In June 2005, just weeks after her dreadful injury, Isabelle Dinoire crossed the doorstep at the University Hospital in Amiens
After taking a handful of sleeping pills to allegedly end her life, Dinoire passed out and was attacked by her own dog. When she regained consciousness, she found out she had lost half her face -- no more lips, no nose, no chin.
"When I came to, there was blood on the ground and I tried to get up, to stand up, but I couldn't manage. I wasn't aware how bad a state I was in, only that I had blood on my arms. I tried to light a cigarette but I never got it to light," Dinoire said.
For a long time, doctors looked on helplessly at her disfigurement. But then a reconstructive specialist at the hospital said he had an idea.
"We all looked at each other and thought the same thing, and though nobody dared pronounce the word 'transplant.' It was kind of staring us in the face," said surgeon Dr. Sylvie Testelin.
Living Behind a Mask
A facial disfigurement is one of the most traumatic injuries a person can face, say many doctors.
"The lack of a face is very powerful narcissistic threat, it means we lose the part of our identity, that's to say, the image we constantly see of ourselves, an image with all its ups and downs," said psychiatrist Dr. Gabriel Burloux.
After her injury, Dinoire always wore a mask to keep people from seeing the hole where her face used to be.
"Even in the corridors the mask is always on. Even when I go for a shower the mask is always on," Dinoire said. "The first time I went outside, in some ways I was happy to be going out but in other ways I was frightened to leave the hospital. At the start, I cried every time I went out.
"Some people don't say anything out of the ordinary; they say hello, they talk. Other people look and shrink back. In the shops, some people even hide out of the way."
In hospitals all over the world, disfigured patients are treated using the same technique: Strips of muscle and skin are taken from the patient and used to reconstruct something that over the course of many successive operations starts to resemble a face.
Dr. Benoit Lengele said the results were usually disappointing.
"We could have reconstructed something like a face with the look of a jigsaw puzzle, with scars all over, on the forehead, on the cheeks as well no doubt; but it would have been something stilted, something deprived of any mobility or the ability to express feelings, and deprived also of its sensitivity, its sensations."
Because of the severity of her injury, Dinoire was in a way the ideal case for carrying out a face transplant.
Devauchelle and his team spent long hours working on the idea of composite tissue grafts -- grafts comprising skin, muscle, nerves, tendons, and blood vessels all in the same piece.
The surgical team was ready to try it, but they knew there would be formidable dangers.
During a transplant, the graft is naturally rejected by the body's immune system after a few days. It is vitally important to administer a treatment that weakens the body's natural defenses and gets it to tolerate the presence of tissue that doesn't belong there.
That's where Dr. Jean Michel Dubernard came in -- he is a transplant specialist with extensive experience with anti-rejection treatments. Dubernard said that he spoke to Dinoire and her father about all the risks she could face.
"And, uh, I was hesitating. But... when she removed the mask, my decision was immediate," he said. "I thought, if she were my daughter, I would not hesitate one minute."
With the main surgical problems resolved, there were still ethical concerns -- the taboo of taking someone's face.
"Unless you think things over carefully, it might seem like you're waiting for someone to die so you can salvage part of them. It's an idea that's hard to shake off," Dinoire said.
Dubernard shrugged off any notion that a face transplant operation was somehow ghoulish or strange.
"I don't like these words, you know, I am a doctor," he said. "Very strange, except they are not doctors, and they ... are not disfigured. We were thinking of the other patients, plenty of other patients that could benefit of this technique in the years to come."
Isabelle Dinoire, Devauchelle and Dubernard and the rest of the surgical team waited three months for a donor. Everything was set up, but if no one turned up before the year end, the whole team knew that tissue retraction would be so far advanced that the transplant would no longer be possible.
At last, on Nov. 26, after a wait of three months, a woman was found who met all the required criteria -- a 46-year-old brain-dead woman, on life support after a reportedly attempted suicide by hanging. Her family accepted the removal of her face for use in a transplant operation.
