Written by Zoe Engels, Contributing Writer and Editor
Did you know that not all transplants are life-saving ones like kidney, lung, and heart transplants? Some are elective and life-altering or life-improving, including hand and full forearm transplants. These breakthrough surgeries give amputees a new limb and the chance to regain some hand function.
Dr. Vijay Gorantla is a surgeon who specializes in reconstructive transplantation, specifically Vascularized Composite Allotransplantation (VCA), which is when muscle, bone, nerves and skin—like the hands (his focus) or face—are transplanted from a deceased donor to someone with a traumatic injury. Dr. Gorantla previously served as the Director of the VCA Program at the University of Pittsburgh Medical Center and the Director of the Veterans Affairs Pittsburgh Hand Transplant Program, and he is now a tenured Professor of Surgery and the Director of the VCA Program at Atrium Health Wake Forest Baptist in North Carolina and the newest SODA Board of Directors member.
SODA had the chance to speak with him via Zoom and learn more about his specialty, the transplantation and rehabilitation process, and what life might look like for hand transplant recipients. Keep reading to learn more and then check out our blog next week to meet one of Dr. Gorantla’s patients, Sheila Advento, who shares her experiences as a hand transplant recipient.
To learn about another type of VCA, a face transplant, read our blog post about Robert Chelsea, the first African American to receive a full face transplant.
How It All Began
Dr. Gorantla was born into a medical family—his parents, sister, and brother-in-law are all doctors, so he developed an interest in human biology early on in his life. His interest in surgery was spurred by a tragic accident in which several of his close friend’s family members died in a car crash. The overwhelmed hospital was not able to provide adequate care at the time and, although the injuries could perhaps have been survivable, everyone involved passed away.
“There are moments and experiences in your life when you think, ‘What if we could do that? Or what could make a difference?’” Dr. Gorantla said. “In medicine as in any field, if you can envision something, however audacious, you can get there in small steps, if not in your lifetime [then] somebody else will.”
Reconstructive transplantation is the new specialty that began just twenty years ago, offering options for those patients with devastating injuries that are not treatable by routine surgical procedures.
What’s a Solid Organ? UNOS classifies reconstructive transplantation as involving “solid organs” because they are not hollow. But, Dr. Gorantla clarified, that although they are not “hollow,” a hand, face or abdominal wall are unique from other “solid” organs like the liver, pancreas, or kidney as they consist of multiple tissues, including skin, muscle, bone, tendons, and ligaments, that constitute a “composite tissue.” However, the unifying criterion for all organs, Dr. Gorantla said, “is anything that is sustained by a blood supply.” The transplants Dr. Gorantla performs are called vascularized composite allografts. They are vascularized, meaning they involve vessels, because of the blood supply; they are composite because of the composite tissues; and allografts are transplanted tissues and organs between genetically non-identical individuals. |
Dr. Gorantla’s career in reconstructive transplantation began at the University of Louisville, where he was a member of a team led by Dr. Warren Breidenbach. That team performed the first hand transplant in the United States in January 1999. The patient, a paramedic, had lost his dominant left hand in a July 4th firecracker accident.
“The thought that you could take a hand from a brain dead donor and transplant it was science fiction at the time for many in the field of hand surgery, and Dr. Breidenbach was proclaimed a renegade by the Hand Society,” Dr. Gorantla said.
Defying all naysayers’ predictions, January 2024 marks the 25-year anniversary of the 1999 hand transplant, which currently holds the record for the world’s longest surviving and functional reconstructive transplant. Since 1999, there have been approximately 50 hand transplants performed in the US alone and more than 150 worldwide!
Finding a Match
Throughout our conversation, Dr. Gorantla emphasized that hand transplants are not for everyone—“they’re for the select set of people who fulfill strict eligibility criteria and have fully understood the lifelong risks, commitments, and responsibilities as a patient to ensure the best possible outcomes.” The patient, he said, is key to success.
In the case of hand transplants, it is particularly important that patients consistently take their immunosuppressants and dedicate themselves to the rehabilitation process and follow-up recommendations provided by their caregiver team. Otherwise, they risk losing the transplanted limb.
Potential patients go through detailed screenings and analyses, both physical and psychological. The latter helps identify their expectations, perceptions, needs, and motivations for a transplant to determine if it’s a fit for them.
“Sometimes we have patients come with a hand that’s amputated, and we ask them a simple question: ‘Why do you want a hand?’” Dr. Gorantla said. “And they say, ‘I want to play golf,’ and that’s it. … There are patients who come and say, ‘Well I want to get back to a job. I want to be able to feed my family because I can’t work without this. … I’ve become a burden on my family.’”
A team comprised of surgeons, clinicians, psychotherapists, social workers, and others makes the collective judgment call about whether the patient is a good fit for a hand transplant.
“The ideal patient is somebody who is not only committed to their transplant and fully understands the long term risks but is also willing to cope with such unanticipated risks and be resilient enough to overcome them with the collaboration, input, help, and support of the physician team, provider, or care and management team,” Dr. Gorantla said.
