Face and hand transplantation

Face and hand transplantation is the surgical transfer of a face, hand or arm from a donor to a person who has lost their own to injury or disease, with the graft's blood vessels, nerves and supporting tissues joined to the recipient's. Both belong to a class of procedures called vascularized composite allotransplantation (VCA): vascularized because the graft survives only if its arteries and veins are connected to the recipient's circulation, composite because it contains several kinds of tissue moved as one anatomical unit, and allotransplantation because donor and recipient are different people.¹ The graft keeps no one alive, yet it needs lifelong immunosuppression, as a kidney or heart does, and that exchange of risk for quality of life has generated much of the ethical debate about it.² By the end of 2024, 53 face transplants and about 151 hand transplants had been performed worldwide.³

§What is transplanted

When the United States brought these grafts under its organ transplant rules, it defined them by behaviour rather than anatomy. A VCA needs its blood vessels surgically connected, contains several tissue types, is transplanted as an anatomical unit, does the same job in the recipient as in the donor, and is not combined with a device. It tolerates only brief storage and is liable to rejection, so it generally requires immunosuppression. The rule named faces, limbs, larynges and abdominal walls as examples.¹

Face grafts range from the central and lower face to the whole face; one total face transplant at NYU Langone in 2015 also carried the scalp, eyelids, both ears and parts of the facial skeleton.⁴ Hand grafts may be single or paired and attached anywhere from the wrist to above the elbow. In a 2026 review of 97 recipients, those with grafts attached high on the forearm or above regained less grip strength and improved more slowly than those with grafts lower down.⁵

The first modern operation, in Lyon in 1998, joined bone, then arteries and veins, then nerves, muscles and tendons, and closed the skin last. Feeling returned only as the recipient's nerves grew into the graft; at six months he could feel deep pressure, but not light touch, in the middle of his palm.⁶

Because the graft is visible, appearance enters the match: the donor for the first US hand transplant was chosen for size, sex and skin tone.⁷ Donors have almost always been deceased. In 2025 a Hanoi hospital reported two forearm and hand transplants from living donors, which it described as the first in the clinical literature, using intact parts of injured limbs that could not be replanted on the donors themselves.⁸

Immunosuppression follows solid-organ practice. Lyon's two double hand recipients received antithymocyte globulin, then tacrolimus, mycophenolate mofetil and prednisone; each had two rejection episodes, visible as skin lesions, that cleared within days on higher steroid doses and immunosuppressant creams.⁹ Essentially all VCA recipients have had drug side effects, mostly attributable to calcineurin inhibitors such as tacrolimus and to steroids.³

§Development history

1. 1964
   First hand transplant attempt
   Surgeons at Clinica Guayaquil in Ecuador graft a hand onto a marine whose own was amputated by a blast. It is irreversibly rejected 21 days later.
2. 1998
   First modern hand transplant
   A team in Lyon, France, transplants the right forearm and hand of a brain-dead donor onto a 48-year-old man.
3. 1999
   First US hand transplant
   Surgeons in Louisville, Kentucky, give a 37-year-old man a new left hand. Within a year he can write and tie his shoelaces.
4. 2000
   First double hand transplant
   Lyon transplants both hands into a man with bilateral amputations.
5. 2005
   First face transplant
   Surgeons in Amiens, France, transplant the central and lower face of a brain-dead donor onto a 38-year-old woman.
6. 2008
   Two whole arms and a near-total face
   A Munich team transplants two complete arms, elbows included, onto a farmer. In Cleveland a woman receives a graft replacing 80% of her face.
7. 2010
   Barcelona claims first full face
   Surgeons in Barcelona transplant what they describe as the first full face, with all its aesthetic and functional units, onto a 30-year-old man disfigured by a ballistic injury.
8. 2018
   First face retransplant
   A Paris team gives a second face to a man whose first, transplanted in 2010, was lost to chronic rejection.
9. 2020
   Face and both hands
   NYU Langone performs what it describes as the first successful combined face and double hand transplant.
10. 2023
    Face with a whole eye
    NYU Langone transplants part of a face together with an entire eye. The eye survives and its retina responds to light, but at one year it has no light perception.

