AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. April 2018, Volume 20, Number 4: 309-323.
doi: 10.1001/journalofethics.2018.20.4.peer1-1804.

Peer-Reviewed CME Article: Original Research

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Facial Disfigurement and Identity: A Review of the Literature and Implications for Facial Transplantation

Facial transplantation provides a viable option for those patients with severe facial defects who are more likely to adapt to their new facial appearance.

William J. Rifkin, Rami S. Kantar, MD, Safi Ali-Khan, Natalie M. Plana, J. Rodrigo Diaz-Siso, MD, Manos Tsakiris, PhD, MSc, and Eduardo D. Rodriguez, MD, DDS

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Facial disfigurement can significantly affect personal identity and access to social roles. Although conventional reconstruction can have positive effects with respect to identity, these procedures are often inadequate for more severe facial defects. In these cases, facial transplantation (FT) offers patients a viable reconstructive option. However, FT’s effect on personal identity has been less well examined, and ethical questions remain regarding the psychosocial ramifications of the procedure. This article reviews the literature on the different roles of the face as well as psychological and social effects of facial disfigurement. The effects of facial reconstruction on personal identity are also reviewed with an emphasis on orthognathic, cleft, and head and neck surgery. Finally, FT is considered in this context, and future directions for research are explored.


“Self-concept” is an idea of the self that is constructed based on how one thinks about, evaluates, or perceives oneself as well as on the responses of others to the self. Baumeister et al. define it as “the individual’s belief about himself or herself, including the person’s attributes and who and what the self is” [1]. The relationship between self-concept, body-image, and appearance is well documented [2, 3], and thus facial disfigurement can have profound psychosocial implications. Substantial research has described the benefits of traditional facial reconstruction with respect to self-concept [4-10]; however, these procedures are often inadequate for more severe facial defects.

Facial transplantation (FT) has become a viable reconstructive option for many patients with severe facial defects, particularly victims of burns and trauma and those with benign tumors like neurofibromatosis. Despite early successes and promising outcomes, ethical concerns remain, particularly with regard to issues of self-concept and the psychosocial consequences of the procedure [11]. Complicating the risk-benefit ratio of this novel procedure, FT recipients require lifelong immunosuppression to prevent rejection, which is associated with renal toxicity, metabolic complications, opportunistic infections, and increased risk of malignancy [12]. FT thus creates a tradeoff between potential improved disfigurement and the chronic disease state associated with required lifelong immunosuppression.

This review will highlight the roles of the face, with a focus on self-concept, as well as the psychosocial impact of facial disfigurement and conventional facial reconstruction. Self-concept will then be evaluated in the context of severe facial disfigurement and FT, and the bioethical implications of the procedure will be considered with an emphasis on psychosocial issues.

Roles of the Face

The face serves a dual role as both a biological organ and an organ of identity. Like other organs, the face has unique anatomy and physiology that contribute to its biological functions [13]. Facial skin acts as an anatomic barrier, retaining body water and regulating heat [14]. Specialized structures perform distinct functions: the eyelids maintain ocular lubrication [15]; the nasal airway conditions and filters inspired air [13, 16]; and the lips form a tight seal around the mouth, allowing consumption of food or drink [16] and normal speech [13]. The face is also an important sensory organ, containing the highest density of free nerve endings in the body [17, 18]. Furthermore, facial proprioceptive information is integral to the sensorimotor processes of speech and other facial movements, and it has been suggested that facial nerve endings might also have immunoregulatory roles [19, 20].

As important as its physiological functions is the key role of the face in identity. Self-concept revolves around the face, as it is the primary means by which humans recognize and interact with each other [13] and the primary mode of self-expression, emotional expression, and social interaction [21]. The intimate relationship between self-concept and appearance is also well documented [2, 3], and the face is a major component of body image and self-worth [22]. It affects how one is perceived and evaluated by others, guiding their impressions and behavior. Important decisions such as life partner and job selection are influenced by biases that depend partly on facial appearance [23], as are criminal justice verdicts [24, 25] and congressional elections [26]. Facial features and skin qualities are major determinants of physical attractiveness and mate selection [13, 27, 28]. Unsurprisingly, attractiveness is the quality that has received the greatest focus in facial appearance research [29]. Those with attractive faces have proven social advantages and are perceived as more popular, assertive, and self-confident [13, 29-33]. These important social consequences of facial attractiveness help to explain the pivotal role of facial appearance in self-concept.

