Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Editorial
Vascularised composite allotransplantation: implications for the Defence Medical Services Matthew Wordsworth,1 C MacIver,2 S Hettiaratchy3,4 INTRODUCTION War and surgical advances are welldocumented companions. The developments in resuscitation and acute surgical care over the last decade of conflict have meant UK military trauma patients are surviving increasingly severe injuries.1 Unprecedented survival means a cohort of survivors with unprecedented injuries. Lower limb amputations from blast injury are often associated with significant hand and facial trauma.2 As we transition to a post-conflict phase in the Defence Medical Services (DMS), the rehabilitation and ongoing surgical reconstruction of these injured service personnel will continue to grow in significance. Vascularised composite allotransplantation (VCA) is a developing reconstructive option that DMS clinicians should have an understanding of. VCA is the transfer of a functional unit of multiple tissue types (skin, nerve, muscle, etc) and can provide a ‘like for like’ reconstruction when conventional techniques are insufficient. Hands, face, abdominal wall and larynx have all been successfully replaced with VCA but at the cost of lifelong immunosuppression.
FACE TRANSPLANTS The first partial face transplant was performed in France by Devauchelle and Dubernard in 2005 on a woman whose nose, lips and cheeks were mauled by a dog.3 To date, 29 face transplants have been performed, the majority in France (10), the USA (7) and Turkey (6).4 While face transplants were initially envisaged for severe burns, they have been performed for animal bites, neurofibromatosis, osteoradionecrosis and vascular anomalies. Nearly a third have been 1
Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK; 2Regional Maxillofacial Unit, Southern General Hospital Glasgow, Glasgow, UK; 3 Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, London, UK; 4 Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Correspondence to Capt Matthew Wordsworth, Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London W2 1NY, UK; [email protected] 268
performed because of ballistic injury.5 These ballistic injury cases often involve loss of substantial parts of the facial skeleton and a facial transplant offers the possibility of restoring soft tissue units and parts of the maxillofacial skeleton. Potential benefits of face transplantation in burns and ballistic injuries have led to the United States Department of Defense (DoD) funding both research and treatment costs for patients treated at the Brigham and Women’s hospital in Boston and the University of Maryland, Baltimore, USA.6–8 The conflict in Afghanistan has increased the proportion of facial injuries in both UK and US soldiers.9 In these polytrauma patients, the traditional techniques used in facial reconstructive techniques may not be available due to the extent of soft tissue loss. Face transplant offers an option for patients in whom conventional reconstruction is unable to functionally restore them. In a relatively short time period from the first face transplant that involved the soft tissue of the perioral and nasal tissues, it is now possible to reconstruct all of the soft tissues above the clavicle, including nose, ears, scalp, functioning eyelids and complete facial skeleton. The specifics of each face transplant vary with the anatomy and requirements of the individual patients, which will require careful multidisciplinary planning. However, the key anastomoses are usually the facial artery and the Vth and VIIth cranial nerves. The sensory reinnervation of the face typically occurs faster and more reliably than motor nerves; however, early function in the facial nerve has been seen at 2 months.10 The face is more than the sum of its functional parts and the psychological benefit of transplantation can revolutionise a patient’s social interaction and confidence (Figures 1 and 2).11 This aesthetic and psychosocial benefit has led to patients being able to reintegrate into society and resume employment, helping resolve the cost–benefit issue that accompanies such costly medical procedures.
HAND TRANSPLANTS Hand transplants are a more common procedure than face transplants, and there
Figure 1 A patient with severe facial burns.
Figure 2 The patient at 1-year post face transplant (Photos with kind permission of Brigham and Women’s Hospital, Boston, Massachusetts, USA).
have been at least 89 transplants (21 of these bilateral).12 The indications for hand transplantation are more weighted to functional improvements rather than the aesthetic benefits of facial transplant. Hand transplant must therefore be considered alongside all the prosthetic options to gauge the degree of functional improvement for that patient. The benefit is clearer for bilateral hand loss as the risks of immunosuppression remain similar and the prosthetic options are fewer. Surgically the procedure is less challenging than a facial transplant; it is technically similar to a hand replantation. While the surgical techniques in hand transplantation may be more familiar, patient selection, rehabilitation and immunosuppression remain complex. The
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Editorial first hand transplant was first performed in 196313 although a lack of understanding of immunosuppression meant it failed within 3 weeks. Subsequent hand transplants with modern immunosuppression in the last 15 years have been successful. A recent review demonstrated a 92% graft survival in patients compliant with their immunosuppression and all of these patients having a return of protective sensation and grip by 15 months.4 This graft survival rate is the best of any organ transplant group.
