- Email: [email protected]
Psychological Considerations in Face Transplantation
International Journal of Surgery 2004; 2: 77–79
Psychological Considerations in Face Transplantation Robert Farrer School of Biomedical Sciences, King’s College London, UK Correspondence to: School of Biomedical Sciences, Guy’s Campus, King’s College London, London, SE1 1UL, UK
As a psychologist, I was fascinated by several of the articles in Vol. 2, issue 1 (2004) of the International Journal of Surgery. The editorial on face transplantation by Barker, Vossen and Banis,1 raises hopes for those suffering profound facial disfigurement because of trauma or disease. The article by Mr. Iain Hutchison2 on the need for proper research designs, if surgeons are to arrive at a scientifically valid set of criteria for such intervention, is timely and highlights the need for fully-informed consent prior to such radical surgery. The harrowing cases of deliberate facial injury, described by Mannan et al,3 although dealing with cutaneous injuries in the main, show the catastrophic physical and psychological consequences of facial disfigurement for the lives of young adults (Fig. 1 below).
Fig. 2. War Wounded 1922. Kriegsverletzer. Watercolour on paper 49 ⫻ 37. 1922.13 Private Collection.
Fig. 1. A soldier wounded on 22nd September 1914. Illustration from Ernst Friedrich, Krieg dem Krieg!, Berlin 1924.
Reading these articles together shows both how much and how little things have changed since the pioneering repairs (at the Queen Victoria Hospital, East Grinstead) to the faces of fighter pilots suffering “standard Hurricane burns” in combat during and after the Battle of Britain.4 Both Sir Archibald McIndoe’s pilots, and the acid-burned women of Bangladesh3 show the need for refuge and respect in a community of sufferers where patients and staff can identify with the unique crisis which deep facial injury heralds for its victims. Once confident in that environment, such patients might begin to “face” the public at large (Fig. 2). The technical demands for the surgical team embarking on whole facial transplantation seem, to this (non-medical) reader, immense. Yet Barker is confident that once a good blood supply to the new face is established, the fine work of linking the nerves responsible for facial expression and oral continence can be performed with slow precision. But what if all the surgical work is successful yet the immunological problem of rejection remains? Rejection in this context will mean more than a return to the facial scarring of the
International Journal of Surgery • Volume 2 • Issue 2 • 2004
patients’ reported in the Bangladesh study, but could leave the patient without any unique facial identity, in the manner of a Von Hagens flayed exhibit. A failed intervention in this case could be worse than the status quo ante. Barker believes that the rejection problems can be managed, but the comparison with hand transplantations (where N, even now, is still small) is not wholly apposite as the psychological meaning of one’s hand, while undoubtedly profound, is not quite the same as one’s face. The idea that the face betrays the essence of one’s “persona” is at least as old as classical theatre where the mask of the actor provided an exaggerated sign for the character’s role and emotion (Fig. 3). It would seem that because of the complex integration of the various nerves and muscles needed for even the most basic expression of emotion,5 the earliest attempts at transplantation might well fail to provide the patient with a satisfactory control over expression. The outcome might not be physical rejection per se but could well leave the patient socially rejected as odd, inexpressive or “cold”. Far from the theatrical amplification of mood provided by the actor’s mask in Greek theatre, we need to countenance the possibility that the newly acquired mask of living flesh is at odds with the person within. This notion was cleverly explored by Kaneto Shindo in the film “Onibaba”.6 In Shindo’s script the woman holds the demonic warrior mask to her face to test its fit, only to find that the mask is now fused to her forever. Attempting to prise off the mask by splitting it, she realizes that there is no longer a boundary between mask and self. A metaphor perhaps, but a psychological rejection of the new face by the recipient seems a far more likely outcome than the statistically remote chance of the dead donor’s face being “recognized” on the recipient’s face by the dead donor’s kin.
77
post-traumatic stress disorder as a result of their injuries. Given that not all the surgeons kept a record of the psychological state of their patients, it is possible that the true figure is higher. This returns us to a discussion of the anticipated range of cases where Barker’s1 proposed intervention is likely to do more good than harm, even allowing for the problems of rejection (here using the term “rejection” to embrace immunological, psychological and social rejection, discussed above). Evidence from patients suffering large excisions to the face, as a result of deep-structure cancer, implies that post-operative care is extremely stressful for the patient, their family and community nursing staff called in to dress the wound.13 A “successful” operation might leave a cancer-free patient quite unable to adapt to the change to their appearance and a psychotic breakdown can result. Presumably these are precisely the cases that might benefit from a transplant, even one which is inexpressive and orally incontinent. There seems to be a sound rationale for attempting these procedures if the alternatives are suicidal depression or psychosis. Clearly, any patients asking for such operations must be capable of fully comprehending the drastic consequences should the technique fail. This makes Clark and Butler’s work14 on identifying the patients most likely to persist with the post-surgical regimen of therapies, particularly pertinent for the long-term success rates of the proposed procedure.