Facial Disfigurement and Self-Concept

Perhaps more so than in the general population, in people with facial disfigurement appearance and self-concept are closely intertwined [34]. Whether congenital or acquired, facial disfigurement can have profound psychosocial implications, including altered body image, reduced quality of life, and poor self-esteem [35-38]. The most frequently reported difficulties relate to negative self-perception and impaired social interaction [39]. While there is not a complete consensus, most research shows that facial disfigurement results in lower self-confidence and a negative self-image that might persist throughout life. Social anxiety, fear of negative social evaluation, and social avoidance are common in those with facial disfigurement [40]. Cleft lip studies have shown that affected children are at greater risk for anxiety, general unhappiness, and self-doubt in interpersonal relationships [41] and that many affected adolescents believe their self-confidence remains affected by their disfigurement [42]. Perhaps most alarmingly, one study showed that the suicide rate among Danish adults with clefts was double that of the unaffected population [43].

Facial disfigurement can impede social interaction in many ways; those affected report challenges meeting new people and making new friends, with resulting difficulty developing long-term relationships [44]. Reactions among family members and peers towards people with disfigurement commonly include teasing, staring, commenting, asking unsolicited questions about the disfigurement, and exhibiting avoidant or negative behavior [45, 46]. Unsurprisingly, these negative interactions can lead to affected persons’ preoccupation with their appearance in anticipation of future similar experiences. This preoccupation with appearance can in turn result in self-isolating behaviors that might exacerbate the psychosocial challenges of disfigurement by shrinking affected persons’ available social support network. Facial disfigurement might also lead to substance abuse, changes in income or occupational status, and relationship problems [47]. Younger patients seem to adapt better to facial disfigurement, especially if it occurs prior to or during puberty [48]. Adults who become disfigured later in life seem to suffer the most and often express discordance between their “new faces” and “real selves” while remaining acutely conscious of how differently they are perceived by society [49]. Interestingly, while increased self-consciousness and decreased independence are common after facial disfigurement, especially if basic functions like speech and eating are affected, several studies have failed to demonstrate a correlation between age, gender, or severity of disfigurement and psychosocial distress [37, 50-52].

Moving forward, research should continue to identify factors predictive of successful adaptation to facial disfigurement. In facial paralysis, for example, family support, faith, humor, strong sense of self, social skills, determination, and networking have been identified as protective factors [53]. While there is likely a complex interplay between physical, cultural, and psychosocial factors and successful adaptation to facial disfigurement, deeper understanding of these factors might help guide development of interventions that facilitate adaptation to facial disfigurement.

Corrective Facial Surgery and Self-Concept

Extensive research has evaluated the impact of corrective facial surgery on self-concept. Studies evaluating psychological outcomes of orthognathic surgery, which involves manipulation of the facial skeleton to restore anatomic and functional relationships in patients with dentofacial abnormalities, have shown the desire for improved appearance to be a major consideration for patients seeking such surgery [4]. Several studies report that patients receiving corrective facial surgery display improvements in measures of personality adjustment, such as psychosis or neurosis, as well as improvements in self-concept, self-identity, self-esteem, and self-conflict [4-10].

In facial disfigurement from head or neck malignancies or related interventions, the face plays a central role in an individual’s self-concept and path to psychological recovery [54]. Costa et al. described how postsurgical facial disfigurement leads to damaged self-concept and how the repair of self-concept is a lengthy and gradual process [54]. After head or neck cancer surgery, patients must undergo a process of body image reintegration [55], which entails “reorganizing perception of self into a once again acceptable unity” [56]. These findings have been corroborated by multiple groups [57, 58] and translate to other forms of corrective facial surgery. For example, elder patients treated with cleft lip repair report experiencing a restored sense of personal identity [59]. Similarly, orthognathic surgery yields consistent improvements in patient quality of life through restoration of physical facial identity [4, 60, 61].

Nevertheless, aesthetic changes resulting from corrective facial surgery can pose a significant psychological burden, requiring patients to rapidly adapt to new facial features and incorporate them into their self-concept [4]. Patients describe this process as “confusing, frightening, and disorienting” but note that a strong support system can ease the challenge [62]. However, patients undergoing major combined orthognathic and cosmetic procedures report that even close friends and family members initially struggle with adapting to their new appearance [61].

