Some might consider it ghoulish to walk around wearing a dead person's face.
But when Gwendolyn Arrington read last week that doctors in Cleveland had gained approval to conduct the world's first face transplant, she was quick to ask if she might be eligible.
As a 22-year-old in 1989, Arrington was severely burned in a gas explosion. More than 30 operations later, her scarred face still sometimes scares children, she said. And, strange as the concept may seem to others, wearing someone else's face would not faze her.
"With all the grafts I've received, patches here and patches there," she said, "I honestly feel like I'm already living with someone else's face."
Arrington's injuries probably are not severe enough to qualify her for the radical procedure, the first of which could come within the next few months. Many people have far more devastating facial injuries -- their eyelids, lips, noses and ears horribly deformed or missing and their lives shrouded in solitude, pain and depression.
That reality means the search for recipients for the first face transplants may be relatively easy.
More difficult, experts say, will be finding people willing to donate their faces after death -- an act with profound, and for many people, disturbing symbolic significance.
Then there will be the toughest test of all: making it work.
More is involved than the intricacies of connecting tiny blood vessels and nerves. For the rest of their lives these patients will have to take immune-suppressing drugs to keep their new faces from being rejected -- potent drugs that cause life-threatening problems of their own.
Those issues help explain why some experts say they are troubled by what appears to be a race among surgeons to be the first to transplant a face.
"A face is not vital. It's not a kidney. It's not a liver. It's not a heart. So is it really worth the risk?" asked Eric F. Trump of the Hastings Center, the Garrison, N.Y.-based bioethics research institute. "I'm not completely against this. But I do think, what's the rush? I think there's a need for more deliberation."
Organ transplantation has long stirred curiosity and controversy, raising cheers as a lifesaving, heroic procedure and fears for its intrusion on identity and bodily integrity.
New ethics issues arose in 1998 when surgeons in France conducted the first human hand transplant from a cadaver. That was the first time a patient took on the risks of lifelong immune-suppressing drugs -- including significantly elevated rates of infection, cancer, and liver and kidney failure -- for a body part not needed for survival.
More than 20 hand transplants have been performed since then, along with a number of other non-lifesaving procedures, including a larynx transplant that restored a patient's ability to speak and the first total tongue transplant, performed last summer.
But face transplants -- now in the final stages of planning in England, the Netherlands, France, Spain and at least three medical centers in the United States -- raise unique issues.
On the plus side, face transplantation promises better appearance and better facial function than the current practice of grafting small pieces of a patient's skin from, say, the abdomen.
Faces have at least five kinds of skin with specialized characteristics -- the inside of the eyelids and lips, for example -- for which standard skin grafts are poor substitutes. For patients whose facial muscles are mostly intact, a transplant of an entire face with its underlying fat and embedded blood vessels could greatly enhance the ability to eat, drink and keep eyes moist.
For patients with deeper disfigurement, some teams are considering transplants that include underlying facial muscles to restore facial mobility. Research suggests that two-thirds of face-to-face communication takes place through facial expressions -- squinty glances, raised eyebrows, pouty lips -- and losing that messaging system can be socially debilitating.
The technical logistics of connecting vessels and nerves are not overly daunting, surgeons say, but face transplants still pose big risks. Foremost is the serious -- but for now unquantifiable -- risk of rejection. That could happen if anti-rejection medications prove inadequate -- doctors do not know how violently the immune system will attack the face -- or because, as happens in about 15 percent of organ transplants, the patient is not diligent about taking the drugs.
The resulting sloughing off of the face would be catastrophic and could prove fatal, doctors said.
"Immunosuppression is the biggest hurdle we need to overcome," said James E. Zins, chairman of plastic and reconstructive surgery at the Cleveland Clinic, where screening for potential recipients is about to begin now that the hospital ethics committee has approved the surgery.
Psychological considerations are also weighty, including the burdens that might come from taking on the most visible part of another's persona.
"The face is central to our understanding of our own identity," a working group of the Royal College of Surgeons of England noted in a report released last November. "Faces help us understand who we are and where we come from . . . providing evidence of parentage, ancestry and racial identity."
