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Hand and face allografts: myth, dream, and reality.

DURING THE PAST DECADE, composite tissue allografts (CTAs) have pioneered a new era in transplantation history. Together with knee joint, larynx, abdominal wall, arm, and even penis allografts, allografts of the hands and face belong to CTAs. Most of these grafts are visible and are not vital. They are life-enhancing rather than life-sustaining, but, in the words of the first transplant patients, they are truly life-giving, and not just life-saving.The introduction of CTAs posed three great challenges. The first was immunological. CTAs are a combination of tissues of diverse embryological origin, histological structure, and function. Each tissue is different in terms of immunogenicity and rejection pattern, and one rejection might cause the rejection of other tissues. The skin, which constitutes the natural barrier with the outside world, is the most immunogenic tissue of the body and the most readily rejected, and the fear of skin rejection is the most likely explanation for the late introduction of CTAs compared with organ transplantation. Bone marrow is also aggressively rejected. This is a well-known phenomenon in clinical bone marrow transplantation. The second challenge was technical. Several surgeons with complementary competencies and experiences had to master both conventional and microsurgical techniques. The first hand and face transplants were performed by international teams of surgeons, whom I consider to be among the best in their fields. The third challenge was psychological. In my mind, it was a major challenge. In 1966, when the dream of hand transplantation was dawning thanks to the hypothesis of hematopoietic stem cell migration, the technique in current use was hand replantation on the same person. The question that badgered me was this: Is it possible to see and use the hands of a dead person, day in, day out? Discussions with Jean Cournut, a leading psychoanalyst at the head of the Freudian school in France, led us to the conclusion that hand appropriation was possible. However, we overestimated the impact of amputation on body image and underestimated its impact on function. On the advice of Jean Cournut, I worked with his colleague, Gabriel Burloux in Lyon, who became a key member of our team.HAND AND FACE ALLOGRAFTSThe hand with its opposable thumb was a key factor in the evolution of humankind and in its domination over other species. The hand plays an essential role in communication with our fellow men, adding colorfulness and expression to language. The hand can wave, give, and caress; it can pick up, grasp, and hold; it can write and sign its name; it can squeeze, punch, fight, strangle, and pull the trigger. In so doing, the hand forges our identity. Moreover, we cannot ignore the practical and symbolical significance of the fingerprint.Our faces characterize us in our own eyes and in that of humankind. Our faces enable us to speak, eat, and drink. They can laugh, smile, and kiss; they can express tenderness and love; they can also cry and be sad. They can show scorn and anger, bite, and spit. Our faces reveal our inner self, our individuality, and above all our identity.Our hands and face raise the question of what it means to be human. They constitute the boundaries between symbols and reality, and are essential to our body image. In 1935, Paul Schilder defined body image as "the picture of the body which we form in our mind." Although this definition does not add much to the term itself, it does have the advantage of linking hand and face to the brain. The hands and face collude with the brain. They enable us not only to project ourselves onto others, but also to perceive ourselves through our interactions with others. When our body undergoes injury, so does our body image. These injuries are narcissistic wounds, and the boundaries between somatic and narcissistic wounds overlap. In an article about the challenges of face transplantation published in a 2004 issue of the American Journal of Law & Medicine, Rhonda Gay Hartman asked a fundamental question: What is the value of a human face? …