Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

748
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
bilateral motor- and sensory-nerve branches and neck
vessels of the recipient in preparation for the arrival of the
graft. All residual functioning portions of the recipients’
faces were preserved, allowing them to return to their pre-
transplantation level of function in the event of transplant
failure. All branches of the facial and trigeminal nerves
were anastomosed unless they were not present due to
injury.
All patients received our standard immunosuppressive
regimen, which included mycophenolate mofetil, methyl­
prednisolone, and antithymocyte globulin (ATG), before
allograft reperfusion. Maintenance immunosuppression in
all cases consisted of mycophenolate mofetil, tacrolimus,
and prednisone taper. Each of the patients received periop­
erative antibacterial prophylaxis with vancomycin and
cefazolin, as well as trimethoprim–sulfamethoxazole and
valganciclovir for prophylaxis against Pneumocystis jiroveci
and cytomegalovirus, respectively.
Unfortunately, in each of the above cases, the patients
had a postoperative infection of differing severity, from
which they all recovered. Additionally, two of the patients
experienced episodes of acute rejection, which was success­
fully managed. In the first two cases, a sentinel flap was
implanted and used as an alternative site by which to
monitor for rejection. In our patients who have undergone
transplantation and demonstrated evidence of rejection, we
have observed that the sentinel flap indicated rejection
more accurately than the facial allograft because it was less
prone to confounding facial-skin conditions. For instance,
the facial allograft may show erythema and local inflamma­
tion from environmental exposure or from conditions such
as rosacea or dermatitis.
As demonstrated by these cases, severe facial deformities
resulting from various injuries can be treated safely with
facial transplantation via the use of a consistent, complex
protocol. Despite important adverse events and a short
follow-up, these cases provide further evidence that full-face
transplantation is able to restore functional defects and to
resurface major deficits.
FUTURE DIRECTIONS
Conventional reconstructive techniques have been largely
inadequate to restore the facial aesthetics and function in
the most severely injured patients. Results from reconstruct­
ing such complex structures as the nose, lips, and eyelids
have been largely disappointing. As a result, the prospect of
improving the treatment of catastrophic facial injuries has
motivated plastic surgeons to further develop the field of
facial transplantation.
At the time of writing, facial transplantation is a techni­
cally feasible procedure. Its indications continue to grow,
expand, and change with each transplant performed and as
more candidates around the world are considered for the
procedure. As longer-term data become available on this
procedure, one of the upcoming challenges to this field will
be refining the indications for performing facial transplan­
tation. Questions surrounding the use of facial transplanta­
tion in children or in patients with systemic medical illness
will need to be addressed once the safety profile of the
procedure is better defined.
outcomes.4,5 In addition to the patient’s report on cosmetic
outcomes, both surgical teams and panels of reviewers have
demonstrated improvements on subjective scores.2
SOCIAL OUTCOMES
In addition to changing the lives of individual patients who
receive the transplant, facial VCA has implications on society
as a whole. While facial appearance is dramatically improved
after facial transplantation, successful societal reintegration
is largely dependent on the patient’s commitment. For this
reason, the social outcomes of facial transplantation are
highly linked to the preoperative selection of appropriate,
well-informed patients as well as continued postoperative
psychiatric counseling. To date, all facial transplantation
patients have accepted their new faces and have had a noted
improvement in self-esteem and self-appearance.2 Further­
more, all patients have been able to integrate themselves
back into their previous lives to varying degrees.2 There is a
report of one patient even returning to work 1 year after
the operation.5
As facial transplantation becomes more common in
society, questions of cost-effectiveness will arise. This is
largely due to the fact that society, rather than these indi­
vidual patients, bears the cost of the transplant procedure,
revisions, subsequent hospitalizations for rejection, and
chronic immunosuppressive medications. Major questions
surrounding the role of society in this procedure have yet
to be answered. To what extent should society finance “elec­
tive” facial transplantation procedures in patients with
defects caused by self-destructive etiologies? Are multiple
reconstructive surgeries and lifelong disfigurement more or
less affordable than early facial transplantation with chronic
immunosuppression? The answers to these and other similar
questions that affect all members of society will require
further investigation, debate, and understanding.
DISCUSSION
All of the above patients provided written informed consent
to participate in our clinical trial for face transplantation, as
approved by the human research committee at Brigham and
Women’s Hospital and by the Army Medical Research and
Materiel Command Human Research Protection Office
after a complete and thorough evaluation by our multidis­
ciplinary team before participation. With substantial input
from an ethicist, there was extensive discussion with each of
three patients, of the indications, risks, and benefits, before
treatment with facial transplantation to enhance function
and appearance.
The surgeons on our transplant team were divided into
teams with specific objectives during the operations. In
each case, one team performed facial allograft recovery that
isolated all major motor and sensory nerves and arterial
and venous components, while at the same time another
team recovered radial forearm flaps to act as sentinel tissue
from the donors for patients one and two. In the third case,
two teams recovered the upper limbs instead from the
donor for patient three. All recovered allografts were per­
fused with University of Wisconsin solution and transported
in an ice-water slurry. Synchronously, another team removed
the skin, contoured the facial tissue remnants, and isolated

CHAPTER 64 — Face Transplantation
749
The visibility of the face transplant skin may contribute to
our ability to detect and treat rejections early. This is a major
advantage compared with solid organ transplantation, where
rejections are often diagnosed late, and are harder to manage.
Work aimed at identifying molecular markers that herald
rejection is ongoing. Should facial transplantation research­
ers identify such markers, this may help mitigate or entirely
avoid episodes of rejection and this may also contribute to
the management of solid organ transplant patients.
The largest remaining challenge to facial transplantation
is the mitigation of the side effects of immunosuppression.
Although important for all transplanted organs, this is of
particular interest when considering facial transplantation,
given that it is considered to be a non-lifesaving procedure
when compared with a solid organ transplant. Increasing
the safety profile (decreasing the toxicities) of immunosup­
pressive medications or perhaps even eliminating the need
for such medications altogether via immune tolerance, will
be the main objective in the coming years for facial trans­
plantation researchers.
Below are several case examples from our institution’s
experience with facial transplantation, which highlight
some of the key features of the procedure and demonstrate
its versatile application to reconstruct the faces of several
patients with a broad array of defects.
The first patient is a 25-year-old man who sustained severe elec-
trical burns over a large body surface area, including the face.
On examination, he was found to be missing nearly all the soft
tissues of the face, including the eyelids, left eye, nose, lips, teeth,
and a large portion of the temporoparietal scalp. His functional
limitations prior to transplantation included no facial expres-
sion, inability to close his mouth, impaired speech, and inability
to breathe through his nose. He received an allograft from a
48-year-old donor with a total ischemia time of 240 min. A radial
forearm graft was also taken from the donor to serve as a sentinel
flap and it was placed in the recipient’s inguinal area. The pro-
cedure took approximately 17 h and blood loss was estimated to
be between 3.0 and 4.0 L. The patient received a total of 23 units
of packed red blood cells, 13 units of fresh-frozen plasma, and
1 unit of platelets. He spent a total of 13 days in the hospital on
the plastic surgery service with four of those days spent in the
intensive care unit immediately after the procedure (Fig. 64.5).
The patient reported that his olfaction was restored on post-
operative day 3 and on day 8, secretion from a suture line grew
Candida albicans and Pseudomonas aeruginosa. Treatment with
micafungin and cefepime was initiated. On day 13, drainage
of a recurrent submental collection was identified as sterile
saliva. Botulinum toxin was ultimately injected into each of the
donor’s submandibular glands to decrease saliva production,
and fluconazole and amoxicillin–clavulanic acid were prescribed
for further antimicrobial treatment. The patient subsequently
underwent a secondary revision procedure on postoperative day
116 where redundant neck skin was partially resected. Since the
initial episode, the patient has only undergone one other episode
of rejection at 22 months post-transplant. The episode was not
resolved with initial pulse dose steroids and instead required 2
days of ATG, after which rapid improvement was noted. Ulti-
mately, this acute rejection resolved with slightly increased doses
of tacrolimus for maintenance.
Roughly 4 months after the procedure, sensation had returned
on the right side of the transplant, along with movement of
right-sided muscle groups and restoration of facial aesthetics. At
3 years post-transplant, the patient’s sensorimotor function con-
tinues to improve, as quantified by improvements in speech, oral
competence, and sensory discrimination over the allograft’s
area. Aesthetics also have continued to improve as muscle tone
is regained, and the patient had dental implants placed.
CASE 64.1  Severe Facial Deformity Resulting from a Burn Injury Reconstructed with Full
Face Allograft
Figure 64.5  (A) Preoperative and (B) postoperative photographs of the patient in Case 64.1.
A
B

750
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
The second patient is a 30-year-old male who also sustained large
body surface burns, which included his face. On presentation,
he was missing large areas of skin over the forehead and cheeks,
as well as his eyelids, soft tissue of the nose, and both upper and
lower lips. He was limited in that he had impaired speech, no
lip closure, no facial expression, and was unable to close his
mouth. He received a facial transplantation from a 31-year-old
donor with an ischemia time of only 120 min. Compared with
the first patient, only 0.5 L of blood was lost during the case and
he had minimal transfusion requirements, only receiving 2 units
of packed red cells. He spent a total of 4 days in the intensive
care unit and 10 total days hospitalized. A radial forearm sentinel
flap was taken from the donor and placed in the recipient’s right
hand (Fig. 64.6).
On postoperative day 4, the patient was found to be able to
talk, eat, and drink. Unfortunately on day 20, erythema and
increased swelling of the facial allograft and sentinel flap
prompted a diagnosis of acute rejection. This was confirmed
with biopsies of the face and sentinel flap and successfully
treated with several pulse doses of methylprednisolone. At about
4 months postoperatively, the patient had several episodes of
unexplained low-grade fever and was subsequently admitted for
polymicrobial bacteremia. The cause of this was believed to be
either his long-term peripherally inserted central catheter or a
periodontal infection. He was treated with vancomycin and levo-
floxacin, and two teeth were extracted before improvement. On
post-transplant month 17, the patient developed an erythema-
tous, papular, pruritic rash limited to the central face. The next
day, the rash spread to the forehead and cheeks with dryness and
scaling of the lips, and a similar rash appeared on the sentinel
flap. Acute rejection was diagnosed by biopsy and his tacrolimus
blood level was noted to be low. Treatment consisted of a meth-
ylprednisolone pulse, followed by a prednisone taper and an
increase in maintenance tacrolimus and mycophenolate mofetil
(MMF). Marked improvement was seen within the first 10 days
of treatment, though full resolution of symptoms was gradual, at
which point tacrolimus and MMF doses returned to baseline.
The patient did experience the return of sensation in the
forehead and chin and a return of gross lip motion, along with
restoration of facial aesthetics. At 3 years after transplant, his
motor and sensory function continues to improve, as quantified
by improvements in speech, oral competence, and sensation.
Additionally, his aesthetics also continued to improve as muscle
tone was regained. He has gone on to have dental implants
placed as well.
CASE 64.2  Severe Facial Deformity Resulting from a Burn Injury Reconstructed with a Full
Face Allograft
Figure 64.6  (A) Preoperative and (B) postoperative photographs of the patient in Case 64.2.
A
B

CHAPTER 64 — Face Transplantation
751
The third patient is a 57-year-old female who suffered significant
traumatic injuries to the face as the result of an animal attack.
On examination, she was missing both of her eyes, nose, eyelids,
lips, and maxilla, and had extensive facial scarring of the remain-
ing face. She was unable to breathe through her nose, unable to
form any facial expression and unable to speak or close her
mouth. She received not only a facial transplant but a bilateral
upper extremity transplant as well from a 42-year-old donor.
Accordingly, at close to 20 h, her case took longer to complete
than the prior patients. She was estimated to have lost 2.5–3.0 L
of blood and received blood transfusions of similar proportion
to the first case. In total, she received 20 units of packed red
cells, 16 units of fresh-frozen plasma, and no units of platelets.
She spent a total of 38 days in the hospital with 18 of them being
spent in the intensive care unit (Fig. 64.7).
On postoperative day 2, the patient suffered an aspiration
pneumonia, which was subsequently complicated by septic
shock. Despite the best efforts of the entire transplant team,
this caused irreversible ischemic changes and eventual thrombo-
sis of both transplanted upper limbs. Salvage attempts with
dobutamine, anticoagulation, and brachial plexus blocks, were
all attempted unsuccessfully but the upper-limb allografts were
ultimately removed on postoperative day 5. The patient did well
afterward until postoperative day 54, when erythema and swell-
ing of parts of the graft were noticed. This prompted a diagnosis
of acute rejection, confirmed on biopsy. The episode was suc-
cessfully treated with pulsed methylprednisolone at a dose of
500 mg/day for 3 days. Nearly 17 months post-transplant, she
developed a second episode of rejection, with swelling and ulcer-
ation along the oral mucosa. The episode was effectively treated
with a combination of dexamethasone oral rinse, topical tacro-
limus ointment, clobetasol gel, and transient increases in main-
tenance dose of tacrolimus, as well as MMF. Symptoms resolved
within 3 weeks and no systemic steroids were needed to treat this
rejection episode.
At 2 months post-procedure, the patient was able to breathe
through her nose and mouth and at 3 months postoperatively,
there was a return of sensation in the transplant, which contin-
ued to improve over the subsequent 3 years. She also demon-
strated further improvements in oral competence and speech.
CASE 64.3  Severe Facial Deformity Resulting from an Animal Attack Reconstructed with a
Full Face Allograft
Figure 64.7  (A) Preoperative and (B) postoperative photographs of the patient in Case 64.3.
A
B

752
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
11. Ibrahim S, Dawson DV, Sanfilippo F. Predominant infiltration of
rejecting human renal allografts with T cells expressing CD8 and
CD45RO. Transplantation 1995;59(5):724–8.
12. Fraser CJ, Scott Baker K. The management and outcome of chronic
graft-versus-host disease. Br J Haematol 2007;138(2):131–45.
13. Fangmann J, Dalchau R, Sawyer GJ, et al. T cell recognition of
donor major histocompatibility complex class I peptides during
allograft rejection. Eur J Immunol 1992;22(6):1525–30.
14. Simpson E. Minor transplantation antigens: mouse models for
human host-versus-graft, graft-versus-host and graft-versus-leukemia
reactions. Arch Immunol Ther Exp (Warsz) 1998;46(6):331–9.
15. Benichou G. Direct and indirect antigen recognition: the pathways
to allograft immune rejection. Front Biosci 1999;4:D476–80.
16. Splendiani G, Cipriani S, Tisone G, et al. Infectious complications
in renal transplant recipients. Transplant Proc 2005;37(6):2497–9.
17. Petruzzo P, Lanzetta M, Dubernard JM, et al. The international
registry on hand and composite tissue transplantation. Transplan­
tation 2008;86(4):487–92.
18. Vicari-Christensen M, Repper S, Basile S, et al. Tacrolimus: review
of pharmacokinetics, pharmacodynamics, and pharmacogenetics
to facilitate practitioners’ understanding and offer strategies for
educating patients and promoting adherence. Prog Transplant
2009;19(3):277–84.
19. Gonzalez-Ulloa M. Restoration of the face covering by means of
selected skin in regional aesthetic units. Br J Plast Surg 1956;9(3):
212–21.
20. Pomahac B, Lengele B, Ridgway EB, et al. Vascular considerations
in composite midfacial allotransplantation. Plast Reconstr Surg
2010;125(2):517–22.
Expert Commentary 
Samir Mardini MD and Hatem Amer MD
With the first face transplant in 2005 came significant excite-
ment as well as apprehension. Among the questions raised
were: Was it necessary? Would it work and last? What will the
complications be? Would it negatively impact deceased donor
consent rates? Fortunately the field continued cautiously and
despite the initial concerns and death of the second case per-
formed, a patient in China who discontinued his immunosup-
pressive medications, there are now more than 30 cases
performed worldwide.
Face transplantation epitomizes the concepts of multidisci-
plinary team based patient care, individualized medicine and
innovative patient centered practice. No two patients’ injuries
are identical. In each case a careful assessment of the needs
of the patient is made, various options explored, and if a face
transplant is deemed the best option surgically for the patient,
a careful medical assessment is necessary to determine sus-
ceptibility to immunosuppression as well as a thorough psy-
chosocial assessment. The latter cannot be over emphasized.
The surgical procedure is long, recovery is lengthy, and strict
adherence to a complex medical and rehabilitative regimen is
necessary. Many patients who would otherwise be suitable
surgical candidates may not be able to receive transplants due
to medical and psychosocial factors.
Though the current world experience is promising, it is dif-
ficult to accurately estimate complication rates and compare
outcomes between centers. This is due to the small number of
cases, the varied regimens employed, and the unique charac-
teristic of each patient’s injuries. Sharing experiences, full
transparency and facilitated reporting is essential to further
understand how best to offer face transplantation to persons
in need. Methods to accomplish this include: dedicated jour-
nals that allow publications of updates on each case performed,
though they may not be novel enough to allow publication
in less specialized journals; presentations at the biannual
meetings of the American Society of Reconstructive Surgery
(ASRT) and the International Society of Vascularized Composite
Allotransplantation (ISVCA); reporting to the International
Registry on Hand and Composite Tissue Transplantation; and
mandated reporting by the United Network for Organ Sharing
(UNOS).
Mitigating the possible complications is of paramount impor-
tance. This requires careful patient selection; and adequate
preparation by teams planning the procedure including the use
of virtual surgical planning and cutting and positioning guides
during the surgical procedure when bone is included (See
figure 63.1). Institutions allowing these procedures to occur
need to have all the necessary resources to support the recon-
structive surgeons and their team, and also have the various
options for reconstruction available so that a face transplant is
one of the options to be considered and not the only option.
The risks of immunosuppression are, correctly, touted as a
significant limitation of nonlife saving organ transplants. The
pursuit of reliable, safe, reproducible tolerance protocols in
solid organ transplantation is ongoing. Although face transplan-
tation may benefit the most from such regimens, developing
such regimens in face transplant recipients is difficult given the
dearth of cases and the implications of graft loss in this setting.
Face transplantation is a pioneering option for patients who
have no other options to regain a reasonable quality of life. It
has benefited from the experience gained in solid organ trans-
plants and will likely benefit those organs with the research
being conducted. With the first face transplant in 2005 it was
great to see plastic surgeons returning to to the home they
created fifty years prior when Dr. Joseph Murray performed the
first successful kidney transplant in 1954.
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3. Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: the
first 9 years. Lancet 2014;384(9960):2153–63.
4. Guo S, Han Y, Zhang X, et al. Human facial allotransplantation: a
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follow-up study. Lancet 2008;372(9639):639–45.
6. Siemionow M, Papay F, Alam D, et al. Near-total human face trans­
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7. O’Neill H, Godden D. Ethical issues of facial transplantation. Br J
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8. Whitaker IS, Duggan EM, Alloway RR, et al. Composite tissue allo­
transplantation: a review of relevant immunological issues for
plastic surgeons. J Plast Reconstr Aesthet Surg 2008;61(5):
481–92.
9. Siemionow MZ, Papay F, Djohan R, et al. First U.S. near-total
human face transplantation: a paradigm shift for massive complex
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10. Shimizu A, Colvin RB. Pathological features of antibody-mediated
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trauma in the major trauma outcome study. Plast Reconstr Surg
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22. Pushpakumar SB, Barker JH, Soni CV, et al. Clinical considerations
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casualties: an outcomes study of patients treated from April 2006
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754
globulin, ATG) or monoclonal (alemtuzumab or basilix­
imab) antibody induction therapy followed by high-dose
tacrolimus, mycophenolate mofetil (MMF), and steroids for
maintenance immunosuppression.4
The adverse effects and toxicities of these immunosup­
pressive agents include metabolic, infectious, and neoplastic
sequelae, and in extreme cases may contribute to patient
mortality. Specifically, the triple-drug regimens have resulted
in nephrotoxicity, hypertension, new-onset diabetes melli­
tus, hyperlipidemia, leukopenia, cardiovascular disease,
and bilateral hip osteonecrosis.5 Opportunistic infections
have also been observed, most commonly with cytomegalo­
virus (CMV), which can be potentially life-threatening
and can trigger acute rejection. This has led some centers
to avoid the high-risk combination of CMV-positive grafts
in CMV-negative recipients in upper extremity transplanta­
tion. Other encountered opportunistic infections include
human papillomavirus, herpes simplex, Staphylococcus aureus
osteitis, Clostridium difficile, molluscum contagiosum, and
mycoses. Malignancy is another common complication after
solid organ transplantation, with an incidence up to five-
fold higher in transplant recipients compared with the
general population. However, most hand and upper extrem­
ity transplant recipients have been followed for <10 years,
so it is difficult to assess the true risk and incidence faced
by these patients with regard to malignancy.
The risks associated with the long term, potentially life­
long usage of these drugs have prevented the widespread
application of VCA as a first-line reconstructive modality in
patients with complex tissue defects and limb loss. There­
fore, there is a critical need for novel protocols that will
allow patients to be weaned off immunosuppression or to
induce tolerance to their grafts.
Several centers around the world, including our own, have
attempted to develop novel, innovative therapeutic concepts
of immunoregulation to reduce systemic immunosuppres­
sion to minimal levels.6 Similarly, recent advances in cell-
based therapies and immunosuppressive drug development
that incorporate the unique elements and biology of vascu­
larized composite allografts have also shown favorable results
at achieving this goal.7 Clearly, the induction of donor-
specific tolerance would obviate the need for long-term
maintenance immunosuppression after extremity transplan­
tation, and great strides in this regard have currently been
made in translational large animal models.6,8,9 However,
until those strategies are implemented in the clinical arena,
Hand and Upper Extremity
Transplantation
Jaimie T. Shores  |  Gerald Brandacher  |  W.P. Andrew Lee
65 
INTRODUCTION
Hand and upper extremity transplantation is the most
common form of vascularized composite allotransplanta­
tion (VCA) or reconstructive transplantation and has
evolved from a procedure only performed at the distal
forearm level to a procedure now being performed above
the elbow more proximally.1 At the time of writing this
chapter, the authors can count 107 hand and upper limb
transplants performed throughout the world. The “modern
era” of hand transplantation was ushered in with the first
hand transplants performed with modern immunosuppres­
sive medications in 1998 in Lyon, France, and 1999 in Lou­
isville, KY.2 While both transplants were unilateral distal
forearm level transplants performed 4 months apart, the
Louisville transplant was the first to demonstrate long-term
success due to patient compliance. This emphasized patient-
centric factors, which are critical to the success of any kind
of transplant. Psychological and social factors are the most
important elements in long-term “graft” maintenance.3
Therefore, all successful upper extremity transplantation
begins with screening. Following screening, careful surgical
planning must be performed and precise execution of both
donor and recipient portions of the transplant operation
must be accomplished. Postoperative monitoring and
therapy are instituted and therapy may be required for
several years to come. Rejection episodes and complications
should be expected and anticipated. This chapter discusses
the key portions necessary for performing and maintaining
a successful upper limb allotransplant.
IMMUNOTHERAPY
Despite the fact that the clinical results and outcomes with
hand and upper extremity transplantation have been highly
encouraging, the requirement of life-long, high-dose, mul­
tidrug immunosuppression associated with a profound side-
effect profile still hampers broader application of these
life-changing reconstructive modalities. Currently, there is
no standard immunosuppressive regimen established for
extremity transplantation; however, most patients have been
treated with a “conventional” triple-drug immunosuppres­
sive strategy, largely extrapolated from solid organ trans­
plantation. This includes either polyclonal (antithymocyte
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
755
antibodies and sensitization, as well as further assessment
for infectious diseases known to complicate the immuno­
logical management and prognosis for rejection and malig­
nancy in the future such as CMV and EBV infection.3 It is
the authors’ practice that recipients who are seronegative
for antibodies, indicating no prior infection with these
viruses, should not receive transplants from CMV+ or EBV+
donors. All patients should include an evaluation by a trans­
plant infectious disease physician to screen for these and
other problems.
Surgical evaluation focuses on the function of the patient
with and without prostheses, and one should also consider
their prior participation in rehabilitation. Surgical planning
focuses on the level of amputation along with associated
hard and soft tissue deficits proximal to the amputation site,
which may either complicate a transplant or require recon­
struction before or during the transplant. Physical evalua­
tion for skin quality, joint range of motion, remaining motor
group strength, location of scars, location of Tinel’s sign
over nerve stumps, limb/stump length and circumference,
palpable pulses, wounds, heterotopic ossification, etc. should
be noted. Radiographic evaluation includes plain films of
both upper limbs and either conventional or computed
tomographic angiography, along with venous phase recon­
structions (Fig. 65.1). Venous mapping is also performed by
ultrasound with vein locations and diameters recorded. We
physically map the veins with a surgical marking pen and
then photograph the limbs for a permanent record of vein
location. MR neurography (Fig. 65.2) may be employed
when necessary to evaluate for location of nerve stumps or
possible traction/avulsion injury of peripheral nerves more
proximal than expected by location of amputation. The
authors perform this imaging on all patients capable of
having MR neurography performed if their mechanism of
injury/amputation allows for the possibility of stretch or
avulsion injury and/or an obvious Tinel’s sign that is repro­
ducible to the correct nerve sensory distribution cannot be
elicited in the vicinity of the amputation stump.
Once patients have been approved following close and
detailed screening, they may be enrolled into our IRB-
approved hand and upper extremity transplant program.
Patients will not be enrolled if they use any form of tobacco,
illegal substance, or cannot commit to staying at our institu­
tion for at least 3 months postoperatively or treating reha­
bilitation as their full-time job for the first 1–2 years after
transplantation.
PREOPERATIVE PLANNING
Each patient gets a reconstructive transplantation operative
plan specifically designed for their particular anatomic
needs. While many will have certain similarities, none are
exactly the same. Planning incorporates known factors such
as soft tissue coverage and skin quality, skeletal factors such
as limb length, joint condition, presence of heterotopic
ossification, vascular imaging, and possible nerve imaging,
as well as unknown factors such as the degree of muscle
versus scar present, quality of remaining muscle, potential
nerve quality and length, tendon length, potential for indo­
lent infection, etc. All surgical planning incorporates our
desire to protect the length of the patient’s limb if at all
possible, assuming the transplant were to fail. This means
we advocate for short-course depletional induction followed
by low-dose maintenance monotherapy to minimize toxici­
ties of conventional immunosuppression and maximize the
risk–benefit ratio for hand and upper extremity transplanta­
tion. Our group has recently successfully implemented such
a protocol for upper extremity transplantation with favor­
able functional and immunologic outcomes.7
INDICATIONS
The authors feel that upper extremity transplant is indi­
cated for individuals of adequate social, psychological,
medical, and immunologic health who have unilateral or
bilateral hand/upper limb loss that has resulted in signifi­
cant functional and/or psychological disability, when a sub­
stantial enough improvement (based on the level of
transplantation and expected functional recovery) can be
anticipated that ethically weighing the balance of risks and
benefits favors transplantation. We hesitate to create specific
indications such as only bilateral amputees or bilateral or
dominant hand unilateral amputees only, because this does
not incorporate the global assessment of function and
potential benefit that a patient may experience through a
thoughtful application of reconstructive transplantation.3
The authors apply this philosophy also through their cell-
based, nonsteroid, monotherapy, immunoregulatory proto­
col, as indicated above.7 However, many centers worldwide,
using traditional immunosuppression do consider only
bilateral amputees or unilateral amputees of dominant
hands only, and exclude nondominant unilateral amputees
and above elbow amputees.
PREOPERATIVE CONSIDERATIONS
PATIENT SCREENING
The importance of screening cannot be emphasized
enough.3 Screening includes evaluations of the patient’s
psychological and social problems, tools, weaknesses, and
strengths. Some patients are hand transplant candidates
due to “bad luck” or circumstances out of their control. But
some are missing limbs due to poor decision-making that
may have been a single episode of lack of judgment, or a
long-standing pattern of bad choices. One must consider if
a pattern of bad choices will change because of a hand trans­
plant. The single best predictor of transplant medication
compliance by a patient is the presence of stable and caring
family/friends actively engaged within the patient’s life.10
Further screening involves evaluation of the patient medi­
cally to see if they are healthy enough to undergo a long
and physiologically taxing procedure and the immunother­
apy regimen to follow without substantially worse risks for
problems such as malignancy, renal disease, heart disease,
pulmonary disease, infection, ocular disease, dental disease,
etc. Many patients may have added risk for infection due to
their initial disease process causing limb loss. Our liver
transplant anesthesia providers also evaluate the patient for
possible line placement and anesthesia risk/concerns.3
Immunological screening involves blood and HLA typing,
assessment for pre-formed donor-specific (DSA) or HLA

