41 - Upper extremity composite allotransplantation

Abstract

Millions of people each year suffer from major upper extremity trauma, resection of upper extremity tumors, or are born with major congenital defects that require many complex reconstructive procedures to repair large upper extremity defects. Conventional management of these tissue deficiencies includes prosthetic rehabilitation or autologous reconstruction, but these modalities are often limited by highly variable outcomes. Vascularized composite allotransplantation (VCA) describes the transplantation of allografts that consist of multiple tissues of variable immunogenicity such as skin, lymph nodes, bone marrow, nerves, vessels, muscles, and bone. The goal of VCA is to improve quality of life for patients with significant composite tissue defects by leveraging the plastic surgery principle of replacing “like with like” to optimize both functional outcomes and aesthetic outcomes. VCA is not a life-saving procedure, but it can significantly enhance a patient’s quality of life. The risk–benefit consideration for patients must include the potential side effects of long-term immunosuppression – treatment that is necessary for graft survival. This comprehensive chapter describes the history and milestones of upper extremity transplantation, the immunologic and experimental foundations for upper extremity VCA, and technical/procedural aspects of performing an upper extremity transplant with clinical pearls. This chapter also describes how to approach rehabilitation and critical immunologic assessment for rejection, with insight into immunosuppressive protocols. Finally, we provide an update on the world experience in upper extremity transplantation and discuss future directions of the field.