THE REQUIREMENTS OF A VCA PROGRAMME The NHS has performed one hand transplant in December 2012 under Professor Kay in Leeds14 and has authorised a face transplant in Glasgow when a suitable patient is identified.15 VCA requires a large and highly skilled multi-disciplinary approach. Patient selection, surgical planning, immunosuppression, in-hospital recovery and out-patient rehabilitation are complex. Finding a size, sex and colour matched donor who is immunologically compatible can be difficult, particularly in military patients who may have been sensitised by massive blood transfusions. The psychological and rehabilitation potential of the recipient requires very careful assessment. Screening and the physical and psychological assessment of the patient may take up to 6 months and posttransplantation patients will require intensive rehabilitation. The medical, and potentially psychological, follow-up will be lifelong for patients who have undergone this procedure. Patients must accept lifelong immunosuppression with the associated risks, monitoring and episodes of acute rejection. In China, their first face transplant patient died after stopping immunosuppression 2 years after surgery16 and a number of Chinese hand transplants have been lost due to a lack of compliance with immunosuppression.17 The surgery itself requires two experienced teams operating simultaneously on the donor and the recipient. If this surgery is to be performed in the UK then the right surgical skill sets and experience must be brought together and the teams need to train together. The first face and maxilla transplant in the USA needed eight plastic and maxillofacial reconstructive micro-surgeons.18 Face transplants particularly require meticulous imaging and understanding of the recipient’s remaining facial anatomy to plan the allograft and sites of key vascular and nervous anatomoses. With the potential for graft failure, there must always be a reconstructive plan
B. In the hands, graft removal is straightforward; in the face, it would be devastating.
IMMUNOSUPPRESSION VCA is a paradigm change in reconstructive surgery. Any functional or psychosocial benefit must be weighed against the requirement for lifelong immunosuppression and the associated risks. Two face transplant patients have been treated for malignancy post-transplant; the world’s first face transplant patient required a hysterectomy for cervical dysplasia and another developed B cell lymphoma because of Epstein–Barr virus transplant reactivation.19 Solid organs transplantation, such as heart and liver transplants, are used to prolong life. A VCA hand or face transplant conversely may shorten life, but many feel that it is a price worth paying for the improvement in quality of life that the surgery can bring. Current drug strategies for immunosuppression are similar to those of solid organ transplantation. Maintenance is typically with triple therapy of tacrolimus, mycophenolate mofetil and prednisolone. Skin is highly antigenic and therefore VCA transplants do suffer from frequent episodes of acute rejection. However, clinical manifestations of these rejections are easily recognised (eg, developing skin erythema) and therefore quickly treated. Only one graft loss in a hand transplant due to chronic rejection has been reported and this was due to intimal hyperplasia in the arteries.20 Opportunistic infectious diseases inevitably affect immunosuppressed transplant patients despite antiviral and antibacterial prophylaxis. Larger volumes of transplanted VCA require higher doses of immunosuppression and appear to be associated with increased complications. An early death was reported from 2009 of a French patient who underwent a simultaneous bilateral hand and face transplant.21 Another patient who underwent a bilateral hand and face transplant at the Brigham and Women’s hospital suffered from septic shock and peripheral ischaemia requiring amputation of the transplanted hands at day 5.22 Military patients might present a particular infectious problem as retained foreign bodies from the initial blast injury could act as a nidus for infection; the optimal timing post-injury for this definitive reconstruction is unclear.
