Charla Nash, the woman who survived a vicious chimp attack last February, was recently told that she isn't a candidate for a face and hand transplant operation at the renowned Cleveland Clinic, where Nash has been receiving care for the past year.
Nash lost her face, fingers, lips nose and eyes when her friend Sandra Herold's 200-pound chimpanzee Travis attacked her at Herold's Stamford, Conn., home.
But her future has been pushed into limbo until doctors further develop the field of tissue transplantation, called allotransplantation.
Nash's attorney, Bill Monaco, said the family was told several weeks ago that the double hand and face transplants the family is hoping for will be fraught with difficulties.
"The Cleveland clinic has determined they don't believe they could adequately handle the hand transplant. So a facility that could handle both would need to do it," said Monaco of Feldman, Kramer & Monaco in Hauppauge, N.Y. "They've been great to Charla, but they can't take her all the way that we had hoped."
Monaco said the family is holding out hope for a double transplant rather than choosing either a face or a hand.
Given Nash's injuries and resulting disabilities, including blindness, it would be a hard decision. If she just had a face transplant and remained blind, she would have a near impossible time negotiating a prosthetic hand.
"It's essential for somebody in her position because she has lost her eyesight. A blind person typically uses their hands for sight," Monaco said.
But without a face transplant, Monaco said Nash will have lifelong difficulty.
"A face transplant would lead to better breathing, better smell, better tastes, better ability to eat -- all of the things we take for granted," he said. "Right now she had trouble just eating."
Cleveland Clinic spokeswoman Angie Kiska said doctors are not doing interviews about the decision or about Charla Nash. However, she said the face transplants are still "experimental" procedures.
"However, due to the complexity of her injuries, the medical team has concluded she is not a candidate for transplantation at this time," the hospital said in a statement.
The Cleveland Clinic was the site of the nation's first human face transplant and the feat has only been accomplished at a handful of sites around the world, including Boston's Brigham and Women's Hospital and the Amiens University Hospital in Amiens, France.
Surgeons at the Jewish Hospital in Louisville, Ky., completed the first hand transplants in the nation more than 10 years ago.
"When a patient is blind, they cannot feel or see their transplanted hand," Dr. Warren Breidenbach, of Jewish Hospital, told The Associated Press. "The feeling in the transplanted hand takes years to grow back."
So even if Nash got a hand transplant, it would be unclear how well she could learn to use her hands again.
Other transplant experts say the double transplant was inevitably going to complicate a process that takes years to coordinate even with a single transplant.
"A double transplant makes finding a donor more difficult, although face is the primary determinant of donor selection, hand must match as well," said Dr. Richard Winters of the department of facial and plastic surgery at Hackensack University Medical Center in New Jersey.
Winters also noted that the operation would be more difficult than the typical single transplant because the removing of both kinds of tissue from a recently deceased donor and then attaching them would have to be coordinated.
"A double transplant needs to be orchestrated simultaneously or preferably in sequence, for example the face followed in several days by the hand," Winters said. And, "Timely restoration of blood flow to transplanted parts is key -- so this requires unorthodox management of the donor."
Winters estimated that an institution like the Cleveland Clinic could get the high level of surgical expertise to do the transplants. However, he said face transplants have had some setbacks in the past and adding a second limb transplant to the procedure could only complicate things further.
"There have been postoperative issues with many of the hand and facial transplant patients done in the U.S.," he said. "Although the science has been elegantly outlined, the translation into clinical practice is very close… but not yet where it needs to be to consider a case like this."
People with transplants -- be it face, limb or organ -- all run the risk that their bodies reject the transplant, or in other words start treating the new tissue as an invasive disease and attack it. Winters said complications from this can be bad enough with a face transplant, but with two separate transplants, an infection or rejection in Nash's body could snowball into a very dangerous situation.
First, to keep patients from rejecting the body, doctors prescribe potent drugs to suppress the immune system. Winters said he worries that trying to get the body to accept two transplants may require dangerous levels of drugs.
"Should problems arise with one transplant or the other, as they often do in this type of surgery, one operation can compromise the other ... or more significantly can synergistically affect the overall morbidity/mortality of the patient," he said.
Monaco said the family is keeping its options open for the future at Cleveland Clinic, or even checking other hospitals to see if they might consider Nash as a candidate for a face-hand transplant.
"We are exploring it. We're exploring other facilities. I don't know of anybody who has done both (face and hand transplants) at the same time," Monaco said. "We're breaking new ground here."
Other hospitals recruiting candidates for face or hand transplants in the United States include Emory University in Atlanta, University of Louisville, University of Pittsburgh, and Brigham and Women's Hospital, according to Dr. Linda Cendales, of the Division of Plastic Surgery at Emory University School of Medicine.
Winters thought European facilities may have different guidelines that would accept Nash as a patient, but other transplant experts weren't so sure.
"She most likely will be met with the same decision (elsewhere)," said Dr. David H. Song, chief of Plastic Surgery at the University of Chicago Medical Center.
"While composite tissue allotransplantation (face, hands and other body parts) presents a promising field, there are still many unanswered questions and I believe once the facts on Ms. Nash's case comes out, the Cleveland Clinic's decisions will most likely be supported…" Song said.
Cendales said other centers will likely be strict as well.
"Currently, these types of transplants are under investigation and therefore are experimental, she said. "Any reputable program would have strict criteria for selecting candidates."
The Associated Press contributed to this article