Inherent psychological traits are important in the incorporation of postoperative facial changes into a person’s identity. Positive preoperative patient self-concept seems to be a crucial predictor of postoperative patient satisfaction with facial features [63]. Similarly, patients with a realistic—as opposed to an idealized—mental representation of their facial appearance and self-perception are more likely to be satisfied with the results of cosmetic surgery than those with distorted self-perceptions [64]. Studies have also shown that there is an adaptation period prior to patients’ ultimate acceptance of their new facial appearance [65]. Frost et al. describe how patients undergoing orthognathic surgery report temporary depression and loss of self-esteem as they adapt to their new facial appearance [66], but Kiyak et al. report that these alterations in self-esteem and body image stabilize after a period of approximately two years [67]. To shed further light on this topic, outcomes-based research that uses or seeks to develop reliable, validated pre- and postoperative psychosocial assessment tools should continue to be prioritized in future psychosocial studies of conventional facial reconstruction.

Limitations of Conventional Reconstruction for Severe Facial Defects

While surgical correction of certain facial defects like cleft lip is often successful, reconstruction of severe facial defects remains a challenge, as both functional and aesthetic deficits must be addressed to recreate the “normal” face. Notably, functional deficits—particularly impaired verbal and emotional communication—often affect mental well-being more negatively than the aesthetic impairments [68]. In cases of extensive soft-tissue or composite soft-tissue and skeletal defects, conventional reconstruction remains largely unable to restore both facial and aesthetic function, and patients are often left with life-long handicaps [68]. Conventional reparative surgery options include multiple rungs of the reconstructive ladder, such as skin grafts, local flaps, distant pedicled flaps, and free flaps, although all have limitations that can result in incomplete functional restoration and aesthetic outcomes. These limitations are most pronounced for defects involving the most critical components of the face with regard to self-concept: central structures like the eyelids, lips, and nose [69]. These facial subunits and midface structures remain nearly impossible to completely reconstruct. For example, recreating the sphincter-like muscle surrounding the lips is sufficiently challenging to render a functional outcome unlikely; it is often complicated by microstomia, oral incompetence, and suboptimal tissue texture and color [70, 71]. Reconstruction of the nose and adjacent facial subunits can also yield disappointing aesthetic results [71]. In severe cases, anatomical repair might be unachievable, and free flaps are used to obliterate the resulting dead space and to seal nasal and sinus cavities and intracranial space [68].

Facial Transplantation, Self-Concept, and Bioethical Implications

FT offers patients new possibilities of repair for these severe defects. Functional outcomes have been promising, especially considering the impaired pretransplant state of most recipients; sensory recovery is common [72, 73], and motor recovery can restore many “social” facial functions [74] and the ability to breath, eat, drink, and speak intelligibly [75, 76]. Aesthetic outcomes have been equally favorable, albeit to varying degrees, exceeding expectations in many cases. Beginning with the first face transplant in 2005, delicate anatomical structures like the eyelids, nasal unit, and lips have been successfully replaced, rather than reconstructed [77, 78].

Nonetheless, over the last decade, various groups have scrutinized and explored the ethical [79-85] and psychosocial [11, 49, 82, 83, 86-88] aspects of FT along with its effect on self-concept. Concerns are rooted in the knowledge that the face plays an essential role in personal identity and self-recognition [11, 49, 82, 83, 87-89] and is a critical mediator of self-expression and interactions with others [82, 90]. Advocating that the face is as an irreplaceable symbolic entity, the Royal College of Surgeons of England [87] and the French National Consultative Ethics Committee for Health and Life Sciences [82] did not initially support FT. A review of all scientific literature related to FT published between 2005 and 2012 found that the majority of articles cited negative “identity change” and resulting psychological effects as the primary concern [11]. Robertson argues that skepticism about FT stems partially from the fact that it involves continuation of the deceased donor in a unique way that does not apply to solid organ donors [84]. The symbolic significance of the face can create an emotionally charged and complicated situation for donor families, who might ultimately refuse donation for this reason [84, 90]. Some virtual studies suggest that donor-to-recipient transfer of facial appearance is minimal in two- [91] and three-dimensional [92] analyses; however, the reproducibility of this result remains uncertain in clinical practice, and ethical obligations towards donors and their families prevent extensive research on the subject.

Another crucial aspect of FT involves ensuring that recipients embrace their new faces. Emotional acceptance of the transplanted face is critical for recipients’ whole-body image integration and self-concept adaptation and for avoiding complex psychosocial issues [85, 88, 90]. Acceptance can also lead to greater participation in postoperative care and compliance [82, 90]. Interestingly, recipient personality traits appear to play an important role in acceptance of the transplanted face. FT patients who demonstrate a strong preoperative self-concept seem better equipped to adapt to changes in physical appearance and suffer fewer negative psychosocial consequences than FT patients lacking a strong preoperative self-concept [86, 88]. Proponents of FT argue that for these psychologically prepared recipients, the procedure allows the regaining of their lost identities [89, 90]. Furthermore, facially disfigured patients report that, in pursuit of regaining their personal identity, they would be more willing to accept the risks of immunosuppression and would tolerate greater risk for FT than for kidney transplantation [88].

