Book Review

Hand Transplantation

N Engl J Med 2008; 358:99-100January 3, 2008

Article

Hand Transplantation
Edited by Marco Lanzetta and Jean-Michel Dubernard. 493 pp., illustrated, with DVD-ROM. Milan, Springer, 2007. $259. ISBN: 978-88-470-0373-6

Hand transplantation is a narrow specialty of reconstructive surgery, with around 39 hands having been transplanted in the past 8 years. Currently, there are six centers in Europe, four in China, and one in the United States where the procedure is performed. One of the editors of Hand Transplantation is Jean-Michel Dubernard, who, in 1998, led the French team that performed the world's first hand transplantation with the use of a modern combination regimen for immunosuppression.

Hand Transplantation is organized into 14 sections and includes a companion DVD that contains video clips showing functional outcomes in some European patients. The chapter contributors include well-known authorities from several subspecialties. Section 1 is a discussion of the history and evolution of microsurgery and hand transplantation from myth to modernity. Section 2 is dedicated to the scientific and experimental basis of hand transplantation. The chapter by Martin Molitor and others on technical aspects of experimental limb transplantation and the chapter by Maria Siemionow and others on animal models of composite tissue allotransplantation should be of particular interest to the trainee entering the field.

The success of hand transplantation depends on effective and substantive multidisciplinary collaboration that involves plastic surgeons, hand and transplant surgeons, immunologists, physical therapists, psychiatrists, ethicists, dermatologists, social workers, nurses, media personnel, and many others. Sections 3 and 4 of the book are devoted to the ethical, medicolegal, and organizational aspects of the procedure, with intriguing insights into identity issues that recipients of hand transplants may have and into the legal implications of living with two different sets of fingerprints.

The technical aspects of hand transplantation are very similar to those of hand replantation. However, important aspects involving the procurement of the donor limb and planning for the recipient are different. Milomir Ninkovic, Aram Gazarian, Marco Lanzetta, and others elaborate on the surgical aspects of donor and recipient management in hand transplantation in excellent chapters in section 5.

The strong antigenicity of the skin component of hand transplants is due to the presence of Langerhans' cells and keratinocytes, and it mandates high levels of prolonged immunosuppressive drug therapy to prevent rejection. The chapters in section 6 discuss the immunologic aspects of skin, as the primary triggers and targets of the immune response in hand transplantation, and other problems such as the risk of graft-versus-host disease that is caused by the bone marrow component of the hand. The various drugs, dosing, protocols, and complications of the immunosuppressive regimens that are used in hand transplantation are detailed in section 7. The outstanding chapter by Stefan Schneeberger and others highlights the role of cytomegalovirus infection in initiating and fueling acute rejection and its deleterious effect on chronic rejection and graft outcomes.

Apart from its immunogenic properties, the skin offers transplant professionals the advantage of being able to visually monitor the graft after transplantation. Biopsies can be guided by clinical examination and directed to areas that seem prone to rejection on the basis of definitive manifestations. The exceptional chapter in section 8 by Jean Kanitakis is a thorough exposition on the phenomenon of skin rejection in hand transplants and on the systems that are used to grade the severity of this rejection.

Functional recovery, more than anything else, determines the eventual outcome of a hand transplant. A surviving hand that lacks motor or sensory recovery is nearly useless. The various chapters in section 9 exhaustively deal with functional aspects of the procedure. Unlike transplants of solid organs, hand transplants are visible and can affect the body image of recipients. These transplants are associated with unique psychosocial considerations, which are discussed in section 10.

The editors have included chapters on other composite tissue transplants in section 11. Vascularized knee, laryngeal, uterine, abdominal wall, and lower extremity transplantation (in conjoined twins) are well covered in chapters that are written by leading authors. In this section, Dubernard and Bernard Devauchelle report on their pioneering experience with facial transplantation. Future directions for hand transplantation are discussed in section 12. Although it is not overtly stated, the book is a compendium of the European experience with hand transplantation. The American and Chinese outcomes are not discussed except briefly in section 13, which summarizes experiences with hand transplantation worldwide.

Each chapter is replete with excellent color plates, illustrations, radiographic images, tables, and figures that fully complement the text. The book includes a bibliography of hand transplantation that is contemporary and comprehensive. Lanzetta and Dubernard should be complimented on this book, which provides stimulating and interesting reading about a groundbreaking field that is at the frontier of reconstructive surgery.

Vijay S. Gorantla, M.D., Ph.D.
W.P. Andrew Lee, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15261
leewpa@upmc.edu