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Jeong Y, Jeon S, Eun S. Validation of Animal Models for Facial Transplantation Research. Transplant Proc 2020; 52:1884-1890. [PMID: 32446689 DOI: 10.1016/j.transproceed.2020.01.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/26/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The development of consistent animal experimental models is important for continued research on specific biological and immunologic aspects of vascularized composite allografts. It is also important for the translation of immune regulation and tolerance induction strategies and treatment ideas from bench to bedside. The purpose of our study is to provide an outline of the use of animal models in simulated facial transplant surgery and to investigate the feasibility of animal model use. METHODS The animals underwent hemifacial flap transplant surgery. The flaps were placed on the external carotid artery and external jugular vein of the donor animal. Twenty-one procedures were performed in 4 different animals (6 rats, 5 rabbits, 6 dogs, 4 pigs). Two experienced plastic surgeons and 5 students performed allotransplant. RESULTS All 4 models were suitable for facial allotransplant with different anatomic characteristics. Average feasibility scores were 4.8 for pigs, 3.6 for rabbits, 3.2 for dogs, and 3.4 for rats. Evaluations concluded that pigs were the most practical and realistic models for facial allotransplant training. Other models achieved validation thresholds. CONCLUSIONS This study is the first comparative validation assessment of animal models used in facial allotransplant. It supports the use of pig models for surgical skills training. Pigs were the preferred simulation models, while rats, rabbits, and dogs were considered inferior models for transplant simulation.
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Affiliation(s)
- Yeonjin Jeong
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Sungmi Jeon
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seokchan Eun
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Visser NJ, Rezaie ES, Friedrich PF, Kotsougiani D, Shin AY, Bishop AT. Effects of Surgical Angiogenesis on Segmental Bone Reconstruction With Cryopreserved Massive-Structural Allografts in a Porcine Tibia Model. J Orthop Res 2019; 37:1698-1708. [PMID: 31042307 PMCID: PMC6824922 DOI: 10.1002/jor.24318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 04/12/2019] [Indexed: 02/04/2023]
Abstract
Cryopreserved bone allografts (CBA) used to reconstruct segmental bone defects provide immediate structural stability, but are vulnerable to infection, non-union and late stress fracture as the majority of the allograft remains largely avascular. We sought to improve the bone vascularity and bone formation of CBAs by surgical angiogenesis with an implanted arteriovenous (AV) bundle, using a porcine tibial defect model. Cryopreserved tibial bone allografts were transplanted in swine leukocyte antigen (SLA) mismatched Yucatan minipigs to reconstruct a 3.5 cm segmental tibial defect. A cranial tibial AV-bundle was placed within its intramedullary canal to induce angiogenesis. The AV bundle was patent in eight pigs and ligated in a control group of eight pigs. At 20 weeks neo-angiogenesis was evaluated by micro-angiography. Bone formation was measured by quantitative histomorphometry and micro-computed tomography. Seven of eight AV-bundles in the revascularized group were patent. One had thrombosed due to allograft displacement. Total vascular volume was higher in the revascularized allografts compared to the ligated group (p = 0.015). Revascularized allografts had increased levels of bone formation on the allograft endosteal surface compared to the ligated control group (p = 0.05). Surgical angiogenesis of porcine tibial CBAs by intramedullary implantation of an AV-bundle creates an enhanced autogenous neoangiogenic circulation and accelerates active bone formation on allograft endosteal surfaces. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1698-1708, 2019.