The 1964 Guayaquil graft relied on cortisone, azathioprine and a single dose of radiation.¹⁰ Hand transplantation resumed in Lyon in 1998, after animal limb grafts had survived long term under newer drug combinations.⁶ Its recipient, the New Zealander Clint Hallam, had the hand removed at his request in London in February 2001 after rejection. Earl Owen, a microsurgeon on the transplant team, said Hallam had gone without his drugs for weeks at a time; Hallam denied causing the rejection.¹¹ The international registry later counted seven hand grafts removed in China for noncompliance with immunosuppression and concluded that success depends on the patient's compliance and careful evaluation.¹²

The Louisville recipient, Matthew Scott, could within a year throw a baseball, turn the pages of a newspaper, write and tie his shoelaces, none of which he had managed with a prosthesis.⁷ Twenty years on, he put the hand's function at about half or a little more.¹³

The first face recipient, Isabelle Dinoire, had been disfigured by her dog; the Amiens team grafted the central and lower face of a brain-dead woman onto her at the age of 38.¹⁴¹⁵ She died in April 2016, aged 49, after what the Amiens hospital called a long illness. The hospital gave no cause; Le Figaro, which first reported the death, said she had had two cancers linked to the transplant and had lost partial use of the grafted lips the year before.¹⁶¹⁵ Connie Culp, the Cleveland recipient of 2008, died in 2020 of complications from an infection that the clinic said was unrelated to her transplant.¹⁷

In July 2008 a Munich team transplanted both complete arms, elbows included, onto a 54-year-old farmer who had lost his arms six years earlier and found prostheses unsuccessful.¹⁸

Jérôme Hamon received a face in 2010 for disfigurement caused by neurofibromatosis type 1. After drugs given for a 2015 illness interfered with his anti-rejection medicines, the graft was removed in November 2017 and replaced in January 2018,¹⁹ the first documented facial retransplantation. His surgeons attributed the loss to chronic antibody-mediated rejection.²⁰

The 2023 eye transplant went to Aaron James, 46, who had been injured by a high-voltage line.²¹ Surgeons joined the donor optic nerve to his own, and the retina responded to light, but at one year the eye had no light perception.²² Devices that bypass the eye, such as cortical visual prostheses, are a separate approach to the same loss.

§Other composite grafts

A laryngeal transplant at the Cleveland Clinic was reported with 40 months of follow-up in 2001,²³ and surgeons in Miami used abdominal wall grafts to close the abdomen in intestinal transplant patients.²⁴ A Stellenbosch University team reported the first successful penis transplant, performed in December 2014; the donor's family agreed after the team undertook to create a neo-phallus for the donor.²⁵ In 2018 Johns Hopkins transplanted a penis, a scrotum without testicles and part of the abdominal wall into a veteran injured by a blast in Afghanistan.²⁶ US statistics count Uterus transplantation as VCA too; it made up 55 of the 92 VCA transplants reported there from 2014 through 2024.²⁷

§Outcomes

A multicentre study followed the first 50 face transplants, performed on 48 patients in 11 countries, for a median of 8.9 years. Counting graft loss or death as failure, 85% of grafts survived five years and 74% ten. Six grafts were lost and ten patients died, and later transplants fared better than earlier ones.²⁸

Face grafts have restored functions that earlier reconstruction had not. Six months after her transplant, the Cleveland patient could breathe through her nose, smell, taste, speak intelligibly, eat solid food and drink from a cup.²⁹ The Barcelona recipient left hospital at four months with near-total sensation and partial recovery of movement.³⁰

