Face transplants have been given the go-ahead by the Royal College of Surgeons, but doubts remain over how safe, effective and appropriate such operations are.

In a new report, a working party from the RCS warned today that there is a substantial risk of the new face failing within five years, and a lifetime on anti-rejection drugs would multiply the recipient’s risks of getting cancer.

While the surgical techniques are well understood and not new, the psychological effects on the donor, the recipient, and their families are unknown territory, the report says, and will require far more intensive follow-up than has ever been attempted before for organ transplants.

Despite these reservations, the working party chaired by the transplant surgeon Sir Peter Morris believes that face transplants should go ahead, so long as 15 conditions it lays out are met.

Martin Milling, a plastic surgeon and a member of the working party, said: "The patients will be the pioneers as much as the surgeons. That includes the donors, the recipients, and their families - a very large number of people. The duty of care to these pioneers can’t be exaggerated."

Peter Butler, the surgeon who is already planning what might be the world's first full face transplant at the Royal Free Hospital in Hampstead, north London, welcomed the report.

"It is a good document and it reflects exactly the way we have been approaching our research, moving forward cautiously and with full knowledge" he said.

The report has been sent to the Royal Free and Sir Peter said that he hoped it would be carefully read and that the hospital would have already met most of the requirements laid out in it. "I can’t say if it does because I haven’t seen the Royal Free’s protocol," he said. "But I would hope it does."

Since the RCS's first report on the subject three years ago, which said that face transplants were too risky, there had been 24 hand and forearm transplants, a partial face transplant in France, and continued research in animals, which had changed their minds, he said.

The major reservations that remain include the risk of acute or chronic rejection. The skin is more prone to rejection than other organs, up to half of which show evidence of the process happening within five years.

In the French patient, Isabelle Dinoire, there were two episodes of early acute rejection which were controlled by "quite massive" doses of immunosuppressive drugs, Sir Peter said.

If the face were rejected, said Professor Nicola Rumsey, a psychologist specialising in research into appearance and a member of the working party, the symptoms would be a loss of mobility and the ability to express emotion.

"The fear of losing the face completely would be extremely damaging, psychologically", she said. "A repeat transplant is not very likely, so a patient would have to go back to a traditional reconstructive procedure.
"Having to go back to square one, or square minus one, would be horrible."

Other long-term risks are posed by immunosuppressive drugs which make all kinds of infections more likely, and multiply cancer risks by a factor of two to four. Compared with these risks, the actual surgical challenge is far less - the techniques have existed for 30 years, Sir Peter said.

The disfigurement charity, Changing Faces, warmly welcomed the report. James Partridge, the charity's CEO who was himself severely disfigured in a car fire as an 18-year-old, said: "By recommending 15 minimum requirements to protect patients throughout the procedure and in the long-term, whether it is successful or fails, the Royal College has rightly made the well-being of the patient its primary concern.

"Changing Faces hopes that the Royal Free Hospital’s Research Ethics Committee will review its decision to give the go-ahead for a full face transplant research project to ensure that the Royal College’s minimum requirements are fully met."

The 15 requirements cover the selection of patients, the technical skill of the surgical team, the provision of adequate and unbiased information to patients - including about how little is known about some of the risks - the provision of long-term psychological support and a guarantee that funds will be available to sustain it, and a properly-constituted ethical approval team to vet all applications for face transplants.

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