Soon, the surgeons at Cleveland Hospital will perform an important surgery. In the coming weeks, 5 men and 7 women will secretly visit Cleveland Hospital for interviews regarding a groundbreaking procedure that has never been attempted anywhere else in the world. This procedure is a face transplant. They will smile, raise their eyebrows, close their eyes, and open their mouths. Dr. Maria Siemionow will examine their cheekbones, lips, and noses. She will ask them what they hope to gain and what they fear the most. Then she will inquire, “Are you afraid you will look like someone else?” Because regardless of who she selects, that person will have to endure a crisis of identity forever.
This is not a television spectacle. This is a frontier in medicine that a doctor is exploring, and she wants the public to understand what she is trying to achieve. The goal is to provide individuals with severely disfigured faces due to burns, accidents, or other tragedies a chance at a new life. The best treatments available today still leave many with scars and deformities that do not resemble or function like normal skin. These individuals have already lost the sense of identity associated with their faces; the transplant merely “removes the outer skin layer” and takes away their internal identity, according to Siemionow.
Proponents argue based on her experience, careful planning, the expert team assembled to assist her, and successful trials on animals and dozens of cadavers to perfect this technique.
However, critics argue that this surgery carries too many risks compared to non-life-threatening organ transplants. They paint a grotesque picture of a worst-case scenario: a transplanted face being rejected by the body, leaving the patient in worse condition than before. Such concerns have undermined recent face transplant projects in the UK and France. After all, to attempt this, a hospital, a surgeon, and a willing patient are needed. The hospital and surgeon are already in place, and the patient is hoped to be found soon.
A combination of two faces?
The “surgery consent form” states that this procedure is so new and its risks so unpredictable that the doctors believe the consent information cannot be precisely defined. Here’s what this form tells potential patients:
-Your face will be separated and replaced with a donated face from a deceased person with similar tissue type, age, gender, and skin color. The surgery will take 8 to 10 hours; hospital stay will be from 10 to 14 days.
-Complications may include infections that can cause your new face to become blackened, requiring a second surgery or tissue reconstruction. Drugs to prevent the body’s rejection response may need to be taken for life, increasing the risk of kidney damage and cancer.
-After the surgery, you may feel regret, disappointment, sadness, or guilt towards the donor. The hospital will try to protect your identity, but it is very likely that the media will find out.
-The hospital will cover all costs for the first patient; costs for subsequent patients have not yet been determined.
Another form informs the family of the face donor that the recipient will not resemble their deceased loved one. The recipient may look like their face prior to injury because the new skin will cover the existing bone and muscle tissue, which shape the face.
All the small elements that create facial expressions – nuances like winking while telling a joke or flushing when complimented – are tied to the brain and personality, not included in the skin layer. Some studies suggest that the final result will be a combination of two faces. The surgeons will graft skin to cover the donor’s face, which will be cremated.
A better solution for injuries
It took over a year to gain approval from 13 members of the hospital’s review board, which oversees research activities. Siemionow has assembled surgeons, psychologists, social workers, therapists, nurses, and supportive patients while working with LifeBanc, an organization that collects body organs, which she hopes will help her find a face.
Initially, no one was on her side, acknowledged board vice president Dr. Alan Lichtin. After months of debate, Siemionow presented photographs of patients. Upon seeing these distorted images, Lichtin was struck by the “failure of current art to help these individuals.” He decided that he did not want to deny this opportunity for the doctor and her patients. The board’s decision did not require unanimity. Ultimately, they all agreed.
All the doctors wish they could have performed a surgery six years ago when a 2-year-old boy attacked by a pit bull was brought to the University of Texas in Dallas, where Dr. Karol Gutowski was training. Other doctors tried to reconnect the boy’s mangled face unsuccessfully. Texas surgeons had to perform 5 skin grafts during a bloody 28-hour operation. A thigh from the boy was cut and used to cover his mouth. A portion of his abdomen was grafted onto the lower part of his face. Two forearms became his lips and mouth.
“The boy will never be normal,” said Dr. Gutowski, now a plastic surgeon at the University of Wisconsin-Madison.
Surviving such injuries can be a “life with a thousand cuts.” Patients endure dozens of surgeries to remove skin inch by inch from their backs, arms, buttocks, and legs. Each time, they can only take a small piece because cutting causes significant bleeding.
Patients often have to return to the hospital every few weeks to reopen old wounds for additional skin grafts. Many years later, many patients still require surgeries. A face transplant – grafting an entire skin flap in one procedure – could be a better solution.
Still, it requires many minor surgeries. One or two veins and arteries on either side of the face will be connected from the donor tissue to the patient. About 20 nerve endings need to be stitched together to attempt to restore feeling and movement. Tiny stitches will anchor the new facial tissue to the patient’s scalp and neck, as well as around the eyes, nose, and mouth.
“In the next 10 years, this could be achievable,” said Dr. John Barker, director of cosmetic surgery research at the University of Louisville, where the first hand transplant in the U.S. occurred in 1999.
