Discussion: Lessons Learned from Simultaneous Face and Bilateral Hand Allotransplantation

433 W read with great interest the recent article by Carty et al. entitled “Lessons Learned from Simultaneous Face and Bilateral Hand Allotransplantation.”1 The authors, who have combined their separate institutional experiences with the most challenging procedure of a combined vascularized composite allotransplantation, provide a detailed description of two cases of concomitant vascularized composite allotransplantation in the form of a simultaneous face and bilateral hand transplantation. Although these two cases represent the only ones in the medical literature to date, the authors are not alone in attempting such “polyanatomical” transplantation. Recent media reports and surgical center reports at the Third Biennial Meeting of the American Society for Reconstructive Transplantation held in November of 2012 in Chicago, Illinois, have confirmed that a concomitant bilateral hand and leg transplantation was attempted in Turkey, resulting in not only the loss of the transplanted grafts but also the death of the patient.2 At another center in Turkey, a triple limb transplant was attempted and resulted in the early loss of a unilateral leg transplant and patient death within 4 months.3 Although it is difficult to ascertain all the factors contributing to graft loss and patient death in these cases of concomitant vascularized composite allotransplantation, what is evident from the peer-reviewed literature, the lay press, and podium presentations at national/international meetings, is the distressing reality that the mortality rate of such concomitant or polyanatomical vascularized composite allotransplantation is 75 percent (three of four patients). The remaining 25 percent (one of four patients) survived lifethreatening complications to lose two of the three transplanted grafts, ultimately acquiring the result that a more “conventional” isolated face transplant could have provided. Vascularized composite allotransplantation represents one of the newest surgical innovations and horizons in which advancements of surgical technique coupled with progress in transplant immunology offer new reconstructive possibilities not previously conceivable. Although the field is still in its infancy, it is imperative that we be critical. Careful analysis of indications, successes, and failures must be performed to ensure that a few high-profile “failures” do not result in unnecessary restraint in application to appropriate candidates who may benefit from a balanced application of this technology with our best intentions and conservative expectations. As we stand on the precipice of possibility, we again must ask ourselves what can we do and what should we do. To argue that these operations should never be attempted would be naive and short-sighted. Nevertheless, the mortality rate is 75 percent and the rate of graft (limb) loss in the surviving patient is 100 percent. How do we ensure the safety of patients who are desperate to consent to operations they, in many cases, cannot possibly fully understand in all their complexity? Mandating that strict ethical oversight is being provided goes without saying. Requiring that the teams involved have previous experience in the type of transplant performed (e.g., face, upper limb, or lower limb) individually before being combined with other transplants seems prudent given the outcomes discussed. Utmost consideration should be given to patient selection, meticulous preoperative planning, and team experience. By itself, hand or face transplantation is a rare operation performed at