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Page 14 of 20 Azoury et al. Plast Aesthet Res 2020;7:4 I http://dx.doi.org/10.20517/2347-9264.2019.44

weeks postoperatively, the patient typically may return to their home residence. We have used FaceTime,
Skype, and other Internet-based video platforms to communicate internationally on an as needed basis.
In-person visits are coordinated between the patient and the treatment team at the center involved in the
[88]
transplant and occur every 2-3 months during the first year and every 6-12 months thereafter .
Although superficial (e.g., skin) detection of rejection is more easily accomplished than that of deeper
structures, the clinical signs of skin rejection are nonspecific. These include findings such as edema,
erythema, erythematous maculopapular rash, hair loss, and desquamation at the fingers [80,103] . Deep biopsies
are rarely performed to diagnose rejection, but one may see lymphocytic infiltrates. Chronic rejection
findings are nonspecific, but involve vessel intimal hyperplasia [104-106] . Our protocol includes weekly skin
biopsies and laboratory tests (renal function, immunosuppression drug concentrations, and complete
blood counts) for the first month and subsequent tapering depending on the stability of the drug levels and
allograft.

Outcomes following VCA are highly dependent on rehabilitation, which is extensive and can last 2-4 years
[107]
to optimize cortical reintegration of the transplanted extremity . Rehabilitation typically begins anywhere
from 12 h to three days after surgery depending on the transplant surgeon preference and is extensive, with
physiotherapy, electrostimulation, and occupational therapy components [88,99] . Physical therapy exercises
include edema management, gentle range of motion exercises, and custom orthosis management. Different
splints are used to protect the grafts, avoid retraction, and facilitate the right position of each hand part
after extensor and flexor tendon balance. Therapy is extensive during the first year and is usually 4-5 h,
five days a week. This regimen is gradually tapered depending on the level of transplant and needs of the
patient [108] .

Rehabilitation for the pediatric transplant recipient was more difficult due to their attention span,
motivations, and emotions. Therapy began six days after transplantation and continued daily for five
weeks in acute care, then two weeks in inpatient rehabilitation, followed by ongoing/school therapy. Time
for patient-caregiver bonding, child life activities, and rest was set-aside during the therapy days and is
as important as the therapy itself. At seven weeks, the patient transitioned to a day hospital program in
his community where he received therapy and schooling for five days per week, and then transitioned
to outpatient therapy. Therapy is ongoing at four years post-surgery and the exact duration necessary
continues to be an area of investigation. Our therapists suggest continuing therapy and minimizing
compensatory motor strategies for two years following plateau of sensorimotor function and cortical
plasticity. Additional procedures may be necessary during the course of follow-up and this should be
discussed preoperatively. These include cosmetic revisions, hardware removal, tendon transfers, and tendon
shortening .
[99]
VCA outcomes
Standardizing outcome measures remains a challenge for extremity VCA given the variety of surgical
protocols, host risk factors, immunosuppressive regimens, and transplant patient/level heterogeneity .
[88]
Moreover, measures and definitions of success are variable. When considering the pediatric patient, there
are no validated outcomes measured for hand function. For the adult patients at our transplant center,
functional outcome measures include the Sollerman test, a standardized measure of manual dexterity for
motor functions; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Hand Transplant
Scoring System [109] . We utilized the two-point discrimination test and Semmes-Weinstein monofilament
tests for sensation [108] . For our pediatric transplant recipient, we used the box and block and nine-hole peg
tests that elucidate progress at the functional activity level and efficiency of upper extremity gross motor
skills compared with baseline . We also used the Functional Independence Measure for Children to assess
[88]
[88]
ability to perform daily activities of living .