In January of 2018, a surgical team from NYU Langone Health performed its second face transplant, replacing much of the upper, middle, and lower face and jaws of a 26-year-old man from California. NYU Langone is one of only a few medical centers in the United States and the only one in New York with a dedicated program for face transplantation.
Beginning the morning of January 5, the surgery took about 25 hours. More than 100 medical professionals took part in the procedure, led by Eduardo D. Rodriguez, MD, DDS, the Helen L. Kimmel Professor of Reconstructive Plastic Surgery and chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone.
This is the third face transplant led by Rodriguez. In August 2015, he and his team performed what is widely considered the most extensive face transplant on record. The recipient in the most recent case was Cameron Underwood of Yuba City, California, who suffered a self-inflicted gunshot wound in June 2016.
Despite several attempts at conventional reconstruction, Underwood was missing most of his lower jaw, all but one tooth, and his nose. He also had suffered damage to his maxillary region and palate, severely impacting his ability to lead a normal life.
“When we first met Cameron, we were confident we could improve his appearance and, more importantly, his function and quality of life,” said Rodriguez. “Advances in medical technology allow us to more rapidly evaluate donors and recipients for face transplant and to perform surgery more safely and efficiently. But in the end, it’s all about the patient. Cameron has put in the work and made the necessary commitments.”
Since the first face transplant in 2005, more than 40 have been performed worldwide. This latest surgery sets significant milestones in the procedure, including the shortest period of time from injury to transplant in the United States at 18 months. Rodriguez notes that this will help with Underwood’s physical and emotional recovery.
“Cameron has not lived with his injury for a decade or longer like most other face transplant recipients have,” said Rodriguez. “As a result, he has not had to deal with many of the long-term psycho-social issues which often lead to issues like severe depression, substance abuse, and other potentially harmful behaviors.”
The surgery also represents the longest distance to travel for a face transplant at 2,800 miles. Underwood was home in California when he was notified a donor was available in New York City. Making matters worse, when his plane took off from the West Coast, the Northeast was bracing for a blizzard. Advance planning and medical air ambulance transportation, however, got Underwood into New York City just in time for presurgical testing.
“When we read about what Dr. Rodriguez had done for his other patients, we knew he was the only person to whom we would trust Cameron’s life,” said Cameron’s mother, Beverly Bailey-Potter, who first read about Rodriguez in a magazine article about one of his previous surgeries. “We were willing to travel the long distance.”
Plus, the surgery included one of the shortest wait times for a donor at six months. Once Underwood cleared all approvals within NYU Langone, he was listed in July 2017 for organ donation with the United Network for Organ Sharing. Locally, LiveOnNY led the effort to find a donor.
On December 31, 2017, six months after Underwood was listed for organ donation, LiveOnNY coordinators identified a potential donor at another medical center in New York City. He was brought to Rodriguez’s attention two days later, and after a series of evaluations, he was accepted as a donor for Underwood.
Financial reimbursement support from commercial insurance was a milestone as well. Most face transplant cases in the United States have been performed under research grants, mostly from the Department of Defense. But Underwood’s third-party private insurer, which he has through his employer, has covered significant costs related to his surgery and his pre-operative and post-operative care.
“This is yet another watershed moment in the advancement of face transplantation,” said G. Leslie Bernstein, administrator for the Face Transplant Program at NYU Langone Health and principal negotiator with Underwood’s private insurer. “Securing coverage for Cameron’s medical care, for both his face transplant and his continuing aftercare, illustrates how this field is moving closer toward an accepted standard of care.”
Plus, the surgery represents significant reductions in surgical time and hospital length of stay. When Rodriguez operated on Richard Lee Norris, his first face transplant patient, in 2012, treating injuries similar to Underwood’s, the surgery took more than 36 hours. Underwood’s case reduced operating room (OR) time by more than 11 hours.
“Having already done two face transplants, we identified even before we entered the OR where we could reduce surgical time,” Rodriguez said. “This is critically important, not only for a fatigue factor for the surgical team, but also for Cameron’s recovery. A shorter surgery often translates into less risk of complications.”
The postoperative care team also achieved significant reductions in various aspects of Underwood’s hospital stay, compared to the first face transplant case performed at NYU Langone. These include total length of stay (37 versus 62 days), ICU days (23 versus 51), and days spent in rehabilitation (7 versus 13).
Much of the presurgical planning and actual surgery on both the donor and recipient were guided by technologies including 3-D computer surgical planning, 3-D printed patient-specific cutting guides, intraoperative navigation, and intraoperative CAT scans, which all ensured that the facial bones were aligned perfectly and that implantable plates and screws used to anchor the grafted face to Underwood were in an ideal position.