Conflicting Interests – None declared. References
Fig. 3. Skat Players 1920 (Otto Dix). Die Skatspieler. Oil on canvas with collage 110 ⫻ 87. 1920.10 Private Collection, on loan to the Galerie der Stadt Stuttgart.
In his work on the management of personal imperfection, Irving Goffman7 noted that the stigmatized try to “pass” as normal by “covering” the defect thus minimizing its significance. This device seems wholly rational. But Goffman goes on to discuss Baker and Smith’s8 work with facially disfigured patients, who are surprisingly ungrateful for the removal of their imperfections by surgery: “..the patient is cast adrift from the more or less acceptable protection it has offered and soon finds, to his surprise and discomfort, that life is not all smooth sailing..” These findings will be familiar to those who have studied the often negative psychological repercussions in patients for whom sight is restored after long periods of blindness.9–11 Bisson’s12 study of the psychological sequalae of facial trauma helps restore some balance between these arguments. At least a quarter of the facially disfigured patients studied by Bisson suffered
1. Barker J, Vossen M and Banis JC. The Technical and Ethical Feasibility of Face Transplantation. International Journal of Surgery 2004; 2: 8–12. 2. Hutchison I. Progress Towards Randomised Controlled Trials in Facial Surgery. International Journal of Surgery 2004; 2: 14–15. 3. Mannan A, Ghani S, Sen SL, Clarke A and Butler PEM. The Problem of Acid Violence in Bangladesh. International Journal of Surgery 2004; 2: 39–43. 4. Hough R and Richards D. The Battle of Britain, p 271. London: Coronet Books, 1989. 5. Darwin C. The Expression of the Emotions in Man and Animals. (2nd Edition 1890) In The Works of Charles Darwin. London, Pickering and Chatto, 1992. 6. Shindo K. Onibaba. 1963 b/w film written/directed Kaneto Shindo. Available in sub-titled widescreen version by Tartan Video. Currently listed April 2004 on Amazon.co.uk 7. Goffman I. Stigma, Notes on the management of spoiled identity. London: Pelican, 1963. 8. Baker WY and Smith LH. Facial Disfigurement and Personality. JAMA 1939; 112: 303. 9. Valvo A. Sight Restoration After Long-term Blindness. New York. American Foundation for the Blind, 1971. 10. Gregory RL. Recovery from Blindness, in Oxford Companion to the Mind. Oxford: Oxford University Press, 1987. 11. Sacks O. To See and Not See, Virgil’s Story, in An Anthropologist on Mars. London: Picador, 1996. 12. Bisson JI. The Psychological Sequelae of Facial Trauma. The Journal of Trauma 1997; 43: 496–500. 13. Thomas A. Dealing with the care in the community of a patient with severe facial cancer. Personal Communication. [email protected] [April 2004]. 14. Clark A and Butler PEM. Patient Selection for Facial Transplantation II: Psychological Considerations. International Journal of Surgery 2004; 2: 118–119.
Response to: R. Farrer
Psychological Considerations in Face Transplantation M.R. Cunningham1 and J.H. Barker2 1
Professor, Department of Psychology and Brain Science, University of Louisville Director, Plastic Surgery Research, Department of Surgery, University of Louisville Correspondence to: Dr John H. Barker, MD, PhD, Director, Plastic Surgery Research, 320, MDR Building, 511, South Floyd Street, Louisville, Kentucky, 40202, USA 2
Farrer1 provided a thoughtful analysis of some of the psychological issues associated with face transplantation and we appreciate the opportunity to respond to them. Farrer emphasised the importance of the face in social life and suggested that “A failed intervention in this case could be worse than the status quo ante.” We concur with this perspective concerning the importance of the face, which positively influences the risk/benefit ratio. We also agree with Farrer’s view that “any patients asking for such operations must be capable
78
of fully-comprehending the drastic consequences should the technique fail.” We are very mindful of the risks, and have a two pronged approach to address this possibility. The first approach is to provide the recipient with an informed consent opportunity that reflects the latest data on the likelihood of rejection. Furthermore, patients would only be accepted into the protocol if they could realistically
International Journal of Surgery • Volume 2 • Issue 2 • 2004
Psychological Considerations in Face Transplantation Robert Farrer School of Biomedical Sciences, King’s College London, UK Correspondence to: School of Biomedical Sciences, Guy’s Campus, King’s College London, London, SE1 1UL, UK
As a psychologist, I was fascinated by several of the articles in Vol. 2, issue 1 (2004) of the International Journal of Surgery. The editorial on face transplantation by Barker, Vossen and Banis,1 raises hopes for those suffering profound facial disfigurement because of trauma or disease. The article by Mr. Iain Hutchison2 on the need for proper research designs, if surgeons are to arrive at a scientifically valid set of criteria for such intervention, is timely and highlights the need for fully-informed consent prior to such radical surgery. The harrowing cases of deliberate facial injury, described by Mannan et al,3 although dealing with cutaneous injuries in the main, show the catastrophic physical and psychological consequences of facial disfigurement for the lives of young adults (Fig. 1 below).
