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SnakebyteXX
12-14-2005, 06:26 AM
As patient mends, transplant uproar builds
By Craig S. Smith The New York Times

WEDNESDAY, DECEMBER 14, 2005


PARIS While the woman who received the world's first facial transplant recovers in her hospital room, a debate over the circumstances of the groundbreaking operation has pitted doctor against doctor and led to a media circus that doctors worry is complicating her recovery.

"Clinically, she's excellent," Dr. Bernard Devauchelle, the surgeon who performed the transplant, said in his office in Amiens, France, on Monday. But psychologically, he added, she is only "good enough."

Meanwhile, a doctor who is a member of the regulatory agency that approved the procedure has called for an investigation into the administrative steps taken for that approval.

Among the most disturbing aspects of the debate are conflicting reports from doctors about whether the transplant was the result of two suicide attempts, one failed, one successful.

Reports that the patient's disfigurement resulted from an attempted suicide raise questions about her emotional stability and ability to consent to such a risky operation.

Reports that the donor committed suicide raise questions about the recipient's psychological future because, if true and the transplant is successful, it will mean that for the rest of her life she will see in the mirror the nose, mouth and chin of a woman who herself met a brutal end.

Those reports surfaced within days of the transplant, apparently originating with the medical teams that removed other organs after the face had been harvested. The reports were confirmed by Olivier Jarde, a member of France's National Assembly and an orthopedic surgeon at the hospital in Amiens where the face transplant was performed. He played no role in the transplant, however.

"I'm absolutely sure," Jarde said when asked last week if the donor had committed suicide. He repeated his assertion Tuesday but declined to say where the information had come from.

The family of the donor, who has been identified as a 46-year-old woman from the northern city of Cambrai, about 30 kilometers, or 20 miles, from the recipient's home, told the funeral director that handled the burial that her death was accidental.

Devauchelle, who removed the part of the face that he later transplanted, said he did not know how the donor died but said that he saw no marks on the donor's neck nor a swollen or distended tongue, which might have been evidence of hanging. The donor had been declared brain dead after four days in a coma and hours before Devauchelle first examined the body in the early morning hours of Nov. 27.

He said he would not have accepted the donor if he had thought that she had hanged herself because of the risk that the blood vessels of the face may have been damaged.

Many people say that it was a suicide attempt by the recipient that led to the disfigurement that the partial face transplant is meant to correct.

Local newspapers have quoted one of her daughters as saying that the family dog scratched and bit away her mother's face after she had tried to kill herself with an overdose of sleeping pills.

The reports of her attempted suicide have been adamantly denied by Dr. Jean-Michel Dubernard, the flamboyant French doctor-politician in charge of her post-transplant treatment. He repeated in a telephone interview Friday that she simply took sleeping pills to relax and was apparently attacked by her dog, probably after stepping on the animal while in a stupor.

But Jarde has said that she did indeed try to kill herself and that the attempt was well known to a handful of doctors in Amiens, including Devauchelle and Dr. Sylvie Testelin, another surgeon on the transplant team.

Devauchelle said Monday that he did not know one way or the other, but that the medical records that arrived with the recipient did not mention a suicide attempt. Testelin could not be reached for comment.

However, the two doctors' surgical protocol submitted to regulators for approval before the operation did acknowledge that the recipient's pill-taking reflected some emotional distress.

"It's true that one could argue that this animal bite took place after the patient had taken some sleeping pills, but she is benefiting from a totally adapted psychiatric treatment, treating separately those issues raised by her initial gesture and those raised by the rehabilitation of her disfigurement," reads the document, a copy of which was obtained by The New York Times.

The recipient, whose first name is Isabelle but whose full identity, like the donor's, cannot be disclosed in France for legal reasons, grew up in Maubeuge, a small industrial town near the Belgian border in northeastern France.

After her father's death, she followed her mother to a government-subsidized housing development in Marly, 30 kilometers to the west near Valenciennes. She married and had two girls, now 13 and 17, but divorced several years ago. She worked intermittently selling knitting wool but had been unemployed for about a year before her disfigurement.

Whether or not her overdose was a suicide attempt, her doctors all say that she had argued with one of her daughters earlier in the evening before taking the pills. She passed out on a sofa in her apartment as the pills took effect and her black Labrador, Tania, apparently tried to wake her, pawing at her face and eventually biting and chewing at her lips, nose and chin.

Jeanne-Marie Binot, director of the local Society for the Protection of Animals, which later took in the dog, said the behavior was not unusual.

"Dogs are carnivores, after all," Binot said, adding that dogs will only chew at human flesh if the subject is inert.

