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Advancements in Transplantation Technology

The world’s first whole-eye and partial-face transplant at NYU Langone Health in New York is a testament to embracing the most difficult challenges and driving continuous advancements in the field of transplantation and beyond. Excerpts from NYU Langone Health

A 46-year-old military veteran from Arkansas, who survived a work-related high-voltage electrical accident, was  given a new lease of life by US-based NYU Langone Health. NYU Langone Health scripted history by performing the world’s first whole-eye and partial-face transplant. The entire left eye and a portion of the face were  transplanted from a single donor. Aaron James of Hot Springs, Arkansas survived the deadly 7,200-volt electric shock while working as a high-voltage lineman in June 2021, when his face accidentally touched a live wire.

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The procedure

James underwent the surgery that lasted approximately 21 hours and included a team of more than 140  surgeons, nurses, and other healthcare professionals, led by Eduardo D Rodriguez, 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.

James had extensive injuries—including the loss of his left eye, his dominant left arm from above the elbow, his  entire nose and lips, front teeth, left cheek area, and chin down to the bone, despite multiple reconstructive surgeries.

Says Dr Rodriguez. “We owe much of our success in this monumental endeavour to the exceptional institutional  support we receive at NYU Langone and the  unwavering dedication of our world-class team in delivering the highest level of care to our patients. This achievement demonstrates our capacity to embrace the most difficult challenges and drive continuous advancements in the field of transplantation and beyond.”

When Texas surgeons were forced to remove James’ left eye after injury due to severe pain, Dr Rodriguez and his team recommended that the optic nerve be cut as close to the eyeball as possible, to preserve as much nerve  length to maximise reconstructive options, including the hope of a potential transplant later. This began the discussion on the possibility of including an eye with the face, something that has never been attempted before.

James was officially listed as a potential recipient in February 2023 with the United Network for Organ Sharing  (UNOS), the private, non-profit organisation that manages the nation’s organ transplant system.

Dr Rodriguez with the team at NYU Langone’s Transplantation and Cellular Therapy Center, part of the Blood and Marrow Transplant Program at Perlmutter Cancer Center, combined the donor eye with donor bone marrow– derived adult stem cells.

According to Dr Samer Al-Homsi, Executive Director of the Transplantation and Cellula Innovation Therapy Center and Professor in the Department of Medicine at NYU Langone, this is the first attempt at injecting adult stem cells into a human optic nerve during a transplant in the hopes of enhancing nerve regeneration.”

He goes on to add, “We chose to use CD34- positive stem cells which have been shown to harbour the potential to replace damaged cells and neuroprotective properties.”

During the transplant, bone marrow that was harvested from the donor’s vertebrae and processed preoperatively to isolate the CD34-positive stem cells was brought into the operating room (OR) and injected at the optic nerve connection of the recipient. The transplanted left eye has shown remarkable signs of health, including direct
blood flow to the retina.

Innovation

Cutting-edge three-dimensional (3D) computer surgical planning, along with patient-specific 3D cutting guides, enabled precise alignment of bones and optimal placement of implantable plates and screws. This meticulous  approach fits the grafted partial face and whole  left eye onto James.

Dr Rodriguez and his surgical team of seven—and OR team of 80—transplanted the following:
• Partial face, including the nose, left upper and lower eyelids, left eyebrow, upper and lower lips, and underlying
skull, cheek, nasal and chin bone segments, with all of the tissues below the right eye including the underlying muscles, blood vessels, and nerves.

• Left whole eye and socket including the orbital bones and all surrounding eye tissues including the optic nerve.

Dr Rodriguez has since performed a Dr Rodriguez has since performed a less extensive follow-up surgery for James to optimise his functional and aesthetic outcome. James plans to have orthodontic treatment and dental rehabilitation in the coming months. Dr Rodriguez and his team collaborated with NYU’s advanced 3D media services centre, LaGuardia Studio, to create a 3D-printed replacement of the donor’s face to restore the integrity of the donor’s identity after the organs were removed to return to his family.

Traditionally, a moulded, hand-painted silicone mask had been used. There are few printers in the world like the  one at LaGuardia, which prints with 60,000 colours.

James spent 17 days in the intensive care unit at NYU Langone. While James’ vision in his native right eye is intact, the transplanted left eye does not currently have any sight. However, over the last six months, his eye has shown remarkable signs of health in other regards based on various clinical tests that measure outcome.

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