By Clare Murphy
Health reporter, BBC News
A French woman who three years ago became the first person in the world to undergo a partial face transplant is by accounts adapting well to her new appearance - both physically and psychologically.
In the UK we could hear any day that a patient has been chosen to become the world's first recipient of a full face transplant.
This has received full approval from all the necessary ethics committees - although it remains unclear when it might take place - or indeed if a patient has even been found.
But whether this operation is days or years away, there is still fierce debate as to whether we really are ready for the cultural and medical implications of transferring a key part of someone's identity from a dead body to a living person.
Who am I?
In fact, for all the concerns about switching identity or "trading faces", those who treated Isabelle Dinoire note that she looks neither like the woman she was prior to being savaged by a dog, nor the dead woman whose face she inherited.
"The patient was very strong before the transplant and very sure of herself when she saw looked in the mirror immediately afterwards," Professor Bernard Devauchelle, who led the operation, told a conference in London aimed at addressing the continuing public discomfort around the issue.
In essence doctors are doing a very peculiar thing. They are taking fit bodies and making them ill
Dr Raj Persaud
Bethlem Royal and Maudsley hospitals
"The transplant was very rapidly integrated into her life - it became a part of who she was."
French doctors have subsequently carried out two more such operations, and have the ethical authorisation to perform five more.
But even now, three operations on and with tangible benefits to those who had lived with horrific disfiguration, the criticism in France from some quarters has yet to abate.
The doctors stand accused of a number of ethical crimes - but one in particular stands out: transplantation is no longer a life-saving necessity, but has been transformed into a question of aesthetics.
This is a charge with which Dr Raj Persaud, a consultant psychiatrist at the Bethlem Royal and Maudsley hospitals, appears to sympathise.
"What is the cause of the suffering: is it society, or is it the face? Is not the real kernel of the problem society at large and its inability to see past that face?" he says.
"In essence doctors are doing a very peculiar thing. They are taking fit bodies and making them ill."
Becoming sick
The long-term medical implications of face transplantation are as yet unknown - but there is little doubt that while the immense psychological burden of disfigurement may be at least partially alleviated, there are other significant risks to someone who is in every other respect healthy.
Ms Dinoire has had two "incidents", when her body's immune system tried to reject the foreign tissue, but so far immunosuppressive drugs are working.
But these drugs - which all transplant patients need to prevent their bodies rejecting the new organ - carry their own side-effects.
Diabetes and osteoporosis are among the consequences of medication which can also lead to renal failure, cardiac arrest, and increasingly, it is believed, cancer.
"What we are seeing as these patients live longer is that they are perhaps three times more likely to develop cancer than the general, age-matched population," said Professor Peter Morris, transplant specialist at the Royal College of Surgeons.
Skin cancer is among the most common. While it is generally seen as one of the most treatable forms of the disease, in the transplant population it "can be quite virulent and spread to other parts of the body much more rapidly", he said.
These risks may be acceptable ones to someone who, without a transplant, will die - and may be equally acceptable to someone whose disfiguration is causing them immense distress.
"But patients need to be aware of these risks, and at present the risk/benefit ratio is impossible to determine," he said. "What's clear at any rate is that these procedures cannot be done without immense psychological and psychiatric input."
Growing faces
There is hope that a number of these thorny ethical and medical issues can be overcome by "growing" a new face, rather than depending on a dead donor.
Using the patients own bone and tissue in reconstruction is one line of inquiry, but the work is still at an early stage.
Stem cells are also a key avenue. But while scientists can grow the complex components of the face individually, combining them into a custom-made, multi-layered face is another question.
"You wouldn't have the problems of rejection, you'd have better control over appearance, and ethically it would be much easier," says Francis Hughes, professor of periodontology at Barts and the London School of Medicine and Dentistry.
"But it is a lengthy process involving many stages - and at present it is still just an aspiration."
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/7277582.stm
Published: 2008/03/04 16:58:03 GMT
2008/3/10
The face of the future
The face of the future
Facial reconstruction is making great advances, and may soon enter the realm of science fiction
Iain Hutchison
The Guardian, Tuesday March 4 2008
Our faces are central to how we feel about ourselves and how society judges us. As babies, we respond to the huge adult face peering over us. As teenagers, we can barely pass a mirror without examining our faces for blemishes. The disproportionate growth of different facial parts in these formative years can often leave us sensitive to prominent features such as noses, lips and chins. In addition, we practice how we want to project ourselves to our peers: our subtle smiles, sensitive listening face and serious gravitas face. We are also judged on many intellectual and personal qualities simply as a result of our facial appearance.
Faces come in all shapes, sizes and colours, but there are artificial standards that have been set throughout history for what constitutes attractiveness. Symmetry between the two facial sides is certainly highly regarded, while the balance of facial proportions described as the Hellenic norms is still prized today - as evidenced by the models in fashion magazines.
So what happens to our self-belief and society's perception of us when our faces change through injury or disease? This depends not only on the severity of the damage but also on factors such as how the damage occurred, the age when it developed and the victim support network available. Older, married patients with fulfilling occupations cope better with these physical traumas than teenagers who rely on their peer group for emotional sustenance.
Our faces are also portals for breathing, smelling, seeing, eating and speech. So they are fundamentally important in our ability to perform vital social functions. The face is important in recognition and identifying people too.
The increasing importance of the face to self-esteem has resulted in a burgeoning desire for treatments to convert faces to the Hellenic norm and arrest the ravages of ageing. Emotional and financial success is often associated with youthful vigour rather than elderly experience.