Nevertheless, the risk-benefit ratio of FT is unique in that, unlike solid organ transplantation (SOT), it does not prolong survival. FT is typically performed only after conventional reconstructive methods are exhausted, with a focus on improving aesthetic, functional, and quality-of-life outcomes. However, like SOT, FT requires lifelong immunosuppression to prevent rejection, which is associated with many adverse effects, including increased risks of malignancy, infection, and metabolic complications. For FT to be ethically acceptable, these risks, along with FT’s effects on self-concept and their psychosocial implications, must be weighed against expected benefits. Indeed, there is widespread acceptance that quality of life of severely disfigured candidates should be considered along with survival [11]. Given the effects of facial disfigurement on patient self-concept and psychosocial well-being and the superior functional and aesthetic outcomes achieved with FT, for select patients, the benefits of the procedure might outweigh the risks.

Despite FT’s encouraging early functional and psychological outcomes, ethical concerns about the procedure remain. Understanding of the long-term psychosocial effects of FT is limited [76, 93-96], and additional data are needed to better evaluate the risk-benefit ratio of the procedure. There are also potential issues of consent, given that face transplant recipients are such a vulnerable patient population. Furthermore, while still technically an experimental procedure, FT is unique, from a research ethics perspective, in that “withdrawal” from any trial is essentially impossible. Future research should focus on identifying emotional and psychological factors that correlate with better psychosocial outcomes. Complementing substantial psychological research on the qualitative outcomes of FT, recent cognitive neuroscience advances on the neural correlates of self-recognition [97-99] could aid multidisciplinary efforts to better understand how reorganization of brain networks supports self-face recognition and how self-processing supports the gradual development of a new facial identity and its mental representation.


The impact of conventional facial reconstruction on self-concept and its resulting psychosocial effects have been heavily researched, but FT has not been studied in this context in similar depth due to the relative infancy of the field. Facial transplant recipients represent a vulnerable patient population given the significant burden of their pretransplant disfigurements as well as the unique posttransplant psychosocial consequences. While FT raises many ethical considerations, for some patients, it provides an effective reconstructive option that can achieve aesthetic outcomes unattainable through conventional techniques. In their intensive preoperative evaluation and postoperative follow-up, FT teams should focus on identifying suitable candidates and educating them within their available support systems regarding FT’s possible impact on self-concept and its psychosocial consequences.


