Healing the scars beneath the surface
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.”