Advances in Hand and Face Transplantation: An Expert Interview With Dr. Jean-Michel Dubernard

Pippa Wysong


September 29, 2010

Face and hand transplantation are relatively new in the world of surgery. The key purpose for transplants is to restore function in patients who have experienced some sort of extreme trauma, but transplants also help improve a patient's body image. Dr. Jean-Michel Dubernard, Professor of Medicine at the University of Claude Bernard in Lyon, France, is known for performing one of the world's first hand transplants, and the first partial face transplant. Recently, Dr. Dubernard spoke to Medscape's Pippa Wysong about the challenges in the field of composite tissue allograft.

Medscape: What is a composite tissue allograft, or CTA?

Jean-Michel Dubernard, MD: This is where the transplanted graft is made from a variety of tissues -- skin, bone, tendon, muscle, vessels. Each tissue type has its own immunogenicity and rejection issues. The surgery and follow-up have the challenges of both microsurgical reconstruction and organ transplantation. It is mostly about restoration of function and an attempt to help people get back to a normal life, as well as improving self-image. People who lose 1 or both hands have a terrible self-image, as do people whose faces have undergone extensive damage.

It took us a long time to develop the procedures that we use today. Over the past couple of decades, several types of CTAs were performed around the world. At our center, we started with the hand, but we have also performed face transplants and abdominal wall transplants.

Medscape: Is 1 type of CTA more advanced than others?

Dr. Dubernard: At present, the hand transplant is far ahead of other CTAs in terms of technique and success. To help advance the science for CTA, I founded the International Registry on Hand and Composite Tissue Transplantation. We have contributors from around the world, and data going back to 1998.

To date, we have data on 52 hand transplants, and 13 face transplants. Of the hand transplants, 16 were double hand transplants; the rest were single. For me, double hand transplants are far more interesting, and there is a real need for them.

Medscape: So, the registry helps with understanding the causes of successes, as well as failures?

Dr. Dubernard: Yes. The registry shows a leading cause for failures is noncompliance with immunosuppressive medications, especially in China.

Medscape: What are the key challenges in performing a hand transplant?

Dr. Dubernard: There are 3 main challenges. One is the technical challenge and restoration of function -- this is slightly easier with the hand than the face. Will the hand work, will it re-integrate correctly and communicate with the brain cortex? The second, and main challenge, is immunologic. The skin is the most immunogenic tissue of the body, as anyone who performs reconstructive surgery using donor grafts knows. The third challenge is psychological.

Medscape: What are the psychological issues?

Dr. Dubernard: One of the main problems is body image. Before the transplantation, if you have 1 hand, you can do nearly everything in your daily life. But your body image is not quite normal. Initially, we thought a new second hand would improve body image, as well as function. But, we overestimated the impact of body image and underestimated the impact of function.

Medscape: Please explain.

Dr. Dubernard: When you have a transplant of 1 new hand, the 2 hands you look at every day will never look the same. Each time you look at your hands, you have the feeling 1 hand is foreign or strange. People have a difficult time adapting to that.

Medscape: What about with 2 transplanted hands?

Dr. Dubernard: First, take a look at quality of life before undergoing a bilateral hand transplant. Your body image is terrible. You are helpless, you can't pick things up, clean yourself, hold a glass of water, or do any normal activities. Plus, prosthetics just are not very good. When you get the transplant, everything improves, plus the hands match. For some patients who lose only 1 hand, it can be better for them to stay that way. But people who lose both hands have nothing but benefit to gain from a transplant.

Medscape: How complex is the surgery for a double hand transplant?

Dr. Dubernard: You need 2 surgical teams to prepare the grafts -- to dissect the arteries, veins, nerves, tendons, muscles, everything. Then, you need 2 teams working simultaneously attaching the donor's hands onto the recipient's stumps. For 1 hand you need 1 team.

Medscape: How long does the surgery take?

Dr. Dubernard: Between 6 and 10 hours. You need people who are excellent with microsurgery techniques.

