Field Of Composite Tissue Allotransplantation Research Articles

Ushering in the era of penile transplantation.

Penile transplantation is a novel approach to management of penile loss in the developing field of composite tissue allotransplantation (CTA). Prior management for significant penile loss has been free flap phalloplasty with issues related to function, cosmesis, and functional loss from the location of flap harvest. Transplantation has been an evolving field with advancement in CTA over the past several decades leading to the option of penile transplant. Management of penile injury with replantation provided some preliminary groundwork on the technical aspects for penile transplantation. Additionally, penile transplantation raises many ethical, emotional, and psychological considerations with need for patience amidst ongoing advancement within the field.

Bilateral hand transplantation: Supporting the patient's choice

Bilateral hand transplantation, as a fairly new reconstructive option for amputees, raises major ethical questions. This article, which is based on the reflections arising from the rich experience of Lyon's team in this field, addresses the topic of supporting the patient in his choice for or against this procedure. How should autonomy be understood in this particular setting? The developing field of composite tissue allotransplantation needs to establish a common thinking on this subject. The article emphasises that, even if it is their right to decide, patients have to be carefully supported to help them make the most consolidated choice possible in this challenging procedure. We deal with the question of the choice between the uncertainty in this innovative procedure and a life-threatening treatment to alleviate a handicap. We outline that the entire process of hand allograft is a unique opportunity for the patients to strengthen and exercise their autonomy in interaction with the medical team.

Ethical Considerations in Face Transplantation: Ethical Issues Related to Inclusion Criteria for Face Transplant Candidates

On November 15, 2004, Cleveland Clinic Foundation’s Institutional Review Board (IRB) granted me the world’s first approval to perform face transplantation in humans. This approval was granted based on over 20 years of work in the field of composite tissue allotransplantation, both in the experimental laboratory as well as in the anatomy laboratory, on cadaver models. The process of approval took over 1 year and a number of meetings in front of the IRB committee, which consisted of about 20 members of different specialties including medicine, transplantation, infectious disease, and surgery; however, also experts in different fields—lawyers, social workers, as well as lay representatives, all having the right to ask questions about the validity of such a new procedure. When it comes to surgical breakthroughs, there is always a lot of controversy around the topic. It is quite understandable that the announcement of Cleveland Clinic having received approval for facial transplantation in humans, in 2004, raised considerable interest from media all over the world, and from this perspective, I must say that the international and national media interest was almost larger than when we actually performed the first US face transplantation in December 2008. Interestingly, there was a lot of support from the media perspective, since it was obvious that our IRB approval was based on years of work in the field of composite tissue allograft transplantation. Also, the medical society supported the idea that, for patients who had lost their faces and were severely disfigured, introduction of new reconstructive options which went beyond what was currently available, was something to be accepted with interest and excitement. The major opponents, however, of the idea of facial transplantation, were experts in ethics. One of them, Dr. Art Caplan, questioned the value of face transplantation and had numerous public interviews where he criticized the idea, as well as having warned society that now patients would be unwilling to donate organs and would be tearing up their drivers’ licenses since, in the United States, organ donation is voluntary and a statement indicating agreement to be an organ donor is displayed on drivers’ licenses. Interestingly, from the surgeons’ perspective, this type of approach could be ethically questionable, specifically when it comes to statements made ex cathedra, without really dealing with disfigured patients and seeing their disability, daily suffering, and inability to maintain physiological functions, as well as normal social lives. This introduces the ethical questions which we had raised during the work on our IRB approval protocol, as well as on the consent form for face transplant candidates. As for any medical procedure, when it comes to a decision about elective and novel surgery, there is always the M. Siemionow (&) Department of Plastic Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk A-60, Cleveland, OH 44195, USA e-mail: siemiom@ccf.org Arch. Immunol. Ther. Exp. (2011) 59:157–159 DOI 10.1007/s00005-011-0121-6

Science of Composite Tissue Allotransplantation

The science of composite tissue allotransplantation (CTA) is rooted in progressive thinking by surgeons, fueled by innovative solutions, and aided by understanding the immunology of tolerance and rejection. These three factors have allowed CTA to progress from science fiction to science fact. Research using preclinical animal models has allowed an understanding of the antigenicity of complex tissue transplants and mechanisms to promote graft acceptance. As a result, translation to the clinic has shown that CTA is a viable treatment option well on the way of becoming a standard of care for those who have lost extremities and suffered large tissue defects. The field of CTA has been progressing exponentially over the past decade. Transplantation of hands, larynx, vascularized knee, trachea, face, and abdominal wall has been performed. Several important observations have emerged from translation to the clinic. Although it was predicted that rejection would pose a major limitation, this has not proven true. In fact, steroid-sparing protocols for immunosuppression that have been successfully used in renal transplantation are sufficient to prevent rejection of limbs. Although skin is highly antigenic when transplanted alone in animal models, when part of a CTA, it has not proven to be. Chronic rejection has not been conclusively demonstrated in hand transplant recipients and is difficult to induce in rodent models of CTA. This review focuses on the science of CTA, provides a snapshot of where we are in the clinic, and discusses prospects for the future to make the procedures even more widely available.

Hand transplantation

Transplantation of a vascularized limb or its components is defined as composite tissue allotransplantation, and is one of the newest areas in surgery. To date, 24 hands have been transplanted onto 18 recipients. The initial results have been promising, and hand transplantation may become an important procedure for functional restoration of upper limbs. However, the ethical aspects of using chronic immunosuppression for a condition which is not life threatening have been the subject of debate. In this article, we review the field of composite tissue allotransplantation.

Past, present, and future research in the field of composite tissue allotransplantation.

In September 1998, a surgical team in Lyon, France, performed the first successful hand transplant. After this historic event, in January 1999, the University of Louisville performed the first hand transplant in the United States. These events sparked interest and debate concerning the justification of performing limb allotransplantation. The field of composite tissue allotransplantation (CTA) has made significant advances in the past two decades, yet advancement of the applications of CTA into the clinical arena had been fairly limited to this point. The most inherent controversy in CTA involves the fact that the clinical applications for the most part involve restoration of function and/or structural integrity. These procedures are done essentially for quality-of-life concerns, not life-saving issues. Present concern involves subjecting CTA recipients to a lifetime of postoperative immunosuppressive therapy. We cannot fully understand where we stand at present and in what future directions the field is heading unless we have an understanding of where we have been in composite tissue transplantation. This article reviews the historical aspects of CTA, discusses the present state of CTA, and speculates on potential future applications of CTA.