Modeling Success
By Beth W. Orenstein
Radiology Today
Vol. 22 No. 4 P. 10

3D printing and surgical planning are keys to a successful face and double-hand transplant.

A surgical team of 16 led by Eduardo D. Rodriguez, MD, DDS, and a support staff of 80 was in the operating room at NYU Langone Health’s Kimmel Pavilion in August 2020 when it completed the first-ever successful face and double-hand transplant. The operation took 23 hours to complete. Surgical planning was a key to its success, and imaging and 3D printing were keys to the planning, says Alyssa Glennon, principal engineer for business development at Materialise, which provided the 3D planning and printing tools.

The patient, Joe DiMeo, 22, had been critically injured in a car accident in July 2018. The accident happened on his way home from his night shift. The roll-over crash left DiMeo with third-degree burns covering 80% of his body. DiMeo was rescued from his burning car by rhythm and blues singer Ted Wizard Mills, original lead singer of the group Blue Magic, who saw it happen from across the traffic median. Mills was able to jump over the median and pull DiMeo out of the burning car to safety.

DiMeo spent four months in the burn unit at Saint Barnabas Medical Center in Livingston, New Jersey, 2 1/2 of them in a medically induced coma. He required multiple skin grafts that left him with no lips or eyelids. Because his fingertips had to be amputated, he had limited hand function. After nearly 20 reconstructive surgeries, his plastic surgeon realized that conventional surgery on his hands and face could do no more for him. And so, he referred the family to Rodriguez, the Helen L. Kimmel Professor of Reconstructive Plastic Surgery and chair of the Hansjorg Wyss Department of Plastic Surgery at NYU Langone.

After assessing the case, Rodriguez and the DiMeo family agreed to list DiMeo with NYU Langone’s Vascularized Composite Allotransplantation program in October 2019. DiMeo was an ideal candidate for the program because he had major limitations in functionality, stripping him of his independence and requiring his mother to act as his primary caregiver, Rodriguez says.

A national search was conducted to identify a donor. Because DiMeo’s immune system had been highly sensitized by multiple blood transfusions and skin grafts after the accident, he had only a 6% chance of finding an exact donor match. DiMeo’s panel reactive antibody had revealed that he would reject 94% of possible donor organs. Consequently, the search was expanded to the entire country. Within 10 months, a donor was found from another region’s organ procurement organization.

“The tricky part was not knowing who the donor was going to be,” Glennon says. While waiting for a donor, Materialise clinical engineers worked alongside a team of NYU Langone surgeons to rehearse the operation in a lab setting as well as develop and fine-tune the surgical plan. “We were able to test out the different options we had come up with for various donor anatomies, but we wouldn’t know until we were there exactly what we had to do,” Glennon says.

Rehearsals Set the Stage
The “rehearsals” involved several Materialise technologies, such as the following:

• An on-screen 3D model based on CT scans. The on-screen model allowed surgeons to virtually plan the procedure and visualize different scenarios in three dimensions. The goal of this step was to create a better understanding of the anatomical bone structure, Glennon says.

• 3D-printed cutting and drilling guides. Cutting and drilling guides were used to create a guided system for bone repositioning and fixation that was unique to the patient’s anatomy. This helped position medical tools with great precision, reducing the overall surgery time, which was important, as it was still quite long, Glennon says.

• 3D-printed sterile identification tags and splints. Tags were created to identify and label various soft tissue structures to enable efficient reattachment, once the donor anatomy was prepared to transplant. 3D-printed splints also enabled optimal donor hand position during soft tissue reconstruction.

Once a donor was identified, the planning team worked quickly. “We got the first notification a donor was known at 6 pm on a Monday,” Glennon recalls. The donor, who was in Dover, Delaware, was taken for CT scans that night. The Materialise team, which was in Detroit, received the images from the scans around 3:15 am. “Once those images came in to us, it took us about eight hours or so to do the conversion to a preoperative plan,” Glennon says. “We were really focused on surgical planning for bony anatomy. We wanted to be sure there would be no surprises in the pre-op plan we gave to Dr. Rodriguez and his surgical team.” Rodriguez traveled to Delaware for an in-person evaluation. Later that same day, the donor was transferred to NYU Langone.

With any transplant, time is of the essence, Glennon says. Depending on the organ, it can last outside the body and remain fit for transplantation for a few hours to two days, at most. Rodriguez’s team knew it had 24 hours to begin the procedure to improve DiMeo’s function, appearance, and quality of life.

Transplant surgery is complex, Rodriguez says, and careful planning is critical to efficiency and accuracy once the patient is on the table. Because it was unique to DiMeo’s anatomy, Materialise’s fully guided system for bone fragment repositioning and fixation helped the surgeons in the operating room (OR) precisely position their tools and reduce overall surgery time.

