Making Faces

[a at e8z.org]

March 9, 2003
http://www.nytimes.com/2003/03/09/magazine/09FACE.html


Making Faces

By CHARLES SIEBERT








A few years ago, in the course of researching an article for this 
magazine about the human heart, I was allowed to accompany a couple of 
surgeons from a hospital near New York on what is known as an organ 
harvest. We were on call to extract a heart from the next available 
''brain dead'' donor.



  ''If anyone asks,'' I remember the head surgeon telling me outside the 
operating room the night our call finally came, ''you are here to 
observe.''



  The other harvest teams -- liver, kidney, pancreas -- were already in 
place when we arrived, pressed elbow to elbow around the operating 
table. I must have frozen a moment upon entering the O.R. I remember a 
number of people turning to stare. One began to approach. There was the 
press of a hand on my right arm. It was the head heart surgeon, leading 
me farther in. He brought me to the very top of the operating table and 
positioned me there, my hands clenched beside the head of the donor. A 
young woman, was all I had been told, who had died earlier that evening 
of a brain aneurysm.



  I first saw only the blue cloth covering the donor's face and then, 
lifting my head, her body, split open from the shoulders to the waist: 
a glistening, multishaded inscape of organs. But for the lungs -- 
spongy pink, diaphanous, rising and falling with the whooshing clicks 
of a respirator -- all that moved was her heart, beating without any 
signal or governance from the brain, beating with no other compulsion 
than its own primordially instilled, deep cellular memory to do so.



  I remember my body making one brief, dizzying pitch forward and then, 
like the quick flip of a focus knob, a compensatory lurch back. And 
then my mind did this: it withdrew, pulled like a just-brushed anemone, 
all of its feelers in. It took refuge in anonymity, the donor's and by 
extension my own. I had seen more of, and further into, this human 
being than I had anyone in my life, and yet somehow to have seen her 
face, the most surface aspect of her, would have been my undoing.



  There are, I now understand, other, unwritten, reasons why civilians 
are prohibited from operating rooms. Whether it is the ultimate genius 
or jest of our biology that it seems to strand us on the very surface 
of its makeup -- rendering us little skiffs of awareness atop our 
inwardly roiling, reticular entrails -- we all live and, perhaps, can 
only go from day to day in a kind of ongoing, airily dismissed story -- 
or film -- of being alive. Indeed, it is only when illness causes that 
film to sputter that we are forced to contemplate its underpinnings, to 
indulge -- as impatiently as we do the tinkerings of a projectionist in 
a suddenly darkened theater -- the detailed descriptions and 
prescriptions of a doctor or, in more dire circumstances, the 
ministerings of a surgeon. But to willfully go into the heart of the 
projection room forever changes the way you view your own and everyone 
else's life story.



  I have relived this moment a number of times in recent months, ever 
since news reports began to appear at the end of last year about the 
latest potential breakthrough in organ transplantation. According to 
Dr. Peter Butler, a consulting plastic surgeon at the Royal Free 
Hospital in London, the technology is now in place for surgeons to 
perform a full-face transplant.



  A separate harvest team will be positioned where I was standing that 
night, some donor's family having extended the parameters of their 
sacrifice to include even their loved one's face. The surgeons will cut 
and lift it away, packing it, as we would that young woman's heart, in 
a cold preservative solution and then spiriting it away to a waiting 
recipient, someone whose natural face has been severely disfigured 
either by disease or an accident. The question, as Butler put it to a 
meeting of the British Association of Plastic Surgeons back in 
November, is not whether we can but whether we should.



  Initial reaction to Butler's announcement has been, somewhat 
predictably, extreme. Most of the reporting has readily abandoned 
science for science fiction. The movie ''Face/Off,'' in which John 
Travolta seamlessly switches faces with the villainous Nicolas Cage, 
has been invoked. Eileen Bradbury, a consulting psychologist at the 
University of Manchester Dental Hospital, suggested that criminals 
would find it easier to adapt to a stranger's face. A writer for The 
Sunday Herald in Scotland breezily speculated about the wealthy aging 
American who, ''thanks to a tragic accident in which a beautiful young 
woman died . . . can now check into the clinic to receive the phizog of 
her dreams.'' Still others spoke of a kind of obverse vanity, people 
donating their faces in order to gain some measure of immortality by 
keeping at least their visages moving a while longer through the world, 
a notion that I soon found myself morphing into the deeply unsettling 
scenario of a person walking down a city street and spotting their dead 
parent's or sibling's face on someone else's head.



