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

Learning Objectives:
At the end of this activity, you will be able to:
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct.
2. Evaluate the usefulness of this information for his or her practice, teaching, or conduct.
3. Decide whether and when to apply the new information to his or her practice, teaching, or conduct.
1 Credit CME

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Abstract

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.

Introduction

“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 documented2,3, and thus facial disfigurement can have profound psychosocial implications. Substantial research has described the benefits of traditional facial reconstruction with respect to self-concept410; 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 procedure11. 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 malignancy12. 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 functions13. Facial skin acts as an anatomic barrier, retaining body water and regulating heat14. Specialized structures perform distinct functions: the eyelids maintain ocular lubrication15; the nasal airway conditions and filters inspired air13,16; and the lips form a tight seal around the mouth, allowing consumption of food or drink16 and normal speech13. The face is also an important sensory organ, containing the highest density of free nerve endings in the body17,18. 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 roles19,20.

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 other13 and the primary mode of self-expression, emotional expression, and social interaction21. The intimate relationship between self-concept and appearance is also well documented2,3, and the face is a major component of body image and self-worth22. 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 appearance23, as are criminal justice verdicts24,25 and congressional elections26. Facial features and skin qualities are major determinants of physical attractiveness and mate selection13,27,28. Unsurprisingly, attractiveness is the quality that has received the greatest focus in facial appearance research29. Those with attractive faces have proven social advantages and are perceived as more popular, assertive, and self-confident13,2933. 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 intertwined34. Quiz Ref IDWhether congenital or acquired, facial disfigurement can have profound psychosocial implications, including altered body image, reduced quality of life, and poor self-esteem3538. The most frequently reported difficulties relate to negative self-perception and impaired social interaction39. 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 disfigurement40. Cleft lip studies have shown that affected children are at greater risk for anxiety, general unhappiness, and self-doubt in interpersonal relationships41 and that many affected adolescents believe their self-confidence remains affected by their disfigurement42. Perhaps most alarmingly, one study showed that the suicide rate among Danish adults with clefts was double that of the unaffected population43.

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 relationships44. 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 behavior45,46. 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 problems47. Younger patients seem to adapt better to facial disfigurement, especially if it occurs prior to or during puberty48. Quiz Ref IDAdults 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 society49.Quiz Ref IDInterestingly, 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 distress37,5052.

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 factors53. 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 surgery4. 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-conflict410.

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 recovery54. 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 process54. After head or neck cancer surgery, patients must undergo a process of body image reintegration55, which entails “reorganizing perception of self into a once again acceptable unity”56. These findings have been corroborated by multiple groups57,58 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 identity59. Similarly, orthognathic surgery yields consistent improvements in patient quality of life through restoration of physical facial identity4,60,61.

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-concept4. Patients describe this process as “confusing, frightening, and disorienting” but note that a strong support system can ease the challenge62. However, patients undergoing major combined orthognathic and cosmetic procedures report that even close friends and family members initially struggle with adapting to their new appearance61.

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 features63. 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-perceptions64. Studies have also shown that there is an adaptation period prior to patients' ultimate acceptance of their new facial appearance65. Frost et al. describe how patients undergoing orthognathic surgery report temporary depression and loss of self-esteem as they adapt to their new facial appearance66, but Kiyak et al. report that these alterations in self-esteem and body image stabilize after a period of approximately two years67. 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 impairments68. 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 handicaps68. 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 nose69. 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 color70,77. Reconstruction of the nose and adjacent facial subunits can also yield disappointing aesthetic results71. 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 space68.

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 common72,73, and motor recovery can restore many “social” facial functions74 and the ability to breath, eat, drink, and speak intelligibly75,76. 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 reconstructed77,78.

