Brendan Marrocco sometimes looks down at his arms and can't believe they really exist.
Until six weeks ago, the 26-year-old didn't have arms. He lost both of his, as well as his legs, in the Iraq War when the armored vehicle he was driving ran over a bomb in 2009. He was the first soldier of the Iraq and Afghanistan wars to lose all four limbs in combat and survive.
But Marrocco has arms again because of a rare double transplant performed by a team of surgeons at Johns Hopkins Hospital on Dec. 18. Marrocco wheeled himself into a media briefing Tuesday using his new limbs.
He and a team of doctors that helped perform the transplant talked about his recovery and what life will be like when the transplanted arms are fully functional.
"It's given me a lot of hope for the future," Marrocco said about the surgery. "I feel like I've been given a second chance."
Marrocco still doesn't have much feeling in his arms and it could be two to three years before he is able to fully use them again. Nerves regenerate at a pace of about one inch a month, meaning recovery can be lengthy, said the lead surgeon, Dr. W.P. Andrew Lee.
"The progress will be slow, but the outcome will be rewarding," Lee said. "Brendan tells us he is up to the challenge."
Marrocco said the arms, though they once belonged to someone else, already feel like a part of him. He instinctively scratches his head and touches his face with them all the time. Sometimes, he folds his new arms in his lap. The arms make him feel like his old self — like he was before the accident.
"They have truly become a part of my everyday life in the last few weeks," he said. "It's like I went back four years ago and I'm me again."
Marrocco was a machine gunner stationed at Forward Operating Base Summerall in Bayji, Iraq, at the time of the explosion that nearly took his life. About six months into his tour of duty, he was driving an armored vehicle in a convoy on a routine mission heading back to base.
He doesn't remember details of the accident. Four soldiers were in the vehicle at the time. Marrocco would later find out that his best friend in the military died and another soldier was wounded. The fourth somehow was unharmed.
Marrocco's injuries were so extensive that his father, Alex Marrocco, said he didn't recognize his son when he first saw him in a military hospital in Germany. The Army infantryman spent months recovering in Germany and at Walter Reed National Military Medical Center in Bethesda before moving to a home in Staten Island, N.Y., built with donations.
He was given prosthetic arms but never fully adjusted to using them. He had become somewhat proficient using the left one, but rarely used the right because it was bulky and hard to maneuver. While he was fairly independent and did many things for himself, his older brother Michael, moved in with him to help out.
Transplanted arms are better for some patients, Lee said, because they allow them to feel sensation. A patient with a prosthesis has to look when he ties his shoes so that his brain will process the activity. However, Lee described a patient with transplanted arms who could tie a ponytail with her hands behind her head out of eyesight.
Transplanted arms allow double amputees to become independent, Lee said. It is hard to perform simple functions with two prosthetic arms, he said. Younger patients also don't always do well with the artificial limbs, he said.
A doctor at Walter Reed first told Marrocco about the possibility of arm transplants and offered to put him in touch with Lee, who was then at the University of Pittsburgh.
After he met with Lee in 2010, Marrocco was on board despite the risks that came with the surgery, including the possibility that it wouldn't work. He decided surgery could be no worse than what he already had endured.
"The worst-case scenario was if I lost the arms I would go back to the way I was," he said.
In the more than two years it took for a pair of suitable donor arms to be found, Lee and his team of doctors moved their program from Pittsburgh to Hopkins. Meanwhile, superstorm Sandy damaged Marrocco's home so badly he had to move out.
Then in mid-December, donor arms became available and Marrocco was bound for Baltimore.
The 13-hour surgery involved a team of 16 surgeons. They came from Hopkins, Walter Reed, the Curtis National Hand Center at MedStar Union Memorial Hospital, UCLA and Pittsburgh.
The doctors first attached the bone using metal plates and screws, Lee said. Teams of doctors then sutured the muscles and tendons and then the blood vessels using a microscope. Next they repaired the nerves before attaching the skin.
"It is a very complicated procedure," Lee said in a phone interview. "It involves a lot of precision."
Marrocco is only one of seven patients in the United States to have undergone successful double arm transplants, Hopkins said. It is the first such procedure performed at Hopkins, but Lee and a team of doctors performed other double- and single-arm transplants at Pittsburgh.
About 60 arm transplants have been performed around the world, Lee believes. He and his team of doctors have other patients waiting for donors and are consulting with others to see if they would make good candidates.
Doctors also used a new treatment to prevent Marrocco's body from rejecting the new limbs, which sometimes happens in transplant procedures. The treatment involved infusing bone marrow cells from the donor's body. Marrocco now has to take fewer drugs to fight rejection. The anti-rejection drugs can damage organs and cause infections.
Infusing the bone marrow helps balance the immune system of the donor arm and the patient, Lee said.
Michael Marrocco, who quit his job to help with his brother's recovery, said he hopes the surgery will help Brendan become even more independent. He said his brother also was determined not to let lost limbs slow him down.
"This surgery is probably the biggest thing to happen in my brother's life," he said.
Brendan Marrocco, who retired from the Army as a sergeant last year, doesn't have a job but has earned veterans disability benefits.
Marrocco said he asked Lee if he could give him new legs too. Although doctors in Europe are transplanting legs, Lee is not yet comfortable with the procedure and said more testing is needed.
That's all right with Marrocco. Arms are a bigger deal because they are used so much.
Marrocco's recovery will involve intensive hand therapy, first in Baltimore and later at Walter Reed. Doctors are doing the minimum treatment now as they allow his tissues to recover from surgery.
They say Marrocco is an eager patient who already has found ways to start using his arms. Doctors said his positive attitude should help him in recovery.
"Right now we are the ones holding him back to let the tissues heal," said Dr. Jamie Shores, clinical director of hand transplantation at Hopkins. "I don't think there is much we will be able to keep him from doing."
Lee said his previous patients have gained almost full function. One double-transplant patient can tie his shoes and use chopsticks, he said.
For his part, Marrocco said he looks most forward to eventually driving again. He has a black Dodge Charger waiting for him when that time comes. He also plans to take up swimming and hand cycling when he is strong enough.
Mostly, he just wants to push his arms to the limit.
"I just want to get the most out of the arms," he said.