  A few months after Butler's announcement, I called him at the Royal 
Free Hospital and asked if we might get together to discuss the 
particulars of face transplant surgery, what is and isn't possible. He 
suggested the following Monday afternoon, 4:30 p.m. at the Starbucks 
just across from the hospital and the southwest gate of Hampstead 
Heath. I made a point of getting there early to secure us a secluded 
alcove, not so much to safeguard our privacy as to spare the feelings 
of any potential eavesdroppers. I had given Butler only a rough outline 
of my appearance, and as I sat watching the front door, I found myself 
beginning to speculate wildly about his. Was he the bearer of some 
horrible facial birth defect of his own, perhaps, or the victim of a 
''Phantom of the Opera''-like accident, driving him now to this radical 
extreme? At just past 4:30 p.m., a tall, lean figure with a full head 
of wavy black hair came striding through the door. Spotting my 
expectant gaze, he stopped to order, then bore his cappuccino directly 
to my table and held out his hand. The only flaw in what would 
otherwise be described as a classically handsome, fine-featured face 
was a slight skin discoloration just above his top lip, a birthmark, 
perhaps, or the result of a schoolyard brawl. Hardly the stuff of 
Gothic mad-scientist lore.



  ''Certainly, identity is a central issue -- 'will I look like the 
donor?''' he explained in a rapid-fire, silken Irish brogue. ''But what 
we're proposing is taking the skin envelope with or without some 
muscle. So if I were to transplant my face onto you, it would look much 
more like you than me, because the skin envelope is elastic. It would 
redrape around your bone and cartilage structure. The things you would 
have of mine are skin tone, texture, eyebrow color, beard, things of 
that nature. That's why what I'm doing now is establishing a database 
for what is essentially a matching process. You and I, for example, are 
reasonably well matched, but obviously. . . .'' He gestured to a 
dark-skinned gentleman who had just stepped up to a nearby side counter 
to stir cream into his coffee. ''I wouldn't transplant your face onto 
his.''



  With the advance of microsurgical techniques and immunosuppresant drug 
therapies that have allowed successful transplantation of hands and 
lower limbs, a number of plastic surgeons have been quietly working in 
recent years toward applying the same skills to the face. In the United 
States, Dr. Maria Siemionow of the Cleveland Clinic has done extensive 
research and animal experimentation in the hopes of soon performing a 
face transplant. In Louisville, Ky., a team including Dr. Warren 
Breidenbach, lead surgeon of the first successful hand transplant, is 
investigating the feasibility of face transplants. Another team of 
surgeons in Australia is also in the planning stages. What Butler has 
done is to bring the matter to the fore in order to initiate a public 
debate about it. The science is in place to proceed tomorrow, but 
Butler is currently setting up the vast infrastructure needed to deal 
with the complex physical and psychological issues that transplanting a 
face entails: surveying prospective patients and donors and meeting 
with transplant coordinators, psychologists and medical ethicists.



  ''I'm always finding new things to address,'' he said. ''It's like a 
tree that keeps branching.''




The typical candidates under consideration by Butler and his team for 
their initial attempt are people with such severe facial burns that 
they have lost not merely appearance but also normal facial function. 
''Their face is disintegrated,'' he said. ''They have no nose. No ears. 
The eyes won't close properly, leaving them open to infection. They 
aren't able to open their mouths. So these patients, aside from the 
aesthetic considerations, would have a considerable improvement in 
quality of life.''