inducing tolerance. Tolerance is a state where the recipient’s immune system is re-educated so that it does not respond to donor tissue but remains reactive to all other antigens. It can be achieved by producing haemotopoeitc chimerism, a state where both recipient and donor haematopoetic cells, including those of the immune system, co-exist in the transplant recipient. This can occur when a patient’s bone marrow is myeloablated and then transplanted with donor bone marrow.23 The patient can then receive an organ or VCA from this same donor without eliciting an autoimmune response. Human trials are underway; the University of Pittsburgh has five patients with hand transplants combined with bone marrow transplantation who are currently on minimal-immunosuppression protocols.24 Bone marrow suppression and bone marrow transplant is clearly not without risk on its own and brings another layer of complexity to VCA transplantation with the risk of graft versus host disease and myeloproliferative disorders. However, if tolerance can be reliably induced in VCA patients then this removes many of the longer-term disadvantages to this reconstructive option. For upper limb amputations, the development of new prosthetic options continues. Select patients are benefiting from myoelectric prosthesis and targeted muscle reinnervation, which can enable impressive prosthetic functionality.25 While the benefits and costs of state of the art prostheses versus hand transplantation can be debated, there is no equivalent mechanical solution for facial units.
CONCLUSIONS VCA is an increasingly accepted and performed reconstructive option. The hope is that VCA will be rendered obsolete by developments in tissue engineering, which may one day provide autologous functional units to reconstruct the hand and face. The US Department of Defense is taking this longer-term view and alongside the funding into VCA transplantation supports the National Tissue Engineering Center and started the Armed Forces Institute of Regenerative Medicine. Until tissue engineering delivers autologous tissues for reconstructive surgery, VCA may be of benefit to our most severely disabled and disfigured soldiers.
THE FUTURE
Acknowledgements The author is grateful for the permission of the patient and Brigham and Women’s hospital to reproduce their photos in this paper.
Novel methods of immunomodulation are being developed, particularly that of
Contributors Written by MW (guarantor), advised and edited by SH and CM.
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
269
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Editorial Funding None. Competing interests CM and SH are surgeons involved in establishing a VCA programme at their NHS hospitals. Provenance and peer review Not commissioned; externally peer reviewed.
6
7
8
To cite Wordsworth M, MacIver C, Hettiaratchy S. J R Army Med Corps 2014;160:268–270. Accepted 7 January 2014 Published Online First 4 February 2014 J R Army Med Corps 2014;160:268–270. doi:10.1136/jramc-2013-000198
9
10
REFERENCES 1
2
3 4
5
270
Penn-Barwell JG, Bishop JRB, Roberts S, et al. Injuries and Outcomes: UK military casualties from Iraq and Afghanistan 2003–2012. Bone Joint J 2013;95-B(Suppl 26). Breeze J, Allanson-Bailey LS, Hunt NC, et al. Surface wound mapping of battlefield occulo-facial injury. Injury 2012;43:1856–60. Devauchelle B, Badet L, Lengele B, et al. First human face allograft: early report. Lancet 2006;368:203–9. Murphy BD. Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges. J Plas Reconst Aesthet Surg 2013;66:1449–55. Siemionow M, Gharb BB, Rampazzo A. Successes and lessons learned after more than a decade of upper extremity and face transplantation. Curr Opin Organ Transplant 2013;18:633–9.
11
12
13 14
15
http://brighamandwomens.org/Departments_and_ Services/surgery/services/PlasticSurg/Reconstructive/ FaceTransplantSurgery/DODstudy.aspx http://umm.edu/news-and-events/news-releases/2012/ university-of-md-completes-most-extensive-fullface-transplant Pomahac B, Bueno EM, Sisk GC, et al. Current principles of facial allotransplantation: the Brigham and Women’s Hospital Experience. Plast Reconstr Surg 2013;131:1069–76. Chan RK. Ten years of war: a characterization of craniomaxillofacial injuries incurred during operations Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 2012;73:S453–8. Pomahac B, Papay F, Bueno EM, et al. Donor facial composite allograft recovery operation: cleveland and Boston experiences. Plast Reconstr Surg 2012;129: 461e–7e. Coffman KL, Gordon C, Siemionow M. Psychological outcomes with face transplantation: overview and case report. Curr Opin Organ Transplant 2010;15:236. The International Registry on Hand and Composite Tissue Transplantation. http://www.handregistry. com Gilbert R. Transplant is successful with a cadaver forearm. Med Trib Med News 1964;5:20. Mayor S. UK surgical team reports encouraging early results of first hand transplantation. BMJ 2013;346: f79. NHS Blood and Transplant Executive Summary. http:// www.nhsbt.nhs.uk/downloads/board_papers/jan12/ r12-15%20Briefing%20note%20re%20non% 20standard%20organ%20transplants%20January% 202012%20_final_.pdf
16
17
18
19
20
21
22
23
24
25
