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Azoury et al. Plast Aesthet Res 2020;7:4 I http://dx.doi.org/10.20517/2347-9264.2019.44 Page 11 of 20

A B

Figure 6. Osseointegration radiograph (A) and skin penetration site (B)

Upper extremity VCA faces controversies and challenges that unfold alongside the procedure itself.
Policy and regulatory issues strongly influence progress of the field, so much so that transplantation is
[91]
being performed at overseas centers as part of clinical trials rather than a standard treatment option .
Preoperatively, patients should be counseled regarding realistic expectations including functional, sensory,
[92]
and aesthetic ones .
Indications and patient selection
A survey of North American hand surgeons indicates that most support upper extremity VCA for
[93]
bilateral or dominant below-elbow amputees . Specific clinical selection criteria and contraindications
developed by the American Society for Reconstructive Transplantation can only be expected to change
with maturation of the field and growing reports of functional outcomes with longer follow-up periods [89,93] .
Patient evaluation is exhaustive and factors including motivation, comorbidities, social support, and
[14]
psychological profile are critical when deciding if and when to proceed . The process involves transplant
physician/surgeons, social workers, psychiatrists, and rehabilitative specialists. Upper extremity VCA
is most frequently performed for forearm and wrist-level amputations, although above-elbow results
are promising and those patients are able to perform many activities of daily living . In more distal
[94]
amputations, extrinsic hand function is possible even without nerve regeneration given the presence of
muscles and tendons. More distally, intrinsic hand function and sensation can be restored more quickly
given the shorter distances necessary for nerve regeneration.

At our institution, the recipient should be HIV-negative, without any coexisting psychosocial or medical
issues, and with a negative cross-match with the donor. Female patients must have a negative pregnancy
test. In general, patients should be between the ages of 18 and 65 years old. In fact, just several years ago,
it was proposed that VCA should not be extended to pediatric patients given the number of unknowns .
[95]
However, in July 2015, we performed a bilateral hand transplantation on an eight-year old prior kidney
[78]
transplant recipient with excellent results at four-year follow-up (unpublished data) .

Pediatric hand transplantation
The greater plasticity of the immature brain and longer potential lifetime are potential advantages of
VCA in the pediatric patient. Obvious challenges of upper extremity VCA in this young population
include informed consent, psychosocial assessment, greater surgical risk in part due to increased
technical complexity, lack of assessment tools of objective outcomes, and compliance with rehabilitation/