Patients get new faces, but also have to look after their real selves

The eyes were his. The ears and forehead, too. But when Maurice Desjardins’ wife saw him immediately after surgery, her first thought was: That is not my husband.

Desjardins lost his nose, lips and jaws to the blast of a hunting rifle seven years ago. After the injury, he would only leave the house wearing a surgical mask. But in May, the 65-year-old became the recipient of Canada’s first face transplant. Now, Desjardins’ wife says, he looks even better than before he was wounded.

“Très beau, très beau,” she repeated over and over in intensive care. “You are beautiful.”

At a packed press conference this week to announce Desjardins’ meticulously detailed operation, lead surgeon Dr. Daniel Borsuk stood in triumph: his team had spent years planning for the 30-hour procedure to replace his mangled face with that of a brain-dead donor.

“The integration of this new organ has been remarkable,” he said.

“We are finally able to deliver Maurice a new face, a new chance at life.”

But adjusting to a new face is different than living with a new heart or kidney. The face is how we communicate, how we recognize each other — for better or worse, it’s what makes us uniquely ourselves. When surgeons first transferred the faces of the dead onto the living more than a decade ago, ethicists questioned whether doctors could adequately assess the psychological impact of such an audacious procedure: on patients, on donors, on their families, on society.

“We are left with the question of what the face transplants, and who the new person actually is,” writes Sharrona Pearl in Face/ON: Face Transplants and the Ethics of the Other. “So much of our identity revolves around our faces; does the face of another bring with it the identity of another?”

American film critic Roger Ebert had his lower jaw removed during aggressive surgery to treat his cancer. In a poignant blog posting in 2010, he reflected on what it might mean to “be whole again” after surgeons announced they had given a new face to a Spanish farmer.

“What if I could go to Spain and return with a complete face?” Ebert wrote. “If you passed me on the street, you might mistake me for a normal man.”

But Ebert, who died in 2013, said he feared “something within me might recoil at the sight” of a new face. “Oh, I have no squeamishness about wearing another man’s face after he has no need of it; I support transplant of all sorts, and when I die I hope my organs can be of use to someone,” he wrote. “But this face, however imperfect, is mine.”

Borsuk and others acknowledge how different a face is from other organ transplants. Borsuk had a special effects artist make a silicone mask of the donor’s face, in fact, so that after his was removed he would not leave the operating room without one.

He also insisted Desjardins undergo a full year of psychotherapy before the operation. Partly to prepare for the possibility of death on the operating table, or that the organ would be rejected by his body later on — but also to steady him for the emotional impact of having someone else’s face staring back at him in the mirror.

But the reality is that patients who have been disfigured by later-life illness or accidents — gunshot wounds, burns, cancer — have already had to adjust to a “new” face.

In the April issue of the AMA Journal of Ethics, face transplant pioneer Dr. Eduardo Rodriguez and his colleagues write about the “discordance” patients feel between their “new faces,” the way they look after trauma, and their “real selves.”

Face transplantation — replacing a mouth, eyelids, or nose rather than attempting reconstruction — offers them something conventional surgery cannot touch: “the regaining of their lost identities,” as the authors write.

There have been 41 face transplants worldwide, and in almost all cases, says French surgeon Laurent Lantieri — who has performed eight of them — recipients “support very easily, very fast, their new face, psychologically.”

“In French, we have two words for the face,” Lantieri says. “Le visage, the expression of the person, the personality, and la face, which is the anatomy.”

With face transplants, “we are transferring la face, and that is something we had to make people understand. Even if the cosmetic aspect is not the best, they really integrate quickly.”

We’ve moved away from the early hysteria around face transplants, says Pearl. “The surgery has been widely accepted. It doesn’t feel experimental in the sense of it being dangerous, in and of itself.” Fears about challenged identities haven’t been realized.

“But it’s hard to really know because the pressure on (patients) to tell inspirational stories is so intense,” she says, “The pressure on this to be this incredible, transformative thing for which people are meant to be grateful, by which they are meant to be ennobled is so powerful that that’s the story we get.”

Pearl believes “living with a face, even though it’s not the face you were born with, is much, much better than living without a face.” But she argues that the stories we tell about such transformations fail to address our own prejudices and fears.

“I think we ought to be turning the lens inward and asking why it is so hard for people to function without a face,” she says. Looking different shouldn’t be “a kind of living death sentence.”

Two weeks ago, Desjardins met one of the few people who might understand what that’s like — a man who may become his surgeon’s next patient. Like Desjardins, he is a hunter with a gunshot wound to the face.

“It’s very weird to meet someone who has experienced the exact same thing as you,” says Borsuk, “who knows what it’s like not to have a face; to be isolated.” One man looking at the other: this is where I’ve come from. The other staring back. “He couldn’t believe that Maurice ever looked like him,” Borsuk says. “It was very emotional, for both of them.”

