More on Hand and Face Transplantation

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

There was a lovely news article on the first California hand transplant patient in the LA Times earlier this week:  Hand transplant patient speaks (bold emphasis is mine)

Emily Fennell, 26, last month became the first person in California to have the revolutionary surgery. Six weeks and many hours of therapy later, she has no regrets. …..

On March 5, Fennell became the first person to undergo a hand transplant in California and the 13th nationwide to have the revolutionary surgery. . ….

"It's crazy how good it looks," she said at her occupational therapy session one morning last week at UCLA, where she spends about eight hours a day working on learning how to move her new hand and fingers. "I knew the match wouldn't be perfect, but if you didn't know what happened, you'd think I just had some kind of orthopedic surgery."  ….

Doctors told her that the biggest risk from the surgery comes from the side effects of lifelong use of strong immunosuppressant medications, which can cause high blood pressure, kidney or liver damage, elevated cancer risks and lower resistance to infections. …..

"I decided the benefits were worth those risks," Fennel said. She has adjusted well to the medications.  ….

She has no sensation yet in the transplanted hand. The nerves grow about one millimeter a day from the connections the surgeons made to her arm, and it will be several more months before sensations develop.

"The hand is connected to me. It's mine," Fennell said. "But until I have feeling in it, it's not going to feel like mine."  ……….

Her therapists encourage her to say "my hand" instead of "the donor hand." It's a psychological adjustment that runs parallel to the physical challenges she deals with.  ……..

This news article coincides with my reading of the journal article on issues related to face transplantation (full reference below).  Both hand and face transplantation have similar issues to other solid organ transplantation.  One of the big issues with hand transplantation is whether the risks are worth it as a hand transplant is not a live-saving procedure as a heart or liver transplant is.

From the article

Two of the world's first four face transplant recipients acquired cytomegalovirus viral infection by means of their donated facial organs. Also, the French experience, and our own, has been challenged by cytomegalovirus reactivation and graft rejection, therefore necessitating a critical evaluation. The authors have also learned, from their own experience, that facial composite tissue allografts containing mucosa and paranasal sinuses present a distinct challenge with regard to their accompanying flora.

Conclusions: Although the risk of donor-derived cytomegalovirus is acceptable in life-saving solid organ transplantation, for face transplantation patients, the scenario is different. When the authors' team performed the first nearly total face/maxilla transplantation (December of 2008), there was little known regarding the consequences of cytomegalovirus-related donor transmission in face transplantation. Therefore, the authors now recommend that all candidates be fully informed as to the risks of cytomegalovirus/infectious transmission and that aggressive viral, bacterial, and fungal prophylaxis be instituted.

As with the young women who would give a year of life for a perfect body, it is a question for the individual (I am coming to believe) to decide.  But for them to decide, we surgeons/doctors must do a better than good job at educating them as to what the risks are AND as to the reality of the limitations that will remain.  The new hand will never work as well as the non-injured one did. 

Read Wolf’s comment on my blog post regarding the Florida student who had a hand transplant.

REFERENCE

Cytomegalovirus and Other Infectious Issues Related to Face Transplantation: Specific Considerations, Lessons Learned, and Future Recommendations; Gordon, C R; Avery, R K; Abouhassan, W; Siemionow, M; Plastic & Reconstructive Surgery. 127(4):1515-1523, April 2011; doi: 10.1097/PRS.0b013e318208d03c

Florida Student Gets Hand Transplant

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

This is a difficult post for me to write.  As much as I admire the surgeons who are pushing this new advance I found myself bothered by this one.  Why?     That’s what I have been asking myself.  After all, Linda Lu, 21 year old, is a college student from Orlando, Florida is ecstatic about the new hand.

"I've already accepted it as my hand since the day I woke up," Linda Lu said during a Monday press conference at Emory University Hospital in Atlanta, where the surgery took place. "But just looking at it, sometimes I still can't believe that it's there... It kind of feels like magic."

"I'm in information technology," Lu said. "So, my primary goal is to be able to type."

Simple enough goal, isn’t it?   When playing the “what would I give up game” my hands are never given up easily.  I could probably learn to sew with only one hand, but it would be difficult and it would become mostly machine sewing.  I could still blog as I could type with one hand – not as fast, but it would get done. 

I would not be able to do surgery with one hand, but a hand transplant would not give that back to me anyway.  The dexterity would never be good enough.

Linda is reported to have lost her left hand when she was 1 year old.  The amputation was done due to complications from Kawasaki disease.

Still I’m left with this uneasy feeling.  Most people born with only one hand/arm adjust well.  For example, look at the baseball pitcher Jim Abbott. 

This healthy young woman will now be placed on anti-rejection medications for life.  It will make any pregnancies she has high-risk ones.  She will be more susceptible to infections.  Some anti-rejection medications increase the risk of cancers.

Just because we can do a procedure doesn’t mean we always should.  I hope my uneasiness regarding this one is misplaced.  After all, I am getting my information from news articles and not from a discussion with the patient.

Newsprint articles

Florida Student Receives Rare Hand Transplant Surgery, FoxNews.com, March 28, 2011

Valencia student has rare hand transplant at Emory University, LA Times, March 28, 2011 (video as well as print)

Related posts:
Double Hand Transplant on Twitter  (August 26, 2010)
Cost of Hand Transplantation?  (September 22, 2010)
Rejection  (December 1, 2010)
New Technology May Help Prevent Rejection in Hand Transplant Patients (December 13, 2010)

New Technology May Help Prevent Rejection in Hand Transplant Patients

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Previously I posted on rejection in hand transplant patients when it was reported double hand transplant on patient Rich Edwards of Oklahoma might “lose the fingertips on his right thumb and pinkie because his body started to reject the new limbs.”

