The medical and psychological complications of a face transplant
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Recently I attended the World Congress on Facial Expression of Emotion at which groundbreaking research on the interplay among the brain, face, and emotions was presented by a world-renowned panel of practitioners and academics.
Although many keynotes were interesting, I was especially intrigued by two surgeons who spoke about the face transplantations and reconstructions they had performed. The first keynote speaker was Dr. Joan-Pere Barret, the specialist who performed the first-ever full-face transplant.
The second keynote speaker on facial transplantations was Dr. Edward J. Caterson, a member of the facial transplant team at Brigham and Women’s Hospital/Harvard Medical School, Boston.
Dr. Caterson has specific expertise and interest in reconstructive plastic surgery, cleft care, craniofacial surgery, and microsurgery which he performs at Nemours Alfred I. duPont Hospital for Children.
Interestingly, his youngest son was born with a cleft lip. A cleft lip or cleft palate occurs when the structures that form the upper lip or palate fail to grow together when the fetus is developing in the womb.
Experiencing for himself the same thing that parents go through when their child is born with this defect made Dr. Caterson an even better surgeon and advocate for the importance of cleft surgeries.
In lieu of the theme that was the focus of the conference, the brain, facial expressions, and emotions, the presentations of these two surgeons dealt with the recovery of emotional expressions after face transplants and facial reconstruction.
To date, about 50 face transplants have been performed. In the year 2005, in France, the first partial face transplant was performed on Isabelle Dinoire, a woman whose face was disfigured in a dog mauling.
The first full face transplant was performed in Spain in 2010 on a patient identified only as Oscar, a man who had accidentally shot himself in the face five years earlier. Dr. Joan-Pere Barret led the surgical team.
Although the surgeries were successful, several patients have died due to complications, infections, or as a consequence of immunosuppressive drugs that are required to prevent organ rejection, but at the same time decrease the body’s ability to fight off cancer cells.
Different causes resulted in facial disfigurement and functional impairment in the patients who have received a facial transplant. Several patients lost their faces through trauma caused by fires, explosions, chemical accidents, industrial accidents, accidental or self-inflicted gunshot wounds, or through mauling by animals. Others suffered from congenital defects or diseases such as tumors, cancers, or infections. Soldiers injured in combat were also among the patient group that received a new face.
Face transplant surgeries are performed for aesthetic reasons and/or to restore mechanical function. Because the face plays a central role in social communication, especially regarding the conveyance of meaning through the display of affective states such as emotions, feelings, and moods, restoring the ability to produce facial expressions is critical to quality of life.
As with screening for any transplant procedure, the procedure starts with psychological management, which includes a pre-operative assessment during which aspects such as psychiatric history, previous treatment compliance, social support, intolerance of uncertainty, and difficulty adapting to change are considered.
Patients are also screened for their motivation. Research in the field of psychology concerning plastic surgery indicates that a focus on functional restoration, together with a psychological approach aimed at increasing self-esteem through the acceptance of deformities, predicts better social integration than a focus on external goals such as job prospects.
Finally, the patient is counseled on aspects of the procedure such as the limitations of the transplantation, the healing process timetable, the source of the donor face, the requirement of a lifelong immunosuppression regimen, and the possibility and consequences of the operation and/or recovery failing. (1)
Following the procedure, face transplant patients will experience a significant psychological impact that accompanies their new appearance, even though psychological management has started ahead of the procedure.
To begin with, it will be the second time that they need to come to terms with an enormous change in appearance and functionality of their face. Obviously, a more positive appearance than before, but another life-altering experience nonetheless.
Additionally, they need to come to terms with the fact that they are ‘wearing’ another person’s face. This realization is not unlike the experience of a heart transplant patient. For instance, heart transplant patients can feel the heart of another person beating in their chest. However, face transplant patients experience an even more profound disruption.
Face transplant patients will, for the rest of their lives, be looking at the face of another person who died and donated their face. But they won’t look exactly like the donor, as the face needs to be fitted to the patient’s bone structure and reconstructed tissues.
Patients need to develop a sense of ownership regarding their new facial features. This is done through the development of an accurate body image. Moreover, they need to establish a new identity. As Lee Joseph mentioned in his article: “Given that the face is central to human identity, any ‘new’ or change of face entails an alteration of identity, philosophically, psychologically, and ethically.” (2)
With the establishment of a new identity, some philosophical questions arise, such as: Does a face transplantation really feel like a fresh start? Do these patients feel like they are wearing a mask and/or that they have lost their identity? Continuity in how we see ourselves and how we are perceived by others is an important factor in our sense of ‘self.’
Interestingly, research indicates that patients tend to develop a mixed identity, partly through ‘appearance persistence,’ preserving their original appearance, and partly through ‘facial appearance transfer’ whereby they identify with their new appearance in a manner that more closely resembles their donor. (2)
In regard to the restoration of facial expressions that communicate emotion, the process of relearning how to communicate emotions via facial expressions is a long and challenging one. Patients who become eligible for a face transplant surgery have already suffered from the inability to use facial expressions for many years.