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Affiliation(s)
- Noortje J Visser
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Elisa S Rezaie
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Patricia F Friedrich
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Dimitra Kotsougiani
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA,Department of Hand-, Plastic- and Reconstructive Surgery,
-Burn Center-, BG Trauma Center Ludwigshafen, Department of Plastic Surgery,
University of Heidelberg, Heidelberg, Germany
| | - Alexander Y Shin
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - Allen T Bishop
- Microvascular Research Laboratory, Department of Orthopedic
Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
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3
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Is Skin the Most Allogenic Tissue in Vascularized Composite Allotransplantation and a Valid Monitor of the Deeper Tissues? Plast Reconstr Surg 2019; 143:880e-886e. [DOI: 10.1097/prs.0000000000005436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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4
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Kotsougiani D, Willems JI, Shin AY, Friedrich PF, Hundepool CA, Bishop AT. A new porcine vascularized tibial bone allotransplantation model. Anatomy and surgical technique. Microsurgery 2017; 38:195-202. [DOI: 10.1002/micr.30255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 08/03/2017] [Accepted: 10/03/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Dimitra Kotsougiani
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
- Department of Hand-, Plastic- and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen; Germany
| | - Joost I. Willems
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
- Orthopedic Surgery Department; Vrije Universiteit medical centre; Amsterdam The Netherlands
| | - Alexander Y. Shin
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
| | - Patricia F. Friedrich
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
| | - Caroline A. Hundepool
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
| | - Allen T. Bishop
- Microvascular Research Laboratory, Department of Orthopedic Surgery; Mayo Clinic; Rochester Minnesota
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Kotsougiani D, Hundepool CA, Willems JI, Friedrich P, Shin AY, Bishop AT. Surgical Angiogenesis in Porcine Tibial Allotransplantation: A New Large Animal Bone Vascularized Composite Allotransplantation Model. J Vis Exp 2017. [PMID: 28829409 DOI: 10.3791/55238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Segmental bone loss resulting from trauma, infection malignancy and congenital anomaly remains a major reconstructive challenge. Current therapeutic options have significant risk of failure and substantial morbidity. Use of bone vascularized composite allotransplantation (VCA) would offer both a close match of resected bone size and shape and the healing and remodeling potential of living bone. At present, life-long drug immunosuppression (IS) is required. Organ toxicity, opportunistic infection and neoplasm risks are of concern to treat such non-lethal indications. We have previously demonstrated that bone and joint VCA viability may be maintained in rats and rabbits without the need of long-term-immunosuppression by implantation of recipient derived vessels within the VCA. It generates an autogenous, neoangiogenic circulation with measurable flow and active bone remodeling, requiring only 2 weeks of IS. As small animals differ from man substantially in anatomy, bone physiology and immunology, we have developed a porcine bone VCA model to evaluate this technique before clinical application is undertaken. Miniature swine are currently widely used for allotransplantation research, given their immunologic, anatomic, physiologic and size similarities to man. Here, we describe a new porcine orthotopic tibial bone VCA model to test the role of autogenous surgical angiogenesis to maintain VCA viability. The model reconstructs segmental tibial bone defects using size- and shape-matched allogeneic tibial bone segments, transplanted across a major swine leukocyte antigen (SLA) mismatch in Yucatan miniature swine. Nutrient vessel repair and implantation of recipient derived autogenous vessels into the medullary canal of allogeneic tibial bone segments is performed in combination with simultaneous short-term IS. This permits a neoangiogenic autogenous circulation to develop from the implanted tissue, maintaining flow through the allogeneic nutrient vessels for a short time. Once established, the new autogenous circulation maintains bone viability following cessation of drug therapy and subsequent nutrient vessel thrombosis.
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Affiliation(s)
- Dimitra Kotsougiani
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic
| | - Caroline A Hundepool
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic
| | - Joost I Willems
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic
| | - Patricia Friedrich
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic
| | - Alexander Y Shin
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic
| | - Allen T Bishop
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic;
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6
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Kotsougiani D, Hundepool CA, Bulstra LF, Friedrich PF, Shin AY, Bishop AT. Recipient-derived angiogenesis with short term immunosuppression increases bone remodeling in bone vascularized composite allotransplantation: A pilot study in a swine tibial defect model. J Orthop Res 2017; 35:1242-1249. [PMID: 27471833 DOI: 10.1002/jor.23378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/26/2016] [Indexed: 02/04/2023]
Abstract
Current vascularized composite allotransplantation (VCA) transplantation protocols rely upon life-long immune modulation to maintain tissue perfusion. Alternatively, bone-only VCA viability may be maintained in small animal models using surgical angiogenesis from implanted autogenous vessels to develop a neoangiogenic bone circulation that will not be rejected. This study tests the method's efficacy in a large animal model as a bridge to clinical practice, quantifying the remodeling and mechanical properties of porcine tibial VCAs. A segmental tibial defect was reconstructed in Yucatan miniature swine by transplantation of a matched tibia segment from an immunologically mismatched donor. Microsurgical repair of nutrient vessels was performed in all pigs, with simultaneous intramedullary placement of an autogenous arteriovenous (AV) bundle in Group 2. Group 1 served as a no-angiogenesis control. All received 2 weeks of immunosuppression. After 16 weeks, micro-CT and histomorphometric analyses were used to evaluate healing and remodeling. Axial compression and nanoindentation studies evaluated bone mechanical properties. Micro-CT analysis demonstrated significantly more new bone formation and bone remodeling at the distal allotransplant/recipient junction and on the endosteal surfaces of Group 2 tibias (p = 0.03). Elastic modulus and hardness were not adversely affected by angiogenesis. The combination of 2 weeks of immunosuppression and autogenous AV-bundle implantation within a microsurgically transplanted tibial allotransplant permitted long-term allotransplant survival over the study period of 16 weeks in this large animal model. Angiogenesis increased bone formation and remodeling without adverse mechanical effects. The method may allow future composite-tissue allotransplantation of bone without the risks associated with long-term immunosuppression. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1242-1249, 2017.