  1. Baumeister RF, Smart L, Boden JM. Relation of threatened egotism to violence and aggression: the dark side of high self-esteem. In: Baumeister RF, ed. The Self in Social Psychology. Philadelphia, PA: Psychology Press; 1999:247.
  2. Harter S. The Construction of the Self: A Developmental Perspective. New York, NY: Guilford Press; 1999.
  3. Grogan S. Body Image: Understanding Body Dissatisfaction in Men, Women, and Children. London, England: Routledge; 2008.
  4. Cadogan J, Bennun I. Face value: an exploration of the psychological impact of orthognathic surgery. Br J Oral Maxillofac Surg. 2011;49(5):376-380.
  5. Lazaridou-Terzoudi T, Kiyak HA, Moore R, Athanasiou AE, Melsen B. Long-term assessment of psychologic outcomes of orthognathic surgery. J Oral Maxillofac Surg. 2003;61(5):545-552.
  6. Flanary CM, Barnwell GM, VanSickels JE, Littlefield JH, Rugh AL. Impact of orthognathic surgery on normal and abnormal personality dimensions: a 2-year follow-up study of 61 patients. Am J Orthod Dentofacial Orthop. 1990;98(4):313-322.
  7. Yin Z, Wang D, Ma Y, et al. Self-esteem, self-efficacy, and appearance assessment of young female patients undergoing facial cosmetic surgery: a comparative study of the Chinese population. JAMA Facial Plast Surg. 2016;18(1):20-26.
  8. von Soest T, Kvalem IL, Skolleborg KC, Roald HE. Psychosocial changes after cosmetic surgery: a 5-year follow-up study. Plast Reconstr Surg. 2011;128(3):765-772.
  9. Imadojemu S, Sarwer DB, Percec I, et al. Influence of surgical and minimally invasive facial cosmetic procedures on psychosocial outcomes: a systematic review. JAMA Dermatol. 2013;149(11):1325-1333.
  10. Reilly MJ, Tomsic JA, Fernandez SJ, Davison SP. Effect of facial rejuvenation surgery on perceived attractiveness, femininity, and personality. JAMA Facial Plast Surg. 2015;17(3):202-207.
  11. Kiwanuka H, Bueno EM, Diaz-Siso JR, Sisk GC, Lehmann LS, Pomahac B. Evolution of ethical debate on face transplantation. Plast Reconstr Surg. 2013;132(6):1558-1568.
  12. Diaz-Siso JR, Bueno EM, Sisk GC, Marty FM, Pomahac B, Tullius SG. Vascularized composite tissue allotransplantation—state of the art. Clin Transplant. 2013;27(3):330-337.
  13. Siemionow M, Sonmez E. Face as an organ. Ann Plast Surg. 2008;61(3):345-352.
  14. Greaves MW. Physiology of skin. J Invest Dermatol. 1976;67(1):66-69.
  15. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18(1):183-195.
  16. Hornung DE. Nasal anatomy and the sense of smell. Adv Otorhinolaryngol. 2006;63:1-22.
  17. Kawakami T, Ishihara M, Mihara M. Distribution density of intraepidermal nerve fibers in normal human skin. J Dermatol. 2001;28(2):63-70.
  18. Connor NP, Abbs JH. Orofacial proprioception: analyses of cutaneous mechanoreceptor population properties using artificial neural networks. J Commun Disord. 1998;31(6):535-542, 553.
  19. Johansson O, Wang L, Hilliges M, Liang Y. Intraepidermal nerves in human skin: PGP 9.5 immunohistochemistry with special reference to the nerve density in skin from different body regions. J Peripher Nerv Syst. 1999;4(1):43-52.
  20. Schulze E, Witt M, Fink T, Hofer A, Funk RH. Immunohistochemical detection of human skin nerve fibers. Acta Histochem. 1997;99(3):301-309.
  21. Bailey LW, Edwards D. Psychological considerations in maxillofacial prosthetics. J Prosthet Dent. 1975;34(5):533-538.
  22. Allport GW. Becoming: Basic Considerations for Becoming a Person. New Haven, CT: Yale University Press; 1955.
  23. Zebrowitz L. Reading Faces: Window to the Soul? Boulder, CO: Westview Press; 1997.
  24. Zebrowitz L, McDonald S. The impace of litigants’ baby-facedness and attractiveness on adjudications in small claims courts. Law Hum Behav. 1991;15(6):603-623.
  25. Eberhardt JL, Davies PG, Purdie-Vaughns VJ, Johnson SL. Looking deathworthy: perceived stereotypicality of black defendants predicts capital-sentencing outcomes. Psychol Sci. 2006;17(5):383-386.
  26. Todorov A, Mandisodza AN, Goren A, Hall CC. Inferences of competence from faces predict election outcomes. Science. 2005;308(5728):1623-1626.
  27. Jones AL, Kramer SS. Facial cosmetics have little effect on attractiveness judgments compared with identity. Perception. 2015;44(1):79-86.
  28. Samson N, Fink B, Matts PJ. Visible skin condition and perception of human facial appearance. Int J Cosmet Sci. 2010;32(3):167-184.
  29. Zebrowitz LA, Montepare JM. Social psychological face perception: why appearance matters. Soc Personal Psychol Compass. 2008;2(3):1497. Accessed March 1, 2018.
  30. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, Smoot M. Maxims or myths of beauty? A meta-analytic and theoretical review. Psychol Bull. 2000;126(3):390-423.
  31. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg. 2006;118(3):741-756.
  32. Berscheid E, Gangestad S. The social psychological implications of facial physical attractiveness. Clin Plast Surg. 1982;9(3):289-296.
  33. Little AC, Jones BC, DeBruine LM. Facial attractiveness: evolutionary based research. Philos Trans R Soc Lond B Biol Sci. 2011;366(1571):1638-1659.
  34. Kent G, Thompson A. The development and maintenance of shame in disfigurement: implications for treatment. In: Gilbert P, Miles J, eds. Body Shame: Conceptualisation, Research and Treatment. Hove, East Sussex, England: Brunner-Routledge; 2002:103-116.
