"A double transplant makes finding a donor more difficult, although face is the primary determinant of donor selection, hand must match as well," said Dr. Richard Winters of the department of facial and plastic surgery at Hackensack University Medical Center in New Jersey.
Winters also noted that the operation would be more difficult than the typical single transplant because the removing of both kinds of tissue from a recently deceased donor and then attaching them would have to be coordinated.
"A double transplant needs to be orchestrated simultaneously or preferably in sequence, for example the face followed in several days by the hand," Winters said. And, "Timely restoration of blood flow to transplanted parts is key -- so this requires unorthodox management of the donor."
Winters estimated that an institution like the Cleveland Clinic could get the high level of surgical expertise to do the transplants. However, he said face transplants have had some setbacks in the past and adding a second limb transplant to the procedure could only complicate things further.
"There have been postoperative issues with many of the hand and facial transplant patients done in the U.S.," he said. "Although the science has been elegantly outlined, the translation into clinical practice is very close… but not yet where it needs to be to consider a case like this."
People with transplants -- be it face, limb or organ -- all run the risk that their bodies reject the transplant, or in other words start treating the new tissue as an invasive disease and attack it. Winters said complications from this can be bad enough with a face transplant, but with two separate transplants, an infection or rejection in Nash's body could snowball into a very dangerous situation.
First, to keep patients from rejecting the body, doctors prescribe potent drugs to suppress the immune system. Winters said he worries that trying to get the body to accept two transplants may require dangerous levels of drugs.
"Should problems arise with one transplant or the other, as they often do in this type of surgery, one operation can compromise the other ... or more significantly can synergistically affect the overall morbidity/mortality of the patient," he said.
Monaco said the family is keeping its options open for the future at Cleveland Clinic, or even checking other hospitals to see if they might consider Nash as a candidate for a face-hand transplant.
"We are exploring it. We're exploring other facilities. I don't know of anybody who has done both (face and hand transplants) at the same time," Monaco said. "We're breaking new ground here."
Other hospitals recruiting candidates for face or hand transplants in the United States include Emory University in Atlanta, University of Louisville, University of Pittsburgh, and Brigham and Women's Hospital, according to Dr. Linda Cendales, of the Division of Plastic Surgery at Emory University School of Medicine.
Winters thought European facilities may have different guidelines that would accept Nash as a patient, but other transplant experts weren't so sure.
"She most likely will be met with the same decision (elsewhere)," said Dr. David H. Song, chief of Plastic Surgery at the University of Chicago Medical Center.