S2EP2: Trigeminal Neuralgia & the World’s First Successful Face & Hand Transplant
In 2018, Joe DiMeo fell asleep at the wheel. In the resulting accident, he suffered third-degree burns over 80% of his body. He was left without eyelids, ears and fingertips.
But in August of 2021, a team at NYU Langone Health performed a face and double hand transplant on Joe. Was the procedure successful? How has his life changed since the surgery?
On this episode of Dentist Brain Candy, I share two journal articles that piqued my interest this week, beginning with the recent Journal of Oral and Maxillofacial Surgery feature on trigeminal neuralgia that describes the symptoms of this long-term facial pain disorder as well as its treatment options.
I go on to discuss the world’s first successful face and double hand transplant surgery, explaining what’s involved in the patient selection process, why 22-year-old Joe DiMeo was a good candidate for the procedure and how he’s doing now.
Listen in for insight into what was involved in the 23-hour face and hand transplant and learn about Dr. Eduardo Rodriguez, the pioneering oral and maxillofacial surgeon who led the surgical team.
The symptoms of long-lasting facial pain disorder trigeminal neuralgia
What causes trigeminal neuralgia and how it’s triggered
The surgical and non-surgical treatment options for trigeminal neuralgia
How Dr. Eduardo Rodriguez led the world’s first successful face and double hand transplant
The team of 140 healthcare professionals who conducted the 23-hour surgery
What made Joe DiMeo a good candidate for the procedure and how he’s doing now
A brief history of human face transplants
The patient selection process for face transplant surgery
Connect with Dr. Bryan McLelland
Speaker: Dr. Bryan McLelland
You’re tuned into Dentist Brain Candy, where we bring relevant, meaningful, value filled knowledge bombs straight to your brain. Featuring your host and oral surgeon. Dr. Bryan McLelland. Now sit back and enjoy the sweet treat of Dentist Brain Candy.
Hello, DBC peeps, and welcome to this week’s episode of Dentist Brain Candy. I am your host, Dr. Bryan McLelland, and thank you so much for tuning in. You’ve probably noticed here in season two that we’ve added to our repertoire to include a YouTube channel titled Dr. Jawbreaker. Now Dr. Jawbreaker is going to be a combination of episodes like this, on that generally geared more towards a dental professional, and then the videos of surgical procedures, which are geared towards the dental professional and just anybody that’s interested. There will also be just the audio version of this available on any podcast player that’s out there, stitch your radio iTunes. Remember if you can go and leave reviews that, really does help bring more people to this program and helps them find us, and is greatly appreciated. Of course, on YouTube, I believe thumbs up leaving a comment down below and subscribing, is also very helpful to get the word out about this program.
And if you enjoy this or want more of this, this is your way of letting me know that you’re out there. So, pause this right now go get that done. Thank you. Couple of announcements here before we get moving. COVID has been quite the nuisance over the last couple of years, although I believe we’re getting near the end of all of this nonsense, and I say that [time cheek 00:01:39]. But we have some live events coming. We had a little hiatus, we’re starting again. So February 18th, that’s right. Coming up February 18th, 2022, we’re going to have an OSHA update, a CPR renewal, HIPAA lunch and learn. And then two afternoon speakers. One of them is myself. I’m going to be speaking about wisdom teeth, maybe 30 to 45 minutes. Indications for referral, timing of referral, reason for extraction, update on the science behind wisdom teeth removal or not removal.
In October 21st, for those of you that can’t make it in February is going to be exact same program. Again, these are all going to be held in Post Falls at the Red Lion Templin’s. It’s a pretty cool venue, it sits right on the Spokane River in Post Falls, Idaho. You guys probably already know this, but I have two practices with Dr. Olson and I, one in the valley and one in Post Falls. So this would be a nice way to get people back together again and get some CE credits. Now, we are going to be streaming this on Facebook live. If you’re in person you can get CE credits, you’re welcome to attend the live if you wish, but there’s no CE credits available for those attending live. So February 18th and October 21st are the dates of those two events. May 13th, Noble Biocare is sponsoring an event. And this event will also be at Red Lion Templin’s in Post Falls.