At Wednesday’s press conference, Borsuk explained that Desjardins is learning how to drink, and how to speak again, “but it will take months before it becomes normal.” It’s also too early to tell how well he will adjust psychologically.

In a recent interview, however, Borsuk said, "Your personality comes through in your expressions, the way you hold yourself. No matter what skin and bone is put on top, you are still going to be yourself.”

As for how Desjardins is feeling right now? “What is most important for face recognition is the eyes. He has his own eyes,” says his psychiatrist, Hélène St. Jacques. And although it has been difficult adjusting to his medications, “he is very happy and grateful.”

As his wife says of his face transplant, “This is done. This is his now.” The machine-guns and trenches of the First World War left thousands of soldiers disfigured. Finely crafted masks made from copper, then painted to match patients’ skin tones improved their appearance to a limited extent. But the British doctor Harold Gillies, now considered a pioneer of plastic surgery, went much further — creating a sort of flesh mask or rudimentary skin graft. His first success was Walter Yeo, who suffered severe burns in combat, losing both his upper and lower eyelids. Skin was taken from his neck and chest and placed over his mid-face, allowing him to blink.

1941

Dr. Archibald McIndoe, the younger cousin of Dr. Gillies, advanced cosmetic surgery by refining the way single slabs of skin, up to the size of an adult palm, were transferred from one part of the body to another. This brought dramatic improvements in the reconstruction of eyelids, lips, cheeks, foreheads and ears. McIndoe also ameliorated patients’ hospital experience, serving them beer as they recovered. Second World War fighter pilots who received experimental treatments from McIndoe formed the famous “Guinea Pig” drinking club, which continued meeting for more than 70 years.

1994

Eleven-year-old Sandeep Kaur was working in a field near her home in India when her hair became tangled in a grass-cutting machine, pulling the flesh from her scalp and face in two jagged pieces. Doctors at Christian Medical College and Hospital decided to forego skin grafts and instead reconnect Kaur’s arteries and veins with her own skin.

2005

Attempting to rouse her from an overdose of sleeping pills, Isabelle Dinoire’s dog gnawed off her nose, chin and lips. To restore her face, French doctors transplanted a triangle of tissue from a brain-dead donor. The procedure made history, but was also highly controversial. And Dinoire, made more susceptible to diseases by the immunosuppressant drugs she was taking, died of cancer in 2016.

2006

Li Guoxing received a partial face transplant from Chinese doctors following a brutal bear attack. But two years after receiving a new cheek, upper lip, nose and eyebrow from a brain-dead donor, he died after foregoing immunosuppressant drugs.

2008

When Connie Culp’s husband shot her at close range, doctors were tasked with reconstructing 80 per cent of her face. A team at Ohio’s Cleveland Clinic restored her nose, cheeks, eye and the roof of her mouth using the muscles, bones and nerves of an organ donor. A man identified as “Oscar” received the world’s first full facial transplant in Spain after accidentally shooting himself in the face. Doctors in Barcelona gave him new skin, cheekbones, facial muscles, teeth, palate, lips and jaw.

2011

While repainting the side of a church, the crane Dallas Wiens was standing on collided with a high-voltage power line. Upon recovery, he was left with a smooth patch of skin traversing his face — scant of eyes, lips or a nose. Doctors performed a full facial transplant at Boston’s Brigham and Women’s Hospital, reconstructing his muscles, nerves and missing features. Wiens remains blind, but the surgery restored his ability to smell, taste and touch.

2012

In 1997, Richard Lee Norris held a loaded shotgun to his face during an argument with his mother. It accidentally went off, maiming everything but his eyes. Fifteen years later, Norris received a full face transplant at the University of Maryland Medical Center.

2013

A Polish man identified as Grzegorz received a face transplant in record time following a workplace accident that left a portion of his brain exposed to infection. Just three weeks after his face was torn off by a stonecutting machine, doctors restored his nose, upper jaw and cheeks using donated bones and tissues.

2015

In 2001, a burning roof collapsed on volunteer firefighter Patrick Hardison, charring his skin and leaving him without hair, ears or eyelids. Hardison underwent 70 surgeries and skin grafts but remained disfigured and feared going out in public. A full face transplant dramatically improved his appearance and his vision.

2018

WHO KNOWS WHAT IT’S LIKE NOT TO HAVE A FACE; TO BE ISOLATED.

France’s Jerome Hamon suffers from a genetic condition that causes disfiguring tumours. He underwent his first full face transplant in 2010. But seven years later, his new face started to die. When another donor face became available, doctors at Paris’ Georges Pompidou Hospital replaced the original tissues. Hamon is a groundbreaking case because bodies that have rejected an organ are generally unable to accept a second transplant.

2018

In a suicide attempt, then 18-year-old Katie Stubblefield blew off her face with a hunting rifle. She survived but was left unrecognizable. Her sinuses, mouth, jaw and facial bones were destroyed, and her eyes were badly damaged. A face transplant at Ohio’s Cleveland Clinic has restored Stubblefield’s facial structure and functions.