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Affiliation(s)
- Dimitra Kotsougiani
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.,Department of Hand-, Plastic- and Reconstructive Surgery, -Burn Center-, BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Caroline A Hundepool
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.,Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Liselotte F Bulstra
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.,Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patricia F Friedrich
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota
| | - Alexander Y Shin
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota
| | - Allen T Bishop
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota
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7
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A Porcine Orthotopic Forelimb Vascularized Composite Allotransplantation Model. Plast Reconstr Surg 2016; 138:461e-471e. [DOI: 10.1097/prs.0000000000002451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Caballero M, Morse JC, Halevi AE, Emodi O, Pharaon MR, Wood JS, van Aalst JA. Juvenile Swine Surgical Alveolar Cleft Model to Test Novel Autologous Stem Cell Therapies. Tissue Eng Part C Methods 2016; 21:898-908. [PMID: 25837453 DOI: 10.1089/ten.tec.2014.0646] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Reconstruction of craniofacial congenital bone defects has historically relied on autologous bone grafts. Engineered bone using mesenchymal stem cells from the umbilical cord on electrospun nanomicrofiber scaffolds offers an alternative to current treatments. This preclinical study presents the development of a juvenile swine model with a surgically created maxillary cleft defect for future testing of tissue-engineered implants for bone generation. Five-week-old pigs (n=6) underwent surgically created maxillary (alveolar) defects to determine critical-sized defect and the quality of treatment outcomes with rib, iliac crest cancellous bone, and tissue-engineered scaffolds. Pigs were sacrificed at 1 month. Computed tomography scans were obtained at days 0 and 30, at the time of euthanasia. Histological evaluation was performed on newly formed bone within the surgical defect. A 1 cm surgically created defect healed with no treatment, the 2 cm defect did not heal. A subsequently created 1.7 cm defect, physiologically similar to a congenitally occurring alveolar cleft in humans, from the central incisor to the canine, similarly did not heal. Rib graft treatment did not incorporate into adjacent normal bone; cancellous bone and the tissue-engineered graft healed the critical-sized defect. This work establishes a juvenile swine alveolar cleft model with critical-sized defect approaching 1.7 cm. Both cancellous bone and tissue engineered graft generated bridging bone formation in the surgically created alveolar cleft defect.
