PLASTIC SURGERY
THE WORLD’S FIRST SUCCESSFUL HAND
TRANSPLANT AT 20 YEARS: Background,
Consequences and Future
Gordon R. Tobin, MD; Christina Kaufman, PhD; Christopher Jones, MD
T
he world’s
first long-
term suc-
cessful
hand trans-
plant was done in Jan-
uary 1999 by a collab-
orative team from the
University of Louisville (UofL) and Kleinert, Kutz and Associates
at Jewish Hospital. (Fig. 1) The enduring success is confirmed by
the high level of function achieved, and its sustained duration –now
20 years. The event drew international attention at the time, but few
then understood its larger dimensions—it was the first enduring
success of a skin-bearing allograft. This breakthrough came after
decades of striving, with consistent laboratory and clinical failures.
These accumulated failures brought universal judgments of biologic
impossibility. Also, few beyond the Louisville investigators foresaw
the implications for face and other potential transplants, and even we
did not imagine the full spectrum of consequences being explored
today. This report will review the prior history, subsequent evolution
and future potential of that landmark event of 20 years ago.
BACKGROUND: THE QUEST FOR SKIN-BEARING AL-
LOGRAFTS
Early myths and imaginations of transplantation to restore lost body
parts were of skin-bearing structures - limbs and facial parts. After
World War II, British biologist Peter Medawar pursued this concept
experimentally, in collaboration with Scottish plastic surgeon, Tom
Gibson. This landmark work founded the field of transplantation
immunology and brought Medawar a Nobel Prize and knighthood.
However, no success in transplanting skin or skin-bearing structures
was achieved. In the 1950s, Boston plastic surgeon Joseph Murray,
MD, and colleagues pursued and achieved kidney transplants,
which led to subsequent vital organ allografts, but none that carried
skin. In 1957, North Carolina plastic surgeon, Erle Peacock, MD,
successfully transplanted flexor tendon mechanisms, again without
skin. Finally, in 1964, Ecuadorian surgeon Roberto Gilbert Elizal-
de, MD, transplanted a skin-bearing structure, a hand. This was
technically successful but was lost to acute rejection within three
weeks. This event solidified the universally-held opinion that skin
immunogenicity was so strong that it could never be overcome.
THE LOUISVILLE ENGAGEMENT
In the mid 1990s, an investigative team in Louisville assembled to
pursue hand and face transplantation studies. It was led by Warren
Breidenbach, MD, of Kleinert, Kutz and Associates, who brought
the relevant expertise in upper extremity replantation of his unit.
Gordon Tobin, MD, of UofL Plastic Surgery, had been exploring the
anatomic challenges of face transplantation for several years prior.
Jon Jones, MD, of UofL Transplantation Surgery, brought up-to-date
knowledge and experience of immunosuppression. A porcine limb
allograft model with all component tissues of a hand, including skin,
was developed. It was transplanted and successfully maintained on
modern kidney transplant-level immunosuppression. With this,
the team’s efforts then evolved to propose human application. This
included an intensive focus on relevant ethical issues, and consul-
tations from nationally respected medical ethicists were obtained.
The team was joined by Martin Klapheke, MD, a UofL transplant
psychiatrist, and an intensive focus was directed to patient selection
criteria. In the light of subsequent events, these elements proved
essential. Before preparations in Louisville were complete, a team
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JANUARY 2019
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