Vascularized Composite Allotransplantation 2.0: The Future Is Now.

Abstract

Landmark achievements have shaped the modern history of vascularized composite allotransplantation. From the first clinically successful hand transplant in 1998 to the first face transplant in 2005, the field has expanded to include larynx, abdominal wall, uterus, penis, and lower extremity transplantation. In the field’s third decade, clinicians are faced with unprecedented challenges and opportunities. Long-term outcome data are scarce but encouraging overall. Forty-six face transplants have been performed, with allograft and recipient survival reaching 10 years in the first reported face transplant.1 Another recipient underwent successful facial retransplantation for chronic rejection 8 years after his initial face transplant.2 Uterine transplantation has expanded rapidly, with over 60 transplants performed and live births from both living- and dead-donor allografts. Over 120 hand transplants have been performed, with one recipient’s survival exceeding 20 years with a functional allograft.3 However, little is known about patients who have lost their transplanted allografts, and the role of retransplantation, targeted muscle reinnervation, and myoelectric prosthetics remains to be explored. Cross-sex extremity transplantation has been reported, expanding donor-recipient matching possibilities. Two attempts at combined face and hand transplantation, a quadruple limb transplant, and a triple limb transplant have resulted in allograft loss or recipient death.4 Nonetheless, a cautious diversification in procedural scope remains on the horizon, highlighting the field’s evolving complexity. With operative feasibility no longer in question, new priorities include technical refinement, pharmacologic innovation, and systems-based interventions. Functional and aesthetic quality standards have improved along with operative time, hospital stay, recovery, and rehabilitation. A deeper understanding of complications and timing of secondary revisions has also emerged.5 Translational research efforts focus on nerve regeneration and cortical reintegration, the safety and efficacy of immunosuppression, and the pursuit of immunologic tolerance, and sustainable improvement in quality of life is redirecting clinical focus toward patient-reported outcome research. Finally, coordinated efforts are needed to ensure the financial and logistical viability of vascularized composite allotransplantation within modern health care systems. The steady increase in the number of procedures and vascularized composite allotransplantation centers with varying levels of experience calls for the establishment of clinical standards, quality benchmarks, and appropriate reimbursement schemes. Guideline development, structured data sharing, and thoughtful regulation should be embraced to promote patient safety and well-being if the field is to cement its viability. Although advances in immunology, tissue engineering, and xenotransplantation may eventually redefine the field’s boundaries, clinical transplantation today continues to be limited by its donor pool despite engagement efforts by organ procurement organizations. Media coverage has been extensive but varying in quality, and members of the general public lack access to relevant, reliable, and understandable information. As vascularized composite allotransplantation recipients reintegrate into their communities and new potential candidates seek care, educating the medical workforce is just as crucial. Many training programs, national associations, and published journals have taken the lead in educating the next generation of leaders in comprehensive plastic and reconstructive care. The field has outgrown its experimental origins and is steadily joining the clinical mainstream. The climb is steep, but vascularized composite allotransplantation is an immunologic breakthrough away from formally joining the reconstructive elevator. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work.