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Van Dieren L, Tawa P, Coppens M, Naenen L, Dogan O, Quisenaerts T, Lancia HH, Oubari H, Dabi Y, De Fré M, Thiessen Ef F, Cetrulo CL, Lellouch AG. Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports. J Surg Res 2024; 298:137-148. [PMID: 38603944 DOI: 10.1016/j.jss.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.
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Affiliation(s)
- Loïc Van Dieren
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine and Health Sciences, Antwerp, Belgium; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Tawa
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Marie Coppens
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Laura Naenen
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Omer Dogan
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | - Hyshem H Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haïzam Oubari
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yohann Dabi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Sorbonne University, Tenon Hospital (AP-HP), Paris, France
| | - Maxime De Fré
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Thiessen Ef
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts.
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Cavaliere A, Rega U, Grimaldi S, Esposito G, Pensato R, D'Andrea F, Longo B, Coiante E, Hersant B, Meningaud JP, La Padula S. Long-term outcomes and future challenges in face transplantation. J Plast Reconstr Aesthet Surg 2024; 92:87-103. [PMID: 38513344 DOI: 10.1016/j.bjps.2024.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
Face transplant (FT) has emerged as a groundbreaking option for patients with severe facial deformities, resulting from congenital disorders, trauma, or tumor ablation. Although reconstructive surgery has made significant strides, the challenges of restoring both form and function remain, particularly in centrally located defects. This review explored the long-term outcomes of FT, addressing its challenges and potential pitfalls. A systematic review following the PRISMA guidelines was conducted, encompassing articles published in English from November 2005 to January 2023, which were searched across PubMed, MEDLINE, and EMBASE databases. Keywords included "face transplant," "face transplant outcomes," and "face transplant long-term." Data on surgical teams, patient demographics, transplant specifics, rejection episodes, additional surgeries, and patient-reported outcomes were extracted and analyzed. In total, 34 articles met the inclusion criteria. Over the 2 decades, 48 FT procedures were performed, with 23 patients followed for at least 3 years. Predominantly, patients were men (80%), averaging 31 years in age. Ballistic trauma (44.6%) and burns (25.5%) were common causes of injury. Chronic rejection emerged as a significant concern, leading to graft loss and necessitating retransplantation in 2 patients. Additional surgical procedures were often required. FT offers a remarkable solution for individuals with extensive facial disfigurement. Successful outcomes depend on factors, such as patient selection, multidisciplinary collaboration, psychiatric evaluation, and post-operative care. Nevertheless, challenges persist, including the need for lifelong immunosuppression and risk of chronic rejection. Although FT has transformed lives, continued success in this evolving field hinges on the ongoing research and vigilant patient management.
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Affiliation(s)
- Annachiara Cavaliere
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Umberto Rega
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Sebastiano Grimaldi
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Giuseppe Esposito
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Rosita Pensato
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Francesco D'Andrea
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Benedetto Longo
- Department of Plastic and Reconstructive Surgery, Università di Roma Tor Vergata, Viale Oxford, 81, 00133 Roma, Italy
| | - Edoardo Coiante
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Barbara Hersant
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Jean Paul Meningaud
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Simone La Padula
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy; Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France.
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Cendales LC, Farris AB, Rosales I, Elder D, Gamboa-Dominguez A, Gelb B, Issa F, Ravindra K, Nankivell BJ, Talbot S, Xu XG, Moris D, Drachenberg CB, Kanitakis J, Selim MA. Banff 2022 Vascularized Composite Allotransplantation Meeting Report: Diagnostic criteria for vascular changes. Am J Transplant 2024; 24:716-723. [PMID: 38286355 DOI: 10.1016/j.ajt.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024]
Abstract
As more data become available, the Banff 2007 working classification of skin-containing vascularized composite allograft (VCA) pathology is expected to evolve and develop. This report represents the Banff VCA Working Group's consensus on the first revision of the 2007 scoring system. Prior to the 2022 Banff-CanXadian Society of Transplantation Joint Meeting, 83 clinicians and/or researchers were invited to a virtual meeting to discuss whether the 2007 Banff VCA system called for a revision. Unanimously, it was determined that the vascular changes were to be included in the first revision. Subsequently, 2 international online surveys, each followed by virtual discussions, were launched. The goals were (1) to identify which changes define severe rejection, (2) to grade their importance in the evaluation of severe rejection, and (3) to identify emerging criteria to diagnose rejection. A final hybrid (in-person and virtual) discussion at the Banff/Canadian Society of Transplantation Joint Meeting finalized the terminology, the definition, a scoring system, and a reporting system of the vascular changes. This proposal represents an international consensus on this topic and establishes the first revision of the Banff 2007 working classification of skin-containing vascularized composite allograft pathology.
