September 18, 2005 in Nation/World

New chance to face the world

Marilynn Marchione Associated Press
Associated Press photo

Matthew Teffteller, of Walland, Tenn., endured many skin graft operations following a fiery auto accident. But he rejected the idea of a face transplant, partly because of fears the operation would go wrong. “What would you do if you didn’t have a face?” he asked.
(Full-size photo)

the face

Key to identity

Forget fingerprints. Unless you’re a detective, the face is the part of human anatomy that is most important to identity.

Many societies consider it so intimate that it must be veiled. Halloween is scary partly because it is masked.

Expressions like “let’s face it,” “face value,” “losing face” and “saving face” reveal how profoundly this feature is stitched into human personality.

“Our face is the window through which others see and come to know us,” wrote three University of Louisville doctors who have proposed doing face transplants.

All of which makes facial disfigurement so devastating to personality. It can lead to depression and suicide. It can confine the deformed to lives as shut-ins, fearful of the finger-pointing and distress their appearance causes others.

It can even contort someone’s psyche into a criminal state. Fiction gives us the Batman villain Two-Face. Reality gives us Bart Ross, who earlier this year shot himself after killing the husband and mother of a federal judge in Chicago. Ross was despondent over facial disfigurement from cancer treatment.

The depth of emotional scars caused by physical ones is one reason Dr. Joseph Locala, a psychiatrist at the Cleveland Clinic, agreed to be part of a team that hopes to do the world’s first face transplant.

He doesn’t view removing a “diseased” face as removing someone’s identity.

“In a sense, you’re regaining your identity” with a transplant, he said. “If you’re unable to smile, you certainly have lost your identity a long time ago.”

CLEVELAND – In the next few weeks, five men and seven women will secretly visit the Cleveland Clinic to interview for the chance to have a radical operation that’s never been tried anywhere in the world.

They will smile, raise their eyebrows, close their eyes, open their mouths. Dr. Maria Siemionow will study their cheekbones, lips and noses. She will ask what they hope to gain and what they most fear.

Then she will ask, “Are you afraid that you will look like another person?”

Because whoever she chooses will endure the ultimate identity crisis.

Siemionow wants to attempt a face transplant.

This is no extreme TV makeover. It is a medical frontier being explored by a doctor who wants the public to understand what she is trying to do.

It is this: to give people horribly disfigured by burns, accidents or other tragedies a chance at a new life. Today’s best treatments still leave many of them with freakish, scar-tissue masks that don’t look or move like natural skin.

These people already have lost the sense of identity that is linked to the face; the transplant is merely “taking a skin envelope” and slipping their identity inside, Siemionow contends.

Her supporters note her experience, careful planning, the team of experts assembled to help her, and the practice she has done on animals and dozens of cadavers to perfect the technique.

But her critics say the operation is way too risky for something that is not a matter of life or death, as organ transplants are. They paint the frighteningly surreal image of a worst-case scenario: a transplanted face being rejected and sloughing away, leaving the patient worse off than before.

Such qualms recently scuttled face transplant plans in France and England.

Ultimately, it comes to this: a hospital, doctor and patient willing to try it.

The first two are now in place. The third is expected to be shortly.

Serious warnings

The “consent form” says that this surgery is so novel and its risks so unknown that doctors don’t think informed consent is even possible.

Here is what it tells potential patients:

Your face will be removed and replaced with one donated from a cadaver, matched for tissue type, age, sex and skin color. Surgery should last 8 to 10 hours; the hospital stay, 10 to 14 days.

Complications could include infections that turn your new face black and require a second transplant or reconstruction with skin grafts. Drugs to prevent rejection will be needed lifelong, and they raise the risk of kidney damage and cancer.

The clinic will cover costs for the first patient; nothing about others has been decided.

Another form tells donor families that the person receiving the face will not resemble their dead loved one. The recipient should look similar to how he or she did before the injury because the new skin goes on existing bones and muscles, which give a face its shape.

All of the little things that make up facial expression – mannerisms like winking when telling a joke or blushing at a compliment – are hard-wired into the brain and personality, not embedded in the skin.

Some research suggests the end result would be a combination of the two appearances.

Surgeons wished they could have done a transplant six years ago, when a 2-year-old boy attacked by a pit bull dog was brought to the University of Texas in Dallas where Dr. Karol Gutowski was training.

The boy received five skin grafts in a bloody, 28-hour surgery. Muscles from his thigh were moved to around his mouth. Part of his abdomen became the lower part of his face. Two forearm sections became lips and mouth.

“He’ll never be normal,” said Gutowski, now a surgeon at the University of Wisconsin-Madison.

Surviving such wounds can be “life by 1,000 cuts.” Patients endure dozens of operations to graft skin inch by inch from their backs, arms, buttocks and legs.

Relatively simply surgery

A face transplant could be a better solution.

Despite its shock factor, it involves routine microsurgery. One or two pairs of veins and arteries on either side of the face would be connected from the donor tissue to the recipient. About 20 nerve endings would be stitched together to try to restore sensation and movement. Tiny sutures would anchor the new tissue to the recipient’s scalp and neck, and areas around the eyes, nose and mouth.

“For 10 years now, it could have been done,” said Dr. John Barker, director of plastic surgery research at the University of Louisville. Several years ago, these doctors announced their intent to do face transplants, but no hospital has yet agreed.

However, Siemionow had been experimenting on animals. She got clinic approval to try the operation on people and insists she is not competing to do the first case.

“I hope nobody will be frivolous or do things just for fame. We are almost over-cautious,” she said.

Siemionow, 55, went to medical school in Poland, trained in Europe and the United States, and has done thousands of surgeries in nearly 30 years. The success of this one depends on picking the right patient.

She wants a clear-cut first case. No children because risks are too great. No cancer patients because anti-rejection drugs raise the risk of recurrence.

“You want to choose patients who are really disfigured, not someone who has a little scar,” yet with enough healthy skin for traditional grafts if the transplant fails, she said.

Dr. Joseph Locala, a clinic psychiatrist, will decide whether candidates are mentally fit. His chief concern: making sure they realize the risks and are well emotionally.

“I’m looking for a psychologically strong person. We want people who are going to make it through,” he explained.

Dr. James Zins, chairman of plastic surgery, expects to be among the 10 to 12 doctors involved in the transplant and has been screening patients.

“We get some pretty strange calls from people who are really not candidates,” he said.

Questions of ethics

Matthew Teffeteller, who lives south of Knoxville, Tenn., might seem an ideal one. Three years ago, he was burned in a horrific car crash that killed his pregnant wife. Despite many surgeries, his face still frightens children. Yet he wouldn’t try a transplant.

“Having somebody else’s face … that wouldn’t be right. I’d be afraid something would go wrong, too. What would you do if you didn’t have a face? Could you live?”

Bioethicist Carson Strong at the University of Tennessee wonders, too.

“It would leave the patient with an extensive facial wound with potentially serious physical and psychological consequences,” he wrote last summer in the American Journal of Bioethics.

Siemionow said critics should admit that risks and need for the transplant are debatable.

“Really, who has the right to decide about the patient’s quality of life?” she asked. “It’s very important not to kind of scare society. … We will do our best to help the patient.”

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