology of Facial Disfigurement: Implications for Whole Face Transplantation

“…The second Working Party Report [2] alluded to the consistent finding in the research literature that the extent of psychological distress resulting from a disfigurement is not well predicted by the type, extent or severity of the disfiguration [2,7]. An accumulation of research clinical experience and personal accounts involving participants with a range of disfiguring conditions has further reinforced this important finding in the intervening years [13,14].…”

“…In the former, it is interesting to note that data from a small number of patients who have now undergone the procedure is prompting a change in the 'mood music' about the potential psychological benefits of WFT. The earlier rhetoric amongst some commentators as well as the media was that the procedure had the potential to provide the answer to the 'social death' of severe facial disfigurement, and to confer extensive benefits in psychological adjustment through changes to facial appearance [2,7], however the reporting of actual outcomes reflect complex trajectories, with gains in some aspects of adjustment, alongside a lack of improvement or a worsening in others.…”

“…After an examination of the new evidence, The Working Party's second report [2] concluded that the consequences of lifelong immunosuppression and its attendant complications and difficulties remained a major concern and significant reservations about the physical and psychological risks to the patient remained. The report advocated considerable caution in those planning to undertake whole face transplantation in the UK.…”

“…The challenge of identifying those who are sufficiently distressed by their disfigurement and/or lack of function to benefit from WFT, yet resilient to cope with the psychological challenges of WFT, and its aftermath was discussed in the second report of the Working Party [2] and has since been reiterated by those planning or undertaking WFT [3,11]. Interestingly, members of one team at the forefront of WFT now recommend that the primary motivation for undertaking the procedure should be to improve function, rather than aesthetics [3].…”

“…The report advocated considerable caution in those planning to undertake whole face transplantation in the UK. Extensive guidance was given on the minimum requirements to be fulfilled before a transplant team should contemplate offering this procedure to patients [2]. This guidance was also designed to provide relevant information for ethical review bodies considering applications to perform WFT, in the hope that only multidisciplinary teams with appropriate experience and expertise and carefully developed protocols for the assessment of suitable patients, for pre-operative and postoperative care would be given ethical approval to undertake WFT in the UK.…”