No one knows just how much a recipient would look like the donor. But experiments on human cadavers suggest that, especially if underlying structures are transplanted with the face, there could be an eerie resemblance.
It's not only the recipients who might be haunted by such a transference, said Peter D. Costantino, a physician at St. Luke's-Roosevelt Hospital Center in New York, part of a team that has been considering a face transplant for a child whose face was ravaged by a tumor.
"What if the parents of the deceased child who donated the tissue want to see the child, because what parent wouldn't want to see the face of their loved one after death?" Costantino asked. "And what if they're not allowed to, but they find out who the patient is and seek them out on their own? There's a lot of stuff that's different with this kind of operation than with other transplants."
That is one reason Costantino believes face transplants should be reserved, for now, for patients who have extreme loss of function -- a mouth or eyes that can no longer close, for example -- and not for people with simple, albeit severely disfiguring, facial damage.
The Royal College report went further than that, concluding "it would be unwise to proceed with human facial transplantation" for any purpose until further physiological and psychological research is completed. A French ethics board in March also rejected a face transplant proposal.
Such findings have little sway with burn victims whose facial features have melted away, with cancer patients whose tumors invaded their nose and mouth, or those who, in a moment of severe depression, put a gun to their mouth, and then flinched.
"Some of these people now regularly consider suicide because their social life is so limited and their sense of self is so negative," said Osborne P. Wiggins, chairman of philosophy at the University of Louisville and part of a team that recently submitted to a Dutch review board a proposal to do a face transplant in collaboration with doctors in Utrecht.
Arrington, the Cleveland burn victim, knows what that isolation feels like. Her daughter, Al-Lexis, uninjured and just shy of 2 years old at the time of the explosion, would not even look at her after the accident.
"My father would say, 'That's your mother. Give her a kiss.' But she would just scream and cry," said Arrington, who works today as a customer service representative for an insurance company. "She was really afraid of me."
Arrington's appearance has improved vastly since then, and she has adjusted well to her lingering disfigurement -- factors that work both for and against her as a transplant candidate. Doctors say they want to reserve the experimental treatment for people with the most devastating injuries.
"This is not a transplant for vanity or for aesthetic improvement," said Maria Siemionow, director of plastic surgery research and training at the Cleveland Clinic.
At the same time, doctors are nervous about trying the experimental procedure on anyone who is not psychologically stable. Those two things could be difficult to find in a single patient.
In fact, selecting the recipients probably will be one of the most difficult tasks, said John H. Barker, director of the University of Louisville's plastic surgery research laboratory. That is a lesson he and his colleagues learned in 1998, he said, when they prepared to perform their first hand transplant and made the mistake of selecting someone who had lost both his hands just a month earlier.
"Psychologically he was just a mess," Barker said. "He got a divorce, and we learned a quick lesson there: You have to wait until the person has adjusted to what's happened to them."
When the Louisville surgeons finally did their first hand transplant in 1999, they learned another lesson: Do not promise donors or their families they will remain anonymous. A newspaper reporter found the deceased hand-donor's name by sifting through the hospital's disposal bin, Barker said, resulting in an invasion of the family's privacy.
Some experts worry that the impact of face transplants could ripple even beyond the recipients, donors and their families by sending a message to society that only "normal" faces are all right.
"This is, in a way, upping the ante of what an acceptable face looks like," said Sara Goering, a University of Washington philosopher.
Others worry that if people come to believe that faces are fair game for procurement after death, then fewer people may volunteer to be organ donors. (Transplant surgeons are in agreement that only people who have given explicit permission should be considered as potential face donors.)
Those kinds of potential problems deserve consideration, said Arrington, the Cleveland burn victim, but ought to be balanced against the needs of people who every day must make the painful choice between loneliness and extreme conspicuousness.
"All I really want," she said, "is to walk down the street and not be so noticeable."
Ironically, for such a high-profile operation, the most important thing a new face has to offer is the relief of simple anonymity.