Exploring plastic surgery and hand transplantation

Since the first human hand transplant in the modern era this surgery has attracted media curiosity and intense debate. That first case, from Lyon, ended in failure when the recipient proved not to be compliant with after-care and immunosuppression, and eventually requested amputation of the transplanted hand. However that case was rapidly followed by one in the United States from Louisville Kentucky, and that transplant endured and recovered impressive function. At the time of writing more than 70 upper limbs have now been transplanted and it remains the commonest vascularised composite allotranplantation.

In recent days surgeons in Houston, Texas have identified a four limb amputee who is now a candidate for the first double above elbow transplant in the United States.Theannouncement was accompanied by many images of this patient and interviews emphasising her profound disability, her remarkably resilient personality and her determination to go ahead with transplantation despite the known risks of prolonged immunosuppression. For someone who has already lost four limbs from overwhelming sepsis this may seem a brave decision, but her husband points out that it would be far more difficult to endure the rest of her life in her current condition. It seems likely that with his support this intelligent woman has chosen a calculated risk against an unpalatable and unendurable certainty.

Over the last two years we have established the framework for a transplantation service in Leeds Teaching Hospital. This has been a long and meticulous process in conjunction with a number of partners and we are now screening patients to select those most likely to benefit at least risk from an upper limb transplantation. During those two years we have formed liaisons, learnt new science, evaluated the known knowledge and continuously debated the ethics and practicalities surrounding this procedure. Hand transplantation seems to divide the world of reconstructive hand surgery. Factions form, and when formed seek all supporting arguments for their point of view whichever it may be. In considering my own point of view I have tried hard to balance these arguments against each other and have concluded that as in so much surgery, there is no single right answer.

Because of the considerable downside of immunosuppression with its undoubted capacity to shorten life and produce infective, neoplastic, or metabolic complications, some units have adopted the very strong attitude that this surgery can only be justified in double amputees. They would hold that the management of the unilateral upper limb amputee should be by prosthetics and point to the dramatic improvements in prosthetics exemplified by Touch Bionics and Ottobock. Certainly some of the results from these modern computer assisted myoelectric prostheses are very impressive and I have no doubt of their valuable role in both amputation and the management of serious brachial plexus injuries. But they remain cold, mechanical, insensate and most importantly not human.

Some people have argued that function should be the overriding goal in hand transplant surgery. It is undoubtedly true that mechanical function can be achieved by these prostheses but that is a small part of the function of the hand, just as it is a small part of the function of the face. Both hand and face are constantly on view, central to human-ness, and have integrated functions that transcend the purely mechanical or the purely sensory. Each embodies, to other humans, particular aspects of beauty and grace. In the compound functions, its beauty, its sexuality and its warmth, the human hand is a far cry from current prostheses. It may of course also be a far cry from current hand transplants but in the best results so far hand transplants get closer.

In the paternalistic approach, surgeons and surgical teams would make the decision for a patient as to whether these additional benefits (or functions) of the hand warrant the risks of transplantation. A more contemporary approach recognises the autonomy of the patient with capacity and recognises the inability of the normally-handed individual to make such a decision for a bilateral or even an unnatural amputee. So personal, cultural, and nuanced are the factors to balance that this decision can only be made by an individual for themselves. There are analogies with patients seeking to exercise their right to die, and it is important for the medical team advising the patient to establish that the patient has capacity and that they are so well-informed that their decision is not influenced by under representation or overrepresentation of facts.

Informed decision-making is difficult to achieve and in hand transplantation there are many known unknowns, key amongst which are the natural history of handlessness (in that we know little about the life impairment and life expectancy of the handless patient) and the morbidity of immunosuppression in an otherwise fit patient (previously immunosuppression has almost always been given to unfit and seriously ill people). It is also almost certain that as this surgery involves we will find that there were unknown unknowns and that is the nature of new directions in medicine.

For most upper limb amputees there are three clear options, no treatment, prosthetics, or transplantation. Only when the first two have been fully considered and exhausted should the last be proposed. I believe that vascularised composite allotransplantation is here to stay and that the current standards of immunomodulation and current knowledge of immunology will only improve, to become more effective with fewer risks at lower costs. We can debate whether the time is right for allotransplantation and for whom, but the people for whom that debate matters most, our patients, will come to their own conclusions given time and knowledge. Many units are eager to announce their transplants (or even in the case of Houston their patients waiting for transplant) but despite the long survivals of many of these transplants the outcome data remain relatively sparse. This is reminiscent of the early days of replantation where simple survival of the replant rather than its function and integration were regarded as success. In Leeds we hope to start the long journey towards understanding this process for ourselves establishing our own knowledge and very openly and continuously publishing our outcomes.

Professor Simon Kay
BAPRAS Full Member