756
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
with the correct surgical sequence used and the plan is
continually refined until all group members are satisfied.
TEAM ASSIGNMENTS
Surgeons are assigned by name to specific teams and tasks,
both incorporating their clinical strengths as well as their
ability to work with individual team members. Usually we
use a plastic surgery hand surgeon and an orthopedic
surgery hand surgeon on each three-member team, with the
additional member being either another hand surgeon, a
microvascular plastic surgeon, or hand surgery/microsurgery
fellow. This balance of team members ensures that appro­
priate soft tissue and hard tissue techniques and care will be
provided. Osteosyntheses are performed by hand surgeons
of either specialty, as long as they have the appropriate
expertise.
preserving a proximal forearm stump with muscle coverage
while still transplanting adequate forearm motors to make
a forearm-hand transplant functional, for example. Conver­
sion of a below elbow to above elbow prosthesis user would
be a devastating complication for a patient who suffers a
transplant loss. However, for a patient with significant elbow
pathology already, replacing this joint with a transplant may
actually allow for better ultimate function and may be a
consideration.
CADAVER REHEARSAL
Surgical plans are discussed in classroom format with group
input and then any remaining questions are worked out as
a group in the cadaver anatomy laboratory. Once the various
components of the surgical plan have been discussed and
worked through, another cadaver rehearsal is performed
Figure 65.1  (A,B) CT angiography of bilateral upper extremity amputee with shrapnel present demonstrating patency and course of the bilateral
brachial arteries with premature termination of both brachial arteries approximately 5 cm proximal to level of amputation.
A
B
Figure 65.2  MR neurography demonstrating peripheral nerve end neuroma location and length being much more proximal than the level of
amputation. (A) Ulnar nerve; (B) radial nerve; (C) median nerve.
A
B
C

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
757
of cold ischemia (ice on the operating table) until the
clamps on the reconstructed artery are released for reperfu­
sion. We typically perform as much muscle, tendon, and
nerve reconstruction as possible while in a bloodless field
due to the preciseness and rapidity with which these can be
performed in this manner compared with the bloody field
of a reperfused transplant. If ischemia time was approach­
ing 7 or 8 h prior to beginning our transplant, however, we
would not hesitate to alter the sequence of events or even
temporarily shunt the graft to allow for some perfusion
prior to continuing with the transplant.
SURGICAL TECHNIQUE
Surgical technique is dependent on the level of
transplantation.11–14 Technique is essentially the same for
bilateral and unilateral transplants except for a need for
enhanced communication between both surgical teams
and the anesthesiology team in regards to blood loss and
reperfusion.15
DONOR OPERATION
Procurements are coordinated by the regional organ pro­
curement organization (OPO) and will likely involve teams
for procurement of abdominal and thoracic organs.16 Prior­
ity of course, is given to maintaining the viability of life-
saving organs during the procurement, so any process that
has significant potential to endanger them will be termi­
nated by the OPO coordinator.16 The upper extremity pro­
curement level depends on the specific donation. For distal
forearm and mid-forearm transplants, an elbow disarticula­
tion is usually adequate in providing soft tissue, vessel
length, nerve length, and extra skin/bone for grafting as
needed (Fig. 65.3). For distal transhumeral transplants, we
recommend a proximal humeral procurement at the highest
level that tourniquet control can be still be maintained.14
The authors have used a thin, non-pneumatic tourniquet
(HemaClear, OHK Medical Devices, Inc, Grandville, MI)
placed as high on the arm as possible over the deltoid with
the tourniquet fixed to the skin with penetrating clamps to
help prevent slippage (Fig. 65.4). For middle or proximal
arm procurements, control may be required via intratho­
racic cannulation and control of the subclavian vessels by
the thoracic procurement team.
Microsurgery (nerve and vascular) is performed by the
plastic surgery hand surgeons, plastic surgery microsur­
geons, or orthopedic hand surgeons who have adequate
training and experience in microsurgery.
ROTATING SURGEONS
In an effort to prevent surgeon fatigue, surgeons are able
to rotate in and out of the operation in teams once the
osteosynthesis begins as the two teams per limb transplanted
reduce to one team. Thus, half the previously operating
members may break and further team members who may
not have yet operated can also be used to help relieve sur­
geons. Typically, the microsurgery team is a different group
than the team performing the osteosynthesis and tendon/
muscle repairs. The microsurgery team may also rotate in/
out individual members as the hours pass, as every vein
capable of coaptation is usually anastomosed resulting in an
artery to vein ratio of 2 or 3 : 1.
USE OR REPLACE EXISTING MOTORS
For many amputees in the middle third of the forearm and
brachium, the decision to use the already present muscles
to power the transplant or replace the existing muscles must
be made. The authors are unaware of any current guidelines
to help direct this decision. The surgeon must decide if the
motors present have adequate length, and cross-sectional
area, and if they themselves have sustained intrinsic damage
that may result in loss of excursion or strength, such as
fibrosis, based on their physical assessment of the patient
and the mechanism of limb loss. It is likely that blast injuries
and ischemic injuries may compromise surviving muscle
and limit its ability to provide excursion or power. However,
replacing these already innervated motors will result in
some loss of motor axon count providing innervation and
allows for “mistakes” in reinnervation, such as synkinesis,
loss of specificity, or failure to reinnervate. In the authors’
limited experience, we currently prefer to replace question­
able forearm motors if half or more of the muscle-tendon
unit length is considered compromised or missing. Even less
experience is present to guide transhumeral transplants.
However, based on our unpublished anatomic research,
even up to the junction of the proximal and middle thirds,
enough new elbow flexor and extensor motor units are
being transferred so that this may be considered an inner­
vated muscle transfer as well. For transplants at the mid-
brachium to distal third, our experience is that adequate
elbow strength is obtainable using the recipient’s own
motors if those muscles are otherwise uncompromised.
ISCHEMIA TIME
The authors are unaware of any clinical studies demonstrat­
ing the critical tolerable cold ischemia time of preservation
solution – infused allograft limbs. Cold ischemia times have
approached 11–12 h in our own experience without known
sequelae. This is a theoretically larger concern in allografts
containing more skeletal muscle such as transhumeral or
proximal forearm transplants, than distal forearm trans­
plants. We have performed small incision forearm fascioto­
mies and carpal tunnel release on a single transhumeral
transplant and did not perform these measures on a second
transhumeral transplant without attributable difference in
outcome. At this time, our algorithm requires maintenance
Figure 65.3  Donor limb procurement for distal or middle forearm
level transplantation by elbow disarticulation.

758
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
region overlying the deltoid muscle with penetrating clamps.
This tourniquet will be left inflated and/or in place until all
organ procurements have been completed. A guillotine
incision is outlined and the medial/volar component
created first with dissection down through the nerves to the
brachial artery/veins. Any divided nerves are tagged if there
is potential for any later question of identity. The brachial
artery is isolated. It is ligated proximally and distal control
is obtained. The largest catheter possible is used to cannu­
late the artery and this is secured with suture. The veins are
clipped or ligated proximally and cut distally. The proce­
dure then proceeds rapidly from medial/anterior to lateral/
posterior dividing muscle with cautery and either disarticu­
lating the elbow or performing an osteotomy with a power
saw through the humerus. Once the limb is completely
detached, it is immediately taken to the back-table, where
perfusion solution is instilled (Fig. 65.6). The solution is
instilled until at least 500 mL have been infused or all efflu­
ent is clear. Typically perfusion volume ranges between
500 mL and 1000 mL. Note is made of which venous system
the dominant drainage of infusion is coming from (brachial
veins vs superficial veins), as this system will be critical for
outflow, though in reality every single vein capable of anastomo­
sis should be anastomosed. The arm is then wrapped in moist
gauze and placed in standard sterile triple bag containment
identical to that of solid organ transplantation, placed on
ice, and secured in a cooler.
For limb procurements performed prior to organ pro­
curement, the operation will usually begin with all surgeons
prepping and draping together with the arms on a hand
surgery table identical to the operation described before.
The abdominal and thoracic viscera teams will open the
chest and abdomen, prepare and cannulate the vessels to
the organs for procurement, but then stop. At this point
they step back and the upper limb procurement team per­
forms the operation described above. Once completed, all
tourniquets are left in place and the chest and abdominal
procurement teams then step back in and continue their
standard operation.
Once all procurement teams have completed their opera­
tions and there is no longer any perfusion within the donor,
a remaining party from the procurement team will remove
the tourniquets and close the skin of the arm stumps. The
Figure 65.4  (A) Cadaver lab rehearsal for donation demonstrating
the high non-pneumatic tourniquet placement for proximal trans­
humeral procurement. (B) Actual procurement utilizing high place­
ment of non-pneumatic tourniquet with clamps holding tourniquet in
position during and after completion.
A
B
Figure 65.5  (A) Bilateral hand transplant patient during initial simultaneous prepping and draping. (B) After completion of simultaneous prep­
ping and initiation of limb procurement.
A
B
A
Depending on the level or procurement and ability of all
teams to work together, upper extremity procurement may
occur concurrent to standard organ procurement, before
actual procurement, or after procurement. We recommend
procuring prior to or during visceral procurement to keep
ischemia times short.
For concurrent procurements, the arm(s) are on a hand
surgery table 90° to the operating table. All surgical teams
simultaneously prep and drape with full exposure of the
arm to the axilla (Fig. 65.5). A tourniquet is inflated after
minimal exsanguination, or in the case of proximal upper
arm procurement, a non-pneumatic tourniquet is placed,
which is self-exsanguinating and secured to the arm in the

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
759
used for the donor limb operating tables. Adequate surgical
lighting should be available by supplementing existing
room lights with portable lights and headlights as needed.11,12
DISSECTIONS
The donor limb dissection is performed with the limb
staying cooled on sterile ice with towels as an interface to
prevent cutaneous cold-induced injury. It begins with stan­
dard incisions made 90° to the incisions used on the recipi­
ent (volar-dorsal incisions to create radial and ulnar skin
flaps vs radial-ulnar incisions to create volar and dorsal skin
flaps) to ensure Z-plasty such as interdigitation postopera­
tively. All structures are elevated and tagged (Fig. 65.9). A
standard surgical marking pen is likely to have its lettering
washed off the tag over time, so a sterile permanent marker
is recommended. The authors typically use cut-up pieces of
Esmarch bandage for the tags, which are anchored via
sutures. Superficial veins are also tagged. Nerves, arteries,
and deep veins are tagged and kept as long as possible. Any
potential areas of nerve compression are decompressed
(carpal tunnel, cubital tunnel). It is very important to limit
the amount of dissection around the arteries to the minimum
necessary and to limit the number of perforators divided
to the cutaneous flaps as well. Small and microclips are
Figure 65.6  Infusion of perfusion solution on back-table with drain­
age of blood and solution from open superficial and deep veins.
Figure 65.7  Venous mapping of recipient limb on-table.
Figure 65.8  The OR set-up for bilateral recipient operation.
Back-table
(recipient)
Back-table
(recipient)
Donor
A
A
A
A
S
S
S
S
S
S
S
S
Donor
Donor
Donor
donor is then fitted with a prosthetic hand with variable
length sleeve, which will attach to the stump of the ampu­
tated limb.
ANESTHESIA CONSIDERATIONS
The authors have found preoperative placement of periph­
eral nerve catheters for postoperative pain management
and theoretical benefit of chemosympathectomy to be
helpful.14 A key point is to not dose the pain catheters with
a long-acting agent prior to surgery. Surgical stimulation at
the operative site may be necessary to maintain the patients
at a normotensive level without undue amounts of crystal­
loid support, which can contribute toward coagulopathy.
Central venous lines and an arterial line are placed prior to
beginning surgery. The immunological induction agent is
given at this time. The ultrasound machine used by the
anesthesiology group for peripheral nerve catheter and vas­
cular access catheter placement is then used by the surgical
team to map peripheral veins on the recipient limb.12 These
are marked with a permanent marker (as opposed to a surgi­
cal marker, which washes off too easily) to locate veins
during the operation (Fig. 65.7).
OPERATING ROOM SET-UP
Each side receiving a transplant has a recipient surgical
team and a donor surgical team, each with its own surgical
technician and set of instruments. Each team may have 2–3
surgeons per team, resulting in 4–6 surgeons per side. For a
bilateral transplant, this translates to 8–12 surgeons in addi­
tion to four surgical technician assistants, sets of instru­
ments, instrument tables, and operative tables (Fig. 65.8).
Thus, the largest operating room available is necessary to
perform a bilateral operation. Free moving back-tables are

760
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
beware of development of rotational deformities that may
be created if the same amount of rotation or pronation/
supination is not used for both osteotomies and osteosyn­
thesis. One should not expect the diameters of the donor
and recipient bones to perfectly match, and so single plate
fixation aligning one or two cortical surfaces only per bone
is obtained. We prefer rigid locking compression plate fixa­
tion. Additional bone graft from the donor is always avail­
able for morselized bone graft if supplementation is needed
at the compressed osteosynthesis site due to size mismatch
or imperfect match of osteotomy angle. Sterile ice is main­
tained in a protected fashion around the donor limb even
after this osteosynthesis to maintain cold ischemia.
MUSCLE/TENDON RECONSTRUCTION
Once the osteotomy is complete, as many as possible, if not
all, deep tendon/muscle units are reconstructed prior to
revascularization. Tendon weave constructs are preferable
to end-to-end repairs when possible, as they are stronger
and allow immediate motion therapy protocols. If ischemia
time has remained low (<6 h), completion of all tendon/
muscle unit reconstruction that does not obscure nerve or
vascular reconstruction should be performed. The authors
favor completing extensor reconstruction first followed by
flexor reconstruction. If end-to-end reconstructions are per­
formed, supplementation for strength by suturing down
fascial overlays or weaving a free tendon or fascial graft
between the two structures may confer added strength. If
ischemia time is long, extensor tendon reconstruction fol­
lowed by revascularization and then flexor tendon recon­
struction should be considered (Fig. 65.10).
NERVE RECONSTRUCTION
If ischemia time allows, nerve reconstruction may be per­
formed more easily in a bloodless field. The most distal yet
tension-free site of nerve coaptation possible should be
chosen to place regenerating axonal growth cones close to
preferable to bipolar cautery. Careful dissection is necessary,
since there is no blood in the vascular tree present. This
gives the surgeon a false sense of security during dissection,
and, if adequate clipping of small vessels is not accom­
plished, this will result in substantial amounts of bleeding
after reperfusion. Any obviously unnecessary tissue can be
trimmed from the specimen, though we are very conserva­
tive here, as the opportunity to remove excess tissue will
always be available. The bones are exposed and pre-plating
with the preselected hardware is performed (Fig. 65.9). This
is accomplished with a few pilot holes and screws placed to
adapt the plate to the correct location and ensure the oste­
otomy can be performed in the correct location.
Simultaneously, the recipient site dissection is ongoing
using skin flaps/incisions perpendicular to those used on
the donor. A sterile tourniquet is used for hemostasis during
the dissection. This portion of the operation can be difficult
as the amount of scar can make identification of normal
structures difficult. Structures are tagged as discussed on the
donor limb. Similar considerations are made to sparing
length on all structures. The bone, nerve, and vessels are
resected back to the longest possible length of healthy
undamaged tissue. Once this process has been completed,
microvascular clamps are placed across all open vessels and
the tourniquet is removed. An ACE bandage or other con­
strictive dressing is placed around the limb for hemostasis
while awaiting completion of the donor limb dissection.
OSTEOSYNTHESIS
After careful discussion between donor and recipient site
teams, the osteotomies are performed. Discussion should
ensure the most accurate match of limb lengths possible
comparing both limbs to one another and considering what
the surgeons believe to be “normal” for the patient’s height.
Measuring directly from bony landmarks and verifying these
measurements on preoperative X-rays of the donor limb
and recipient limb are helpful. Avoid measuring distances
through a mobile soft tissue envelope, as this leads to error.
Once the osteotomy is completed, the plate may be reat­
tached to the donor limb on the back-table through the
predrilled holes if considered favorable for osteosynthesis
(e.g., distal forearm level transplants). Surgeons should
Figure 65.9  Back-table preparation of donor limb complete with
distal radius plate attached.
Figure 65.10  Reperfusion in progress after release of arterial clamps
with warm water irrigation after extensor tendon reconstruction but
prior to flexor tendon reconstruction. The authors now repair all pos­
sible structures that will not interfere with vascular reconstruction
prior to reperfusion.