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Affiliation(s)
- Linda C Cendales
- Department of Surgery, Duke University, Durham, North Carolina, USA.
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Ivy Rosales
- Department of Pathology, Immunopathology Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Armando Gamboa-Dominguez
- Departamento de Patología. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Bruce Gelb
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Fadi Issa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | | | - Simon Talbot
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaowei G Xu
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Cinthia B Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jean Kanitakis
- Department of Dermatology, Ed. Herriot Hospital, Lyon, and Dept. of Pathology, Lyon Sud Hospital Center, Pierre Bénite, France
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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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Egro FM, Schilling BK, Fisher JD, Saadoun R, Rubin JP, Marra KG, Solari MG. The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue. J Hand Microsurg 2024; 16:100011. [PMID: 38854368 PMCID: PMC11127549 DOI: 10.1055/s-0042-1757182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications. Methods A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering. Results VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting. Conclusion VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.
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Affiliation(s)
- Francesco M. Egro
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Benjamin K. Schilling
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - James D. Fisher
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Rakan Saadoun
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - J. Peter Rubin
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Kacey G. Marra
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Mario G. Solari
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Ren D, Chen J, Yu M, Yi C, Hu X, Deng J, Guo S. Emerging strategies for tissue engineering in vascularized composite allotransplantation: A review. J Tissue Eng 2024; 15:20417314241254508. [PMID: 38826796 PMCID: PMC11143860 DOI: 10.1177/20417314241254508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/28/2024] [Indexed: 06/04/2024] Open
Abstract
Vascularized composite allotransplantation (VCA), which can effectively improve quality of life, is a promising therapy for repair and reconstruction after face or body trauma. However, intractable issues are associated with VCA, such as the inevitable multiple immunogenicities of different tissues that cause severe rejection, the limited protocols available for clinical application, and the shortage of donor sources. The existing regimens used to extend the survival of patients receiving VCAs and suppress rejection are generally the lifelong application of immunosuppressive drugs, which have side effects. Consequently, studies aiming at tissue engineering methods for VCA have become a topic. In this review, we summarize the emerging therapeutic strategies for tissue engineering aimed to prolong the survival time of VCA grafts, delay the rejection and promote prevascularization and tissue regeneration to provide new ideas for future research on VCA treatment.
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Affiliation(s)
- Danyang Ren
- Department of Plastic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Chen
- Department of Plastic Surgery, Linhai Branch, The Second Affiliated Hospital, Zhejiang University School of Medicine, Taizhou, Zhejiang, China
| | - Meirong Yu
- Center for Basic and Translational Research, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chenggang Yi
- Department of Plastic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xueqing Hu
- Department of Plastic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Junjie Deng
- Joint Centre of Translational Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Joint Centre of Translational Medicine, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang, China
- Zhejiang Engineering Research Center for Tissue Repair Materials, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang, China
| | - Songxue Guo
- Department of Plastic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China
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Longo B, Pomahac B, Giacalone M, Cardillo M, Cervelli V. 18 years of face transplantation: Adverse outcomes and challenges. J Plast Reconstr Aesthet Surg 2023; 87:187-199. [PMID: 37879143 DOI: 10.1016/j.bjps.2023.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 08/19/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Since the first procedure performed in 2005, face transplantation has been debated as viable approach for the treatment of severe craniofacial defects. Despite the benefits provided, the experience in face allotransplantation has brought to light a significant risk of complications, including allograft removal or loss, and mortality. The present study is intended to provide an updated review on complications and major challenges witnessed over 18 years of experience in the field. METHODS A systematic review of PubMed, MEDLINE, Cochrane, Google, and Google Scholar databases on face transplantation was conducted according to PRISMA guidelines up to April 2023. Articles providing details on cases of face allograft loss, removal, and patient death were included. Online articles and media reports were assessed to include information not disclosed in peer-reviewed literature. Face transplant centers were contacted to have updated follow-up information on single-face transplant cases. RESULTS The search yielded 1006 reports, of which 28 were included. On a total of 48 procedures performed in 46 patients, adverse outcomes were gleaned in 14 cases (29%), including seven allograft losses (14.6%), and the death of ten patients (21.7%). Chronic rejection was the leading cause of allograft loss, with a median time from transplant to irreversible rejection of 90 months (IQR 88.5-102). The main causes of death were infectious complications, followed by malignancies, non-compliance to immunosuppression, and suicide. The median time to death was 48.5 months (IQR 19-122). CONCLUSIONS To the best of our knowledge, this is the first study providing a comprehensive review of adverse outcomes in face transplantation. Considering the high rate of major complications, the heterogeneity of cases and single-center approaches, and the absence of published standards of care, the development of a consensus by face transplant teams holds the key to the field's advancement.
