What do you see when you look in the mirror? Imagine if it all changed - in a matter of seconds. Plastic surgeon Dr. Eduardo Rodriguez performs highly complex face transplant procedures on patients who are willing to risk it all - for a new face.
Season 1 Episode 3 - Nobody Knew Who I Was
Features: Dr. Eduardo Rodriguez, MD, DDS and Patrick Hardison
Narration: Maggi van Dorn
Dr. Eduardo Rodriguez: What does one think when they expect a face transplant? And I would wonder what does a patient feel like when they think they're going to get new face?
Maggi van Dorn: If you look in a mirror, you immediately recognize your eyes, nose, lips, and chin. It’s almost impossible to imagine having any face other than your own. And why would you? The changes most of us experience in our face happens gradually, over years and decades. But what if the face you saw in the mirror every day was destroyed in a few seconds?
ER: All of these patients want is just to walk outside in the world and have no one stare at them. My name is Eduardo Rodriguez and I'm chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone health.
MVD: Doctor Rodriguez is one of just a handful of physicians who has performed a face transplant. He takes the face of a deceased donor, and attaches it carefully to a wounded recipient. It’s about as complicated as a surgery can be.
ER: There's no second chance. There's no take back. There's no rendering, there's no editing.
MVD: But for firefighter Patrick Hardison, the decision to get a transplant was clear.
Patrick Hardison: I was thinking about my children and things in life that I would miss out on not being able to see and granted I would have still been alive but I wasn't living. I wanted to live life to the fullest.
MVD: From SiriusXM and NYU Langone Health, this is Vital Signs, where medicine is made personal. I'm your host, Maggi van Dorn. The path to medical innovation is often winding, full of roadblocks and detours that - only in hindsight - are seen as necessary. Dr. Eduardo Rodriguez almost didn’t become a doctor at all.
ER: I was not 100% certain which way I wanted to go. But the decision tree became simple when I was not accepted to medical school. I went to dental school here in New York, NYU, and I decided to choose a career as an oral and maxillofacial surgeon. There was one wonderful mentor who told me, you need to go a little further, you know. That basic oral surgery, private practice would not be enough for me.
MVD: This mentor saw something in Dr. Rodriguez, and encouraged him to apply again to medical school. The decision to go back and try again after being rejected the first time, it’s something he speaks about often.
ER: You know, often most of us, humanity in general, tries to shy away from things that we do not do well or we fail at. And for me to revisit the possibility of going back to medical school, which is kind of reconsidering something that I did not get accepted in, was a bit frightening. But I did pursue it.
MVD: Dr. Rodriguez was accepted, and completed medical school and a general surgery residency. But when it came time to choose a specialization, plastics was not top of mind.
ER: I didn't really want to become the routine plastic surgeon. I didn't want to become a beautician.
MVD: But it’s almost as if plastic surgery chose him.
(news clips) Shock and awe on the Iraqi military… Every night, American troops injured in Iraq by the thousands… Many wounded soldiers returning from Iraq need plastic or reconstructive surgery...
ER: We were just in the midst of wars in Iraq and Afghanistan, and we were seeing injuries coming back from IED blasts and a lot of patients and soldiers with portions of their jaw gone, their mandible, their lips. And we had the capacity of, for example, taking some tissue from your arm and blood vessels and shape it up and make it into lips. Never really looked like lips. It covered the hole. It contained the saliva. You could speak a little better, but it never really functioned like tissue.
MVD: As the wars raged in the Middle East, Dr. Rodriguez went to Taiwan to train in a highly specialized field known as reconstructive microsurgery. It involved operating on the kinds of complex injuries he witnessed in soldiers returning from Iraq.
ER: I came back to the States and I took a job in Maryland. It’s a remarkable trauma center dealing with all kinds of massive casualty, whether it's a ballistic entry from violence in the city or high speed motor vehicle collisions. At that time people were thinking about face transplants, but no one really knew that this was a reality.
MVD: And then, suddenly it was a reality. In 2005, a woman in France named Isabelle Dinoire became the first person to ever receive a partial face transplant.
(Isabelle Dinoire speaks French at a news conference)
MVD: She had been mauled by her dog, her face badly damaged. It was a 15-hour operation that replaced her nose, lips, and chin with those of a donor.
(news audio) It was the first operation of its kind. The pioneering surgery paved the way for transplants all around the world, and it offered her a second chance.
MVD: This development was a revelation for Dr. Rodriguez.
