Vascularized Composite Allotransplantation in a Post-COVID-19 Pandemic World.

Abstract

The coronavirus disease 2019 (COVID-19) pandemic is having a massive impact on public health and the global economy. Health care systems’ adaptation to this growing challenge has necessitated a redefinition of plastic surgeons’ scope of practice and role within their communities. The specialty was quick to answer the call of duty. Initiatives included voluntary deployment to help treat affected patients, and donation of personal protective equipment, ventilators, and clinical space. Nationwide recommendations to cancel or postpone elective operations and academic conferences were appropriately accompanied by a reconfiguration of practice patterns, clinical flows, research priorities, and educational modalities.1 Overcoming the devastating medical toll of the crisis and repercussions of social isolation must now be balanced with rising economic instability. Together, these factors are likely to redefine the field’s culture. This is already evident in the accelerated adoption of telemedicine and transition of educational activities to online formats.2 As we strategize and reorganize, it is imperative to meticulously plan the resumption of elective procedures and research endeavors. In recent years, vascularized composite allotransplantation has grown as a field and shown improving, yet still variable, functional and aesthetic results, long-term survival, and quality-of-life outcomes. Review of the recent preclinical literature reveals redundant study designs with elusive clinical translatability, despite improved focus on nerve regeneration and immunologic tolerance.3 Meanwhile, several vascularized composite allotransplantation centers have emerged, many of which have yet to accrue clinical experience. Current events call for a reevaluation of clinical and research priorities in vascularized composite allotransplantation. In a post–COVID-19 world, the field of vascularized composite allotransplantation will need to address three fundamental areas of relevance: (1) patient safety, (2) collaboration across vascularized composite allotransplantation programs, and (3) resource allocation. Beyond infectious precautions, patient safety should be comprehensively optimized through appropriate recipient selection and donor workup, updated operative and perioperative quality assurance protocols, and the establishment of dependable remote postoperative follow-up.4 This is particularly relevant, as immunocompromised recipients belong to a high-risk patient category, and measures such as isolation and travel bans restrict access to physical examination and biopsy for rejection monitoring and treatment. Little is known about COVID-19 in the transplant population, with mixed outcomes reported in kidney recipients.5 Significant morbidity and mortality seem to be related to patients’ demographic and clinical characteristics, time since transplantation, immunosuppressive regimen, and antiviral strategy, whereas successful recovery has also been reported with careful dosing of immunosuppression. With safe resumption of transplant practices, a data-driven approach is essential. Standard protocols should be developed to streamline donor and recipient testing, manage immunosuppressive regimens, and review the safety and efficacy of empiric antiviral therapies. It will be essential to centralize efforts and collaborate across teams to establish clinical guidelines and quality benchmarks in a time of judicious research funding allocation. The COVID-19 pandemic has uniquely presented both unprecedented challenges and opportunities. Plastic surgeons are asked to reinvent their practices and redefine the boundaries of the field. As we join our medical colleagues in addressing this crisis, we must work together to advocate for our patients and the future of our specialty in an evolving landscape. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this article. No funding was received for this work.