Latest Face Transplant at NYU Advances the Field

Megan Brooks

November 29, 2018

Cameron Underwood, a 26-year-old from Yuba City, California, who received a face transplant at NYU Langone Health 11 months ago, made his first public appearance at a press conference in New York City today.

Underwood suffered a self-inflicted facial gunshot wound in June 2016. The procedure was the second successful face transplant performed at NYU Langone Health. The transplant was performed under the leadership of Eduardo Rodriguez, MD, chair of the Hansjörg Wyss Department of Plastic Surgery. It was the third such transplant conducted under Rodriguez's leadership.

Underwood's face transplant set several important milestones for medicine and is the most sophisticated and technologically advanced procedure of its kind, according to a press statement issued by NYU Langone Health.

Transplant recipient Cameron Underwood. NYU Langone Health

Owing to the extent of Underwood's injury, 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 maxillary and mandibular bones, including all 32 teeth and gums; the palate and the floor of the mouth (excluding the tongue, although Underwood's tongue required some reconstruction); the lower eyelids and cheeks (the patient's upper eyelids were preserved); and the nose and sections of the nasal passage.

State-of-the-art Technology

The transplant team used state-of-the-art technology to guide presurgical planning and the actual surgery on both the donor and recipient. This included use of 3D computer surgical planning, 3D printed patient-specific cutting guides, intraoperative navigation, and intraoperative CT scanning, which ensured that facial bones were aligned perfectly and that implantable plates and screws used to anchor the grafted face 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," Rodriguez said in the statement.

The NYU team has also reduced surgery time. Underwood's surgery took roughly 25 hours, compared to 36 hours for the first face transplant Rodriguez performed in 2012 at the University of Maryland. That surgery involved injuries similar to Underwood's.

"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 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, the postoperative care team achieved significant reductions in the amount of time required for various aspects of Underwood's hospital stay, compared with the first face transplant performed at NYU Langone. These included reductions in total length of stay (37 days vs 62 days), number of days in the intensive care unit (23 vs 51), and number of days spent in rehabilitation (7 vs 13).

A "Watershed Moment"

Another milestone in Underwood's case — financial reimbursement support from his insurance company.

Most face transplant cases in the United States have been performed under research grants, mostly from the US Department of Defense. Underwood's employer-provided insurance company covered significant costs related to his surgery and to pre- and postoperative care.

"This is yet another watershed moment in the advancement of face transplantation," G. Leslie Bernstein, MPA, administrator for the Face Transplant Program at NYU Langone Health and the principal negotiator with Underwood's private insurer, said in the release. "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."

Following the surgery on January 5, Underwood spent several weeks at NYU Langone. He was discharged on February 16, "weeks" ahead of schedule, to an apartment near NYU, where he continued outpatient rehabilitation, which included physical, occupational, and speech therapy, according to the statement.

On March 29, he returned home to Yuba City. Underwood returns to New York City for monthly follow-up appointments. Like all transplant recipients, he remains on a strict regimen of antirejection medications to ensure that he does not experience a rejection episode, which has not occurred, NYU said in the statement.

The first face transplant was performed in 2005. Since then, more than 40 have been performed worldwide.

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