Guo S, Han Y, Zhang X, et al. Human facial allotransplantation: a 2-year follow-up study. Lancet 2008;372:631–8. Pei G, Xiang D, Gu L, et al. A report of 15 hand allotransplantations in 12 patients and their outcomes in China. Transplantation 2012;94:1052–9. Alam DS. The Technical and Anatomical Aspectsof the World allotransplantations in 12 patients and their outcomes. Arch Facial Plast Surg 2009;11:369–77. Morelon E, Testelin S, Petruzzo P, et al. Outcome 5 years after the first human partial face transplantation. Paper presented at the American Transplant Congress; April 30 to May 4, 2011, Philadelphia, PA. Kaufman CL, Blair B, Murphy E, et al. A new option for amputees: transplantation of the hand. J Rehabil Res Dev 2009;46:395–404. Lantieri L, Hivelin M, Audard V, et al. Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes. Am J Transpl 2011;11:367–78. Pomahac B, Pribaz J, Eriksson E, et al. Three patients with full facial transplantation. N Engl J Med 2012;366:715–22. Leonard DA. Induction of tolerance of vascularized composite allografts. Transplatation 2013;95: 403–9. Gorantla VS. Upper extremity transplantation: the Pittsburgh Experience. Tenth Meeting of the International Hand and Composite Tissue Allotransplantation Society, 2011. Kuiken T. Targeted reinnervation for improved prosthetic function. Phys Med Rehabil Clin N Am 2006;17:1–13.
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Vascularised composite allotransplantation: implications for the Defence Medical Services Matthew Wordsworth, C MacIver and S Hettiaratchy J R Army Med Corps 2014 160: 268-270 originally published online February 4, 2014
doi: 10.1136/jramc-2013-000198 Updated information and services can be found at: http://jramc.bmj.com/content/160/4/268
These include:
References Email alerting service
This article cites 18 articles, 1 of which you can access for free at: http://jramc.bmj.com/content/160/4/268#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Vascularised composite allotransplantation: implications for the Defence Medical Services Matthew Wordsworth,1 C MacIver,2 S Hettiaratchy3,4 INTRODUCTION War and surgical advances are welldocumented companions. The developments in resuscitation and acute surgical care over the last decade of conflict have meant UK military trauma patients are surviving increasingly severe injuries.1 Unprecedented survival means a cohort of survivors with unprecedented injuries. Lower limb amputations from blast injury are often associated with significant hand and facial trauma.2 As we transition to a post-conflict phase in the Defence Medical Services (DMS), the rehabilitation and ongoing surgical reconstruction of these injured service personnel will continue to grow in significance. Vascularised composite allotransplantation (VCA) is a developing reconstructive option that DMS clinicians should have an understanding of. VCA is the transfer of a functional unit of multiple tissue types (skin, nerve, muscle, etc) and can provide a ‘like for like’ reconstruction when conventional techniques are insufficient. Hands, face, abdominal wall and larynx have all been successfully replaced with VCA but at the cost of lifelong immunosuppression.
FACE TRANSPLANTS The first partial face transplant was performed in France by Devauchelle and Dubernard in 2005 on a woman whose nose, lips and cheeks were mauled by a dog.3 To date, 29 face transplants have been performed, the majority in France (10), the USA (7) and Turkey (6).4 While face transplants were initially envisaged for severe burns, they have been performed for animal bites, neurofibromatosis, osteoradionecrosis and vascular anomalies. Nearly a third have been 1
Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK; 2Regional Maxillofacial Unit, Southern General Hospital Glasgow, Glasgow, UK; 3 Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, London, UK; 4 Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Correspondence to Capt Matthew Wordsworth, Plastic and Reconstructive Surgery Department, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London W2 1NY, UK; [email protected] 268
performed because of ballistic injury.5 These ballistic injury cases often involve loss of substantial parts of the facial skeleton and a facial transplant offers the possibility of restoring soft tissue units and parts of the maxillofacial skeleton. Potential benefits of face transplantation in burns and ballistic injuries have led to the United States Department of Defense (DoD) funding both research and treatment costs for patients treated at the Brigham and Women’s hospital in Boston and the University of Maryland, Baltimore, USA.6–8 The conflict in Afghanistan has increased the proportion of facial injuries in both UK and US soldiers.9 In these polytrauma patients, the traditional techniques used in facial reconstructive techniques may not be available due to the extent of soft tissue loss. Face transplant offers an option for patients in whom conventional reconstruction is unable to functionally restore them. In a relatively short time period from the first face transplant that involved the soft tissue of the perioral and nasal tissues, it is now possible to reconstruct all of the soft tissues above the clavicle, including nose, ears, scalp, functioning eyelids and complete facial skeleton. The specifics of each face transplant vary with the anatomy and requirements of the individual patients, which will require careful multidisciplinary planning. However, the key anastomoses are usually the facial artery and the Vth and VIIth cranial nerves. The sensory reinnervation of the face typically occurs faster and more reliably than motor nerves; however, early function in the facial nerve has been seen at 2 months.10 The face is more than the sum of its functional parts and the psychological benefit of transplantation can revolutionise a patient’s social interaction and confidence (Figures 1 and 2).11 This aesthetic and psychosocial benefit has led to patients being able to reintegrate into society and resume employment, helping resolve the cost–benefit issue that accompanies such costly medical procedures.
