Face transplantation is now accepted as a “feasible and necessary treatment” for severely disfigured patients, according to a review article in the December issue of Plastic and Reconstructive Surgery®.

To date, 25 facial transplants have been performed worldwide, and the procedure is expected to become more common in the years ahead. Harriet Kiwanuka and colleagues of Brigham and Women’s Hospital in Boston analyzed published articles on the ethics of face transplantation to see how the ethical debate has shifted over time. They found that initial concerns about the effect of a new face on patients’ identity has faded as experience shows the benefits of facial transplants in helping patients with severe facial disfigurement return to a more normal life.

Kiwanuka and coauthors identified 110 articles discussing the ethics of face transplantation published from 2002 to 2012. Nearly half of the papers appeared in the year before and after the first facial transplant—performed by a French team in 2005. Since then, the number of ethical discussions on face transplantation has gradually decreased, the study showed,

The papers showed a “time-related trend” in ethical positions. All of the articles published in 2002 concluded that face transplantation was not ethically justified. By 2008, all published papers acknowledged the ethical concerns, but concluded that they were outweighed by the benefits of successful facial transplant.

The researchers identified a core group of 15 topics that recurred through the years. The most common issues were related to “identity change/psychological effects,” the need for lifelong immunosuppressive drugs to prevent rejection of the transplanted face, and the risks versus benefits of face transplantation.

Many of the early concerns over identity focused on the idea of “wearing someone else’s face,” but these concerns have faded, as experience showed that facial transplant recipients gain a new appearance that is “neither identical to the recipient’s nor the donor’s face.” Plastic Surgery Practice recently discussed these issues in an interview with Daniel S. Alam, MD, a facial plastic surgeon at the Cleveland Clinic Foundation in Ohio, in our November 2013 issue.

Recently, some new issues have come to light, such as patient selection for face transplantation, the inability of severely disfigured patients to lead normal lives, and the high costs of face transplantation. Many recent papers focus on characteristics of the “ideal recipient” for facial transplant. One report cites the “Catch-22” of face transplantation: the patients who are most capable of coping with face transplantation may be those who need it least, because they are coping well with their disfigurement.

Moreover, new questions have also surfaced. They include: Should face transplantation be considered for children? What are the issues related to race/ethnicity? As face transplant becomes more common, how will donor tissues be allocated?