Healing Hands

On the morning of April 15, 2018, Priya Patel grasped the steering wheel of her car with both hands for the last time. She was driving alone along the Newport coast, headed to the grocery store, when her vehicle suddenly, inexplicably, caught fire.

She does not recall what happened next: All she remembers is thinking, “This is it.” Patel suffered burns across much of her body, including severe burns on both arms. Two months later, her injuries resulted in the amputation of all her fingers and thumbs.

The next two and a half years would be the most difficult of Patel’s life — a time of healing, searching, frustration and shattered expectations — and would culminate in a historic, first-of-its-kind surgical milestone performed at the Department of Orthopaedic Surgery at Keck Medicine of USC.

The Long Road to Recovery

Patel spent a total of three months in the hospital. In addition to amputating her fingers and thumbs, doctors treated her third-degree burns with skin grafts. She was sedated for her first two months in the hospital, giving her body time to heal. She woke to see bandages enveloping what was left of her hands.

“For me, this was devastating,” Patel says.

Her family was there for her: Her husband, Sanjay Patel, had kept a vigil by her side, as did her daughter, Mukti, and her son, Darshan. At the time, Mukti had just graduated from the University of California, Berkeley, and worked for a startup. Darshan was an undergraduate at the USC Marshall School of Business; he graduated while his mother was in the hospital.

I couldn’t cook for my kids. I couldn’t help others. I couldn’t even help myself.

Priya Patel

The amputations left Patel with both her palms intact, but only small nubs where her fingers and thumbs used to be. After spending another month in the hospital to recuperate, she returned home, where her family — including her mother, who had come to live with them — took care of her.

At home, Patel entered a three-month recovery period. Her mobility was limited, and she spent most of her time healing and in physical therapy. By October — around six months after the accident — she had healed enough for her bandages to come off. Soon after, what Patel describes as the lowest point in her life began.

“I was very miserable after I came home. I felt like I couldn’t do anything,” she says. Everyday tasks, such as combing her hair, using the restroom or even feeding herself, had become impossible. “I couldn’t cook for my kids. I couldn’t help others. I couldn’t even help myself.”

One Size Does Not Fit All

The Patels immediately began to search for options — anything that could help Priya regain some of her lost independence and restore her quality of life. They reached out to specialists at hospitals and academic medical centers across the country.

“Half of them did not respond or said there was nothing they could do for her,” Sanjay Patel recalls. “The other half said prosthetics. That was their solution.”

Today’s prosthetic hands are sophisticated pieces of technology. Twitching the muscles and nerves of residual limbs in different ways can train these robotic-looking hands to perform a wide range of grips and motions. The problem was that these systems were designed for whole-hand amputees. Patel still had her palms.

“The electronic fingers they gave me were too long,” Patel says, remembering how exasperated she was by the experience. “So even though I’m trying, I can’t hold anything, not even a bottle. I’m trying and trying, and I got so exhausted and frustrated.”

Other surgeons recommended a double hand transplant from a human cadaver. While this initially sounded like a viable option to Patel, the procedure would require amputating her remaining hands — an uncomfortable prospect. She would also have to take immunosuppressive drugs for the rest of her life, putting her at increased risk for infections and serious diseases, such as cancer, kidney damage, diabetes, osteoporosis and heart disease. It would also significantly limit her ability to travel.

“My kids and Sanjay were completely against [it],” Patel says.

Her hopes grew when she discovered a surgeon who performed a different type of transplant — a toe-to-hand transplant — to help people who had lost their fingers to amputation. With this surgery, a patient’s toes could be transferred to their hands, a procedure that, for Patel, seemed to check every box. She would regain the ability to hold and manipulate objects. She would not need to take immunosuppressants. She made an appointment.

I tried toe-transplant-USC. And Dr. Milan’s name came up.

Priya Patel

“He would only do the big toe, and that’s it,” Patel says. Without other digits, she knew she would not be able to grasp objects or truly regain the use of her hands. “I asked him if he could do the others, and he said only one at a time. And each surgery would have to be a year apart.”

Patel’s composure, patience and optimism collapsed at the possibility of a decade or more of continual surgery. She managed to make it back to the car with her husband before dissolving into tears.

A few days later, home alone, she realized she had never tried a simple Google search for the phrase “toe transplant.” Using what she calls “her nubs” — the smooth mounds that were all that remained of her missing fingers — she punched the phrase into her iPad. At first, nothing promising appeared. So she refined her search to include local universities.

“I tried toe-transplant-USC,” Patel says, smiling. “And Dr. Milan’s name came up.”

A Perfect Match

Milan Stevanovic is a professor of Orthopaedic Surgery at the Keck School of Medicine of USC and program director of the USC Joseph H. Boyes Hand Fellowship Program. A practicing surgeon of almost 40 years, he is widely considered one of the world’s foremost experts on treating disorders of the hands and upper extremities, including nerve injuries, trauma, burns, reconstructive microsurgery, and limb and digit replantation.

His experience was perfectly suited to Patel’s case. Stevanovic came to the United States from the University of Belgrade 30 years ago, where he was chief of the hand and upper extremity program and replantation team.

She didn’t have diabetes, heart problems or significant medical problems. I thought she had a 95% chance of success.