Following the surgery, however, the patient still has a long way to go before emotional expressions are fully restored. In some cases, there is only partial recovery, due to incomplete muscles or nerve regeneration.
Relearning emotional expressions entails how to produce them. Patients are consciously practicing the expressions that map to basic emotions such as happiness, anger, fear, and disgust. Later more fine motor skills and subtle expressions will be required in order to relearn how to produce more nuanced or micro-expressions.
After receiving a face transplant, some patients find it difficult to align their physical appearance with their emotional expressions, creating a dissonance between internal feelings and the way they are expressed externally. Other patients experience asymmetrical movements in their faces which distort their intended expression. Still others experience limitations in their range of movement, for instance, not being able to smile or frown completely.
Another important aspect of the recovery is the change in sensorial aspects that these patients feel when they touch their faces. Some patients experience ‘phantom face’ sensations. The phantom limb phenomenon that amputees can experience, face transplant patients sometimes sense parts of their original face. (3) The phenomenon of ‘phantom face’ interferes with the patient’s development of an accurate body image and a sense of facial ownership.
Through these distortions, the emotional feedback loop of transplant patients can be affected. An emotional feedback loop refers to a cyclical process through which stimuli coming from the environment (such as the reactions of others to the appearance of the patient) will influence intrapersonal feelings in a certain way making them think and act in alignment with those feelings which in turn can inspire other complicated feelings, thoughts and actions. This cycle entails a bi-directional feedback loop which can be positive or negative.
After a face transplant, some patients have difficulties recognizing their emotional expressions when they look at themselves in the mirror or see pictures of themselves. Scientists argue that the new face might also interfere with the patient’s ability to mimic others. These negative aspects could impede mentalizing about themselves and others on the basic and affective level.
Basic mentalizing pertains to our most primitive level of mentalization at which mimicry is an important component. Through conscious mimicry — the awareness of the action or skill of imitating someone’s behavior and emotional expressions — we can infer the mental states of others by examining our mimicking behavior. This ability to synchronize our behavior with others is also critical to establishing rapport with others. Studies show that mimicry is strongly associated with success in social interaction. (4)
The second level of mentalization, affective mentalizing, is the root of empathy and compassion. Affective mentalizing is a highly critical competence in detecting fight, flight, or freeze reactions, all of which can impede our ability and willingness to understand others and disrupt our mentalization efforts. (4)
In other words, face transplant patients may not be inclined to respond appropriately to the emotional expressions of others, or to experience empathic feelings due to such mentalization impediments.
Taking the perspective from the outside world, face transplant patients’ appearance will have improved significantly, however, people will still notice that they are different. Patients often report that strangers still react to them in the same manner as before the operation, with mixed feelings of discomfort, curiosity, and empathy, or sometimes sympathy and pity, and that these patients encounter stigmatization, making it hard for them to frequent public spaces.
They notice that other people avoid them due to their own discomfort. Because transplant patients have not fully restored their facial expressions, people tend to misinterpret their intentions, misjudge them, and find them unapproachable. In other words, the patient’s inability to use emotional expressions in an effective manner impedes the mentalization efforts of others in their attempt to accurately infer the transplant patient’s mental state.
Because of these continuing nonverbal communication difficulties and mentalization impediments, face transplant patients can become (or stay) socially isolated. This, in turn, can lead to heightened feelings of frustration, anxiety, and depression. It underscores the importance of ongoing psychological support and a strong social network to help face transplant patients get through a long-term recovery procedure with lifelong implications, including the continuing commitment to the immunosuppression regime.
Public awareness campaigns and media coverage about facial transplants can help to address the social challenges of transplant patients and support them in attaining social acceptance.
Every life story that these people have to share includes accounts of bravery and pioneering spirit in the medical development of facial transplant procedures.
Within the medical field, neuroscientists are constantly exploring new techniques that enhance nerve reconnection and nerve recovery to improve the recovery process. They are also studying how brain areas involved in emotional experiences and expressions interact with the transplanted face to see whether emotional feedback can be re-established.
In conclusion, face transplantation remains, in many respects, an experimental procedure that will continue to require new studies on physical, psychological, and ethical implications, and the implementation of adjustments based on the ever-evolving understanding of the procedure and the required after-care.
References:
Brill S.E., Clarke A., Veale D.M., Butler P.E. (2006). Psychological management and body image issues in facial transplantation. Body Image. 3(1):1–15. doi: 10.1016/j.bodyim.2005.12.002. Epub 2006 Jan 31.
Lee, J. (2019). Face Transplantation and Identity: Hidden Identities, Exceptions, and Exclusions. Kennedy Institute of Ethics Journal, 29(2), 125–158. doi:10.1353/ken.2019.0018
Şavklıyıldız, A., Özkan, Ö., Uysal, H. et al. (2021). Adaptive analysis of cortical plasticity with fMRI in full face and arm transplants. Brain Imaging and Behavior 15, 1788–1801. https://doi.org/10.1007/s11682-020-00374-8
van der Putten, A. A. J. T. (2023). Mastering Mentalization. ToM PRESS.