How did you prepare for this?

We've been working with Brendan for a few years. As we waited for a donor, we kept planning his surgery. Every time we would come up with a plan, all the surgeons would get together and practice on cadavers. Brendan's operation was probably the fifth version of the original plan we had.

How do you practice for an arm transplanthaving two cadavers and moving the arms from one to the other?

Actually that's kind of how we do it. First we practice procuring the limbs from the donor. We take way more than we plan on using, because we want to have extra tendons, nerves, and blood vessels.

The problem with that is we don't get cadavers that are sized similarly to each other. For Brendan, we're not going to accept a donor that's not his size. The skin tone has to be the same, the body size has to be the same, the age appearance of the extremities has to be the same. But on the cadaver rehearsals, we'll accept more disparity. That makes us actually solve harder problems, which is a good thing.

Where did the donor arms come from?

They're people who donate their bodies for organ donations. They have to be a living donor whose heart is still beating but who has been pronounced brain dead. I think it's a rough thing for the families of the donors, because it's the worst time of their lives and they're being asked to make this incredible gift. We were lucky to find this terrific family that wanted to make that donation to help Brendan.

What happens after you've found the perfect match?

We actually go and procure the arms ourselves. The organ procurement organization won't let anyone disturb the donor physiologically until every part that might help someone [kidneys, liver] has been placed. Once that has happened, then they let all of the surgeons come together at once. We all travel to wherever the donor is, and we all inspect the patient. The cardiac surgeons look at the heart, others may look at the lungs, and what we will do is get X-rays of the arms and try to look at the blood vessels to make sure the blood flow is good enough.

When we do the procurement, we take the arms off at the level that we've decided way in advance, and then we perfuse them with a special preservation solution. And then we put them on ice and take them back. And by the time we get back to the hospital, the recipientin this case Brendanis already in the OR, asleep and ready for the operation.

What do you do first?

The surgeons divide up into four teams. There's one team for Brendan's right arm and one team for his left arm. Each of those teams opens up his skin in a very specific way, and they're going to . . . isolate his blood vessels, his nerves, and his muscles, and the bones, and get everything ready. And at the same time that's happening, there's a team for the right donor arm and a team for the left donor arm. Those teams are simultaneously dissecting out the same nerves and blood vessels and muscles on the donor arms. We constantly talk back and forth to try to create similarly sized limbs, and to accommodate for any anatomic variations. And then we put the bones together first.

After you attach the bone, what comes next?

We usually do the tendons or the muscles. That depends what level we're [working] at. If you're more distal in the limbmeaning towards the wristthere aren't really muscles to attach at that level, it's mostly tendons. But if you move closer to the shoulder the tendons give way to the muscles.

The procedure must have been different for each of Brendan's arms, since one was amputated above the elbow and one was amputated below the elbow. On the left side, where the elbow was still intact, we lifted the entire forearm muscles off of their bony origins on the donor arm, and then we refastened those down to the bony origins on Brendan's forearm. And we anchored the muscles on top of the muscles that he already had there.

How did you attach the new muscles to Brendan's arm?

If you look at your own forearm, most of your muscles for flexing your fingers and wrist attach to the bone on the inside of your elbow. There's a bony prominence there called the medial epicondyle. We took them all off of that point on the donor, and then we drilled a couple of holes into that bone on Brendan. We put some anchors down in the bone, with sutures attached to the anchors, and then we sewed the new muscles down from the donor. Then there's another bony prominence on your elbow called the lateral epicondyle, and that's where most of the muscles that extend your wrist and fingers are, and we did the same thing there.

And what about for the other arm, which was amputated above the elbow?

There it's a little more straightforward. He's got three-quarters of his biceps muscle and his brachialis muscle, which are the muscles that flex the elbow, and he's got three-quarters of his triceps muscle, which straightens the elbow. And so we just sewed those arms together.

And then the nerves came next?

We just disconnected the nerves from Brendan's muscles, and we reattached them to the nerves controlling the new muscles that we just attached.

Do you use any of the donor nerves, or are you simply moving Brendan's nerves into the new arms?

We use both. A surgeon will come and try to line up all the microscopic nerve fibers as well as possible. Everything past the amputation site dies; the reason that we line it up so well is the nerve cells on the near side of the cut have to grow down into the little tubules that are created when the axons past the cut die and vacate. They have to grow all the way back down to the muscles in the forearm and the fingers. We have to align those things as well as we can to promote normal growth all the way down. As they grow, Brandon will gradually start to control the muscles. The last thing will be getting sensations in his palm and his fingertips.

So at this point you've got the bones screwed together, the tendons and muscles sewed on, and the nerves lined up. What's next?