Nonetheless, over the last decade, various groups have scrutinized and explored the ethical7985 and psychosocial11,49,82,83,8688 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-recognition11,49,82,83,8789 and is a critical mediator of self-expression and interactions with others82,90. Advocating that the face is as an irreplaceable symbolic entity, the Royal College of Surgeons of England87 and the French National Consultative Ethics Committee for Health and Life Sciences82 did not initially support FT. Quiz Ref IDA 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 concern11. 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 donors84. The symbolic significance of the face can create an emotionally charged and complicated situation for donor families, who might ultimately refuse donation for this reason84,90. Quiz Ref IDSome virtual studies suggest that donor-to-recipient transfer of facial appearance is minimal in two-91 and three-dimensional92 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 issues85,88,90. Acceptance can also lead to greater participation in postoperative care and compliance82,90. Interestingly, recipient personality traits appear to play an important role in acceptance of the transplanted face. Quiz Ref IDFT 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-concept86,88. Proponents of FT argue that for these psychologically prepared recipients, the procedure allows the regaining of their lost identities89,90. 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 transplantation88.

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 survival11. 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 limited76,9396, 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-recognition9799 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.

Conclusion

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.

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Article Information

AMA Journal of Ethics

AMA J Ethics. 2018;20(4):309-323.

AMA CME Accreditation Information

The American Medical Association designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

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

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

Author Information:

  • 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.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

