Bilateral Hand Transplantation Research Articles

Changes in functional and structural brain connectivity following bilateral hand transplantation

As a surgical treatment following amputation or loss of an upper limb, nearly 200 hand transplantations have been completed to date. We report here a magnetic resonance imaging (MRI) investigation of functional and structural brain connectivity for a bilateral hand transplant patient (female, 60 years of age), with a preoperative baseline and three postoperative testing sessions each separated by approximately six months. We used graph theoretical analyses to estimate connectivity within and between modules (networks of anatomical nodes), particularly a sensorimotor network (SMN), from resting-state functional MRI and structural diffusion-weighted imaging (DWI). For comparison, corresponding MRI measures of connectivity were obtained from 10 healthy, age-matched controls, at a single testing session. The patient's within-module functional connectivity (both SMN and non-SMN modules), and structural within-SMN connectivity, were higher preoperatively than that of the controls, indicating a response to amputation. Postoperatively, the patient's within-module functional connectivity decreased towards the control participants' values, across the 1.5 years postoperatively, particularly for hand-related nodes within the SMN module, suggesting a return to a more canonical functional organization. Whereas the patient's structural connectivity values remained relatively constant postoperatively, some evidence suggested that structural connectivity supported the postoperative changes in within-module functional connectivity.

Computerized Surgical Planning in Face Transplantation.

Face transplantation (FT) has emerged as a critical intervention for patients with complex facial deformities unsuitable for conventional reconstructive methods. It aims to restore essential functions such as facial expression, mastication, and speech, while also improving psychosocial health. The procedure utilizes various surgical principles, addressing unique challenges of craniofacial complexity and diverse injury patterns. The integration of Computerized Surgical Planning (CSP) leverages computer-aided technologies to enhance preoperative strategy, intraoperative navigation, and postoperative assessment. CSP utilizes three-dimensional computed tomography, printing, angiography, and navigation systems, enabling surgeons to anticipate challenges and reduce intraoperative trial and error. Through four clinical cases, including a groundbreaking combined face and bilateral hand transplant, CSP's role in FT is highlighted by its ability to streamline operative processes and minimize surgical revisions. The adoption of CSP has led to fewer cadaveric rehearsals, heightened operative precision, and greater alignment with preoperative plans. Despite CSP's advancements, it remains complementary to, rather than a replacement for, clinical expertise. The demand for technological resources and multidisciplinary teamwork is high, but the improved surgical outcomes and patient quality of life affirm CSP's value in FT. The technology has become a staple in reconstructive surgery, signaling a step forward in the evolution of complex surgical interventions.

Somatosensory and motor representations following bilateral transplants of the hands: A 6-year longitudinal case report on the first pediatric bilateral hand transplant patient

A vascularized composite tissue allotransplantation (VCA) was performed at the Children’s Hospital of Philadelphia (CHOP), on an 8-year-old patient in 2015, six years after bilateral hand and foot amputation. Hand VCA resulted in reafferentation of the medial, ulnar, and radial nerves serving hand somatosensation and motor function. We used magnetoencephalography (MEG) to assess somatosensory cortical plasticity following the post-transplantation recovery of the peripheral sensory nerves of the hands. Our 2-year postoperative MEG showed that somatosensory lip representations, initially observed at “hand areas”, reverted to canonical, orthotopic lip locations with recovery of post-transplant hand function. Here, we continue the assessment of motor and somatosensory responses up to 6-years post-transplant. Magnetoencephalographic somatosensory responses were recorded eight times over a six-year period following hand transplantation, using a 275-channel MEG system. Somatosensory tactile stimuli were presented to the right lower lip (all 8 visits) as well as right and left index fingers (visits 3-8) and fifth digits (visits 4-8). In addition, left and right-hand motor responses were also recorded for left index finger and right thumb (visit 8 only).During the acute recovery phase (visits 3 and 4), somatosensory responses of the digits were observed to be significantly larger and more phasic (i.e., smoother) than controls. Subsequent measures showed that digit responses maintain this atypical response profile (evoked-response magnitudes typically exceed 1 picoTesla). Orthotopic somatosensory localization of the lip, D2, and D5 was preserved. Motor beta-band desynchrony was age-typical in localization and response magnitude; however, the motor gamma-band response was significantly larger than that observed in a reference population.These novel findings show that the restoration of somatosensory input of the hands resulted in persistent and atypically large cortical responses to digit stimulation, which remain atypically large at 6 years post-transplant; there is no known perceptual correlate, and no reports of phantom pain. Normal somatosensory organization of the lip, D2, and D5 representation remain stable following post-recovery reorganization of the lip’s somatosensory response.