We can think of the face as an underlying skeletal scaffold made up of highly complex bony architecture with air sinuses to lighten our heads so we don't drag them along the floor. These air sinuses are also important in speech and breathing. Within these bones we have teeth, which hold our lips and cheeks out in an attractive fashion. Draped over this bone is skin with highly complicated three-dimensional patterns. Skin has different texture, thickness and hair-bearing capacity at various sites on the face.
Surgical advances have achieved the ability to mimic the face's underlying bony landmarks, but we cannot use skin from other sites of the body to exactly mimic facial skin. Therefore the face transplant carried out by Professors Devauchelle and Testelin in 2005, replacing the skin of a patient's nose, lips and cheek, was a major breakthrough in surgical reconstruction of the facial soft tissues. It captured the public imagination, not only because of the dramatic physical result but also because it suggested the possibility of great advances in cosmetic surgery. However, the public did not consider the immense risks of the immunosuppressant drug therapy necessary to prevent rejection of the transplant from a dead donor. These drugs cause muscle-wasting, bone loss and spotty skin, and increase the risks of malignant tumours developing. So there is no current role for face transplantation in cosmetic surgery.
Face transplants clearly have a role to play for severe burn victims, but they are not life-saving operations. Each patient must consider the risk-benefit ratio before embarking on such a dramatic course. There are also psychological effects caused by carrying around somebody else's facial skin - for the patient, their family and the family of the person whose skin was donated.
Researchers are working on growing spare body parts from a patient's own stem cells. The potential for "tissue engineering" is immense, because there is no need for immunosuppressants. This is still in the realm of science fiction, but could become reality within a decade. We have already seen growth of a patient's skin cells in the laboratory and growth of a replacement lower jaw within the patient's body using computer modelling and the patient's stem cells. The future awaits, and face transplants may already be consigned to history.
· Iain Hutchison is consultant oral and maxillofacial surgeon at Barts and the London NHS Trust. A public debate on The Face and Reconstruction takes place today from 10.30am to 1.30pm at Queen Elizabeth Hall in London's Southbank Centre
savingfaces.co.uk
Facial reconstruction is making great advances, and may soon enter the realm of science fiction
Iain Hutchison
The Guardian, Tuesday March 4 2008
Our faces are central to how we feel about ourselves and how society judges us. As babies, we respond to the huge adult face peering over us. As teenagers, we can barely pass a mirror without examining our faces for blemishes. The disproportionate growth of different facial parts in these formative years can often leave us sensitive to prominent features such as noses, lips and chins. In addition, we practice how we want to project ourselves to our peers: our subtle smiles, sensitive listening face and serious gravitas face. We are also judged on many intellectual and personal qualities simply as a result of our facial appearance.
Faces come in all shapes, sizes and colours, but there are artificial standards that have been set throughout history for what constitutes attractiveness. Symmetry between the two facial sides is certainly highly regarded, while the balance of facial proportions described as the Hellenic norms is still prized today - as evidenced by the models in fashion magazines.
So what happens to our self-belief and society's perception of us when our faces change through injury or disease? This depends not only on the severity of the damage but also on factors such as how the damage occurred, the age when it developed and the victim support network available. Older, married patients with fulfilling occupations cope better with these physical traumas than teenagers who rely on their peer group for emotional sustenance.
Our faces are also portals for breathing, smelling, seeing, eating and speech. So they are fundamentally important in our ability to perform vital social functions. The face is important in recognition and identifying people too.
The increasing importance of the face to self-esteem has resulted in a burgeoning desire for treatments to convert faces to the Hellenic norm and arrest the ravages of ageing. Emotional and financial success is often associated with youthful vigour rather than elderly experience.
We can think of the face as an underlying skeletal scaffold made up of highly complex bony architecture with air sinuses to lighten our heads so we don't drag them along the floor. These air sinuses are also important in speech and breathing. Within these bones we have teeth, which hold our lips and cheeks out in an attractive fashion. Draped over this bone is skin with highly complicated three-dimensional patterns. Skin has different texture, thickness and hair-bearing capacity at various sites on the face.
Surgical advances have achieved the ability to mimic the face's underlying bony landmarks, but we cannot use skin from other sites of the body to exactly mimic facial skin. Therefore the face transplant carried out by Professors Devauchelle and Testelin in 2005, replacing the skin of a patient's nose, lips and cheek, was a major breakthrough in surgical reconstruction of the facial soft tissues. It captured the public imagination, not only because of the dramatic physical result but also because it suggested the possibility of great advances in cosmetic surgery. However, the public did not consider the immense risks of the immunosuppressant drug therapy necessary to prevent rejection of the transplant from a dead donor. These drugs cause muscle-wasting, bone loss and spotty skin, and increase the risks of malignant tumours developing. So there is no current role for face transplantation in cosmetic surgery.
Face transplants clearly have a role to play for severe burn victims, but they are not life-saving operations. Each patient must consider the risk-benefit ratio before embarking on such a dramatic course. There are also psychological effects caused by carrying around somebody else's facial skin - for the patient, their family and the family of the person whose skin was donated.
Researchers are working on growing spare body parts from a patient's own stem cells. The potential for "tissue engineering" is immense, because there is no need for immunosuppressants. This is still in the realm of science fiction, but could become reality within a decade. We have already seen growth of a patient's skin cells in the laboratory and growth of a replacement lower jaw within the patient's body using computer modelling and the patient's stem cells. The future awaits, and face transplants may already be consigned to history.
· Iain Hutchison is consultant oral and maxillofacial surgeon at Barts and the London NHS Trust. A public debate on The Face and Reconstruction takes place today from 10.30am to 1.30pm at Queen Elizabeth Hall in London's Southbank Centre
savingfaces.co.uk
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