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Affiliation(s)
- Montserrat Caballero
- 1 Plastic Surgery, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Justin C Morse
- 2 Plastic and Reconstructive Surgery, The University of North Carolina School of Medicine , Chapel Hill, North Carolina
| | | | - Omri Emodi
- 4 Oral and Maxillofacial Surgery, Rambam Medical Center , Haifa, Israel
| | - Michael R Pharaon
- 5 Plastic Surgery, Kapiolani Hospital for Women and Children , Honolulu, Hawaii
| | - Jeyhan S Wood
- 2 Plastic and Reconstructive Surgery, The University of North Carolina School of Medicine , Chapel Hill, North Carolina
| | - John A van Aalst
- 1 Plastic Surgery, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
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9
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Özmen S. Bilateral Vascularized Composite Skin/Bone Transplantation Models. Plast Reconstr Surg 2015. [DOI: 10.1007/978-1-4471-6335-0_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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10
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Vascularized Composite Allotransplantation Models. Plast Reconstr Surg 2015. [DOI: 10.1007/978-1-4471-6335-0_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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12
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Ibrahim Z, Cooney DS, Shores JT, Sacks JM, Wimmers EG, Bonawitz SC, Gordon C, Ruben D, Schneeberger S, Lee WPA, Brandacher G. A modified heterotopic swine hind limb transplant model for translational vascularized composite allotransplantation (VCA) research. J Vis Exp 2013. [PMID: 24145603 DOI: 10.3791/50475] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Vascularized Composite Allotransplantation (VCA) such as hand and face transplants represent a viable treatment option for complex musculoskeletal trauma and devastating tissue loss. Despite favorable and highly encouraging early and intermediate functional outcomes, rejection of the highly immunogenic skin component of a VCA and potential adverse effects of chronic multi-drug immunosuppression continue to hamper widespread clinical application of VCA. Therefore, research in this novel field needs to focus on translational studies related to unique immunologic features of VCA and to develop novel immunomodulatory strategies for immunomodulation and tolerance induction following VCA without the need for long term immunosuppression. This article describes a reliable and reproducible translational large animal model of VCA that is comprised of an osteomyocutaneous flap in a MHC-defined swine heterotopic hind limb allotransplantation. Briefly, a well-vascularized skin paddle is identified in the anteromedial thigh region using near infrared laser angiography. The underlying muscles, knee joint, distal femur, and proximal tibia are harvested on a femoral vascular pedicle. This allograft can be considered both a VCA and a vascularized bone marrow transplant with its unique immune privileged features. The graft is transplanted to a subcutaneous abdominal pocket in the recipient animal with a skin component exteriorized to the dorsolateral region for immune monitoring. Three surgical teams work simultaneously in a well-coordinated manner to reduce anesthesia and ischemia times, thereby improving efficiency of this model and reducing potential confounders in experimental protocols. This model serves as the groundwork for future therapeutic strategies aimed at reducing and potentially eliminating the need for chronic multi-drug immunosuppression in VCA.
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Affiliation(s)
- Zuhaib Ibrahim
- Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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13
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Abstract
Vascularized composite allotransplantation has become established as a clinical specialty since the first successful hand transplant was performed in 1998. Data now available indicate that hand and face transplants offer patients good functional outcomes and significant improvements in quality of life. Despite the debilitating nature of the injuries treated by such transplants, the defects are generally not life threatening, making it difficult for physicians to recommend life-long immunosuppression that can itself have grave consequences. One potential solution to this dilemma is the induction of immunologic tolerance of the tissue transplants because tolerance would eliminate the need for such immunosuppression. Transplant tolerance may also prevent chronic rejection, a significant source of late graft loss after organ transplantation.Induction of mixed hematopoietic chimerism is a robust approach to establishing such transplant tolerance, which recently led to the first clinical application of a tolerance induction protocol for kidney transplantation. In this manuscript, we review the current status of VCA and of research directed toward bringing a tolerance approach to the VCA field. We also discuss the potential clinical significance of these studies and outline the remaining obstacles to introduction of a tolerance induction protocol to clinical practice in hand or face transplantation.
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Brandacher G, Grahammer J, Sucher R, Lee WPA. Animal models for basic and translational research in reconstructive transplantation. ACTA ACUST UNITED AC 2012; 96:39-50. [PMID: 22457176 DOI: 10.1002/bdrc.21002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Reconstructive transplantation represents a bona fide option for select patients with devastating tissue loss, which could better restore the appearance, anatomy, and function than any other conventional treatment currently available. Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the potential side effects of chronic multidrug immunosuppression. Thus, any reconstructive measures to improve these non-life-threatening conditions must address a delicate balance of risks and benefits. Today, several exciting novel therapeutic strategies, such as the implementation of cellular therapies including bone marrow or stem cells that integrate the concepts of immune regulation with those of nerve regeneration, are on the horizon. The development of reliable and reproducible small and large animal models is essential for the study of the unique immunological and biological aspects of vascularized composite allografts and to translate such novel immunoregulatory and tolerance-inducing strategies and therapeutic concepts from the bench to bedside. This review provides an overview of the multitude of small and large animal models that have been particularly designed for basic and translational research related to reconstructive transplantation.