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Affiliation(s)
- Benedetto Longo
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy.
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martina Giacalone
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| | - Massimo Cardillo
- National Transplants Center, National Institute of Health, Italian Ministry of Health, Rome, Italy
| | - Valerio Cervelli
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
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Kauke-Navarro M, Noel OF, Knoedler L, Knoedler S, Panayi AC, Stoegner VA, Huelsboemer L, Pomahac B. Novel Strategies in Transplantation: Genetic Engineering and Vascularized Composite Allotransplantation. J Surg Res 2023; 291:176-186. [PMID: 37429217 DOI: 10.1016/j.jss.2023.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/18/2023] [Accepted: 04/30/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Despite the clinical success in vascularized composite allotransplantation (VCA), systemic immunosuppression remains necessary to prevent allograft rejection. Even with potent immunosuppressive regimens (tacrolimus, mycophenolate mofetil, and steroids), most patients experience several rejection episodes, often within the same year. The risk of systemic side effects must constantly be weighed against the risk of under-immunosuppression and, thus, acute and chronic rejection. In this context, genomic editing has emerged as a potential tool to minimize the need for toxic immunosuppressive regimens and has gained attention in the fields of solid organ transplantation and xenotransplantation. This strategy may also be relevant for the future of VCA. METHODS We discuss the topic of genetic engineering and review recent developments in this field that justify investigating tools such as clustered regularly interspaced short palindromic repeats/Cas9 in the context of VCA. RESULTS We propose specific strategies for VCA based on the most recent gene expression data. This includes the well-known strategy of tolerance induction. Specifically, targeting the interaction between antigen-presenting cells and recipient-derived T cells by CD40 knockout may be effective. The novelty for VCA is a discovery that donor-derived T lymphocytes may play a special role in allograft rejection of facial transplants. We suggest targeting these cells prior to transplantation (e.g., by ex vivo perfusion of the transplant) by knocking out genes necessary for the long-term persistence of donor-derived immune cells in the allograft. CONCLUSION Despite the demonstrated feasibility of VCA in recent years, continued improvements to immunomodulatory strategies using tools like clustered regularly interspaced short palindromic repeats/Cas9 could lead to the development of approaches that mitigate the limitations associated with rejection of this life-giving procedure.
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Affiliation(s)
- Martin Kauke-Navarro
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Olivier F Noel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Samuel Knoedler
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adriana C Panayi
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viola A Stoegner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut; Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Lioba Huelsboemer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut; Institute of Musculoskeletal Medicine, University Hospital Muenster, Münster, Germany
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.
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Knoedler L, Knoedler S, Panayi AC, Lee CAA, Sadigh S, Huelsboemer L, Stoegner VA, Schroeter A, Kern B, Mookerjee V, Lian CG, Tullius SG, Murphy GF, Pomahac B, Kauke-Navarro M. Cellular activation pathways and interaction networks in vascularized composite allotransplantation. Front Immunol 2023; 14:1179355. [PMID: 37266446 PMCID: PMC10230044 DOI: 10.3389/fimmu.2023.1179355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is an evolving field of reconstructive surgery that has revolutionized the treatment of patients with devastating injuries, including those with limb losses or facial disfigurement. The transplanted units are typically comprised of different tissue types, including skin, mucosa, blood and lymphatic vasculature, muscle, and bone. It is widely accepted that the antigenicity of some VCA components, such as skin, is particularly potent in eliciting a strong recipient rejection response following transplantation. The fine line between tolerance and rejection of the graft is orchestrated by different cell types, including both donor and recipient-derived lymphocytes, macrophages, and other immune and donor-derived tissue cells (e.g., endothelium). Here, we delineate the role of different cell and tissue types during VCA rejection. Rejection of VCA grafts and the necessity of life-long multidrug immunosuppression remains one of the major challenges in this field. This review sheds light on recent developments in decoding the cellular signature of graft rejection in VCA and how these may, ultimately, influence the clinical management of VCA patients by way of novel therapies that target specific cellular processes.
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Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Catherine A. A. Lee
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sam Sadigh
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Lioba Huelsboemer
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Viola A. Stoegner
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Andreas Schroeter
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Barbara Kern
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Vikram Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Christine G. Lian
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - George F. Murphy
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
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10
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Lee CAA, Wang D, Kauke-Navarro M, Russell-Goldman E, Xu S, Mucciarone KN, Sohrabi S, Lian CG, Pomahac B, Murphy GF. Insights from Immunoproteomic Profiling of a Rejected Full Face Transplant. Am J Transplant 2023:S1600-6135(23)00405-7. [PMID: 37037378 DOI: 10.1016/j.ajt.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/24/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
Vascularized composite allografts (VCAs) of faces and extremities are subject to chronic rejection that is incompletely understood. Here we report on immunoproteomic evaluation of a full facial VCA removed 88 months after transplantation due to chronic rejection. CD8-positive T cells of donor (graft) origin infiltrating deep intragraft arteries in apposition to degenerating endothelium of chimeric recipient origin in association with arteriosclerotic alterations. Digital spatial proteomic profiling highlighted proteins expressed by activated cytotoxic T cells and macrophages as well as pathway components involved in atherogenic responses, including IDO1 and STING. Chronic facial VCA rejection thus involves T cell/macrophage-mediated accelerated arteriosclerosis not normally represented in punch biopsies and potentially driven by persistent graft-resident effector T cells and recipient target endothelium that chimerically repopulates graft arteries.
