Claire O'Connell talks to the doctor who leads the team which is getting closer to carrying out what may be the world's first entire face transplant
Imagine wearing somebody else's face after their death. What kind of psychological impact would that have?
For many people the concept of transplanting a whole face from a donor to a living recipient is arresting to say the least, if not downright disturbing.
But public and medical attitudes to the approach are growing more positive, according to Irish consultant plastic surgeon Peter Butler, who will give a free, public talk in Dublin on Thursday.
He heads the 30-strong UK facial transplant team at London's Royal Free Hospital and later this month will seek final ethical approval to carry out what may be the world's first entire face transplant.
"It is amazing the difference between four years ago and now in terms of acceptability," says Butler, who over the past 14 years has researched the practicalities, ethics, psychology and perception of transplantation as a way to treat patients with severe disfigurement.
Most recently, the success of partial face transplants has increased public interest in the area and has turned heads within the medical community.
Last year a team of French surgeons transplanted part of a donor's face onto a woman who had been severely disfigured by a dog attack, and in April a Chinese team performed a similar transplant on a man who had been mauled by a bear.
"They have both done it with the partial face and produced what we could never produce with reconstruction," says Butler.
But while an entire face transplant is now technically possible and could eventually give the recipient a face with about 70-80 per cent function, it is not a procedure to be undertaken lightly.
The operation itself would take around 12 hours in total to remove the donor's whole face and transplant it onto the recipient. Then the recipient would take immune-suppressing medication for the rest of their life to help stop the body rejecting the donor's tissue.
This medication could increase the risk of infection, diabetes or cancer. Add to this the potentially enormous psychological burden of quite literally presenting someone else's face to the world.
One focus of the UK team's research has been to develop a set of screening tools to ensure the potential recipient is psychologically robust enough to cope with the aftermath of such a ground-breaking operation.
They have received numerous requests from patients who want to receive a face transplant, including some from Ireland, and since last December they have had ethical approval to start selecting potential recipients.
An ideal candidate would probably be a burns patient who is otherwise fit and healthy, able to cope with the image readjustment, medication programme and media attention, and who has a supportive social network.
There is also the spectre of the face being rejected, but as a comparison, Butler notes that of the 24 hands that have already been transplanted onto humans, not one has been lost through acute rejection.
Butler recognises the potential physical and psychological upheaval for the recipient. But he points out that one in eight people, based on UK statistics, are living with a facial deformity. For those who are, the impact of looking different can be so great that it stops them from going out in public.
How many people with a facial deformity did you see walking down the street today? he asks.
"There is evidence that 60 per cent have problems with social isolation, integration, holding down jobs. There are also reports that they may have four times the national average of suicide," says Butler.
He finds that people's negative attitudes change when he explains the reasons for doing a face transplant with a severely disfigured patient.
"When you look at the patients and you explain their quality of life, you can see why we are talking about this."
Donation of faces is another area where public engagement has a critical input, and Butler's team has worked with focus groups to gauge their perceptions.
"We found the biggest issue around potential donation was identity," he says. "Like if I donated the face of my loved one, would I see them walking down the street?"
But he explains that the underlying bone structure of the recipient has a large impact on how the transplanted face will look. "If I take your soft-tissue envelope off your face and put it on bones, it will deform to those bones. What you will get is the skin tone, thicknesses and texture of the donor but you won't get the craniofacial structure. So you will get a hybrid that is something in between, but more like the recipient than the donor."
And carrying an organ donor card will not automatically put your face up for grabs. "We have always stated from the very beginning that we would seek specific consent," says Butler, whose team has made the consent process for face donation more robust to include psychologist reviews, feedback and education.
They are also developing tools to assess facial function and disfigurement so they can measure the success of the transplant. "For me it has been a very interesting journey," says Butler.
Peter Butler will give the Academy Times lecture Face Transplant: Science fiction to science fact this Thursday at 6.30pm, Burke Theatre, Trinity College Dublin. Tickets are free but must be reserved at www.ria.ie or by phone on 01-676-2570
For more information see www.facialtransplantation.org.uk
What are the psychological effects of surgery?
What does receiving a face transplant do to a person's mind? That is a topic of hot debate at the moment, according to Nichola Rumsey, professor of appearance and health psychology at the University of the West of England. She says the face is central to our own self-image and to how we recognise and interact with others.
"Faces are particularly important when you meet other people for the first time - we tend to look at people's faces and form a very quick impression of what they are like and act on the basis of that impression," she says.
"So the face is like a gatekeeper to how we deal with people we haven't met before and we don't know."
Rumsey describes the ethical and psychological aspects of facial transplantation as "complex and difficult" but believes that a full face transplant will not only take place but will eventually become more common.
"That's what happens, you have some very new technological procedure and there are all sorts of question marks raised about it at the beginning and then it does become more widespread."
She notes the UK facial transplant team has a good psychological input, which she welcomes, but she still has more general concerns about the approach. "I'm not against it as a procedure, but I am very anxious about the immunological risk to the person and the psychological impact because you are going to have be very tough to cope with the regime."