Put a picture of Frankenstein’s monster in your mind, and you will almost certainly think of a stiff creature with a piecemeal stitched on face. Reflect upon the nineties movie “Face/Off” and you might think that face transplants enable you to seamlessly change appearance from one great looking guy to another at the drop of a hat. Of course, the truth is somewhere between those two extremes, and in recent years a select few people with severest of disfigurements have undergone face transplants, enabling them to return some of the function to their face.
Fig. 1 Face surgery scene from Face/Off. Image from Fogs’ movie reviews
The face is one of the most complex and distinctive parts of a person’s body. It takes up to 46 muscles  to smile, and the inability to do so in a symmetrical manner is a key sign someone is having a stroke. The color of someone’s face tells us if they are sick. Eyelids must be able to open and close in order to keep our eyes moist. Eyebrows and eyelashes keep dust and bits out of our eyes. Lips allow us to eat, talk, smile/frown, kiss, and grow mustaches in support of Movember. Noses let us moisten and filter the air entering our bodies. Ears let us direct sound and hold our earbuds when we listen to music. Not to mention the cosmetics industry is worth billions of dollars.
We use the phrase “lose face” to describe when someone has lost respect of others. But what if you literally lose your face to fire, cancer, or an animal attack? Depending on the severity of the injury, tens of rounds of plastic surgery using tissues from other areas of the body can restore some of the function. But in other cases the damage is too severe, and more drastic measures are needed.
In 2005, the first partial face transplant occurred on a French woman who had been mauled by her dog. It was considered a major medical accomplishment at the time, as the woman went from missing the tip of her nose and cheeks to being able to feel and control her new face within 18 months  post surgery. The surgery has since been completed on approximately 20 people, but remains a complicated and very risky procedure .
Fig. 2 Overview of how Patrick Hardison received a new face after suffering a severe facial injury in a fire. Image .
The major risks and challenges associated with face transplants include rejection, the amount of scar tissue, number of tissue types transplanted, ethics, and matching donor and recipients. Rejection occurs when the patient’s immune system recognizes the new face as foreign and therefore attacks it, so all transplant recipients take immunosuppressive drugs for the rest of their lives. By reducing the activity of the immune system, these drugs also increase the risk of opportunistic infections and cancer . The second challenge is that of scar tissue; due to the initial injury itself as well as the numerous subsequent surgeries to reconstruct the face, surgeons must remove considerable scar tissue before applying the new face. On a related note are the technical challenges associated with transplanting the new face; skin, cartilage, nerves, muscles, blood vessels and sometimes bone must all be transplanted, such that face transplant surgeries can involve 150 medical personnel  and take up to 36 hours. Finally is the thorny issue of ethics. The idea of donating your face after you die may seem like a bit of a terrifying concept, as you might think that your family will see the recipient as a kind of walking dead reincarnation of you. However, the appearance of a face depends not only on the flesh transplanted, but also the underlying bone and tissue structure (i.e. the recipient). In other words, the result of the face transplant in Face/Off is not even close to the truth. Nonetheless, faces don’t appear on national registries and require a donor registration distinct from that done with your driver’s license, so finding a face of the correct size, skin tone, and gender is challenging.
Once limited to sci-fi movies, face transplants now offer great promise for assisting in the recovery of the many people suffering severe disfiguring injuries each year. Just as decades of advances in microsurgery, transplant medicine, and anesthesia were necessary for these long complicated surgeries to occur, the future must hold a greater social acceptance of and willingness to donate to face transplants.
Would you donate your or one of your loved one’s face?
Scheve, Tom. “How many muscles does it take to smile?” How Stuff Works. http://science.howstuffworks.com/life/inside-the-mind/emotions/muscles-smile.htm (Accessed August 21st 2016)
 Dubernard, Jean-Michel, Benoit Lengelé, Emmanuel Morelon, Sylvie Testelin, Lionel Badet, Christophe Moure, Jean-Luc Beziat, Stéphanie Dakpé, Jean Kanitakis, Cédric D’Hauthuille, Assia El Jaafari, Palmina Petruzzo, Nicole Lefrancois, Farid Taha, Angela Sirigu, Giovanni Di Marco, Esther Carmi, Danielle Bachmann, Sophie Cremades, Pascal Giraux, Gabriel Burloux, Olivier Hequet, Nathalie Parquet, Camille Francès, Mauricette Michallet, Xavier Martin, and Bernard Devauchelle. “Outcomes 18 Months after the First Human Partial Face Transplantation” *New England Journal of Medicine *357 (2007): 2451-2460. http://www.nejm.org/doi/full/10.1056/NEJMoa072828#t=articleTop (Accessed August 21st 2016)
 Lee, W.P. Andrew. “Human Craniomaxillofacial Allotransplantation: A Face Transplant Research Study” Johns Hopkins Medicine. http://www.hopkinsmedicine.org/transplant/programs/reconstructive_transplant/face_transplant.html (Accessed August 21st 2016)
 Dantal, Jacques, and Soulillou, Jean-Paul. “Immunosuppressive Drugs and the Risk of Cancer after Organ Transplantation” New England Journal of Medicine 31 (2005):1371-3. http://www.nejm.org/doi/pdf/10.1056/NEJMe058018 (Accessed August 21st 2016)
 Christensen, Jen, and Elizabeth Cohen. “The ‘most extensive’ face transplant in history gives firefighter new life” CNN.com. http://www.cnn.com/2015/11/15/health/face-transplant-firefighter/ (Accessed August 21st 2016)
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