Management of massive transfusion and coagulation during bilateral hand transplantation surgery

Dear Editor, Massive transfusion (MT) aims to limit hypoperfusion till surgical hemostasis could be attained and takes into account volume status, tissue oxygenation, management of bleeding, and coagulation abnormalities.[1] However, it may not be possible to follow recommended protocols of MT strictly during hand transplant surgeries as, in addition to restoring blood volume, ensuring good perfusion and avoidance of thrombus formation in transplanted hands is critical. A 46 year-old-female, bilateral hand amputee, was posted for bilateral upper extremity allotransplantation (supracondylar level on the right side and mid-arm level on the left side). The donor was a 45 year-old-female who was declared brain dead following trauma. The recipient received standardized general anesthesia and immunosuppressants as per protocol. Femoral arterial, internal jugular, femoral venous, and two 16G saphenous catheters were placed. Her initial hemoglobin was 13.2 g/dL. Reperfusion of transplanted hands was done around 6 h intraoperatively following which there was major surgical bleeding and hemoglobin dropped <5 g/dL multiple times despite aggressive fluid replacements. The surgery lasted 15 h, and she received 12 units of packed red blood cells (PRBCs), 4 units of fresh frozen plasma (FFP), 2 L of hydroxyethyl starch, 600 mL albumin, 15 L of Kabilyte (acetated intravenous fluid), and 40 mL of 10% calcium gluconate. Intraoperative fluid management was guided by continuous arterial and central venous pressure monitoring, frequent arterial blood gas analysis including electrolyte levels, platelet count, prothrombin time, and thromboelastography (TEG). She required noradrenaline infusion up to 0.2 mcg/kg to maintain mean arterial pressure >65 mmHg, and urine output was >1 mL/kg/h. Intraoperatively, perfusion of transplanted hands was impeded by arterial and venous thrombi which required multiple thrombectomy and reanastomoses and fasciotomies for decompression. Therefore, a certain degree of coagulopathy was accepted to prevent further thrombus formation and hence MT protocols were not strictly followed. The aim was to maintain good perfusion of hands with target hemoglobin of 10 g/dL with hemodilution to facilitate perfusion across anastomoses. In 48 h, she had received a total of 21 units of PRBC and 9 units of FFP. Coagulation parameters were maintained at safe acceptable levels [Table 1]. Other than hypothermia, she did not develop any major complications such as renal or lung injury secondary to MT.Table 1: Laboratory investigation results and interventionsMT is defined as replacement of one entire blood volume within 24 h, transfusion of >10 units of PRBCs in 24 h, transfusion of >4 units of PRBCs in 1 h, or replacement of 50% of total blood volume within 3 h.[2] Consumption of coagulation factors during massive bleeding and dilution of remaining factors due to volume expanders add to coagulopathy and altered hemostasis.[3] Coagulation tests are usually time-consuming and may not greatly help in guiding therapy during ongoing massive bleeding. TEG tests the entire hemostatic system including platelet function and fibrinolytic system. Therefore it is useful in managing complicated coagulopathies with timely intervention.[2] Ideally, MT protocols are to be activated after transfusion of 4–10 units which have a predefined ratio of RBCs, FFP/cryoprecipitate, and platelet units (1:1:1 or 2:1:1 ratio).[4,5] It is concluded that during bilateral hand transplantation surgeries, management of MT should be individualized taking into account hemoglobin levels, coagulation profile, and perfusion of transplanted hands. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Mobilizing Public Interest in Vascularized Composite Allotransplantation: An Analysis of Online Traffic.

