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Restoring Form and Function: At the Forefront in Transplantation

Jaimie Shores - Hand Surgeon (left)
Chad Gordon - Craniomaxillofacial Surgeon

As pioneers in an emerging field—reconstructive facial transplantation of the hand and face—Jaimie Shores and Chad Gordon bring innovative perspective and expertise to the specialty at Johns Hopkins. Along with W. P. Andrew Lee, the team’s efforts in the OR and the laboratory are setting a prodigious standard.

Gordon, for example, is one of few craniomaxillofacial surgeons worldwide to specialize in allotransplantation for midfacial injuries so severe that conventionally treated patients typically become recluses. As part of a surgical team for the composite-tissue facial transplant for a patient who had been shot point blank in the face, Gordon has watched the grafts reclaim lives.

That’s given him and Hopkins colleagues a pioneer’s passion to improve transplant techniques and make the surgery for hands, faces and other complex organs safer and more accessible.

“A successful transplant is not just one that’s pink and alive,” says Gordon. “It’s also a triumph of form and function.” But the newness of the field means there’s room for improvement. He’s noticed, for example, that in all face grafts to date, patients’ jaws aren’t well aligned.

Gordon’s response was to develop a new approach for optimizing the “hybrid occlusion” between the two dissimilar donor/recipient jaws, a technique that includes creating a prefabricated, impression splint from donor and recipient to carry into the OR, and a protocol to use it.

Surgical technique isn’t the only hurdle.

“Immunosuppression is a constant concern in transplantation,” says hand surgeon Jaimie Shores, “and affects our work in an unusual way.” He and colleagues face the ironic dilemma of being able to offer life-enhancing hand transplants, but because the surgery isn’t life-saving, subjecting patients to the rigors of standard triple-drug immunosuppression for a lifetime has potential to cause more harm than good.

Frustrated by that, Lee and surgeon-immunologist Gerald Brandacher developed a gentler protocol which they and Shores use. It whittles the number of immunosuppressants to a single, nonsteroid drug by infusing the donor bone marrow cells into the transplant recipient. Their approach applies a new theory of raising the body’s immunological regulatory capacity rather than indiscriminately suppressing its immune system—a protocol that’s been successfully applied in five hand transplant recipients.

That unique immunomodulatory strategy is likely one reason behind the Department of Defense’s major support and funding of the new service and its research. Johns Hopkins’ proximity to Walter Reed National Military Medical Center is prompting plans to help the severely wounded warriors who could lead a more normal life with the surgery.

Research to Push Away Boundaries

“If our research has an overarching theme,” says Gerald Brandacher, “it’s favoring the risk-to-benefit balance in reconstructive transplantation.”

Brandacher, scientific director of the composite tissue allotransplantation program, and the 14 full-time research fellows who staff the reconstructive transplantation laboratory he heads

aim to avoid the need for heavy immunosuppression after face or hand transplantation. At the same time, they’re working to heighten the body’s ability to accept the donor tissue, and they want to enhance the rate and tempo at which nerves will regenerate after surgery to balance out the risks of these highly complex operations.

In a new, dedicated, 2,000-square-foot facility complete with a state-of-the-art microsurgical suite and close to Hopkins’ established Transplant Surgery, Tissue Regeneration and Biomedical Engineering labs, all that seems possible.

Among projects under way are:

• Exploring a new immunomodulatory treatment strategy that eliminates the need for long-term medication after hand and face transplantation

• Testing novel stem cell-based techniques to speed nerve regeneration, including after lowerextremity transplantation (supported by the The Melina Nakos Foundation)

• Developing new, noninvasive methods to detect graft rejection at its earliest, treatable stages

• Studying cortical reintegration and how nerve pathways within the brain “rewire” after limb transplantation

• Establishing the first-ever large-animal model to study functional, immunological and aesthetic outcomes

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