Earlier this year, our trauma team received a consult page for a 26-year-old man with a self-inflicted gunshot wound. When we arrived in the emergency department, the extent and severity of the wound made us question what help could be offered to this patient. Before us was a man with no recognizable face, in its place a confused medley of intermingled skin, soft tissue, and bone. Our team stabilized him, but we were all silently thinking that this man was destined for a life of reconstructive surgery.
Few good options exist for surgical reconstruction of severe facial deformities due to trauma or burns. The uniqueness of the shape and structure of the face, as well as its functions, complicate any attempt at reconstruction. Conventional reconstructive methods require multiple trips to the operating room, often resulting in visible scarring and greater tissue and quality mismatch, yielding a patchwork appearance. In addition, conventional methods deliver suboptimal reconstruction of the nose, lips, and eyelids that lead to obvious deficits in breathing, chewing, and seeing, respectively. 
The State of the Face Transplantation
Face transplantation is a novel procedure with a promising future. With forty procedures already performed worldwide, more medical centers are beginning to offer face transplantation.  This uptick indicates increasing numbers of clinicians and patients are deciding face transplantation is superior to conventional reconstructive methods. Face transplants have shown improvement in motor and sensory function as compared to conventional reconstruction. This has allowed for the possibility of emotional facial expression, an improved sense of self with the attendant psychological benefits, and an overall increase in quality of life. These patients have been able to resume work, enjoy sharing meals in public, and take part in recreational and leisure activities; they have been able to reintegrate socially, which for many patients is life changing. Despite these improvements over conventional reconstructive techniques, face transplantation is still considered experimental.
One of the biggest obstacles to broader acceptance of face transplant surgery is a lack of evidence showing that the benefits of this procedure outweigh the risks of life-long immunosuppression. Immunosuppressive therapy is necessary to prevent rejection of the facial allograft and has shown good results thus far, but significant side-effects remain. These include the increased risk of developing oncologic malignancy and metabolic complications like diabetes mellitus. Even while taking immunosuppressive medications, acute rejection is the most common complication, and occurs in eighty percent of face transplants within the first year. The reality of chronic rejection and allograft loss was made apparent in early 2018 with the first face retransplant.
Whether patients can truly understand the risks of face transplantation has become the center of ethical contention regarding informed consent for the procedure. Although informed consent is itself a topic deserving of a full discussion, one that should cover organ donation and sourcing as well as the cost of the transplant, it is beyond the scope of this paper. The focus will be how one might weigh an individual's interests with the pressures of social convention: is social reintegration worth the added risk posed by face transplantation? In a world where our faces seem all the more tied to our social identity, perhaps so.
The Face and Social Value
One's face is a locus of value in all cultures. It is so important to humans that the brain has an area solely devoted to recognizing it.  A photographic portrait of one's face is generally required in identification such as driver's licenses and passports, to authenticate one's identity. Banks require such identification to secure financial transactions, as does travel between countries. Legal and financial functioning in society has traditionally relied heavily upon one’s face. The current generation may treasure the face more than most. In 2015, the International Business Times hypothesized that young adults will take more than twenty-five thousand pictures of themselves during their lifetimes. The Oxford English Dictionary coined this photographic self-portraiture the “selfie.” Selfies are collected and posted on online social media platforms to be “liked” and shared by friends and family, and have flourished as a means of self-expression.  Selfies allow us to choose how the world views us rather than succumbing to being described by others,  further strengthening the bond between our identity and our face.
In light of this, retail, law enforcement, and even airports are using facial recognition technology to target consumers, personalize searches, and identify passengers. On an individual level, analysts believe the trend will continue to mobile phones, with more devices incorporating the sophisticated facial identification system introduced by the iPhone X.  Digitizing the face into a biometric password for mobile devices highlights the social function of our visage. If we can afford it, our face can now be used to access our private messages and social networks, as well as banking accounts and travel plans. Essentially, our legal and financial existence in the world has been updated to no longer require an individual to be present physically when facial recognition can authenticate our identity remotely with just a glance at our mobile devices.
While facial recognition technology is a life-enhancing feature, it is not perfect. Not only does it reinforce societal status as the cost can be a barrier to access; but also, facial recognition software may not adequately detect faces with severe facial deformities.  This may disparage individuals with outlying variations of facial features and further narrow the expectations of what members of society ought to look like.