Despite growing public interest in and extensive media coverage of facial transplantation, a recent survey study found that only 63% of laypersons demonstrate basic awareness of the field.1 On February 3, 2021, our institution published a press release regarding our latest transplant recipient, who received a face and bilateral hands. We present this viewpoint to discuss our analyses of webpage traffic and Google trends, which illustrates the public’s curiosity regarding vascularized composite allotransplantation (VCA) and sheds light on how we may overcome the field’s key obstacles; in particular, donor pool expansion. Analysis of online traffic enables researchers to derive market intelligence by gauging public interest. Its relevance in transplantation was demonstrated by Gordon et al.,2 who used webpage traffic data to highlight the effectiveness of call-to-action campaigns for living kidney donors. We compared the online traffic of our facial transplantation program’s homepage during the week of the press release (February 2, 2021, to February 8, 2021) with that of the preceding week. A 1230.67% increase in visits to our facial transplantation program’s homepage (https://nyulangone.org/locations/face-transplant-program) was revealed. Most of the traffic (72.60%) was driven by natural searches, indicating organic interest from the public (Fig. 1). Such interest was further supported by Google trends showing the greatest annual spike in queries during the week of the press release (Fig. 2).Fig. 1.: Face transplant program webpage visits by acquisition channel in the week of the press release. “Organic search” refers to visitors who found our website using search tools such as Google. “Direct access” refers to visitors who accessed the webpage without clicking on a link. “Referring domains” refers to visitors who clicked on a link in other webpages, and “social media” refers to visitors coming from social media posts (eg, Facebook, Instagram).Fig. 2.: Google trends analysis. Graphical representation of Google queries in the United States for face transplant (dark purple) and face and hand transplant (light purple) between July 26, 2020, and July 11, 2021, demonstrating the maximum value for both relevant search terms occurred during the week of January 31, 2021, to February 6, 2021, coinciding with the press release. The y axis shows the normalized search frequency; each data point is divided by the total searches in a given geography and time range to compare relative popularity. The resulting numbers are scaled on a range of 0 to 100 based on a topic’s proportion to all searches on all topics. The x axis shows the time frame of relevant search results.Organ transplantation is hindered by a limited supply of donors; facial transplantation donor identification is uniquely challenging because of the stringent immunologic, cephalometric, and aesthetic considerations that must be taken into account.3 Moreover, unlike solid organs, facial transplantation donation requires a separate consent with the approval of a decedent’s family, further constricting the theoretical donor pool. Previous research has shown that 48% of Americans would be willing to donate their face.4 However, estimates show that only one-third of the U.S. population has completed advanced directives,5 and it is likely that significantly fewer have discussed facial transplantation donation with relevant family members. The general public, as a broad stakeholder, wields considerable power to advance the field of VCA. Educational interventions have proven successful at increasing public awareness and willingness to donate.1 The organic interest in VCA generated through public relations may be leveraged to inform and mobilize potential donors at the time of peak engagement. Moreover, public education could also be helpful in promoting legislative actions to reduce friction in the donation process. Given the spike in interest generated by our press release, timely provision of educational material and direct links to local donor registries would be crucial to make the best use of public interest. In summary, we found a substantial increase in traffic to our facial transplantation program’s webpage after issuing a press release on a successful face and bilateral hand transplant. Donor shortages remain one of the greatest challenges in the field of VCA. Spikes in interest represent unique opportunities that can be leveraged to educate the public, promote advocacy of the field, and expand the donor pool. ACKNOWLEDGMENT The authors thank the donor and recipient patients and families. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Hand Therapy Regimen for Functional Recovery Following Combined Face and Bilateral Hand Transplantation.

Intensive postoperative rehabilitation therapy is associated with positive functional recovery in hand transplants (HTs). Our goal is to share the hand therapy protocol developed for our patient who underwent a combined face and bilateral HT. The patient is a 23-year-old right-hand-dominant male with a history of third-degree burns to 80% of his body following a motor vehicle accident. A multidisciplinary evaluation established his candidacy for a combined face and bilateral HT, and surgery took place in August 2020. Our individualized hand therapy protocol consisted of 4 phases. The pre-surgery phase focused on planning the orthotics and patient/caregivers' education on the rehabilitation process. The intensive care unit (ICU)/acute care phase involved hand allograft protection and positioning via orthotic fabrication, safe limb handling, and edema/wound management. The inpatient rehabilitation phase aimed to prepare the patient for independent living via neuromuscular and sensory re-education, improvement of upper extremities strength/flexibility, training basic activities of daily living, and providing a home exercise program (HEP). Finally, the outpatient phase aimed to maximize our patient's range of motion and independency in performing his routine activities and HEP. The patient's post-transplant functional outcomes showed a significant improvement compared to the pre-operative baseline. We hope this report sheds light on a comprehensive hand therapy program in HT.

317.4: Bilateral Hand Transplantation at a Tertiary Care Centre in India

317.4: Bilateral Hand Transplantation at a Tertiary Care Centre in India

106. Tendon Tensioning in Hand Transplantation: Emerging Principles From the First Successful Full Face and Bilateral Hand Transplant

106. Tendon Tensioning in Hand Transplantation: Emerging Principles From the First Successful Full Face and Bilateral Hand Transplant

The First Successful Combined Full Face and Bilateral Hand Transplant

Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

VCA in the Era of the COVID-19 Pandemic.

