In January 2018, a surgical team from NYU Langone Health performed its second face transplant, replacing much of the upper, mid, and lower face and jaws of a 26-year-old man from California. NYU Langone Health is one of only a handful of medical centers in the United States—and the only one in New York State—with a dedicated program for face transplantation.
The surgery, which began the morning of Friday, January 5, took approximately 25 hours, concluding the following morning. A team of more than 100 medical professionals, including surgeons, nurses, and other staff, was once again 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 performed under the leadership of Dr. Rodriguez. In August 2015, he and his team at NYU Langone performed what is widely considered the most extensive face transplant on record.
The recipient in this recent case is Cameron Underwood of Yuba City, California, who suffered a self-inflicted facial gunshot wound in June 2016. As a result, and despite several attempts at conventional reconstruction, Underwood was missing the majority of his lower jaw, all but one tooth, and his nose, as well as suffering damage to his maxillary (upper face) 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,” Dr. Rodriguez says. “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 has 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.
Shortest Period of Time from Injury to Face Transplant in the United States—18 Months
Underwood was wounded in June 2016, approximately 18 months prior to his surgery—a significantly shorter duration of time from initial injury than previous cases publicly reported in the United States. Dr. Rodriguez points out that this will help with physical and, equally important, emotional recovery, therefore avoiding the psychological burden of living with such a disfigurement.
“Cameron has not lived with his injury for a decade or longer like most other face transplant recipients have,” he says. “As a result, he has not had to deal with many of the long-term psychosocial issues which often lead to issues like severe depression, substance abuse, and other potentially harmful behaviors.”
Longest Distance to Travel for Face Transplant—2,800 Miles
Underwood was home in California when he received a call from Dr. Rodriguez that a donor had been identified and had to travel across the country to arrive in New York City in time for his surgery. To complicate matters, when his plane took off from the West Coast, the entire Northeast region of the country was bracing for a major blizzard nicknamed “The Bomb Cyclone.” But through advance planning with medical air ambulance transportation services, Underwood arrived just in time for his 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,” says his mother, Beverly Bailey-Potter, who first read about Dr. Rodriguez in a magazine article about one of his previous surgeries. “We were willing to travel the long distance.”
One of the Shortest Wait Times for a Donor—6 Months
Once Underwood’s case cleared all approvals within NYU Langone, he was officially listed in July 2017 for organ donation with the United Network for Organ Sharing (UNOS), the private, nonprofit organization that manages the nation’s organ transplant system.
Locally, the effort to find a donor for Underwood was led by LiveOnNY, the organ recovery organization for the greater New York metropolitan area and a member of UNOS. On December 31, 2017, just six months after Underwood was listed for organ donation, coordinators from LiveOnNY identified a potential donor at another medical center in New York City. He was brought to Dr. Rodriguez’s attention two days later, and after a series of evaluations, was accepted as a donor for Underwood.
Financial Reimbursement Support from Commercial Insurance
Most face transplant cases in the U.S. have been performed under research grants, mostly from the U.S. Department of Defense. However, Underwood’s third-party private insurer, which he has through his employer, has covered significant costs related to his surgery, as well as pre- and postoperative care.
“This is yet another watershed moment in the advancement of face transplantation,” says G. Leslie Bernstein, administrator for the Face Transplant Program at NYU Langone Health and the 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.”
Significant Reductions in Surgical Time and Hospital Length of Stay
When Dr. Rodriguez operated on Richard Lee Norris, his first face transplant patient, at the University of Maryland in 2012—whose injuries were similar to Underwood’s—the surgery took more than 36 hours. In Underwood’s case, Dr. Rodriguez and his team were able to reduce 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,” Dr. Rodriguez says. “This is critically important, not only from a fatigue factor for the surgical team, but also for Cameron’s recovery. A shorter surgery often translates into less risk of complications.”
In addition, Underwood’s postoperative care team achieved significant reductions in various aspects of his hospital stay, compared with the first face transplant case performed at NYU Langone. These include total length of stay reduced from 62 days to 37 days, days in the intensive care unit (ICU) reduced from 51 to 23, and days spent in rehabilitation reduced from 13 to 7.
Most Technologically Advanced Face Transplant
Much of the presurgical planning and actual surgery on both the donor and recipient were guided by state-of-the-art technology. The use of three-dimensional computer surgical planning, three-dimensional printed patient-specific cutting guides, intraoperative navigation, and intraoperative CAT scan ensured that 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,” says Dr. Rodriguez.
Because of the extent of Underwood’s injury, Dr. Rodriguez and his team had to graft the entire mid and lower components of the donor’s skull and face. This included transplanting and reconstructing the following:
- maxillary (upper jaw) and mandibular (lower jaw) bones, including all 32 teeth and gums
- palate (roof of the mouth) and floor of the mouth, excluding the tongue, although Underwood’s tongue required some reconstruction)
- lower eyelids and cheeks; Underwood’s upper eyelids were preserved
- 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 Dr. Rodriguez and his team performed the transplant.
Dr. 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, Rodriguez and his team used for the first time a new approach to restore the integrity of the donor’s identity after the face was removed: a three-dimensional printed mask of the donor’s face. In partnership with a team from NYU’s advanced three-dimensional media services center, LaGuardia Studio, they made a high-resolution scan of Fisher’s face to create a lifelike, synthetic mask that went on his body prior to returning it to his family. Previously, a molded, hand-painted silicone mask had been used. There are few printers in the world like the one at LaGuardia, which prints with 60,000 colors.
Helen Irving, president and chief executive officer of LiveOnNY, adds, “We believe the three-dimensional mask makes the donation journey more comfortable and, perhaps, a bit easier for the donor family.”
About the Donor
William Fisher was a 23-year-old Manhattan resident, a chess champion, 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. Will also was a registered organ donor, a status he actually designated in his teens.
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,” says 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,” says Sally. “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.”
Sally also adds, “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.”
What Lies Ahead
Following 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, NYU Langone’s partner organization that provides individuals with craniofacial differences comprehensive care by funding medical, surgical, dental, psychosocial support, travel, and housing.
From there, he continued outpatient rehabilitation including physical, occupational, and speech therapy. Cameron also received orthodontic treatment for several months, supported by myFace.
On March 29, he returned home to Yuba City just in time for the Easter holiday. Underwood comes back to New York City monthly for follow-up appointments.
Like all transplant recipients, Underwood remains on a strict regimen of anti-rejection medications for the rest of his life to ensure that 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,” says Bruce 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,” he says. “I will never forget that. 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. The journey hasn’t been easy, but it’s been well worth it.”
Multimedia Materials Available
Multimedia materials, including pre- and post-photos, quote sheet, broll package, and a three-dimensional surgical visualization video, are available upon request.