In the early hours of 28 May 2005, Isabelle Dinoire woke up in a pool of blood. After fighting with her family the night before, she turned to alcohol and sleeping tablets \u201cto forget\u201d, she later said.<\/p>\n
Reaching for a cigarette out of habit, she realized she couldn\u2019t hold it between her lips. She understood something was wrong.<\/p>\n
Isabelle crawled to the bedroom mirror. In shock, she stared at her reflection: her nose, lips, and parts of her cheeks were gone, replaced by a raw, mangled wound.<\/p>\n
While Isabelle was unconscious, her beloved dog Tania, a cross between a Labrador and a Beauceron, had chewed away her features.<\/p>\n
\u201cI could see a pool of blood next to me,\u201d Isabelle told<\/a> the BBC. \u201cAnd the dog was licking the blood. But I couldn\u2019t imagine that it was my blood or my face.\u201d<\/p>\n On 27 November 2005, Isabelle received the world\u2019s first face transplant at University Hospital, CHU Amiens-Picardie, in northern France. The surgery was part of an emerging field called vascularized composite allotransplantation<\/a> (VCA), that transplants parts of the body as a unit: skin, muscle, bone and nerves.<\/p>\n Two teams, overseen by Bernard Devauchelle, Sylvie Testelin and Jean-Michel Dubernard, grafted a donor\u2019s nose, lips and chin onto Isabelle\u2019s skull. The donor, a 46-year-old woman, had died by suicide. The donor graft was painstakingly attached: sensory nerves to restore feeling, motor nerve fibres for movement, arteries and veins to establish blood flow. The operation involved 50 people and took more than 15 hours.<\/p>\n The results were presented<\/a> to the press the following February, when Isabelle amazed the world by speaking through her new mouth and drinking water from a cup. \u201cI now have a face like everyone else,\u201d she said. \u201cA door to the future is opening.\u201d<\/p>\n The case for face transplants seemingly made, several teams scrambled to perform their nation\u2019s first. The US saw the first partial face transplant (2008), then the first full one (2011); the first African American recipient (2019); the first face and double hand transplant combined (2020); the first to include an eye (2023). There have been about 50 face transplants to date, and each milestone brought new grants, donations and prestige for the doctors and institutions involved.<\/p>\n The patients, meanwhile, continue on living as they can. Some of them, like Isabelle, have suffered greatly. Others, like Joe DiMeo, who received the world\u2019s first double hand and face transplant at NYU Langone in 2020, find new ways to forge a career by selling their stories online. But he and his wife Jessica, a nurse, are constantly trolled, and the spectre of rejection never leaves.<\/p>\n Jessica and Joe DiMeo (the first double hand and face transplant recipient). Photograph: April Kirby<\/p>\n For the past six years, I have been researching the history of face transplants, interviewing surgeons and patients in the US, France, China, Spain, Italy, Mexico and Canada. I have contributed to surgical articles and conferences, brought patient voices to the table, and advised on a critical Department of Defense-funded study to regulate all kinds of VCA.<\/p>\n What I\u2019ve found is alarming: it\u2019s a field where negative data is often buried, driven by funding battles and institutional rivalry. In places where publicity functions as marketing, some clinics expose patients to intrusive media attention. Support networks are uneven, and few patients are prepared for the toll of lifelong immunosuppressants. Add to this picture a set of ethical challenges: face transplants take otherwise healthy people with disfigured faces and turn them into lifetime patients.<\/p>\n People tend to remember a dramatic \u201cbefore and after<\/a>\u201d. The reality is different.<\/p>\n Dallas Wiens<\/a> thought he\u2019d won the medical lottery when he became America\u2019s first full face transplant recipient in 2011. The 25-year-old electrician was electrocuted while painting a church; this destroyed his face and his sight. Dallas worried that his daughter Scarlette would be bullied for how he looked. He wanted to give \u201csomething back\u201d to veterans. He wanted to be able to hail a cab.<\/p>\n Like Isabelle, Dallas was grateful to his donor and surgeons. He attended medical conferences so surgeons could see the results. He met prospective patients and was courted by global media as proof that face transplants worked.<\/p>\n For several years, the narrative held; then reality intruded.<\/p>\n The anti-rejection drugs that kept his new face alive destroyed his kidneys. Dallas had repeated episodes of rejection, each requiring stronger immunosuppression. He lived in Texas, in poverty, with his beloved wife Annalyn, who was also blind. Dallas\u2019 primary medication alone cost $120 per month, a significant expense on disability benefits.<\/p>\n \u201cIt\u2019s one thing to be told about risks,\u201d Dallas told me when his kidneys were failing. \u201cIt\u2019s another thing to experience them.\u201d<\/p>\n In the US, now the world\u2019s leader in face transplants, the Department of Defense has bankrolled most operations, treating them as a frontier for wounded veterans while private insurers refuse to cover the costs.<\/p>\n With insurance unwilling to pay until the field proves its worth, surgeons have been eager to show results. A 2024 JAMA Surgery study<\/a> reported five-year graft survival of 85% and 10-year survival of 74%, concluding that these outcomes make face transplantation \u201can effective reconstructive option for patients with severe facial defects\u201d.<\/p>\n Yet patients like Dallas tell a different story. The study measures survival, but not other outcomes such as psychological wellbeing, impact on intimacy, social life and family functioning, or even comparisons with reconstruction.