Dinoire, out with her family for the weekend, rushed back to Amiens. "That was it, it was total panic on board. I was all of a fluster. I hurried up, got my belongings together, called a taxi. It was a real race," she said.
At midnight, despite the prevailing good mood in the operating room, the tension was thick while the team made the last preparations. At 2 a.m., Devauchelle confirmed that the donor's face matched all requirements and began to remove it.
Testelin and Lengele had to prepare Dinoire's face for the transplant
"Which involved exploring the retracted, scarred tissue, very difficult to access for a surgeon, and finding all the muscles, all the vessels, all the nerves that we had identified beforehand as essential structures to be rebuilt, a perfect match for those Bernard Devauchelle was going to take from the donor," Lengele said.
At half-past six, the "retrieval" team arrived with the new face. With no time to lose, Dubernard and Deuvachelle worked on perfectly aligning the donor face with the reimplantation site.
When the main artery was sutured, the team knew it was "the moment of truth." As the artery was unclamped and the circulation was restarted -- the doctors erupted with emotion.
Lengele and others said the moment was magical. "When we wipe the face clean, when it comes back to life and we take off the clamps, what we see is a person resurfacing, a new, restored person, and that's the moment a surgeon stops being a surgeon and becomes a man or woman again and can live through the moment with a human's feelings and everything that stirs within," he said.
After leaving intensive care, Dinoire was transferred to a hospital in Lyon. Two days later, with the surgical team there, she was handed a mirror to see her new face.
"I was frightened of looking but when I did it was already marvelous and I couldn't believe it. I thought it was going to be all bruised and swollen, that it was going to be ugly, but it was already wonderful," Dinoire said.
The ordeal for Dinoire or her doctors wasn't over yet. Media from all over the world was obsessed with the story.
"I have to say also that we were harassed by media from all over the world," said Dubernard. "And it was a big problem for us. But also for our patient, because we wanted to protect this patient."
The unexpected publication of a newspaper article forced the team to comment in a press conference on their pioneering achievement a lot earlier than intended. But the news unleashed in the weeks following seemed to concentrate solely on the donor and on Dinoire's private life.
"They end up saying any old thing. Because no one can know exactly what it's like," Dinoire said. "I don't think there's anyone who can imagine everything I've felt."
Despite that, Dinoire's physical condition was progressing well, as she began to feel sensation in her new face. She does exercises each day to keep the progress going.
"It's not hard exercise --frowning, smiling, trying to raise the bottom lip. I'm beginning to resemble what I was like before," she said.
But doctors needed to monitor Dinoire's condition closely.
"We have no publications to refer to, no experience from similar cases, so we have to remain extremely vigilant, because we are partly ignorant of the signs that might warn us of a possible start of rejection," said Dr. Jean-Luc Beziat, part of the recovery team.
Monthly check-ups showed astonishing progress in muscle sensitivity and control.
But from February on, it became increasingly difficult to keep Dinoire away from the media spotlight. At a second press conference, she was asked by a reporter the first thing she wanted to do when she returned home. Dinoire replied: "Live with my daughters again and try to live normally without anyone pestering me."
Dinoire will always be the first person to have received a face transplant, so interest in her case is not likely to go away anytime soon.
"Ah yes, I was saved. Lots of people write to me telling me to keep my chin up, to fight on, that it's wonderful. Somewhere along the line it's a miracle," Dinoire said.
In the town of Amiens, in northern France, Dinoire agreed to meet last week with one of the documentary producers and to let them see her new face.
Her progress is remarkable -- the scars are far less visible and the muscles in her new face are gaining strength and mobility. Her expressions are becoming fuller and she seems well on the road to a complete recovery.
While facial transplant operations will remain an extremely rare medical option, they are no longer unthinkable. It is a remarkable gift -- Isabelle Dinoire is now able to live a life without a mask, without isolation. She can literally smile again and her life has begun anew.
"She's returning to a normal life," Dubernard said. "She is looking for a new apartment. And we hope that she will be able to return to work by October to social life. ... I'm very optimistic."