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
761
irrigated with warm saline and visible signs of perfusion are
observed extending all the way into the fingertips over the
next several minutes (Fig. 65.10).
Microvascular clamps are kept distal to the coaptation of
any already completed venous anastomoses to force venous
return out through open veins. Dark red blood is collected
as previously discussed. After a few minutes, the blood
becomes brighter red and at this time, we remove the venous
microvascular clamps and allow venous egress intravascu­
larly. The remaining open veins are then coupled or hand
sewn. Every vein capable of being anastomosed is coupled
or hand sewn. The final vein to artery ratio is typically 2 or
3 : 1. In our experience, the microvascular surgery is the
most time-consuming and difficult part of the operation,
with special emphasis placed on correctly orienting veins
and arteries by linear vector and tension around the elbow,
and finding adequate numbers of veins. The authors prefer
to place an implantable venous Doppler probe on a vein felt
to have significant flow within the limb for postoperative
monitoring immediately before skin closure.
SKIN CLOSURE
Any remaining structures (muscles, tendons, nerves) that
have not yet been joined have their reconstruction com­
pleted. The wounds are thoroughly irrigated and closure is
performed over two or more closed suction drains. Skin
flaps are interdigitated for a loose closure (Fig. 65.12). Esti­
mation of retrograde perfusion in the donor skin flaps can
sometimes be difficult. For this reason, recipient skin flaps
should never be debrided or shortened until final closure
is being performed. Skin grafts from leftover donor limb
may be plentiful and can be used if necessary for skin
closure, though full-thickness flaps are always preferred. A
combination of deep absorbable interrupted sutures and
their end organ targets. Nerve transfers to enhance motor
recovery may be considered but the authors have not yet
utilized this technique. The surgeon’s preferred method of
nerve coaptation should be utilized. The authors favor
nerve coaptations using the fewest number of microsutures
possible, supplemented by fibrin blue. We have also used
nerve wraps around coaptation sites.
REVASCULARIZATION
Revascularization is performed after as many structures that
can be repaired in a bloodless field are completed before
ischemia time becomes too prolonged. In reality, the safe
amount of ischemia time for such operations is not cur­
rently known. In practice, we prefer to begin vascular recon­
struction after no more than 7–8 h of cold ischemia have
elapsed. Arterial reconstruction is performed and all avail­
able vena comitans and deep and superficial veins that are
considered capable of anastomosis are hand sewn or
coupled. Typically, a few vena comitans or deep veins
and most superficial veins are left open until after reperfu­
sion has been performed to allow efflux of the initially
perfusing blood and leftover perfusion solution to occur
outside the vascular tree. This is collected in a basin and
recycled using an autotransfusion device that suctions,
filters, and rinses the effluent and prepares it for transfusion
if necessary (Fig. 65.11).
Immediately prior to releasing the clamp from the anas­
tomosed artery to initiate reperfusion, the ice is removed
from the field and warm irrigation is readied. The anesthe­
sia team should recognize that blood transfusions should be
hanging and infusing as both blood loss and an increase in
intravascular space are both about to occur. A single dose
of intravenous steroids is provided prior to reperfusion
to help mitigate ischemia reperfusion injury. We do not
routinely bolus with heparin for reperfusion. The limb is
Figure 65.11  Transhumeral shunted replant of author (J.T.S.) dem­
onstrating the collection of blood allowed to egress after reperfusion
rather than return into systemic circulation. This blood is collected in
a basin and then suctioned into a filtration device that prepares the
blood for autotransfusion back into the patient if necessary.
Figure 65.12  (A,B) Left proximal forearm transplant after closure
with skin flap interdigitation.
A
B

762
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
PROXIMAL FOREARM (see Case 65.2, left
forearm)
Radial and ulnar donor skin flaps are created and the recipi­
ent skin flaps are anterior/posterior to maintain excellent
innervated coverage of the olecranon and antecubital fossa.
Maintenance of all recipient muscle covering the proximal
forearm stump is a priority in regard to possible salvage if a
transplant were to fail. Maintaining bony length is also a
priority to enable adequate prosthetic fitting. However, the
proximal forearm motors will be inadequate to power the
transplanted hand and forearm. This is dealt with by elevat­
ing a flexor-pronator and extensor origin sleeve off of the
donor medial and lateral epicondyles and proximal radius/
ulna containing periosteum and any ligamentous soft tissue
firmly adherent to the muscle mass for later suture anchor­
ing.17 Care is taken to avoid injury to the posterior interos­
seus nerve as it traverses the supinator. This sleeve is elevated
through a dorsal incision on the subcutaneous border of
the ulna providing exposure for radius and ulnar fixation
dorsally. The sleeve is circumferentially elevated back to the
point of the donor osteotomies and then no farther on the
volar side. The dorsal incision allows for further exposure
only as required to obtain adequate plate fixation. Osteo­
synthesis with rigid forearm plates is used dorsally on the
ulna first, then radius for stabilization. The authors prefer
an ulnar shortening osteotomy plate for the ulna to achieve
excellent compression, then use a 3.5 mm stainless steel
metaphyseal plate on the radius.13 The radial nerve and its
individual branches of PIN, brachioradialis, ECRL, ECRB,
and the SRN may be identified in the donor and recipient.
These branches in the recipient are divided and tagged to
the ECRB, PIN, and SRN. The median nerve is divided in
the recipient at the level of its first motor branch to the
pronator teres. The ulnar nerve is divided within the FCU
substance just distal to the first motor branch.
Once the osteosynthesis is performed, the donor flexor-
pronator mass and extensor mass are draped over the same
muscles of the recipient. Two large bone anchors are placed
into each of the medial and lateral epicondyle. These are
used to suture down the origins and their attached ligamen­
tous and periosteal tissues. Further sutures are then used to
suture the donor origins directly to the recipient muscle
masses. The nerves are transferred as distal as possible to
the donor nerves (which will be just proximal to where they
were transected in the donor).
The brachial artery at the elbow is then reconstructed.
The tendency to leave significant laxity in the brachial artery
should be resisted, as it will kink during elbow flexion and
thrombose on-table. In an effort to maintain the most ideal
perfusion to the recipient radius and ulna and muscle mass,
we prefer to anastomose the proximal end of the donor
brachial artery into the side of the recipient brachial artery
to maintain stump perfusion. Venous reconstruction is per­
formed end-to-end. Skin flaps are closed after trimming and
interdigitation.
TRANSHUMERAL (see Cases 65.1 and 65.2, right
upper limbs)
Skin flaps should be designed that allow for no extension
of incision over the olecranon. If this can be done with
skin sutures or skin staples is used. Sterile pulse-oximetry
probes are placed on the thumb or index and the small
finger with comparison of readings and waveforms. This will
also be used for postoperative monitoring.
DRESSINGS
Sterile petrolatum gauze strips are used to cover the inci­
sions and fluffy sterile gauze is used to wrap the limb in a
nonconstrictive manner. Depending on the level of trans­
plant, a single plaster slab splint is placed to support any
joints requiring support or immobilization in the preferred
position. A circumferential cast should not be used as the
limbs will swell over the coming hours to days.
The patient may then be taken to the transplant or surgi­
cal intensive care unit for close monitoring. Extubation may
occur in the OR or the ICU, depending on the needs of the
patient.
TRANSPLANT LEVEL, SPECIFIC
TECHNIQUES
The authors have published techniques for proximal
forearm level and transhumeral level transplants.11–14
DISTAL FOREARM (see Case 65.1, left hand)
Radial and ulnar skin flaps are elevated on the donor limb
extending into a carpal tunnel release incision providing
excellent access to all flexor tendons, nerves, and vessels.
The dorsal incision need not cross the wrist. Skin flap per­
forators from the radial and ulnar artery are maintained
(Fig. 65.13). The recipient has anterior and posterior skin
flaps elevated down to fascia. Bony stabilization is performed
using volar locking volar radius and ulnar plate fixation.
Tendon/muscle repair using tendon weave technique is
performed whenever possible. Typically the extensors are
connected first followed by flexors with tensioning to
re-create a natural cascade. Radial, ulnar, and anterior inter­
osseus (if adequately sized) vascular reconstructions are
performed. Patients with a carpal remnant may be able to
undergo fascicular repair to median recurrent motor
branch, ulnar deep motor branch, and possible sensory
specific nerve repairs (Fig. 65.14). More proximal amputa­
tion levels may require group fascicular or epineural repairs
versus entubulation.
MIDDLE FOREARM
Radial and ulnar skin flaps are elevated on the donor with
volar extension into a carpal tunnel release. The dorsal inci­
sion does not need to cross the wrist. The recipient has volar
and dorsal skin flaps elevated down to fascia. Perforators in
donor skin flaps are spared at all costs. Bony stabilization is
performed using 3.5 mm locking compression plates.
Muscle-to-muscle repairs are performed and reinforced
with overlaid or woven fascial grafts or tendon grafts
when possible. Radial, ulnar, and anterior interosseus
(if adequately sized) vascular reconstructions are per­
formed. Epineural repair or nerve entubulation is per­
formed for neurorrhaphies.

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
763
steel metaphyseal plate is used with 3.5 mm screws distally
and 4.5 mm screws proximally. This plate has been stout
enough, in our experience, to avoid the need for “90-90”
plating or medial and lateral column plating, which is not
ideal considering the soft tissue exposure necessary and the
fact that the probability is low that the two humeri will be
exactly the same to allow perfect alignment of both columns
simultaneously.14 Muscle and fascia repairs of the triceps are
medial and lateral skin flaps on the donor limb, then this
provides anterior and posterior skin flaps on the recipient
with the ability to extend the medial incision for more pro­
ximal vascular and median/ulnar nerve access as needed
(Fig. 65.15). It also provides adequate anterolateral access
for bony fixation proximally. We prefer to perform this
with single plate fixation using the anterolateral interval
beneath the lateral brachialis.14 A 4.5/3.5 mm wide stainless
Figure 65.13  Distal forearm transplant illustration. (Illustration Copyright ©2012 by The Johns Hopkins Health System Corporation. Illustration
created by Devon Medical Art, LLC.)
Brachioradialis (Brac)
Flexor carpi radialis (FCR)
Flexor pollicis longus
(FPL)
FPL
FCR tendon
FDP tendons
FDS tendons
PL tendon
FCU tendon
Brac
Skin flap
Skin flap
Recipient arm
Donor hand
Skin flap
Radial artery
Median nerve
Radius
Cephalic vein
Skin flap
Palmaris longus
(PL)
Flexor carpi ulnaris
(FCU)
Flexor digitorum
superficialis (FDS)
Flexor digitorum
profundus (FDP)
Basilic vein
Ulnar
Ulnar nerve
Ulnar artery

764
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
utilizing complete transplantation of the forearm muscula­
ture, passive digit motion and gentle wrist passive motion
are initiated immediately, though care is taken to not disrupt
the anchored/sutured flexor-pronator or extensor origins
at the medial and lateral humeral epicondyles. For trans­
humeral transplants, digit and wrist passive motion may
begin immediately. We keep the elbow immobilized for at
least 6 and up to 12 weeks, depending on the degree of
healing or stretching of the elbow flexor/extensor repairs.
As motor reinnervation progresses, more and more active
activities are included in therapy. Some 4–6 h/day of
therapy, 4–5 days/week, with at least 1 h/day of stretching
on “non-therapy” days, is required during the first year, and
this may continue for the second to third years, depending
on the level of transplantation and timing of plateau of
functional improvement.
Patients should learn to inspect and evaluate themselves
daily for rashes and swelling, which herald acute rejection.
Additionally, since they lack protective sensation for many
months after transplant, they must be especially careful to
not traumatize or burn the transplanted limbs, as this will
not only cause local injury, but also may invoke an immune
response initiating an aggressive episode of acute rejection.
Sun exposure should be limited for similar reasons.
Most patients should not expect their function to plateau
for 2–3 or more years after transplantation, depending on
the level of transplant. Most patients, except for perhaps the
most distal forearm transplants, may benefit from revision
surgeries focused on removing tendon adhesions, stabiliz­
ing more proximal joints to allow better strength and excur­
sion in more distal joints (e.g., wrist fusion in proximal arm
transplant), or tendon transfers for intrinsic weakness.
COMPLICATIONS
Complications may include immunotherapy-related compli­
cations including malignancy, infection, or rejection, or
surgical complications, which can be divided into immedi­
ate and late complications. Immediate complications are
usually related to either vessel thrombosis or bleeding.
Immediate complications require immediate operative
exploration and intervention to prevent allograft loss and
maintain patient safety. In general, when hand transplanta­
tion is performed in isolation (not being combined with
face or lower extremity transplantation), the mortality rate
is extremely low. To date, the authors are aware of only
single mortality caused by hand transplantation in 72
patients transplanted with 107 limbs. However, when com­
bined with face or leg transplantation, combined immediate/
delayed patient mortality is 75%.18
Immediate complete graft loss has occurred in four
known patients19–22 (including the single isolated hand
transplant mortality above), with one loss being only partial
(fingertips only on bilateral distal forearm transplant), out
of 72 known transplanted patients. Many hand transplant
patients have undergone operative revision for hardware
removal, non-union, tenolysis, tendon transfer, joint fusion,
and other procedures to improve function.23 Many of these
revision procedures are expected outcomes and not neces­
sarily “complications.” The remaining known complications
in worldwide experience are listed in Table 65.1.5
performed first, followed by brachialis and biceps. Rein­
forcement with fascial onlay or tendon weave can be
performed as necessary. Median, radial, ulnar, lateral ante­
brachial, and medial antebrachial nerves are coapted. End-
to-end brachial artery reconstruction is performed and all
available veins are anastomosed. Care must be taken to
ensure that for more distal transhumeral transplants, too
much laxity within the brachial artery is not permitted, as it
will kink and thrombose with elbow flexion. In addition,
one may consider taking donor sural vein graft during the
procurement if this is allowed by the organ procurement
organization within the donation agreement signed by the
donor family and the local policies and procedures. This
vein graft can be used for an interposition to extend the
reach of the vascular reconstruction if necessary, especially
in cases where the recipient does not have adequate vein
graft donor sites of their own.
POSTOPERATIVE CONSIDERATIONS
In the ICU, the authors’ protocol for monitoring of the
allo-flap or “graft” uses standard clinical assessments for
perfusion such as color, warmth, and capillary refill, as well
as pulse-oximetry probes on the ulnar and radial digits com­
paring saturation and waveforms, handheld pencil Doppler,
and the implanted venous Doppler probe. Dressings are
typically changed after 48–72 h, and all dressing changes
are performed in a sterile manner for the first 2–3 weeks.
Hand therapy is initiated within 48–72 h of transplant
with passive stretching and splinting, which may continually
change over the coming weeks. Patients with distal forearm
transplants who have strong tendon reconstructions may
begin active and passive hand therapy almost immediately,
while those with mid-forearm transplants with fragile end-
to-end coaptations are only allowed very gentle passive
motion for the first 3–4 weeks. Those with reinforced end-
to-end coaptations may begin somewhat earlier per the sur­
geon’s preference. For proximal forearm transplants
Figure 65.14  Palmar recipient site dissection for hand transplant
performed at distal forearm level with individual median and ulnar
motor and sensory nerve branch identification for specific
neurorrhaphies.

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
765
Figure 65.15  Transhumeral transplant illustration. (Illustration Copyright ©2012 by The Johns Hopkins Health System Corporation. Illustration
created by Devon Medical Art, LLC.)
Biceps
Biceps
Skin flap
Skin flap
Skin flap
Skin flap
Triceps
Triceps
Plate
Humerus
Ulnar nerve
Ulnar nerve
Ulnar artery
Radial artery
Brachialis
Brachialis
Cephalic vein
Radial nerve
Median nerve
Brachial
artery
Recipient arm
Donor arm
Basilic vein
Basilic vein
OUTCOMES
Hand transplantation success rates in terms of “graft sur­
vival” are 83.1% when including all kinds of hand trans­
plants performed in all countries.24 However, when
performed in isolation (not combined with a face or leg
transplant) in the United States, Western Europe, and Aus­
tralia, success rates are 90.5% with no reported mortalities.24
When hand transplantation is combined with face or leg
transplantation, the mortality rate has been 75% and hand
survival rate has been 0% so far, in the four cases performed
Table 65.1  Late Complications in Hand Transplantation
Surgical
Metabolic/Immune
Infectious
Non-union
Hardware failure
Poor muscle/tendon excursion
Soft tissue necrosis
Poor motor/sensory recovery
Nephrotoxicity
Hyperglycemia
Avascular necrosis
Cushing syndrome
Serum sickness
PTLD
CMV
Herpes simplex
Osteomyelitis
Cutaneous mycoses
Cutaneous papilloma virus infection
C. difficile enteritis

766
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
worldwide.18 Functional outcomes are more difficult to both
define and tabulate in hand and upper extremity transplan­
tation, as there is no centralized reporting of standardized
data that all sites currently participate with. However, the
International Registry on Hand and Composite Tissue Allo­
transplantation has reported that all participating recipients
have regained protective sensation after 1 year and have
improved ability to perform activities of daily living.5
FUTURE DIRECTIONS
The future of reconstructive transplantation depends on
four factors. The first is the currently requisite immunosup­
pression. Immunoregulation protocols that can minimize or
altogether eliminate the need for “immunosuppression,”
which is directly responsible the metabolic, neoplastic, and
infectious complications that can be seen in transplantation,
will be required to further mitigate the risks to otherwise
healthy patients who do not have life-threatening medical
problems but could be given such problems with conven­
tional immunotherapy.
The second factor is nerve regeneration. Our ability to
transplant more proximal levels, or obtain satisfactory
results with other types of transplantation such as lower
extremity, are limited by what we perceive as limits in nerve
regeneration that prevent adequate motor recovery from
being attained. Speeding axonal regeneration, maintaining
the motor endplate and muscle mass, or both, will be
required to improve outcomes and reach these more proxi­
mal levels of transplantation.
The third factor is tissue engineering. At some point in
the future, one can fathom that a day with allograft donation
will no longer be necessary as regenerative techniques may
be available that “regrow” in situ in a lost limb, or could be
used to fabricate an “iso”-graft limb ex vivo that is then
replanted using traditional microsurgical techniques.
A fourth option is a non–tissue-based limb reconstruction
utilizing advanced neural-robotic interfaces that could
control an osseointegrated advanced robotic limb providing
not only motor control but also sensory and haptic
feedback.
While the latter two options sound like science fiction,
they are in fact not only possible, but also feasible in the not
too distant future. However, even closer to reality are the
first factors of immunoregulatory strategies that result in
“true” or at least “operational” tolerance, i.e., is, a transplant
that no longer requires immunosuppression to be main­
tained. Many centers throughout the world have protocols
showing promise in small and large animals, and a few very
limited clinical trials for solid organ transplantation are
under way. In addition, techniques for enhancing nerve
regeneration are constantly being developed, though few
are usually shown to be clinically advantageous. However,
the one mainstay of nearly every immunotherapy regimen
in solid organ and reconstructive transplantation has dem­
onstrated some low level of nerve regeneration enhance­
ment: tacrolimus. While this alone is not sufficient to enable
even more proximal levels of transplantation, it is the first
nerve therapeutic to be used for such a purpose, with at least
some laboratory science supporting its use.
As the future of upper (and lower) limb transplantation
unfolds, these achievements will be made to usher in a new
era of reconstructive transplantation that does not end at
just limbs but may enhance all manner of reconstructive
surgery’s difficult problems.
The patient’s right elbow had significant injury and so replace-
ment of the elbow in addition to the hand and forearm was
planned via a transhumeral transplant on the right side and a
distal forearm level transplant on the left side (Figs 65.16, 65.17,
65.18).
CASE 65.1  Bilateral Upper Limb Loss Due to Hands Caught in a Farm Machine
Figure 65.16  Preoperative right proximal forearm and left distal forearm amputations. The right elbow joint has significant post-traumatic
arthritis and a proximal radioulnar joint synostosis.
Continued

