MEDICINE OUTSIDE THE BOX
( continued from page 17 ) with the insight that developing a new and better animal model was needed to test the hypothesis that new immunosuppressant strategies ( calcineurin inhibition and induction therapy ) could escape the “ box of impossibility .” I credit Dr . Breidenbach with the drive and enthusiasm to engage in this task , with the great replantation expertise of his partners at Kleinert-Kutz Hand Care Center . I suggested that we subsequently test allografts beyond the hand , especially the face and its components , and elements of the trunk . The funding support of Jewish Hospital , led by Henry Wagner and Douglas Shaw , was essential to pursuing this research , as was acceptance by UofL Surgery Chairman , Hiram C . Polk Jr ., MD , and partners of the Hand Section . Breaking out of the “ box ” ( or the “ pig-pen ,” since Dr . Jones proposed a porcine research model ) followed , as unprecedented control of skin rejection with acceptable immunosuppressant doses was achieved . 5
Prior to human application , further original insights and judgements were essential to ultimate success . Years earlier , Francis Moore , MD , ( Chair of Surgery at Harvard University , and transplant pioneer ) proposed a highly transparent public and professional disclosure process , which we followed . 6 Also , Martin Klapheke , MD , UofL Transplant Psychiatrist , joined the team , and designed a careful screening process for potential recipients . 7 The great value of his contributions was shown subsequently , when premature loss of technically successful transplants elsewhere resulted from recipient psychological problems . Unlike a heart or kidney transplant , which function automatically , a successful hand transplant requires integration into a recipient ’ s sense of self , and the personal discipline to pursue long and intensive physical therapy . Like all transplants , hand and skin-bearing allografts require adherence to intensive medication and testing protocols for success .
To clinically apply our research , teams were first formed in Lyon , France , and here . The first hand transplants then followed . 8 , 9
Several potential recipients for our first transplant did not meet the standards defined by Dr . Klapheke . In late 1998 , a left-hand amputee passed our rigorous screening , and received a distal forearm and hand transplant at Jewish Hospital in January 1999 ( Fig . 1 ). Graft survival , plus excellent functional return followed ( Fig . 2 ). 9 , 10 , 11 This first transplant became , and still is , the world ’ s longest surviving skin-bearing allograft , with sustained useful function , now at 23 years after transplantation and counting ( Fig . 3 ). 11 , 12 Moreover , this successful , sustained transplant of a skin-bearing structure , opened transplant options beyond the upper extremity to face , abdominal wall and other composite transplants , with a focus of restoring function and quality of life . The reproducibility of this landmark breakthrough is confirmed by our second hand transplant passing the 20 year mark in 2021 , again with excellent sustained function .
As a result of these local , national and international efforts , a new transplantation field has emerged , which is called Vascularized Composite Allotransplantation ( VCA ). 12 Over 300 vascularized composite allografts have been done worldwide . Notable successes include face transplantation , ( for extreme disfigurement and function loss ), abdominal wall transplantations ( for insufficient capacity after multi-organ transplants and sepsis ) and genital transplantations ( for loss from war explosives such as improvised explosive devices ). In addition , non-skin epithelial-bearing structures , such as trachea and uterus , have become included in this new field . Over 25 academic centers of VCA clinical and basic science have been established worldwide , accompanied by a National VCA Society , an International VCA Society , and a scientific VCA journal , all of which continue to have significant input and representation from UofL . Our first recipient , Mr . Scott has actively participated in the development of the field , serving as a role model and source of information for prospective hand transplant candidates , and serving as a patient representative on the OPTN / UNOS VCA Committee .
The Louisville team that challenged the concept of impossibility
( Fig . 2 ) The first recipient , Mr . Matthew Scott , with Drs . Tobin ( L ) and Breidenbach ( R ) ( Fig . 3 ) The first recipient at 20 years post-transplant , with Dr . Christina Kaufman .
18 LOUISVILLE MEDICINE