Preparing for the world's first face transplants

'A nightmare that never ends'
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.

The person must bond with the transplant team, especially Siemionow. How much would she want to know about the person?

“Everything possible. It’s a commitment on both sides,” she said.

Dr. Joseph Locala will decide whether candidates are mentally fit. His chief concern: making sure they realize 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, Locala knows they often have been coached on what to say to be chosen. He’d 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.

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. For someone to be chosen, “they’re going to have to get a pass from every member of the team.”

Matthew Teffeteller might seem an ideal candidate.

Hair is driving him crazy. What used to be a beard can’t grow through the skin-graft quilt that Vanderbilt University doctors stitched over parts of his face that were seared off in a car crash. Trapped under this crust, hair festers, leading to staph infections, pain and more surgeries.

“It’s a nightmare and it never ends,” he said. “Being burned is the worst thing that can happen to you. I’m about sure of it.”

Teffeteller, 26, lives south of Knoxville, in the foothills of Great Smoky Mountains National Park where he worked, ironically, as a fire fighter. The day after Valentine’s Day in 2002, he was taking his pregnant wife to buy a cowboy hat and go country line dancing to celebrate their first anniversary.

“The next thing I remember, everything just went all to pieces...there was a big explosion. I remember seeing gas splash off of the windshield,” he said.

Rear-ended by a truck, his car flipped and caught on fire. His wife died. He was burned trying to free her.

“They said my face was charcoal black,” he said.

He didn’t see it for two months, until he glimpsed a mirror on his way to therapy.

“Oh, my God,” he thought. “I remember seeing my eyes pulled open. I remember my ears were burned off, and I remember my bottom lip being pulled down.”

Three years later, his face still frightens children. Yet he wouldn’t try a transplant.

“Having somebody else’s face ... that wouldn’t be right. When I look in the mirror, I might be scarred but I can still tell that it’s me,” he said.

“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.

Ethical questions
Such worries led the Royal College of Surgeons in England and the French National Ethics Advisory Committee to decide it shouldn’t be tried. Any doctor considering it should examine soul and conscience, Strong wrote.

Ironically, people most emotionally devastated by disfigurement are those most likely to seek a transplant and least able to cope with uncertain results, media attention and loss of privacy, ethicists from England wrote in the same journal.

One worried that a donor family might have unhealthy expectations of seeing a loved-one “live on” in another person’s body, or that recipients might want to see and approve a potential face.

No way, said Siemionow.

“It’s not a shopping mall. They need to rely on our judgment. If they are starting to shop, they are not good candidates,” she said.

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.”

If all of the candidates back out, “that’s OK. It means that we are not ready yet,” she said.

But if a transplant succeeds, many people who live in misery could benefit, said Gutowski, the Wisconsin surgeon.

“Someone’s got to push the envelope,” he said. “In retrospect, we’ll know whether it should be done.”

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