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Affiliation(s)
- Catherine A A Lee
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Diana Wang
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | | - Shuyun Xu
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Kyla N Mucciarone
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Sadaf Sohrabi
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Bohdan Pomahac
- Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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11
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Panayi AC, Knoedler S, Kauke-Navarro M, Haug V, Obed D, Pomahac B. Face transplantation: a bibliometric analysis of the top 100 most cited articles. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-023-02045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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12
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Regulatory T Cells: Liquid and Living Precision Medicine for the Future of VCA. Transplantation 2023; 107:86-97. [PMID: 36210500 DOI: 10.1097/tp.0000000000004342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transplant rejection remains a challenge especially in the field of vascularized composite allotransplantation (VCA). To blunt the alloreactive immune response' stable levels of maintenance immunosupression are required. However' the need for lifelong immunosuppression poses the risk of severe side effects, such as increased risk of infection, metabolic complications, and malignancies. To balance therapeutic efficacy and medication side effects, immunotolerance promoting immune cells (especially regulatory T cells [Treg]) have become of great scientific interest. This approach leverages immune system mechanisms that usually ensure immunotolerance toward self-antigens and prevent autoimmunopathies. Treg can be bioengineered to express a chimeric antigen receptor or a T-cell receptor. Such bioengineered Treg can target specific antigens and thereby reduce unwanted off-target effects. Treg have demonstrated beneficial clinical effects in solid organ transplantation and promising in vivo data in VCAs. In this review, we summarize the functional, phenotypic, and immunometabolic characteristics of Treg and outline recent advancements and current developments regarding Treg in the field of VCA and solid organ transplantation.
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13
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La Padula S, Pensato R, Pizza C, Coiante E, Roccaro G, Longo B, D’Andrea F, Wirz FS, Hersant B, Meningaud JP. Face Transplant: Indications, Outcomes, and Ethical Issues-Where Do We Stand? J Clin Med 2022; 11:jcm11195750. [PMID: 36233619 PMCID: PMC9571096 DOI: 10.3390/jcm11195750] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The addition of face allotransplantation (FT) to the head and neck reconstructive surgery arsenal has started a true revolution. This study is aimed at providing an extensive analysis of the current practice of composite tissue allotransplantation. Moreover, a thorough description of pre-procedural, intra-operative, and post-procedural settings, indications, contraindications, outcomes, ethical considerations, and future perspectives is provided. Methods: The authors’ experience was supplemented with a literature review performed by using the PubMed, MEDLINE, and Embase databases on 21 February 2022. The search terms used were “face transplantation indications”, “face transplantation complications”, and “face transplantation ethical issues”. Results: The most recent achievements and long-term clinical sequelae of FT are classified and summarized. A large number of records (4435) were identified. Seventy-five articles were assessed for eligibility. Publications without new data and reports with a patient follow-up < 5 years were excluded. Nineteen articles met the criteria for inclusion. Conclusions: The most recent achievements in the field of FT may be combined with cutting-edge regenerative medicine procedures and innovative immunological processing. It is paramount to build strong international networks between the world FT experts in order to achieve higher-level outcomes and reduce the complication rate. Nevertheless, the utmost caution is required in patient selection, clinical assessment, strict follow-up, and rejection management.