HAND TRANSPLANTS Hand transplants are a more common procedure than face transplants, and there
Figure 1 A patient with severe facial burns.
Figure 2 The patient at 1-year post face transplant (Photos with kind permission of Brigham and Women’s Hospital, Boston, Massachusetts, USA).
have been at least 89 transplants (21 of these bilateral).12 The indications for hand transplantation are more weighted to functional improvements rather than the aesthetic benefits of facial transplant. Hand transplant must therefore be considered alongside all the prosthetic options to gauge the degree of functional improvement for that patient. The benefit is clearer for bilateral hand loss as the risks of immunosuppression remain similar and the prosthetic options are fewer. Surgically the procedure is less challenging than a facial transplant; it is technically similar to a hand replantation. While the surgical techniques in hand transplantation may be more familiar, patient selection, rehabilitation and immunosuppression remain complex. The
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Editorial first hand transplant was first performed in 196313 although a lack of understanding of immunosuppression meant it failed within 3 weeks. Subsequent hand transplants with modern immunosuppression in the last 15 years have been successful. A recent review demonstrated a 92% graft survival in patients compliant with their immunosuppression and all of these patients having a return of protective sensation and grip by 15 months.4 This graft survival rate is the best of any organ transplant group.
THE REQUIREMENTS OF A VCA PROGRAMME The NHS has performed one hand transplant in December 2012 under Professor Kay in Leeds14 and has authorised a face transplant in Glasgow when a suitable patient is identified.15 VCA requires a large and highly skilled multi-disciplinary approach. Patient selection, surgical planning, immunosuppression, in-hospital recovery and out-patient rehabilitation are complex. Finding a size, sex and colour matched donor who is immunologically compatible can be difficult, particularly in military patients who may have been sensitised by massive blood transfusions. The psychological and rehabilitation potential of the recipient requires very careful assessment. Screening and the physical and psychological assessment of the patient may take up to 6 months and posttransplantation patients will require intensive rehabilitation. The medical, and potentially psychological, follow-up will be lifelong for patients who have undergone this procedure. Patients must accept lifelong immunosuppression with the associated risks, monitoring and episodes of acute rejection. In China, their first face transplant patient died after stopping immunosuppression 2 years after surgery16 and a number of Chinese hand transplants have been lost due to a lack of compliance with immunosuppression.17 The surgery itself requires two experienced teams operating simultaneously on the donor and the recipient. If this surgery is to be performed in the UK then the right surgical skill sets and experience must be brought together and the teams need to train together. The first face and maxilla transplant in the USA needed eight plastic and maxillofacial reconstructive micro-surgeons.18 Face transplants particularly require meticulous imaging and understanding of the recipient’s remaining facial anatomy to plan the allograft and sites of key vascular and nervous anatomoses. With the potential for graft failure, there must always be a reconstructive plan
