Designing and utilizing 3D-printed skin incision guides during the first Dutch bilateral hand-arm transplantation

S Hummelink,A.S Kruit,S.E.R Hovius,D.J.O Ulrich

doi:10.1016/j.bjps.2021.03.076

Abstract

To preoperatively plan skin incision in the case of the first Dutch bilateral hand-arm transplantation. A bilateral hand-arm transplantation has been performed for the first time in the Netherlands in 2019. In the context of preparation for this surgical procedure, the optimal patient-specific skin flap was determined. Skin flaps should be properly matched between donor and recipient to ensure sufficient tissue for the approximation of skin over the tendon anastomosis, adequate distal tip perfusion, and esthetics. Preoperatively, stereophotogrammetry was obtained from the upper extremities of the patient and a volunteer with similar body physique. Skin flap dimensions were determined for each extremity, which resulted in patient-specific incision patterns. Combining this digital information yielded practical skin incision guides for both the donor and acceptor arms. Finally, the computer-aided designs were 3D printed. The 3D prints were convenient to utilize in both shaping the donor flaps as in preparing the acceptor extremities, taking only a few seconds during precious ischemia time. There was sufficient skin flap perfusion, and the wound-healing followed an uncomplicated course. No corrections were made to the initial skin incisions. Three-dimensional printed templates were successfully utilized in the first Dutch bilateral hand-arm transplantation. We believe its usage increased time efficiency, improved the match of skin flaps in donor and recipient arms, and allowed us to control the amount of skin surplus without skin flap tip necrosis. In these procedures where time is of the essence, we believe preoperative planning is imperative for its success.

Highlights

Over 100 known hand/upper extremity transplantations have been performed worldwide since the first successful transplantation in 1998.1–3 Until 2019, this complex procedure had not yet been performed in the Netherlands
Our patient was a highly motivated and physically strong 44year-old, who suffered severe sepsis in 2014. She developed acute kidney failure and diffuse intravascular coagulation and required amputation of both legs below the knee; her left hand was at the radiocarpal level and her dominant right hand was at the metacarpal level due to necrosis
We describe the process of creating 3Dprinted skin incision guides for both donor and acceptor, utilizing readily available methods of imaging and printing available in most academic hospitals nowadays

Summary

Introduction

Over 100 known hand/upper extremity transplantations have been performed worldwide since the first successful transplantation in 1998.1–3 Until 2019, this complex procedure had not yet been performed in the Netherlands. Our patient was a highly motivated and physically strong 44year-old, who suffered severe sepsis in 2014 She developed acute kidney failure and diffuse intravascular coagulation and required amputation of both legs below the knee; her left hand was at the radiocarpal level and her dominant right hand was at the metacarpal level due to necrosis. She recovered well with the restoration of her kidney function. During the 18-month waiting period for a suitable donor, the surgical team prepared the procedure extensively and practiced cadaveric graft procurement and replantation. An extensive protocol with a predefined order of operative steps was developed to ensure all involved healthcare professionals achieved maximum surgical efficiency while patient safety was maintained. 4

Results

Discussion

Conclusion