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Affiliation(s)
- Simone La Padula
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
- Correspondence:
| | - Rosita Pensato
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Chiara Pizza
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Edoardo Coiante
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Giovanni Roccaro
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Benedetto Longo
- Department of Plastic and Reconstructive Surgery, Università di Roma Tor Vergata, Viale Oxford 81, 00133 Roma, Italy
| | - Francesco D’Andrea
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | | | - Barbara Hersant
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Jean Paul Meningaud
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
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14
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Non-HLA Antibodies in Hand Transplant Recipients Are Connected to Multiple Acute Rejection Episodes and Endothelial Activation. J Clin Med 2022; 11:jcm11030833. [PMID: 35160284 PMCID: PMC8837026 DOI: 10.3390/jcm11030833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
The role of anti-HLA antibodies in transplant rejection is well-known but the injury associated with non-HLA antibodies is now widely discussed. The aim of our study was to investigate a role of non-HLA antibodies in hand allografts rejection. The study was performed on six patients after hand transplantation. The control group consisted of: 12 kidney transplant recipients and 12 healthy volunteers. The following non-HLA antibodies were tested: antibody against angiotensin II type 1 receptor (AT1R-Ab), antibody against endothelin-1 type-A-receptor (ETAR-Ab), antibody against protease-activated receptor 1 (PAR-1-Ab) and anti-VEGF-A antibody (VEGF-A-Ab). Chosen proinflammatory cytokines (Il-1, IL-6, IFNγ) were used to evaluate the post-transplant humoral response. Laboratory markers of endothelial activation (VEGF, sICAM, vWF) were used to assess potential vasculopathy. The patient with the highest number of acute rejections had both positive non-HLA antibodies: AT1R-Ab and ETAR-Ab. The same patient had the highest VEGF-A-Ab and very high PAR1-Ab. All patients after hand transplantation had high levels of laboratory markers of endothelial activation. The existence of non-HLA antibodies together with multiple acute rejections observed in patient after hand transplantation should stimulate to look for potential role of non-HLA antibodies in humoral injury in vascular composite allotransplantation.
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15
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A systematic review of immunomodulatory strategies used in skin-containing preclinical vascularized composite allotransplant models. J Plast Reconstr Aesthet Surg 2021; 75:586-604. [PMID: 34895853 DOI: 10.1016/j.bjps.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 06/13/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute rejection remains a vexing problem in vascularized composite allotransplantation (VCA). Available immunosuppressive regimens are successful at minimizing alloimmune response and allowing VCA in humans. However, repeated rejection episodes are common, and systemic side effects of the current standard regimen (Tacrolimus, MMF, Prednisone) are dose limiting. Novel immunomodulatory approaches to improve allograft acceptance and minimize systemic toxicity are continuously explored in preclinical models. We aimed to systematically summarize past and current approaches to help guide future research in this complex field. METHODS We conducted a systematic review of manuscripts listed in the MEDLINE and PubMed databases. For inclusion, articles had to primarily investigate the effect of a therapeutic approach on prolonging the survival of a skin-containing preclinical VCA model. Non-VCA studies, human trials, anatomical and feasibility studies, and articles written in a language other than English were excluded. We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. RESULTS The search retrieved 980 articles of which 112 articles were ultimately included. The majority of investigations used a rat model. An orthotopic hind limb VCA model was used in 53% of the studies. Cell and drug-based approaches were investigated 58 and 52 times, respectively. We provide a comprehensive review of immunomodulatory strategies used in VCA preclinical research over a timeframe of 44 years. CONCLUSION We identify a transition from anatomically non-specific to anatomical models mimicking clinical needs. As limb transplants have been most frequently performed, preclinical research focused on using the hind limb model. We also identify a transition from drug-based suppression therapies to cell-based immunomodulation strategies.
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16
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Kauke M, Panayi AC, Safi AF, Haug V, Perry B, Kollar B, Nizzi MC, Broyles J, Annino DJ, Marty FM, Sinha I, Lian CG, Murphy GF, Chandraker A, Pomahac B. Full facial retransplantation in a female patient-Technical, immunologic, and clinical considerations. Am J Transplant 2021; 21:3472-3480. [PMID: 34033210 DOI: 10.1111/ajt.16696] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 01/25/2023]
Abstract
There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.
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Affiliation(s)
- Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget Perry
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie-Christine Nizzi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Justin Broyles
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald J Annino
- Division of Otolaryngology, Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Indranil Sinha
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anil Chandraker
- Schuster Transplantation Research Center, Renal Division, Boston, Massachusetts, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Moris D, Cendales LC. Sensitization and Desensitization in Vascularized Composite Allotransplantation. Front Immunol 2021; 12:682180. [PMID: 34456906 PMCID: PMC8385557 DOI: 10.3389/fimmu.2021.682180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/27/2021] [Indexed: 01/02/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is a field under research and has emerged as an alternative option for the repair of severe disfiguring defects that result from severe tissue loss in a selected group of patients. Lifelong immunosuppressive therapy, immunosuppression associated complications, and the effects of the host immune response in the graft are major concerns in this type of quality-of-life transplant. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury-related factors, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibody (DSA) formation and graft rejection in the context of VCA still remain poorly understood. The most common antigenic target of preexisting alloantibodies are MHC mismatches, though recognition of ABO incompatible antigens, minor histocompatibility complexes and endothelial cells has also been shown to contribute to rejection. Mechanistically, alloantibody-mediated tissue damage occurs primarily through complement fixation as well as through antibody-dependent cellular toxicity. If DSA exist, activation of complement and coagulation cascades can result in vascular thrombosis and infarction and thus rejection and graft loss. Both preexisting DSA but especially de-novo DSA are currently considered as main contributors to late allograft injury and graft failure. Desensitization protocols are currently being developed for VCA, mainly including removal of alloantibodies whereas treatment of established antibody-mediated rejection is achieved through high dose intravenous immunoglobulins. The long-term efficacy of such therapies in sensitized VCA recipients is currently unknown. The current evidence base for sensitizing events and outcomes in reconstructive transplantation is limited. However, current data show that VCA transplantation has been performed in the setting of HLA-sensitization.