Next is reinstating the blood flow. If you're above the elbow or just slightly below the elbow, there's really just one main artery to the arm that we repair, and that's called the brachial artery. If you're closer to the hand, the brachial artery is separated into two different or three different arteries that we'll put together. But the real challenge is doing all the veins. You have a lot more veins bringing blood out of the arm than you have arteries bringing blood in. We have to find adequate veins to put together to bring the blood out, because the arm will die if the blood can't get out.

What we'll frequently do is, we'll put the arteries together and maybe one or two veins and we'll let the blood back into the new arms. And because they've been without blood flow for so long, the blood flow in the arms at first has all sorts of metabolic toxins that we don't want getting back into the recipient's circulation. So we'll let the blood bleed out of the new arm into a basin, and we recycle it through a machine that washes it and tries to make it suitable for transfusion. We let the arm bleed for about five minutes until the color improves, and then we take the clamps off a couple of veins and let the blood return to the body.

The arm changes color as you let the blood flow back in?

That's right. We all watch with great interest as the arm starts to turn pink. As soon as we take the clamps off the artery, we take all the ice off the arm, then we start irrigating the arm with warm saline to try to promote vasodilation, and you can just watch the pinkness and the color march out and start to fill the hand and the fingers. Everybody gets really excited when we do that because that's when we know, "Alright, this arm is going to live."

And then closing everything up must be the easiest part, right?

Well, you think it is, but it's never easy. We have to join the skin in a way that will allow healing but won't have the development of scar contractures. As the scar heals, it will contract and get tighter and tighter, and can constrict and cause a problem. And for some reason you think that you've got plenty of skin because you've got the recipient's skin plus somebody else's skin, but it's always just barely enough.

What would happen if there wasn't enough?

We usually have some extra tissue from the donor, so we can take a graft. We never actually throw anything away; we keep everything sterile in case we need spare parts, and we can use that as sort of patches to fill in extra skin if we need it. But most of the time we don't need it.

What happens after it's all sewn up?

We usually get a set of X-rays to make sure everything looks fine. We put some different internal monitoring devices in. We have a Doppler probe that attaches via wire to tell us what the blood flow on the inside of the arm is like. We use pulse oximeters to see what the oxygen flow is through each of the fingers, and we compare the numbers between the hands.

Will Brendan ever have much normal functionality in his arms?

Well, it'll never be quite the same as you and I. If he gets 80 percent of the function of you or I, then I think that would be a great result. The thing that a lot of these patients have is the desire and the necessity to adapt. He may not have quite the agility that you have with your fingers, but he'll still figure out a way to tie his shoes.

To Brendan, will they feel like his own arms?

Eventually they will, but that requires his nerves growing in. And then it requires the recipient to psychologically accept them. And Brendan has already accepted them. He can already feel some sensation and in his mind, they are his arms. And physically they are becoming his arms already.

I understand Brendan is undergoing some sort of new technique to prevent his immune system from rejecting the new body parts?

Yeah, we're trying to minimize the medications that transplant patients have to take, and our goal is to eventually eliminate the medications altogether. People who take immunosuppression medications are more prone to develop infections, cancers, high blood pressure, diabetes. What we've been able to do with our protocol is to keep them on just a single drug that's not a steroid. The way we're able to do that is by giving them a dose of the donor's bone marrow about two weeks after the transplant. And we think that this dose of bone marrow helps them tolerate the transplant better because it helps their immune system. We're still doing ongoing research to try to make it better and better.

If I lost my arm in an accident, is there a reason to choose a prosthetic arm versus a transplant?

You're limited by your anatomy and your health. Everyone who wants a hand transplant, we first make them try to rehabilitate with a prosthetic. And if you find that you can get through your life with a prosthetic just fine, then you don't need a transplant. But if you find the prosthetic isn't doing what you want, then you may be interested in a transplant.

Prosthetics are getting better and better. But the problem that most patients tell me is that they're heavy, they're uncomfortable, and they don't offer, for the most part, any sensory feedback. Feeling what your hand is doing is a big part of how your hand works. You don't have to look at your hand as you put your hair up or brush your teeth. You know exactly how hard you're squeezing an egg. But prosthetics don't offer any of that.

If the prosthetics get better, maybe they'll surpass these kinds of surgeries like Brandon's. But then again, if the immunosuppression protocols get better, if we get to a point where you don't need any medications, then why would you accept a prosthetic? And by the same token, if we ever approach the point where I can take cells from your body and in six months or a year, I can grow you a new arm in a lab and surgically attach it, you'll never need any medication because it's all your own cells. Why would you ever need a transplant?

I think that we're really in the infancy in terms of restoration of limbs and body parts, and I'm really excited to see what happens in the future.

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