What comes with a new face?

For roughly 30 patients across the globe who have received face transplants, the answer is both very simple and complex: A new face brings a measure of normalcy after years of living with the unrelenting social cataclysm of disfigurement.

For patients like Patrick Hardison, whose precedent-setting transplant was unveiled in New York this week, normalcy meant shopping at Macy’s without enduring the hushed remarks and quickly-averted stares of strangers. It meant touching his new chin and feeling sprouts of stubble for the first time in 14 years. It meant looking his teenage daughter in the eye, offering a familiar nod of reassurance, and wiping tears from his new face. It meant going to a sandwich shop with an old friend and wrapping his mouth around a gyro.

But a new face exacts certain costs as well, experts said this week. When physicians surgically attach a deceased donor’s skin and facial features to a recipient's disfigured head, that patient takes on a lifelong risk that the new tissue, which powerfully attracts the immune system’s attention, will be attacked and rejected. A handful of patients have died after getting new faces.

Most extensive face transplant ever performed is a success in New York

A team of medical professionals in New York City has successfully performed the most ambitious facial transplant ever attempted, involving the transfer of eyelids, scalp, ears and subcutaneous bony structures, to restore normal facial figures to a volunteer firefighter whose entire head was grievously...

A team of medical professionals in New York City has successfully performed the most ambitious facial transplant ever attempted, involving the transfer of eyelids, scalp, ears and subcutaneous bony structures, to restore normal facial figures to a volunteer firefighter whose entire head was grievously...

(Melissa Healy)

Other burdens are far more subtle. In most cases, transplant recipients also feel a deep responsibility for a donor’s legacy. Sometimes this includes a relationship with a bereaved family.

“This is a huge psychological shift,” said medical ethicist Jennifer Blumenthal-Barby of Baylor College of Medicine in Houston, who has examined the ramifications of facial transplantation. Candidates for such surgery “have to be pretty psychologically robust to get through this,” she added.

What doesn’t come with a new face? An identity crisis, experts said.

“It’s not to say it won’t happen, but how these patients are going to integrate this new identity hasn’t been that big an issue,” said Dr. Mark Ehrenreich, a University of Maryland psychiatrist who was part of a facial transplantation team there in 2012. Scales that measure patients’ quality of life, self-image and social confidence “have shown people do remarkably better” after surgery than they did before, Ehrenreich added.

Given the central role that the face plays in forming a human being’s sense of self, that may come as a surprise. But Richard Lee Norris, the transplant recipient in that 2012 case, says it’s really pretty simple.

The medications come with an array of punishing side effects beyond the ever-present threat of infection. Transplant recipients face the lifelong prospect of anemia, arthritis, sleep difficulties, nausea, headache, tremors and mood swings, as well as weakened bones and the cardiovascular risk that comes with having high blood pressure and high cholesterol.

Those risks are not unique to people who get new faces: all solid organ recipients must take them. But they do pose a unique ethical quandary for people like Norris and Hardison.

Unlike patients for whom an organ transplant is a lifesaving necessity, no patient undergoing facial transplant would die without the surgery. On the contrary, Rodriguez said, candidates must be healthy enough to withstand a procedure that has resulted in death for at least four patients and, in Hardison’s case, required 26 hours under anesthesia.

For an essentially healthy patient to undertake the risk of both surgery and of a lifetime of anti-rejection drugs, “all of the procedure’s potential psychosocial benefits have to be weighed against these harms,” Blumenthal-Barby said. There’s also the risk that a new face won’t bring future happiness.

For Norris, the ethical conundrum was easy to resolve.

“It is a lifesaving operation, depending on how you define ‘living,’” said Norris, who became disfigured in a gun accident. “If you live as a recluse and deal with disgusting comments every day, that’s really not a life.”