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
767
CASE 65.1  Bilateral Upper Limb Loss Due to Hands Caught in a Farm Machine—cont’d
Figure 65.18  Right supracondylar and left distal forearm transplant patient. (A) Driving and (B) eating with chopsticks.
A
B
Figure 65.17  (A–C) Early postoperative result after supracondylar and distal forearm level transplants with radiographs demonstrating
fixation.
A
B
C

768
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
7. Schneeberger S, Gorantla VS, Brandacher G, et al. Upper-extremity
transplantation using a cell-based protocol to minimize immuno­
suppression. Ann Surg 2013;257:345–51.
8. Leonard DA, Kurtz JM, Mallard C, et al. Vascularized composite
allograft tolerance across MHC barriers in a large animal model.
Am J Transplant 2014;14:343–55.
9. Ibrahim Z, Cooney DS, Shores JT, et al. A modified heterotopic
swine hind limb transplant model for translational vascularized
composite allotransplantation (VCA) research. J Vis Exp 2013;80.
10. Dobbels F, Vanhaecke J, Dupont L, et al. Pretransplant predictors
of posttransplant adherence and clinical outcome: an evidence
base for pretransplant psychosocial screening. Transplantation
2009;87:1497–504.
11. Azari KK, Imbriglia JE, Goitz RJ, et al. Technical aspects of the
recipient operation in hand transplantation. J Reconstr Microsurg
2012;28:27–34.
12. Hartzell TL, Benhaim P, Imbriglia JE, et al. Surgical and technical
aspects of hand transplantation: is it just another replant? Hand
Clin 2011;27:521–30.
13. Higgins JP, Shores JT, Katz RD, et al. Forearm transplantation
osteosynthesis using modified ulnar shortening osteotomy tech­
nique. J Hand Surg [Am] 2014;39:134–42.
Access Figures 65.19 to 65.20, as well as
case example 2 online at
.inkling.com
REFERENCES
1. Shores JT, Imbriglia JE, Lee WP. The current state of hand trans­
plantation. J Hand Surg [Am] 2011;36:1862–7.
2. Shores JT, Brandacher G, Schneeberger S, et al. Composite tissue
allotransplantation: hand transplantation and beyond. J Am Acad
Orthop Surg 2010;18:127–31.
3. Shores JT. Recipient screening and selection: who is the right can­
didate for hand transplantation. Hand Clin 2011;27:539–43.
4. Schneeberger S, Khalifian S, Brandacher G. Immunosuppression
and monitoring of rejection in hand transplantation. Tech Hand
Up Extrem Surg 2013;17:208–14.
5. Petruzzo P, Dubernard JM. The International Registry on Hand and
Composite Tissue Allotransplantation. Clin Transpl 2011;247–53.
6. Brandacher G, Lee WP, Schneeberger S. Minimizing immunosup­
pression in hand transplantation. Expert Rev Clin Immunol
2012;8:673–84.
Expert Commentary
L. Scott Levin, MD, FACS
Hand and upper extremity transplantation has become a reality
and serves as an example of restorative surgery that by defini-
tion, exceeds the capabilities of reconstructive surgery, based
on the ability to transplant identical functional tissue compo-
nents from one human to another. Beginning with the use of
the operating microscope in 1960, micro­vascular surgery con-
tinues to grow. In the reconstructive elevator, the traditional
stop on the top floor, that being autogenous free tissue transfer,
has been surpassed by another stage of development, the era
of vascularized composite allotransplantation.
Given the functional impairment and common rejection of
conventional or even myoelectric prostheses by the amputee,
hand and upper extremity allotransplantation provides new
hope for functional restoration, as well as psychological benefit
from enhanced body image. Thus far, the majority of patients
who have been transplanted have the benefit-to-risk ratio
tipped in their favor with functional improvement of their day-
to-day activities of daily living. The requirements for immuno-
suppression are similar to solid-organ transplant patients, and
continued efforts and research are trying to eliminate this liabil-
ity from VCA.
In addition to allotransplantation, improvements of upper
extremity prostheses, such as the use of osseointegration and
neural signaling interfaces, as well as nerve transfers in the
amputee in the form of targeted muscle reinnervation, are pro-
viding additional pathways for the upper extremity amputee to
reintegrate into society. While some believed that hand and
upper extremity allotransplantation as a pursuit would not
survive, it is clear that this surgery is here to stay and will only
become more widespread as more centers engage in this
restorative option.
Principles regarding hand and upper extremity transplanta-
tion mandate that a close relationship be established with solid
organ transplant physicians and surgeons. Preparation for hand
transplantation is unique and requires restructuring and reori-
entation of institutional facilities, dedicated therapists who
understand hand transplantation for postoperative manage-
ment, and the custom tailoring of procedures for a particular
recipient. It is fine-tuned in cadaver laboratories as part of
intense surgical rehearsal to ensure success.
At the time of writing, in the last 17 years, upper extremity
transplantation has evolved from unilateral hand to the docu-
mentation of patients that have been transplanted at the proxi-
mal humerus level, with outstanding results that are improved
compared with the use of bilateral prostheses, and in many
cases, exceed function that would be obtained by prosthetic
use. These levels, including proximal humerus, mid-humerus,
proximal forearm, mid-forearm, distal forearm, hand, and partial
hand amputations, have all been performed with a high degree
of early success, as being defined as the part surviving for more
than 1 year.
Function in the proximal allotransplants has been largely
based on reinnervation of muscles and protective sensibility
return, and certainly more distal levels where functional muscle
groups of the recipient are in place have a more rapid and
ensured functional recovery because there is no need for rein-
nervation of functional muscle groups.
Strategies related to immunosuppression include so-called
conventional kidney equivalent immunosuppression with triple-
drug therapy, movement toward steroid weaning therapy, and
other cellular-based therapies that have promise, but yet require
more time and more patients enrolled in such protocols to
consider monotherapy a gold standard. What is known is that
hand and upper extremity transplantation is, in many centers
now, evolving to become the standard of care for certain trau-
matic amputees. Future directions will involve the application of
hand and upper extremity VCA in congenitally acquired amputa-
tions and in traumatic amputations in young children, who
would benefit from this restorative surgery, particularly with their
propensity to achieve enhanced nerve recovery at a young age.
In addition to the surgical and scientific advances in North
America, health policy is guiding vascularized composite allo-
transplantation, and the United Network for Organ Sharing
(UNOS) has formed a subcommittee of physicians, ethicists,
transplant surgeons, and regulators to ensure appropriate
allocation and control of vascularized composite allotrans­
plantation. Our hope in the future is that because of UNOS’s
involvement and oversight, ultimately this restorative surgery
will be covered by insurance, and third parties, to provide for
the ability to pay for these expensive, but quality of life enhanc-
ing procedures.

CHAPTER 65 — Hand a nd Upper Extremity Transplantation 768.e1
Due to the short length of the forearm, all extrinsic flexors and
extensors were planned for replacement. However, in the event
of a transplant failure, the authors wanted to maintain the below
elbow stump and the muscle tissue covering these, so the patient
could go back to using a below elbow prosthesis and not require
conversion to an above elbow amputation, resulting in a bilateral
above elbow amputee. Therefore, on the left side, the extensor
origins and flexor pronator origins were removed from the
donor and elevated into the forearm distal to the planned oste-
otomy sites. These were then secured over the top of the native
muscles and anchored to the medial and lateral epicondyles.
Median, ulnar, PIN, SRN, and ECRB-Br (radial nerve) were all
transferred into the donor muscles after osteosynthesis was per-
formed utilizing an ulnar shortening plate for ulna compression
and metaphyseal LCP plate for the radius.
The humerus was transplanted at the mid-humeral level with
maintenance of the native elbow flexor/extensor units and
repair of radial, ulnar, and median nerves and the most distal
above elbow levels possible (Figs 65.19, 65.20).
CASE 65.2  Bilateral Upper (and Lower) Limb Loss Due to an Explosion Injury
Figure 65.19  (A,B) Preoperative photographs of right transhumeral and left proximal forearm amputations. (C) Preoperative angiogram
of right arm showing cut-off of brachial artery at the middle upper arm. (D) Right arm X-ray. (E) Left forearm X-ray. (F) Preoperative angio­
gram of left forearm demonstrating termination of radial and ulnar arteries shortly after bifurcating from the brachial artery.
A
B
C
D
E
F

768.e2 PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
CASE 65.2  Bilateral Upper (and Lower) Limb Loss Due to an Explosion Injury—cont’d
Figure 65.20  (A) Pre-transplant image of left proximal forearm. (B) Possible donor forearm incisions indicated. (C) Post-fixation X-rays.
(D) Inset skin flaps. (E) Pre-transplant image of right upper extremity. (F) Donor arm procured and demonstrating skin flap incisions.
(G) Post-fixation X-rays. (H) Inset skin flaps.
A
E
F
G
H
B
C
D

CHAPTER 65 — Hand a nd Upper Extremity Transplantation
769
20. Kaufman CL, Breidenbach W. World experience after more than
a decade of clinical hand transplantation: update from the Louis­
ville hand transplant program. Hand Clin 2011;27:417–21.
21. Cendales LC Clinical update and update on hand and face trans­
plant outcomes: speed update on world experience with clinical
VCA chairs. American Society for Reconstructive Transplantation,
3rd Biennial Meeting, Chicago, IL; 2012.
22. Cendales LC. Speed update on the world experience on hand
transplantation. HCTAS, 11th Meeting of the International Hand
and Composite Tissue Allotransplantation Society. Wroclaw,
Poland: 2013.
23. Cavadas PC, Ibanez J, Thione A. Secondary surgery for functional
improvement after hand transplantation. Ann Plast Surg 2011;67:
421–2.
24. Shores JT, Brandacher G, Lee WPA. Hand and upper extremity
transplantation: an update of outcomes in the worldwide experi­
ence. Plast Reconstr Surg 2015;135(2):351e–360e.
14. Shores JT, Higgins JP, Lee WP. Above-elbow (supracondylar) arm
transplantation: clinical considerations and surgical technique.
Tech Hand Up Extrem Surg 2013;17:221–7.
15. Lang RS, Gorantla VS, Esper S, et al. Anesthetic management in
upper extremity transplantation: the Pittsburgh experience. Anesth
Analg 2012;115:678–88.
16. McDiarmid SV, Azari KK. Donor-related issues in hand transplanta­
tion. Hand Clin 2011;27:545–52.
17. Haddock NT, Chang B, Bozentka DJ, et al. Technical implications
in proximal forearm transplantation. Tech Hand Up Extrem Surg
2013;17:228–31.
18. Shores JT, Lee WP, Brandacher G. Discussion: Lessons learned
from simultaneous face and bilateral hand allotransplantation.
Plast Reconstr Surg 2013;132:433–4.
19. Jablecki J, Kaczmarzyk L, Domanasiewicz A, et al. Unsuccessful
attempt of forearm transplantation–case report. Ann Transplant
2010;15:53–6.

770
Laryngeal, Abdominal
Wall, and Uterus
Transplantation
Ömer Özkan  |  Özlenen Özkan
66 
INTRODUCTION
Composite tissue allotransplantation (CTA) involves trans­
plantation of various complex tissues embryologically
derived from different layers that can include musculoskel­
etal structures (nerve, bone, muscle, etc.), skin and mucosa,
and their adnexal extensions. These differ from well-known
solid organ allotransplantations, which are lifesaving proce­
dures, intended to improve quality of life. These have
benefited from the introduction of more specific immuno­
suppressive agents, with fewer adverse effects and greater
efficacy, resulting in a significant improvement in the out­
comes of solid organ transplantation over the past few
decades. Striking successes in the field of kidney, liver, and
heart transplantation have encouraged further investigation
into these more multifaceted transplants.
Although theoretically any part of the body could be
transplanted as a composite tissue, in practice, only the
hands,1–5 face,6–8 larynx,9–12 lower extremity,13 uterus,14–16 and
abdominal wall17–20 have been transplanted to date, and in
relatively limited numbers. The first clinical success with
hand transplantation, and recent exceedingly high rates of
patient satisfaction with hand and face, have fueled the
desire to start composite tissue transplantation programs in
many medical centers around the world. Although this
public demand for reconstructive transplantation is increas­
ing due to early promising results, composite allotransplan­
tation is far more complex and difficult than other forms of
organ transplantation. The main challenge facing CTA is
the high risk of immunosuppression, which is worthwhile in
solid organ transplantation in terms of the risk–benefit
ratios. Drugs used for immunosuppression still broadly sup­
press the immune system and are associated with develop­
ment of opportunistic infections, a high risk of neoplastic
formations, and vital end-organ toxicities. In addition, the
medical ethics of composite allotransplantation have also
been the subject of debate.
Despite relatively wide experience with the hand, which
has been exceptionally favorable from both a physician and
patient standpoint, and recent experiences with face allo­
transplantations, clinical applications for other CTAs are
still limited in number and are only performed in a few
respected centers worldwide.
LARYNGEAL ALLOTRANSPLANTATION
Absence of a larynx is associated with the loss of a human-
sounding voice, an impaired sense of taste and smell, a
disposition to a high risk of lower bronchoalveolar infec­
tion, and psychosocial disintegration. There is no ideal
method for substituting the larynx, either with a like tissue
using any organic tissue transfer with the help of microsurgi­
cal techniques or prefabrication and replacement by pros­
thetic materials. Although there have been many recent
developments in the fields of tissue engineering, nanotech­
nology, and regenerative medicine, larynx allotransplanta­
tion seems to be the only method capable of reproducing
all the properties of a functional original larynx, in current
practice.9–12
The first clinical attempt at laryngeal transplantation was
in 1969.9 A 62-year-old man with carcinoma of the larynx
was the recipient of a larynx from a 40-year-old donor. He
survived well in the early postoperative period and experi­
enced a well-treated acute rejection. Unfortunately, the
patient died due to tumor recurrence at postoperative
month 8.
The first successful laryngeal allograft procedure took
place in 1998.10 The recipient was a 40-year-old man who
had been in a road accident 20 years previously, resulting
in laryngeal dysfunction. A laryngopharyngeal complex,
including thyroid, parathyroid, and five rings of the trachea
was transplanted. The patient now swallows normally, and
there has been an evident improvement in his quality of
life. Objective voice measurements are within normal limits
for intensity, maximum phonation time, and airflow for age.
ARTERIAL ANATOMY (Fig. 66.1 and Figs 10.4
and 10.5)
The human larynx is perfused by the superior and inferior
thyroid arteries together with branches of the dorsal lingual
branch of the lingual artery. Barium latex injection studies
have shown that the superior laryngeal artery, the first
branch of the superior thyroid artery, can nourish all laryn­
geal tissues. Injection of the unilateral main superior thyroid
artery showed that this perfuses all laryngeal tissues and
upper tracheal rings.
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

CHAPTER 66 — Laryngeal, Abdominal Wall, a nd Uterus Transplantation
771
RECIPIENT PROCEDURE
The entire vascular and neural structure of the larynx is
delineated. An orthotopic position for transferred tissue
is created by removing the strap muscles. If present, it is
essential to keep the hyoid bone in place in order to ensure
that the tongue base and laryngeal elevation are normal.
Depending on the presence of a defect in the recipient
pharynx, a part or whole pharynx can be transplanted,
together with the larynx. Based on the size of the defect,
and considering the prevention of the fistula or stricture,
a relatively large size of pharynx can be transplanted. A
pouch is created for the pharynx and larynx and pharyn­
geal anastomosis is established in the upper part, the upper
part of the tracheal stroma is revised, the donor trachea
is sutured to this in an end-to-end manner, and the stoma
is re-created superiorly.
Both superior thyroid arteries are anastomosed to the
recipient arteries, or to a branch of the external carotid
arteries, in an end-to-end manner, or directly to the external
carotid arteries in an end-to-side manner. Donor internal
jugular veins or branches that drain the transferred tissue
are anastomosed to the recipient internal jugular veins or
their related branches in an end-to-end or end-to-side
The superior thyroid arteries are 1.5–2.5 mm in diameter,
and length can be adjusted based on the desired pedicle
length in cadavers, extending even to common carotid
arteries.
VENOUS ANATOMY
Venous return is consistent with concomitant veins and can
again be adjusted based on the pedicle length required,
extending to the branch of the internal jugular vein to the
main trunk of the internal jugular vein (Figs 66.1 and 10.5).
NEURAL ANATOMY
Reinnervation is essential in order to successfully restore
a functional larynx unit with normal laryngeal speech
and breathing. Laryngeal muscles could be described
as “clever muscles,” since the high density of motor
fibers in the recurrent nerve innervates these small-sized
muscles.
All muscles within the larynx are innervated by the recur­
rent laryngeal nerve (Fig. 66.1), except for the cricothyroid
muscle, which is innervated by a branch of the superior
laryngeal nerve known as the “external laryngeal nerve.”
The laryngeal mucosa are innervated by different nerves
above and below the vocal cords. While the upper part is
innervated by the internal laryngeal nerve branch of the
superior laryngeal nerve, the recurrent laryngeal nerve
innervates the lower part. Providing sensorial innervation is
essential in eliciting cough in order to prevent aspiration of
saliva, food, and liquids, and in order to ensure normal
mobility of the vocal cords.
INDICATIONS
The procedure itself is not a lifesaving one and is only
intended to improve quality of life. The ideal recipients are
young trauma victims. Other recipients might be patients
who have suffered a large benign tumor or low-grade malign
tumor resection. However, the latter indication should be
well investigated due to the high incidence of tumor recur­
rence in immunosuppressive patients.
LARYNGEAL COMPOSITE TISSUE COMPONENT
(Fig. 66.1)
The transplanted tissue includes the cartilage structure of
the larynx and upper trachea, functional muscles of the
larynx, mucosal lining of the larynx and trachea, the
pharynx, and the neurovascular pedicle of the larynx.
FLAP DESIGN
DONOR PROCEDURE
The entire pharyngolaryngeal complex together with
upper 5–6 tracheal rings and thyroid and parathyroid
glands is harvested, leaving the neurovascular pedicle
intact. The vascular pedicle of the harvested tissue includes
the superior thyroid arteries, the internal jugular veins as
an extension of the superior and middle thyroid veins, the
superior laryngeal nerves, and the recurrent laryngeal
nerves bilaterally.
Figure 66.1  Laryngeal composite allograft.
Superior laryngeal nerve
Recurrent laryngeal nerve
Superior thyroid artery
Middle thyroid vein
Jugular vein

772
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
ABDOMINAL WALL
ALLOTRANSPLANTATION
Intestinal allotransplantation is a current and challenging
method for treating complicated intestinal failure, with
recent advances in immunosuppression and surgical tech­
niques, resulting in improved survival for patients.17–20
Although considerable experience exists in the most
respected centers, one of the main technical problems is
closure of the abdomen without tension. Many potential
patients have lost natural anatomic orientation of the abdom­
inal compartment. Additionally, most of these patients suf­
fered repeated laparotomies, enterocutaneous fistulas,
wound infections, etc. that cause severe abdominal wall integ­
rity problems. Failure with proper closure of the abdominal
wall after allotransplantation leads to a large open wound.
The aim is then to close the wound in a staged manner,
despite a high risk of complications, such as infection, tissue
exposure problems (mechanical problems that may leave
tissues unprotected, fistula formation, bleeding, and elec­
trolyte imbalance), and delayed rehabilitation.
The cadaveric composite abdominal wall myofasciocuta­
neous flap has been described in order to address this
problem.
ARTERIAL ANATOMY (see Fig. 66.2 and Figs 11.3
and 11.6)
The composite abdominal wall flap is perfused by the infe­
rior epigastric vessels. These are left in continuity with the
common femoral or iliac arteries.
VENOUS ANATOMY (see Fig. 11.8)
Venous drainage is achieved by the concomitant veins.
NEURAL ANATOMY (see Figs 11.9 and 11.10)
Since only structural tissue coverage is needed, no nerve
trunk is included in the transferred tissue.
INDICATIONS
The main indication is impossible or high-risk direct abdom­
inal closure in patients undergoing intestinal allotransplan­
tation.
ABDOMINAL WALL COMPOSITE TISSUE
COMPONENT (Fig. 66.2)
The transplanted tissue includes one or both rectus abdomi­
nis muscles, overlying fascia, underlying sheet and abdomi­
nal subcutaneous tissue, and skin.
FLAP DESIGN
The surface area may range from 150 cm2–500 cm2, based
on patient age and size.
DONOR PROCEDURE
The donor does not need to be matched with the recipient
in HLA typing. ABO blood identification should be
manner, based on size match and recipient venous drainage
maintenance. Both superior laryngeal nerves and recurrent
laryngeal nerves of the transplanted tissue are sutured to
their recipient matches.
FLAP MODIFICATIONS
The concept of partial laryngeal transplantation has recently
been introduced due to potential problems such as wound
healing, adaptation, and aspiration difficulties. However, it
is likely that improved functional results will emerge in the
future.
POSTOPERATIVE CARE
Tracheostomy tubes and drains can be removed a few
days after surgery. After removal of the tracheostomy tube,
because of the lack of sensorial and motor innervation,
the possibility of aspiration should be kept in mind and
all preparations should be made ready. Salivary secretion
is reduced using glycopyrrolate and atropine. Nasogastric
or gastric tubes can be used for feeding for at least
2 weeks.
Vascularity of the transplanted tissue is monitored as
routine microvascular tissue transfer using clinical param­
eters such as direct examination, with the help of endo­
scopic imaging bleeding, control of tissue tonus, etc. and
with Doppler flowmeters.
Any possible rejection attack should be identified and
checked again using direct imaging under endoscopic
examination and microscopic examination of the mucosal
parts.
Patients should be closely monitored for metabolic, infec­
tious, or organic complications of the drugs used for immu­
nosuppression, such as hypertension, diabetes mellitus,
renal toxicity, osteoporosis, and avascular femoral head
necrosis.
IMMUNOSUPPRESSIVE PROTOCOL
The immunosuppressive protocol for the first successful
case was as follows:10 muromonab-CD3 (5 mg/day); cyclo­
sporine (500 mg/day); methylprednisolone (50 mg/day,
decreasing to 20 mg in 4 days); and mycophenolate mofetil
(MMF) (1 g twice a day). The patient suffered a rejection
attack 15 months postoperatively, and this was overcome
using a high dose of steroid. Cyclosporine was changed to
tacrolimus 4 mg twice daily, together with 1 mg of MMF
daily and 7.5 mg of prednisolone/day.
Wide-spectrum antibiotic therapy should be adminis­
tered for the first 10 postoperative days. Sulfadoxine
pyrimethamine was administered to prevent Pneumocystis
carinii pneumonia. CMV prophylaxis is performed with
valganciclovir.
FUTURE LANDMARKS
Research for laryngeal transplantation will proceed on
the basis of organ-specific immunosuppression, with func­
tional improvements in neuromuscular-specific innervation,
partial laryngeal transplantation, and, more importantly,
transplantation without the use of any immunosuppressive
drug.

