A Statistical Comparative Assessment of Face and Hand Transplantation Outcomes to Determine Whether Either Meets the Standard of Care Threshold.

BACKGROUND: Hand and face transplantation has established itself as a clinical option for certain reconstructive problems. The purpose of this study was to carry out a rigorous statistical analysis of all hand and face transplantations to determine whether hand and/or face transplantation is the standard of care. METHODS: Data from September of 1998 until March of 2014 on all hand and face transplantations in the world were obtained through publications, news articles, personal communications, and presentations. Data on solid organ transplantation were obtained from the Scientific Registry of Transplant Recipients for comparison with the results of hand transplantation. Resampling and permutation statistical analysis was used to compare structured cohorts of hand, face, and solid organ transplantation. RESULTS: Routine immunosuppression can achieve intermediate- to long-term graft survival in hand transplantation that is empirically superior to solid organ transplantation. Chronic rejection in hand transplantation is statistically significantly less than in solid organ transplantation. Renal failure in hand and face transplantation is empirically less than in solid organ transplantation. Bone marrow transplant with hand transplantation produces both statistically superior and statistically inferior results compared with hand transplantation without bone marrow. In hand transplantation, acute rejection does not seem to increase late allograft loss. The function of hand transplantation is statistically significantly superior to prosthesis yet inferior to hand replantation. Not all hand and face transplants have good results, yet those hand transplants completed within certain parameters obtain excellent results. CONCLUSIONS: Certain hand transplants arguably can be considered the standard of care. Face transplantation requires more time and patient numbers and a clearer definition of inclusion and exclusion criteria before standard of care assessment can be made.

Hand and upper extremity transplantation: an update of outcomes in the worldwide experience.

BACKGROUND: Hand/upper extremity transplantation is the most common form of vascularized composite allotransplantation performed to date. An Update of worldwide outcomes is reported. METHODS: The authors summarize the international experience with 107 known transplanted hand/upper extremities in 72 patients. Data from published medical literature, national and international meetings, lay press reports, and personal communications were utilized to provide the most up-to-date summary. RESULTS: Although 24 losses (including four mortalities) are known, three of the four reported mortalities and eight of 24 limb losses were caused by multiple type vascularized composite allotransplantations (combined upper and lower limb or upper limb and face). Seven more losses were attributable to 15 patients in the early experience in China. In the United States and Western Europe, only three other non-acute graft losses have been reported, resulting in a patient survival rate for unilateral or bilateral hand transplantation in isolation of 98.5 percent and an overall graft survival rate of 83.1 percent. CONCLUSIONS: Published functional outcomes continue to demonstrate improvement in function and quality of life. The international experience supports the idea that, for properly selected individuals, hand and upper extremity transplantation should be considered an important treatment option.

Successes and lessons learned after more than a decade of upper extremity and face transplantation.

PURPOSE OF REVIEW: This review aims to present the most recent updates on face and upper-extremity allotransplantation. RECENT FINDINGS: To date, 27 face and more than 89 upper-extremity allotransplantations have been performed. Both the face and hand transplants restored form, function and patients' social integration. The complications were comparable with solid organs; however, face transplantation, as well as the combination of face and double hand transplantation, presented with significant morbidity and mortality. Evidence of chronic rejection was confirmed in hand transplants, but it has not been reported yet for facial transplantation. Novel immunosuppressive protocols have allowed a decrease in the number and dosages of traditional immunosuppressants. With increased awareness that following face and hand transplantation, the return of function is more important than anatomical restoration of the missing parts, there has been an important shift in the ethical debate weighing the risks and benefits of face and hand allotransplantation. SUMMARY: Early results after face and upper extremity transplantation are promising, with 5-year survival rates greater than in solid organ transplants. However, these procedures still need to be closely monitored and the outcome data should be rigorously reported to the central patient registry database to allow continuous surveillance.