The location and extent of the victim's wounds also suggest that she was deeply unconscious when they occurred, consistent with a serious overdose of sleeping pills. "It would have to be a very, very large overdose," said Dr. Michel Levy, president of France's anesthesiologists' union.

One or both of her daughters found her in the morning and called the local emergency services, which arrived with a team of doctors who took her to the local hospital in neighboring Valenciennes. Several days later, she was transferred to the university hospital in Amiens because of the severity of her injury.

There she became a patient of Devauchelle, the head of maxillo-facial surgery there. He quickly decided that she was a transplant candidate.

"It was a very disturbing injury, because the skeleton was exposed and her jaw would move as she spoke," said Dr. Sophie Cremades, her primary psychiatrist. She underwent intense psychiatric treatment to ensure that she could endure the difficult operation and the challenges ahead, including life-long drug treatment and the persistent potential that her body could reject the graft, as well as the psychological difficulties of accepting another person's face.

Once she returned to her home, she took down the mirrors in her apartment because the sudden sight of her disfigured face was so frightening, according to her doctors.

Some American teams have said they would not have performed such a psychologically challenging transplant on a patient with a questionable emotional history, but the French doctors involved in her case argue that even a suicide attempt is not a disqualifying factor.

The doctors argue that their patient showed enough mental fortitude to tip the scales in her favor and that her otherwise bleak outlook, together with the overwhelming benefits of a successful transplant to herself and others, outweighed any doubts.

Word went out to hospitals in the region to be on the lookout for potential donors. The first response came at the end of November when the donor was declared brain dead at a hospital in Lille, just 135 kilometers away.

The hospital e-mailed Devauchelle photographs of the woman and he rushed to Lille.

He said he was "stupefied" by how perfectly the brain-dead woman's face matched that of the recipient.

He cut away a triangular section of her face and rushed with it back through rain and snow to Amiens where he performed the transplant using microscopes.

Isabelle's ordeal is only beginning. She will have to face intense scrutiny by the world's media once she emerges from the protective cocoon of her hospital room.

Critics have already questioned the ethics of a commercial arrangements brokered by Dubernard in which exclusive rights for photographs and video of the operation were given to Microsoft's Corbis photo agency under an agreement that allows her to share in the proceeds from the materials' sale.

Devauchelle said she is starting to smile, though it is too early to tell whether the movement involves the muscles of her graft.

He said it will be six months before he knows how much feeling or movement her face will have.

PARIS While the woman who received the world's first facial transplant recovers in her hospital room, a debate over the circumstances of the groundbreaking operation has pitted doctor against doctor and led to a media circus that doctors worry is complicating her recovery.

"Clinically, she's excellent," Dr. Bernard Devauchelle, the surgeon who performed the transplant, said in his office in Amiens, France, on Monday. But psychologically, he added, she is only "good enough."

Meanwhile, a doctor who is a member of the regulatory agency that approved the procedure has called for an investigation into the administrative steps taken for that approval.

Among the most disturbing aspects of the debate are conflicting reports from doctors about whether the transplant was the result of two suicide attempts, one failed, one successful.

Reports that the patient's disfigurement resulted from an attempted suicide raise questions about her emotional stability and ability to consent to such a risky operation.

Reports that the donor committed suicide raise questions about the recipient's psychological future because, if true and the transplant is successful, it will mean that for the rest of her life she will see in the mirror the nose, mouth and chin of a woman who herself met a brutal end.

Those reports surfaced within days of the transplant, apparently originating with the medical teams that removed other organs after the face had been harvested. The reports were confirmed by Olivier Jarde, a member of France's National Assembly and an orthopedic surgeon at the hospital in Amiens where the face transplant was performed. He played no role in the transplant, however.

"I'm absolutely sure," Jarde said when asked last week if the donor had committed suicide. He repeated his assertion Tuesday but declined to say where the information had come from.

The family of the donor, who has been identified as a 46-year-old woman from the northern city of Cambrai, about 30 kilometers, or 20 miles, from the recipient's home, told the funeral director that handled the burial that her death was accidental.

Devauchelle, who removed the part of the face that he later transplanted, said he did not know how the donor died but said that he saw no marks on the donor's neck nor a swollen or distended tongue, which might have been evidence of hanging. The donor had been declared brain dead after four days in a coma and hours before Devauchelle first examined the body in the early morning hours of Nov. 27.

He said he would not have accepted the donor if he had thought that she had hanged herself because of the risk that the blood vessels of the face may have been damaged.

Many people say that it was a suicide attempt by the recipient that led to the disfigurement that the partial face transplant is meant to correct.

Local newspapers have quoted one of her daughters as saying that the family dog scratched and bit away her mother's face after she had tried to kill herself with an overdose of sleeping pills.

