As we scrutinize our own faces for wrinkles and flaws, we can fail to notice what a marvelous organ the face is. Our faces are the most distinctive part of our visible body, a mysterious mosaic of the physical and the psychical. Faces are the body’s workaholics: They confer and confirm identity, express emotion, communicate meaning, perform basic functions necessary for life, and enable us to experience the world through our senses.
Take a moment to look in a mirror. What do you see? Most of us would answer, “Myself.”
My. Self. Our faces are the outer image we attach to our inner sense of self, to who we are and where we fit in the world. Faces root us in our culture, in the rituals and rules about how we present ourselves and how we see others. In some cultures, faces are veiled and hidden. Other cultures draw attention to faces with displays of tattoos, piercings, and scarification. In the contemporary world, faces are often a blank canvas to be manipulated with cosmetic surgery, injections, and intricate makeup techniques learned on YouTube. If we allow them to age, our faces will tell our life story. They connect us to the past in our ancestors and to the future in our children.
At the simplest level of identity, our faces function as our passport photo to the rest of the world. But they’re also the way others seek to know us more deeply, to discover who we are behind that photo. “Appearance is the most public part of the self. It is our sacrament, the visible self that the world assumes to be a mirror of the invisible, inner self,” wrote Harvard Medical School psychologist Nancy Etcoff in her book Survival of the Prettiest.
Whether the emotions we express with our faces are evolutionary adaptations or learned social behaviors is a topic hotly debated among social scientists. Charles Darwin argued in 1872 that facial expressions displaying some emotions are universal adaptations. In the late 1960s the psychologist Paul Ekman concluded that Darwin was correct. Human beings, across cultures, recognize specific facial displays associated with basic emotions: anger, disgust, fear, joy, sadness, and surprise.
Look in the mirror again. Think about what you can do with that face. You can kiss the ones you love, bite into an apple, sing, and sigh. You can smell freshly cut grass. You can gaze at your newborn and touch your cheek to his. Beyond showing (or not showing) our emotions, faces enhance our ability to communicate with language. We smile, we wrinkle our noses, we wink, we grimace, we perform countless expressions as we converse, often without even realizing it.
Now visualize what goes on beneath that astonishing face. We have 43 mimetic muscles to express emotion and articulate speech. We have four major muscles on each side of the face that move the jaws and complex lingual muscles that assist in swallowing and speech. The face is also made up of layers of blood vessels, sensory and motor nerves, cartilage, bone, and fat. Cranial nerves control the motor muscles and transmit sensory information to the brain, enabling us to see, smell, taste, hear, and feel sensation on the skin.
Go back to the mirror one more time. Look at your incredible face.
Imagine what it would mean to lose it.
Katie was just 18 when she lost her face. That face now exists only in photographs. In a cruel reversal of the before-and-after makeovers of reality TV and Instagram, her “before” photos show a girl with a wide smile and flawless skin, a girl so young and beautiful she could have walked off the cover of Seventeen magazine.
This photographic evidence didn’t persuade Katie. “I never thought of myself as beautiful,” she told me one day, a few months after we met. Her mother, Alesia, wasn’t surprised to hear it. Katie was a perfectionist, she said: “Katie has a big heart for other people, but she was always so hard on herself.” When I looked at the photos again, I saw a hint of fragility in her face, a glimmer of the cost of being perfect.
Katie was an irrepressible little girl, her older sister, Olivia McCay, told me. “She was fearless, very fearless, and a lot of fun.” She developed a quick, sarcastic sense of humor, a trait she shared with her brother, Robert. But as she grew older, Olivia noticed, Katie put enormous pressure on herself to achieve. “She wanted to be the best in all of these sports that she’d never even tried before,” Olivia said. “She wanted to be the best academically. She studied for hours, all the time.”
When Katie was in high school, the family made two major moves. Her sophomore year they moved from Lakeland, Florida, where she grew up, to Owensboro, Kentucky. She’d just settled in when they moved again, a year later, to Oxford, Mississippi. Her father, Robb, who’d been a minister and educator, and Alesia took jobs teaching at a small Christian school. Katie enrolled as a junior and fell in love with a classmate. They started talking about marriage. “This one was just so serious for so young,” Olivia said. “She just grew up so fast that year.” After the moves, she said, “I think she was ready to have some stability and some consistency.”
She didn’t get them. In her senior year Katie’s world unraveled. She was already contending with chronic gastrointestinal troubles and surgery. She’d had her appendix taken out the year before, and complications led to the removal of her gallbladder in January of her senior year. Two months later, the Stubblefields told me, the school’s headmaster informed them that he would not renew their contracts and then abruptly fired Alesia. Katie, who had trusted the headmaster, felt betrayed.