ER: I remember the day specifically in my house when I looked at that front cover of a New York Times showing her before and after picture. I think all of us were just impacted. Because reviewing the number of cases that I had done, a number of operations that I had performed on these soldiers to give them a result that was, I could say was suboptimal compared to this one operation that Isabelle Dinoire received. Once that case was performed in Paris, it alleviated that issue for me. But I will say with great honesty, and I never, I'm embarrassed to say this. When you see that happen, you're like, ah, I wish it would have been me. But part of it, like our failures, I'm glad that someone else did it and it was the first one was done. And now it allowed me to focus on how do we make this better?
MVD: Dr. Rodriguez may not have been first, but he was determined to be the next. And yet, even the most talented, qualified surgeons experience moments of doubt.
ER: I'll tell you first of all, any, any surgery that I do any day, even though you're ready to do it, there's always a component of anxiety, right? Because you're caring for someone who's completely vulnerable, defenseless, and you have to cut them in some manner to make them better. There's no second chance. There's no take back. There's no rendering, there's no editing. You want to do something that has not been performed anywhere in proximity to the hospitals that I work in. So there's a lot of personal concerns. Can I do it? Is this too ambitious? Am I being egotistical? You know, I want to make sure that my inclination to do this and my aspiration to do this is sound and organic.
MVD: As you might imagine, performing a face transplant is no easy task. First, Dr. Rodriguez and his colleagues secured a grant from the Office of Naval Research. Next, they practiced.
ER: This is an operation that frankly I’ve never done. All we've done is practice on cadavers and practice as a team. But practice, you know, repetition is the mother of all studies.
MVD: Dr. Rodriguez and his team also had to carefully plan logistics.
ER: You really have to put a coordinated team effort of individuals that are going to be able to perform this lengthy operation. It occurs in two operating rooms. There's two teams, there's a recipient team, there's a donor team.
MVD: Transplant surgeries are, by nature, lifesaving procedures. If someone is gravely ill, and without a new heart, new lungs, new kidney - they would die. When it comes to face transplant, the stakes are different. Undergoing this surgery is likely to shorten the recipient’s life span.
ER: What I do with all these patients, I lay out the facts very clearly and I tell them that there's a possibility that you could die in the operating room. When we try to immune suppress, you could have a hyper acute rejection episode and you may not be able to make it. So I let them know that the more ambitious we are, the potential for problems are greater. And even if everything goes well, what's the longest lifespan that I could promise you? And I always tell him 10 years, because I don't know. I think it's fair for them to understand the severity of undergoing an operation like this.
MVD: It’s one thing to say you’d like to do a face transplant. It is quite another to actually do it. And to find someone who believes the risks are worth it.
Patrick Hardison: I never thought of it as a risk. It was all the reward. Well, I guess when you live with something that you dread and you hate daily for 14 years, one day it was just a little inkling of hope. I'm all in.
MVD: Patrick Hardison was no stranger to risk. As a firefighter in Mississippi, he ran into burning buildings to save other people’s lives. It was all part of the job. And then, one day in 2001, a call came in to assist with a fire in a nearby county.
PH: So we load up and get down there and we'll get to the structure and you can see the fire coming through the roof of the building. And they told us there was a lady inside the house. So we go inside, look inside the house, make the search, and we didn't find her. We came out and told them she wasn't there and then her husband was outside and he was jumping up and down, just hysterically upset and came out and said, please go back in there. She's in that house. So we changed the bottles out on our packs, go back into house, look again for the lady, got in the very back room. That's when everything kind of fell apart and, uh, she wasn't there.
MVD: The woman Patrick was searching for had never been in the house at all. Her car was outside, but she was fishing across the street, out of harm’s way.
PH: I knew I was in trouble, so I held my breath and everything started melting down on me, so I had to get that off of me so I could get to a window. Then I saw a window, so I got to that window, I could see to throw my body out of the window. By this time I was totally on fire and a fellow fireman grabbed me and pulled me out of the window and they squirted me down and put me out. And uh, nobody knew who I was. Even my fellow firemen who I've known since I was six, eight years old, didn't know. And I, it kind of upset me when he, he didn't know who I was, and he kept saying, who is this? And I looked at him and said, man, it’s me! They turned me over and looked at the name on the back of my coat and knew that it was me.
MVD: When the roof collapsed on his head, the fire destroyed Patrick’s eyelids, lips, ears, and nose. He had no normal tissue throughout his entire face, scalp, and most of his neck.