CHAPTER 66 — Laryngeal, Abdominal Wall, a nd Uterus Transplantation
773
FLAP MODIFICATIONS
The composite flap can be harvested based on a cuff of
external iliac or femoral vessels in such a way as to contain
the deep circumflex iliac, deep inferior epigastric, superfi­
cial epigastric, and superficial circumflex vessels for a larger
flap with more reliable circulation.
The posterior rectus sheath fascia can be transplanted in
continuity with the falciform ligament of the liver in the case
of liver transplantation.20 In this situation, the flap is nour­
ished by the hepatic artery, which has been anastomosed
to the recipient artery as a standard procedure in liver
transplantation.
POSTOPERATIVE CARE
The perfusion of the flap is monitored as routine clinical
follow-up of the free flap in terms of color, tonus, blood
refill, needle puncture, and bleeding nature and, if neces­
sary, monitoring of vascular anastomoses using a Doppler
flowmeter.
Any possible rejection attack should be identified and
checked by taking routine biopsy specimens and evaluated
by microscopic examination.
The patient should be closely monitored for metabolic,
infectious, or organic complications involving the drugs
used for immunosuppression, such as hypertension, diabe­
tes mellitus, renal toxicity, osteoporosis, or avascular femoral
head necrosis.
IMMUNOSUPPRESSIVE PROTOCOL
The immunosuppressive protocol at the best-known center
is as follows:17–19 induction consists of administration the
anti-CD52 monoclonal antibody alemtuzumab (0.3 mg/kg)
immediately preoperatively, immediately postoperatively,
and on postoperative days 3 and 7. Maintenance immuno­
suppression is based on tacrolimus with a targeted serum
level of 10 µg/L. In rejection attacks, corticosteroids are
used in high doses.
All other prophylactic antibiotic protocols are similar to
those used in other allotransplantations.
FUTURE LANDMARKS
In the light of improvements in immunological modalities,
composite allografts may be transplanted without using any
immunosuppressive drugs. They also may be used more
rationally as an isolated composite tissue without any other
visceral organ in the case of massive abdominal wall defects
occurring after massive trauma, resections, or complicated
surgical procedures.
UTERUS TRANSPLANTATION
Having offspring is a major component of identity and plays
a significant role in social interactions. It has played a role in
the future lives of, and guarantees the continuation of, the
next generation for almost all couples, since the beginning
of history. Assisted reproductive techniques have been devel­
oped over several decades. However, no current approach
has been able to treat the problem known as uterine-related
considered, as with other allotransplantations. The com­
posite abdominal wall tissue can be transplanted in the
same session as the intestinal allotransplantation or in a dif­
ferent session a few days later, harvesting from a different
donor. Composite flap harvesting has been performed as
part of a combined multi-organ procurement procedure in
a heart-beating donor. The procedure starts with an upper
part incision, a Mercedes-like incision, which starts from
median sternotomy to extend to the bilateral subcostal
line. Then a continuous vertical bilateral incision is made
in the lateral borders of both rectus abdominis muscles. In
the groin region, the two incisions are connected trans­
versely in the midline. Both inferior epigastric vessels are
dissected and followed until common femoral vessels are
identified. The length of the vascular pedicle is determined
based on the desired length obtained. If necessary, dissec­
tion can be extended to obtain iliac vessels as the donor
pedicle. The composite abdominal wall flap is flushed with
perfusion solution and packed with ice, as with other donor
organs.
RECIPIENT PROCEDURE
After reperfusion of the intestinal or multivisceral allograft,
the composite allograft is transferred as a separate tissue.
Vessels of the composite tissue are anastomosed to the iliac
vessels in an end-to-side manner. The length of the pedicle
is adapted in a smooth curve to prevent uneven tension or
kinking. The transplanted abdominal tissue is incorporated
into the edges of the recipient abdominal wall defect.
Figure 66.2  Abdominal wall composite allograft.
Deep inferior epigastric vessels
External iliac vessels
Abdominal wall composite graft

774
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
• Resection of the uterus due to hemorrhage or trauma
except for malign tumors
• Age 18–45
• No history of major trauma or surgery likely to negative
affect outcomes
• Healthy organs and systems
• Psychosocial stability
• Good health with no contraindications for immunosup­
pressive agents
• Informed concern regarding all adverse effects of immu­
nosuppressive agents
The ideal recipient is a patient with Rokitansky–Kustner–
Mayer–Hauser syndrome or a woman who lost her uterus
during a previous pregnancy due to postpartum hemor­
rhage. A patient with low-grade malignancy treated success­
fully and who has been free of tumor for more than 5 years
could be added to the indication list in the future, based on
acquisition of greater experience. However, this later indica­
tion should be well investigated due to the high incidence
of tumor recurrence in immunosuppressive patients.
UTERINE TRANSPLANTED TISSUE COMPONENT
(Fig. 66.3A)
The transplanted tissue includes the uterine corpus, the
proximal part of the tubal component no more than
1–1.5 cm in size (to use only supportive meaning), uterine
cervix, and a few proximal centimeters of the vagina, all
together with the vascular pedicle structure.
FLAP DESIGN
DONOR PROCEDURE
The following diagnostic evaluations should be performed
in the donor before harvesting the uterus:
• Abdominopelvic ultrasonography and Doppler flowmetry
to evaluate the anatomic and vascular structure of the
uterus
• ThinPrep Pap test for the cervix
• Testing for human papillomavirus (a cervical scrape
immediately transferred into ThinPrep solution)
Surgical Procedure in the Donor
The donor procedure starts before solid organ procure­
ment.14,15 A midline abdominal incision is made. The uterus
and ovaries are isolated and exposed. Dissection is started
from the urine bladder dome, harvesting the peritoneal
sheets until vesicouterine reflection. In the posterior part,
the uterosacral ligaments are detached from the sacrum
and dissected as far as the pararectal space together with
overlining peritoneum. The round ligaments are dissected
and transected as far as possible near to the inguinal liga­
ments. The infundibulopelvic ligaments are clamped and
divided. The suspensory ligaments of the ovaries are
clamped and incised, and the ovaries are excluded from
the allograft. The ovarian arteries and veins are dissected,
ligating and dividing the ovarian branches, keeping the
branches to the uterus intact in their course in the superior
part of the uterus until their origin, and encircled with
infertility (URI), which may result from congenital agenesis
or any formation deformities of the uterus, or else may have
traumatic or surgical causes. The only accepted solution to
URI to date has been surrogacy, though this is not acceptable
in all parts of the world.14–16
The idea that uterine allotransplantation could be used
in URI is supported by several animal studies resulting in
healthy offspring. Furthermore, clinical experience with
solid organ and composite tissue allografts showed that
the immunological obstacle to allotransplantation could be
overcome with the usual immunosuppressive regimens.
Additionally, it has been shown that a woman receiving solid
organ transplantation can have a healthy child, if special
care is taken over various matters affecting the patient and
fetus. Consequently, the only remaining question in uterus
transplantation is an ethical one.
ARTERIAL ANATOMY
The uterus has bilateral vascular supply. It is mainly per­
fused by the uterine artery, which is a branch of hypogastric
artery that arises from the anterior division of the internal
iliac artery. It also receives blood supply from the ovarian
artery that arises from the abdominal aorta. The termina­
tion of the ovarian artery around the midlevel of the uterine
corpus joins the uterine artery and forms anastomosis with
its branches. The uterine artery travels to the uterus, cross­
ing the ureter anteriorly, reaching the uterus by travelling
along the cardinal ligament (Fig. 66.3A).
The uterine arteries are 1.3–1.5 mm in diameter, and the
length can be adjusted, based on the desired pedicle length
in cadavers, extending to the hypogastric artery and even
the internal iliac artery.
Injection of a unilateral uterine artery showed that it
perfuses the entire uterus.
VENOUS ANATOMY
Venous return is consistent with concomitant veins, which
have a tortuous structure and form a network around the
corresponding artery. The length can again be adjusted
based on the pedicle length required, extending to the
internal iliac vein together with the arterial structure (Fig.
66.3A).
NEURAL ANATOMY
Although the nerves of the uterus are derived from the
hypogastric and ovarian plexuses and third and fourth
sacral nerves, no nerve trunk is included in the transferred
tissue.
INDICATIONS
The procedure itself is not a lifesaving one and is only
intended to improve quality of life. The ideal donor should
be selected based on the following criteria:
• Infertility related to the uterus
• Desire for uterine transplantation
• Medical impossibility of having a baby
• Congenital uterine agenesis

CHAPTER 66 — Laryngeal, Abdominal Wall, a nd Uterus Transplantation
775
them. The vascular pedicles are encircled with vessel loops.
The vascular pedicle is exposed and identified near to the
hypogastric vessels, and all other branches are ligated and
divided. The vascular dissections are carried up to the
common iliac vascular structures. In the inferior part, the
cardinal ligaments are incised, and all vaginal branches of
uterine vascular pedicles are ligated and delicately divided.
The uterus is retracted toward the superior under tension.
The upper part of the vagina is palpated and entered by
a circumferential incision including 4–5 cm of the proxi­
mal vagina. The vascular pedicles including the bilateral
common iliac arteries and veins, and ovarian arteries and
veins are divided. The extirpated uterus is then wrapped
with cold gauze for topical hypothermia. Following bilateral
common iliac artery cannulation and perfusion with perfu­
sion solution in order to ensure removal of all blood cells
and fibrin and to induce central core cooling for tissue
preservation until revascularization, the uterus is packed
in ice for transportation.
RECIPIENT PROCEDURE
In order to prevent any possible damage from high doses
of immunosuppressive agents, especially during the induc­
tion phase after transplantation, the recipient is prepared
for in-vitro fertilization (IVF), and embryos are collected
before the transplantation procedure.
Surgical Procedure in Recipient
The recipient procedure starts when uterine allograft blood
circulation is established based on the common iliac vascu­
lar pedicles during the donor procedure.14,15 A midline sub­
umbilical incision is made, and intra-abdominal adhesions
– if present – are lysed. The space between the urinary
bladder and rectum is identified and prepared. The internal
and external iliac vessels are dissected bilaterally. The uterus
allograft is placed in the orthotopic position. The proximal
part of the recipient vagina or previously reconstructed neo­
vagina is exposed and marked, and an oval segment is
excised. Anastomosis is performed between the vaginal
opening of the donor uterus and the recipient neo-vaginal
vault using single interrupted sutures. A uterosacral attach­
ment is provided between the relevant donor ligaments and
peritoneal continuation and presacral peritoneum using 2-0
nonabsorbable sutures. After measuring the estimated
length of the bilateral donor iliac vascular pedicles, consid­
ering the most stretched position for future planned preg­
nancy and twisting in the case of an extremely long pedicle,
smooth curves are provided bilaterally. Anastomoses are
performed between the recipient’s external iliac arteries
and veins and the donor’s hypogastric arteries and veins in
an end-to-side manner with 6-0 nonabsorbable sutures. Con­
sidering the position of the donor ovarian vascular pedicles,
if it does not create a complex network the anastomoses of
the ovarian arteries can be performed if the position of the
donor ovarian vascular pedicles does not create a complex
network. The donor round ligaments are attached to the
recipient inguinal ligaments using 2-0 nonabsorbable
sutures. The uterovesical ligament of the donor is placed
over the recipient urine bladder and sutured with 3-0
absorbable sutures, and utero-vesical reflection is estab­
lished. Bilateral salpingeal tubes are ligated and divided to
prevent any possible ectopic pregnancy. The position of the
vessel loops. The anterior and posterior leaves of the broad
ligaments are incised and dissected in continuation with
perivesical and pararectal peritoneal sheets, including the
uterine arteries and veins inside. Since numerous small
veins surround the uterine arteries, forming a network
pattern, particular efforts should be made to preserve
Figure 66.3  (A) Uterine allograft. Schematic representation of the
surgical procedure. Note bilateral salpingeal tubes were ligated. (B)
Three-dimensional ultrasonographic appearance of the transplanted
uterus and endometrium.
Vagina
Uterus
Hypogastric
artery
Hypogastric vein
Ovary
External iliac vessels
A
B

776
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
IMMUNOSUPPRESSIVE PROTOCOL
Antithymocyte globulin and prednisolone are administered
in the initial induction period. Antithymocyte globulin is
initiated intraoperatively at a dose of 2.5 mg/kg per day.
Prednisolone is started on the day of surgery, at 1000 mg,
and tapered down to 20 mg, 1 week postoperatively. On day
7, tacrolimus is started (0.2 mg/kg per day with blood levels
between 15 ng/mL and 20 ng/mL), and antithymocyte
globulin is stopped on day 10.14,15
Maintenance treatment consists of prednisolone (20 mg/
day); tacrolimus (blood levels between 15 ng/mL and
20 ng/mL for the first 3 months, then tapered to 7–10 ng/
mL at 6 months postoperatively) and mycophenolate mofetil
(MMF) (2 g/day).
FUTURE LANDMARKS
Research for uterine transplantation will investigate organ-
specific immunosuppression, and the achievement of more
functional improvements. Improvements in assisted repro­
ductive techniques specific to uterine transplantation will
be the main issue for having healthy offspring. More impor­
tantly, transplantation without the use of any immunosup­
pressive drug, or immunosuppressive drugs with lower
side effects, and with fewer teratogenic effects on the fetus,
will gain more acceptance and confirm the feasibility of
uterus transplantation. However, real feasibility will be con­
firmed only after an uneventful delivery with a healthy
mother and infant.
CASE REPORT
The patient, a 22-year-old woman, was admitted to the Gyne­
cology and Obstetrics Department of Akdeniz University
Hospital in Antalya, Turkey, desiring to have a baby.14 She
had Rokitansky–Kustner–Mayer–Hauser syndrome, with a
total absence of uterus and vagina. Vaginal reconstruction
using the segmental jejunum transfer technique was per­
formed 2 years previously by our team in the same hospital.
Since then, she had married and had a regular sex life.
She and her husband were admitted to the infertility
clinic to investigate the possibility of having children. Our
uterus is checked for strong support to prevent any possible
twisting, prolapse, or anterior or posterior kinking. After
homeostatic control, the abdomen is closed in two layers
(Fig. 66.3B).
FLAP MODIFICATIONS
The uterus can be harvested from a live donor16 (mainly
from a relative of the recipient in order to secure a better
HLA match and entail fewer ethical issues). However, the
main drawback of the procedure is providing a shorter vas­
cular pedicle that can cause vascular insufficiency due to
possible tension resulting from an enlarged uterus during
pregnancy. Another major problem is adding surgical risk
to a completely healthy donor. The surgical procedure is
similar, except for having a shorter vascular pedicle and the
need for special care during harvesting supportive tissues
and dissection around the ureter in order not to jeopardize
donor vital structures.
POSTOPERATIVE CARE
Viability of the uterus is monitored clinically by gynecologi­
cal examination and using venous and arterial Doppler flow­
metry. The patient is seen twice a week for routine physical
and blood examinations, including complete blood count,
kidney and liver function tests, and drug levels.
Any possible rejection attack should be identified and
checked again using direct imaging under gynecological
examination, and microscopic examination of specimens
taken on a frequent basis (2-week intervals in the early
stage, and 1- and 3-month intervals later) from the vaginal
part of the transplanted tissue. Endometrial biopsy is evalu­
ated every 3 months in the early period and 6-month inter­
vals in the later period, to evaluate the immunological,
functional, and structural status of the transplanted tissue
(Fig. 66.4).
The patient should be closely monitored for metabolic,
infectious, or organic complications from the drugs used for
immunosuppression, such as hypertension, diabetes melli­
tus, renal toxicity, osteoporosis, or avascular femoral head
necrosis.
The patient’s menstrual cycle should be noted to evaluate
endometrium function and its responses to hormones.
Figure 66.4  Microscopic examination of vaginal and uterine allograft. (A) Endometrial biopsy showing slight edema of the stroma, vacuoliza­
tion of the glandular epithelium without any infiltration, focal necrosis, and apoptotic bodies. (B,C) Immunohistochemical staining showing
evenly distributed (B) CD4-positive and (C) CD8-positive lymphocytes.
A
B
C
A
B
C

CHAPTER 66 — Laryngeal, Abdominal Wall, a nd Uterus Transplantation
777
arteries and veins and the donor’s hypogastric arteries and
veins, in an end-to-side manner. The sequence for vascular
anastomoses was right artery, right vein, left artery, and left
vein. After completing right arterial and venous anastomo­
ses, both vascular clamps were released; the uterus rapidly
assumed a normal color and fresh colored bleeding from
the open edges was observed. The donor round ligaments
were attached to the recipient inguinal ligaments. The
uterovesical ligament of the donor was placed over the
recipient’s urine bladder and sutured, and uterovesical
reflection was established. Since in-vitro fertilization was
planned, bilateral salpingeal tubes were ligated and divided
to prevent any possible ectopic pregnancy. The position of
the uterus was checked for strong support to prevent any
possible twisting, prolapse, or anterior or posterior kinking.
After homeostatic control, the abdomen was closed in two
layers. De-epithelialization was performed in the upper left
thigh, and the donor sentinel skin graft was placed there.
This skin graft was used for indirect monitoring of the
immunological behavior of the allograft, aiming to avoid
any inadvertent failure to detect rejection attack of the rela­
tively buried uterine allograft.
IMMUNOSUPPRESSIVE PROTOCOL
In the initial induction period, antithymocyte globulin and
prednisolone were administered. Antithymocyte globulin
was initiated intraoperatively at a dose of 2.5 mg/kg per day.
Prednisolone was started on the day of surgery, at 1000 mg,
and tapered down to 20 mg, 1 week postoperatively. On day
7, tacrolimus was started (Prograf, 0.2 mg/kg per day with
blood levels between 15 ng/mL and 20 ng/mL), and anti­
thymocyte globulin was stopped on day 10.
Maintenance treatment consisted of prednisolone (20 mg/
day), tacrolimus (blood levels between 15 ng/mL and
20 ng/mL for the first 3 months, then tapered to 7–10 ng/
mL 6 months postoperatively) and mycophenolate mofetil
(MMF) (2 g/day).
PROPHYLAXIS
Wide-spectrum antibiotic therapy was administered for the
first 10 days postoperatively to prevent infectious complica­
tions. Sulfadoxine pyrimethamine was administered to
prevent Pneumocystis carinii pneumonia. Oral nystatin drops
were administered for fungal prophylaxis and oral valacyclo­
vir tablets for CMV prophylaxis. Antithrombotic prophylaxis
was with aspirin and subcutaneous heparin.
RESULTS
No re-surgery due to vascular compromise was required.
Viability of the uterus was monitored clinically by gyneco­
logical examination and using venous and arterial Doppler
flowmeter. She has been seen twice a week since for routine
physical and blood examinations, including complete blood
count, kidney, and liver function tests and drug levels.
No rejection attack has occurred in the following period
of postoperative 2 years. The patient developed no sign of
serum sickness. No other metabolic or infectious complica­
tions related to the immunosuppressive protocol occurred.
The patient acquired irregular menstrual cycles 3 weeks
later. These became completely regular after a few months.
clinical team was a multidisciplinary one of specialists,
including reconstructive surgeons, infertility specialists,
perinatologists, transplant surgeons, anesthesiologists, trans­
plant psychiatrists, bioethicists, transplant infectious-disease
specialists, and immunologists. We then applied to the
General Directorate of Curative Services of the Turkish Min­
istry of Health for certification for our uterine allotransplan­
tation protocol. After several interviews, briefings with the
candidates, and assessments, final approval was obtained in
the first quarter of 2011. The patients were registered with
a regional organ procurement organization. We also drew
up a detailed informed consent form and a legal contract.
This contract mentioned all possible complications related
to this potentially life-threatening and non-lifesaving proce­
dure, especially well-known or foreseeable drug-related com­
plications such as severe infections, diabetes, kidney failure,
lymphoma, and bone necrosis. Risks for possible pregnancy
and fetal life were discussed and included in the form.
To prevent any possible damage from high doses of
immunosuppressive agents, especially during the induction
phase after transplantation, the recipient was prepared for
in-vitro fertilization (IVF) and embryos were obtained
before the transplantation procedure
THE DONOR
The donor was a brain-dead woman aged 22 who died after
a traffic accident and was matched to the patient in age,
blood group, and major human leukocyte antigen (HLA)
types, in another hospital in the same city. The transplant
coordinator received informed consent from the donor’s
family to recover and transplant the donor’s uterus together
with solid organs. The donor and recipient’s blood group
was A. The donor and recipient shared three HLAs. The
patient had no anti-HLA reactive antibodies and retrospec­
tive cross-match was negative. The donor and recipient were
cytomegalovirus negative.
Abdominopelvic ultrasonography revealed no anomaly,
especially regarding the donor uterus. There was no lesion
in the cervix of the donor evaluated by ThinPrep Pap test.
Testing for human papillomavirus (HPV) was performed.
SURGICAL PROCEDURE
The transplant took place on August 9, 2011. A six-surgeon
team, including four attending staff, worked simultaneously
in two operating rooms in different hospitals. One team
prepared the recipient, while the second team recovered
the donor uterine allograft. After allograft procurement
and transfer to the recipient room, all members of the team
continued the operation together.
The donor procedure started before solid organ procure­
ment. The vascular pedicles including bilateral common
iliac arteries and veins, and ovarian arteries and veins were
divided, and the extirpated uterus was wrapped with cold
gauze for topical hypothermia. The recipient procedure
started when uterine allograft blood circulation was estab­
lished based on the common iliac vascular pedicles during
the donor procedure. The uterine allograft was transferred
in orthotopic position as described above. Anastomoses
were performed between the recipient’s external iliac