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Affiliation(s)
| | - Linda C. Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
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18
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Sipilä M, Kiukas EL, Lindford A, Ylä-Kotola T, Lauronen J, Sintonen H, Lassus P. The four category systematic approach for selecting patients for face transplantation. J Plast Surg Hand Surg 2021; 56:79-86. [PMID: 34255990 DOI: 10.1080/2000656x.2021.1933995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Ten patients with severe facial defects treated between 1995 and 2017 formed the study group. Data was collected from patient charts and clinical, radiological and laboratory examinations. Facial deficiencies were subdivided into four different categories: anatomical region (10 facial subunits), facial function, aesthetic defect (range 0-9-worst), and impact on health-related quality of life (HRQoL) (15D questionnaire, range 0-1). Immunological status and possible contraindications were also evaluated. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 to 10 injured facial subunits. All patients had at least partial loss of facial function. The mean aesthetic disfigurement score was 6.4. The median lowering of 15D score was -0.107. None were significantly sensitized although four patients had relative contraindications and one patient had an absolute contraindication for FT. Three patients with a severe overall facial deficiency were considered as potential FT candidates. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of 4 key categories: anatomical regions affected, facial function, aesthetics, and HRQoL.
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Affiliation(s)
- Matias Sipilä
- Department of Plastic Surgery, Helsinki University Hospital University of Helsinki, Helsinki, Finland
| | - Emma-Lotta Kiukas
- Department of Plastic Surgery, Helsinki University Hospital University of Helsinki, Helsinki, Finland
| | - Andrew Lindford
- Department of Plastic Surgery, Helsinki University Hospital University of Helsinki, Helsinki, Finland
| | - Tuija Ylä-Kotola
- Department of Plastic Surgery, Helsinki University Hospital University of Helsinki, Helsinki, Finland
| | - Jouni Lauronen
- Finnish Red Cross Blood Service, Histocompatibility Laboratory, Helsinki, Finland
| | - Harri Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Patrik Lassus
- Department of Plastic Surgery, Helsinki University Hospital University of Helsinki, Helsinki, Finland
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19
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Akdogan N, Ersoy-Evans S, Gokoz O, Erdem Y, Nasir S. Early recognition of chronic rejection in a face allotransplant patient with alopecia. J Cutan Pathol 2021; 48:1286-1297. [PMID: 34085296 DOI: 10.1111/cup.14069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/06/2021] [Accepted: 05/30/2021] [Indexed: 11/26/2022]
Abstract
The features of chronic rejection (CR) in full-face vascularized composite allotransplantation (VCA) are not well-known. Herein, we report a full-face transplant patient that experienced two episodes of acute rejection (AR) and three episodes of AR/CR over the course of 6-years. The patient noticed a small, round patch of hair loss in his beard 9 months after the second AR episode, which occurred 21 months post-transplantation. Biopsy of the alopecic patch showed lichen-planopilaris-like features, which was suggestive of early CR. Despite an increase in immunosuppressive dosages, the alopecia progressed. Following the second and third AR/CR episodes, the alopecia became more pronounced, with the addition of hyperpigmentation as well as sclerosis and telangiectasia. The findings of multiple biopsies showed CR. Based on these findings we think that alopecia with lichen-planopilaris-like histopathological features similar to grade III AR features, particularly in hair follicles appears to be an early finding of CR in the presented patient. The findings further indicate that follicular involvement may be a significant feature of CR in VCA patients and that it can present prior to sclerosis, vasculopathy, or loss of adnexa. The present case is uniquely important because of the distinctive presentation of CR, with hair follicles clinically and histopathologically affected, leading to progressive and irreversible alopecia with lichen-planopilaris-like histopathology.
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Affiliation(s)
- Neslihan Akdogan
- Department of Dermatology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Sibel Ersoy-Evans
- Department of Dermatology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Ozay Gokoz
- Department of Pathology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Yunus Erdem
- Department of Nephrology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Serdar Nasir
- Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Hacettepe University, Ankara, Turkey
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20
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. SUMMARY This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.