One can ask, are we solving a problem of social reintegration for these patients by offering face transplant, or facilitating social prejudice against facial disfigurement by “correcting” it? For millennia, good moral character has been associated with beautiful faces, while ugliness has been associated with evil or immoral persons.  Cinematographically, this association occurs frequently. In the James Bond films, for example, the fight between good versus evil pits the handsome agent against a facially disfigured villain.  Studies show that this evaluation is not exclusive to movies or novels, but is instead deeply enculturated in society. [19,20,21]
A Chance to Reintegrate
Even in an imperfect society in which people with distorted facial features are subject to ridicule and social ostracism,  it is important to highlight that not everyone seeks facial reconstruction. Charities like Changing Faces provide advice, support and psychosocial services to people with visible differences to help them lead the lives they want.  While it is not easy to navigate the social stigma they face, people who embrace their physical differences have shared inspiring and uplifting stories.  For this reason, Changing Faces championed Face Equality Day as a campaign to create a society in which everyone is valued for their unique contribution regardless of their facial appearance. Nonetheless, facial disfigurement is associated with having poor social support, financial strain, and increased symptoms of depression and anxiety.  One solution would be to engage aggressive measures to promote a culture accepting of individual differences. Perhaps, for example, one could start by introducing emojis with facial deformity to be included with the arrival of emojis inclusive of a range of disabilities that is set to be released in late 2019. [26,27]
Simultaneously, we cannot ignore the powerful influence the face has in social engagement and social roles. Even though techniques to treat severe facial deformity have progressed over time, physicians still face a number of ethical (and practical) dilemmas regarding what to do to treat facial disfigurement and how to do it. Ideally, reconstruction would be comparable to the individual’s original features with little associated deficits or procedural sequelae, but this is only seen in science fiction. In the interim, face transplantation—not belittling the consequences and economic costs of life-long immunosuppression—encourages full participation in social relationships by restoring a human aesthetic with motor and sensory function. This should not be undervalued given current societal priorities. 
As our ability to perform successful face transplants improves, more cases of severe facial deformity will look towards weighing the advantages of this life-enhancing procedure over its risks, especially if the primary treatment goal for the patient with facial deformity considers bodily integrity compatible with survival as well as social inclusion, societal reintegration, and maximization of functional and life potentials. The patient with a self-inflicted gunshot wound from the opening vignette will undergo conventional reconstruction to address their facial trauma. This is so despite having indications for face transplantation similar to almost half of current face transplant recipients.  In fact, the fortieth transplantation worldwide was performed on the youngest recipient yet, a 21-year-old female, to treat facial deformity resulting from a gunshot wound. The patient and surgeons believed that despite risks of life-long immunosuppressive therapy, face transplantation would give her the best chance to reintegrate into society.  Yet for the patient from the opening vignette, biologic survival will be prioritized as of paramount importance in all reconstructive efforts, thus putting psychosocial well-being in the passenger’s seat.
For face transplantation to become a standard of care for the treatment of severe facial deformity will require a paradigm shift that recognizes the social and societal value of the face. It would require that we provide more than just biologic survival to patients with facial disfigurement. Instead, it requires that we consider outcomes that go beyond the health of the graft and physical healing of the person to include functional, social, and wellbeing indices. Simply put, the standard of care for facial deformity must include a comprehensive biopsychosocial assessment of what it would mean for an individual to flourish. Including these outcomes will help us redefine what success means in reconstructive surgery of the face. To put it into perspective: a successful reconstruction is one where balance of patient preference and provider expertise results in biologic survival of the allograft and patient, but also in a life well lived—one imbued with personal and social meaning.
Because the face carries such importance for living in today’s society, adopting face transplantation as a standard therapeutic option may soon be more widely accepted as worth its medical risks in order to meaningfully change a patient’s life with social reintegration and future potential. The clinical success in correcting severe facial deformities not amenable to conventional reconstructive techniques, the improved quality of life and reversal of social isolation, along with scientific advances should soon warrant the change of face transplantation from investigative to accepted therapy. This change would reduce financial and other barriers to affected patients who would benefit from this procedure, like the patient my team encountered following a self-inflicted gunshot wound. For this patient, and others like him, we can hope and advocate for face transplant so that he may fulfill his potential for a life well lived. The time has come to recognize whole-person health and flourishing, not just mere survival. The time for face transplant to become standard therapy is now.
Miguel Dorante can be reached at: firstname.lastname@example.org.
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