And we’re going to have Ken Parrish, being one of our two speakers on that day. And his talk is titled Unlocking The Power of Innovation. Understanding the benefits of Thai ultra in the zeal surface technologies. Discover how the new implant topography promotes early oseointegration, learn the rule of DTX studio, which is a software for treatment planning and its ease of use. In the afternoon, we’re going to have Ian McNichols from WEO Media, probably pronounced weo media, I don’t know. Best practice for driving new patient growth and how to get new patients for all this new implant technology that you just learned. Hope to see you guys there. Also want to let you guys know about Jet Virtual Consults. Jet Virtual Consults is an app that I had developed for my practice, and it has been phenomenal. And the whole idea of this app is more than just the video consults.
This app will increase your productivity by 10 to 15% at a minimum. It will help you collect patient’s health history, their surgical history, their medical history, before even showing up at your office. They can take pictures of their cards, their insurance cards, before they come in or anything else you want them to take a picture of. They can review and sign your financial policy, they can review and sign your HIPAA policy, and that’s right. You can have your own forms within this app itself. If you’re doing a surgical procedure like extraction of wisdom teeth, dental implants, jaw surgery, et cetera, there are informed consent videos that are available as well. And then, it helps you collect reviews and increase the number of reviews that you have by doing a screening process, to make sure patients that are happy four or five stars are greater, are directed to the internet to leave an online review for you.
And then the grand finale of course, is the ability to do a video conference or video tele a dentistry/telemedicine consult that you can get paid for, so the patient can do this from the comfort of their own home or whoever they wish. Currently, I mandate five consults per day that are virtual. The average cost of a turnover of a room is somewhere in the 50 to $75 range. So if you do five consults a day at $50, that’s $250 that’s saved just right out the gate. Not to mention the increase in productivity. I was able to do the same number of consults in one hour less time, and do one hour’s worth of more surgery, which massively increases my productivity. So if you want to learn more about that, just go to Jeffer.consults.com or email me at email@example.com. To go back to the CE events if you want to register for those, just email at info@Libertysurgerycenter.com or go to Eventbrite and search for Liberty oral surgery CE events. I do recommend emailing, it’s probably a little more predictable at this point.
Now, the first thing I’d like to talk about today is trigeminal neuralgia. Now trigeminal neuralgia, a really nice review article in the JOMS, that’s the Journal of Oral and Maxillofacial Surgery. Pages are 2378 to 2371 in 2021. The article is short and succinct, but quite useful. So, this article is by Ellie Farini. So trigeminal neuralgia is a long lasting facial pain disorder that affects the trigeminal nerve, clever name. Trigeminal neuralgia, trigeminal nerve. An even mild stimulation of the face can cause severe and excruciating pain. Initially it is experienced a short mild attacks, but this pain disorder can progress causing longer and more frequent bounces of pain and discomfort. Trigeminal neuralgia affects men more than women and is likely to occur in people who are more than 50 years of age. The symptoms include involving one of the three branches of the trigeminal nerve, which include the ophthalmic nerve or V1, the maxillary nerve or V2, and the manipul nerve V3. One, two, or all three of these can be affected individually or at the same time. However, trigeminal neuralgia commonly affects the men and maxillary branches only.
Symptoms include one of the more of the following patterns. Pain in the cheek, jaw, teeth, gum, or [teeth 00:07:24]. Pain usually affects one side of the face. The episodes of pain are severe in shooting that may feel like an electric shock. Pain can last a few seconds to several minutes, and the pain can be focused on one spot or spread to a wider area on the face. Sometimes there are trigger points associated with this. Some of the triggers which may set off pains include eating, drinking, smiling, brushing teeth, talking, touching your face or washing your face. Trigeminal neuralgia is caused by a disruption of the trigeminal nerve. Most commonly the problem is contact between a normal blood vessel and the trigeminal nerve at the base of your brain. The disorder can also be a result of just aging, and people with multiple sclerosis do you have an increased incidence of trigeminal neuralgia. So, if you have trigeminal neuralgia, oftentimes it includes seeing an oral and maxillofacial surgeon, and or a neurologist, and or a neurosurgeon.
