Peru to Baltimore, for two new thumbs

Brief visa stay forces rare simultaneous surgeries


Three months ago, a young Peruvian whose hands had been injured in an explosion showed up at Union Memorial Hospital with a stack of medical records and an ambitious request: New thumbs, please.

Remarkably, surgeons granted his request. With his visa due to expire Friday, Francisco del Alamo-Benavente now thinks he can return home and realize his dream of becoming a chef, an occupation that would require enough strength and dexterity to slice a steak or peel a garlic clove.

"It was just a setback," the 22-year-old former army officer said of the accident that obliterated the thumbs on both hands. "But now I know I'm going to do this."

After the explosion, surgeons in Lima, the Peruvian capital, offered to perform radical surgery in which they would fashion thumbs from toes taken from his feet.

Since the 1970s, surgeons have performed toe-to-hand transplants using microscopes that enable them to visualize tendons and vessels a millimeter across and thread fine enough to float in the air. Though patients may not regain the sensation and strength they were born with, they often recover enough to perform essential tasks. What's more, the loss of a toe doesn't keep them from walking and, in many cases, running.

The possibility intrigued the young man and his father, Francisco del Alamo-Sota, but they thought it wise to consult doctors at a world-class hand center. A friend who works at the Peruvian Embassy in Washington helped them explore options in the United States, a search that led them to the Curtis National Hand Center at Union Memorial.

The center draws a sizable international clientele and, in Maryland's trauma system, it is the designated referral center for the most complex hand injuries. Its surgeons also treat birth defects such as webbed fingers.

Six weeks ago, surgeons there performed a toe-to-hand transplant on Del Alamo-Benavente's left hand - using the second rather than the big toe because it seemed an appropriate size.

His right hand presented a different challenge. The blast left little bone to support a toe transplant, so instead surgeons converted the index finger.

"It's a surgery we do with some frequency, sometimes in children who are born without a thumb," said Dr. Thomas J. Graham, director of the Curtis National Hand Center and the surgeon who transformed the index finger into a thumb.

Dr. James P. Higgins, who along with Dr. Michael A. McClinton performed the toe-to-hand transplant, said cases such as Del Alamo-Benavente's are particularly gratifying.

"You can make such a huge improvement," said Higgins. "You feel like you've turned a patient's life around 180 [degrees]."

The human thumb, positioned opposite the other fingers, makes it possible to thread a needle or pluck a coin off the floor. The thumb also enables a person to grip a hammer powerfully enough to smash a nail through hardwood. And it completes the wrap-around grip needed to hold cylindrical objects such as a soda can.

Last Thursday, Del Alamo-Benavente sat opposite occupational therapist Dale Eckhaus and tried simple maneuvers such as stacking colored cones on top of each other and fitting plastic pipes together.

The second was a two-handed task. Smiling and chatting amiably with Eckhaus, who speaks rudimentary Spanish, the young man used one hand for finer operations and the other in a supporting role.

"Most of what we do are functions using both hands, and I'm trying to have him recover his usual pattern of motion because the brain gets rusty, too," she said.

So far, Del Alamo-Benavente has gained little sensation in either of his new thumbs. With effort, he can move them slightly. Motion and strength could return sooner than feeling, which depends on the inch-a-month regrowth of nerve fibers.

Even when sensation returns, it may be sharper deep within than on the surface.

"He could get protective sensation - is it hot or cold?" Graham said. "We'd also like to think he'll be able to discern the shapes of objects as well as being able to pick them up."

The accident that transformed Del Alamo-Benavente's life occurred in June 2004, when he handled an explosive device that he mistakenly thought was disarmed. He tapped it twice, setting off a blast that tore off both thumbs as well as the index finger on his left hand.

Recounting the incident through hospital secretary Celia Cruz, who speaks fluent Spanish, he said he first worried about the condition of his uniform. Then, reality set in.

"What about my face, my head, my body?" he said to a soldier who was also injured in the blast. It wasn't until officers in a passing vehicle came to his rescue and whisked him aboard that he thought to look at his hands, which had not yet begun to hurt.

"It was like looking at a flower that was all opened up," he said.

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