Then, on March 25, 2014, Katie picked up her boyfriend’s phone and found texts to another girl. When she confronted him, her family told me, he broke up with her.
Hurt and angry, Katie went to Robert’s place in Oxford, where she furiously texted and paced, back and forth. Robert called their mother. While the two were outside talking about how upset Katie was, she went into the bathroom, put the barrel of Robert’s .308-caliber hunting rifle below her chin, and pulled the trigger. When Robert kicked in the locked door, he found his little sister covered in blood. “And her face is gone,” he recalled, still shaken by the memory.
The bullet was a pernicious thief. To get a measure of what it stole from Katie, hold your hands up to your face, palms out, your thumbs touching beneath your chin and your index fingers touching between your eyebrows. Your hands are framing the part of Katie’s face she lost. Gone were part of her forehead; her nose and sinuses; her mouth, except for the corners of her lips; and much of her mandible and maxilla, the bones that make up the jaws and front of the face. Her eyes remained, but they were askew and badly damaged.
This is how Katie arrived more than five weeks later at the clinic, which was founded in Cleveland, Ohio, in 1921 by four doctors, three of whom had served together during World War I and had come home inspired by the military model of teamwork among specialists. In Memphis, Tennessee, where Katie was first operated on, doctors had saved her life against all odds, but their attempt to cover the gaping wound with a tissue graft from her abdomen hadn’t worked.
Brian Gastman, the first clinic doctor to see Katie, lifted her onto a gurney and wondered if she would make it. She was so tiny. Just 105 pounds. Even if she survived, he wasn’t sure she would have enough tissue for all the reconstructive work he needed to do. “It was not great,” he said. “Her brain was basically exposed, and I mean, we’re talking seizures and infections and all kinds of problems. Forget the face transplant; we’re talking about just being alive.”
In his 27 years of training and practice, Gastman said, this was one of the worst face traumas he’d ever encountered. Beyond the wound to her face, she had traumatic brain injury from the bullet’s concussive force to her frontal lobe, optic nerve, and pituitary gland. The damage to her pituitary threw her hormones and sodium levels out of whack, which can be deadly. Taking charge of Katie’s care, Gastman organized a multidisciplinary team of 15 specialists to address all her issues, from endocrinology to psychiatry.
Gastman, who is 48, gives the impression that he’s always late, claiming that he has an attention deficit disorder personality. If he weren’t joking, it would make sense, considering his many roles. He specializes in head, neck, skin, and high-risk soft-tissue cancers. As a plastic surgeon, he removes tumors and does follow-up reconstructions. He also co-directs the melanoma and high-risk skin cancer program and runs his own research lab.
Robb, Alesia, and Katie often say that Gastman loves Katie like a daughter. I asked him about that. The question made him uncomfortable, and he paused a moment before answering. “I’m not a touchy-feely–type person to begin with, whether it be my own family members or Katie,” he said carefully. “But I feel very responsible to her. This is my life mission. With someone like her, who’s so young, it’s the pinnacle. This is what my training should be for.”
“Katie loves Dr. Gastman,” Alesia said, “but she has an old-man crush on Dr. Papay.” Papay, who is 64, chairs the clinic’s Dermatology and Plastic Surgery Institute. He acts as the suave counterpoint to Gastman, with his silvery gray hair and bon vivant manner. His years of work with face transplants also make him the voice of experience and wisdom on the clinic’s face transplant team.
Papay studied biomedical engineering before going to medical school; his training taught him to “work from failure,” anticipating potential problems and devising solutions. Papay told me he gravitated to plastic surgery because it’s about function as much as form. “Everyone thinks that we’re the cosmetic guys, the hairdressers of surgery, and we do face-lifts and breast augmentations,” he said. “But in plastic surgery and now face transplants we’re innovators—we’re fix-it guys.”
Over the course of many surgeries, Gastman and a team of specialists stabilized Katie and patched her face. They removed and repaired shattered bones. To create a nasal passage and protect her brain, Gastman made a rudimentary nose and upper lip from her thigh tissue rolled up inside out. For a chin and lower lip, he used a piece of her Achilles tendon. The doctors fashioned a new lower jawbone from titanium and a piece of her fibula with flesh still attached, using as a guide a 3D model made from a scan of Olivia’s jaw. To move Katie’s eyes closer together, they attached to her skull a distraction device, adjusting it day by day. It was challenging work, and Gastman was proud of it.
Katie had never seen this face, but she had come to know it by touch—the crooked tube of flesh in the center, the bulbous chin. She knew her eyes looked as though someone had grabbed her by the cheeks and jerked up on one side and down on the other.
She called this face, the second of her young life, Shrek.