B. In the hands, graft removal is straightforward; in the face, it would be devastating.
IMMUNOSUPPRESSION VCA is a paradigm change in reconstructive surgery. Any functional or psychosocial benefit must be weighed against the requirement for lifelong immunosuppression and the associated risks. Two face transplant patients have been treated for malignancy post-transplant; the world’s first face transplant patient required a hysterectomy for cervical dysplasia and another developed B cell lymphoma because of Epstein–Barr virus transplant reactivation.19 Solid organs transplantation, such as heart and liver transplants, are used to prolong life. A VCA hand or face transplant conversely may shorten life, but many feel that it is a price worth paying for the improvement in quality of life that the surgery can bring. Current drug strategies for immunosuppression are similar to those of solid organ transplantation. Maintenance is typically with triple therapy of tacrolimus, mycophenolate mofetil and prednisolone. Skin is highly antigenic and therefore VCA transplants do suffer from frequent episodes of acute rejection. However, clinical manifestations of these rejections are easily recognised (eg, developing skin erythema) and therefore quickly treated. Only one graft loss in a hand transplant due to chronic rejection has been reported and this was due to intimal hyperplasia in the arteries.20 Opportunistic infectious diseases inevitably affect immunosuppressed transplant patients despite antiviral and antibacterial prophylaxis. Larger volumes of transplanted VCA require higher doses of immunosuppression and appear to be associated with increased complications. An early death was reported from 2009 of a French patient who underwent a simultaneous bilateral hand and face transplant.21 Another patient who underwent a bilateral hand and face transplant at the Brigham and Women’s hospital suffered from septic shock and peripheral ischaemia requiring amputation of the transplanted hands at day 5.22 Military patients might present a particular infectious problem as retained foreign bodies from the initial blast injury could act as a nidus for infection; the optimal timing post-injury for this definitive reconstruction is unclear.
inducing tolerance. Tolerance is a state where the recipient’s immune system is re-educated so that it does not respond to donor tissue but remains reactive to all other antigens. It can be achieved by producing haemotopoeitc chimerism, a state where both recipient and donor haematopoetic cells, including those of the immune system, co-exist in the transplant recipient. This can occur when a patient’s bone marrow is myeloablated and then transplanted with donor bone marrow.23 The patient can then receive an organ or VCA from this same donor without eliciting an autoimmune response. Human trials are underway; the University of Pittsburgh has five patients with hand transplants combined with bone marrow transplantation who are currently on minimal-immunosuppression protocols.24 Bone marrow suppression and bone marrow transplant is clearly not without risk on its own and brings another layer of complexity to VCA transplantation with the risk of graft versus host disease and myeloproliferative disorders. However, if tolerance can be reliably induced in VCA patients then this removes many of the longer-term disadvantages to this reconstructive option. For upper limb amputations, the development of new prosthetic options continues. Select patients are benefiting from myoelectric prosthesis and targeted muscle reinnervation, which can enable impressive prosthetic functionality.25 While the benefits and costs of state of the art prostheses versus hand transplantation can be debated, there is no equivalent mechanical solution for facial units.
CONCLUSIONS VCA is an increasingly accepted and performed reconstructive option. The hope is that VCA will be rendered obsolete by developments in tissue engineering, which may one day provide autologous functional units to reconstruct the hand and face. The US Department of Defense is taking this longer-term view and alongside the funding into VCA transplantation supports the National Tissue Engineering Center and started the Armed Forces Institute of Regenerative Medicine. Until tissue engineering delivers autologous tissues for reconstructive surgery, VCA may be of benefit to our most severely disabled and disfigured soldiers.
THE FUTURE
Acknowledgements The author is grateful for the permission of the patient and Brigham and Women’s hospital to reproduce their photos in this paper.
Novel methods of immunomodulation are being developed, particularly that of
Contributors Written by MW (guarantor), advised and edited by SH and CM.
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
269
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Editorial Funding None. Competing interests CM and SH are surgeons involved in establishing a VCA programme at their NHS hospitals. Provenance and peer review Not commissioned; externally peer reviewed.
