New study examines ethics of procedure and obtaining patients’ consent

Facial transplantation, a novel procedure where the face of a deceased person is transplanted to a facially disfigured patient, is a controversial topic in the field of plastic surgery. The risks involved can include rejection, infection, cancer, and death. For the first time, a study led by researchers at McGill University, provides evidence that patients with severe facial disfigurement are less likely to appreciate these significant risks, highlighting the importance of informed consent.

Through a rigorously designed study, under the guidance of Dr. Mirko S. Gilardino, Chief of the Division of Plastic and Reconstructive Surgery at McGill University Health Centre, the research team dissected the ethical dilemmas related to this procedure while shedding light on aspects that surgeons need to take into consideration when obtaining consent from patients for this surgery. Their findings were recently published in Annals of Surgery.

Scientific evidence has shown that emotionally laden conditions such as cancer cause significant psychological distress that can, in turn, bias patients’ perception of certain treatments.  However, this has never been shown in the realm of facially disfigured patients.  “What is special about facial transplantation is its association with identity – an added dimension that sets this surgery apart from other procedures,” explains Dr. Hassan ElHawary, a resident physician at McGill’s Division of Plastic and Reconstructive Surgery. “Our paper showed that facial disfigurement alters patients’ perception of facial transplantation.  Our results specifically highlight that patients with facial disfigurement focus less on the potential complications of the surgery and hence are more willing to undertake the risk of undergoing aggressive treatments.”

Dr. Ali Salimi, Dr. Mirko Gilardino and Dr. Hassan ElHawary


A study long in the making
 While pursuing his graduate studies at University College in London, Dr. ElHawary first studied the association between patients’ psychological state and their health outcomes. Subsequently, as a medical student at McGill, he noted significant differences in the perception of medical treatments between patients and healthy people. This sentiment led him to collaborate with Dr. Ali Salimi, a resident physician in the Department of Ophthalmology whose research interests focus on improving surgical outcomes and patient satisfaction.  “Our study demonstrates that the psychological trauma that facially disfigured patients experience can affect how they perceive the potential outcomes of facial transplantation and possibly downplay many of the life-threatening complications associated with it,” says Dr. Salimi. “In other words, under psychological stress, facially disfigured patients are more likely to focus on the positive side of the operation while ignoring its potential complications. This is crucial, as it highlights areas that physicians should focus on when obtaining patients’ informed consent prior to surgery.”

The authors stress that the point of the study was not to advocate for or against this surgery, but rather shed light on the biases in perception that facially disfigured patients might have and therefore set the stage for further improvements in the process of informed consent.  “Facial transplantation is a newer surgical option for facially disfigured patients –  but  as Plastic Surgeons leading this innovation, we must be extremely careful not to let the patients’ strong and understandable motivation for a single procedure “cure” to supercede our current understanding of the realistic functional and aesthetic outcomes of this procedure, and the real risks and complications,” says Dr. Gilardino. “The fatality rate or risk of serious complications such as transplant loss are not insignificant at this time, as demonstrated in the literature. This should improve over time, but we must advance this treatment ethically and ensure our patients clearly understand the current state of knowledge, realistic outcomes and risks.”

Helping to ensure patients are properly informed

The authors believe this study represents a stepping-stone in the continuously improving process of informed consent and will help to ensure that patients truly understand the benefits and risks of any surgery before consenting to undergoing the operation.  They believe that the next step is to assess the implication of various novel adjuncts to the informed consent process for psychologically traumatized patients, for example staged consent where informed consent is taken over several days or even weeks to ensure patients truly understand the risks and benefits of the proposed treatment. Additional steps could include showing potential face transplant recipients video of results of previously transplanted patients, demonstrating the dynamic and functional outcomes that can be expected.

“We believe that the medical community has the responsibility to engage in this discussion more thoroughly in order to provide the most optimal and ethical care, not only for facially disfigured patients, but for all patients experiencing psychological stress,” says Dr. ElHawary.


“Ethics of Facial Transplantation: The Effect of Psychological Trauma Associated With Facial Disfigurement on Risk Acceptance and Decision Making,” by H. ElHawary, A. Salimi and M. Gilardino was published in the Annals of Surgery, on July 7, 2020. DOI: 1097/SLA.0000000000004156

October 16, 2020