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Affiliation(s)
- Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryand 21205, USA.
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15
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Nguyen JT, Ashitate Y, Buchanan IA, Ibrahim AMS, Gioux S, Patel PP, Frangioni JV, Lee BT. Bone flap perfusion assessment using near-infrared fluorescence imaging. J Surg Res 2012; 178:e43-50. [PMID: 22664132 DOI: 10.1016/j.jss.2012.05.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 04/18/2012] [Accepted: 05/03/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Microsurgical vascularized bone flaps are a versatile technique for reconstructing large bone defects. However, the assessment of perfusion is challenging, because clinical examination is difficult intraoperatively and often not possible postoperatively. Therefore, it is important to develop techniques to assess the perfusion of vascularized bone flaps and potentially improve the surgical outcomes. Near-infrared (NIR) fluorescence imaging has previously been shown to provide real-time, intraoperative evaluation of vascular perfusion. The present pilot study investigated the ability of NIR imaging to assess the perfusion of vascularized bone flaps. METHODS Vascularized bone flaps were created in female Yorkshire pigs using well-established models for porcine forelimb osteomyocutaneous flap allotransplantation (n = 8) and hindlimb fibula flaps (n = 8). Imaging of the bone flaps was performed during harvest using the FLARE intraoperative fluorescence imaging system after systemic injection of indocyanine green. Perfusion was also assessed using the standard of care by clinical observation and Doppler ultrasonography. NIR fluorescence perfusion assessment was confirmed by intermittent clamping of the vascular pedicle. RESULTS NIR fluorescence imaging could identify bone perfusion at the cut end of the osteotomy site. When the vascular pedicle was clamped or ligated, NIR imaging demonstrated no fluorescence when injected with indocyanine green. With clamp removal, the osteotomy site emitted fluorescence, indicating bone perfusion. The results using fluorescence imaging showed 100% agreement with the clinical observation and Doppler findings. CONCLUSIONS Vascularized bone transfers have become an important tool in reconstructive surgery; however, no established techniques are available to adequately assess perfusion. The results of our pilot study have indicated that NIR imaging can provide real-time, intraoperative assessment of bone perfusion.
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Affiliation(s)
- John T Nguyen
- Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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16
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Kuo YR, Shih HS, Lin CC, Huang CC, Yang JCS, Wu WS, Goto S, Chen CL, Lee WA. Swine Hemi-Facial Composite Tissue Allotransplantation: A Model to Study Immune Rejection. J Surg Res 2009; 153:268-73. [DOI: 10.1016/j.jss.2008.03.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 03/26/2008] [Accepted: 03/31/2008] [Indexed: 10/22/2022]
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17
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Whitaker IS, Duggan EM, Alloway RR, Brown C, McGuire S, Woodle ES, Hsiao EC, Maldonado C, Banis JC, Barker JH. Composite tissue allotransplantation: a review of relevant immunological issues for plastic surgeons. J Plast Reconstr Aesthet Surg 2008; 61:481-92. [PMID: 18248779 DOI: 10.1016/j.bjps.2007.11.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Accepted: 11/16/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Composite tissue allotransplantation of hand, facial and other tissues is now a clinical reality. The terminology, treatment principles, drug combinations, dosage schedules and mechanisms of the immunosuppression medications on which contemporary transplant surgery is based are unfamiliar to plastic surgeons and most healthcare providers outside the field of transplantation medicine. With this in mind, the purpose of this manuscript is to provide plastic surgeons with a comprehensive and understandable review of key immunological principles relevant to composite tissue allotransplantation. METHODS We present an overview of the immunological basis of composite tissue allotransplantation aimed at the plastic surgery readership, based on our own experience plus manuscripts sourced from MEDLINE, EMBASE, text books, ancient manuscripts and illustrations. RESULTS In this manuscript we provide the reader with a brief history of composite tissue allotransplantation (CTA), a concise description of the immunological terminology, treatment approaches, risks associated with immunosuppressive therapy, risk acceptance, and current research avenues relating to contemporary CTA. CONCLUSION Today, as transplant and reconstructive surgeons join forces to move hand and facial tissue allotransplantation into the clinical arena, it is important that plastic surgeons have an understanding of the major immunological principles upon which this new treatment is based.
