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Huelsboemer L, Boroumand S, Kochen A, Dony A, Moscarelli J, Hauc SC, Stögner VA, Formica RN, Pomahac B, Kauke-Navarro M. Immunosuppressive strategies in face and hand transplantation: a comprehensive systematic review of current therapy regimens and outcomes. FRONTIERS IN TRANSPLANTATION 2024; 3:1366243. [PMID: 38993787 PMCID: PMC11235358 DOI: 10.3389/frtra.2024.1366243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/21/2024] [Indexed: 07/13/2024]
Abstract
Background Recipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections. Methods A systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA. Results The standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients. Conclusions Based on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.
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Affiliation(s)
- Lioba Huelsboemer
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sam Boroumand
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Alejandro Kochen
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- Regenerative Wound Healing Center, Yale School of Medicine, New Haven, CT, United States
| | - Alna Dony
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Jake Moscarelli
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sacha C Hauc
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Viola A Stögner
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Richard N Formica
- Department of Medicine, Section of Nephrology and Transplantation, Yale School of Medicine, New Haven, CT, United States
| | - Bohdan Pomahac
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
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Presence of Donor Lymph Nodes Within Vascularized Composite Allotransplantation Ameliorates VEGF-C-mediated Lymphangiogenesis and Delays the Onset of Acute Rejection. Transplantation 2021; 105:1747-1759. [PMID: 34291766 DOI: 10.1097/tp.0000000000003601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lymphatic system plays an active role in modulating inflammation in autoimmune diseases and organ rejection. In this work, we hypothesized that the transfer of donor lymph node (LN) might be used to promote lymphangiogenesis and influence rejection in vascularized composite allotransplantation (VCA). METHODS Hindlimb transplantations were performed in which (1) recipient rats received VCA containing donor LN (D:LN+), (2) recipient rats received VCA depleted of all donor LN (D:LN-), and (3) D:LN+ transplantations were followed by lymphangiogenesis inhibition using a vascular endothelial growth factor receptor-3 (VEGFR3) blocker. RESULTS Our data show that graft rejection started significantly later in D:LN+ transplanted rats as compared to the D:LN- group. Moreover, we observed a higher level of VEGF-C and a quicker and more efficient lymphangiogenesis in the D:LN+ group as compared to the D:LN- group. The presence of donor LN within the graft was associated with reduced immunoactivation in the draining LN and increased frequency of circulating and skin-resident donor T regulatory cells. Blocking of the VEGF-C pathway using a VEGFR3 blocker disrupts the lymphangiogenesis process, accelerates rejection onset, and interferes with donor T-cell migration. CONCLUSIONS This study demonstrates that VCA LNs play a pivotal role in the regulation of graft rejection and underlines the potential of specifically targeting the LN component of a VCA to control graft rejection.
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Abstract
SUMMARY Facial vascularized composite allotransplantation has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. The authors report on the first Canadian face transplant. A 64-year-old man sustained a gunshot wound, which resulted in extensive midface bony and soft-tissue damage involving the lower two-thirds of the face. In May of 2018, he underwent a face transplant consisting of Le Fort III and bilateral sagittal split osteotomies in addition to skin from the lower two-thirds of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microsurgical anastomoses of the facial (three branches) and infraorbital nerves were performed bilaterally. At 18-month follow-up, the aesthetic outcome was excellent. Partial restoration of light touch sensation had been observed over the majority of the allograft. Although significantly affected, animation, speech, mastication, and deglutition were continuously improving with intensive therapy. Nevertheless, the patient was now tracheostomy and gastrostomy free. Despite these limitations, he reported a high degree of satisfaction with the procedure and had reintegrated into the community. Four grade I episodes of acute rejection with evidence of endotheliitis were successfully treated. Postoperative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and antifungal therapy. Undoubtedly, immunosuppression represents the greatest obstacle in the field and limits the indications for facial vascularized composite allotransplantation. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft.
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