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21
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Vascularized Composite Allotransplantation and Immunobiology: The Next Frontier. Plast Reconstr Surg 2021; 147:1092e-1093e. [PMID: 34019530 DOI: 10.1097/prs.0000000000007954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Gray KM, Peterson JM, Padilla PL, Smith JM, Zapata-Sirvent RL, Branski LK, Norbury WB, Dziewulski P. Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis. J Burn Care Res 2021; 42:465-472. [PMID: 33091131 DOI: 10.1093/jbcr/iraa188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.
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Affiliation(s)
- Kelsey M Gray
- School of Medicine, University of Texas Medical Branch, Galveston
| | - Joshua M Peterson
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Pablo L Padilla
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Jeffrey M Smith
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Ramón L Zapata-Sirvent
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - Ludwik K Branski
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - William B Norbury
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - Peter Dziewulski
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
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23
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Aral AM, Zamora R, Barclay D, Yin J, El-Dehaibi F, Erbas VE, Dong L, Zhang Z, Sahin H, Gorantla VS, Vodovotz Y. The Effects of Tacrolimus on Tissue-Specific, Protein-Level Inflammatory Networks in Vascularized Composite Allotransplantation. Front Immunol 2021; 12:591154. [PMID: 34017323 PMCID: PMC8129572 DOI: 10.3389/fimmu.2021.591154] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/14/2021] [Indexed: 12/26/2022] Open
Abstract
Systems-level insights into inflammatory events after vascularized composite allotransplantation (VCA) are critical to the success of immunomodulatory strategies of these complex procedures. To date, the effects of tacrolimus (TAC) immunosuppression on inflammatory networks in VCA, such as in acute rejection (AR), have not been investigated. We used a systems biology approach to elucidate the effects of tacrolimus on dynamic networks and principal drivers of systemic inflammation in the context of dynamic tissue-specific immune responses following VCA. Lewis (LEW) rat recipients received orthotopic hind limb VCA from fully major histocompatibility complex-mismatched Brown Norway (BN) donors or matched LEW donors. Group 1 (syngeneic controls) received LEW limbs without TAC, and Group 2 (treatment group) received BN limbs with TAC. Time-dependent changes in 27 inflammatory mediators were analyzed in skin, muscle, and peripheral blood using Principal Component Analysis (PCA), Dynamic Bayesian Network (DyBN) inference, and Dynamic Network Analysis (DyNA) to define principal characteristics, central nodes, and putative feedback structures of systemic inflammation. Analyses were repeated on skin + muscle data to construct a "Virtual VCA", and in skin + muscle + peripheral blood data to construct a "Virtual Animal." PCA, DyBN, and DyNA results from individual tissues suggested important roles for leptin, VEGF, various chemokines, the NLRP3 inflammasome (IL-1β, IL-18), and IL-6 after TAC treatment. The chemokines MCP-1, MIP-1α; and IP-10 were associated with AR in controls. Statistical analysis suggested that 24/27 inflammatory mediators were altered significantly between control and TAC-treated rats in peripheral blood, skin, and/or muscle over time. "Virtual VCA" and "Virtual Animal" analyses implicated the skin as a key control point of dynamic inflammatory networks, whose connectivity/complexity over time exhibited a U-shaped trajectory and was mirrored in the systemic circulation. Our study defines the effects of TAC on complex spatiotemporal evolution of dynamic inflammation networks in VCA. We also demonstrate the potential utility of computational analyses to elucidate nonlinear, cross-tissue interactions. These approaches may help define precision medicine approaches to better personalize TAC immunosuppression in VCA recipients.
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Affiliation(s)
- Ali Mubin Aral
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vasil E Erbas
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medicalpark Gaziantep Hospital, Gaziantep, Turkey
| | - Liwei Dong
- Plastic and Aesthetic Surgery Department, XiJing Hospital, Xi'an, China
| | - Zhaoxiang Zhang
- Plastic and Aesthetic Surgery Department, XiJing Hospital, Xi'an, China
| | | | - Vijay S Gorantla
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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24
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Abstract
Initially overlooked in favor of T cell-mediated rejection, the importance of the humoral alloimmune response has progressively emerged. As a result, antibody-mediated rejection is now widely recognized as the main cause of late allograft loss in most (if not all) types of solid-organ transplantation. Over the last 2 decades, vascularized composite allotransplantation (VCA) has appeared for replacing tissue defects in patients for whom no other satisfactory reconstructive options were available. Although it is now clear that VCA recipients can develop donor-specific antibodies, conclusions made in solid organ transplantation regarding antibody-mediated rejection may not systematically apply to VCA. Here, we propose to use the experience gained in organ transplantation to shed light on the path that shall be followed to evaluate and manage humoral alloreactivity in VCA recipients.