The treatment includes nonsurgical and surgical approaches. Nonsurgical modalities include medications. And these medications can include things like Tegretol or Carbamazepine, Amitriptyline, Baclofen which is a muscle relaxant. And although it’s not in this article Neurotin or Gabapentin, is also used for the treatment of trigeminal neuralgia, particularly in my area. Surgical procedures are divided into two categories, either open procedures or lesional procedures, or lesioning procedures.
So, open surgery includes microvascular decompression, and it involves surgical exposure of the trigeminal nerve root by a neurosurgeon, decompressing the nerve and moving to the blood vessel away from the point of compression. This may result in relieving painful episodes and return to normal nerve function. Lesioning procedures. There are many minimally invasive procedures that can be used to treat trigeminal neurology of patients. Percutaneous, radiofrequency, rhizotomy is one. This minimally invasive technique uses heat to relieve pain by destroying the part of the nerve that causes pain. The surgeon passes small needle through the cheek, into the trigeminal nerve and use the heat current to destroy some of the nerve fibers.
Percutaneous balloon compression. This technique uses a needle that passes through the cheek to the trigeminal nerve. This surgeon places a tiny balloon then inflates it. The inflated balloon compresses the nerve and injures the fibers that cause pain. Percutaneous glycerol rhizotomy.This technique uses a liquid agent glycerol, to selectively damage the nerve. This interferes with the transmission of pain signals to the brain. Keep in mind that all of these will lead to some level or degree of paraesthesia and permanent numbness. And then there’s procedures that are stereotactic. Radiosurgery, such as gamma knife or cyber knife, this procedure delivers a single dose of ionizing radiation to a small precise target at the trigeminal nerve root. This ultimately interrupts transmission of pain and signals to the brain. The next thing that I’d like to discuss is really just a more an article, a contemporary article about a surgeon. An oral maxillofacial surgeon named Eduardo Rodriguez. And this individual is quite impressive, is quite accomplished, and is doing face transplant surgery. And actually was recently quarterback for a face transplant and a hand transplant surgery. Yes, you heard me right, face and hands at the same time.
So this was out of AMuS today in the most recent January release in 2022, the article goes like this. Dr. Rodriguez starts off by just saying that the first time he saw in a small animal model that a facelift or at least a partial facelift could be done, he was thinking, wow, how do we get this to clinical trials? Roughly 17 years later as head surgeon, Dr. Rodriguez led more than 130, 140 healthcare professionals at New York’s University, NYU Langone Health, it conducted the roles first face and hand transplant. A 22 year old new burn victim received a donor’s hands and a full face during the 23 hour surgery in August of 2020.
In total, Dr. Rodriguez has led four face transplant procedures. The latest surgery, patient Joe Damil suffered third degree burns over 80% of his body in a 2018 car crash. After he fell asleep on his way home from a night shift as a product tester. After about 20 reconstructive surgeries, the 22 year old had severe facial scars, no lips or eyelids and amputated finger tips. With the goal of transplanting, the patient’s face in hands, the surgery posed the most complex operation dr. Rodriguez has ever performed. Two previous attempts by other surgeons to simultaneously transplant a face and hands were both unsuccessful.
The first patient in 2009 in Paris died a month later because of infection. In 2011, a transplant in Boston, Massachusetts treated a woman muled by a chimpanzee, but her hands were removed days later. Team rehearsed this surgery in 2019 until the COVID 19 pandemic hit, and at NYU Langone Health resources and attention turned towards treating for those emergency patients and Damil’s transplant was postponed. Can you imagine having yourself as the surgeon, as the doctor, and especially as the patient, all psychologically prepared and you’re ready to go new face, new hands, knowing that this has only been done a handful of times and that you could die being postponed, dang as something else. I’m going to try to show you some pictures here of what this guy’s face looks like in his pictures. But, the whole mantra of this was that failure is really not an option, failure’s equals death in this particular situation, or quite possibly death. Six surgical teams, including one for each hand and the other for the face simultaneously operated in the donor and recipient rooms. So if you think about that, you’ve got like a donor.
