Changing face of medicine
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 the world's first face transplant.
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.
Whoever she chooses will endure the ultimate identity crisis.
Dr 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, Dr Siemionow contends.
Her supporters point to her experience and 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 far too risky for something that is not a matter of life or death as for example 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, a doctor and a patient willing to try it.
The first two are now in place. The third is expected to be shortly.
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 donor, matched for tissue type, age, sex and skin colour. Surgery should last eight 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 for the rest of your life, and they raise the risk of kidney damage and cancer.
After the transplant you might feel remorse, disappointment, or grief or guilt toward the donor.
The clinic will try to shield your identity, but the press likely will discover it.
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 bone and muscle, 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 will graft skin to cover the donor's wound, but a closed casket or cremation will be required.
It took more than a year to win approval from the 13-member Institutional
Review Board, the clinic's gatekeeper of research.
Dr Siemionow assembled surgeons, psychiatrists, social workers, therapists, nurses and patient advocates, and worked with LifeBanc, the organ procurement agency she expects will help obtain a face.
At first, not everyone was on her side, acknowledged the board's vice-chairman, Dr Alan Lichtin. After months of debate, Dr Siemionow brought in photographs of potential patients.
Looking at the contorted images, Mr Lichtin said he was struck by "the failure of the present state of the art to help these people".
He decided he didn't want to deprive the surgeon or patients of the chance.
The board's decision didn't have to be unanimous.
In the end, it was.
Surgeons wished they could have done a transplant six years ago, when a two-year-old boy attacked by a pit bull dog was brought to the University of Texas in Dallas where Dr Karol Gutowski was training.
Other doctors had tried to reattach part of the boy's mauled face but it didn't take. The Texas surgeons did five skin grafts in a bloody, 28-hour surgery. Muscles from the boy's 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 Dr Gutowski, now a reconstructive 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. Only small amounts can be taken at a time because of bleeding.
Surgeons often return to the same areas every few weeks, reopening old wounds and building up skin. Years later, many patients are still having surgeries. A face transplant applying a sheet of skin in one operation 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, where the first hand transplant in the US was performed in 1999.
Several years ago, these doctors announced their intention to do face transplants, but no hospital has yet agreed. They also are working with doctors in the Netherlands; nothing is imminent.
However, Dr Siemionow had been doing experimental groundwork. She already had creatures that resembled raccoons in reverse white rats with masks of dark fur from years of face transplant experiments.
She developed a plan and got clinic approval before going public, 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.
Dr Siemionow, 55, went to medical school in Poland, trained in Europe and the US, and has done thousands of surgeries in nearly 30 years. The success of this one depends on picking the right patient.
Dr Joseph Locala will decide whether candidates are mentally fit. His chief concern: making sure they realise the risks.
"They almost need to understand as much as the surgeon," he said.
A psychiatrist who has worked with transplant patients for 11 years, Dr Locala knows they often have been coached on what to say to be chosen. He would veto candidates who had abused alcohol or drugs, because they may not comply with medications.
Likewise someone who had attempted or seriously threatened suicide, or with little family or friends for support.
"I'm looking for a psychologically strong person. We want people who are going to make it through," he explained.
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