Hand Transplants

Back in 1997, Hollywood scored a box-office hit with “Face/Off,” the science-fiction thriller starring John Travolta and Nicolas Cage, in which an FBI agent and a freelance terrorist surgically switch faces such that no one, not even their families, can tell them apart.

Now, 18 years later, Dr. W. P. Andrew Lee is gearing up to do the real thing here in Baltimore.

Well, not exactly. 

“Obviously, it makes an excellent movie, but we are not transplanting personal identity,” says Lee, director of the Department of Plastic and Reconstructive Surgery at Johns Hopkins University. “It is more of a hybrid of the two faces, depending on the underlying facial skeleton and how the patient uses facial expression, which is connected to the brain and personality.”

Back in 2010, Hopkins announced it had lured Lee, 57, away from the University of Pittsburgh Medical Center (UPMC), a significant upset for his former institution. Lee brought with him six surgeons after successfully performing the world’s first bilateral (two limbs) hand transplant there one year earlier and earning himself and the university international recognition.

Hopkins, which has one of the oldest and most respected surgical programs in the country, had yet to perform a hand transplant when it offered Lee, a graduate of its medical school and of Harvard University, his own department of plastic surgery to try and entice him there. (Typically plastic surgery is a division of a larger department of surgery, as it is at UPMC.) It worked.

Lee has happily settled into a new home overlooking the Inner Harbor and has become a regular at restaurants Thames Street Oyster House in Fells Point, Wine Market Bistro in Federal Hill and Woodberry Kitchen in Hampden. Just don’t ask him about his football allegiance: He admits he’s still a Steelers fan.

Since arriving in Baltimore, Lee and his team have gone on to successfully perform a bilateral hand transplant at Hopkins, their 10th hand transplant overall and sixth patient. That patient, Brendan Marrocco, a then 26-year-old Army infantryman, lost both his hands and legs in a 2009 roadside bomb attack in Iraq. In December 2012, Marrocco received a transplant of two arms from a deceased donor.

Hand transplants are more complicated than internal organ transplants—heart or liver for example—because they involve bones, blood vessels, fat, muscles, tendons, nerves and skin (hence the term “vascularized composite tissue allotransplantation”). They are among the rarest and riskiest surgeries performed in the U.S. today. Only seven bilateral hand transplants have ever been successfully performed in the country.

The big breakthrough came in 2007, explains Lee, when, with the help of “brilliant scientists” from Pittsburgh’s Thomas E. Starzl Transplantation Institute, he developed the immune modulatory protocol, a three-pronged approach to vascularized composite tissue allotransplantation that offers patients lower risk of rejection and less potentially harmful drug therapy. Lee and his fellow researchers had discovered after two decades of laboratory research that if they took bone marrow from a dead donor’s bones and placed it into a recipient’s body prior to the transplant procedure, the recipient’s immune system would be primed to accept the new limb—a process Lee calls “immune modulation.”

Antibody treatments and the administration of one anti-rejection drug as opposed to the usual and sometimes-toxic three-drug cocktail traditionally used for organ transplantation complete the process.

Back then, Lee predicted that he would one day be able to apply this technique to face transplants. Like the human hand, a person’s face is made of composite tissues—and, he believes, “the same immunology protocol should work.”

After receiving the approval of Hopkins’ institutional review board in 2012, Lee is now ready to realize this ambition. He says his team, composed of roughly 40 surgeons, anesthesiologists and nurses, is currently screening patients for the clinical trial phase of a new face transplant program at Hopkins. And the potential candidates are lining up— wounded U.S. soldiers, gunshot victims and victims of flame and acid burns to the face.

“There’s this very unfortunate practice, primarily in developing countries, where an acid attack to the face is used as a form of revenge, and those are some of the most tragic cases you can see,” he explains. “Young women are coming to us after such injuries with completely deformed faces, having lost most of their facial features after acid was poured on their faces.”

However, Lee says his group is “very stringent” about waiting to operate until they can make optimal matches between donors and recipients. His team employs both a transplant psychiatrist and psychologist to help screen candidates to make sure they are up to the emotional and physical challenges.

Another barrier to performing face transplants: the emotional shock to the donor family. “We’ve found it particularly difficult to get families to participate,” Lee says. To ease that discomfort, his team has hired a medical artist and a prosthetist who can create “amazingly realistic” facial prostheses to fit on the donor’s body for open casket funerals.

The money for the clinical trials is in place, thanks to institutional support from Hopkins and about $10 million of grants Lee has received from the U.S. Department of Defense, a sponsor of Lee’s work since his early days at UPMC. The procedure is not covered by insurance like other organ transplant operations because it’s not yet considered mainstream, although Lee predicts this will change.

Lee concedes that face transplants will not save lives, but they will “significantly improve quality of life.” Beauty is an important part of being human, he says, and “something that’s always on our minds as plastic surgeons.”

Transplant surgeries are extremely long and involved events. When a team of 150 at the University of Maryland Medical Center completed the most extensive full face transplant to date in March 2012, it took 36 hours. Lee’s hand transplants take about 12. To set the right mood for the challenging scene, he often plays opera music in the operating theater.

“Puccini and Verdi operas, the more melodic the better,” he says.

Back in Pittsburgh, the young residents used to complain when Lee would blast “Tosca” and “Turandot” over the speakers. If anything, he’s turning up the volume at Hopkins, where he regularly selects his own soundtrack for performing long surgeries.

“As my position becomes more senior, the more reserved people have become in expressing their displeasure [at my musical taste],” Lee notes, with a wry smile. “People don’t seem to object anymore.”

Geoffrey W. Melada is editor-in-chief of the Washington Jewish Week.