A few years ago, doctors here announced plans to perform face transplants, but no hospital agreed. They also worked with doctors in the Netherlands but made no progress.
However, during that time, Siemionow began conducting foundational experiments. She developed creatures similar to panda bears with swapped faces – white mice with dark-furred faces – after years of face transplant experiments. She crafted a project and gained hospital approval before going public, asserting that she is not competing to perform the first face transplant. “I hope no one is too vain or doing everything just to gain fame. We need to be very cautious,” she stated.
Siemionow, 55, studied medicine in Poland and trained in Europe and the U.S. She has performed thousands of surgeries over nearly 30 years. The success of this procedure will depend on selecting appropriate patients.
‘A Nightmare That Never Ends’
She wanted to have a perfect first case. She didn’t choose children due to the high risks involved. She avoided cancer patients because the anti-rejection drugs increase the risk of disease recurrence.
“You want to choose patients who are truly disfigured, not someone with just a small scar,” she said, but this person must have healthy enough skin to undergo traditional skin grafting in case the facial transplant surgery fails. This person needs to have a bond with the transplant team, especially with Siemionow. How well does she want to know about this person? “Everything is possible. This is a commitment from both sides,” she said.
Dr. Joseph Locala will determine whether the candidates are psychologically suitable. His only concern is to ensure they understand their risks. “They need to understand almost as well as the surgeons do,” he said.
As a psychologist who has worked with transplant patients for over 11 years, Locala knows they are often guided on what to say to be selected. He opposes candidates who are addicted to alcohol or drugs, as they may not adhere to medical protocols.
He also opposes those who have attempted or threatened suicide or those who have too few family members or friends supporting them. “I’m looking for someone who is psychologically strong. We need people who can overcome all difficulties,” he explained.
Dr. James Zins, president of the American Society of Plastic Surgeons, estimates that around 10 to 12 doctors will participate in this transplant and he is currently reviewing patients. “We get some pretty strange calls from people who aren’t really patients,” he said. If a person is selected, “they must have the approval of every team member.”
It seems that Matthew Teffeteller is an ideal candidate. The issue of facial hair drives him crazy. The hair cannot grow through the skin graft that doctors at Vanderbilt University stitched onto his face after he suffered severe burns in a car accident. Trapped under this graft, the hair became infected and rotted, causing him to suffer from a staph infection, pain, and ongoing surgeries.
“It’s a nightmare that never ends,” he said. “Being burned alive is the worst thing that can happen to you. I’m almost sure of that.”
Teffeteller, 26, lives in southern Knoxville, at the foothills of the Great Smoky Mountains National Park, where he works as a firefighter. A day after Valentine’s Day in 2002, he took his pregnant wife to buy a cowboy hat and went dancing to celebrate their anniversary.
“The next thing I remember is everything shattering… a serious car crash. I remember seeing gasoline splashing onto the windshield,” he recalled. After being hit from behind by a truck, his car flipped and caught fire. His wife died. He suffered severe burns while trying to save her. “They said my face was as black as coal,” he noted.
He didn’t want to look at his face for two months, until one day he caught a glimpse of himself in the mirror on the way to therapy. “Oh my God,” he recalled, “I remember seeing my eyes bulging out. Both of my ears were burned off, and my lower lip hung down.” Three years later, his face still terrified children. But he still didn’t want to try a transplant. “Wearing someone else’s face… that just doesn’t feel right. When I look in the mirror, I might be scared, but I still know it’s me,” he said.
“I’m also afraid that something might go wrong. What would you do if you didn’t have a face? Could you live?”
Bioethicist Carson Strong at the University of Tennessee also grapples with this question. “Patients will have a more significant facial wound with serious potential physical and psychological consequences,” he wrote in the American Medical Ethics Journal last summer.
Ethical Questions
Such concerns have led the Royal College of Surgeons in England and the French National Ethics Committee to decide against trials. Any doctor considering it needs to reflect on their conscience, Strong wrote.
Ironically, those most emotionally harmed by facial disfigurement are often the ones most eager for a transplant and may struggle to cope with uncertain outcomes, as well as the media attention and loss of privacy, according to British ethicists writing in the same journal.
Another concern is that the donor’s family might expect to see their loved one “revived” in another person, or the recipient might want to see and choose their “potential” face.
This is not possible, Siemionow said. “This is not a supermarket. They need to rely on our judgment. If they start wanting to choose, then they are not good candidates,” she said.
Siemionow stated that critics must acknowledge that there are many debates between the risks and the need for transplants. “Really, who has the right to decide on the quality of a patient’s life?” she asked, “One very important thing is that they will not make society afraid… We need to do our best to help patients.”
If all patients withdraw, “that’s okay. It means we are not ready yet,” she said.
But if facial transplant surgery is successful, it could greatly benefit many people living in despair, according to Gutowski, a surgeon in Wisconsin. “Someone has to do something,” he said, “In hindsight, we will know whether it should have been done or not.”
