The importance of being someone else: the duplicity paradox

Each of us has heaven and hell in him”

― Oscar Wilde, The Picture of Dorian Gray

There you are, in front of the mirror. It’s the end of a day like any other. Maybe you are too tired to be rational. Half-closed eyes. Your reflection looks like a faded photograph. And yet, despite being overrun by tiredness, you can still catch a glimpse of yourself. Like it happened yesterday and any other day of your life until this one. You never really thought about it, but your face has something unique, irreplaceable. Never mind if stress or junk food are consuming the good looks you had in your 20s, some part of you is still there, unchanged. What would happen if tomorrow everything was different, if that reassuring self-feeling suddenly vanished?

Nine years from the first partial face transplant, performed in France in 2005, the prestigious medical journal The Lancet published a review based on 28 pioneer surgical interventions performed throughout the world on severely disfigured individuals. The face transplant, as opposed to other procedures defined “life-saving”, is put in a rather different, “life-changing”, context, and subject to considerations of ethical nature. Otherwise healthy individuals are subject to an intervention that will lead them to potentially lifelong immunosuppression therapy, with chance of complications including infections, cancer, graft loss, and death. Nevertheless, the significant improvement in terms of quality of life and body image represents per se a sufficient reason for choosing this option in accurately selected individuals.

Stories of common people

While the concept of people changing their own faces is usually associated with science fiction (Vanilla Sky, Face/Off), the stories of real cases are those of common men and women who had to deal with a terrible change in their lives. The first partial face transplant was conducted in 2005 on a 38 year old French woman, Isabelle Dinoire, who had received cheek, nose, lips and chin injuries following a dog attack. The first total transplant, however, took place in 2010 in the Vall d’Hebron University Hospital of Barcelona. The 30 year old Spanish man submitted to this reconstructive intervention had sustained extended damage after a car accident happened 5 years earlier. In the list of 28 patients who received a transplant, the most frequent causes were represented by burns, traumas, animal bites and neurofibromatosis.

A difficult path

One of the most serious consequences of a facial transplant is skin rejection. All subjects submitted to facial transplantation presented an acute rejection episode within one year of the procedure, usually well controlled with corticosteroids. Additional challenging issues were represented by the restoration of normal facial sensation and motor function. Thermal and light touch sensation recovery usually starts after a few weeks from the procedure. The motor function recovery, in which the nerve coaptation plays a crucial role, appear to be slower than the sensory restoration. The recovery of facial movement and functions (such as smiling, drinking, eating, and speaking) is therefore more complex and requires longer times (6-8 months).

Living with a new face

To accept a new face, and with it the dilemma of bringing on oneself someone else’s traits, is one of the aspects most feared by people undergoing an intervention of face transplant. However, in terms of psychological outcomes, results demonstrate that patients generally show a better quality of life. The percentage of depression is significantly reduced and this is accompanied by an improved self-awareness and greater social interaction. In several cases the patients went back to work a few months after the procedure.

Unhappy about our own body

The refusal of someone’s own image due to physical defects deemed unacceptable is not just a modern stereotype. In the bible of modern psychiatry (DSM 5) there exists a section dedicated to the body dysmorphic disorder, a condition related to the way in which people perceive their own physical defects (real or imaginary). Such a condition can have a profound impact on social life and work environment. In addition, a recently added diagnostic criterion describes repetitive behaviours or mental acts in response to preoccupation with perceived defects or flaws in physical appearance. The importance of prominent appearance-related compulsive behaviours has been suggested by the frequent observation of this symptom in medical literature, and highlights the potentially severe implications of the disorder.

Who really are we?

The impressive milestones reached in the field of transplant surgery show us that becoming someone else is no longer a distant possibility. Changing our own image mostly means changing our lives, and represents one of the popular trends of our time. Every day countless people choose to change their body chasing an often unreachable ideal of perfection, sometimes overlooking a hazy, but always present, perception of self. Like modern Dorian Grays, perhaps one day we will walk the earth forgetful of who we really are, in a complex duplicity of existence. Only to find out, eventually, that what lies inside is not so easy to hide.

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