Psychological management and body image issues in facial transplantation Simon E. Brill a , Alex Clarke a, * , David M. Veale b , Peter E.M. Butler a a Department of Plastic & Reconstructive Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK b Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK Received 12 April 2005; received in revised form 19 December 2005; accepted 21 December 2005 Abstract Facial transplantation, although controversial, is proposed as a major advance in facial reconstructive surgery, with the first partial transplant having taken place in France in November 2005. Although the psychological impact of facial transplantation will not be understood until several procedures have been carried out, this article examines the psychological issues likely to arise with particular reference to body image. A detailed framework for anticipation and management of psychological change is proposed. Pre-operative preparation must include thorough psychological preparation for the patient and their family. The immediate post- operative period is likely to be challenging, and a detailed management plan is proposed emphasising early return to function; subsequent psychological issues including altered body image, anxiety, shame, depression, communication and behavioural avoidance are discussed and a management strategy based on cognitive behavioural principles is proposed for the first post- operative year. Previous discussion frames psychological outcome in terms of complication and risk, tending to downplay the potential advantages of a successful procedure; the focus of this paper is on ensuring psychological adjustment as an inevitable consequence of change. # 2006 Elsevier B.V. All rights reserved. Keywords: Facial transplantation; Transplantation; Psychology; Body image Background Following reports of successful composite tissue allograft, in particular bilateral hand transplantation (Dubernard et al., 2003), facial allograft (cadaveric whole face transplantation) was proposed as the next logical step in facial reconstructive surgery (Hettiar- atchy & Butler, 2003). The first partial face transplant (of the nose, lips and chin) was carried out by Dubenard and colleagues, in France, in November 2005. As this first patient demonstrates, facial transplantation will be used to alleviate functional impairment, for example, where burns contractures prevent mouth opening or other facial movement, where the eyelids have been lost (leading to corneal ulceration and blindness) or where the nose or ears have been lost. It provides opportunities for functional improvement and improved cosmesis currently impossible with other surgical techniques. The final appearance is likely to be a composite of donor and recipient faces, not identical to either original face but retaining some superficial donor characteristics such as eyebrows (Clarke & Butler, 2005). Like any new radical procedure, face transplantation has excited considerable interest and debate. In order to present the potential risks and benefits of the procedure, www.elsevier.com/locate/bodyimage Body Image 3 (2006) 1–15 * Corresponding author. Tel.: +44 20 7794 0500x3672. E-mail address: alex.clarke@royalfree.nhs.uk (A. Clarke). 1740-1445/$ – see front matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.bodyim.2005.12.002