For hands, the registry reported in 2010 that all recipients had regained protective sensation, 90% tactile and 82.3% discriminative sensation, and that motor recovery let patients perform most daily activities.¹² A 2015 review put patient survival after hand transplantation alone at 98.5% and overall graft survival at 83.1%.³¹ Disability scores fell significantly after hand transplantation in a 2022 review,³² and bilateral recipients report better quality of life than unilateral ones on a general health survey, though not lower disability scores.⁵ The Leeds service reported in 2025 that all 17 limbs it had transplanted into ten patients were surviving; nine patients had needed further surgery.³³

The relevant comparison is with a prosthesis. A 2016 multicentre study of five below-elbow transplant recipients and seven prosthesis users found no significant difference on three standard tests of function and disability, though the transplant recipients scored higher on four of eight quality-of-life scales.³⁴

§Risks

Between 85% and 90% of VCA recipients have had rejection within the first year, against about 5% of kidney recipients.³ In hand recipients acute episodes were reversible when treated promptly,¹² but chronic rejection is the leading cause of face graft loss, with a median of 90 months to irreversible rejection in one review.³⁵ A 2023 review of 115 face and upper-limb recipients found acute rejection in 89%, opportunistic infection in 58% and partial or complete graft loss in 19%, and judged complications more frequent than previously reported.³⁶

The drugs harm other organs. In 99 recipients, kidney function fell in the first year and did not return to pretransplant levels, and the decline correlated with tacrolimus levels.³⁷ Immunosuppression also raises Cancer risk. A 2026 review of 15 recipients with malignancies found 24 tumours. Thirteen were skin cancers, none of them melanoma, and 85% of those arose on the recipient's own skin rather than the graft; a third of the recipients developed post-transplant lymphoproliferative disorder, which the authors report carried a 50% mortality rate.³⁸

Among face recipients the main causes of death have been infection, then cancer, stopping immunosuppression and suicide.³⁵ A 2022 review of 96 hand recipients found 16 with an amputated graft and 5 deaths.³² Combined grafts carry more risk: three of the four hand-transplant deaths known by 2015 were in recipients of multiple grafts,³¹ and of two combined face and double hand attempts before 2020, one patient died about a month later and the other lost the hands within days.³⁹ Among 43 hand recipients surveyed by the registry, graft loss was associated with anxiety and post-traumatic stress disorder, and was more common among those judged to have unrealistic expectations.⁴⁰

§Ethics, identity and consent

In November 2003 a Royal College of Surgeons of England working party judged face transplantation unwise until complications could be better controlled. Its 2006 second edition accepted the procedure as inevitable, set 15 minimum requirements, and said that with independent review individual patients might proceed in an appropriately regulated research setting. It noted that immune tolerance had been shown in animals but not satisfactorily in humans.⁴¹ A review of 49 ethics papers on hand transplantation found harm to the patient the most discussed principle and traced the debate to the procedure's life-enhancing rather than life-saving nature and its need for long-term immunosuppression.²

An early question was whether recipients would resemble donors. In a 2010 simulation swapping the central face between photographs of 100 volunteers, observers recognised the donor in the composite 2.6% of the time and the recipient 66%, largely from hair, ears and head outline.⁴² The US rule likewise judged that a recipient's face scan is unlikely to match the donor's, whereas a hand transplant transfers the donor's fingerprints.¹ Unlike the proposed head transplantation, a face graft leaves brain and body in place, so its identity questions concern recognition rather than the puzzles of persistence discussed in Personal identity and continuity. It also sits at the reconstructive end of debates about Morphological freedom, restoring an ordinary appearance rather than altering a healthy one.

