"Most programs do exclude patients who are non-compliant or not adherent with medical therapy, and most exclude patients who continue to engage in the same behaviors that resulted in end-organ damage -- intravenous drug abuse, continued alcoholism, et cetera," said Dr. David Cronin, director of liver transplantation at Froedtert Memorial Lutheran Hospital in Milwaukee. "On the issue of face transplantation, I suspect that many of the candidates incurred their 'end-organ failure' from an accident or war-related injury."
So while there are standard exclusion criteria for some forms of organ transplant -- for example, a patient in need of a liver may be denied a spot on the UNOS waiting list if he cannot abstain from alcohol for six months before surgery -- there are currently no such restrictions for face transplant candidates.
This makes is difficult to determine whether Maki, who has a past history of drug abuse, would normally fit the bill of an ideal organ recipient. By the same token, the world's first face transplant patient, Frenchwoman Isabelle Dinoire, in a much-publicized story, continued her smoking habit as her grafted tissue healed.
Rather, facial transplant patients are largely selected by a process of elimination -- those patients for whom other surgeries have not worked.
"In my mind, facial transplants have to occur when traditional methods fail," said lead surgeon Dr. Bohdan Pomahac of Brigham and Women's Hospital in Boston at the Thursday press conference.
The extent of Maki's injuries, Pomahac said, certainly fulfilled this criterion. Pomahac was the burn surgeon on duty when Maki arrived in the Brigham and Women's Hospital emergency department after the accident that destroyed his face.
"He burned off his face, including nose, upper lip, roof of the mouth, et cetera," Pomahac said.
Indeed, Maki's injuries were so profound that there are hints that Brigham and Women's Hospital may have bent its previous rules on who could be considered a viable patient for the procedure.
As late as last year, Brigham and Women's had publicly stated that it would not perform this kind of transplant because of ethics guidelines that it created when face transplants first became a viable option. Citing the rigors and side effects of immunosuppressant therapy to prevent organ rejection, the hospital's old rules, now changed, would only allow a patient to receive a face transplant procedure if he or she already was using these drugs after a procedure such as a heart or kidney transplant.
However, doctors and ethicists have subsequently agreed the move was likely justified.
"It is hard for us to imagine how difficult it was for Jim. He feared going outside," Pomahac said. "I feel that we are here on a mission, using cutting-edge technology to restore patients' lives."
While finding a family who is willing to donate the face of their deceased loved on is still a challenging prerequisite for face transplant surgery, the number of patients involved in these surgeries is still small enough that large-scale selection criteria probably do not come into play.