CLEVELAND — In the next few weeks, five men and seven women will secretly visit the Cleveland Clinic to interview for the chance to have a radical operation that's never been tried.
They will smile, raise their eyebrows, close their eyes, open their mouths. Dr. Maria Siemionow will study their cheekbones, lips and noses. She will ask what they hope to gain and what they most fear.
Then she will ask, "Are you afraid that you will look like another person?"
Because whoever she chooses will endure the ultimate identity crisis.
Siemionow wants to attempt a face transplant.
This is no extreme TV makeover. It is a medical frontier being explored by a doctor who wants the public to understand what she is attempting: to give people horribly disfigured by burns, accidents or other tragedies a chance at a new life.
Today's best treatments still leave freakish, scar-tissue masks that don't look or move like natural skin. These people have lost the sense of identity that is linked to the face; the transplant is merely "taking a skin envelope" and slipping their identity inside, Siemionow contends.
Her supporters note her experience, planning, the experts she has assembled to help, and the practice she has done on animals and cadavers.
But her critics say the operation is too risky for a condition that is not life-threatening, as most organ transplants are. They paint the frighteningly surreal image of a worst-case scenario: a transplanted face being rejected and sloughing away, leaving the patient worse off.
Such qualms recently scuttled face transplant plans in France and England.
Ultimately, it comes to this: a hospital, a doctor and a patient willing to try. The first two are in place; the third is expected to be shortly.
The "consent form" says that this surgery is so novel and its risks so unknown that doctors don't think informed consent is possible. Here is what it tells potential patients:
Your face will be removed and replaced with one donated from a cadaver, matched for tissue type, age, sex and skin color. Surgery should last 8 to 10 hours; the hospital stay, 10 to 14 days.
Complications could include infections that turn your new face black and require a second transplant or reconstruction with skin grafts. Drugs to prevent rejection will be needed lifelong, raising the risk of kidney damage and cancer.
After the transplant you might feel remorse, disappointment, grief or guilt toward the donor. The clinic will try to shield your identity, but the media probably will discover it.
The clinic will cover costs for the first patient; nothing about others has been decided.
Another form tells donor families that the person receiving the face will not resemble their dead loved one. The recipient should look similar to how he or she did before the injury because the new skin goes on existing bone and muscle, which give a face its shape.
Research suggests the result will be a combination of the two appearances.
It took more than a year to win approval from the 13-member Institutional Review Board, the clinic's gatekeeper of research. Siemionow assembled surgeons, psychiatrists, social workers, therapists, nurses and patient advocates, and worked with LifeBanc, the organ procurement agency she expected would help obtain a face.
At first, there was opposition, acknowledged the board's vice chairman, Dr. Alan E. Lichtin. After months of debate, Siemionow brought in photographs of potential patients.
Looking at the contorted images, Lichtin said he was struck by "the failure of the present state of the art to help these people." He decided he didn't want to deprive the surgeon or patients of the chance.
The board's decision didn't have to be unanimous, but it was.
Surgeons wished they could have done a transplant six years ago, when a 2-year-old boy attacked by a pit bull was brought to the University of Texas in Dallas, where Dr. Karol A. Gutowski was training.
Other doctors had tried to reattach part of the boy's mauled face but it didn't take. The Texas surgeons did five skin grafts in a bloody, 28-hour surgery. Muscles from the boy's thigh were moved around his mouth. Part of his abdomen became the lower part of his face. Two forearm sections became lips and mouth.
Surviving such wounds can be "life by 1,000 cuts." Patients endure dozens of operations to graft skin from their backs, arms, buttocks and legs. Only small amounts can be taken at a time because of bleeding.
Surgeons often return to the same areas every few weeks, reopening old wounds and building up skin. Years later, many patients are still having surgeries. A face transplant -- applying a sheet of skin in one operation -- could be a solution.