ER: He had undergone over 80-something operations to give him some sense of normalcy of which was not normal by any means.
MVD: On paper, Patrick was a compelling candidate for a face transplant. But that didn’t mean he would get one.
ER: Well, it's not an operation, first of all, that I perform on everyone. There are plenty of patients that I actually counsel them that this is not the right operation for them. They often, uh, seek us out, seek me out. Patrick Hardison lived that way for close to 15 years. Face transplant patients, they've lived that way and they will tell you they can't go on living that way. Because for them, they feel that the life that they have is not a normal life. And you could partially understand that yes, they're walking, they're breathing. But living from our standards, they can't do what they'd like to do socially whenever they want to do it. They have severe limitations.
MVD: For Patrick, undergoing this risky procedure wasn’t just about how he looked. Because of the damage done to his eyes, he was slowly going blind.
ER: The primary motivation to perform his face transplant was to give him functioning eyelids. Without eyelids, you really don't have the ability to see. In his case, his eyeballs, or globes as we call them, were perfect. He had normal vision, but his eyelids were so scarred down that they almost looked like little pinholes. And if you put your hands in front of your eyes and you create little pinholes, you can see however you have a tremendous limitation in visual field
MVD: Dr. Rodriguez is not your typical surgeon. His practice is far too intimate for him to be a fleeting presence in his patients’ lives.
ER: First of all, all the patients that I care for, for me, they're like my family. I really take on a tremendous deal of responsibility, sometimes too much. With the face transplant patients, it's probably, I would say maybe to the extreme. And the reason for that is that I feel people that are in positions of desperation are really not capable of making informed decisions. So I really need to make sure they understand what they're getting into. I have them evaluated by our clinical psychologists, clinical psychiatrists, social worker. I want to understand what the family dynamics are. What's the support at home? It's a complete workup. Usually requires many visits back and forth to New York. And then we meet as a group, and that's defined as the Patient Selection Committee. We even have an ethicist. Everybody is in and everybody has a vote.
MVD: Before he can operate, Dr. Rodriguez spends a lot of time with his patients, not only in his office, but in theirs. And in their kitchens, and living rooms… Dr. Rodriguez needs to see it all.
ER: I often take a select group of members of my team and we go visit them at their homes. I don't just go for one day for pictures. I want them to get sick of me in three days. And you know why that's important? Because you're going to show me behaviors that are probably going to be more typical. Whether good or bad, I want to see it.
MVD: In Patrick’s case, that meant parachuting into the life of a busy, married father of five, and considering not only how a face transplant would impact Patrick, but also his young children.
PH: They came down to Mississippi also and individually sat down, psychologist and everybody sat down and talked to my kids one on one. And that helped ease my kids' minds on things. That answered a lot of questions for them cause they knew I was in the best possible care. It wasn't any guesswork, it was everything possibly that could be done, Dr. Rodriguez made sure that it was 100% above and beyond the best care any patient can receive. And he does all his patients that way.
MVD: It took about a year to identify an appropriate donor for Patrick. But eventually, the call came. A 26-year old bike messenger and avid cyclist named David Rodebaugh was thrown from his bike and suffered major head trauma. He was declared brain dead but his face had been largely spared. Amazingly, he was a genetic match to Patrick. Patrick’s face transplant was the first one ever performed at NYU Langone, and the first in New York State. It took 26 hours and involved a team of more than 100 physicians, nurses, and technical and support staff.
ER: Patrick's operation was also very tricky because underneath all that scarring, I could appreciate that he could blink, he could smile, but it was just the overlying scarring that would limit that. So my hypothesis was I'm going to remove all the scarring of his face and get him down to barren facial muscles and then put a new face on him. There are many muscles of facial expression around our mouth and our nose. There's circular muscles around their eyelids that allow us to blink and close our eyes. So I would overlay the face, skin, subcutaneous tissue, muscle, nasal cartilage, bones over his muscles. Hopefully that would move. Right? No one had ever proven that before.
MVD: It was one of the most extensive, and technologically advanced face transplants in history. Thanks to cutting-edge processes that allow Dr. Rodriguez to do real-time mapping during a procedure itself, and make changes as he goes. It’s one of the ways he can make this incredibly personalized surgery even more so.
ER: We can create specific instruments for that operation, specific cutting guides in the areas that I want to cut the skeleton and we can actually on a computer screen I can take the face of a donor and put it on the recipient and see where it fits. I could see where the malalignment’s going to occur and I can refine my operation and create the cuts in a manner that will allow the donor's facial skeleton to fit real time into the recipient defect - like a puzzle.
