Medicine: A Transplant First

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So much of how we see ourselves--and how other people see us--is bound up in our faces that the idea of transplanting one person's visage onto another seems not just improbable but bizarre. And yet for the past few years, surgeons at a handful of medical centers in the U.S. and Europe have been cautiously preparing for just such a procedure to offer hope to patients who have been severely disfigured by burns or accidents. No one had yet raised a scalpel to try, in part because of numerous medical, ethical and psychological concerns that had to be considered first. That's one reason it was so startling to learn last week that the first face transplant--albeit a partial one--has taken place. Doctors in France reported that they took a triangular patch of facial tissue containing the nose, lips and chin of a brain-dead donor and transplanted them onto a 38-year-old mother of two who had been severely mauled by a dog last May.

By all accounts, the operation, which was approved by at least three different sets of public-health and ethics authorities, was a success. The match and color of the transplanted section "were even better than we had expected," said Dr. Bernard Devauchelle, coordinator of one of the surgical teams. "In just four hours we had re-established vascular connections between the skin fragment and [the patient]."

Surgery is, however, just the beginning of the woman's medical odyssey. She must take powerful drugs for the rest of her life to ensure that her immune system does not reject the graft. Of all the tissues in the body, the skin provokes a particularly strong rejection response, which makes sense when you consider that one of its functions is to act as a barrier against germs. The weakened immune system that results from the drugs also increases the risk of cancer.

The doctors hope to further reduce the danger of rejection by injecting the patient with stem cells taken from the bone marrow of the original donor. That is an experimental approach in which the donated stem cells should, in effect, teach the woman's immune system to tolerate the graft.

The facial transplant, which would have been unusual under any circumstances, stirred heated debate following a French media report that the woman might have sustained her injuries during a suicide attempt in which the dog apparently bit her in an effort to wake her up. That raised the question of whether she was stable enough psychologically to give consent to the operation, never mind care for herself afterward. But Dr. Jean-Michel Dubernard, one of the surgeons who operated on the woman, denied the report. "There was no suicide attempt," he told reporters. Instead, he said, the woman took a sleeping pill after a family fight, and the dog bit her when she stepped on it in the night. She was examined by several psychiatrists, he added, who determined that she was a suitable candidate for transplant.

Others criticized the operation as a rush to make history. "I believe a better result could have been achieved with careful facial reconstruction," says Dr. Denys Pellerin, vice president of the French National Academy of Medicine. "This procedure was based on ambition."

Dubernard would have none of it. "For us, it was not a matter of being first," he told TIME. "It just happened that we had a good candidate and a good donor and an excellent team."