A surgical team from NYU Langone Health performed a face and double hand transplant for a 22-year-old New Jersey resident severely burned in a horrific car crash. The surgery included transplanting both hands and the full face of a single donor. It marked the first successful combination transplant case of its kind in the world.
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About the Procedure
The surgery, which began the morning of Wednesday, August 12, took approximately 23 hours—a total surgery time shorter than NYU Langone’s most recent face-only transplant for Cameron Underwood performed in 2018. A team of more than 140 healthcare professionals, including surgeons, nurses, and other staff, was once again led by Eduardo D. Rodriguez, MD, DDS, director of the Face Transplant Program, the Helen L. Kimmel Professor of Reconstructive Plastic Surgery, and chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone.
The recipient in this recent case is Joe DiMeo of Clark, New Jersey, who received third-degree burns over 80 percent of his body from a car accident in July 2018. Despite having approximately 20 reconstructive surgeries, DiMeo had extensive injuries—including amputated fingertips, severe facial scarring, and no lips or eyelids—that affected his vision and daily activities, and severely limited his ability to live a functional and independent life.
“Joe was an ideal candidate for this procedure; he’s extremely motivated and dedicated to recovering the independence he lost after his accident,” says Dr. Rodriguez. “Thanks to the institutional support we received here at NYU Langone and a world-class team committed to providing the best care for our patient, we’ve succeeded in a tremendous undertaking that shows we can continue to take on new challenges and advance the field of transplantation.”
A New Chapter for a Pioneering Program
This is the fourth face transplant performed under the leadership of Dr. Rodriguez and the first hand transplant under his direction. While two other simultaneous face and hand transplant attempts are known to have been performed, in each case there was an adverse outcome: one patient ultimately died due to infectious complications, and another required removal of the hands after they failed to thrive.
“Fundamentally, I viewed this as the same type of surgical exercise as our previous successful face transplants,” Dr. Rodriguez says. “I saw no reason why we couldn’t achieve this outcome to help improve Joe’s function and quality of life.”
As they do in all transplant operations, the surgeons sought to complete the procedure as quickly as possible to limit the ischemia time, or the amount of time the donated tissue is not receiving a blood supply. The surgery was precisely orchestrated to connect the tissues quickly in order to ensure the optimal outcome for the recipient as well as for the other lifesaving organs made available by the donor.
Navigating the COVID-19 Pandemic
Just three months after DiMeo was listed for organ donation with the United Network for Organ Sharing (UNOS) in October 2019, the first coronavirus disease (COVID-19) case was identified in the United States. In March, elective surgeries were halted in New York. Medical professionals in New York City, including members of NYU Langone’s face and hand transplant team, were reassigned to work in COVID-19 units as the number of positive cases surged.
Despite the additional demands during this time, the core surgical team continued to safely perform monthly rehearsals to ensure a seamless operation when the time came. DiMeo was listed for just 10 months before a donor was identified; his total time from injury to transplant was 2 years.
A Needle in a Haystack
Due to the multiple lifesaving blood transfusions and skin grafts DiMeo received after the initial accident, his immune system was highly sensitized. His panel reactive antibody (PRA), which reveals the percentage of donors the recipient would reject, was 94 percent—meaning he had just a 6 percent chance of finding a compatible donor. Adding in other factors such as bone structure and skin tone matching meant that “finding Joe the perfect donor was like finding a needle in a haystack,” says Dr. Rodriguez.
Locally, the effort to find a donor for DiMeo was led by LiveOnNY, the organ recovery organization for the greater New York metropolitan area and a member of UNOS. To expand the pool of potential donors, NYU Langone broadened the donor search to organ procurement agencies across the country. An exact match for DiMeo was ultimately identified by Gift of Life, the regional organ donor program serving Southern New Jersey, Pennsylvania, and Delaware. After Dr. Rodriguez traveled to Delaware to perform a series of evaluations, the donor’s body was brought to NYU Langone for the transplant surgery.
“Gift of Life Donor Program is proud to have collaborated with such a distinctive team of medical professionals on the first face and bilateral hand transplant in U.S. history. We congratulate our colleagues at NYU Langone Health on this pioneering medical milestone and are thrilled to hear that the patient is doing so well,” says Richard D. Hasz Jr., MFS, CPTC, vice president of clinical services, Gift of Life Donor Program. “This transplant was possible because a selfless family said yes to this unique donation. The donor’s mother shares that she is proud and comforted that her son was able to help another young man while also saving and healing others through organ and tissue donation. She says her son will always be her angel. Gift of Life salutes the donor family’s enduring generosity and pays tribute to the heroic donor. It was an honor to coordinate the donation on their behalf and to contribute our national leadership and expertise in organ procurement and the coordination of these rare and complex donations to help heal and transform a young man’s life. Our thoughts are with the donor family and the recipient that they find the healing and hope donation makes possible.”