  Having done trial procedures with cadavers, Butler estimates that the 
harvesting or ''degloving'' of a face would take approximately two 
hours, depending on the depth of the excision. It is possible to remove 
not just skin and subcutaneous fat and muscle but, in the instance of 
those recipients who have lost some of their skeletal structure, part 
of the donor's bone and cartilage as well. Still, the deeper the cut, 
the more complex becomes the reattachment. Once into the sublayers of 
musculature and bone, there is an increased risk of both rejection and 
infection, and the problem of having to fuse the donor's facial nerves 
with those of the recipient, whose face would have already been 
removed. That, however, does not guarantee the proper synaptic relays 
between the nerves and could result in what is known as dyskinesia, an 
internal misfiring of nerve signals that could leave patients twitching 
uncontrollably or smiling when they mean to frown. For these reasons, 
Butler is hoping to limit initial attempts to the so-called skin 
envelope, a subtle bit of sculpturing and resurfacing in and of itself.



  Once removed from a donor, a face, much like a heart, can survive 
without adequate blood supply for only a matter of hours before it 
begins to suffer tissue damage. With the recipient's scar tissue 
removed and the essential arteries and veins exposed, surgeons would 
attach them to the corresponding arteries and veins in the harvested 
face in order to supply both nourishment and drainage. Experiments 
conducted thus far with animals have shown great success with 
revascularization of the facial organ. Should a human recipient's 
subsequent immunosuppression therapy prove successful, they would then 
face months, even years, of painful healing and physical therapy just 
to achieve minimal function.



  But first Butler has to decide who will be his inaugural patient. He 
and his team are leaning toward the idea of an adult patient who has 
already adapted well to his or her deformity, someone who would 
therefore have the physical and psychological resiliency both to adapt 
to another face or -- should ''things go pear-shaped,'' as Butler put 
it -- to revert back to the former condition without suffering further 
damage. Originally, it was thought a child might make a more ideal 
patient, someone between the ages of 18 months and 5 years, before 
facial recognition becomes a real factor.



  ''But just think of that for a moment,'' Butler said. ''Imagine trying 
to ask the parents of a recently brain-dead child for his or her face. 
That's going to present a very significant obstacle to this whole 
procedure.''



  The obstacle may not be limited to children as donors. Butler told me 
of a psychological survey that he conducted of 120 people at his own 
hospital, one-third of them doctors, one-third nurses and one-third 
laypeople. The majority answered that they would accept someone else's 
face if they required one. No one, however, not even his closest 
colleagues, said they would donate their own.



  Even some advocates for the disfigured balk at the idea. James 
Partridge, chief executive of Changing Faces, a nonprofit organization 
for those who have severe facial deformities, was quoted as saying that 
the prospect of face transplants could hinder people's ability ''to 
face their disfigurement with confidence.''



  Butler steeled himself when I mentioned Partridge and said, ''My 
answer to that is there are those, however small a subset of humanity 
they represent, who are suffering greatly from their deformity and have 
approached me about receiving relief through a transplant.''




It is revealing of us and of the airy thinness of the ''story'' by 
which we live from day to day that the transplantation of our most 
surface organ should inspire our deepest awe and antipathy. Each day, 
livers and kidneys and hearts extend people's lives; but with the face, 
our minds readily leap to abstract, contorted extremes because to us it 
is less a functioning, physical organ than the essence of the self. The 
very word denotes surface, outward appearance, an assumed bearing or, 
as in the expression ''to lose face,'' our very value or standing in 
other people's eyes. The face is, in effect, our frontispiece, and the 
prospect of losing it figuratively or literally -- or of willfully 
changing it in order to escape the confines of identity and flesh -- 
has long been an abiding fixture of our storytelling, from ancient 
myths of metamorphosis through classical and Elizabethan drama to 
modern-day sci-fi films and novels, especially the shape-shifting, 
meat-cage-dumping visions of cyberpunk fiction. But the fact that 
Butler's announcement immediately brought these deep-seated fears and 
fantasies to the fore only further underscores the disjunction between 
our thoughts and the intricate inner biology of which thoughts are 
merely another exudate. Our focus, in other words, remains fixed upon 
the matter of being us rather than the matter of our being.