VCA in the Era of the COVID-19 Pandemic.

5-Year Activity and Participation Outcomes of the First Successful Pediatric Bilateral Hand Transplantation: A Case Report

Aims Describe the 5-year outcomes of the first successful pediatric bilateral hand transplantation. Methods The child underwent quadrimembral amputation at age two and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes, patient-reported measures, and parent-reported measures were repeated over a 5-year period. Results Observation assessments revealed functional dexterity skills and modified independence to full independence with self-care activities. The parent reported the child had moderate difficulty with upper extremity functioning 25-, 41-, and 48-months post-transplantation, and mild difficulty at 60-months; the child reported no difficulties in this domain at 41 months. Five years post-transplantation the child reported enjoying many age-appropriate activities, and high-quality peer relations were endorsed by both parent and child. Conclusion The child developed hand movements for daily activities and was completing daily activities with improved efficiency. Health-related quality of life outcomes were favorable.

Combined Face and Bilateral Hand Transplant: Preparation, Execution, and Early Functional Outcomes

Combined Face and Bilateral Hand Transplant: Preparation, Execution, and Early Functional Outcomes

Spotlight in Plastic Surgery: April 2021.

Spotlight in Plastic Surgery: April 2021.

Successful transatlantic bilateral hand transplant in a young female highly sensitized to HLA class II antigens

Vascularized composite allografts may be more susceptible to rejection than other types of organ transplants, particularly in sensitized recipients. We describe a successful transatlantic bilateral hand transplant in a 40-year old woman who was highly sensitized to class II HLA antigens including HLA-DPB1 (UNet CPRA = 86%). Prior to transplantation, we selected an upper limb donor based on HLA class II matching and absence of donor specific antibodies, given evidence that class II mismatches are associated with acute cellular rejection in hand transplants. The patient was conditioned using five doses of thymoglobulin, and her immunosuppression included tacrolimus, rapamycin, mycophenolate, and prednisone. Post-transplant, the patient non-DSA anti-HLA antibody levels drastically increased, but only transiently and weak DSAs developed, which became undetectable by two months posttransplant. Following transplantation, periodic biopsies over 6 months indicated no evidence of rejection except for transient Banff grade 1 and one sample with grade 2 acute rejection. There was no evidence of rejection on her recent 1-year follow-up. The patient is currently healthy, has recovered protective sensibility, and is regaining excellent function. This case highlights the importance of pre-transplantation planning, donor selection/compatibility, and ethical considerations in the ultimate success of VCA.

An Individualized Physiotherapy and Rehabilitation Program for Bilateral Hand Transplantations.

This article describes a rehabilitation program and the long-term results after its application in 2 double-hand transplantation patients after 9- and 4-year follow-up periods. A personal rehabilitation program was planned to commence as early as possible after postoperative patient stabilization. Splinting, edema, positioning, passive and active joint movements, daily life activity modification and education, and occupational therapy were also emphasized. Positioning, edema, and passive joint movements were started in the acute phase. Strengthening and exercises were continued for 8 weeks and later for functional gains and adaptation to daily living activities. Subjective and overall results were quite satisfactory. The Hand Transplantation Score System, Disabilities of the Arm Shoulder and Hand, Semmes Weinstein Monofilaments, sensory tests, and modified Kapandji index improvements were all within good acceptable ranges. Although rapid recovery and functional development were observed in the first 4 years, these are still continuing at the time of writing. The most important determining factors in the success of rehabilitation are to return to daily life and the ability to acquire functional skills. Long-term follow-up of the patients in this study showed that they were able to return to their independent daily lives and that external assistance decreased to a minimum.

Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study.

Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA. The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants. Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation. Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

Measuring Functional Outcomes After Bilateral Vascularized Composite Hand Allotransplantation: A Report of 3 Cases

