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Page 12 of 20 Azoury et al. Plast Aesthet Res 2020;7:4 I http://dx.doi.org/10.20517/2347-9264.2019.44
[77]
immunosuppression demands . Preoperative evaluation of the pediatric patient includes multiple
visits with orthopedic/plastic surgery, transplantation medicine, and occupational/physical therapy [78,88] .
[77]
The child’s goals for functional independence are the focus of the occupational therapy assessment .
Psychosocial aspects are assessed by a child psychologist, pediatric transplantation pharmacist, and a
social worker. Informed consent must include a discussion with both the patient and parents regarding all
possible risks from the surgery while addressing the unknowns.

The consequences of long-term immunomodulation may become more apparent in this group and
[95]
some remained concerned for potential learning disabilities and growth impairment . It is unclear if
pediatric patients will have worse rejection episodes or adverse effects of medications when compared
with adult patients, although that has not been a concern in our pediatric VCA patient to date. In addition,
unpublished data from our institution suggest that hand-forearm growth in the pediatric patient are as
you would expect based on replantation literature and normal growth in the non-transplanted pediatric
population.

Overseas hand-forearm transplantation
For the first time in upper extremity VCA history, a successful transatlantic upper extremity VCA was
performed at the University of Pennsylvania. Our group was approached by colleagues from Hopital
European Georges Pompidoi at Paris Descartes University in 2016 to list a European patient for a bilateral
hand transplant. The recipient and donor were separated hundreds of miles between France (country of
residence) and the United States (VCA team), respectively. The recipient’s preoperative assessment was done
in France; however, she was unable to have the transplant in her country due to health-system issues. The
director of the University of Pennsylvania program (Levin LS) raised support, including financial, for the
endeavor and coordinated the team of 30+ specialists and surgeons who would be necessary to perform the
transplant. Meanwhile, the patient underwent health screening in France and, simultaneously, coordination
with the organ procurement organization was performed to enable a match. Our team calculated precise
travel scenarios so that, if donor limbs became available, the recipient patient could begin her travels to
Philadelphia in time. Appropriate documentation for travel was ensured much in advance of donor limb
availability. In August 2016, the director of the hand transplant program received a call that donor hands
were available and the patient then immediately embarked on a 700 mile trip to Philadelphia. The surgery
proceeded as expected, lasting nine hours. Aside from the need for minor hematoma evacuation on
Postoperative Day 17 for bilateral extremities, the recovery was excellent. French surgeons and specialists
with extensive VCA experience then assumed her care upon return, and she returned to the University of
Pennsylvania for follow-up eight months later. Her motor and sensory exam has been improving [Figure 7].
Since then, another transatlantic hand transplantation was performed, again in a French recipient, without
any event. We were happy to have had such an impact on the quality of life of these overseas patients.

Technical considerations
Checklists are followed closely for all aspects of the operation. In brief, the recipient is prepared first by
obtaining peripheral nerve blocks and central venous and large bore intravenous access. General anesthesia
is then administered and the residual limbs are dissected under tourniquet control, identifying and
tagging all key structures similar to the donor limb preparation. This can be the most difficult part of the
operation as tendons, vessels, and nerves are often enveloped in scar tissue. Simultaneously, the donor team
is working to prepare and tag vital structures in the transplant extremities. The bones are then prepared
with custom cut guides according to the preoperative plan. Once the donor and recipient limbs are fully
prepared and structures tagged by the surgical teams, osteosynthesis is performed. Depending on the
cold ischemia time and level of transplant, either vascular anastomoses can be performed at this stage or
tendon/muscle repairs. We prefer to reperfuse the limbs as soon as possible to limit ischemia-reperfusion
injury. This is followed by tendon/muscle repairs and then nerve repairs. Skin closure is performed in a