778
PART 6 — RECONSTRUCTIVE TRANSPLANT S URGERY
REFERENCES
1. Dubernard JM, Owen ER, Herzberg G, et al. Human hand allograft:
report on first 6 months. Lancet 1999;353:1315–20.
2. Dubernard JM, Owen E, Lefrancois N, et al. First human hand
transplantation. Transpl Int 2000;13:S521–4.
3. Dubernard JM, Petruzzo P, Lanzetta M, et al. Functional results
of the first human double-hand transplantation. Ann Surg
2003;238:128–36.
4. Petruzzo P, Lanzetta M, Dubernard JM, et al. The international
registry on hand and composite tissue transplantation. Transplan­
tation 2008;86(4):487–92.
5. Özkan Ö, Demirkan F, Özkan Ö, et al. The first (double) hand
transplantation in Turkey. Transplant Proc 2011;43:3557–60.
6. Dubernard JM, Lengelé B, Morelon E, et al. Outcomes 18 months
after the first human partial face transplantation. N Engl J Med
2007;357:2451–60.
7. Lantieri L, Meningaud JP, Grimbert P, et al. Repair of the lower
and middle parts of the face by composite tissue allotransplanta­
tion in a patient with massive plexiform neurofibroma: a 1-year
follow-up study. Lancet 2008;372:639–45.
8. Siemionow MZ, Papay F, Djohan R, et al. First U.S. near-total
human face transplantation: a paradigm shift for massive complex
injuries. Plast Reconstr Surg 2010;125:111–22.
9. Kluyskens P, Ringoir S. Follow-up of a human larynx transplanta­
tion. Laryngoscope 1970;80:1244–50.
10. Strome M, Stein J, Strome M, et al. Laryngeal transplantation and
40-month follow-up. N Engl J Med 2001;344:1676–9.
11. Birchall MA, Bailey M, Barker EV, et al. Model for experimental
revascularized laryngeal allotransplantation. Br J Surg 2002;89:
1470–5.
12. Birchall MA, Lorenz RR, Berke GS, et al. Laryngeal transplantation
in 2005: a review. Am J Transplant 2006;6:20–6.
13. Cavadas PC, Thione A, Carballeira A, et al. Bilateral transfemoral
lower extremity transplantation: result at 1 year. Am J Transplant
2013;13:1343–9.
14. Ozkan O, Akar ME, Ozkan O, et al. Preliminary results of the first
human uterus transplantation from a multiorgan donor. Fertil
Steril 2013;99:470–6.
15. Ozkan O, Akar ME, Erdogan O, et al. Uterus transplantation from
a deceased donor. Fertil Steril 2013;100:e41.
16. Brännström M, Johannesson L, Dahm-Kähler P, et al. First clinical
uterus transplantation trial: a six-month report. Fertil Steril
2014;101:1228–36.
17. Levi DM, Tzakis AG, Kato T, et al. Transplantation of the abdomi­
nal wall. Lancet 2003;361:2173–6.
18. Selvaggi G, Levi DM, Cipriani R, et al. Abdominal wall transplanta­
tion: surgical and immunologic aspects. Transplant Proc 2009;41:
521–2.
19. Sevaggi G, Levi DM, Kato T, et al. Expanded use of transplantation
techniques: abdominal wall transplantation and intestinal auto­
transplantation. Transplant Proc 2004;36:1561–3.
20. Agarwal S, Dorafshar AH, Harland RC, et al. Liver and vascularized
posterior rectus sheath fascia composite tissue allotransplantation.
Am J Transplant 2010;10:2712–16.
21. Hofmann GO, Kirschner MH, Wagner FD, et al. Allogeneic vascu­
larized transplantation of human femoral diaphyses and total knee
joints – first clinical experiences. Transplant Proc 1998;30:2754–
61.
22. Guimberteau JC, Baudet J, Panconi B, et al. Human allotransplant
of a digital flexion system vascularized on the ulnar pedicle: a
preliminary report and 1-year follow-up of two cases. Plast Reconstr
Surg 1992;89:1135–47.
23. Birchall M. Tongue transplantation. Lancet 2004;363(9422):1663.
24. Jones TR, Humphrey PA, Brennan DC. Transplantation of vascular­
ized allogeneic skeletal muscle for scalp reconstruction in a renal
transplant patient. Transplantation 1998;65:1605–10.
25. Hu W, Lu J, Zhang L, et al. A preliminary report of penile trans­
plantation: part 2. Eur Urol 2006;50:1115–16.
26. Hu W, Lu J, Zhang L, et al. A preliminary report of penile trans­
plantation. Eur Urol 2006;50:851–3.
OTHER CTAS IN CASE REPORTS
A few other tissues have been transplanted to restore tissue
loss. A successful allogenic vascularized knee;21 vascularized
digital flexion system;22 lower extremity;13 tongue;23 vascular­
ized skeletal muscle;24 and penis25,26 (the most recent
removed for psychological reasons 2 weeks later) have been
published as case reports.
Expert Commentary 
David W. Mathes, MD, FACS
The emerging field of reconstructive transplantation is not
limited to face and hand transplantation. The expanding clini-
cal use of a vascularized composite allograft (VCA) now
includes larynx, abdominal wall, lower extremity, uterus, and
most recently a successful report of a penis transplant. As in
face and hand transplantation, the central issue for the clini-
cal application of these transplants is balancing the benefit
of the transplant with the risks posed by the need for chronic
immunosuppression.
One of the first VCAs transplanted in the United States was
the larynx. However, laryngeal transplantation is currently
limited to treating only those patients without a history of
malignancy. This limitation has significantly affected the
amount of patients that could benefit from this transplant. In
addition, it is clear that these transplants are affected by
chronic immunosuppression just as solid organ transplants
such as heart and kidney. This is illustrated by the recent
explantation of the first laryngeal transplant in 2014, due to
a slow process of chronic rejection.
Abdominal wall transplantation could benefit a much larger
patient population possibly benefiting those with abdominal
wall dysfunction due to recurrent hernia or an open abdomen
after major trauma. Currently, these transplants have only
been used in patients undergoing simultaneous visceral
organ transplantation and given the high-risk nature of the
patient population, we do not have a significant number of
long-term outcomes to evaluate. The current transplants
have also not addressed functional reinnervation of the
muscle that would be critical if the transplant is to truly
restore function.
The clinical transplant of the larynx and the abdominal wall
does not have any significant ethical issues, as has been
seen in the introduction of uterus transplantation. This trans-
plant is unique in that it only needs to be present for the
duration of the pregnancy and it also may be more easily
immunosuppressed, as it does not contain an antigenic cuta-
neous portion. The chapter discussed the authors’ use of
a deceased donor for the transplantation of the uterus.
However, the transplants performed at Sahlgrenska Univer-
sity Hospital in Sweden uses living donors. The first success-
ful uterus transplant that led to the delivery of a child was a
transplant from mother to daughter and the donor operation,
unlike the cadaveric transplant, comes with a set of surgical
risks to the donor. The successful application of this trans-
plant is likely based on the success profile of yielding a live
birth and the avoidance of the complications of immunosup-
pression on both the mother and child.
These alternative transplants offer solutions to problems
that are often not solved with current surgical techniques.
However, as with hand and face transplants, their application
will likely depend on our ability to modify the need for chronic
immunosuppression and avoidance of chronic rejection.

e210
INTRODUCTION
More than 89 upper extremities and 30 face transplants
have been performed worldwide since 1998, proving that
vascularized composite allotransplantation (VCA) is techni­
cally feasible and guarantees long-term survival under cur­
rently available immunosuppressive regimens.1
VCA is not a lifesaving procedure, thus minimization or
withdrawal of the systemic immunosuppression is impera­
tive to avoid the long-term deleterious complications related
to the chronic use of the immunosuppressive treatment.
When compared with solid organ transplants, vascularized
composite allografts contain a histologically heterogeneous
array of different tissue types (skin, muscle, bone, bone
marrow, lymph nodes, nerve, and tendon) that present dif­
ferent immunogenicity. Experimental models of limb trans­
plantation showed that skin is one of the most antigenic
tissues, and when combined with muscle, subcutaneous
tissues, and bone (including bone marrow), can generate a
high immunologic response.2,3 The vascularized muscle
component of the limb allografts was shown to be less anti­
genic than skin3; whereas bone presents lower immunoge­
nicity; and cartilage, tendon, and vessels are the least
antigenic tissues.2,3
In this chapter the authors discuss the basics of transplan­
tation immunology, the mechanisms of allograft acceptance,
and rejection as pertinent to vascularized composite
allografts. An overview of the tolerance mechanisms and
strategies developed to achieve tolerance is presented, as
well as a short summary of the novel cell-based therapies,
and their role in induction of transplantation tolerance.
Considering the increasing number of vascularized compos­
ite allografts performed worldwide, as well as their applica­
bility to the complicated cases of reconstructive surgery, it
seems imperative that plastic surgeons should become famil­
iar with these techniques and the related immunologic con­
cepts, in order to select the most appropriate candidates
and to properly inform and consent patients for these novel
procedures of reconstructive transplantation.
BASICS OF TRANSPLANTATION
IMMUNOLOGY
THE ROLE OF THE MHC/HLA ANTIGENS
The major histocompatibility complex (MHC) genes code
the strongest transplant antigens.4 Human MHC molecules
called human leukocyte antigens (HLAs) are codified by a
group of genes located on the short arm of chromosome 6.
Each parent provides a haplotype (a linked set of MHC
genes) to each offspring in the co-dominant inheritance.
There are two classes of the MHC or HLA molecules. MHC
class I molecules (HLA-A, HLA-B, and HLA-C) are expressed
on all nucleated cells and generally present endogenous
antigens, such as viruses and self-protein fragments to CD8+
T cells. Class II molecules (HLA-DP, HLA-DQ, and HLA-DR)
are constitutively expressed only on professional antigen-
presenting cells (APCs), including dendritic cells, macro­
phages, and B-cells. Their expression may be upregulated
on epithelial and vascular endothelial cells after exposure
to proinflammatory cytokines. Class II molecules present
antigens derived from the extracellular proteins to the CD4+
T-cells.5,6 The degree of HLA mismatch between the donor
and the recipient plays a role in determining the risk of
chronic rejection and graft loss in solid organ transplanta­
tion. HLA-A, -B, and -DR (three pairs, six antigens) are
traditionally used for typing and matching before kidney or
pancreas transplantation. The HLA-Cw, -DP, and -DQ typing
is currently used by many transplant centers. For kidney
transplants, the long-term graft survival is best in HLA-
identical living related kidney transplants. The major effect
is attributed to the match of the DR antigen, and the order
of importance for HLA match in kidney transplants is
HLA-DR > HLA-B > HLA-A, respectively.6
Data from the International Hand and Composite Tissue
Transplantation Registry reveal that high mismatch rates for
the hand transplantation cases were recorded in 50% of the
recipients (for all or five out of six antigens) and in 57% of
face transplant recipients.7
Immunology and Research
in Reconstructive
Transplantation
Maria Z. Siemionow  |  Bahar Bassiri Gharb  |  Antonio Rampazzo
67 
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

CHAPTER 67 — Immunology a nd Research in Reconstructive Transplantation
e211
ALLORECOGNITION PATHWAYS
Allorecognition can occur by one of the three pathways:
direct, indirect, and semi-direct.14,15 In the direct pathway,
recipient’s T-cells recognize the intact allogeneic HLAs
expressed by the donor cells. In the indirect pathway, T-cells
recognize peptides derived from the donor HLAs presented
by the recipient APC. In the semi-direct pathway, the recipient
dendritic cells or other APCs, acquire the intact HLAs from
the donor cells and present them to the recipient T cells.
The direct and indirect pathways are well recognized in
organ transplantation, whereas the semi-direct pathway is
not of the clinical importance.
The direct pathway is very important in the immediate
post-transplant period. Without appropriate immunosup­
pression, a strong and effective alloresponse would be initi­
ated, primarily due to the high number of the recipient
T-cells that will recognize the graft antigens and will cause
the acute cellular rejection. While the indirect pathway of
allorecognition may also participate in the acute rejection,
it is predominantly observed in the late onset of rejection,
as well as in the chronic rejection.14,15 As long as the allograft
is present within the host, the recipient’s APCs can pick up
the alloantigens, shed them from the graft, and start the
alloimmune response. Therefore, lifelong maintenance
immunosuppression is required in order to prevent both
the acute as well as chronic allograft rejection.
T-CELL ACTIVATION
T-cell activation is the key process of allograft rejection (Fig.
67.1). T cells recognize the alloantigens through T-cell
receptors (TCR). The initiation of the intracellular signal­
ing requires additional peptides known as CD3 complex,
and the antigen-specific signal (signal 1) is transduced
NON-HLA ANTIGENS
Acute and chronic graft rejection can occur in HLA-identical
sibling transplants, indicating presence of the immune
response to non-HLA antigens. Several non-HLA related
antigens and antibodies derived from either the alloim­
mune or autoimmune responses have been reported.8,9
ABO BLOOD GROUP ANTIGENS
ABO blood group antigens are expressed on the red blood
cells, on vascular endothelial cells, and other cells. ABO
incompatibility triggers hyperacute rejection of the organ
due to the presence of the preformed hemagglutinin A
and/or B antibodies. Desensitization protocols to remove
the preformed hemagglutinins from the recipient’s circula­
tion have been used for the ABO incompatible transplants.10
The rhesus factor (Rh) and other red cell antigens are not
relevant to the organ transplants, since they are not
expressed on the vascular endothelium.4
MINOR HISTOCOMPATIBILITY ANTIGENS
Minor histocompatibility antigens (MiHAs) are small endog­
enous peptides that occupy the antigen-binding site of the
donor MHC molecules. They are generally recognized by
CD8+ cytotoxic T-cells, leading to graft rejection. MiHA play
an important role in pathogenesis of the graft-versus-host
disease in patients who have received an HLA-matched
bone marrow transplants.11 H-Y MiHA is encoded by the
Y chromosome in males and can induce alloimmune
response when a male organ is transplanted into a female
recipient.12 MHC class I related chain A and B (MICA and
MICB) are also expressed on the endothelial cells. Antibod­
ies against MICA and/or MICB can cause antibody-mediated
rejection (AMR) and graft loss.13 Some minor transplant
antigens may be derived from the mitochondrial proteins
and enzymes.4
Figure 67.1  Immunologic mechanisms of acute allograft rejection. Acute rejection is attributable to the primary activation of T cells and
the consequent triggering of various effector mechanisms. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography
©2014. All Rights Reserved.)
Th
APC
MHC
class II
TNF-
IFN-
CD4
IL-2
IL-4
IL-5
IL-6
IL-2
IFN-
IL-2
IFN-
M
B
TC
NK
Cell mediated
cytotoxicity
Complement
Antibodies
ADCC
Graft cells
Cell damage
Inflammatory
mediators
Lytic damage
vascular
occulsion

e212
PART 6 — RECONSTRUCTIVE TRANSPLANT SU RGERY
mediated cytotoxicity, help macrophage-induced delayed
type hypersensitivity response (CD4+Th1), and help B cells
for antibody production (CD4+Th2). A subset of activated
T cells becomes the alloantigen-specific memory T cells.19,20
Current immunosuppressive medications act, blocking dif­
ferent steps of T-cell activation (Fig. 67.2).
B-CELL ACTIVATION
B cells express antigen-specific receptors as immunoglobu­
lins on their surfaces. When these receptors bind donor
HLA antigens in the presence of helper T cells (CD4+Th2),
B cells are activated. They divide, differentiate, and become
plasma cells to secrete antibodies. Some activated B cells
become memory B cells.21–23 The helper T cells may facili­
tate B-cell activation either through the intimate membrane
contact involving a variety of receptors and ligands (such as
CD40:CD154) or through the secreted soluble cytokines
(such as IL-4).17,21,23 These HLA antibodies bind antigens
and can cause graft injury either by activating the comple­
ment cascade (complement-dependent cytotoxicity) or via
the Fc receptor on natural killer (NK) cells, neutrophils,
and eosinophils (antibody-dependent cellular cytotoxicity).
In addition to producing antibodies, B cells are also the
APCs. B cells can present allograft-derived antigens to T
cells for T-cell activation through the indirect pathway of
allorecognition.5,6
REJECTION
The rejection process is an inflammatory process developed
by a specific immunologic response to the allograft antigens.
through the TCR-CD3 complex.5 Two signals are needed for
complete T-cell activation. The second co-stimulatory signal
depends on the receptor-ligand interactions between T cells
and the APCs (signal 2). Numerous co-stimulatory pathways
have been described, and blockage of these pathways can
lead to antigen-specific inactivation or T cell death.16–18
The best-studied co-stimulatory signals occur through the
CD28-B7 and CD154-CD40 pathways. CD28 and CD154 are
expressed on the T cells, and their ligands B7 and CD40 are
expressed on the APCs. T cells also express cytotoxic
T lymphocyte-associated antigen-4 (CTLA-4), which is
homologous to the CD28 and has a higher affinity than
CD28 to bind B7. However, when CTLA-4 binds B7, it pro­
duces an inhibitory signal to terminate the T-cell response.
This unique interaction leads to the clinical development
of a fusion protein CTLA-4-Ig (belatacept) as a new immu­
nosuppressive medication.18
The combination of signals 1 and 2 activates three down­
stream signal transduction pathways: the calcium-calcineurin
pathway, the RAS-mitogen activated protein kinase pathway,
and the IKK-nuclear factor κB (NF-κB) pathway. These three
pathways further activate transcription factors, including the
nuclear factor of the activated T cells, activated protein-1,
and the NF-κB, respectively. Several new molecules and cyto­
kines including CD25, CD154, interleukin-2 (IL-2), and
IL-15 are subsequently expressed.5 IL-2 and IL-15 deliver
growth signals (signal 3) through the mammalian target of
the rapamycin pathway and phosphoinositide-3-kinase
pathway, which subsequently trigger the T-cell cycle and
proliferation. The fully activated T cells undergo clonal
expansion and produce a large number of cytokines and
effector T cells, which eventually produce CD8+ T-cell
Figure 67.2  Schematic overview of mechanism and sites of action of current immunosuppressive agents. These are mostly calcineurin
inhibitors, such as cyclosporine and tacrolimus, which suppress interleukin-2 production by T cells. Treatment with mycophenolate mofetil
causes death by apoptosis in a large proportion of activated T cells by inhibiting DNA synthesis and suppressing antibody formation by B cells.
Sirolimus provides immunosuppression by inhibiting activation signals – it does this by affecting the G1 phase of the cell cycle and blocking
the second signals of activation delivered by interleukin-2, interleukin-4, and interleukin-6 to T cells. (Reprinted with permission, Cleveland Clinic
Center for Medical Art & Photography ©2014. All Rights Reserved.)
MHC class II
CD40
B7-1
B7-2
CD28
IL-2
receptor
CD40L
CD3, TCR
Ca
IL-2
production
M
G2
Cell
cycle
G2
S
IL-2
gene promoter
Calcineurin
NFAT
APC
T-Cell
Nucleus
Anti-TCR
mAb T10b9
OKT3, ATG
Prednisolone
Sirolimus
Cyclosporine
Tacrolimus
MMF
Azathioprine
Anti-CTLA4
mAB LEA29Y
Anti-CD25 mAB
Daclizumab
Basiliximab