Fig. 2. War Wounded 1922. Kriegsverletzer. Watercolour on paper 49 ⫻ 37. 1922.13 Private Collection.
Fig. 1. A soldier wounded on 22nd September 1914. Illustration from Ernst Friedrich, Krieg dem Krieg!, Berlin 1924.
Reading these articles together shows both how much and how little things have changed since the pioneering repairs (at the Queen Victoria Hospital, East Grinstead) to the faces of fighter pilots suffering “standard Hurricane burns” in combat during and after the Battle of Britain.4 Both Sir Archibald McIndoe’s pilots, and the acid-burned women of Bangladesh3 show the need for refuge and respect in a community of sufferers where patients and staff can identify with the unique crisis which deep facial injury heralds for its victims. Once confident in that environment, such patients might begin to “face” the public at large (Fig. 2). The technical demands for the surgical team embarking on whole facial transplantation seem, to this (non-medical) reader, immense. Yet Barker is confident that once a good blood supply to the new face is established, the fine work of linking the nerves responsible for facial expression and oral continence can be performed with slow precision. But what if all the surgical work is successful yet the immunological problem of rejection remains? Rejection in this context will mean more than a return to the facial scarring of the
International Journal of Surgery • Volume 2 • Issue 2 • 2004
patients’ reported in the Bangladesh study, but could leave the patient without any unique facial identity, in the manner of a Von Hagens flayed exhibit. A failed intervention in this case could be worse than the status quo ante. Barker believes that the rejection problems can be managed, but the comparison with hand transplantations (where N, even now, is still small) is not wholly apposite as the psychological meaning of one’s hand, while undoubtedly profound, is not quite the same as one’s face. The idea that the face betrays the essence of one’s “persona” is at least as old as classical theatre where the mask of the actor provided an exaggerated sign for the character’s role and emotion (Fig. 3). It would seem that because of the complex integration of the various nerves and muscles needed for even the most basic expression of emotion,5 the earliest attempts at transplantation might well fail to provide the patient with a satisfactory control over expression. The outcome might not be physical rejection per se but could well leave the patient socially rejected as odd, inexpressive or “cold”. Far from the theatrical amplification of mood provided by the actor’s mask in Greek theatre, we need to countenance the possibility that the newly acquired mask of living flesh is at odds with the person within. This notion was cleverly explored by Kaneto Shindo in the film “Onibaba”.6 In Shindo’s script the woman holds the demonic warrior mask to her face to test its fit, only to find that the mask is now fused to her forever. Attempting to prise off the mask by splitting it, she realizes that there is no longer a boundary between mask and self. A metaphor perhaps, but a psychological rejection of the new face by the recipient seems a far more likely outcome than the statistically remote chance of the dead donor’s face being “recognized” on the recipient’s face by the dead donor’s kin.
77
post-traumatic stress disorder as a result of their injuries. Given that not all the surgeons kept a record of the psychological state of their patients, it is possible that the true figure is higher. This returns us to a discussion of the anticipated range of cases where Barker’s1 proposed intervention is likely to do more good than harm, even allowing for the problems of rejection (here using the term “rejection” to embrace immunological, psychological and social rejection, discussed above). Evidence from patients suffering large excisions to the face, as a result of deep-structure cancer, implies that post-operative care is extremely stressful for the patient, their family and community nursing staff called in to dress the wound.13 A “successful” operation might leave a cancer-free patient quite unable to adapt to the change to their appearance and a psychotic breakdown can result. Presumably these are precisely the cases that might benefit from a transplant, even one which is inexpressive and orally incontinent. There seems to be a sound rationale for attempting these procedures if the alternatives are suicidal depression or psychosis. Clearly, any patients asking for such operations must be capable of fully comprehending the drastic consequences should the technique fail. This makes Clark and Butler’s work14 on identifying the patients most likely to persist with the post-surgical regimen of therapies, particularly pertinent for the long-term success rates of the proposed procedure.