  35. Rumsey N, Clarke A, White P, Wyn-Williams M, Garlick W. Altered body image: appearance-related concerns of people with visible disfigurement. J Adv Nurs. 2004;48(5):443-453.
  36. Rumsey N, Clarke A, Musa M. Altered body image: the psychosocial needs of patients. Br J Community Nurs. 2002;7(11):563-566.
  37. Rumsey N, Clarke A, White P. Exploring the psychosocial concerns of outpatients with disfiguring conditions. J Wound Care. 2003;12(7):247-252.
  38. Broder H, Strauss RP. Self-concept of early primary school age children with visible or invisible defects. Cleft Palate J. 1989;26(2):114-118.
  39. Crerand CE, Sarwer DB, Kazak AE, Clarke A, Rumsey N. Body image and quality of life in adolescents with craniofacial conditions. Cleft Palate Craniofac J. 2017;54(1):2-12.
  40. Rumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body Image. 2004;1(1):83-97.
  41. Millard T, Richman LC. Different cleft conditions, facial appearance, and speech: relationship to psychological variables. Cleft Palate Craniofac J. 2001;38(1):68-75.
  42. Turner SR, Thomas PW, Dowell T, Rumsey N, Sandy JR. Psychological outcomes amongst cleft patients and their families. Br J Plast Surg. 1997;50(1):1-9.
  43. Herskind A, Christensen K, Juel K, Fogh-Anderson P. Cleft lip: a risk factor for suicide. Paper presented at: 7th International Congress on Cleft Palate and Related Craniofacial Anomalies; November 2, 1993; Broadbeach, Queensland, Australia.
  44. Robinson E. Pyschological research on visible differences in adults. In: Lansdown R, Rumsey N, Bradbury E, Carr A, Partridge J, eds. Visibly Different: Coping with Disfigurement. Oxford, England: Butterworth-Heinemann; 1997:102-111.
  45. Rumsey N. Body image and congenital conditions with visible differences. In: Cash T, Pruzinsky T, eds. Body Image: A Handbook of Theory, Research and Clinical Practice. New York, NY: Guilford; 2002:226-233.
  46. Rumsey N. Optimizing body image in disfiguring congenital conditions. In: Cash T, Pruzinsky T, editors. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York, NY: Guilford; 2002:431-439.
  47. Rozen RD, Ordway DE, Curtis TA, Cantor R. Psychosocial aspects of maxillofacial rehabilitation. I. The effect of primary cancer treatment. J Prosthet Dent. 1972;28(4):423-428.
  48. Knorr NJ, Hoopes JE, Edgerton MT. Psychiatric-surgical approach to adolescent disturbance in self image. Plast Reconstr Surg. 1968;41(3):248-253.
  49. Rumsey N. Psychological aspects of face transplantation: read the small print carefully. Am J Bioeth. 2004;4(3):22-25.
  50. Fingeret MC, Yuan Y, Urbauer D, Weston J, Nipomnick S, Weber R. The nature and extent of body image concerns among surgically treated patients with head and neck cancer. Psychooncology. 2012;21(8):836-844.
  51. Fingeret MC, Vidrine DJ, Reece GP, Gillenwater AM, Gritz ER. Multidimensional analysis of body image concerns among newly diagnosed patients with oral cavity cancer. Head Neck. 2010;32(3):301-309.
  52. Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ. Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support. Head Neck. 2003;25(2):103-112.
  53. Meyerson MD. Resiliency and success in adults with Moebius syndrome. Cleft Palate Craniofac J. 2001;38(3):231-235.
  54. Costa EF, Nogueira TE, de Souza Lima NC, Mendonça EF, Leles CR. A qualitative study of the dimensions of patients’ perceptions of facial disfigurement after head and neck cancer surgery. Spec Care Dentist. 2014;34(3):114-121.
  55. Dropkin MJ. Body image and quality of life after head and neck cancer surgery. Cancer Pract. 1999;7(6):309-313.
  56. Callahan C. Facial disfigurement and sense of self in head and neck cancer. Soc Work Health Care. 2004;40(2):77.
  57. Roing M, Hirsch JM, Holmstrom I, Schuster M. Making new meanings of being in the world after treatment for oral cancer. Qual Health Res. 2009;19(8):1076-1086.
  58. O’Brien K, Roe B, Low C, Deyn L, Rogers SN. An exploration of the perceived changes in intimacy of patients’ relationships following head and neck cancer. J Clin Nurs. 2012;21(17-18):2499-2508.
  59. Khalil W, da Silva HL, Serafim KT, Volpato LE, Casela LF, Aranha AM. Recovering the personal identity of an elderly patient with cleft lip: a case report. Spec Care Dentist. 2012;32(5):218-222.
  60. Hunt OT, Johnston CD, Hepper PG, Burden DJ. The psychosocial impact of orthognathic surgery: a systematic review. Am J Orthod Dentofacial Orthop. 2001;120(5):490-497.
  61. Guzel MZ, Sarac M, Arslan H, Nejat E, Nazan K. A new face by combined surgery for patients with complex dentofacial deformity. Aesthetic Plast Surg. 2007;31(1):32-41.
  62. Cadogan, Bennun, 379.
  63. van Steenbergen E, Litt MD, Nanda R. Presurgical satisfaction with facial appearance in orthognathic surgery patients. Am J Orthod Dentofacial Orthop. 1996;109(6):653-659.
  64. Slavin B, Beer J. Facial identity and self-perception: an examination of psychosocial outcomes in cosmetic surgery patients. J Drugs Dermatol. 2017;16(6):617-620.
  65. Brodsky L. Identity change as a consequence of oral surgery. Aesthetic Plast Surg. 1978;2(1):303-310.
  66. Frost V, Peterson G. Psychological aspects of orthognathic surgery: how people respond to facial change. Oral Surg Oral Med Oral Pathol. 1991;71(5):538-542.