CHAPTER 67 — Immunology a nd Research in Reconstructive Transplantation
e213
Components of acute composite allograft rejection
include vasculitis, dermatitis, myositis, and perineural
involvement – confirmed through the skin biopsy speci­
mens taken from the human hand and face transplant
recipients29–31 and from the skin biopsies provided by the
multicenter hand and abdominal wall transplant cases.32
However, severe acute rejection in solid organ allograft
recipients has been attributed to the humoral mech­anism
of the alloantibody-mediated syndrome, as a conse­quence
of alloantibody production against donor HLA.33 Pres­
ence of the donor-specific antibodies has been documented
in recipients of the upper extremity transplants and
although their significance has not been completely eluci­
dated, there have been instances where a clear link with the
acute rejection has been shown.34,35
CHRONIC ALLOGRAFT VASCULOPATHY
(CHRONIC REJECTION)
Chronic allograft destruction is a slow process that occurs
over months and/or years and presents common character­
istics in all solid organ transplants. The frequency of chronic
allograft vasculopathy correlates with the acute rejection
episodes, recipient sensitization, insufficient MHC-antigen
matching, recipient age and race, inadequate immunosup­
pression, hypertension, cytomegalovirus (CMV) infection/
reactivation, prolonged ischemia time of the graft before
transplantation, smoking, and hyperlipidemia.36
Kaufman et al.37 reported graft vasculopathy in two out
of nine hand transplant patients, with one case requiring
plasmapheresis and one resulting in graft loss. Some level
of vasculopathy was present in all of these patients, despite
normal conventional vascular imaging and unremarkable
histology of the skin biopsies. To date, no evidence of chronic
rejection has been reported in face transplant patients.1
Based on the similarity of histopathologic lesions observed
in the hand transplant recipients when compared with the
histologic specimens of the solid organ transplants, the
mechanism of chronic rejection in the VCA transplants can
be elucidated.
IMMUNOLOGIC FACTORS OF CHRONIC REJECTION
The hallmark of chronic graft rejection is attributed to the
endothelial injury of the affected vessels. Initial vascular
injury initiates an inflammatory cascade, which in turn leads
to the allograft arteriosclerosis and graft fibrosis. The cardi­
nal feature is represented by the luminal obliteration. Block­
age occurs due to the proliferation of the smooth muscle
cells that have migrated from the vessel wall and deposited
matrix proteins. Ultimately, interstitial fibrosis leads to
allograft dysfunction (Fig. 67.3). Many studies emphasize
that both direct and indirect allorecognition of donor anti­
gens promotes development of transplant vasculopathy.38
NON-IMMUNOLOGIC FACTORS OF
CHRONIC REJECTION
Brain death involves a syndrome that includes rapid swings
in blood pressure, hypotension, coagulopathy, pulmonary
changes, hypothermia, and electrolyte abnormalities.36
Organs procured from the living donors are superior to
those of brain dead donors, suggesting that brain death can
Within the first post-transplant year, 85% of hand and face
recipients experienced at least one episode of acute rejec­
tion.24 Rejection of vascularized composite allografts is
assumed to be mediated by mechanisms similar to those
observed in solid organ transplantation.25 Based on our
understanding of the rejection process in the solid organ
transplants, brief descriptions of the various mechanisms
that underlie the rejection process in VCA are presented
below.
HYPERACUTE REJECTION
Hyperacute rejection develops very rapidly within a few
minutes after transplantation and represents the classic
example of the antibody-mediated rejection process associ­
ated with the preexisting antibodies against the MHC of
donor cells. Anti-MHC antibodies may be present in the
recipient’s circulation due to prior blood transfusions, rejec­
tion of the previous transplants, or multiple pregnancies. In
addition, the presence of antibodies against the ABO blood
group system can induce hyperacute rejection.26 Most of the
damage that occurs during the hyperacute rejection process
affects the endothelial cells of capillary vessels and small
arterioles. Immunologic complexes on the vessel endothe­
lial cells activate the complement and coagulation cascade,
which leads to damage of the vascular endothelium and
ultimately to the graft dysfunction. Hyperacute rejection has
never been observed in VCA.24
ACCELERATED REJECTION
Development of accelerated rejection takes place between
24 h and 5 days after transplantation. The increased risk of
developing an accelerated phase of rejection arises from
sensitization of the allograft recipient, for example, by a
previous allograft. Accelerated rejection is associated with
the interstitial hemorrhages, vascular thrombosis, and leu­
kocyte infiltrations. Graft destruction is accompanied by
extensive endothelial deposition of humoral mediators IgM,
IgG, C3, fibrin and leukocyte infiltrations, as well as by allo­
antibody production. Pro-inflammatory cytokines such as
IFN-γ and IL-6 are present within the graft and contribute
to the graft damage.27 Accelerated rejection is considered a
classic, humoral mediated response; it precedes T-cell-
dependent mechanisms.
ACUTE REJECTION
Acute rejection occurs within a few days to a few weeks after
transplantation. Acute humoral rejection is clinically deter­
mined by the following factors: morphologic evidence of
tissue injury; the presence of complement factor 4 (C4)
deposition as the immunopathologic evidence of the
antibody-mediated action; and serologic evidence of circu­
lating antibodies to the donor human histocompatibility
antigens (HLA) or other endothelial antigens.28 This process
may be related to changes in the graft arteries or parenchy­
mal cells. During acute rejection, fibrinoid necrosis of arter­
ies and aggregation of the platelets and fibrin in the lumen
of the affected vessels leads to vascular obstruction. In addi­
tion, leakage and focal tissue necrosis occur, and inflamma­
tory cells accumulate in the interstitium of the graft. Acute
rejection is primarily a cell-mediated process and arises
from the activation of T cells and the subsequent triggering
of the various effector mechanisms.

e214
PART 6 — RECONSTRUCTIVE TRANSPLANT SU RGERY
the antigen-specific tolerance induction (Fig. 67.4).40,41 Lack
or loss of self-tolerance is likely to result in the autoimmune
responses and cellular and tissue damage, and in conse­
quence can lead to the clinical onset of the autoimmune
disease. Interactions between the antigen-presenting cells
and the lymphocytes are critical for self-tolerance, and these
are known to take place in the thymus (central tolerance)
and peripheral lymphoid tissues (peripheral tolerance).
In the thymus, the developing lymphocytes with no
marked reactivity against the self-peptides are positively
selected in the thymic cortex and enter circulation as the
mature lymphocytes. In contrast, developing lymphocytes
with the marked reactivity against self-peptides undergo
negative selection (clonal deletion) in the thymic medulla.40
Some potentially self-reactive T lymphocytes may escape
from the thymus into the periphery. Peripheral tolerance
mechanisms are operative in the extra-thymic lymphoid
tissues and include elimination of the self-reactive T cells,
anergy, antigen ignorance, apoptosis, exhaustion, and active
suppression by the regulatory T cells. Anergy is the state in
which T cells are alive but unable to respond to the antigen
stimulation.42 Anergy may be induced by the lack of
co-stimulatory signals and, in consequence, this process may
lead to apoptosis.43,44 Ignorance may occur when the donor
antigens (e.g., from the graft) are not delivered to the recip­
ient lymphoid system or when the recipient lymphocytes are
unable to recognize the donor antigens. For true antigen-
specific tolerance, the immune system must not respond to
the allograft antigens, but maintain its ability to respond to
influence graft quality. Animal models reveal that after brain
death, the levels of catecholamines and cytokines increase
and MHC class I and II antigens are upregulated, implying
that the immunogenic response in the peripheral organs is
increased.39
A second non-immunologic factor that may increase the
immunologic response is the ischemia-reperfusion injury.
Ischemia-reperfusion may contribute not only to the early
delayed graft function but also to the late allograft dysfunc­
tion, and it may be a risk factor for chronic allograft vascu­
lopathy. Total allograft ischemia time includes the transient
warm ischemia time before or during allograft removal from
the donor, the cold ischemia time associated with organ
preservation, and ischemia time during the period of organ
revascularization.38 The factors associated with organ
removal, storage, and engraftment may increase the immu­
nogenicity of allografts by upregulation of the MHC anti­
gens and activation of the cytokine cascade, which in turn
leads to the leukocyte infiltration and ultimately to the oblit­
erative vasculopathy and fibrosis.39
TOLERANCE
Immunologic self-tolerance is a stable state in which the
immune system does not react destructively against self-
antigens. To maintain self-tolerance and to defend against
pathogens, a highly balanced mechanism has evolved for
generation of the antigen-specific effector cell responses and
Figure 67.3  Immunologic mechanism of chronic allograft vasculopathy. The hallmark feature of chronic graft rejection is injury to the
vessels’ endothelium. The culprit lesion is luminal obliteration caused by blockage of the blood vessels in the graft. Blockage occurs because
of the proliferation of smooth muscle cells that have migrated from the vessel wall and deposited matrix proteins. Ultimately, fibrosis leads to
allograft dysfunction. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2014. All Rights Reserved.)
M
Fibrosis
Smooth muscle
cell proliferation
T
TGF-
IFN-
IL-1
IFN-
IL-2
Antibodies
CMV
Luminal
obliteration
Vessel
endothelial cells

CHAPTER 67 — Immunology a nd Research in Reconstructive Transplantation
e215
myeloablation and replaced fully (100% donor cells) by the
donor hematopoietic cells, or mixed chimerism, which is
induced after non-myeloablative host conditioning when
donor and recipient hematopoietic cells coexist with the
recipient (donor cells >1% and <100%).49 Macrochimerism
can be assessed by flow cytometry and monoclonal antibod­
ies specific for the donor MHC class I and class II. The third
type of chimerism is defined as microchimerism (donor-
derived cells <1%) and usually occurs spontaneously after
organ transplantation.49,52–54
Early experimental protocols in mice, relied on the mye­
loablative conditioning and complete reconstitution with
donor hematopoietic stem cells in order to achieve engraft­
ment and chimerism55; however, such protocols carry signifi­
cant morbidity and a risk of impaired immunocompetence,
which would not be considered acceptable outside the field
of hematological malignancy. The development of non-
myeloablative conditioning regimens leading to the engraft­
ment and mixed chimerism with significantly reduced
morbidity, represents a key step in the search for clinically
relevant tolerance induction regimens and have been dem­
onstrated in the small56 and large animal models,57 as well
as in the clinical protocols.58
Interestingly, the establishment of stable, mixed chime­
rism may not be required for the rejection-free, long-term
survival of various organs and tissues. In both the precli­
nical and clinical studies, the transient mixed chimerism
was found to be sufficient for the induction of renal allo­
graft tolerance.59,60 Leventhal et al.61 reported establish­
ment of durable chimerism and kidney transplant tolerance,
without graft versus host disease. Non-myeloablative con­
ditioning and transplantation of the enriched hemato­
poietic stem cells in combination with infusion of the
dendritic cells, resulted in development of chimerism and
permitted weaning of immunosuppression in five out of
eight patients.
In contrast to the kidney studies and despite the success
reported in rodents, the studies in large animal recipients
of bone marrow and vascularized composite allografts
other antigens, including viruses and bacteria.45,46 Although
the main goal in organ transplantation is to develop com­
plete stable tolerance to prevent immunosuppression-
related side effects, this goal is difficult to achieve in all
organ recipients because of the heterogeneity of the donor-
recipient combinations, the immune status, and the severity
of underlying disease. Currently, the definition of tolerance
(normal graft function, normal histology, and withdrawal of
immunosuppression) is incomplete and represents a chal­
lenge in clinical practice.
A new concept of “prope” (almost) tolerance was first
introduced by Calne et al.47 and is defined as the donor-
specific hyporesponsiveness under a low dose of immuno­
suppressive therapy. A concept of prope tolerance leads to
reduced immunosuppression-related side effects and allows
for improved allograft survival without episodes of acute or
chronic rejection.47,48
Sachs stated that the simple definition of transplantation
tolerance – graft acceptance in the absence of exogenous
immunosuppression – is not sufficient in the clinical prac­
tice because a downregulatory response (not merely the
absence of a response) is currently considered a tolerant
state, regardless of the mechanism.45 This partial tolerant
state with a minimal baseline nontoxic dose of maintenance
therapy is suggested to be clinically more appropriate.
CHIMERISM AND DONOR BONE
MARROW TRANSPLANTATION
The persistence of donor-origin cells within the recipient
compartment is known as chimerism.49 Transplanted organs
contain large numbers of cells of bone marrow origin known
as the passenger leukocytes.50,51 These cells may migrate
from the transplanted tissues and colonize the lymphoid
and non-lymphoid organs of the recipients. The load of the
donor leukocytes can be increased in the recipients by infu­
sion of the donor bone marrow cells. Donor hematopoietic
cells can develop two types of macrochimerism: full chime­
rism when the recipient immune system is destroyed by
Figure 67.4  T-helper 1 (Th1) cytokines are involved in cellular immunity and in allograft rejection, whereas T-helper 2 (Th2) cytokines promote
humoral immunity and allograft acceptance. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2014. All Rights
Reserved.)
Th1 cytokines
IL-2
IFN-
TNF-
Th2 cytokines
Rejection
Acceptance
IL-4
IL-5
IL-10
TGF-

e216
PART 6 — RECONSTRUCTIVE TRANSPLANT SU RGERY
murine model, administration of T-regulatory cells of the
donor origin, combined with anti-CD40L monoclonal anti­
body, CTLA4Ig co-stimulatory blockade, and a short course
of rapamycin, resulted in cell engraftment, development of
stable multilineage chimerism, and subsequent tolerance to
skin allograft following radiation-free conditioning and con­
ventional dose bone marrow transplantation in a fully mis­
matched murine.73 Rapamycin proved to facilitate selective
expansion of T-regulatory cells while inhibiting clonal pro­
liferation of the effector cells.74
Issa et al. demonstrated the ability of Tregs to prevent
transplant arteriosclerosis (a hallmark of chronic graft rejec­
tion), and uniquely, to induce tolerance to human skin
allografts.75 There is also evidence that in the context of
bone marrow transplantation, donor CD4+CD25+ cells may
protect against acute graft-versus-host disease (GvHD).76,77
The outcomes of these experiments are certainly encourag­
ing, but further work is required to refine the specificity of
the Treg markers, and to provide evidence of the efficacy of
this protocol in the large animal models prior to consider­
ing the therapeutic application of T-regulatory cells in the
clinical cases of VCA.
DENDRITIC CELLS
Dendritic cells (DCs) as the specialized antigen presenting
cells, are known to facilitate immunologic tolerance.78,79
They exert their tolerogenic effects through the interaction
with T cells and they have been shown to suppress CD4+ and
CD8+ T cell proliferation80 and to control the activation and
function of the CD4+ CD25+ Foxp3+ Tregs.81
The immature dendritic cells (characterized by a low
expression of the cell surface MHC II and co-stimulatory
molecules) induce tolerance on interaction with T cells,
while mature dendritic cells (high expressers of the MHC
II and co-stimulatory molecules) induce an effector response
from the T cells.82 However, it has been demonstrated that
dendritic cells may be directed toward change of the phe­
notype by ligation of specific cell surface receptors.83
Tolerance of cardiac transplants has been achieved in
rodent models following administration of the donor
allopeptide-pulsed DCs in combination with a short course
of antilymphocyte serum.84 Long-term survival of skin
allografts and hind-limb composite tissue allotransplants,
have also been demonstrated, in some cases supported by
expansion of Tregs.85–89 In the context of mixed chimerism
protocols, it has been demonstrated in the murine model
that co-transplantation of bone marrow cells with the imma­
ture dendritic cells leads to engraftment and stable multi­
lineage chimerism without cytoreductive conditioning and
with no evidence of GvHD. These chimeras showed long-
term acceptance of cardiac allografts, and while skin toler­
ance was not achieved, the challenged skin grafts showed
significantly prolonged survival.90
There have been some early studies in non-human pri­
mates, which demonstrated the presence of the tolerogenic
dendritic cells which modulated T-cell responses to alloan­
tigens.91 It was also demonstrated that dendritic cells are
able to induce tolerance in rhesus macaques and facilitate
expansion of T-regulatory cells in human volunteers.92,93
These findings point to the possibility of “negative cellular
vaccines” as a potential route to tolerance in the composite
transplants, but further preclinical work is required.
suggest that these transplants may have more stringent
requirements.62 A series of preclinical studies in the large
animal models indicates, that while tolerance of the muscu­
loskeletal components of the vascularized composite
allografts may be induced by protocols leading to transient
chimerism, induction of tolerance to the skin components
is associated with the engraftment of donor hematopoietic
stem cells, leading to the development and maintenance
of mixed chimerism.63–65 In large animal models, the
most promising results have been achieved using non-
myeloablative conditioning regimens and hematopoietic
stem cell transfer in the MHC-matched animals receiving a
short course of the immunosuppressive therapy.65,66
In the human hand allograft recipients, despite the trans­
fer of the bone marrow component, peripheral chimerism
has not been detected. Only transient microchimerism was
reported, and described as presence of the donor antigen-
presenting cells in the epidermis only at 77 days after hand
transplantation; however, it was not detected thereafter.67,68
Immunosuppressive protocol of the first French face
transplant patient included thymoglobulin, tacrolimus,
mycophenolate mofetil, prednisone, and two infusions of
the donor bone-marrow cells.69 The patient did not develop
graft-versus-host disease and only a very low level of micro­
chimerism (0.1% of the donor cells within the CD34+
enriched bone marrow cell population) was detected in the
peripheral blood at 2 months after transplantation.70 At 5
years after transplantation, the patient is on maintenance
immunosuppression consisting of sirolimus, mycophenolate
mofetil, and prednisone.70
Schneeberger et al.34 reported early results of a protocol,
which combined pre-transplant lymphoid depletion with
the delayed post-transplant donor bone marrow cell infu­
sion. This protocol resulted in graft survival under tacroli­
mus monotherapy in five hand/forearm transplant
recipients. Patients demonstrated sustained improvement
in the motor function and sensory recovery. Infections were
not reported. Post-transplant immunomonitoring revealed
transient presence of moderate levels of the donor-specific
antibodies and adequate immunocompetence. High-
resolution ultrasound biomicroscopy demonstrated the
presence of patent vessels with mild luminal narrowing/
occlusion reported only in 1 patient. Protocol skin biopsies
showed absent or minimal perivascular cellular infiltrates.
CELL-BASED THERAPIES IN VCA
Achieving mixed chimerism while minimizing the adverse
effects of the conditioning protocols remains a challenging
task and a variety of cell-based therapies have been investi­
gated as the potential adjunct therapies in an effort to
enhance transplant engraftment and survival and to miti­
gate complications such as GVHD.
T-REGULATORY CELLS
T-regulatory cells (Tregs) represent a population of the lym­
phocytes capable of suppressing the immune responses.
CD4+CD25+FoxP3+ T regulatory cells were shown to prevent
both the acute and chronic rejection of skin and cardiac
allografts.71,72
Following radiation-free conditioning and delivery of
conventional dose of bone marrow in a fully mismatched

