With just 25 cases on the books worldwide, leading surgeons push to bring the procedure mainstream as a medical necessity.
In the field of facial transplantation, the person-defining portion of our frontage is referred to as the "critical central face." These features -- eyes, nose, mouth, and chin -- are critical because they comprise the part that others recognize, the part responsible for expressing emotions and for facilitating human connections. Far as it may be from the recipient's native face (and also, surgeons are quick to point out, from resembling the organ donor who provided the flesh and bone), the new face redefines that person's life.
When you meet a face transplant recipient, you become immediately aware that you're talking to someone extraordinary. Connie Culp, who lost her original face to a bullet in 2004, is one of the two face transplant recipients who speak in the early morning of the third day of the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery. What renders their presence especially strange, amid presentations on "Fat Grafting for Facial Rejuvenation" and "Varying Midface Lift Approaches," is that they and their surgeons are being celebrated not for having been brought tantalizingly close to an ideal of beauty, but because they remind those present why faces are taken so seriously to begin with.
The awareness that you're in the presence of greatness comes differently with the four doctors on the panel, all of whom are partly responsible for this major scientific advancement, first performed in France in 2005 and of which there have since been 24 more instances worldwide. At first glance the surgeons -- Drs. Bernard Devauchelle and Sylvie Testelin, who were on the team that performed the very first procedure, Dr. Jean Paul Meninguad, who, with seven procedures under his belt, is the world's most experienced facial transplant surgeon, and Dr. Daniel Alam, part of the team that restored Culp's face, making U.S. history -- appear fully ordinary. Alam, up close, is shorter than one might expect a giant in his field to be; the other three must apologize for their thick accents. But as they speak of what they have accomplished, backed up by video testimony, it becomes easy to recognize that they, too, are extraordinary.
And they, the doctors, all speak reverently of having witnessed something even more extraordinary: the real-life "It's Alive!" moment when a rubbery mask of flesh, reattached to a new head's major vessels, suddenly flushes with blood. They all describe the wonder of the moment, downplaying their own hard work in order to admit, "There's always a leap of faith when it actually works."
They describe smaller miracles too -- the first smile, which one patient surprised everyone with by pulling off earlier than expected. Another's newfound ability to go out in public and be noticed by no one. One patient speaks of his gratitude for having a job at a post office outside of Barcelona -- a miracle for anyone, he says, in Spain's current economic climate. As Alam speaks of what it means to be a face in the crowd, distinguishable from 200,000 others by the human brain, he tears up, and it feels genuine. A patient in a video characterizes receiving his new face as "the difference between living and surviving."
Other aphorisms emerge: "When you have no face you're nobody;" "It's impossible to live with a mask." When earlier this year a piece in The New Yorker featured Devauchelle, much was made of the undeniable miraculousness of the face transplant. The piece also dwelled on the debate over whether this advancement might represent "surgical heroism at expense of good medicine." Though we now that we know we can do it, Devauchelle explains today, the limits for when we should do it are unresolved.
Alam, for his part, doesn't want face transplants to be seen as a miracle anymore. He wants the procedure instead to fall in the realm of basic standard of care, and not just for their potential to restore the patients' ability to talk, taste, and smell. Because the most extraordinary thing about meeting a face transplant recipient like Culp is the fact that you're able to recognize her as a person at all. He speaks of how a newborn infant is able to recognize its mother's face within the first 50 hours of life. He speaks of studies that look at our brains as we look at people without faces: the amygdala registers them as "monster" rather than "human." He speaks of wanting to fix not the patients, but the people who see them, so that the patients can be recognized, befriended, loved.
The risks, of course, remain real and potentially grave. Aside from the danger of the face being rejected, the panelists list complications such as HPV, kidney infections, skin herpes, and lymphoma. They question whether the right patient can be someone who has already undergone dozens of reconstructive surgeries, or someone who is blind, or someone who has not yet fully grown. Afterwards, Culp herself speaks of the higher standard her new face holds her to: She can no longer drink because of the medications she is on, and can no longer sunbathe because the immunosuppressants -- which keep her body from rejecting the transplant -- increase her risk of developing melanoma. As she speaks, Roy, her significant other of two years, stands close by. Culp's transformation has been hard on some, including a former best friend with whom she is no longer in contact, but for Roy, it would seem her new features are more of a window, allowing him to recognize the woman he has known for over 25 years who remains, unchanged, inside.
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Calling this big issue of restoring personhood the difference between science and medicine, Alam is trying to find a way to bridge the two. He expresses regret that he is Culp's surgeon, but not her doctor. It is his vision that the field will advance to the point where deciding to do a face transplant is no longer a brave foray into a new world, thought of by some as more showy than strictly necessary. Giving someone a face, he argues, is not "cosmetic surgery in extremis," as the initial backlash described in The New Yorker put it, nor is it exploitative. For the right patient, and despite the risks, it is a necessity.
The panelists concede that "most important for everybody is life." But they ensure that the question remains: What is life without a face?