Jewish Hospital Hand Care Center and the Christine M Kleinert Institute have released news on a new medical device which may allow detection of rejection at an earlier stage.  Early detection could then improve treatment and perhaps prevent limb loss as with the team’s 4th patient Dave Armstrong who had his transplanted hand amputated in April 2009 due to rejection.

I first read about this new device, an ultrasound biomicroscopy device, in Wave3.com’s December 6, 2010 article: New technology helping keep transplanted hands attached.  Today I found the December 9, 2010 press release from the team (bold highlight is mine).

Despite recent setbacks, Dr. Richard “Rich” Edwards, the nation’s third double hand transplant recipient, continues to progress under the care of Kleinert Kutz and Associates hand surgeons at Jewish Hospital in Louisville, Ky.

Dr. Edwards experienced complications in mid-November when signs of rejection caused him to be hospitalized for several days.  Michael Marvin, M.D., chief of transplantation, Jewish Hospital/University of Louisville, and Rosemary Ouseph, MD, director of kidney transplantation at University of Louisville, who have overseen Edwards’ post-surgical immunosuppressant drug regimen, added steroid shots to Dr. Edwards’ routine to counteract the rejection.

The complication, which resulted in a loss of blood flow has caused the tip of Dr. Edwards  right pinkie to turn black. He had already had the tip of the thumb turn black due to a loss of blood flow shortly after the transplant. Unfortunately, those fingertips may eventually need to be removed.

Dr. Warren Breidenbach, partner at Kleinert Kutz  and Associates and assistant clinical professor of surgery at the University of Louisville said, “ The left hand is doing great and has good function. I call the right hand the “miracle hand” because of blood flow issues early on. The good news about the right hand is it has re-established blood flow and his hand function has almost caught up with the left hand.  The bad news is the right hand does not have the same volume of blood flow as the left, but it does have enough to survive.  The right hand remains a problem hand with an unknown future.  We are in uncharted waters with the right hand.”

Breidenbach added, “All hand transplant patients have the risk of loosing a hand at any time. In addition, all patients go through a rejection episode in the first six months. Dr. Edwards was around three months out from the transplant.  He had swelling which compromised the blood flow in mid November.“

Dr. Edwards remains closely monitored by the team at the Christine M. Kleinert Institute for Hand and Microsurgery (CMKI), including Christina Kaufman, PhD., executive director of CMKI and assistant professor at the University of Louisville.  Dr. Kaufman uses ultrasound biomicroscopy (UBM), a new technology that utilizes very high frequency ultrasound (20-70 MHz) to noninvasively monitor blood flow, vessels, arteries and artery intima, or thickness, which is where signs of potential rejection often first appear.

The device, which has not yet been approved for clinical use, was purchased with funds from the Department of Defense in January 2010.  Each of the previous hand transplant patients are also being monitored using UBM. Currently, Dr. Edwards is being tested every two weeks.

“Using this new technology we have done a great deal of investigation,” said Kaufman.  “There is a push to reduce the immunosuppressant medications, but we do not want to risk the loss of the hand.  With this machine, we are hoping to be able to reduce the drug regimen with maximum safety.  We are making advances and we’re getting better. That’s what research is about.”

Dr. Edwards continues therapy on his hands five-days-a-week with the therapists at the Christine M. Kleinert for four-hours-a-day. His wife, Cindy Edwards, assists him with additional therapy on his own several times each day, seven-days-a-week. His hands have already helped him regain independence in his daily activities.  He can brush his teeth, comb his hair, take his shirt on and off and feed himself throughout an entire meal – all activities that he was unable to do unaided before the transplant.  He hopes to be able to return to his home in Edmond, Oklahoma for the holidays.

“Every one to two days, I can see a change in my hands,” said Dr. Edwards.  “They are the best Christmas gift that I have ever been given.”

“These are minute changes, but when you work with his hands all day every day, those changes are encouraging,” said Cindy Edwards.  “He’s come a long way in less than four months.”

Dr. Edwards worked as a chiropractor before losing both hands when his truck caught fire on February 11, 2006.  Unable to escape the burning vehicle, he was severely burned on his face, back, arms and hands, leaving very little tissue in both hands.

Dr. Breidenbach led the team of surgeons from Kleinert Kutz, Christine M. Kleinert Institute and the University of Louisville who performed the initial 17 ½ hour surgical procedure August 24-25, 2010, at the Jewish Hospital Hand Care Center.  He continues to manage Dr. Edwards’ follow-up care.

The Composite Tissue Allotransplantation program is a partnership of physicians, researchers and healthcare providers at the Jewish Hospital Hand Care Center, Kleinert Kutz and Associates, the Christine M. Kleinert Institute and the University of Louisville. The group developed the pioneering hand transplant procedure and has performed five other hand transplants since 1999.  Kentucky Organ Donor Affiliates coordinated the hand donation for the team’s hand transplant procedures.

The hand transplant is sponsored by the Department of Defense, Office of Naval Research and Office of Army Research to further research in the composite tissue allotransplantation program.

Patient and physician information, photography and video are available at www.handtransplant.com and http://www.jhsmh.org/hand.