  67. Kiyak HA, Hohl T, West RA, McNeill RW. Psychologic changes in orthognathic surgery patients: a 24-month follow up. J Oral Maxillofac Surg. 1984;42(8):506-512.
  68. Pomahac B, Nowinski D, Diaz-Siso JR, et al. Face transplantation. Curr Probl Surg. 2011;48(5):293-357.
  69. Hui-Chou HG, Nam AJ, Rodriguez ED. Clinical facial composite tissue allotransplantation: a review of the first four global experiences and future implications. Plast Reconstr Surg. 2010;125(2):538-546.
  70. Cordeiro PG, Santamaria E. Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg. 1999;103(7):1850-1856.
  71. Furuta S, Sakaguchi Y, Iwasawa M, Kurita H, Minemura T. Reconstruction of the lips, oral commissure, and full-thickness cheek with a composite radial forearm palmaris longus free flap. Ann Plast Surg. 1994;33(5):544-547.
  72. Pomahac B, Pribaz J, Eriksson E, et al. Restoration of facial form and function after severe disfigurement from burn injury by a composite facial allograft. Am J Transplant. 2011;11(2):386-393.
  73. Devauchelle B, Badet L, Lengele B, et al. First human face allograft: early report. Lancet. 2006;368(9531):203-209.
  74. Siemionow M. The decade of face transplant outcomes. J Mater Sci Mater Med. 2017;28(5):64. doi:10.1007/s10856-017-5873-z.
  75. Siemionow M, Papay F, Alam D, et al. Near-total human face transplantation for a severely disfigured patient in the USA. Lancet. 2009;374(9685):203-209.
  76. Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: the first 9 years. Lancet. 2014;384(9960):2153-2163.
  77. Dorafshar AH, Bojovic B, Christy MR, et al. Total face, double jaw, and tongue transplantation: an evolutionary concept. Plast Reconstr Surg. 2013;131(2):241-251.
  78. Sosin M, Ceradini DJ, Levine JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg. 2016;138(1):205-219.
  79. Agich GJ, Siemionow M. Facing the ethical questions in facial transplantation. Am J Bioeth. 2004;4(3):25-27.
  80. Agich GJ, Siemionow M. Until they have faces: the ethics of facial allograft transplantation. J Med Ethics. 2005;31(12):707-709.
  81. Baylis F. A face is not just like a hand: pace Barker. Am J Bioeth. 2004;4(3):30-32.
  82. Canto-Sperber M, Deschamps C, Dien, MJ, Michaud J, Pellerin D; National Consultative Ethics Committee for Health and Life Sciences. Opinion no. 82: composite tissue allotransplantation (CTA) of the face (full or partial facial transplant). Published February 6, 2004. Accessed February 22, 2018.
  83. Morris P, Bradley A, Doyal L, et al. Face transplantation: a review of the technical, immunological, psychological and clinical issues with recommendations for good practice. Transplantation. 2007;83(2):109-128.
  84. Robertson JA. Face transplants: enriching the debate. Am J Bioeth. 2004;4(3):32-33.
  85. Wiggins OP, Barker JH, Martinez S, et al. On the ethics of facial transplantation research. Am J Bioeth. 2004;4(3):1-12.
  86. Furr LA, Wiggins O, Cunningham M, et al. Psychosocial implications of disfigurement and the future of human face transplantation. Plast Reconstr Surg. 2007;120(2):559-565.
  87. Morris PJ, Bradley JA, Doyal L, et al. Facial transplantation: a working party report from the Royal College of Surgeons of England. Transplantation. 2004;77(3):330-338.
  88. Soni CV, Barker JH, Pushpakumar SB, et al. Psychosocial considerations in facial transplantation. Burns. 2010;36(7):959-964.
  89. Siemionow M, Agaoglu G. The issue of “facial appearance and identity transfer” after mock transplantation: a cadaver study in preparation for facial allograft transplantation in humans. J Reconstr Microsurg. 2006;22(5):329-334.
  90. Swindell JS. Facial allograft transplantation, personal identity and subjectivity. J Med Ethics. 2007;33(8):449-453.
  91. Pomahac B, Aflaki P, Nelson C, Balas B. Evaluation of appearance transfer and persistence in central face transplantation: a computer simulation analysis. J Plast Reconstr Aesthet Surg. 2010;63(5):733-738.
  92. Chandawarkar AA, Diaz-Siso JR, Bueno EM, et al. Facial appearance transfer and persistence after three-dimensional virtual face transplantation. Plast Reconstr Surg. 2013;132(4):957-966.
  93. Petruzzo P, Testelin S, Kanitakis J, et al. First human face transplantation: 5 years outcomes. Transplantation. 2012;93(2):236-240.
  94. Roche NA, Blondeel PN, Vermeersch HF, et al. Long-term multifunctional outcome and risks of face vascularized composite allotransplantation. J Craniofac Surg. 2015;26(7):2038-2046.
  95. Chang G, Pomahac B. Psychosocial changes 6 months after face transplantation. Psychosomatics. 2013;54(4):367-371.
  96. Lantieri L, Grimbert P, Ortonne N, et al. Face transplant: long-term follow-up and results of a prospective open study. Lancet. 2016;388(10052):1398-1407.
  97. Devue C, Brédart S. The neural correlates of visual self-recognition. Conscious Cogn. 2011;20(1):40-51.
  98. Apps MA, Tajadura-Jiménez A, Sereno M, Blanke O, Tsakiris M. Plasticity in unimodal and multimodal brain areas reflects multisensory changes in self-face identification. Cereb Cortex. 2015;25(1):46-55.
  99. Apps MA, Tajadura-Jiménez A, Turley G, Tsakiris M. The different faces of one’s self: an fMRI study into the recognition of current and past self-facial appearances. Neuroimage. 2012;63(3):1720-1729.