One team procuring one hand, one team procuring the other hand, another team procuring the face, that’s three teams. Now on the patient Joe Damil, you’ve got one team that’s going to work on one hand, one team that’s going to work on the other hand, and then Dr. Rodriguez working on the face. The 16 surgical team, 80 member OR team transplanted the hands to the mid forearm and the full face, including the ears, the nose, the eyelids, and the underlying skull.Dr. Rodriguez said the surgery went better than expected. Craziness, let me show you some pictures. So here’s a picture of our handsome Joe [pand 00:14:20] good looking fella. And then the injuries, check that out. What a change, what a difference. And if we go up here, there’s some 3d planning that was done, and some modeling. Sorry, my fingers are over that of what was going to happen. Now want to show you actually at the end here, I’m going to show you what he looks like.
The surgery for the face and transplanted hands lasted 23 hours. And then the patient looked at his face. Before and after the transplant photos are coming your way, I’m going to make you wait. So Damil is now doing well, he’s extremely motivated. They do a whole bunch of psychological and social testing ahead of time and counseling to make sure the patients are adequate and well chosen for these procedures. He’s now lifting weights. He’s petting a dog, he’s actually grasping objects. That means his hands have some level of movement. Crazy. And he grasps objects such as balls, and he moves them. As soon as we can get them off the pain medications, he wanted to be off to see Dr. Rodriguez. He still has that same spirit. He’s a fighter. He’ll always tell you that he doesn’t give up. He’s not a cliche, he’s got the right attitude. We’re very, very proud of him.
History of transplants. I’d like to give you just a little touch up above that, or a little information about that. Human face transplants pose a relatively new world. Yeah, no kidding. Huh. And new challenges with fewer than 50 operations performed across the globe. The first partial face transplant was done in 2005, by an OMS [Bernard De Varaivel 00:15:57], a plastic surgeon Benoit Lengele and a transplant specialist team John Michelle du Bernard in France, to treat a woman that was muled by her dog to replaced the patient’s nose, chin and lips. The patient died in 2016, and this was done in 2005 at the age of 49 after experiencing infections and developing cancer. A team at Cleveland clinic performed the first US face transplant and reportedly the fourth in the world in 2008. In a 2008 on a woman’s shot by her husband in a botched murder suicide, it was a 22 hour operation that involved the nose, the eyelid, the skin, the muscles, the teeth, and the nerves, and was at the time considered the most complex face transplant according to the Institute.
Patient died in 2020 that’s 12 years later, at 57 due to an infection unrelated to her transplant. In 2010, the first full place transplant was conducted in Barce Spain. The 24 hours surgery was conducted on a 31 year old man injured in a shooting accident. The first full face transplant in the United States in 2011, at Brigham and Women’s Hospital in Boston, treated a 25 year old man whose face was severely injured. And when as a cherry picker, he touched an electrical wire. I just imagine this guy in a cherry tree, picking cherries and his face touching some wire and electrocuting him. Man. A 30 member team conducted this 15 hour surgery that transplanted the skin, nose, lips, as well as the underlying muscle and nerve from an anonymous donor. Rodriguez performed his first human transplant in 2012 at the university. It was a 36 hour surgery. Compared to Rodriguez’s first face transplant, this procedure was definitely shorter. Let’s see, 36 to 24 hours. Yeah, that’s a lot. Still, 24 hour surgery, man, that’s something else. Compared to Dr. Rodriguez’s first face transplant. This surgery was more than 11 hours shorter.
