The Ethics of Facial Allotransplantation

A Systematic Review

Xiangxia Liu, MD, PhD; Sarah Langsdon, MD; Wesley Holloway; Shuqia Xu, MD; Qing Tang, MD; Yangbin Xu, MD, PhD; Sai Ram Velamuri, MD; William Hickerson, MD


Plast Reconstr Surg Glob Open. 2019;7(10):e2425 

In This Article

Abstract and Introduction


Background: Currently, there are more than 40 cases of facial allotransplantation performed by 13 different groups in 10 countries. Although it has become a potential option to reconstruct and restore the function and appearance of severely facially disfigured individuals, the ethical concerns of facial allotransplantation remain unsolved. We conducted a systematic review to better understand the ethical concerns on facial allotransplantation and the changing trends of the ethical debate over time.

Methods: A systematic review of 3 databases was performed to identify articles related to ethical topics on facial allotransplantation. The inclusion criteria were peer-reviewed articles written since 1995 on the topics of ethics and facial allotransplantation in English, French, and Chinese languages. The ethical concerns extracted from the included articles were categorized into 4 core principles of ethics: autonomy, beneficence, nonmaleficence, and justice. The different themes under these 4 principles were extracted and subgrouped. The positions of the included articles were collected. Joinpoint regression was applied to compare the frequency of themes and positions by publication year. We presented the main topics on ethical concerns and the changing trends in ethical themes and principles of facial allotransplantation.

Results: There were 889 articles identified initially. After excluding 265 duplicated articles, 624 articles were included for title/abstract review process, and 148 articles were included in final data analysis. The publication year was from 2002 to 2018 with 136 articles in English, 11 in French, and 1 in Chinese. The most addressed principle was nonmaleficence (117/148, 79.1%), followed by beneficence (116/148, 78.4%), justice (103/148, 69.6%), and autonomy (86/148, 58.1%). The themes on immunosuppression/rejection, quality of life, and identity were the top 3 addressed ethical concerns. Twelve of 13 most addressed ethical themes demonstrated a decreasing trend after 2004. The themes of identity under beneficence showed a significant decrease after 2004. Ethical concerns on the cost/financial topic were the only one showing consistently increase trends from 2002 to 2018. There was a significant increase of the papers in favor of facial allotransplantation procedure comparing to those were against or neutral before and after 2008.

Conclusions: More and more articles support facial allotransplantation as a feasible option to reconstruct and restore the function and appearance of severely facially disfigured individuals. The requirement of life-long immunosuppression therapy, quality of life, and identity center the ethical debates. Supported by favorable short-term results, 12 of 13 most addressed ethical concerns have trended down. The theme of cost/financial topic becomes more frequently addressed in recent years.


The human face is a complex 3-dimensional structure that is central to human identity.[1,2] Facial appearance identifies our gender, age, and ethnicity; it conveys our emotions and allows us to interact with our surrounding world.[3] When the essential features and functions of the human face are damaged, it has not only physical but emotional and psychological consequences. With advancing technological and available immunosuppressive regimens, facial allotransplantation for severely disfigured patient became possible. The ethics on facial allotransplantation has been at the forefront of the ongoing debate even before the world's first successful case in France in 2005. Within the past 13 years, the field has expanded remarkably. More than 40 cases were reported from 10 different countries, including France, China, United States, Spain, Belgium, Turkey, Poland, Russia, Finland, and Canada.[4–6]

In 2016, Isabelle Dinoire, the world's first face transplant patient, died after a long illness, adding one more to a total 7 deaths so far.[7] Like her initial introduction into the spotlight, her death perpetuated the ongoing debate. In early 2018, a French team performed the second facial allotransplantation on a patient who lost his graft due to chronic rejection.[8] These newly monumental developments in facial allotransplantation add more valuable data to the ethical debate and could shift the trends potentially. In this article, we performed a systematic review of the ethics on facial allotransplantation, collected the data of 4 core principles of bioethics: autonomy, beneficence, nonmaleficence, and justice, the authors' positions on facial allotransplantation, and presented the changing trends in ethical themes, principles, and positions of facial allotransplantation over time.