Conflicting Interests – None declared. References
Fig. 3. Skat Players 1920 (Otto Dix). Die Skatspieler. Oil on canvas with collage 110 ⫻ 87. 1920.10 Private Collection, on loan to the Galerie der Stadt Stuttgart.
In his work on the management of personal imperfection, Irving Goffman7 noted that the stigmatized try to “pass” as normal by “covering” the defect thus minimizing its significance. This device seems wholly rational. But Goffman goes on to discuss Baker and Smith’s8 work with facially disfigured patients, who are surprisingly ungrateful for the removal of their imperfections by surgery: “..the patient is cast adrift from the more or less acceptable protection it has offered and soon finds, to his surprise and discomfort, that life is not all smooth sailing..” These findings will be familiar to those who have studied the often negative psychological repercussions in patients for whom sight is restored after long periods of blindness.9–11 Bisson’s12 study of the psychological sequalae of facial trauma helps restore some balance between these arguments. At least a quarter of the facially disfigured patients studied by Bisson suffered
1. Barker J, Vossen M and Banis JC. The Technical and Ethical Feasibility of Face Transplantation. International Journal of Surgery 2004; 2: 8–12. 2. Hutchison I. Progress Towards Randomised Controlled Trials in Facial Surgery. International Journal of Surgery 2004; 2: 14–15. 3. Mannan A, Ghani S, Sen SL, Clarke A and Butler PEM. The Problem of Acid Violence in Bangladesh. International Journal of Surgery 2004; 2: 39–43. 4. Hough R and Richards D. The Battle of Britain, p 271. London: Coronet Books, 1989. 5. Darwin C. The Expression of the Emotions in Man and Animals. (2nd Edition 1890) In The Works of Charles Darwin. London, Pickering and Chatto, 1992. 6. Shindo K. Onibaba. 1963 b/w film written/directed Kaneto Shindo. Available in sub-titled widescreen version by Tartan Video. Currently listed April 2004 on Amazon.co.uk 7. Goffman I. Stigma, Notes on the management of spoiled identity. London: Pelican, 1963. 8. Baker WY and Smith LH. Facial Disfigurement and Personality. JAMA 1939; 112: 303. 9. Valvo A. Sight Restoration After Long-term Blindness. New York. American Foundation for the Blind, 1971. 10. Gregory RL. Recovery from Blindness, in Oxford Companion to the Mind. Oxford: Oxford University Press, 1987. 11. Sacks O. To See and Not See, Virgil’s Story, in An Anthropologist on Mars. London: Picador, 1996. 12. Bisson JI. The Psychological Sequelae of Facial Trauma. The Journal of Trauma 1997; 43: 496–500. 13. Thomas A. Dealing with the care in the community of a patient with severe facial cancer. Personal Communication. [email protected] [April 2004]. 14. Clark A and Butler PEM. Patient Selection for Facial Transplantation II: Psychological Considerations. International Journal of Surgery 2004; 2: 118–119.
Response to: R. Farrer
Psychological Considerations in Face Transplantation M.R. Cunningham1 and J.H. Barker2 1
Professor, Department of Psychology and Brain Science, University of Louisville Director, Plastic Surgery Research, Department of Surgery, University of Louisville Correspondence to: Dr John H. Barker, MD, PhD, Director, Plastic Surgery Research, 320, MDR Building, 511, South Floyd Street, Louisville, Kentucky, 40202, USA 2
Farrer1 provided a thoughtful analysis of some of the psychological issues associated with face transplantation and we appreciate the opportunity to respond to them. Farrer emphasised the importance of the face in social life and suggested that “A failed intervention in this case could be worse than the status quo ante.” We concur with this perspective concerning the importance of the face, which positively influences the risk/benefit ratio. We also agree with Farrer’s view that “any patients asking for such operations must be capable
78
of fully-comprehending the drastic consequences should the technique fail.” We are very mindful of the risks, and have a two pronged approach to address this possibility. The first approach is to provide the recipient with an informed consent opportunity that reflects the latest data on the likelihood of rejection. Furthermore, patients would only be accepted into the protocol if they could realistically
International Journal of Surgery • Volume 2 • Issue 2 • 2004