A pioneering Cork-born doctor is leading the team that has been given the green light for the world's first full facial transplant. Peter Butler tells Ben Quinnwhat drives him
It was an encounter with a teenager whose face had been horrifically burned that was to be a turning point in the life of Peter Butler. As a junior doctor in Dublin, Butler met a 19-year-old man who had lost his nose and ears and was afraid to leave his house because of the reactions of people in the street. "It was a humiliation, really, because I suddenly realised how limited we were with regards to our surgical ability to treat somebody," says Butler. Challenging those limitations became his life's work, and now he is on the verge of a medical landmark: completing the world's first full face transplant.
Just over two weeks have passed since the media-friendly Cork-born surgeon received the green light to carry out the pioneering procedure, and in a cafe near the Royal Free Hospital, in north London, he is speaking with infectious enthusiasm about the road ahead.
He describes the idea of transplanting a "new" face on to a patient in need of one as "a necessity". "To me it's very pragmatic," he says. "It's actually a solution to their problem right now. Some people come up to me and say it's not a necessity, that it's actually dangerous and should not happen, but because I deal with these patients I know what a terrible life they have, so surely they should be the ones that decide whether this is a necessity for them, and not somebody else."
Facial disfigurement, he says, can isolate people from society, forcing them to lead, in Butler's words, twilight lives. "They come out in the evening to go to the corner store - not to the supermarket, because they get stared at there. They sometimes have substance-abuse problems, not just alcoholism, and so they feel that their life isn't really a life."
The issue of face transplants has been in the public eye since French surgeons made history last year by carrying out the first partial face transplant, on Isabelle Dinoire, who had her chin, her mouth and part of her nose replaced after she had been mauled by her dog. The operation prompted debate about the ethics of face transplants. Jean-Michel Dubernard, the French surgeon who performed Dinoire's transplant, said psychological factors were a serious issue for many patients. "Psychological consequences of hand and face allografts show that it is not so easy to use and see permanently a dead person's hands, nor is it easy to look in a mirror to see a dead person's face," he wrote.
Butler, who heads a 30-strong facial-transplant-surgery team at the Royal Free, has become the UK's best-known advocate of facial surgery. The tall and broad-shouldered 44-year-old has been described as charismatic and strikingly handsome, and his profile is only heightened by the fact that his wife, Annabel, with whom he has four children, is the daughter of Michael Heseltine, the former deputy leader of the Conservative Party.
Although Butler has had to get used to a certain amount of media interest in his life, he appears bemused by the continuing interest in him, which he has come to view as an ideal opportunity to advocate the case for facial transplantation. "The reason I talk is to try to educate. What someone writes will potentially change someone's opinions, and that is why I do lots of public- engagement exercises," he says.
From a family of four children, Butler may always have been destined for a career concerned with the health of others. His mother and both of her parents were pharmacists, and his father was a professor of dentistry at Trinity College in Dublin. As his career developed, Butler concentrated on looking for "solutions" to the problem of facial disfigurement, eventually discovering them in transplantation and tissue engineering, or the growing of tissues.
"Tissue engineering at that stage was an emerging field. It had not really been done very much, and transplantation was definitely the most unsexy subject in plastic surgery, because everyone thought that it would never happen."
Techniques were, however, being pioneered in the US, where Butler was to take on a research fellowship in plastic surgery at Massachusetts General Hospital, which is part of Harvard Medical School. "It was like a breath of fresh air," he says. "There was a can-do attitude, and they would embrace you and push you if you had ideas."
He completed his training in London, where he is now a consultant plastic surgeon and senior lecturer at the Royal Free and University College hospitals. The last formal opposition to his pioneering transplant was removed when the Royal College of Surgeons issued a cautious go-ahead, laying down a list of 15 minimal requirements before the surgery can happen. Thirty-eight people wishing to undergo the operation have approached his team so far, and Butler is now looking towards drawing up a shortlist of candidates who meet the selection criteria. Eventually, and probably after many months, four patients will be selected, to be operated on at six-month intervals.
The operation will involve removing skin, fat, blood vessels, veins and arteries from a deceased donor's face, which will then be reconnected to the recipient. Afterwards, the patient will have to take immunosuppressant drugs to stop his or her body from rejecting the new tissue.
Such progress has not come cheap. Butler has invested many thousands of pounds in the project, although he remains coy about just how much. "I haven't a clue, and I also wouldn't say because my wife would murder me," he says, laughing. "I started this research 14 years ago, and part of it involves my flying back and forth to the United States at different intervals, looking at different research projects, funding research projects, funding exhibitions we have done, funding lab resources, funding salaries. I wouldn't really want to know, because it might shock me. Fourteen years is a long time."
The progress that has been made has come about despite some stiff opposition to face transplants from different and disparate quarters, including Changing Faces, a leading British charity representing people with disfigurements.
Why does he think the subject conjures up so much passion? "It comes down to the fact that there are people with a definite viewpoint that this is negative, that this is not a good idea. But there are very few people in the world who would know every single aspect of facial transplantation and the issues around it, the risks and benefits. Whether their opinion is valid only time will tell, really. It is surprising to me that some of these people don't realise that I have thought about this for a long time."
Butler claims that he has received many letters of support - and little or no hate mail. As for being Irish in Britain, and working in a profession where some might suspect the heavy hand of an establishment, he says he has never felt like an outsider. Indeed, he goes so far as to describe it as an advantage, adding: "I can be myself. Being Irish, I can be much more emotional. The one thing about English society is that it is very accepting. I am always amazed at how accepting it is. You can achieve anything you want to achieve."
Could he have achieved the same had he stayed in Ireland? "That's a good question. Unfortunately, I left Ireland with all these research ideas because I couldn't get support for them and also because the infrastructure really wasn't there to support it," he says. "Going to where I did provided me with access to a concentration of really phenomenal people, and the can-do attitude."
It now appears that a team in Cleveland might perform a full facial transplant before Butler's team, although he is at pains to reject any notion that he is involved in a competition or race. He paints a picture of researchers and surgeons in the UK, US, France and China all working towards the same goal, collegiately. "In the end we might even be fifth or sixth or seventh, and that might make it easier for us to do it, because the patient will be less nervous. I know that there are a lot of patients whom I have talked to who actually don't want be first or second or third but happily would be fourth or fifth, because they want to see if it works and what the issues are. Also, they don't want the press to be involved."
When that medical landmark is reached, surgical pioneers will look towards the next frontier: the growing of new cartilage and skin. In effect, patients in decades to come could grow new faces. "Why not?" says Butler. "I'm not a fortune teller, but I am pragmatic. I'll take on any type of technology that will potentially make patients' lives better."