The development of organ transplantation programmes has had an important effect on the research for the human psychological response and adaptation in recipients. It has been traditionally accepted that organ transplantation can produce a series of stressing factors and may trigger a change in the psychosocial adaptation. They include:

When we consider face transplantation separately, all these fears, guilt feelings, anxiety, etc. are amplified (Table 4.2). Reasons for this behaviour include questions of identity and communication, personal psychological adaptation to deformity and support.

Our face is extremely relevant for the development and maintenance of our identity. It helps us and others to understand ourselves, our whereabouts, who we are and our prospects. If we are deprived of a face, we can no longer recognise ourselves; our body image disaggregates, causing a profound existential crisis. We may follow, thus, that introducing a new face (that of the others, the donor) may bring problems even worse than those pre-existing, especially in the area of identity.

Conscious and unconscious face expressions are necessary to relate and communicate with the rest of the world. One-third of the communication with other people is non-verbal, depending on face expressions. The coordination of face muscles, nerves and tissues is essential for this part of human interaction. There are different pathways that connect face structures and cerebral functioning, recognising our status of expression, i.e. smiling signals neuronal connections that in turn produce a feeling of well-being. More research will be necessary to understand how the face mimic influences our psychological status.

It is well supported in literature that psychological stress is not necessarily proportional to the severity of face deformity. Some patients function well with severe devastating injuries, whereas others show important stress and anxiety with small scars and minimal deformities. When we consider trauma patients, it is not uncommon to diagnose important levels of stress and anxiety, although it is not per se a formal indication for transplantation. The same patient may show excellent psychosocial adaptation in the rehabilitation and chronic phase. However, we may not assume, though, that time is a good remedy for face deformity adaptation. Patients that adapt well have in common a high threshold of self-esteem, good family and social support, excellent communication skills and a sense that the deprivation of a normal face should not impede happiness and good quality of life. On the other hand, patients that show difficulties in social adaptation believe that physical appearance is of paramount importance for well-being and success. They show important levels of anxiety, depression and psychosocial difficulties, searching surgery to improve physical appearance and improve their social interaction and sense of well-being. In general terms, this group of patients is psychologically very vulnerable, although they show a high motivation for surgery and compliance. Still, non-realistic expectations regarding surgical outcomes may be present. They require strong team support since they are very vulnerable during the postoperative period, specially regarding uncertainty of final outcomes and treatment side effects. When we deal with this type of patients, it is imperative to follow them closely. We understand that some of our treatments do not offer a complete resolution of symptoms, and secondary deformities may be present. It is also uncertain whether the salutary effects of face transplants, particularly in the sphere of psychosocial improvement and social interaction, will be maintained over time.

A good psychological support is essential throughout the whole process of face transplantation for recipients, family members and donor’s family and relatives. Specialised professionals well versed in face deformity and solid organ transplantation should perform it. Psychiatrists and psychologists are core members of the face transplant team, dealing with:

Patients that go through a programme of face transplantation experience three different phases (Table 4.5). Firstly, patients are evaluated; an indication is performed and will go through a long time waiting for a donor search. As soon as the face transplant is a reality, patients are admitted to the hospital and have a hospital stay that may last a few weeks depending on the complexity of the transplants and the potential complications. During this phase the patient is coached and supported, creating a protective environment. Finally, the recipient is discharged from hospital; this final phase may produce new feelings of stress and anxiety. Patients will return to their normal environment and family and social circle; they will be exposed to family and friends’ reactions, both to their new appearance and their new communication skills. This uncertainty will mark also the future success of the face transplant. It will be necessary to have a constant support for the patient and family. The patient needs to understand that the team’s support is ready and can be obtained in a rapid manner anytime during this period. It is not only a question of the new face appearance acceptance, but also to face and learn strategies to control emotions and the new relationship with others. Face sensibility and function will improve constantly during the first year, changing gradually the communication skills and the way the patient relates with people. If mass media has been involved or press releases performed, the patient may be recognised by strangers and attract attention. This situation can be positive for some patients, although may be distressing for others, requiring attention and modulation.