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Affiliation(s)
- Iain S Whitaker
- Department of Surgery, University of Louisville, 511 South Floyd Street, 320 MDR Building, Louisville, KY 40202, USA
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Abstract
Composite tissue allotransplantation holds great potential for reconstructive surgery. That these procedures can be successful has been clearly demonstrated by the success of hand, face, and larynx transplants around the world. Although the immunology of composite tissue allotransplantation mirrors that of any allogeneic organ transplant, there are several unique aspects to these grafts. This article reviews the immunology of transplantation, histocompatibility testing for composite tissue allotransplantation, graft rejection, immunosuppression, and specific immunologic considerations of composite tissue allotransplantation.
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Affiliation(s)
- Diane J Pidwell
- Department of Pathology, Jewish Hospital, Louisville, KY 40202, USA.
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Duhamel P, Bey E, Petit F, Cariou JL. [Experimental and clinical experience of composite tissues allotransplantation in reconstructive surgery]. ANN CHIR PLAST ESTH 2007; 52:399-413. [PMID: 17597279 DOI: 10.1016/j.anplas.2007.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 05/17/2007] [Indexed: 12/22/2022]
Abstract
Composite tissue allotransplantation (CTA) is a new concept in reconstructive surgery to improve major physical defects with no current solution. Although not a life-saving procedure, tissue replacement by CTA offers great potential for improving quality of life but relies on lifelong immunotherapy. This new practice has become achievable with the refinement of microsurgical techniques, with experience gained from limb and scalp replantations, with the development of organ transplantation and the release of new immunosuppressive drugs. Experimental and clinical research made it possible. The first human cases of CTA proved the reality and the feasibility of the concept. While the early functional results of these allografts are encouraging, they will need to be assessed in the long-term, and development of less toxic - more efficient immonu-suppressive drugs will be a permanent requisite to the broadening of CTA. Although long-term outcome and potential adverse effects of chronic immunosuppression remain uncertain, as for organ transplantation, CTA is already a potential solution for some highly selected patients carrying physical disabilities such as large facial defects and bilateral hand amputation.
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Affiliation(s)
- P Duhamel
- Service de chirurgie plastique et maxillofaciale, hôpital d'instruction des Armées Percy, 101, avenue Henri-Barbusse, 92141 Clamart cedex, France.
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Barker JH, Stamos N, Furr A, McGuire S, Cunningham M, Wiggins O, Brown CS, Gander B, Maldonado C, Banis JC. Research and Events Leading to Facial Transplantation. Clin Plast Surg 2007; 34:233-50, ix. [PMID: 17418674 DOI: 10.1016/j.cps.2006.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.
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Affiliation(s)
- John H Barker
- Department of Surgery, 511 South Floyd Street, 320 MDR Building, University of Louisville, Louisville, KY 40202, USA.
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Gander B, Brown CS, Vasilic D, Furr A, Banis JC, Cunningham M, Wiggins O, Maldonado C, Whitaker I, Perez-Abadia G, Frank JM, Barker JH. Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery. Transpl Int 2007; 19:868-80. [PMID: 17018121 DOI: 10.1111/j.1432-2277.2006.00371.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Each year an estimated 7-million people in the USA need composite tissue reconstruction because of surgical excision of tumors, accidents and congenital malformations. Limb amputees alone comprise over 1.2 million of these. This figure is more than double the number of solid organs needed for transplantation. Composite tissue allotransplantation in the form of hand and facial tissue transplantation are now a clinical reality. The discovery, in the late 1990s, that the same immunotherapy used routinely in kidney transplantation was also effective in preventing skin rejection made this possible. While these new treatments seem like major advancements most of the surgical, immunological and ethical methods used are not new at all and have been around and routinely used in clinical practice for some time. In this review of composite tissue allotransplantation, we: (i) outline the limitations of conventional reconstructive methods for treating severe facial disfigurement, (ii) review the history of composite tissue allotransplantation, (iii) discuss the chronological scientific advances that have made it possible, (iv) focus on the two unique clinical scenarios of hand and face transplantation, and (v) reflect on the critical issues that must be addressed as we move this new frontier toward becoming a treatment in mainstream medicine.