Donor families face a distinct request. US guidance says VCA authorization may not be assumed under the general term "organ" donation and should be sought separately, after organs and tissues. Families are told the donor's appearance will change, may request a face mask moulded from the donor's features or a prosthetic hand, and are warned that birthmarks or fingerprints can compromise anonymity.⁴³

Transplant or prosthesis

For someone missing a hand, the alternative is a prosthesis with no drug risk. Transplant recipients who had used prostheses have described them as heavy, ill-fitting and difficult to use, and the National Academies noted in 2025 that prostheses do not yet integrate sensation as a hand does, a gap that Neuroprosthetics research aims to close. A Walter Reed representative told the National Academies committee that veterans with amputations may be reluctant to accept the risks of lifelong immunosuppression; the report adds that a transplant disqualifies a service member from deployment. One written submission predicted that improving myoelectric prostheses would, once their cost falls, make hand transplantation an ethical dilemma.³ The 2016 comparison concluded that transplantation should stay restricted, with people missing both hands the best candidates.³⁴

§Regulation and payment

Until 2014 the United States regulated these grafts as tissues through the Food and Drug Administration. A rule effective on 3 July 2014 redefined them as organs under the national transplant network and the National Organ Transplant Act, bringing them under its ban on transferring organs for valuable consideration. The rule did not address insurance coverage and expected wounded service members from Iraq and Afghanistan to form a significant share of candidates.¹ VCA donation must be explicitly and specifically authorized, and OPTN guidance issued after the rule took effect said very few donor registries offered a way to do so.⁴³

Volumes are small beside solid-organ transplantation (see Organ shortage). From 2008 to 2024 the United States averaged about one face and two hand transplants a year from deceased donors, against 14,682 kidney transplants.³ Its registry recorded 37 non-uterus VCA transplants from 2014 through 2024, with trauma the leading indication.²⁷

A 2025 National Academies report, funded through the Department of Defense, found that the procedures were not a routinely offered standard treatment, had mostly been done under research protocols, and faced substantial barriers to growth in the United States. Insurers did not yet cover the procedures, and no US programme had obtained third-party payment for the surgery itself; money came from research grants, largely from the Department of Defense, and from philanthropy and hospitals. The Veterans Health Administration covers long-term immunosuppressants but does not guarantee surgical costs.³ The Cleveland Clinic said in 2018 that most US face transplants had been paid for by a Defense Department grant programme,⁴⁴ and NYU Langone paid for a 2015 face transplant itself.⁴⁵ Access therefore depends on a few funded centres, a pattern discussed in Access and inequality.

In the United Kingdom, a hand and upper limb transplantation service at Leeds runs on a standard-of-care basis, its founders having judged the evidence sufficient by 2012.³³

§Research directions and outlook

The main goal is to reduce or end lifelong immunosuppression. In Pittsburgh, five hand recipients transplanted in 2009-2010 received antibody induction, then tacrolimus alone, with donor bone marrow cells given on day 14; skin rejections were infrequent, but no donor cells were detected in the blood and all stayed on tacrolimus.⁴⁶ Drug-free tolerance has been demonstrated in animals. In miniature swine, animals given donor blood-forming cells to create a mix of donor and recipient cells accepted composite grafts, skin included, after immunosuppression ended, until the experiments stopped at up to 504 days; two of the six developed graft-versus-host disease, which the authors called unacceptable for clinical use.⁴⁷ In rats, one injection of a tacrolimus-releasing gel extended median graft survival beyond 100 days, against 33.5 with tacrolimus alone.⁴⁸

Hand grafts tolerate little time without blood flow, which confines donor recovery to a small geographic area. Five human upper limbs kept for 24 hours on near-normothermic perfusion appeared viable, though none was transplanted.⁴⁹

A thin and uneven evidence base

Outcome data come from case reports, single-centre series, registries that depend on what centres report,⁴⁰ and reviews that fill gaps from press reports and personal communications.³¹³⁵ Counts also disagree: one review counted seven face graft losses among 46 patients by April 2023, a multicentre study six among 48 by September 2023.³⁵²⁸ The prosthesis comparison cited above involved 12 people.³⁴ As of 2026 no clinical method regrows or engineers a functioning human hand or face; Limb regeneration and Tissue engineering cover that research, and Osseointegration describes prostheses anchored directly to bone.

§See also

• Uterus transplantation
• Head transplantation
• Myoelectric prosthetics
• Osseointegration
• Organ shortage
• Xenotransplantation
• Limb regeneration
• Personal identity and continuity

§References