References
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.Google Scholar
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
13.
Siemionow  M, Sonmez  E.  Face as an organ.  Ann Plast Surg. 2008;61(3):345–352.Google ScholarCrossref
14.
Greaves  MW.  Physiology of skin.  J Invest Dermatol. 1976;67(1):66–69.Google ScholarCrossref
15.
Jelks  GW, Jelks  EB.  The influence of orbital and eyelid anatomy on the palpebral aperture.  Clin Plast Surg. 1991;18(1):183–195.Google Scholar
16.
Hornung  DE.  Nasal anatomy and the sense of smell.  Adv Otorhinolaryngol. 2006;63:1–22.Google Scholar
17.
Kawakami  T, Ishihara  M, Mihara  M.  Distribution density of intraepidermal nerve fibers in normal human skin.  J Dermatol. 2001;28(2):63–70.Google ScholarCrossref
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.Google ScholarCrossref
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.Google Scholar
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.Google ScholarCrossref
21.
Bailey  LW, Edwards  D.  Psychological considerations in maxillofacial prosthetics.  J Prosthet Dent. 1975;34(5):533–538.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
26.
Todorov  A, Mandisodza  AN, Goren  A, Hall  CC.  Inferences of competence from faces predict election outcomes.  Science. 2005;308(5728):1623–1626.Google ScholarCrossref
27.
Jones  AL, Kramer  SS.  Facial cosmetics have little effect on attractiveness judgments compared with identity.  Perception. 2015;44(1):79–86.Google ScholarCrossref
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.Google ScholarCrossref
29.
Zebrowitz  LA, Montepare  JM.  Social psychological face perception: why appearance matters.  Soc Personal Psychol Compass. 2008;2(3):1497. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811283/. Accessed March 1, 2018.Google ScholarCrossref
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.Google ScholarCrossref
31.
Bashour  M.  History and current concepts in the analysis of facial attractiveness.  Plast Reconstr Surg. 2006;118(3):741–756.Google ScholarCrossref
32.
Berscheid  E, Gangestad  S.  The social psychological implications of facial physical attractiveness.  Clin Plast Surg. 1982;9(3):289–296.Google Scholar
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.Google ScholarCrossref
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.Google Scholar
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.Google ScholarCrossref
36.
Rumsey  N, Clarke  A, Musa  M.  Altered body image: the psychosocial needs of patients.  Br J Community Nurs. 2002;7(11):563–566.Google ScholarCrossref
37.
Rumsey  N, Clarke  A, White  P.  Exploring the psychosocial concerns of outpatients with disfiguring conditions.  J Wound Care. 2003;12(7):247–252.Google ScholarCrossref
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.Google Scholar
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.Google ScholarCrossref
40.
Rumsey  N, Harcourt  D.  Body image and disfigurement: issues and interventions.  Body Image. 2004;1(1):83–97.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google Scholar
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.Google Scholar
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.Google Scholar
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.Google ScholarCrossref
48.
Knorr  NJ, Hoopes  JE, Edgerton  MT.  Psychiatric-surgical approach to adolescent disturbance in self image.  Plast Reconstr Surg. 1968;41(3):248–253.Google ScholarCrossref
49.
Rumsey  N.  Psychological aspects of face transplantation: read the small print carefully.  Am J Bioeth. 2004;4(3):22–25.Google ScholarCrossref
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.Google ScholarCrossref
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.Google Scholar
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.Google ScholarCrossref
53.
Meyerson  MD.  Resiliency and success in adults with Moebius syndrome.  Cleft Palate Craniofac J. 2001;38(3):231–235.Google ScholarCrossref
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.Google ScholarCrossref
55.
Dropkin  MJ.  Body image and quality of life after head and neck cancer surgery.  Cancer Pract. 1999;7(6):309–313.Google ScholarCrossref
56.
Callahan  C.  Facial disfigurement and sense of self in head and neck cancer.  Soc Work Health Care. 2004;40(2):77.Google Scholar
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google Scholar
65.
Brodsky  L.  Identity change as a consequence of oral surgery.  Aesthetic Plast Surg. 1978;2(1):303–310.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
68.
Pomahac  B, Nowinski  D, Diaz-Siso  JR,  et al.  Face transplantation.  Curr Probl Surg. 2011;48(5):293–357.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
73.
Devauchelle  B, Badet  L, Lengele  B,  et al.  First human face allograft: early report.  Lancet. 2006;368(9531):203–209.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
76.
Khalifian  S, Brazio  PS, Mohan  R,  et al.  Facial transplantation: the first 9 years.  Lancet. 2014;384(9960):2153–2163.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
79.
Agich  GJ, Siemionow  M.  Facing the ethical questions in facial transplantation.  Am J Bioeth. 2004;4(3):25–27.Google ScholarCrossref
80.
Agich  GJ, Siemionow  M.  Until they have faces: the ethics of facial allograft transplantation.  J Med Ethics. 2005;31(12):707–709.Google ScholarCrossref
81.
Baylis  F.  A face is not just like a hand: pace Barker.  Am J Bioeth. 2004;4(3):30–32.Google ScholarCrossref
82.
Canto-Sperber  M, Deschamps  C, Dien  MJ, , Michaud  J, Pellerin  D;  National Consultative Ethics Committee for Health and Life Sciences.  Composite tissue allotransplantation (CTA) of the face (full or partial facial transplant). http://www.ccne-ethique.fr/sites/default/files/publications/avis082en.pdf. Published February6 , 2004. Accessed February 22, 2018.Google Scholar
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.Google ScholarCrossref
84.
Robertson  JA.  Face transplants: enriching the debate.  Am J Bioeth. 2004;4(3):32–33.Google ScholarCrossref
85.
Wiggins  OP, Barker  JH, Martinez  S,  et al.  On the ethics of facial transplantation research.  Am J Bioeth. 2004;4(3):1–12.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
88.
Soni  CV, Barker  JH, Pushpakumar  SB,  et al.  Psychosocial considerations in facial transplantation.  Burns. 2010;36(7):959–964.Google ScholarCrossref
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.Google ScholarCrossref
90.
Swindell  JS.  Facial allograft transplantation, personal identity and subjectivity.  J Med Ethics. 2007;33(8):449–453.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref
93.
Petruzzo  P, Testelin  S, Kanitakis  J,  et al.  First human face transplantation: 5 years outcomes.  Transplantation. 2012;93(2):236–240.Google ScholarCrossref
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.Google ScholarCrossref
95.
Chang  G, Pomahac  B.  Psychosocial changes 6 months after face transplantation.  Psychosomatics. 2013;54(4):367–371.Google ScholarCrossref
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.Google ScholarCrossref
97.
Devue  C, Brédart  S.  The neural correlates of visual self-recognition.  Conscious Cogn. 2011;20(1):40–51.Google ScholarCrossref
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.Google ScholarCrossref
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.Google ScholarCrossref

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