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Affiliation(s)
- Brian Gander
- Department of Surgery, University of Louisville, KY 40202, USA
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Morris P, Bradley A, Doyal L, Earley M, Hagen P, Milling M, Rumsey N. Face Transplantation: A Review of the Technical, Immunological, Psychological and Clinical Issues with Recommendations for Good Practice. Transplantation 2007; 83:109-28. [PMID: 17264807 DOI: 10.1097/01.tp.0000254201.89012.ae] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Three years ago, the Working Party on Facial Transplantation concluded that until there was more information available about risks any potential patient would be exposed to, it would be unwise to proceed with transplantation of the human face. Over the last three years, there has been a deepening understanding of the potential psychological problems of facial transplantation as well as a very considerable debate on the ethical aspects of the procedure. Further data on experimental work in animal models of facial transplantation as well as medium-term follow-up data from 24 hand and forearm transplants in 18 patients has now become available. Furthermore, a partial facial transplantation has been performed in France and a second one in China. In this second edition of the report, the technical, immunological, psychological, and ethical issues are discussed again in the light of this developing knowledge. In particular, there has been a major expansion of the sections on the psychological and societal issues, as well as the ethical and legal problems of facial transplantation. The working party still has considerable reservations about facial transplantation. Although it accepts that on balance the risks cannot be precisely quantified, they remain substantial. Therefore, if patients are allowed to make an informed choice to proceed, they must be very carefully selected and protected in the process, along with the families of both the donors and the recipients. To achieve this, the working party insists that 15 minimum requirements, described at the end of this report, must be fulfilled before it would be appropriate for a research ethics committee/institutional review board to approve of a proposal to undertake facial transplantation.
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Affiliation(s)
- Peter Morris
- Centre for Evidence in Transplantation, Royal College of Surgeons of England and London School of Hygiene & Tropical Medicine, University of London, London, United Kingdom.
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Ozmen S, Ulusal BG, Ulusal AE, Izycki D, Siemionow M. Composite Vascularized Skin/Bone Transplantation Models for Bone Marrow-Based Tolerance Studies. Ann Plast Surg 2006; 56:295-300. [PMID: 16508361 DOI: 10.1097/01.sap.0000199154.85697.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is an ongoing need to understand the mechanisms of bone marrow-based allograft tolerance. This is important in clarifying the diverse variables influencing the ultimate outcome of the solid organ and composite tissue transplants. To establish bone marrow transplantation as a routine clinical application, further experimental studies should be conducted to overcome the obstacles related to the bone marrow transplantation. These obstacles include graft versus host disease, immunocompetence, and toxicity of the conditioning regimens. For these purposes, novel experimental models are needed. In an attempt to provide a reliable research tool for bone marrow-based tolerance induction studies, we introduced different experimental models of modified vascularized skin/bone marrow (VSBM) transplantation technique for tolerance induction, monitoring, and maintenance studies. In this skin/bone transplantation model, the technical feasibility of concurrent or consecutive transplantation of the combination of bilateral vascularized skin, vascularized bone marrow, or vascularized skin/bone marrow transplants was investigated. Isograft transplantations were performed between genetically identical Lewis (LEW, RT1) rats. Five different experimental designs in 5 groups of 5 animals each were studied. Group I: Bilateral vascularized skin (VS) transplantation; group II: bilateral vascularized skin/bone transplantation; group III: vascularized skin transplantation on one side and vascularized skin/bone transplantation on the contralateral side; group IV: vascularized bone transplantation on one side and vascularized skin/bone transplantation on the contralateral side; group V: vascularized bone transplantation on one side and vascularized skin transplantation on the contralateral side. Successful transplantations were performed in all groups. The survival of the isograft transplants was evaluated clinically and histologically. All skin flaps remained pink and pliable and grew new hair. The viability of the compact bone, bone marrow and skin at 100 days posttransplant was confirmed by histologic evaluation, and bone marrow revealed active hematopoiesis. Bilateral skin/bone transplantation model may serve as an experimental tool to study new strategies in tolerance induction by altering the amount of the immunogenic load in the form of skin transplant and bone marrow delivery in the vascularized form, allowing for expedited engraftment of stem and progenitor cells.
