| Composite Tissue Allografting (CTA)/Reconstructive Transplantation |
HAND TRANSPLANT
Likely the most common type of CTA/reconstructive transplant is a hand transplant. Unlike solid organ transplants, these are life-enhancing rather than life-saving. The hands are used in many ways, including writing, typing, carrying one's children, holding objects, putting on clothes, bathing, driving a car, etc. They also provide the sensation of touch and they feel temperature. Loss of a hand is most frequently caused by trauma such as motor vehicle accidents, machine crush injury, military warfare, electrocution/burn, and recreational explosives (firecrackers, guns).
Prosthetic devices do not give their recipients full range of motion, and they do not restore the sense of touch or temperature. "Hand transplantation", however, offers patients hope for these functional outcomes. During a hand transplant, a donor gives his/her limb to the recipient upon death. The limb is a complex set of tissues that includes skin, blood vessels, nerves, tendon, cartilage, fat, muscle, and bone. Careful attention is made to match the size of the hand, wrist, and fingers to the patient's native limb. Also, limb skin tone and hair are matched. As of March 2011, there have been a total of 70 hands transplanted on 52 patients around the world. In the USA, the University of Louisville is the most experienced (www.handtransplant.com).
Prior to transplant, recipients are carefully screened by medical, surgical, and psychosocial clinicians to assess coping skills and body image issues. Can the patient tolerate another person's limb attached to his/her body? Psychologically, will they accept or reject it? Will they comprehend and accept the requirement of life-long immunosuppression in order to prevent transplant rejection (just like an organ transplant)?
Sometimes, hand transplant involves both limbs (bilateral), sometimes only the dominant limb. Sometimes the forearm is included, sometimes a portion of the upper arm is included. To watch an animation about the surgical procedure click here: http://www.handtransplant.com/TheProcedure/HandTransplantAnimation/tabid/150/Default.aspx
For more facts about the complexity of the hand, and how donors and patients are selected, click here: http://www.handtransplant.com/TheProcedure/HandTransplantFactSheet/tabid/90/Default.aspx
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FACE TRANSPLANT
Facial transplants are another form of CTA/reconstructive transplantation. The procedure is still considered experimental because it has only been performed a few times around the world. Usually, the indication for facial CTA is severe burn injury (direct flame or electrocution), motor vehicle or machinery accident with degloving (removal of the face by pulling it away from the skull), animal mauling, or congenital tumors. As with hand CTA, facial CTA gives the patient a complex set of new tissue from the donor, including skin, hair, nerves, muscle, blood vessels, fat, cartilage, and bone (for example, jaw and teeth). Because these tissues are placed over the bone structure of the recipient, the recipient DOES NOT assume the "look" of the donor.
Facial disfigurement can be emotionally devastating and it can cause extreme functional problems as well. After a significant trauma, patients can have difficulty opening/closing their mouth and/or eyes, they might lose their nose and/or lips, their hair, their ears. They might even lose their eyes. The outer ear (what you see) is important to funneling sound waves into the ear canal. The lips are important for speech as well as eating. The nose is important for smell and taste. Odors can lead us to pleasant things and keep us away from harmful things. Eyes (if they remain) need to be kept clean, protected, and lubricated and this is helped via functioning eyelids. This said, the "face" is more than a cosmetic concept; it is very much a functional concept.
As with hand transplantation, careful medical, surgical, and psychosocial screening is involved. Recipients must take immunosuppressant medication for the rest of their lives in an effort to prevent graft rejection. Recipients should also not smoke as this restricts oxygenation to the new tissues. Body image issues are explored in detail before transplant because the face is very much a "social organ" and there is even the potential for a worse outcome after transplant. Can the patient handle that? What if the outcome does not meet expectations?
I am currently aware of two deaths after face transplant. In China, a patient who received a facial CTA after being mauled by a bear did well with his transplant but after a few years, he stopped taking his immunosuppressant medication (he decided to take herbal medication instead). http://www.a-s-r-t.com/news/news6.html
In France, a patient who received a facial CTA after a 3rd degree burn injury died two months after transplant from an infection (pseudomonas with cardiac arrest). Lantieri L. et al, American Journal of Transplantation 2011; 11: 367?378
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ROLE OF THE TRANSPLANT ETHICIST IN CTA
CTA/reconstructive transplantation is a very complex topic that is filled with ethical issues. Three important matters are patient selection, patient advocacy, and informed consent. Because transplant ethicists are highly trained specialists in the field of medical ethics and transplantation, they are key players on CTA Teams. When I was on the faculty at the Cleveland Clinic, I was fortunate to work with Dr. Siemionow's facial CTA Team (2004-2007). During that time I worked to optimize the research subject [patient] consent form and I also developed a guide for the ethics assessment of recipient candidates. This is a rubric of questions for the ethicist to guide the interview process when the candidate is assessed for decision-making capacity and their overall ethical suitability to receive a facial CTA. During that time, I also functioned as a research subject [patient] advocate, very similar to the role of the living donor advocate. Below is a list of some of my publications and interviews:
Bramstedt KA. 2011. Informed Consent for Facial Transplantation. In Seimeinow M (ed) The Know How of Facial Transplantation. Springer: London, 255-260.
Siemionow M, Bramstedt KA, Kodish EK. Ethical issues in face transplantation. Curr Opin Organ Transpl 2007;12: 193-197.
Interviewed by author Laura Greenwald for her books about facial plastic surgery, Heroes with a Thousand Faces. Cleveland Clinic Press, 2007 (see pp 252-254) & Eye of the Beholder: True Stories of People with Facial Differences, Kaplan Publishing, 2009 (see pp 248-249).
Interviewed by writer Mac Overmyer for books about face transplantation, Transplanting a Face: Notes on a Life in Medicine, Cleveland Clinic Press, 2008 (see p. 81) & Face to Face: My Quest to Perform the First Full Face Transplant, Kaplan Publishing, 2009 (see pp 158-160).
Journal Interview, Medical Ethics Advisor, regarding the ethical issues associated with face transplantation. (Crossing new frontier: Paving the way to make face transplantation reality? July 2006, volume 22, issue 7).
Interviewed by Cleveland Clinic Magazine regarding IRB use of bioethics consultation services for the face transplant project. ("First, do no harm". Spring 2006, volume 3, issue 1, pp 10-12 & 14).
Journal Interview, Berkeley Medical Journal, regarding the ethical issues associated with face transplantation. November 2005.
For more info about CTA, please contact the American Society for Reconstructive Transplantation: http://www.a-s-r-t.com/
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