A piece of surgical showmanship. That鈥檚 how many saw the first transplant of a human hand from a cadaver two years ago. The patient, a New Zealander called Clint Hallam, didn鈥檛 help. Apparently, he had lost his hand in an accident while in prison. His doctors had known little about his past-even microsurgeon Earl Owen who brought Hallam to France for the operation and who co-led the operating team. Owen is medical director of the privately funded Microsearch Foundation in Sydney. Could his pioneering procedure pave the way for transplanting whole limbs, faces, penises even? Rachel Nowak talked to Owen about the future for this kind of surgery-and the fate of his most famous patient.
Do you know where Hallam is now?
He鈥檚 in Lyon, France. He was examined recently. It鈥檚 some months since he left Australia and he鈥檚 had no medical treatment or testing or biopsies by us during that time.
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And he鈥檚 doing fine?
I didn鈥檛 say he鈥檚 doing fine. He鈥檚 a problem for his doctors because we can鈥檛 control his medication unless we can do biopsies of his skin and muscles and blood levels of his drugs. And we haven鈥檛 been able to do that. The evidence from our first blood test is that it鈥檚 possible he hasn鈥檛 been taking all his drugs.
Is there a risk of him losing his hand?
Yes, there鈥檚 an extraordinarily high risk of him losing his hand. It鈥檚 very frustrating for the entire team that he鈥檚 the only patient any of us have ever had in the world who isn鈥檛 interested in following any doctor鈥檚 suggestions or protocols. Although he says he is-I think that should be said. He probably thinks he鈥檚 doing the right thing. He often says: 鈥淚 know my own body better than any doctor.鈥�
How did you choose Hallam as the patient for the first hand transplant?
I chose the candidates from my top drawer, which contains letters from thousands of people who鈥檝e been writing to me since 1970 saying they had bits of them missing-legs, arms, penises, hands, fingers, ears, noses-and could I please do a transplant? We got down to 10, and then 3. They all said that within a few hours of me ringing them they would drop everything, get on the nearest plane, and fly to Europe. The first one I rang was not Hallam, but that person couldn鈥檛 come.
The operation would have been less controversial if you had found a patient who needed a double hand transplant where the potential gains more easily outweighed the risks. Did you consider that?
The other members of the team wanted to start with a double hand because that would be easier to justify because the patient couldn鈥檛 do anything. My point was that it was essential that the first operation be a success, and since skin is the hardest tissue to immunosuppress, I wanted less skin to deal with than you would have with two hands.
Has Hallam鈥檚 past affected the field?
Yes it has, and in a bad way. It gave our detractors and the medical dinosaurs-which the profession has in abundance-reasons to say we should not have done it. They argued that it hadn鈥檛 been done before and probably wouldn鈥檛 work, that it wasn鈥檛 necessary because he has another hand, that the drugs could affect his life span, and that he was not a worthy patient to start with. I find that last comment extraordinary, from doctors who are supposed to have the Hippocratic oath at the heart of their professional lives.
So if you鈥檇 known more about Hallam, would you have still have gone ahead with the operation?
I treat all my patients the same. I have never asked and never will ask anybody if they are a serial killer, a rapist, or whatever. It just never occurs to a doctor. People come to you for treatment and for help. It鈥檚 my duty to try to help.
Will you be doing more hand transplants?
We鈥檝e applied for permission in France and Italy to do five double hand transplants to assess how we can improve everything about the transplant: the doses of the cocktails of drugs, the mobility of the hand, and things like that. We are not interested at this stage in doing anything but advancing knowledge so everybody can have the same chance. But cadaver parts are an interim solution that won鈥檛 last very long-there are ways being devised to clone parts of the body.
Unlike a kidney or a heart transplant, a hand transplant doesn鈥檛 save a life, but the recipient still has to take all the risks of immunosuppressant drugs. Did Hallam succumb to anything?
Hallam had pre-diabetes beforehand and we warned him, and it鈥檚 in his legal papers which he signed, that he most probably would get diabetes, and he has.
Do you think it鈥檚 worth the risk?
If his life is really at risk then we can cut off that hand the minute he starts rejecting, if he wishes, and if we think fit. We don鈥檛 believe his life is at risk, but he should be under strict medical control. Just as the first heart and kidney transplant patients have been followed up for life.
How important were the immunosuppressant drugs for the success of the operation?
Hallam had more than double the regeneration speed of his nerves than anyone in history. The effect of the newer immunosuppressant drug is to somehow prevent the total degeneration of the transplanted nerve and to allow more rapid growth of the axonal proteins of the nerve in the arm down the tracts left by the nerve in the transplanted hand. The nerve grew 36 centimetres in 9 months, which is impossible normally. He has got almost perfect feeling. Our second patient, Denis Chatelier, who received a double hand transplant in January, has feeling in his fingertips.
How do patients feel about having someone else鈥檚 hand on the end of their arm?
Hallam always said that as soon as he gets anything it鈥檚 his and he鈥檇 seen the hand as being his from before he had the transplant. Immediately he woke up with the hand transplant on he said: 鈥淎t last, I have my hand back.鈥� And he鈥檚 said it鈥檚 his up until now, when he鈥檚 in two minds about whether he can have freedom of travel and whether it might become an inconvenience to be always having to report to doctors.
