A huge multidisciplinary team at NYU Langone Health has successfully undertaken the world’s first whole-eye and partial-face transplant on a man who suffered horrific injuries after a high-voltage electrical accident. The landmark surgery opens new possibilities for future advancements in vision therapies.
In June 2021, 46-year-old Aaron James’ face accidentally touched a live wire while he was working as an electrical lineman. Although he survived the 7,200-volt electric shock, a feat in itself, Aaron, who hails from Hot Springs, Arkansas, was left with devastating injuries that included the loss of his left eye, nose and lips, front teeth, left cheek and chin, and his left arm from above the elbow.
The journey to a groundbreaking operation
Aaron was introduced to the multidisciplinary NYU Langone Health team a couple of months after his accident and began early-phase reconstructions at a Texas medical center where he was receiving care. Over the following year, the possibility of a face transplant was discussed with NYU Langone’s Drs Eduardo Rodriguez, director of the Face Transplant Program, and Helen Kimmel, professor of reconstructive plastic surgery.
When Texas surgeons had to remove Aaron’s left eye due to severe pain, Rodriguez recommended cutting the optic nerve as close to the eyeball as possible as preserving nerve length would maximize reconstructive options, including the potential for an eye transplant down the track. This triggered ongoing discussions about combining a face transplant with a whole-eye transplant, something that had never been attempted before.
“Given Aaron needed a face transplant and will be taking immunosuppressive drugs regardless, the risk versus reward ratio of transplanting the eye was very low,” said Rodriguez. “Despite the eye being successfully transplanted, from a cosmetic standpoint, it would still be a remarkable achievement.”
Quick turnaround: On the donor waitlist
In February 2023, Aaron was officially shortlisted as a transplant recipient with the United Network for Organ Sharing (UNOS), the private, non-profit organization that manages the US’ organ transplant system. LiveOnNY, the organ procurement organization for the greater New York metropolitan area, was also involved in finding a donor. Three months after Aaron was listed for organ donation, LiveOnNY identified a potential donor who, after testing, was deemed suitable. The journey from injury to transplant took a little under two years.
Rodriguez led the transplant surgery, which took place on May 27, lasted around 21 hours and included a team of more than 140 surgeons, nurses, and other healthcare professionals. Two surgical teams simultaneously operated in two ORs, one that housed the donor and one for Aaron.
Overcoming the challenges of eye transplantation
While corneal transplants have become relatively common, successful whole-eye transplants are rare due to the intricacies of the optic nerve and the challenges of nerve regeneration, immune rejection and restoring blood flow to the retina. To overcome these challenges, the NYU Langone team combined the donor eye with bone marrow-derived adult stem cells harvested from the donor’s vertebrae.
“This is the first attempt of injecting adult stem cells into a human optic nerve during a transplant in the hopes of enhancing nerve regeneration,” said Samer Al-Homsi, executive director of the Transplantation and Cellular Therapy Center and professor in NYU Langone’s Department of Medicine. “We chose to use CD34-positive stem cells which have been shown to harbor the potential to replace damaged cells and [have] neuroprotective properties.”
Incorporating stem cells into the eye transplant procedure provides a learning opportunity.
“We have now demonstrated that the procedure is safe and potentially efficacious, but we need time to determine if this step plays a role in enhancing the chance of sight restoration and if there’s anything further that can be done in the future to optimize the procedure,” Al-Homsi said.
State-of-the-art tech transforms face transplantation
State-of-the-art technology was crucial to the face transplantation process, both before and during surgery. 3D computer surgical planning and patient-specific 3D cutting guides enabled precise alignment of bones and optimal placement of implantable screws and plates, ensuring that the face and eye were seamlessly integrated into Aaron’s face.
In addition to transplanting the whole left eye and socket, including the orbital bones, surrounding eye tissues, and the optic nerve, Rodriguez and his seven-strong surgical team – assisted by an OR team of 80 – transplanted a long list of facial features. It included the partial face, including the nose, left upper and lower eyelids, left eyebrow, upper and lower lips, and underlying skull, cheek, nose and chin bone segments, with all of the tissues below the right eye, including the underlying muscles, blood vessels, and nerves.
Post-transplant progress and seeing into the future
Aaron spent only 17 days in the intensive care unit at NYU Langone, one of the shortest recoveries among Rodriguez’s face transplant recipients. He was discharged to a nearby apartment on July 6 and continued outpatient rehabilitation that included physical, occupational and speech therapy. Rodriguez performed minor follow-up surgery to optimize Aaron’s functional and aesthetic outcome.
“Beyond the eye, the quality of Aaron’s results from the face transplant is special,” Rodriguez said. “You would never think he underwent such a procedure so recently. He looks great.”
The success of the eye transplant has exceeded expectations.
“The progress we’ve seen with the eye is exceptional, especially considering that we have a viable cornea paired with a retina showing great blood flow five months after the procedure,” said Bruce Gelb, a transplant surgeon at the NYU Langone Transplant Institute. “This far exceeds our initial expectations, given our initial hope was that the eye would survive at least 90 days. We will continue to monitor, and I am excited to see what else we may learn over time.”
Aaron can’t currently see out of the transplanted left eye. However, over the last six months, the eye has shown remarkable signs of health. Rodriguez and a posse of research scientists and clinicians continue to meet and discuss restoring Aaron’s sight.
“This is certainly one extraordinary step in the right direction,” said Steven Galetta, neuro-ophthalmologist and Professor and Chair of Neurology at NYU Langone. “We’re now crossing into the frontier of the central nervous system. Whatever happens next allows the opportunity for various methods to try to enhance the remaining aspects of the retina, whether it be through growth factors, stem cells, or a device that can pick up the signals and then bypass things along that optic nerve pathway. I’m looking forward to further advancements from this case in collaboration with the very talented minds that made it happen here at NYU Langone.”
Grateful and motivated
Rodriguez continues to be impressed by Aaron’s determination.
“Aaron has been extremely motivated to regain the function and independence he lost after his injury,” he said. “We couldn’t have asked for a more perfect patient.”
Returning to Arkansas on September 14 with his wife, Meagan, and daughter, Allie, Aaron travels to New York monthly for follow-up appointments.
“I’m grateful beyond words for the donor and his family, who have given me a second chance at life during their own time of great difficulty,” Aaron said. “I hope the family finds solace in knowing that part of the donor lives on with me. I will also forever be thankful to Dr Rodriguez and his team for changing my life. My family and I wouldn’t have been able to navigate this difficult journey without their expertise and support. Our hope is that my story can serve as inspiration for those facing severe facial and ocular injuries.”
The video below, produced by NYU Langone Health, provides an animation of how the eye and face transplant was performed.
Source: NYU Langone Health