Dr. Milan Stevanovic

“She told me she went to see some other fellows who said she was too old for that procedure,” Stevanovic says. “She didn’t have diabetes, heart problems or significant medical problems. I thought she had a 95% chance of success.”

Stevanovic and Patel decided that a three-toe transplant with one big or “great” toe and two smaller toes would be her best option to regain the ability to grip and manipulate objects. If the procedure was successful on her dominant hand — her right — they would perform a second three-toe transplant a year later on her left hand.

The complexity of the surgery was not a deterrent for Stevanovic or Patel. “I never did more than a two-toe transfer, but I had performed over 100 cases,” Stevanovic says. “She was otherwise very healthy, a good candidate, this was the best way for her case, and she agreed.”

“Dr. Milan gave me so much confidence,” Patel says. “I asked him if he was going to do one surgery at a time for each toe, and he said, ‘Why? Why do you want to have six surgeries?’ And I was in heaven when he said that.”

However, Patel and her family’s excitement was tempered when Stevanovic explained the full extent of the surgery. The procedure could take 24 hours; at the time, a six-toe transfer — done in just two operations — had never been done before.

The family gathered to make the decision of whether or not to proceed.

“The kids were scared,” Patel remembers. “They said my presence was so important to them, and they didn’t want anything to happen to me. But I said not to worry. Dr. Milan gave me so much positivity. He’s the guy who can help me now.”

The Day of Surgery

The procedure — a three-toe transfer for functional reconstruction of severely burned hands — took place approximately one year after the accident. Preoperative imaging confirmed the blood vessels and nerves that could be used in the transfer. The great toe was transplanted first, followed by the two smaller, adjacent toes. Microsurgical needles that are 70 microns in diameter — half the size of a single strand of human hair — were used to reconstruct the vasculature of the hand. A tiny amount of bone, about one centimeter per toe, was left on the foot to preserve the ability to balance and walk.

A single toe transfer to the hand is considered by hand surgeons and microsurgeons to be one of the most challenging procedures.

Dr. Rachel Lefebvre

“A single toe transfer to the hand is considered by hand surgeons and microsurgeons to be one of the most challenging procedures,” says Rachel Lefebvre, an assistant professor of clinical orthopaedic surgery at Keck Medicine who helped Stevanovic during the procedures. “It takes everything we know and combines it into one surgery. To do this surgery for not only one toe but three toes at a time — and to perform it for both hands — is a microsurgical tour de force.”

In total, the first surgery took 15 hours to complete. Including prep and recovery time, it was a 19-hour process.

“You have to have a very ready and good team to stay 15 hours, working full time,” Stevanovic says. “But we are the oldest hand surgery program in the United States. We have one of the best programs in the country for free functional muscle transfer. Gayane Cabrera, our operating room coordinator, had us ready for 15- and 16-hour surgeries; she even did one of these during the height of the pandemic. With an excellent team, you can do things people never dreamed could be done before.”

“My Heart Keeps Thanking You”

— from Priya Patel’s handwritten note to Milan Stevanovic

The recovery period following the surgery was extensive. Patel had to keep both her foot and her hand elevated. Her arm was wrapped in a cone of protective bandages, with the tips of her new fingers just visible enough to confirm that they remained healthy and pink. After six interminably long months, she was finally able to experience the results.

“At last, I was able to hold my spoon, to eat food by myself. Two and a half years of people shoving food in my face,” she says with a laugh. “I was so happy I was in tears.”

The second surgery, which took place during the height of the COVID-19 pandemic, took slightly longer at 16 hours. One year after the first surgery, Patel could use her right hand to grip with five pounds of pressure and could walk with a normal gait. With this hand, she penned a letter to Stevanovic, which is on display in his home office. A year after the second surgery, her newly transplanted left hand could apply three pounds of pressure. Her right hand could apply nine.

Our daily mission is to tackle the most complex cases and provide solutions to patients that others did not think possible

Dr. Jay R. Lieberman

The combined procedure demonstrated the skill and dedication of an experienced surgical team. It stands as a milestone in orthopedic surgery, broadening the possibilities for patients who, like Patel, do not conform to standardized interventions or solutions.

“Dr. Stevanovic is a truly gifted hand and microvascular surgeon,” says Jay R. Lieberman, professor and chair of the Department of Orthopaedic Surgery. “Our daily mission is to tackle the most complex cases and provide solutions to patients that others did not think possible.”

In January, the combined two-stage, six-toe transfer procedure was recognized by the American Society for Reconstructive Microsurgery as the Best Microsurgical Case of the Year.

For Patel, the familiar rhythms of life, centered on family, have returned. Mukti is currently a graduate student at the USC Rossier School of Education in the Marriage and Family Therapy program. After graduating from USC Marshall, Darshan immediately returned to USC for an additional year, earning a degree in human biology and finally allowing his mother to attend his graduation in person.

“The thing I most like to do is cook for my family, for my kids,” Patel says, recalling how much she lost after the accident. “And when I told them, ‘I cooked today. Me.’ That was the best feeling ever.”

When asked about Stevanovic, Patel, as she does so often, speaks with her hands, placing them over her heart. “He gave me my life back,” she says. She opens her palms wide toward her home, her family and everything around her. “This is what he gave me.”