Ultimately, Rodriguez and his team transplanted both hands to the mid-forearm—including the radius and ulna, three dominant nerves to the hand, six vessels requiring vascular connections, and 21 tendons—and a full face—including the forehead, eyebrows, nose, eyelids, lips, both ears, and underlying skull, cheek, nasal, and chin bone segments.

No additional imaging was required at the time of the surgery, Glennon says. “I don’t think they used imaging until the end when they were completing the microvascular portion of it,” she says. It was helpful that preplanning eliminated the need for imaging during the majority of the operation. With all the surgeons and support staff who had to be in the OR, it was crowded, Glennon says. “Pulling in a C-arm would have been a tremendous space challenge.”

High-quality CT imaging was also critical to the success of the procedure, Glennon says. “It all starts with imaging. If someone calls us and says we have a patient, the first thing I say is, ‘Take a CT.’ The quality of those images is going to determine the details with the rest of the case. Without a strong bottom of the pyramid, the rest doesn’t stand up as well,” she says.

A Good Match
One of the key challenges for the planning team was the potential difference in size between the donor and the recipient, Glennon says. Once the planning team knew who the donor was and had the images, it could provide precise surgical guides to the surgeons. The 3D-printed guides were patient-specific and showed the surgeons exactly where they needed to cut and drill and where to reattach the body parts. Materialise engineers provided some guidance on the scans.

“We let them know how thin the slices should be and the details we needed to see,” Glennon says. “Dr. Rodriguez and his team were heavily involved in making sure all the communications between us and radiology worked out well, and we had no reason to rescan the patient or the recipient.”

Materialise also provided bone models—one-to-one replicas of the recipient’s anatomy. The surgeons could hold the models in their hands and see them without soft tissue, Glennon says. This way, when they started to cut, they understood where the muscle was supposed to attach.

“With the 3D-printed tags that we provided to identify the various structures on the donor and recipient, it was a matter of matching up the tags, which increased the speed and accuracy during a time-critical surgery,” she says.

DiMeo was in the hospital for 45 days after his transplant, from August 13 to September 28, and has had no acute rejection episodes. In November, he was discharged 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, and psychosocial support, as well as travel and housing. Four months after his surgery, DiMeo was able to dress and feed himself and throw a ball to his dog, Buster. He is doing some resistance training with his new hands using free weights and machines and beginning to practice his golf swing again.

Follow-up procedures are planned as his swelling continues to subside. “That could take up to a year,” Glennon says. DiMeo likely will need surgery to slim down his anatomy. “The surgeons built in extra tissue knowing there would be significant swelling, and they will need to clean that up and fine-tune the attachment points,” Glennon says.

Valuable Experience
DiMeo’s transplant occurred during the COVID-19 pandemic, which surged early in New York. However, the surgical team was able to continue safely performing monthly rehearsals and complete 11 of them before the donor was found and the surgery scheduled. DiMeo waited just 10 months for his donor, despite the pandemic.

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 pavilion has cutting-edge technology and expansive operating rooms where six skilled surgical teams—one for each hand and another for the face of both the donor and the recipient—were able to simultaneously operate on the patient and the donor.

According to NYU Langone, DiMeo’s was the first-ever successful face and double-hand transplant. At least two other surgeries were tried and failed. In one case in Paris, France, in 2009, the recipient died from infectious complications 28 days following the transplants. In another unsuccessful transplant case, performed in Boston in 2011, the transplanted hands had to be removed after 48 hours when they failed to thrive.

DiMeo’s surgery required less than the 25 hours it took NYU Langone surgeons to complete a face-only transplant for Cameron Underwood in 2018. To honor the donor in DiMeo’s surgery, lifelike, 3D replacements of the donor’s face and hands were made in partnership with a team from NYU’s LaGuardia Studio, an advanced 3D media services center. The lifelike replacements were placed on the donor’s face and hands before the body was returned to the family.

More than 140 health care professionals were involved in DiMeo’s pre- and postsurgical care. “The rock stars are the physicians in the trenches doing the transplant,” Glennon says. But just as they do at a concert, rock stars need sound engineers and a road crew. “For us,” she says, “we’re like a behind-the-scenes band member, providing the imaging that goes into putting on this great concert and supporting it.”

While DiMeo’s case was unique, the process could easily apply to less complex and more common surgeries, Glennon says. The medical applications of 3D printing enable researchers, engineers, and clinicians to develop innovative, personalized treatments that help improve and save lives, she says. Glennon expects that offering virtual planning software tools, 3D-printed anatomical models, and personalized surgical guides and implants is the future—a future that’s already here.

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.