The delicate balance of hand transplants
A successful hand transplant has a long list of ingredients: a motivated patient; a team of plastic surgeons, orthopedists, neurosurgeons and others to reattach bone, ligaments, nerves and blood vessels; and a suitable donor hand that matches the patient’s size, skin color and even hair patterns.
The surgery, which can run as long as 14 hours, has been available for a little more than 10 years — the first successful hand transplant was performed in France in 1998, with the U.S. following a year later. Since then, about 40 patients worldwide have received new hands.
Now UCLA is opening a hand transplant center, the fourth in the United States. Dr. Kodi Azari, who has helped perform five of the 11 U.S. hand transplants, is the facility’s surgery director. He spoke with The Times about the delicate work and remaining hurdles and why hand surgery keeps him up at night.
What has been the biggest barrier to hand transplantation?
The steps are very similar to performing a reattachment of a severed hand, which we’ve been doing for 40 years now. What’s new is the marriage of the hand surgery to transplantation.
Advancements in medication and immunosuppression therapy are allowing us to get to this point. The first hand transplant was done in 1964, but it failed after two weeks because they didn’t have the appropriate medication. Now the science is significantly improved, and a few brave souls — doctors and patients — were willing to take great risks and try it again. Hand transplantation may soon be considered standard … rather than an experimental procedure.
Technically, what’s the hardest part of the surgery?
One of them is repairing the blood vessels. Sometimes there’s an enormous size mismatch — one is small and one is big. It’s like a garden hose that you’ve cut. To try to put it back together, you can put the two ends together, but if one side is much larger, it will leak.
Alternatively, you can tie off one of the ends and then come in with the other one from the side. It’s still complicated, though. It’s tremendously hard to do. These aren’t big blood vessels; they’re amazingly small. Some of the veins are only 1 millimeter in diameter.
What I find the most interesting part is rebalancing the tendons. Your hand is an amazing tool. It has the power to swing a sledgehammer, yet at the same time it has the precision to play a concert piano. The precision is based on the balance between tendons on the back of your hand and the palm of your hand. These have to be absolutely perfectly balanced, and one of the critical elements in a transplant surgery is reestablishing that balance.
Are there still important advancements to be made in how this surgery is done?
It’s pretty established, but we have developed some new techniques. Though not grand — we’re not going to win a Nobel Prize or anything — there have been a lot of refinements that have improved the approach.
One is the way we fix the nerves. A nerve looks like a coaxial cable for your TV, except it doesn’t have the green-to-green and red-to-red markers, so you have to figure out how to attach the appropriate cables. In my most recent patient, I figured out how to do that, and I think this patient will have the best nerve function out of anybody yet.
Can you tell me about one of your past patients?
Sure. He is a former Marine. He had a training injury where he lost his hand with explosives. He used prosthetic devices, yet he found them to be unacceptable; in his mind, he needed more. He was a young, healthy, ambitious man, and what was available through prosthetics was not enough for him.
He’s doing very well. He’s in school, and he’s becoming an auto mechanic. I love to quote him — “This is my hand. I don’t have to take it off, I don’t have to put it on. I can feel with it. I can sit in a car and hold my girlfriend’s hand, and feel her hand.”
He said he can feel things with his new hand almost as well as his uninjured hand, which is remarkable, and I fully expect that he’s going to continue making more improvement. But this is not something that happens overnight; it takes months and years.
What’s usually the hardest part for patients?
The hardest part really is that they have to be on anti-rejection meds. That’s actually the hardest part for both the patient and the doctor. The doctor has to find the right dosage — enough so that hand does well but not too much to have possible infections and other complications.
Do the patients ever have a hard time accepting the new hand?
That’s one of my concerns, yet in order to make sure they don’t, we have a very rigorous screening of the patients that we choose. I haven’t had anyone say, “This is not my hand. This is someone else’s hand. Oh my God, what have I done?”
Initially, they call it “the hand.” After maybe a few months, it becomes “my hand.” They’ve actually accepted it as theirs. It just happens gradually.
After surgery, when they get to the recovery area, they see this thing attached to them, this hand. The first thing I have them do is move their fingers. I say, “Move your thumb, move your index finger” — by the time we get to the pinky finger, I’m usually in tears, and then I look at them, and they’re usually in tears too.
So it’s emotional for you too?
Definitely. I remember the first transplant I did. For almost a week after, I couldn’t sleep because I was so excited, because of my sheer joy. There are very few times in one’s life when you can be involved in something that really transcends the mundane day-to-day. That was one of those times. We’re really pushing the frontiers of science and medicine.
What are your hopes for the UCLA center?
This program is designed to advance the field, especially for our wounded heroes, who deserve the best of care. These men and women really gave everything for their country.
Hand transplantation is not for everyone. Some people do very well with prosthetic devices; other people don’t. If we can offer them hand transplants safely, effectively and with good function, how much more can you ask for?
In the past, we used to do transplants to save lives; now we’re doing them to improve the quality of life — and that’s quite remarkable.
For more information about the procedure and the UCLA hand transplant center program, visit handtransplant.ucla.edu.