Combined Face and Bilateral Hand Transplant: Preparation, Execution, and Early Functional Outcomes

PURPOSE: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. The field has advanced considerably since the first successful hand transplant in 1998 and the first face transplant in 2005. To date, over 40 bilateral hand transplants have been reported in the literature, along with 47 face transplants. These include two unsuccessful attempts at combined transplantation of face and bilateral hand allografts. Through objective assessment of reports of these past attempts, as well as evidence-based procedural design through serial cadaveric rehearsals, we established a protocol for comprehensive reconstruction of a composite face and hand injury in a carefully selected patient. This case represents the first successful combined full face and bilateral hand transplant ever performed. METHODS: A 21-year-old male was referred with sequelae of an 80% total body surface area burn sustained in a motor vehicle accident 1 year before. Facial injuries included extensive scarring and near total fusion of the eyelids, tissue deficit at the nose and ears, as well as debilitating left neck contracture. Bilateral upper extremities were severely scarred after multiple split thickness skin grafting procedures, with proximal digital syndactyly and distal amputations. The reconstructive approach was refined through 11 monthly cadaveric rehearsals, utilizing computerized surgical planning, objective outcome analysis, and validated teamwork assessment tools. These same measures were used to evaluate the clinical transplant outcomes. Computed tomography and angiography were performed 4 weeks postoperatively, and positional analysis was conducted for comparison with the preoperative surgical plan. Functional assessment included active range of motion, grip strength, sensory assessment, Carroll’s Upper Extremity Function test, and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Combined full face (eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation at the forearm level was performed over 23 hours, with donor and recipient operations executed in adjacent operating rooms and involving 140 personnel. The patient subsequently underwent staged soft tissue advancement of the forearms on postoperative days 8, 26, 42, and 82, as well as forehead lift and eyelid revisions on postoperative days 42 and 82. Computerized surgical outcome analysis was performed on postoperative day 29, and functional assessments were performed at 3 and 6 months posttransplant. Extremity skeletal landmarks were all found to be within 4 mm of the computerized surgical plan. Range of motion, grip strength, Carroll’s test scores (left = 58 at 6 months posttransplant versus 13 pretransplant, right = 61 at 6 months posttransplant versus 20 pretransplant), and Disabilities of the Arm, Shoulder, and Hand evaluation (37 at 6 months posttransplant, versus 90 pretransplant) showed substantial improvement. At over 6 months post-transplant, the patient has had no episodes of acute rejection on an innovative immunologic surveillance protocol. CONCLUSIONS: Combined full face and bilateral hand transplant is a feasible comprehensive reconstructive solution for composite face and bilateral hand injury in the appropriately selected recipient. Team preparation, coordination of multidisciplinary care, meticulous donor selection, intensive physical and occupational therapy, and vigilant immunologic surveillance are essential features of procedural success and postoperative recovery.