Medscape: Are there differences in complexity or challenges related to how high up on the arm the amputation was done?

Dr. Dubernard: At the wrist level, it's relatively easy, in my opinion. But when you get near the elbow, you have to suture the muscle between them; it's more difficult than suturing a tendon to a tendon. Also, near the elbow it takes longer for the nerve regeneration to occur. We will soon be attempting arm transplants -- I just got authorization to launch a research project on arm transplant just below the shoulder.

Medscape: Who are the best candidates for hand transplant? Have enough surgeries been done to know that?

Dr. Dubernard: As far as we can tell now, the best candidates are those who had amputation after trauma. It's more difficult with burn patients, although we tried it on 2 patients. We are still learning about this. It's the same for face transplants.

Medscape: How long does it take for function to occur?

Dr. Dubernard: It depends on the level of the amputation. Usually sensitivity is back after 6 or 8 months, and motoricity after 1 year. It comes back slowly, it's progressive. Sensitivity comes back, I think around 98% worth. It depends on the patient. About 90% to 95% of motoricity returns.

Medscape: Is there an increasing number of surgeons wanting to do these transplantations now?

Dr. Dubernard: In France, we were the first center. Now 2 or 3 other centers will start doing this in France. There are surgeons doing this in Canada, the United States, China, South America, Italy, Spain, and other parts of the world. It's a necessary service although it is not considered life-saving. I say it's a life-giving procedure.

Medscape: What are the indications for face transplant?

Dr. Dubernard: We are at the beginning of this field. Our first face transplants were traumatic injuries. One patient was severely mauled by a dog; another was a fireman caught in a fire where all the lower parts of the face, including the maxilla, were destroyed. There were also some cases with benign tumors; we are about to perform one now. The first face transplant was performed only 5 years ago in 2005 and the first hand transplant 12 years ago. We are still on a learning curve.

Medscape: Which is more difficult: face or hand transplants?

Dr. Dubernard: A face transplant is more difficult technically. Interestingly, psychologically, appropriation is easier for the face. For some reason it's easier to adapt to a new face than a new hand. We think the explanation is that if you want to look at your face, you have to look in a mirror. But you use your hands all the time; they are always in your range of vision.

Medscape: How much of an improvement can people see with the face transplant?

Dr. Dubernard: In our experience, it's a very important improvement, especially with respect to function. Our first patient could not eat, drink, smoke, or kiss. She couldn't go anywhere without wearing a mask. Now she has all those functions back and has returned to a normal life. Getting people back to their lives is why we do this.

Medscape: What are the key technical challenges with doing a face transplant?

Dr. Dubernard: It depends on the amount being transplanted. A whole face is a more difficult transplant than part of a face. For the whole face, you have the problem of the eyelids, which are there to protect the eye. They are tricky to attach. Overall, it's very technical. The challenges vary between patients. For example, destruction from an electrical burn is completely different than damage from a gunshot. With the hand, each case is different, but the differences are not as complex as the face.

Medscape: If a plastic surgeon is interested in learning the techniques for CTA, and performing these sorts of surgeries, what should he or she do?

Dr. Dubernard: For surgeons interested in venturing into this area, start by looking at the medical literature. Learn about the history, the challenges, and who is doing what. Go to the International Hand and Composite Tissue Allograft Society -- IHCTAS, which will meet in Atlanta in June 2011.

Medscape: Can surgeons get specific training in CTA?

Dr. Dubernard: There is no training for 1 person to do this -- it requires a team. You need ear, nose and throat specialists; plastic surgeons; immunologists; transplantologists; and more.

Medscape: What are the cosmetic considerations with transplants?

Dr. Dubernard: We select donors who have the same type of skin and skin tone.

Medscape: If a patient who has undergone such a transplant shows up in the office of a cosmetic surgeon asking for further refinements to look more "normal," what should the surgeon do or say?

Dr. Dubernard: Send the patient back to the team who performed the transplant.

Medscape: Thanks for talking to Medscape.