Many of the risks come with the immunosuppressants themselves. They can cause problems that are life-limiting, life-shortening, or life-threatening, like diabetes, high cholesterol, hypertension, infectious diseases, or even cancer. Patients must decide for themselves if the benefits of the transplant, in their specific case, will outweigh the lifelong burdens and risks.
Once a patient is deemed a good fit for a hand transplant, the extensive process of procuring the limb begins. Again, very different from solid organs like the liver, lungs, kidneys, or heart, additional factors must be considered in donors such as skin color, tone, and texture; gender; and the size of the limb. These factors are taken into account to ensure a proper anatomical and cosmetic match between donor and recipient.
The recipient’s details are shared with their Organ Procurement Organization (OPO). The physicians use plastic or silicone swatches, like makeup swatches at beauty stores, to convey the shade and tone they are looking for. Once the OPO finds a complementary limb, they share the length and diameter; while the hand might be a match in terms of skin tone, it still might not be a match in terms of its dimensions.
“You don’t want to transplant an NFL or NBA player’s upper limb or hand onto a normal person where the bulk of the muscle and span of the hands is completely different,” Dr. Gorantla explained.
After a match is found, the organ recovery is coordinated. In organ recovery, the heart and lungs are removed from the deceased donor first, followed by the kidneys, liver, and other internal, life-saving organs. A goal of reconstructive transplantation is not to interfere with life-saving organ donation. The hands are thus recovered last or after organs that have been allocated in that donor. They are perfused with vital solutions and transported in coolers to the hospital where the surgery will take place and individual components, like bone, muscles, tendons, and blood vessels, are methodically and meticulously connected and repaired.
The Recovery
The rehab process is different for everyone. Factors that come into play include whether the person is a single or double amputee and the level or height of the amputation, meaning how high up on the arm the transplant begins.
What’s On Your Nerves? “These transplants are very different from organs not just [in] the sense that they not only have to be connected to blood vessels but the nerves have to also be connected,” Dr. Gorantla said. “They don’t connect nerves to a heart, … kidney, … [or] liver, so you might say that [those organs] don’t feel. You metaphorically think hearts feel, but hearts really don’t feel.” He added, “In the case of a hand, you need multiple nerves—nerves that allow you to move, nerves that allow you to sense, to feel pain, to feel touch, to feel pleasure. It’s a very complicated organ. … No organ other than the hand or face, is directly connected to the brain. [A site in the brain’s] prefrontal cortex supplies the hand. When you amputate somebody, that area disappears, and the face area takes over. It’s called the plasticity of the brain. The brain is very plastic. It’s the reason why there are so many more things that impact the rehab [process].” Essentially, throughout rehab, the hand is being trained and “reprogrammed” via reconnection of the nerves to the recipient stump as well as integration into the brain, all of which takes a lot of time. Patients may be in rehab for eight hours a day for six to eight months, sometimes years. Some patients, Dr. Gorantla said, may decide they can’t take it anymore and drop off, so they gain less function of their transplanted limb than others who stick with it. The level or height of the amputation matters because, the higher up on the arm it is, the greater the length the nerve needs to grow. Nerves grow at a pace of approximately one millimeter per day! |
With extensive rehab, a patient may get fifty to sixty percent of function back, but that percentage can vary significantly depending on the patient, their previous and current occupation, and their goals.
Function is relative, and the impact of a hand transplant is different for every patient. It all comes down to the patient and their expectations.
“Let’s say I was at Julliard playing piano before I lost my hand,” Dr. Gorantla said. “Now, I get a hand transplant. I may never play piano again because my function still may not be as intricate as [it was] before the hand transplant. A 50 percent return of function may be useless for a professional like a musician or pilot but huge for a person who was a mason [laying bricks] before the amputation. So, the threshold for success in terms of functional return is different for every patient, making understanding motivation and setting the right expectations key for success in these patients.”
Dr. Gorantla continued, “I’m not saying piano players are bad patients, but I’m saying you’ve got to set the expectations. You can say, ‘You may never play the piano again. Are you okay with that?’ And, ‘You may be back a desk job or in front of a computer, but if you want to be back at the piano, you may not benefit much from a hand transplant.’”
What’s Next?
Dr. Gorantla knows that the future of transplantation rests heavily on organ, eye, and tissue donation advocacy and education efforts among today’s youth. In fact, his son, Aarnav, recently started a SODA chapter at his high school and is connecting with his peers and community at large to improve awareness and outreach, sharing his passion for organ donation.
SODA, which has recently formalized a partnership with Donate Life America, is Ieading National efforts amongst today’s youth regarding the importance of organ donation to society.
Before SODA’s 60+ chapters were established on high school and college campuses nationwide, Dr. Gorantla said organ donation education among students was generally limited to showcases and workshops hosted by OPOs. What was lacking for the words to resonate and have a greater impact, he said, was peer-to-peer education. Our chapter leaders are helping fulfill that need.
In turn, Dr. Gorantla said students’ roles as advocates and educators shows them how big of an impact they can have in their communities and on society when they pursue their passions and the causes they care about, creating a positive spark and domino effect.
Are you looking to be the spark and join a high school or college nonprofit? See if there’s already a SODA chapter you can join on your campus or apply to start a SODA chapter at sodanational.org/students.