In March, the United Network for Organ Sharing authorized the UW Medical Center to be one of 20 centers nationwide for performing face, hand, arm and abdominal wall transplants. Dr. Peter Neligan, who will be part of the team on these surgeries, spearheaded the effort to establish the University of Washington as a center for these rare and complex surgeries, known as vascularized composite allograft, or VCA, transplants. The first surgeries could begin by next spring.
Can you explain how VCA transplants are different from traditional single-organ transplants?
They’re different in that several tissue types are transplanted, including skin, fat, muscle, nerve and bone and in the case of hand transplants, tendon and cartilage. So they are highly antigenic, meaning that the body recognizes these tissues as foreign. Other transplants are solid-organ transplants and contain only the tissue of that organ.
What makes them so challenging?
They’re technically challenging because so many tissues have to be transplanted. In the face, the nerves have to be dissected from the donor and reattached to the recipient’s nerves. Reattaching the blood supply is probably the least challenging. In the hand, all the tendons and nerves have to be dissected from the donor and reattached to the recipient. Similarly, the abdominal wall nerves are reattached, and the muscles aligned with the recipient’s muscles. These transplants are medically challenging because the immune system has to be suppressed for life so that the body doesn’t reject the transplant. The immunosuppressive drugs that are used can cause significant other health problems.
Who are the most likely patients for these sorts of transplants?
These transplants are designed for patients who can’t be reconstructed by conventional means. So in the face, it is designed for patients not only with severe disfigurement, but also with functional problems, such as the inability to close the lips. Hand and upper-extremity patients have major functional problems because they are missing an arm or arms. Abdominal wall transplants are for those patients who will generally also have an intestinal transplant and whose abdomen is so scarred from previous surgery that closure of the wound over the intestinal transplant is difficult.
These transplants are reportedly extremely rare. Why did you feel it was important to create this opportunity at the UW?
These transplants are rare for several reasons. Probably the biggest reason is because of the immunosuppression that is required. Because these drugs are required for transplantation, every effort is made to reconstruct the patient by conventional means that don’t require immunosuppression. However, VCA is in its infancy, and I am confident that advances will be made in immunotherapy that will allow transplants to become more mainstream. That would allow us, for example, to reconstruct functioning eyelids, something we can’t do now. So I think this is the beginning of the era of spare-parts surgery.