“Technical advances have increased our ability to tackle the most complex cases more precisely with maximal aesthetic and functional results,” said Rodriguez.
Because of the extend of Underwood’s injury, Rodriguez and his team had to graft the entire middle and lower components of the donor’s skull and face. This included transplanting and reconstructing:
- The maxillary and mandibular bones, including all 32 teeth and gums
- The palate and floor of the mouth, excluding the tongue, though Underwood’s tongue required some reconstruction
- The lower eyelids and cheeks, though Underwood’s upper eyelids were preserved
- The nose and sections of the nasal passage
As in most face transplant surgeries, the recovery of the donor’s face and other organs occurred in one operating room, while Underwood was prepared for the transplant in an adjoining OR. Once the donated face was procured, it was brought to Underwood’s OR, where the transplant was performed.
Rodriguez has since performed several less extensive follow-up surgeries on Underwood to optimize his functional and aesthetic outcomes after swelling subsided and his face further healed. In addition, the team created a 3-D mask of the donor’s face to preserve the integrity of his identity after his face was removed.
In partnership with a team from NYU’s advanced 3-D media services center, LaGuardia Studio made a high-resolution scan of the donor’s face to create a lifelike, synthetic mask that went on his body prior to its return to his family. Previously, a molded, hand-painted silicone mask had been used. There are few printers in the world like LaGuardia’s, which offers 60,000 colors.
“We believe the 3-D mask makes the donation journey more comfortable and, perhaps, a bit easier for the donor family,” said Helen Irving, president and chief executive officer of LiveOnNY.
Donor William Fisher was a 23-year-old Manhattan resident, a chess champion, an aspiring writer and filmmaker, and a student at Johns Hopkins University. He is fondly remembered by his family and friends as extremely intelligent, funny, and compassionate. He also was a registered organ donor, a status he designated while he was a teenager.
After being identified in the hospital as a potential donor for Underwood by LiveOnNY, and with consent from his family, Fisher was transported to NYU Langone, where further tests were conducted to confirm him as an ideal match. His surgery included not only the recovery of his face but other organs as well including his heart, liver, kidneys, eyes, and other tissues for immunologic research.
“None of this would have been possible without Will and his mother, Sara, who chose to give the gift of life,” said Irving. “Their generosity saved not only Cameron’s life, but other lives as well. LiveOnNY was honored to help fulfill their wishes. With the continued selflessness of donors and their loved ones like the Fisher family, and the drive and determination of transplant partners like NYU Langone, the positive impact of donation and transplantation will continue to grow.”
Still deeply saddened by the loss of her son, Sally, as Sara prefers to be called, acknowledges the importance of Will’s decision to be an organ donor.
“My son’s death was a tragedy. I am thankful that, in honoring his decision, we were able to give life to others, and especially that Will and Dr. Rodriguez have given Cameron and his family a chance to recapture their dreams,” said Sally.
“Being a part of this experience has been a source of strength for me during a very difficult time. I don’t think I would have survived Will’s death if not for Cameron. Cameron has his whole life ahead of him, and I love the idea that Willie is helping him have a better life,” Sally said.
After the surgery, Underwood spent several weeks at NYU Langone. He was discharged on February 16, weeks ahead of schedule, to a nearby apartment provided by myFace, an NYU Langone’s partner that provides individuals with craniofacial differences comprehensive care by funding medical, surgical, dental, and psychosocial support, travel, and housing.
From the, Underwood continued outpatient rehabilitation including physical, occupational, and speech therapy. He also received orthodontic treatment for several months, supported by myFace. On March 29, he returned home to Yuba City in time for Easter. He returns to New York City each month for follow-up appointments.
Like all transplant recipients, Underwood will remain on a strict regimen of anti-rejection medications for the rest of his life to ensure he does not have a rejection episode, which he has yet to have.
“We are thrilled that Cameron is responding so well to the transplant,” said Bruce E. Gelb, MD, a transplant surgeon at NYU Langone. “Our team has established a successful, novel, patient-donor matching protocol and immune suppression regimen that we believe provides the best outcomes for our patients because the risk of rejection and toxicity is greatly minimized.”
Underwood remains positive and focused on his new life and is grateful to his donor and the Fisher family for what they have done for him.
“Will and his family made an incredible sacrifice to give back to me what had been lost. I will never forget that,” Underwood said.
“I’m also eternally grateful to Dr. Rodriguez and his face transplant team. My family and I could not have made this journey without them. We hope my experience inspires others who have severe facial injuries to have hope, as I was inspired by others who came before me,” Underwood said. “The journey hasn’t been east, but it’s been well worth it.”