<\/p>\n Most surgeons care about their patients, though they will have their own personal ambitions. Globally, there are perhaps 20 (mostly male) specialized surgeons capable of face transplants; nobody could become part of that elite group without ambition, for themselves, and for the field. And what can they do, surgeons say, if the system doesn\u2019t provide?<\/p>\n It\u2019s a double-bind. Without proof of success, face transplants are experimental. And because the procedures are experimental, patients\u2019 long-term needs aren\u2019t covered by grants, leaving patients to carry the burden.<\/p>\n Dallas and Annalyn Wiens. Dallas died in 2024 of kidney failure. Photograph: April Kirby<\/p>\n \u201cI don\u2019t have $100 for Ubers to and from hospital,\u201d Dallas said, explaining how public transport led to infections, given his weakened immune system, and infections could make his face reject. \u201cBut if I don\u2019t attend, it can be seen as non-compliance. Is that fair?\u201d<\/p>\n On 27 September 2024, Dallas died suddenly at his home in Fort Worth. His death certificate lists complications due to electrocution, his original 2008 accident. His wife Annalyn still doesn\u2019t know what happened. \u201cHis body gave up,\u201d she said. \u201cHe was constantly tested and made to feel like a guinea pig. I wanted his body to be left alone.\u201d<\/p>\n Annalyn had Dallas\u2019 body cremated quickly, fearful that the DoD or Yale would want it for research. Neither did, but it says something about the gap between surgical intentions and patient experiences that this was her fear.<\/p>\n That fear was also expressed privately to me by a member of Isabelle\u2019s immediate family, who wants to remain anonymous. From their perspective, Isabelle\u2019s face transplant was not a success, despite launching an entire field.<\/p>\n In fact, nobody expected France to do the first face transplant. Those in the know presumed it would be Cleveland Clinic, where Maria Siemionow had spent years refining the method and the ethics.<\/p>\n In contrast, Devauchelle\u2019s first application for ethical approval was rejected. In the early 2000s, French ethicists were, like those in the UK, concerned about immunosuppressant risks \u2013 and psychological ones. How could anyone cope with seeing another person\u2019s face in the mirror?<\/p>\n For his next, successful bid, Devauchelle teamed up with Dubernard, who was not only an influential member of the French National Assembly, but also the surgeon who had made history in 1998 with the world\u2019s first hand transplant<\/a>. And making history has always brought glory, especially for transplant surgeons.<\/p>\n What of Isabelle? Three months before her operation, she signed a contract with British documentary maker Michael Hughes, agreeing to let cameras document her transformation in exchange for payment. The Times of London revealed<\/a> this deal, showing how a vulnerable, suicidal woman with no face had been effectively \u201csold\u201d even before surgery. Isabelle was swayed by the promise of a bright future, though that never transpired.<\/p>\n Describing how he watched the blood flow into Isabelle\u2019s lips in surgery, Dubernard compared himself to the prince who awakened Sleeping Beauty, adding: \u201cI still see her image among the stars in my dreams\u201d.<\/p>\n Isabelle felt less like a princess than a circus animal.<\/a> After the transplant, she spoke of being tormented: \u201cEveryone would say: Have you seen her? It\u2019s her. It\u2019s her \u2026 And so I stopped going out completely.\u201d<\/p>\n Living with a stranger\u2019s face was as psychologically difficult as ethicists feared. Two years after the transplant she spoke<\/a> to the strangeness of having \u201csomeone else\u2019s\u201d mouth. \u201cIt was odd to touch it with my tongue. It was soft. It was horrible.\u201d<\/p>\n And then one day she found a new hair on her chin \u2013 \u201cIt was odd. I\u2019d never had one. I thought, \u2018It\u2019s me that has given it life, but the hair is hers.\u2019\u201d<\/p>\n Surgeons and ethicists observed that Isabelle wasn\u2019t given proper alternatives, and she wasn\u2019t in a good state of mind; the most the French team has conceded is that she wasn\u2019t an \u201cideal patient\u201d.<\/p>\n Isabelle might have fared better in a country like Finland, where transplants are anonymous. Patients and families are not harassed by journalists \u2013 as Isabelle and her family were \u2013 and clinics don\u2019t use patients as media opportunities.<\/p>\n Instead, Isabelle never resumed a normal life, never returned to work or good mental health, and from 2013 experienced regular episodes of rejection. In 2010 she contracted cervical cancer, followed by lung cancer. She died in 2016, though her surgeons deny this was connected to immunosuppressant use.<\/p>\n In fact, Isabelle\u2019s face died before she did; after it became necrotic, it was removed and replaced with a graft from her thigh. As she told her family, she \u201cdidn\u2019t want to die without a face\u201d.<\/p>\n I also learned from Isabelle\u2019s immediate family member that her wellbeing declined dramatically after her transplant, and that she was in \u201cpsychological distress\u201d when consenting for the procedure. \u201cThey took her away from us, so we didn\u2019t have the power to dissuade or counsel her.\u201d And after each psychiatric appointment, she would come home \u201cat the lowest, full of guilt and suicidal desires\u201d. More than once, according to her, she attempted suicide after her transplant; this story isn\u2019t part of the record.<\/p>\n Robert Chelsea, the first African American to receive a new face, wanted to kiss his daughter\u2019s cheek. Now he can, but his daughter can\u2019t look at him the same way.<\/p>\n \u201cOnly when he opens his mouth, I know it\u2019s him\u201d, she says, otherwise he\u2019s a stranger. Today, Robert is in and out of hospital and unable to find income.<\/p>\n