William J. Rifkin is a predoctoral research fellow in the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City, where he is also pursuing his medical degree. His research interests include vascularized composite allotransplantation, facial transplantation, microsurgery, wound healing, and transplantation immunology.

Rami S. Kantar, MD, is a surgery resident and current postdoctoral research fellow in the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City. He is interested in academic and outreach craniofacial reconstructive plastic surgery.

Safi Ali-Khan earned his undergraduate degree in Romance languages from New York University and is now completing his MD at NYU School of Medicine in New York City. His professional interests include plastic and craniofacial surgery, with a special focus on pediatric and transgender populations, as well as medical ethics and the relationships between medicine and identity.

Natalie M. Plana completed her undergraduate studies with a major in natural sciences at Fordham University and is currently pursuing her MD at NYU School of Medicine in New York City. She is also a predoctoral research fellow at the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health, focusing her efforts on facial transplantation, craniofacial surgery, academic issues in medicine, and surgical education and simulation.

J. Rodrigo Diaz-Siso, MD, is a postdoctoral research fellow in the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City. Dr. Diaz-Siso’s clinical interests include craniofacial surgery, microsurgery, and general reconstructive surgery, and his research interests include vascularized composite allotransplantation, facial transplantation, and surgical education.

Manos Tsakiris, PhD, MSc, is a professor of psychology at Royal Holloway, University of London. His interdisciplinary research, based on neuroscientific and psychological experimental paradigms as well as on neurophilosophical approaches to selfhood, focuses on empirically identifying the basic neurocognitive principles governing the sense of agency and body-ownership and the interaction between them.

Eduardo D. Rodriguez, MD, DDS, is the Helen L. Kimmel Professor of Reconstructive Plastic Surgery and chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City. He has performed two full-face and scalp transplantations to date, and his research interests include the technical refinements of facial transplantation as well as ethical aspects of the procedure.

William J. Rifkin and Rami S. Kantar contributed equally to this work.

Ethical Issues in Face Transplantation, May 2010

The Ethics of Face Transplantation, September 2005

Plastic Surgery’s Contributions to Surgical Ethics, April 2018

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.