The length of state was about 25 days in intensive care unit by 28, and rehabilitation for six days. Patients submit requests for transplant at NYU with careful evaluation by clinical psychologists, psychiatrist, and ethicist, a large team is involved in patient selection. And patients must understand the consent process very well. But the operation offers a patient at a new chance of living. So Dr. Rodriguez explaining, and that he’s unsure with how long they will live with the transplant due to potential complications and issues related to under going operations, including infections and the effects of long-term medications. The future of these face transplants. The first face transplant Dr. Rodriguez led was 36 hours. Well, the most recent one was 23 hours. Dr. Rodriguez said he does not become tired during the long surgery, he’s is running on adrenaline. He takes breaks to drink coffee and to use the restroom. It’s glad to know that at least he’s human.
As for the future, other opportunities are subunit face transplants, transplanting portions of the face or the jaws, including skin or bony tissue. I think the major limiting factor in these patients have been the lifelong medications that potentially compromise our lives. And what Dr. Rodriguez is talking about here, is that despite doing testing and making sure they’re an adequate match, and that would be a fascinating discussion all on its own. They still have to take things like immunosuppressants, like tacrolimus and progra, et cetera. So, I just thought that this was like an amazing article, and I’m so pleased that an oral and maxillofacial surgeon is kind of one of the leaders in this really in the world. This Dr. Rodriguez is fantastic for our specialty is doing courageous. Really just courageous work, only overshadowed by the courage of his patients that are moving forward and doing this.
Now I want to show you the before and after picture. And we know that this patient’s a rockstar because they’re clearly a Boston Bruins fan. So check this out. Forgive me for the difficulties in transferring this through video, but I think you at least get a good feel for where he was before, and where he was after the success of that. Check out those arms and hands, love the tattoos, love how healthy and normal those hands look, definitely some contracture there. I’d love to more about that, but anyways, check that out. Hope you love this article as much as I did. Well, guys, that concludes this week’s episode of Dentist Brain Candy. I want to remind you about something that is current and pressing. If you’re interested in a continued discussion about how to generate income outside of the practice of dentistry and oral maxillofacial surgery, contact Chris Salazar.
He is a friend of mine that currently has an investment. The name of his company is Archstone Capital. If you email me at firstname.lastname@example.org, I’ll get you in touch with Chris. He currently has like a 57 unit apartment building that he is looking for an additional $300,000 worth of investment, which will generate significant cash flow on a monthly basis. I haven’t looked into this particular deal yet, but every deal Chris has sent to me has at least an eight to 10% preferred return for the investor. So, on that’s on an annualized basis. So if I do some quick math, 10 percent’s an easier number. 300,000 is $30,000 per year once stabilized. So that means roughly once the project is completed, which means it’s a value add. In other words, there’s stuff that needs to get done. It needs to be fully tented.
300,000 is going to translate into $30,000 per year. You do 30,000 divided by 12 and you are well it’s 36, be $3,000 a month. So you’re somewhere in the… Just going to spitball like 23 to $2,600 a month. Check in the mailbox by making this one investment. You can use IRAs, you can use 401ks. And I’m just telling you what I’m doing for investments. Of course, you got to know that I am not an investment advisor, talk to your accountant, but I’ve never heard anybody and any of my friends or colleagues come and present these kind of things that have been vetted by someone that I know and trust. So hopefully, and trust me, this is stuff that I’m investing in. So just email email@example.com or firstname.lastname@example.org, and I will get you in touch with Chris. Keep in mind that this investment is time sent sensitive, although he has other investments coming and projects coming in the future. If you want this one, you got to jump on this thing fairly quickly to get the information.
So, thank you for tuning in. I hope you like this. Please leave the reviews, high star ratings, comment down below, all the good stuff to make this become seen and known out there and the big bad world. So, appreciate it. Catch you next time and see on the flip side.
Thanks for tuning in on another episode of Dentist Brain Candy. Don’t forget to check out our website for suite upcoming events and remember to sign up for our email@example.com. There is no guarantee as to the accuracy of this in information, and no treatment decision should be based on this information presented. Although every attempt is made to be accurate and factual, some items discussed are the opinion of the author and no liability will be assumed for the content presented.