“Dr. Rodriguez and the NYU Langone transplantation team continue to show that organ donation and transplantation is an ever-expanding field that continues to help people in new and exciting ways,” says Helen Irving, president and chief executive officer of LiveOnNY. “It is important to remember that none of this would be possible without the selfless organ donor who chose to give the gift of life. This is groundbreaking work that will continue to save lives as more New Yorkers sign up on the New York State Donate Life Registry.”
Scientific and Technological Advances
In collaboration with Depuy Synthes and Materialise, much of the presurgical planning and the surgery itself were guided by state-of-the-art technology. The use of three-dimensional (3D) computer surgical planning and 3D-printed patient-specific cutting guides ensured that bones were aligned perfectly and that implantable plates and screws were in the best position to anchor the grafted face and hands to DiMeo. The collaborations were integral to the success of the surgery.
DiMeo’s surgery was the first of its kind to be performed in NYU Langone’s new Kimmel Pavilion, which opened in June 2018. The cutting-edge technology and expansive operating rooms (ORs) enabled six highly skilled surgical teams—one for each hand and another for the face of both the donor and recipient—to simultaneously operate in both the donor and recipient rooms.
“We practiced the surgery nearly a dozen times over the course of a year, and in the ORs we had teams ensuring everyone followed the steps exactly so we didn’t skip a beat or get out of sequence. Ultimately, it went better than I ever expected,” says Dr. Rodriguez.
The teams followed a finely calibrated schedule to transplant and reconstruct the donor’s hands and face onto DiMeo. Dr. Rodriguez and his surgical team of 16—and OR team of 80—transplanted the following:
- both hands to the mid-forearm, including the radius and ulna, 3 dominant nerves to the hand, 6 vessels requiring vascular connections, and 21 tendons
- full face including the forehead, eyebrows, both ears, nose, eyelids, lips, and underlying skull, cheek, nasal, and chin bone segments
Dr. Rodriguez has since performed several less extensive follow-up surgeries for DiMeo to optimize his functional and aesthetic outcomes.
Advances in immune system monitoring allowed for the initial successful match as well as DiMeo’s lack of rejection episodes to date. “As we did with our previous face transplant recipients, we again used our unique immunosuppression regimen for Joe’s face and hand transplant,” says Bruce E. Gelb, MD, transplant surgeon at NYU Langone. “Through very close immune system monitoring, we have been able to avoid early rejection and safely tailor Joe’s immunosuppression therapy specifically for him.”
In addition, Dr. Rodriguez collaborated with NYU’s advanced 3D media services center, LaGuardia Studio, to create 3D-printed replacements of the donor’s face and hands to restore the integrity of the donor’s identity after the organs were removed. Traditionally, a molded, hand-painted silicone alternate had been used. There are few printers in the world like the one at LaGuardia Studio, which prints with 60,000 colors.
A Patient Dedicated to Recovery
Following the surgery, DiMeo spent several weeks at NYU Langone, first in the intensive care unit and then continuing his recovery at NYU Langone’s Rusk Rehabilitation inpatient unit. He was discharged on November 24 to a nearby apartment provided by myFace, NYU Langone’s partner organization that provides individuals who have craniofacial differences with comprehensive care by funding medical, surgical, dental, psychosocial support, travel, and housing. From there, he continued outpatient rehabilitation including physical, occupational, and speech therapy.
“The rehabilitation demands on Joe are greater than any of our previous face transplant patients,” says Dr. Rodriguez. “With the added element of his hand therapy, Joe has performed up to five hours of rehabilitation daily—and he is constantly pushing for more. He’s completely focused on his goal of gaining greater independence and freedom.”
DiMeo’s hand therapy protocols were created by physical and occupational therapists at NYU Langone’s Rusk Rehabilitation. “Because of the skin grafts he received after his initial accident, Joe had very specific needs, and we designed our protocol with him in mind,” says April D. O’Connell, OT/L, clinical specialist for hand and upper extremity rehabilitation. “Ultimately everything we do with him is with the goal of getting him back to the activities of everyday life he enjoyed before, like feeding and dressing himself, lifting weights, and playing golf.”
DiMeo remains positive and focused on regaining the elements of life he lost after his 2018 accident. He’s grateful for what his donor and the donor’s family have done for him during their own time of great difficulty.
“This is a once-in-a-lifetime gift, and I hope the family can take some comfort knowing that part of the donor lives on with me,” says DiMeo. “My parents and I are very grateful that I’ve been given this second chance. We’re also incredibly thankful to Dr. Rodriguez and the team of therapists, nurses, and surgeons who helped me get to where I am today.”
For others who may be suffering from similar debilitating injuries, DiMeo encourages them to consider a face or hand transplant: “If I can do it, so can you.”
This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Reconstructive Transplantation Research Award Program under award no. W81XWH-15-2-0036. Opinions, interpretations, conclusions, and recommendations are those of the author and are not necessarily endorsed by the Department of Defense.