The reports of her attempted suicide have been adamantly denied by Dr. Jean-Michel Dubernard, the flamboyant French doctor-politician in charge of her post-transplant treatment. He repeated in a telephone interview Friday that she simply took sleeping pills to relax and was apparently attacked by her dog, probably after stepping on the animal while in a stupor.

But Jarde has said that she did indeed try to kill herself and that the attempt was well known to a handful of doctors in Amiens, including Devauchelle and Dr. Sylvie Testelin, another surgeon on the transplant team.

Devauchelle said Monday that he did not know one way or the other, but that the medical records that arrived with the recipient did not mention a suicide attempt. Testelin could not be reached for comment.

However, the two doctors' surgical protocol submitted to regulators for approval before the operation did acknowledge that the recipient's pill-taking reflected some emotional distress.

"It's true that one could argue that this animal bite took place after the patient had taken some sleeping pills, but she is benefiting from a totally adapted psychiatric treatment, treating separately those issues raised by her initial gesture and those raised by the rehabilitation of her disfigurement," reads the document, a copy of which was obtained by The New York Times.

The recipient, whose first name is Isabelle but whose full identity, like the donor's, cannot be disclosed in France for legal reasons, grew up in Maubeuge, a small industrial town near the Belgian border in northeastern France.

After her father's death, she followed her mother to a government-subsidized housing development in Marly, 30 kilometers to the west near Valenciennes. She married and had two girls, now 13 and 17, but divorced several years ago. She worked intermittently selling knitting wool but had been unemployed for about a year before her disfigurement.

Whether or not her overdose was a suicide attempt, her doctors all say that she had argued with one of her daughters earlier in the evening before taking the pills. She passed out on a sofa in her apartment as the pills took effect and her black Labrador, Tania, apparently tried to wake her, pawing at her face and eventually biting and chewing at her lips, nose and chin.

Jeanne-Marie Binot, director of the local Society for the Protection of Animals, which later took in the dog, said the behavior was not unusual.

"Dogs are carnivores, after all," Binot said, adding that dogs will only chew at human flesh if the subject is inert.

The location and extent of the victim's wounds also suggest that she was deeply unconscious when they occurred, consistent with a serious overdose of sleeping pills. "It would have to be a very, very large overdose," said Dr. Michel Levy, president of France's anesthesiologists' union.

One or both of her daughters found her in the morning and called the local emergency services, which arrived with a team of doctors who took her to the local hospital in neighboring Valenciennes. Several days later, she was transferred to the university hospital in Amiens because of the severity of her injury.

There she became a patient of Devauchelle, the head of maxillo-facial surgery there. He quickly decided that she was a transplant candidate.

"It was a very disturbing injury, because the skeleton was exposed and her jaw would move as she spoke," said Dr. Sophie Cremades, her primary psychiatrist. She underwent intense psychiatric treatment to ensure that she could endure the difficult operation and the challenges ahead, including life-long drug treatment and the persistent potential that her body could reject the graft, as well as the psychological difficulties of accepting another person's face.

Once she returned to her home, she took down the mirrors in her apartment because the sudden sight of her disfigured face was so frightening, according to her doctors.

Some American teams have said they would not have performed such a psychologically challenging transplant on a patient with a questionable emotional history, but the French doctors involved in her case argue that even a suicide attempt is not a disqualifying factor.

The doctors argue that their patient showed enough mental fortitude to tip the scales in her favor and that her otherwise bleak outlook, together with the overwhelming benefits of a successful transplant to herself and others, outweighed any doubts.

Word went out to hospitals in the region to be on the lookout for potential donors. The first response came at the end of November when the donor was declared brain dead at a hospital in Lille, just 135 kilometers away.

The hospital e-mailed Devauchelle photographs of the woman and he rushed to Lille.

He said he was "stupefied" by how perfectly the brain-dead woman's face matched that of the recipient.

He cut away a triangular section of her face and rushed with it back through rain and snow to Amiens where he performed the transplant using microscopes.

Isabelle's ordeal is only beginning. She will have to face intense scrutiny by the world's media once she emerges from the protective cocoon of her hospital room.

Critics have already questioned the ethics of a commercial arrangements brokered by Dubernard in which exclusive rights for photographs and video of the operation were given to Microsoft's Corbis photo agency under an agreement that allows her to share in the proceeds from the materials' sale.

Devauchelle said she is starting to smile, though it is too early to tell whether the movement involves the muscles of her graft.

He said it will be six months before he knows how much feeling or movement her face will have.



web page (http://www.iht.com/articles/2005/12/13/news/face.php)