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It's only a matter of time before real surgeons perform a face transplant, say experts such as Dr. W.P. Andrew Lee, chief of plastic surgery at the University of Pittsburgh Medical Center.

Successful human hand transplants during the past five years have increased the feasibility and likelihood that face transplants will be attempted on humans, said Lee, a hand surgeon. The potential benefits of a face transplant are great to patients severely disfigured by burns or accidents.

But the question is, are the risks worth it? Powerful and toxic anti-rejection drugs could shorten lives for what is not a life-saving operation, said Lee. And an array of ethical concerns also have kept a face transplant from being tried so far.

The ethical issues are "as bad as I've ever encountered in 25 years in bioethics," said Arthur Caplan, chairman of the department of medical ethics at the University of Pennsylvania Medical School in Philadelphia.

People with severe facial disfigurement are treated by a series of operations that transplant tissue, fat, nerves and other needed structures from elsewhere in their bodies. In solving one problem, another area can be left susceptible to infections, scarring and sometimes disfigurement, Lee said.

Even after scores of operations, patients sometimes still look disfigured, and surgeons cannot adequately rebuild noses or ears, Lee said.

The University of Louisville will seek permission -- probably within the next few months -- from its Institutional Review Board to transplant a face from a cadaver to a live recipient, said spokeswoman Kathy Keadle.

Researchers in England and France also are discussing performing face transplants.

Researchers there are preparing a proposal to request permission from the Institutional Review Board to transplant a face from a cadaver donor to a live recipient. The board likely would spend a minimum of two months reviewing the proposal.

Hand and face transplants are similar and involve multiple systems -- skin, muscles, fat, blood vessels and nerves -- making them more complicated and more susceptible to rejection than single organ transplants, which involve only one type of genetic material, Lee said. Hand and limb transplants also involve bones and tendons.

The results of limb transplant experiments on animals are promising, and his team "may start doing a project on face transplants in the rats, probably in the fall," Lee said.

Rats and pigs that have had limbs transplanted at Pitt have lived without anti-rejection drugs for up to a year, which in some cases was the rest of their natural life spans, Lee said.

The biggest problem has been found in the pigs, which are closer to humans than rats. Pigs tend to reject the epidermis, the outermost layer of skin, the surgeon said.

If a human's epidermis were rejected, it likely would slough off naturally, and surgeons could repair it with skin grafts, he said.

Lifelong immunosuppressant therapy comes with several significantly increased risks: catching potentially deadly infections; developing malignant and life-threatening cancers, and toxicity that can damage other organs, including the liver and kidneys, and lead to other serious diseases, such as diabetes, Lee said.

"As many as 88 percent of organ transplant recipients receive some type of opportunistic infection," he said.

Lee said he doesn't think face transplant surgery is worth the risk unless the risk can be lowered dramatically.

"Face and hand transplants improve the quality of life but not the quantity of life," he said.

Lee and five other Pitt researchers are conducting animal studies to determine how to wean patients off anti-rejection drugs or at least lower the doses to less toxic levels.

The University of Louisville has done cadaver-to-cadaver face transplants, Keadle said.

It is the only U.S. institution to have attempted hand transplants on humans. Two hand transplants performed there were successful, she said.

Worldwide, 18 hand transplants have been reported, although only 14 have been confirmed, Lee said. Two of the transplanted hands had to be amputated later, he said.

Amputation works for failed hand transplants. But medical ethicists such as Caplan question what would happen to a patient whose body was rejecting a new face.

If another face was not available for transplant, the one being rejected could be removed and the patient treated like a burn victim, wrapped in bandages and treated with antibiotics, Lee said.

Caplan does not think that is an acceptable alternative.

"It's one thing to say your heart is rejecting and you're going to die within seconds. If your face is sloughing off your body -- can you imagine? It's a nightmare," Caplan said.

Neither Caplan nor Lee thinks the world is ready for face transplants, but both believe the research should continue.

Caplan argues not only that more animal studies are needed first, but that a face transplant should be tried first on a brain-dead patient because the potential psychological and physical pain are so great.

Among the unanswered ethical questions, Caplan said: What if a recipient undergoing rejection no longer wanted to be a part of the experiment and wanted to die? Would it be fair to force that person to endure more suffering and another transplant? Would interracial donations be permitted? What about from one gender to another?

He worries that even the discussion of a potential face transplant could cause would-be organ donors to shred their donor cards, even though donors can specify which body parts are donated.

"We need to have a (national) policy on this," Caplan said. "We need to think this through." The psychological and social ramifications need to be thought through more thoroughly, and institutions need to be prepared to emotionally support the patients and donors family, he said.

Critics worry that it would be disconcerting to see the deceased donor's face on someone else, but Lee said that's unlikely.

"The public perception of 'Face/Off' is not entirely accurate," he said of the 1997 movie in which the faces of characters played by John Travolta and Nicholas Cage were transplanted onto the other, looking exactly like the original.

In reality, the transplanted face probably would lose some of its identity, because the recipient's underlying bone structure would be different, Lee said. After the transplant, the person probably would look a little like himself and the donor, he said.

"My suspicion is it would still look like the recipient, because the bony structure is still the same and the personality would still be the same," he said.

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