Likely the most common type of VCA/reconstructive transplant is a hand transplant. 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 2016, there have been more than 100 hand transplants world-wide. In 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)?
Facial transplants are another form of VCA/reconstructive transplantation. As of 2016, there have been 32 face transplants performed world-wide. Usually, the indication for facial VCA 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 VCA, facial VCA 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 three deaths after face transplant. In China, a patient who received a facial VCA 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). Int J Surg2011; 9: 600–607.
In France, a patient who received a facial VCA after a 3rd degree burn injury died two months after transplant from an infection (pseudomonas with cardiac arrest). Am J Transpl 2011; 11: 367-378.
Another patient died of recurrent cancer three years after facial VCA. Cavadas PC.Speed-update on world experience with clinical VCA. In: ASRT 3rd Biennial Meeting; 2012; Nov. 15–17; Chicago, IL.
UTERUS TRANSPLANT & LIVING DONOR VCA
VCA can also involve living donors. In 2014 a Swedish medical team reported that there had been 9 living donors who gave uterine tissue to women seeking pregnancy. Several of these donors were mothers giving their uterus to their daughter. One serious donor complication was reported, a ureterovaginal fistual which was later repaired. One recipient has given birth to a baby boy. You can read about these cases here: http://www.ncbi.nlm.nih.gov/pubmed/24582522 and http://www.ncbi.nlm.nih.gov/pubmed/25301505
Uterus transplantation is an experimental procedure for women with uterine infertility (absent or malformed uterus). As of 2016, there have been over 15 uterus transplants worldwide, some using a uterus from a deceased donor and some using a uterus from a living donor. So far, the best outcomes (5 live births) have occurred with living donors. One woman who had a live birth with a living donor uterus is now pregnant with her second child: http://www.bionews.org.uk/page_663839.asp
It is important to note that many women who have uterine infertility also have just one kidney and this can increase their risk of preeclampsia during pregnancy. Preeclampsia is a serious disorder of pregnancy in which women have high maternal blood pressure, protein in the urine and severe fluid retention. It has consistently been shown that pregnancy after solid organ transplant does not adversely affect the graft function of the donor organ or survival of the mother.
ROLE OF THE TRANSPLANT ETHICIST IN VCA
VCA/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 members of VCA Teams. When I was on the faculty at the Cleveland Clinic, I was fortunate to work with Dr. Siemionow's facial VCA 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 VCA. During that time, I also functioned as a research subject [patient] advocate, very similar to the role of the living donor advocate. I have also worked as an ethicist for hand and uterus transplant teams. Below is a list of some of my publications and interviews:
Bramstedt KA. Increasing donation opportunities for vascularized composite allografts: An analysis of worldwide donor registries and procurement organization web content (VOLAR Study). Prog Transpl 2016;26:in press. https://www.ncbi.nlm.nih.gov/pubmed/27543201
Bramstedt KA as a co-author of chapter 7 (VCA):The Transplantation Society of Australia and New Zealand, Organ Transplantation from Deceased Donors:Consensus Statement on Eligibility Criteria and Allocation Protocols, version 2.0, Background Review, Nov 2014.
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.
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