March 9, 2003
Making Faces
By CHARLES SIEBERT
[
www.nytimes.com]
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.