CHAPTER 67 — Immunology a nd Research in Reconstructive Transplantation
e217
MESENCHYMAL STEM CELLS
Mesenchymal stem cells (MSCs) are a component of the
bone marrow stroma, and play a homeostatic role in hema­
topoiesis, through synthesis of cytokines and growth
factors.94,95 MSCs have been shown to lack expression of the
co-stimulatory molecules and consequently, have limited
capability for stimulating alloreactive T cells.96–98 Further­
more, MSCs possess immunological inhibitory potential,
suppressing proliferation in the mixed lymphocyte cultures
and prolonging skin allograft survival in the rodent trans­
plantation model.99,100
The natural physiologic role of the MSCs within bone
marrow stroma, has been found to be successful in treat­
ment of GvHD in patients following bone marrow transplan­
tation.101 MSCs were proven to facilitate engraftment and
induction of tolerance to composite limb allografts. In the
rat model of hindlimb allotransplantation, supported with
an immunosuppression protocol consisting of antilympho­
cyte serum, rapamycin, total body irradiation, bone marrow
cells transplantation, and MSCs, the animals exhibited
stable chimerism, tolerated their transplanted limbs for over
100 days without any exogenous immunosuppression, and
showed no evidence of GvHD.102 Application of the MSCs
as the supportive therapy was successful in combination with
bone marrow transplantation in tolerance induction in the
large animal model. In an outbred miniature swine model,
the survival of heterotopic hindlimb allografts was achieved
for over 200 days in animals treated with irradiation, bone
marrow transplantation, and 28-day protocol of cyclospo­
rine, combined with three doses of donor MSCs. Interest­
ingly, while no signs of GvHD were observed, the same
regimen in the absence of MSCs resulted in a maximal
allograft survival of 57 days and symptoms of severe GvHD
leading ultimately to animals’ death.103
The only clinical application of MSCs, in the VCA, was
reported by Del Bene et al.104 where autologous MSCs were
infused at 12 h, following double hand transplantation. The
immunosuppressive protocol consisted of basiliximab,
tacrolimus, mycophenolate mofetil, and methylpredniso­
lone. Prednisone was completely withdrawn at 7 months
post-transplantation.
MSC-based protocols alone or in combination with other
cell therapies seem promising in VCA; however, their appli­
cation is still at the experimental stage and further proof of
their efficacy is needed.
Expert Commentary 
Yur-Ren Kuo MD, PhD, FACS
More than 120 upper extremities and face transplants have
been performed worldwide since 1998, proving that vascular-
ized composite allotransplantation (VCA) is technically feasible
and guarantees long-term survival under currently available
immunosuppressive regimens. However, VCAs are not rou-
tinely performed for tissue reconstruction because of the
potentially harmful adverse effects associated with lifelong
administration of immunosuppressive agents. The ideal immune
suppression regimen in VCA is a challenge that remains unan-
swered as illustrated by the significant variation among centers
performing these procedures. Although similarities to solid
organ transplantation protocols exist, there are significant dif-
ferences that require a unique approach to achieve the neces-
sary suppression while attempting to minimize associated
complications. Therefore, researchers have been eagerly
seeking alternative methods that overcome the immunologic
barrier for establishing lifelong tolerance, while minimizing toxic-
ity. Consequently, a reduction of maintenance immunosup-
pression or applied new co-stimulatory blockade has recently
been investigated in some small clinical trials. In contrast, pre-
clinical experimental focused on immunomodulatory protocols
have been performed in different animal models. There is an
abundance of experimental protocols that are promising for
tolerance induction. Non- or partially myeloablative conditioning
in animal models are indispensable for the development of
tolerance strategies. Some of these new cell therapy strategies,
such as donor bone marrow transplantation (BMT), immature
dendritic cells, bone marrow-derived, or adipose tissue-derived
mesenchymal stem cells (MSCs), regulatory T-cells, etc., have
already been tested in preclinical models with encouraging
results. In clinical trials, hematopoietic stem cell or MSC infu-
sions have been attempted in VCA patients with the goal of
inducing chimerism, and minimizing post-transplant immune
suppression. Moreover, application of less or short-term immu-
nosuppressants can be achieved when in combination with
cell-based therapy. However, details of how these cells act at
different sites (such as allografts, lymph nodes, thymus, spleen,
or bone marrow) for tolerance induction are yet to be charac-
terized. This information will relate to how to optimize the cell-
based therapy protocols in terms of the timing and route of
administration, frequency and dose of administered cells, and
the appropriate combination of immunosuppressant to admin-
ister. The hope is to have further translational studies and
development of new immunomodulatory strategies for clinical
trials in VCA.

e218
PART 6 — RECONSTRUCTIVE TRANSPLANT SU RGERY
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91. Zahorchak AF, Kean LS, Tokita D, et al. Infusion of stably imma­
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92. Dhodapkar MV, Steinman RM, Krasovsky J, et al. Antigen-specific
inhibition of effector T cell function in humans after injection of
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93. Dhodapkar MV, Steinman RM. Antigen-bearing immature den­
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96. Majumdar MK, Keane-Moore M, Buyaner D, et al. Characteriza­
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97. Glennie S, Soeiro I, Dyson PJ, et al. Bone marrow mesenchymal
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98. Krampera M, Glennie S, Dyson J, et al. Bone marrow mesenchy­
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99. Sbano P, Cuccia A, Mazzanti B, et al. Use of donor bone marrow
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in a preclinical rat model. Arch Dermatol Res 2008;300:115–24.
100. Bartholomew A, Sturgeon C, Siatskas M, et al. Mesenchymal stem
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54. Starzl TE, Demetris AJ. Transplantation tolerance, microchime­
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441–55.
55. Ildstad ST, Sachs DH. Reconstitution with syngeneic plus alloge­
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131:305e–7e.

779
Peripheral Nerve
Allotransplantation
Amy M. Moore  |  James T.W. Saunders  |  Susan E. Mackinnon
68 
INTRODUCTION
Peripheral nerve injuries are common and can be function­
ally devastating. Improved understanding of nerve topogra­
phy, injury, and regeneration has led to advances in
peripheral nerve surgery and increased treatment options
for our patients.
Traditionally, when a tensionless repair cannot be per­
formed, a nerve autograft is employed to bridge the defect.
However, autografts can be associated with additional surgi­
cal sites, increased operative time for harvesting, and poten­
tial donor site morbidity, including sensory loss, scarring,
and debilitating neuroma formation.1–3 Further, in the cases
of large, segmental or multiple limb injuries, the amount
of expendable autograft becomes a limitation. For these
reasons, alternatives including nerve allotransplantation
and processed nerve allografts were developed.
More recently, vascularized composite tissue allotrans­
plantation has become a reality for the treatment of devas­
tating injuries involving traumatic amputations or significant
facial disfigurement. Since 1998, over 100 hand and 30 face
transplants have been performed, with published reports of
72 hand and 19 face transplantations.4 The function of these
transplanted parts is dependent on specificity and efficacy
of the nerve regeneration. The purpose of this chapter is to
explore and review nerve autograft alternatives. Specifically,
we focus on the biology of nerve allografts, review the clini­
cal experience of nerve allotransplantation, and discuss
nerve regeneration in the setting of vascularized composite
allotransplantation (VCA). We will also briefly describe the
clinical evidence for the use of nerve conduits and pro­
cessed nerve allografts.
PERIPHERAL NERVE REGENERATION
A peripheral nerve injury initiates a highly regulated and
sophisticated sequence of events. This process is dependent
on the degree of nerve injury. Establishing the severity of
the injury will help predict if recovery is possible and if surgi­
cal intervention is needed. Seddon first classified nerve
injury into neurapraxia, axonotmesis, and neurotmesis.
Sunderland and Mackinnon later revised the classification
system (Table 68.1).123,124 A neurapraxia involves localized
myelin damage. The axon is preserved and thus the nerve
does not undergo degeneration.5 Axonal disruption, in con­
trast, leads to Wallerian degeneration distal to the site of
injury with coordinated activation of Schwann cells (SCs)
and macrophages to remove myelin and axonal debris.5–9
Proximal to the injury, mitogenic cytokines released
by the injured axons induce SCs to change into a proliferat­
ing phenotype.10,11 These proliferating SCs organize into
columns along the basement membrane of endoneurial
tubes and are referred to as “bands of Büngner” and they
support axonal regeneration. Axons are initially pruned and
then begin to sprout and regenerate along these bands to
reestablish nerve continuity and reach the end-organ
Table 68.1  Classification of nerve injury
Seddon
Sunderland
Description
Recovery
Neuropraxia
I
Conduction block
Spontaneous recovery
Axonotmesis
II
Axonal Injury
Spontaneous recovery
III
Axonal and Endoneurium Injury
Partial recovery without surgical intervention
IV
Axonal, Endoneurium, and Perineurium Injury
No recovery without surgical intervention
Neurotmesis
V
Axonal, Endoneurium, Perineurium, and
Epineurium Injury (Nerve Transection)
No recovery without surgical intervention
VI
Mixed pattern injury
Mixed recovery based on injury pattern
(From Millesi H. Bridging defects: autologous nerve grafts. Acta Neurochir Suppl 2007;100:37–8 and Abrams M, Widenfalk J. Emerging
strategies to promote improved functional outcome after peripheral nerve injury. Restor Neurol Neurosci 2005;23[5–6]:367–82.)
PART 6  —  RECONSTRUCTIVE TRANSPLANT SURGERY

780
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
SCs and extracellular matrix, despite undergoing Wallerian
degeneration themselves.15 Autografts are typically chosen
based on their caliber, the length of the nerve gap, donor
site morbidity, and ease of harvest. Due to the ease of
harvest, the long length, and minimal donor site morbidity,
one of the most commonly used autografts is the sural
nerve.16,17 Other suitable nerves for interpositional grafts are
reviewed in Table 68.2.
target.12–14 In humans, this regenerative rate is reported to
occur at 1–3 mm/day.14
Segmental nerve defects or tension at the site of injury
will disrupt the normal cascade of events preventing regen­
eration. Traditionally, interposed autografts have served as
a bridge or structural framework to allow regeneration to
proceed and are considered the gold standard. They provide
the necessary medium for regeneration, including viable
Table 68.2  Characteristics of suitable interpositional nerve graft options
Nerve graft
Potential length
Characteristics
Sural
30–40 cm
Formed from the medial cutaneous sural nerve originating from the tibial nerve
Common donor nerve
Descends the leg between the two heads of the gastrocnemius becoming superficial just
before it is joined by the sural communicating branch off the peroneal nerve
The donor defect involves the lateral and posterior part of the lower third of the leg but
decreases in size over time
Medial
antebrachial
cutaneous
20 cm
Travels down the arm medial to the brachial artery then becomes superficial to the deep
fascia in the middle of the arm and runs distally with the basilica vein
Typically bifurcates proximal to the medial epicondyle into anterior and posterior branches
Harvesting the anterior branch avoids loss of sensation over the elbow
Lateral
antebrachial
cutaneous
5–8 cm
Distal continuation of the musculocutaneous nerve
Exits from under the biceps tendon and splits into an anterior and posterior branch, running
with the cephalic vein
Sensory defect involves the anterolateral forearm but can involve the volar radial or
dorsoradial thumb
Significant or total overlap of sensory innervation with the superficial sensory radial nerve
Posterior
cutaneous
nerve of the
forearm
2–5 cm
Sensory branch of the radial nerve
Arises from the radial nerve in the spiral groove and passes through the lateral head of the
triceps
Descends down the lateral aspect of the arm and terminates at the dorsal forearm and wrist
Provides sensation to the posterolateral forearm and is rarely used
Superficial
radial nerve
15–20 cm
Prone to painful neuroma formation, therefore not a first-line choice
It may be used for proximal radial nerve injuries
Separates from the radial nerve just distal to the elbow
Becomes superficial as it wraps around the brachioradialis 7 cm proximal to the wrist crease
Sensory defect corresponds to the dorsum of the thumb and the 1st and 2nd web spaces
Dorsal sensory
branch of the
ulnar nerve
4–6 cm
Appropriate size and length for use as a digital nerve
Takeoff from the ulnar nerve 5 cm proximal to the wrist
Travels along the dorsomedial aspect of the wrist before dividing into two or three terminal
dorsal branches
Painful neuroma formation is not typical
Donor defect involves the dorsal ulnar wrist, hand, and proximal parts of the ulnar two fingers
Posterior
interosseous
nerve
6 cm
Terminal portion of the PIN provides wrist joint capsule proprioception
Lies deep to the 4th extensory compartment
Good donor for digital nerve defects
No apparent motor or sensory defect

CHAPTER 68 — Peripheral Nerve Allotransplantation
781
Table 68.2  Characteristics of suitable interpositional nerve graft options—cont'd
Nerve graft
Potential length
Characteristics
Anterior
interosseous
nerve
7 cm
Terminal portion of the AIN provides wrist joint capsule proprioception and innervates the
pronator quadratus
Lies adjacent to the anterior interosseous artery on the volar aspect of the interosseous
membrane as it enters the pronator quadratus
No clinically apparent motor or sensory defect
Superficial
peroneal nerve
30–35 cm
Major lateral branch of the common peroneal nerve innervating the peroneus longus and
brevis, in addition to providing sensation to the lateral aspect of the lower leg and dorsal foot
Consistently long graft
Donor defect motor and sensory
Saphenous
nerve
40 cm
Largest cutaneous branch of the femoral nerve
Becomes subcutaneous between the sartorius and gracilis tendons
Advances down the leg next to the saphenous vein
Donor defect involves the medial aspect of the lower leg
Do not take the saphenous and sural nerve from the same leg as their cutaneous innervation
overlaps and the resulting donor defect is significant
Intercostal
nerves
20 cm
Mixed motor/sensory nerve innervating accessory respiratory muscles of the thoracic wall
and overlying skin
Donor site incision can be large and invasive
Risk of pneumothorax
Avoid harvesting T4 intercostal nerve to preserve sensation to nipple areola complex
Lateral
cutaneous
nerve of the
thigh
10–20 cm
Donor defect involves loss of sensation to the anterolateral aspect of the thigh.
(Adapted from Slutsky D. A practical approach to nerve grafting in the upper extremity. Atlas Hand Clin 2005;10[1]:73–92 and Meek MF,
Coert JH. Clinical use of nerve conduits in peripheral-nerve repair: review of the literature. J Reconstr Microsurg 2002;18[2]:97–109.)
NERVE ALLOTRANSPLANTATION
In large, segmental, complex, or multi-limb nerve injuries,
the amount of available autograft sources may be limited.
Nerve allografts, from either a cadaver or living donor
provide an abundant source of nerve graft. They also avoid
the donor site morbidity of nerve autografts, but require
systemic immunosuppression for their use. In the presence
of adequate immunosuppression, nerve allografts provide
equal regeneration and function of an autograft.18,19 Studies
even demonstrate enhanced regeneration in nerve allografts
due to the regeneration-enhancing effects of the immuno­
suppressant, tacrolimus.20,21
Systemic immunosuppression has known risks. These
include, but are not limited to, increased risk for opportu­
nistic infections, nephrotoxicity, and decreased cancer
immunosurveillance, resulting in malignancy.22,23 Due to the
toxicity and risks of immunosuppression, the indication for
nerve allografts has been narrow, and careful selection of
the patients is important. Currently, nerve allotransplanta­
tion is reserved for unique clinical situations of devastating
nerve injuries that are not amenable to nerve transfers or
nerve autografting, and conservative management would
result in a nonfunctional limb or nonmanageable pain.
Nerve allotransplantation is unique when compared with
solid organ and composite tissue transplantation. The nerve
allografts act as a biological and temporary conduit through
which host motor and sensory axons traverse to reach the
host end-organ target. Thus, nerve allografts require only
temporary systemic immunosuppression,24 which can be
withdrawn once the axons have crossed the allograft.18,25
SCHWANN CELLS AND IMMUNOLOGY OF
NERVE ALLOTRANSPLANTATION
As previously discussed, SCs are an integral part of injured
axonal recovery as they provided both neurotrophic factors
and structural integrity.7,11,26 In both nerve autografts and
allografts, SCs are essential for supporting axonal regenera­
tion and subsequent remyelination.27–29 In nerve allografts,
both donor and host SCs proliferate and support axonal
regeneration as long as adequate immunosuppression is
present (Fig. 68.1A).

782
PART 6 — RECONSTRUCTIVE TRANSPLANT SURGERY
CURRENT STRATEGIES FOR NERVE
ALLOTRANSPLANTATION
Effort to mitigate donor alloantigenicity and host immune
response to allografts is currently the source of significant
clinical and laboratory investigation. In an attempt to
prevent rejection of the allogenic nerve and simultane­
ously allow nerve regeneration, two strategies have been
employed: (1) minimize the antigenicity of the nerve graft
and (2) minimize the host immune response to the allo­
graft tissue.
Strategies to decrease the antigenicity of the nerve
graft include numerous decellularizing techniques such
as cold preservation, radiation, lyophilization, and freeze-
thawing.40–50 These attempts to minimize the induction of
the host immune response created nerve grafts with incon­
sistent efficacy in supporting nerve regeneration. Due to
their acellular nature and sometimes altered structural
make-up, these treated grafts failed to reach results equiva­
lent to autologous nerve grafts, especially over longer graft
lengths.51,52 Thus, these techniques are not utilized indepen­
dently in practice.
Cold preservation has successfully been shown to reduce
allogenicity of nerve allografts. The effects are dependent
on length of exposure. Increased storage time leads to
decreased allogenicity (6 weeks) but also correlates with
decreased axonal regeneration.53,54 One week of cold pres­
ervation, however, reduced the expression of MHC class II
alloantigens but did not reduce the number of viable
Host SC migration is essential in the process of nerve
regeneration across a nerve allograft. It occurs from both
the proximal and distal nerves.30,31 Eventually, donor SCs are
lost, despite adequate immunosuppression, but this is from
an unclear mechanism and may involve chronic rejection
or episodes of subtherapeutic immunosuppression. Our
laboratory explored SC migration and found, under immu­
nosuppression, host SC migration into the graft is delayed.
However, after regeneration was completed and immuno­
suppression was stopped, host SC migration occurred imme­
diately to fill in the gaps left by the loss of the rejected donor
SCs along the graft (Fig. 68.1E).32
SCs are also known to play a large immunogenic role in
nerve allograft rejection. They express major histocompat­
ibility complex I (MHC-I), a molecule on cellular mem­
branes that is responsible for displaying fragments of
intracellular proteins to T cells to either trigger or prevent
an immune response. Transplanted SCs also increase their
expression of MHC II molecules,33–38 a family of molecules
found on antigen-presenting cells and B-cell lymphocytes,
increasing their host rejection response. For this reason, SCs
are recognized as a prime target of the host alloimmune
response.33–39 Because SCs play a large role in both axonal
regeneration and allograft rejection, immunosuppression
cannot be safely withdrawn until regeneration has reached
the end-target organ. Functionally, removal of immunosup­
pression prior to repopulation of the donor graft by host
SCs will result in donor SC death and a subsequent, devastat­
ing conduction block (Fig. 68.2).14,24
Figure 68.1  Schwann cell migration in a nerve allograft. (A) Nerve autograft contains native, non-immunogenic, Schwann cells that are
capable of supporting axonal regeneration. (B) Nerve allografts contain immunogenic non-host Schwann cells capable of supporting axonal
regeneration under immunosuppression (yellow box). (C) Migration of host Schwann cells, to slowly replace donor Schwann cells, occurs from
both proximal and distal nerve stumps into the donor graft to support axonal regeneration. (D) Over time, the entire donor Schwann cell popu­
lation of the nerve allograft is replaced with host Schwann cells. (E) After complete replacement of the donor Schwann cell population, immu­
nosuppression can be withdrawn without risk of the host initiating an immunogenic response to the allograft tissue.
Cell body
Nerve autograft
Nerve allograft
Immunosuppression
Muscle
Graft
Immunosuppression withdrawal
Schwann cell migration
Schwann cell migration
A
B
C
D
E

CHAPTER 68 — Peripheral Nerve Allotransplantation
783
Figure 68.2  Effects of premature immunosuppression withdrawal in nerve allograft. (A) Nerve autograft contains native, nonimmunogenic,
Schwann cells that are capable of supporting axonal regeneration. (B,C) Under immunosuppression, host Schwann cells migrate from both
the proximal and distal nerve stumps into the donor graft to slowly replace donor Schwann cells capable of supporting axonal regeneration.
(D) Premature withdrawal of immunosuppression results in rejection of donor Schwann cells and segmental loss of myelination. (E) Demyelin­
ation results in conduction block.
Cell body
Nerve autograft
Nerve allograft
Immunosuppression
Muscle
Graft
Conduction block
Early immunosuppression withdrawal
Schwann cell migration
Schwann cell migration
A
B
C
D
E
SCs.50,54,55 Thus, our current clinical protocol involves 7 days
of cold preservation of the nerve allografts at 4–5°C in Uni­
versity of Wisconsin solution prior to implantation (see
Table 68.4).
The advent of successful systemic immunosuppressive
therapy has further allowed nerve allotransplantation to
have clinical importance.56–58 Early work in peripheral
nerve allograft immunosuppression involved the use of
cyclosporine, but later shifted to the more potent calcineu­
rin phosphatase inhibitor, FK-506.14,19–21,59,60 FK-506, also
known as tacrolimus, inhibits the activation of T-cell prolif­
eration,60 but has been shown in numerous animal models
to enhance and accelerate nerve regeneration.31,61,62 Numer­
ous calcineurin-independent pathways have been impli­
cated in FK-506’s ability to enhance regeneration via
mediators including growth associated protein 43 (GAP 43),
FKBP-52, heat shock protein 90 (HSP-90), and cytoskeletal
dynamics, but the exact mechanism has not yet been
elucidated.63–66 Regardless of the mechanism, FK-506’s
ability to speed regeneration and increase reinnervation of
distal targets is well accepted.
Our clinical and laboratory experience with FK-506 has
provided parameters for maximizing the benefits of this
immunosuppressant. Low-dose/subtherapeutic doses of
FK-506 equally provide regenerative enhancement to full
dose administration.67 Thus, alternative immunosuppression
regimens such as co-stimulatory blockade can be used with
low-dose FK-506. However, the beneficial results of FK-506
were eliminated when both full dose and co-stimulatory
blockade were given.67
The timing of FK-506 administration is also important
when considering the beneficial effects of the drug. Delay
of administration should be avoided and preloading the
drug before nerve repair should be considered. Animal
studies revealed that the neuroregenerative effects dimin­
ished with delayed administration.68 If given after 5 days in
a transection and repair model, no beneficial effects of the
drug were seen. Preloading the drug 3 days before nerve
transection and repair, in contrast, further enhanced the
neuroregenerative effects.69 Although this timing is not pos­
sible in vascularized composite allotransplantation (VCA)
due to the unpredictable nature of donor availability, there
is a window of time – while the donor tissue is being pro­
cured and prepared – when administration of loading doses
of FK-506 could be given. Ideally, FK-506 should be given
for the duration of nerve regeneration and should be
included in the maintenance regimens in VCA.14
Our current immunosuppressive regimen involves both
graft pretreatment and systemic immunosuppression. The
senior author’s clinical experience and preferences will be
elaborated on in the next section.
CLINICAL EXPERIENCE WITH NERVE
ALLOTRANSPLANTATION
As discussed previously, the indications for nerve allotrans­
plantation are limited due to the risks of immunosuppres­
sion. Currently, nerve allotransplantation is reserved for
unique clinical situations of devastating nerve injuries that