Currently, numerous assessment tools are available to measure functional outcomes after bilateral hand transplantation. The purpose of this article is to present our experience utilizing quantitative assessment tools for functional evaluation and to describe our results after bilateral hand transplantation. A single surgeon's experience with bilateral hand transplantation from 2011 to 2016 was retrospectively reviewed. Three bilateral hand transplantations were performed in 2 adults and 1 child. Aminimum 2-year follow-up evaluation was available. For the adult patients, postoperative outcome measures included patient-reported pain and disability scores, return of sensation, muscle strength, range of motion, and return to work/activities of daily living, the Hand Transplant Scoring System (HTSS), theSollerman hand function test, and complications. For our pediatric patient, postoperative outcome measures included the Functional Independence Measure for children (WeeFIM) scale, a functional independence measure for children, the 9-Hole Peg Test, the Box and Block test, and complications. Our 2 adult patients were age 28 and our pediatric patient was age 8 at transplantation. Follow-up ranged from 2 to 7 years. The functional assessments were performed over a period from 11 to 48 months after transplantation. Both adult patients achieved functional independence and the HTSS, Short Form-36 Health Score (SF-36), DASH, and Sollerman tests demonstrated sequential improvement compared with pretransplantation scores assessed with the use of prostheses. Our pediatric patient demonstrated improvement in his Box and Block test score for each hand at sequential visits after transplantation. His 9-Hole Peg Test demonstrated improvement, and his WeeFIM assessment at 20 months indicated a greater level of independence. Patient-reported outcomes and the Sollerman test when used in addition to the HTSS appear to reflect functional improvement in adult patients after bilateral hand transplantation. Although children pose a unique challenge with functional assessment, we found the WeeFIM assessment, 9-Hole Peg Test, and the Box and Block test helpful in evaluating functional outcomes in our pediatric patient. Therapeutic V.

Editorial introductions

Current Opinion in Organ Transplantation was launched in 1996. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of organ transplantation is divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Xian C. LiXian C. LiDr Xian C. Li is Professor of Immunology, Weill Cornell Medicine of Cornell University and director of Immunobiology &Transplant Sciences at Houston Methodist Hospital in Houston Texas. He also holds the Max and Lillie Frosch Centennial Chair at Houston Methodist. His lab studies the fundamental mechanisms of transplant rejection and transplant tolerance. The goal of his team is to advance transplant medicine through fundamental research. Dr. Xian Li is recognized with many awards and elected memberships; He received the American Society of Transplantation (AST) Young Investigator Award, AST Wyeth Basic Science Award, and the AST Wyeth Achievement Award. Dr. Li has served in the AST basic science advisory council, TTS basic science committee, chair of the AST Grants Executive Committee, and Chair of ATC 2018. He is an elected member of the American Society for Clinical Investigation, a standing member of the NIH study sections and DOD grant review panels. He is now an associate editor of American Journal of Transplantation and the journal of Transplantation. Linda C. CendalesLinda C. CendalesDr Linda C. Cendales, MD, is an Associate Professor of Surgery, a Duke Health Scholar, and the Director of the Vascularized Composite Allotransplantation at Duke University Medical Center. During her fellowship in Hand and Microsurgery, Dr Cendales helped organize the first VCA team in the U.S. and participated in the country's first two hand transplants in Louisville, KY. She was subsequently the first surgeon accepted into the Transplant Surgery and Immunobiology Fellowship at the National Institutes of Health (NIH). During her time at the NIH, Dr Cendales established and published a model of VCA in nonhuman primates and has one of the largest experiences in VCA in non-human primates reported in the scientific literature. She organized the first international symposium on VCA histopathology at the International Banff Conferences on Allograft Pathology leading to the published classification system now used as a standard for clinical reporting of rejection. Prior to joining Duke, Dr Cendales established the VCA program at Emory University and led the multi-disciplinary team that performed Georgia's first hand transplant in March 2011. While at Duke, Dr Cendales established the VCA program and led the multi-disciplinary team that performed North Carolina's first hand transplant and first bilateral hand transplant in May 2016 and in November 2018 respectively. Dr Cendales is the Principal Investigator of clinical and translational studies in VCA funded by the U.S. Department of Defense. Dr Cendales is an Associate Editor for the American Journal of Transplantation, is the Chair of the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) Vascularized Composite Allograft (VCA) Committee, and the co-chair elect of the American Transplant Congress, and the Past-President of the International Society of Vascularized Composite Allotransplantation Society (ISVCA). She has co-authored numerous scientific manuscripts, abstracts, and invited publications. Similarly, Dr Cendales has made countless presentations at national and international meetings.

Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States?

Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.

Massive cortical reorganization is reversible following bilateral transplants of the hands: evidence from the first successful bilateral pediatric hand transplant patient.

In this repeated measures case study, we show that sensory deafferentation after limb amputation leads to changes in cortical somatotopic maps which are reversible after restoration of sensory input. Using magnetoencephalography (MEG), we observed in a child with bilateral hand transplants large‐scale shifts in somatosensory lip cortical representation from anatomic hand area to anatomic face region. After recovery of tactile sensation in the digits, responses to finger stimulation were localized to orthotopic sensory cortex, but with atypical electrophysiologic features (amplitude and frequencies).