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Affiliation(s)
- Selahattin Ozmen
- Cleveland Clinic Foundation, Department of Plastic Surgery, OH 44195, USA
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Cendales LC, Xu H, Bacher J, Eckhaus MA, Kleiner DE, Kirk AD. Composite Tissue Allotransplantation: Development of a Preclinical Model in Nonhuman Primates. Transplantation 2005; 80:1447-54. [PMID: 16340790 DOI: 10.1097/01.tp.0000183292.57349.27] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Composite tissue allotransplantation (CTA) has been recently introduced as a potential treatment for tissue loss secondary to burns, injuries, or resections. However, the optimal strategies to prevent CTA rejection remain undefined. Presently, no CTA model exists to evaluate human-specific immunosuppressants or the relative immunogenicity of all CTA tissues. METHODS We established a NHP CTA model utilizing a sensate osteomyocutaneous radial forearm flap that avoids functional impairment even in the case of graft loss. The model was evaluated in19 monkeys that underwent auto- or allotransplantation, with or without subtherapeutic immunosuppression to temporarily characterize rejection. RESULTS Autografts showed no evidence of rejection. Nonimmunosuppressed allografts were rapidly rejected showing a perivenular T-cell infiltrate. This was associated with subsequent alloantibody formation and led to graft thrombosis without prominent dermal infiltration. Subtherapeutically immunosuppressed animals also developed alloantibody and rejected in a delayed fashion exhibiting a marked dermal lymphocytic infiltrate similar in magnitude and distribution to previously reported human cases. CONCLUSION Our NHP model for CTA is well tolerated by NHPs, results in allosensitization, is responsive to immunosuppression, allows for the evaluation of CTA histology and can be used for the systematic preclinical evaluation of therapeutic maneuvers to improve allograft survival.
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Affiliation(s)
- Linda C Cendales
- Orthopedic Section, Office of the Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892-1102, USA.
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Abstract
Transplantation of a vascularized limb or its components is defined as composite tissue allotransplantation, and is one of the newest areas in surgery. To date, 24 hands have been transplanted onto 18 recipients. The initial results have been promising, and hand transplantation may become an important procedure for functional restoration of upper limbs. However, the ethical aspects of using chronic immunosuppression for a condition which is not life threatening have been the subject of debate. In this article, we review the field of composite tissue allotransplantation.
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Affiliation(s)
- Hebe D Kvernmo
- Department of Orthopaedics, Division of Hand and Microsurgery, National Hospital, NO-0027 Oslo, Norway.
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Morris PJ, Bradley JA, Doyal L, Earley M, Hagan P, Milling M, Rumsey N. Facial transplantation: a working party report from the Royal College of Surgeons of England. Transplantation 2004; 77:330-8. [PMID: 14966404 DOI: 10.1097/01.tp.0000113810.54865.be] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Peter J Morris
- Working Party, The Royal College of Surgeons of England, London, UK.
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Breidenbach WC, Tobin GR, Gorantla VS, Gonzalez RN, Granger DK. A position statement in support of hand transplantation. J Hand Surg Am 2002; 27:760-70. [PMID: 12239664 DOI: 10.1053/jhsu.2002.35306] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The scientific basis for human trials of hand transplantation was both experimental and clinical. Prolonged survival of limb transplants was achieved in small and large animals by using novel immunosuppressive drugs. Further, all tissue components of the hand (skin, muscle, tendon, nerve, bone, and joint) were individually transplanted with success in humans. After appropriate institutional review of the ethics, experimental data, treatment protocol, and informed consent, clinical trials were approved. Thirteen hands have been transplanted onto 10 recipients, with resultant low morbidity and no mortality. With the exception of one recipient who requested amputation after the second year, results of hand transplantation have been highly successful. Functional return mirrored that seen after hand replantation. The limbs were progressively integrated into activities of daily living and professional tasks. The hand and patient survival rate exceeds the initial results of any previously transplanted organ. This success strongly supports continuation of these human trials.
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Affiliation(s)
- Warren C Breidenbach
- Christine M. Kleinert Institute of Hand and Microsurgery, Jewish Hospital, Louisville, KY 40202, USA
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Affiliation(s)
- William P Cooney
- Department of Orthopaedic Surgery, The Mayo Clinic, 200 First St., Rochester, MN 55905, USA
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