  And yet it is toward the latter realm -- that of our own biology, our 
own ''projection rooms'' -- that science is now increasingly drawing 
our attentions. However small a group for whom face transplants are 
viable, somehow the very news of it affects and reflects our changing 
sense of self. It is as though we are all collectively undergoing a 
kind of face transplant, or at least the equivalent psychological 
trauma of not seeing in the mirror anymore the altogether special, 
distinct entity we thought we knew. We are all, in a sense, having to 
stretch our psyches around what I've come to think of as our 
''biological plasticity,'' the increasing knowledge of our makeup and 
the seemingly limitless ability such knowledge gives us to manipulate 
and reshape that makeup.



  Grotesque manipulations are possible, to be sure: imagine chimeric 
mice with nascent human brain cells developing within their tiny 
skulls. In the early 90's, a team of scientists found a way to grow on 
a mouse's back bovine cells in the shape of a human ear. But while our 
minds may run wild with visions of a world besieged by hordes of 
superintelligent, ear-bearing mice, eavesdropping on our every 
conversation, the real work of science proceeds, guided as it has 
always been by a sense of parochialness and proportion.



  A team of Israeli scientists recently announced the successful 
development from human stem cells of whole and fully functioning 
kidneys in mice. The implications here are stunning, to say the least. 
You can begin to imagine a carefully nurtured, laboratory-grown shadow 
self. Not the oft- and ill-conceived whole clone, but a potentially 
lifesaving palette of organs or organ-specific tissue grown from your 
own biological clay and therefore not subject to the rejection donated 
organs are.



  We tend to fancy ourselves apart from the rest of nature. It is an 
isolating trick of our consciousness and that story we live by, one 
that naturally makes us want to transcend our mortal confines and seek 
answers about our origins and true essences in a noncorporeal, 
unearthly realm. The ultimate paradox is that those answers are all 
contained within our DNA, life's common biological clay: the 
dynamically perfect and scintillic symmetries of which we and all other 
creatures are just brief and increasingly interchangeable assemblages.



  One scientist I know at the National Institutes of Health has been 
doing groundbreaking heart-disease research based upon the stunning 
fact that the very same, exquisitely aligned, energy-efficient muscle 
fibers that nature invented way back in evolutionary time to power the 
beating of a fly's wings at 150 beats a second are the very same design 
nature devised to help power the beating of our hearts. Meanwhile, 
through advanced fossil studies and DNA analysis of the single-cell 
anaerobic bacteria that live in deep hot ocean seeps known as 
fumaroles, scientists have been able to glimpse the earliest formation 
of all life. They have shown, for example, that the different working 
components of the cells in our bodies, the nucleus, the mitochondria 
and so on are themselves the distant descendants of the various 
single-cell bacteria that used to cover the earth in the earliest days 
of its fiery formation and eventual vaporous cooling. Hell's fires and 
heaven's airy vapors, it turns out, aren't imaginative conceits; 
they're distant cellular memories, visions that, if we could turn our 
faces and our gazes inward toward the matter of us, we would see 
emanate from ourselves and all life forms -- from the merest mud snake 
to the sun-twiddling poplar leaf.



  We are on the cusp of being able to see even our faces -- the most 
easily abstracted aspect of our existence -- as one more part of our 
biology. That would somehow represent the most profound advance in the 
process of understanding who we are and what we are really seeing when 
we look in a mirror. As we were getting up to go that afternoon, Butler 
told me that in recent weeks, as news of his announcement had got out 
and had time to settle, a number of e-mail messages had come his way 
from people, some offering to become the first recipients and some, as 
well, from willing donors.



  ''An elderly couple wrote,'' Butler said. ''The husband, 72 years old, 
just learned he's got an incurable illness, doesn't have more than a 
year to live. They said they felt it was very important that they give 
something, and both asked to be put on the list.''






Charles Siebert is the author most recently of ''A Man After His Own 
Heart,'' a memoir developed from an article he wrote for the magazine, 
to be published by Crown in 2004.