How many hand transplants have been done since Hallam鈥檚?
Chatelier is our most recent. There鈥檚 been one since in Austria, a double hand that was done a few months ago. In all there鈥檚 six of them. Two done in China, one in America and our two. That鈥檚 eight hands. All the hands are on and functioning at this time.
Does having a hand transplant get rid of phantom pain?
If it鈥檚 done correctly, if the nerve is rejoined very, very carefully, microsurgically. Even though the hand and the arm are from two different people, you still have to match the axonal bundles in each of the major nerves as closely as possible. That鈥檚 the most difficult thing, but we think we鈥檝e been successful in our patients-in both of them the disordered feelings in the stump have been replaced by actual feeling in their finger tips.
Will you move onto whole limb transplants?
Yes. Now we鈥檝e shown that you can suppress skin rejection with the doses that we have in our cocktail, we will gradually move up to the elbow, and so on. We鈥檒l do the upper limbs before the lower limbs.
What about face transplants?
When you have skin ripped off the face or the scalp it鈥檚 only skin, nearly every time. The muscle and the nerve supply are usually intact. So you only have to connect a blood supply to the transplanted skin. Technically that is quite possible.
What limits are there to body part transplants?
Why should there be any limits, except the brain and the spinal cord?
Do you know of any veterinary surgeons who are attempting to do limb transplants on pets?
No, the vets are not picking up on it yet, they鈥檇 prefer us to experiment on humans.
You were one of the first surgeons to sew back a child鈥檚 finger in 1970, the first to reverse a vasectomy, and the first with the hand transplant鈥�
I was the first to reverse a vasectomy microsurgically using a reliable technique. I鈥檝e done over 4000 men since and we have phenomenal results. On average, these men were ten years out from their vasectomies when they had the operation, and 85 per cent of them have since fathered children. I was also one of the first to reverse women鈥檚 sterilisation. And I did the first long nerve graft on a sciatic nerve in 1972. The child was run over by a car which ripped out the back of his leg. Then there鈥檚 the case of Dimka Ashkenazy, the son of the pianist Vladimir Ashkenazy, who was flown to us after a dreadful accident-a speedboat propeller went over his leg and virtually cut it off. My assistant Hari Kapila and I rebuilt his leg, including his sciatic nerve. He won his school 200 metres race two years later.
How much does being first matter to you?
I haven鈥檛 done anything to get there first.
So what brought you into microsurgery?
I was always going to be a surgeon. I couldn鈥檛 stand the fact that premature babies born with nasty congenital deformities were left to die. My burning desire was to get to the world鈥檚 best children鈥檚 hospital of the time and try to find a way to save them. I worked at the Great Ormond Street children鈥檚 hospital in London in the 1960s. The problem is that the arteries and veins on a one-pound newborn baby are so small you can鈥檛 see them, let alone operate on them. I tried to use magnifying glasses, but it didn鈥檛 work so I went to Carl Zeiss, the microscope makers in West Germany, with drawings of what I thought surgeons needed-foot controls, and optics that could be used by two surgeons sitting opposite each other. To my surprise, they were very enthusiastic and made one in a few weeks from the parts of other microscopes. Surgeons at Great Ormond Street encouraged me because I was an upstart Australian who鈥檇 be going back to Australia and be no threat to anybody in England. We did operations that were not possible before we had microscopes-repairing conditions such as oesophageal atresia where the baby is born with the oesophagus going into the lung and the trachea into the stomach. I felt like I was the Messiah coming back to Australia with new techniques that could-and did-go into every branch of surgery.
Does microsurgery seem old hat to you now?
No, because I love doing it. It鈥檚 meticulous and it brings me in contact with the Almighty because I see living tissues. Looking down a microscope underneath the skin, it鈥檚 just like looking at a coral reef, it鈥檚 so full of colour and activity. You do a vasectomy reversal, or a facial nerve graft, and it sounds like there should be blood and gore, but there鈥檚 none because we can see everything under the microscope, even the capillaries, and so avoid cutting anything that would cause bleeding. It鈥檚 in terrific colour, it鈥檚 three-dimensional and you鈥檙e sculpting some person鈥檚 new personality if you鈥檙e reconstructing. I鈥檓 the luckiest surgeon that ever lived. All I do is put things back.
So what will be next?
Every time I look down the microscope, I see that when you put a micro-suture into tissue, the tissue shrinks away from it. The micro-suture could be a fifth of the width of one of the hairs on your finger, just 10 or 15 micrometres, and yet I watch myself damaging tiny little arteries or nerves. When we put three stitches into a bundle of nerve fibres, we destroy at least 25 per cent of the available axonal material. I wanted to find a way we could avoid using sutures in surgery, so for six or seven years we鈥檝e been working on sutureless surgery. We鈥檝e come up with a totally new concept. We use the energy of a beam from a micro-laser and a special solder to joining arteries and veins end to end without any stitches. It鈥檚 quite sensational and I am thrilled to pieces.