MVD: But it was only after the surgery, when Patrick woke up, that Dr. Rodriguez and his team could determine if his transplant was a success.
PH: The main thing was that I just had pinholes to see out of. That's all I could see. I had no peripheral vision, it was just pinholes that I could see out of. And they had told me going into this that they expected my eyes to be closed for 60 days.
MVD: A primary goal of his surgery was to give Patrick the ability to blink, which would preserve and restore his vision.
PH: He'd come in every day and see how you're doing and he could see movement of my eyeballs and stuff. And he was standing and sitting right in front of my face on that 10th day. And, and he said, try real hard, open 'em. And I tried, and I remember trying real hard and they just popped open. He jumped back and said, Oh my God, he opened his eyes. So that was a great day.
MVD: By all accounts, Patrick’s surgery was a technical success. But a face transplant procedure is delicate in many ways. Someone else’s life must be tragically cut short for it to happen at all. And the match can’t just be genetic: Skin tone, sex, size, age, race - they all factor in. So, how does Dr. Rodriguez prepare his patients for the first time they’ll see their new face?
ER: I want to make sure that I'm there when they look at their face for their first time in a mirror. And I want to be supportive and explain to them what is going on. So we plan it, and I inform them, tomorrow we're going to go ahead and look together in a mirror. And it's amazing. It's pretty nerve wracking for them, which is to be expected. And I tell them, I want to do this with family around you, with people that love you. We want to be together and we want to look together for the first time.
MVD: Dr. Rodriguez also needed to be sure that Patrick could actively participate in his own care when he left the hospital.
ER: When someone has a face transplant, we usually keep them around for a while. They’re about a month in the hospital just to be careful, and watching and kind of giving them rehab, making sure all the medication levels are good. By the second month we’re doing a lot of outpatient visits. We support him, we put him in an apartment and we have them go to all their outpatient visits. I want to see how responsive they are to their own care. And Patrick had a lot of opportunities to interact on his own and be out and about. And I think one of the things that he enjoyed the most was just walking around New York City and having no one stare at him. His old normal was putting on his prosthetic ears, wearing his glasses, wearing a baseball cap. That was, he had done that for so many years, close to 15 years, that he has a new face, it was definitely a shock. Not the way he feels now. When he looks at the way he looked like before, he cannot comprehend how he survived that long.
MVD: Face transplantation is one of the great achievements in the history of medicine. But it is a young and imperfect procedure, and Dr. Rodriguez and his colleagues know they’re still learning. Like all progress, there are celebrations, and also setbacks.
ER: It's a huge commitment and it's a lot of resources for one patient to make this happen. But I think ultimately it's worth it. The science has advanced a great deal. Where we’ve come from from 2005, I think there’ve been close to 45 transplants throughout the world. If we look at those number of transplants, it has not come without sacrifice. There have been five patients that have died. But I think the benefit of all of this is that these are individuals that are living their lives the way they want to live, that they could not live looking the way they did before we transplanted them.
PH: Because I was thinking about my children and things in life that I would miss out on if, you know, not being able to see. And granted, I would have still been alive but I wasn't living. I wanted to live life to the fullest. I wanted to be able to see my kids, see my grandkids. I wanted to do those type things for my family. And whatever that risk was, I was willing to take it. God didn't keep me here on this earth just to die on the operating table from this. Don't give up hope. I did, but I met Dr. Rodriguez, that was the glimpse of hope. And then, where I’m at today, that's life is great and it's, it's what you make it. And he helped me put one foot in front of the other to get my hope where it's at today and it's just, it's just great.
VO: Vital Signs is a co-production of NYU Langone Health and SiriusXM. The podcast is produced by Jim Bilodeau, Julie Kanfer, Rob Schulte and Keith King with sound design by Jim Bilodeau and writing from Julie Kanfer. SiriusXM’s executive producers are Beth Ameen and me, Maggie van Dorn in partnership with Allison Clair and Jim Mandler at NYU Langone Health. Don't miss a single episode of Vital Signs and subscribe for free wherever you listen to podcasts. To hear more from the world-renowned doctors at NYU Langone, tune in to Doctor Radio on SiriusXM channel 110 or listen any anytime on the SiriusXM app. For the Vital Signs podcast. I’m Maggie van Dorn. Join us next time as we bring you the stories of medicine made personal.