6
7
8
To cite Wordsworth M, MacIver C, Hettiaratchy S. J R Army Med Corps 2014;160:268–270. Accepted 7 January 2014 Published Online First 4 February 2014 J R Army Med Corps 2014;160:268–270. doi:10.1136/jramc-2013-000198
9
10
REFERENCES 1
2
3 4
5
270
Penn-Barwell JG, Bishop JRB, Roberts S, et al. Injuries and Outcomes: UK military casualties from Iraq and Afghanistan 2003–2012. Bone Joint J 2013;95-B(Suppl 26). Breeze J, Allanson-Bailey LS, Hunt NC, et al. Surface wound mapping of battlefield occulo-facial injury. Injury 2012;43:1856–60. Devauchelle B, Badet L, Lengele B, et al. First human face allograft: early report. Lancet 2006;368:203–9. Murphy BD. Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges. J Plas Reconst Aesthet Surg 2013;66:1449–55. Siemionow M, Gharb BB, Rampazzo A. Successes and lessons learned after more than a decade of upper extremity and face transplantation. Curr Opin Organ Transplant 2013;18:633–9.
11
12
13 14
15
http://brighamandwomens.org/Departments_and_ Services/surgery/services/PlasticSurg/Reconstructive/ FaceTransplantSurgery/DODstudy.aspx http://umm.edu/news-and-events/news-releases/2012/ university-of-md-completes-most-extensive-fullface-transplant Pomahac B, Bueno EM, Sisk GC, et al. Current principles of facial allotransplantation: the Brigham and Women’s Hospital Experience. Plast Reconstr Surg 2013;131:1069–76. Chan RK. Ten years of war: a characterization of craniomaxillofacial injuries incurred during operations Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 2012;73:S453–8. Pomahac B, Papay F, Bueno EM, et al. Donor facial composite allograft recovery operation: cleveland and Boston experiences. Plast Reconstr Surg 2012;129: 461e–7e. Coffman KL, Gordon C, Siemionow M. Psychological outcomes with face transplantation: overview and case report. Curr Opin Organ Transplant 2010;15:236. The International Registry on Hand and Composite Tissue Transplantation. http://www.handregistry. com Gilbert R. Transplant is successful with a cadaver forearm. Med Trib Med News 1964;5:20. Mayor S. UK surgical team reports encouraging early results of first hand transplantation. BMJ 2013;346: f79. NHS Blood and Transplant Executive Summary. http:// www.nhsbt.nhs.uk/downloads/board_papers/jan12/ r12-15%20Briefing%20note%20re%20non% 20standard%20organ%20transplants%20January% 202012%20_final_.pdf
16
17
18
19
20
21
22
23
24
25
Guo S, Han Y, Zhang X, et al. Human facial allotransplantation: a 2-year follow-up study. Lancet 2008;372:631–8. Pei G, Xiang D, Gu L, et al. A report of 15 hand allotransplantations in 12 patients and their outcomes in China. Transplantation 2012;94:1052–9. Alam DS. The Technical and Anatomical Aspectsof the World allotransplantations in 12 patients and their outcomes. Arch Facial Plast Surg 2009;11:369–77. Morelon E, Testelin S, Petruzzo P, et al. Outcome 5 years after the first human partial face transplantation. Paper presented at the American Transplant Congress; April 30 to May 4, 2011, Philadelphia, PA. Kaufman CL, Blair B, Murphy E, et al. A new option for amputees: transplantation of the hand. J Rehabil Res Dev 2009;46:395–404. Lantieri L, Hivelin M, Audard V, et al. Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes. Am J Transpl 2011;11:367–78. Pomahac B, Pribaz J, Eriksson E, et al. Three patients with full facial transplantation. N Engl J Med 2012;366:715–22. Leonard DA. Induction of tolerance of vascularized composite allografts. Transplatation 2013;95: 403–9. Gorantla VS. Upper extremity transplantation: the Pittsburgh Experience. Tenth Meeting of the International Hand and Composite Tissue Allotransplantation Society, 2011. Kuiken T. Targeted reinnervation for improved prosthetic function. Phys Med Rehabil Clin N Am 2006;17:1–13.
Wordsworth M, et al. J R Army Med Corps December 2014 Vol 160 No 4
Downloaded from http://jramc.bmj.com/ on September 9, 2015 - Published by group.bmj.com
Vascularised composite allotransplantation: implications for the Defence Medical Services Matthew Wordsworth, C MacIver and S Hettiaratchy J R Army Med Corps 2014 160: 268-270 originally published online February 4, 2014
doi: 10.1136/jramc-2013-000198 Updated information and services can be found at: http://jramc.bmj.com/content/160/4/268
These include:
References Email alerting service
This article cites 18 articles, 1 of which you can access for free at: http://jramc.bmj.com/content/160/4/268#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
