Face

On 27th November 2005 in Amiens, France a team of surgeons performed the first human face transplant. Or did they? Face. A word, a concept, structure, challenge. What is the extent and breadth of the concept, the complexity of the structure, the enormity of the challenge? I was interested to read the editorial in our sister journal from across the water, Atlantic or Pacific, depending upon perspective. Those surgeons were given the opportunity to redress or perhaps address the negative and interestingly unlawful editorial that had followed their landmark surgery. They refer to ‘Lessons in Elegance’ but the descriptions of their soul searching would better be titled ‘Lessons in Eloquence’. There is no doubt that what they undertook was a bold and brave experiment but I could not help feeling like many others I suspect, a little ‘short changed’ when I discovered the actual extent of the ‘facial’ transplant. The pre-operative pictures though, invoke similar emotions as when viewing burns patients, in particular victims of acid assault. Professor Devauchelle is a maxillo-facial surgeon (Fig. 1). If he had been a Plastic, Reconstructive and Aesthetic surgeon would it have been different? I do not think so. We do noses. We do functional lips. But let us face it, the best nose I can achieve is with a free-style free flap, thinned, refined, but it will never have the elegance, yes elegance, of the natural nose. And is that what Professor Devauchelle and his team were seeking? Lips? An interesting observation on the tendency to hyperbole of our sister journal is to look at recent reports of lower lip reconstruction.^{,  ,}  Again we find Professor Devauchelle has been there before. Peter Butler wrote an editorial in this journal last year crystallizing a consensus of opinion that unless we venture into the unknown then we will never make progress. This contrasts somewhat with the armchair specialists who have the comfort of their lofty world to insulate them from the flesh and blood of human disfigurement, deformity and distress. In the UK the Working Party on facial transplantation concluded that it would be ‘unwise to proceed with the transplantation of the human face’ but modified their opinion in the face of a greater understanding of the psychological and biological concepts involved, and, two successful partial facial transplants performed elsewhere.

But the question still remains, what is a face? I was originally going to entitle this editorial ‘Changing Faces?’ Without the question mark this would be the title of a book written by an extraordinary human being, James Partridge. It is also the name of a very successful charity that he founded. James is an absolutely delightful person who radiates charm and confidence. James sustained very severe facial burns as a teenager and underwent classic plastic surgical reconstruction by that master surgeon John Clarke using tube pedicles. These were developed simultaneously but independently by Harold Gillies at the Queen Mary's Hospital Sidcup and Ophthalmic surgeon Vladimir Petrovich Filatov in Odessa, Russia, between 1916 and 1917. I look at the face of James on the cover of his book, the one year post-operative view of Isabelle Dinoire, the pictures of Sandeep Kaur, and reflect on the tenacity of the human spirit to face and overcome adversity. Surgeons must continue to be bold and brave and explore the very basic, practical details of facial reconstruction, facial transplantation and perhaps ultimately facial regeneration. It is in this spirit that I have chosen the paper from Wang Hui Yong and colleagues to lead this issue that marks the two year anniversary of Professor Bernard Devauchelle's pioneering achievement. Wang Hui Yong and colleagues have dissected off the entire face from fresh cadavers and, in a previous report in the Chinese literature, they have exchanged facial allografts with different donors and commented on the remarkably different faces. I think it is this aspect of facial transplantation that both worries and excites the psychologist. I have a friend and colleague at the Chinese University, Professor Michael Harris Bond. He is a Professor of Psychology and some years ago he wrote a book entitled ‘Beyond the Chinese Face’. The title resonates as I look at the face of the Chinese cadaver in Figure 5 of Wang et al.’s paper. Is this a face? Or a mask? One reveals, one hides. We have to keep an open mind and do the best we can with what we have got.

Reverting to John Clarke, he wrote a book entitled ‘A Colour Atlas of Burn Injuries’ and Figure 5.36 on page 85 shows the reconstruction of a young man who had severe alkali burns of face and eyes. This patient was the first patient I had looked after who had lost his face. He worked in a warehouse and had emptied some water into a barrel that he thought was empty. The barrel however contained residues of sodium hydride and this young man sustained devastating chemical and thermal burns to his face. Over the years I have had to cut off several, not many, but several faces and it is always done with a sense of surgical despair. Tissue engineering can help; local, pedicled and free flaps can help but at the best we leave our patients disfigured. Hence James and his charity and his psycho-social skills training taking the face out, and projecting the personality, the identity, the charm, the humour beyond the physical form. And the alternative? Professor Devauchelle, transplantation, elegance. But what lies beneath? What lies beyond? Only time will tell.