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