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25
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Hautz T, Messner F, Weissenbacher A, Hackl H, Kumnig M, Ninkovic M, Berchtold V, Krapf J, Zelger BG, Zelger B, Wolfram D, Pierer G, Löscher WN, Zimmermann R, Gabl M, Arora R, Brandacher G, Margreiter R, Öfner D, Schneeberger S. Long-term outcome after hand and forearm transplantation - a retrospective study. Transpl Int 2020; 33:1762-1778. [PMID: 32970891 PMCID: PMC7756600 DOI: 10.1111/tri.13752] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/04/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Between 2000 and 2014, five patients received bilateral hand (n = 3), bilateral forearm (n = 1), and unilateral hand (n = 1) transplants at the Innsbruck Medical University Hospital. We provide a comprehensive report of the long-term results at 20 years. During the 6-20 years follow-up, 43 rejection episodes were recorded in total. Of these, 27.9% were antibody-related with serum donor-specific alloantibodies (DSA) and skin-infiltrating B-cells. The cell phenotype in rejecting skin biopsies changed and C4d-staining increased with time post-transplantation. In the long-term, a change in hand appearance was observed. The functional outcome was highly depending on the level of amputation. The number and severity of rejections did not correlate with hand function, but negatively impacted on the patients´ well-being and quality of life. Patient satisfaction significantly correlated with upper limb function. One hand allograft eventually developed severe allograft vasculopathy and was amputated at 7 years. The patient later died due to progressive gastric cancer. The other four patients are currently rejection-free with moderate levels of immunosuppression. Hand transplantation remains a therapeutic option for carefully selected patients. A stable immunologic situation with optimized and individually adopted immunosuppression favors good compliance and patient satisfaction and may prevent development of DSA.
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Affiliation(s)
- Theresa Hautz
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Franka Messner
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Hubert Hackl
- Division of BioinformaticsBiocenterMedical University of InnsbruckInnsbruckAustria
| | - Martin Kumnig
- Department of Psychiatry, Psychotherapy and PsychosomaticCenter for Advanced Psychology in Plastic and Transplant SurgeryMedical University of InnsbruckInnsbruckAustria
| | - Marina Ninkovic
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Valeria Berchtold
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Johanna Krapf
- Department of Plastic, Reconstructive and Aesthetic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Bettina G. Zelger
- Department of PathologyMedical University of InnsbruckInnsbruckAustria
| | - Bernhard Zelger
- Department of DermatologyMedical University of InnsbruckInnsbruckAustria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Gerhard Pierer
- Department of Plastic, Reconstructive and Aesthetic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | | | - Robert Zimmermann
- Department of Plastic, Reconstructive and Aesthetic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Markus Gabl
- Department for Trauma SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Rohit Arora
- Department for Trauma SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation (VCA) LaboratoryDepartment of Plastic and Reconstructive SurgeryJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Raimund Margreiter
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
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26
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Abstract
AbstractPurpose of ReviewSkin provides a window into the health of an individual. Using transplanted skin as a monitor can provide a powerful tool for surveillance of rejection in a transplant. The purpose of this review is to provide relevant background to the role of skin in vascularized transplantation medicine.Recent FindingsDiscrete populations of T memory cells provide distributed immune protection in skin, and cycle between skin, lymph nodes, and blood. Skin-resident TREGcells proliferate in response to inflammation and contribute to long-term VCA survival in small animal models. Early clinical studies show sentinel flap rejection to correlate well with facial VCA skin rejection, and abdominal wall rejection demonstrates concordance with visceral rejection, but further studies are required.SummaryThis review focuses on the immunology of skin, skin rejection in vascularized composite allografts, and the recent advances in monitoring the health of transplanted tissues using distant “sentinel” flaps.
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27
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Kimberly LL, Ramly EP, Alfonso AR, Diep GK, Berman ZP, Rodriguez ED. Equity in access to facial transplantation. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106129. [PMID: 33060187 DOI: 10.1136/medethics-2020-106129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 06/11/2023]
Abstract
We examine ethical considerations in access to facial transplantation (FT), with implications for promoting health equity. As a form of vascularised composite allotransplantation, FT is still considered innovative with a relatively low volume of procedures performed to date by a small number of active FT programmes worldwide. However, as numbers continue to increase and institutions look to establish new FT programmes, we anticipate that attention will shift from feasibility towards ensuring the benefits of FT are equitably available to those in need. This manuscript assesses barriers to care and their ethical implications across a number of considerations, with the intent of mapping various factors relating to health equity and fair access to FT. Evidence is drawn from an evolving clinical experience as well as published scholarship addressing several dimensions of access to FT. We also explore novel concerns that have yet to be mentioned in the literature.
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Affiliation(s)
- Laura L Kimberly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
- Division of Medical Ethics, Department of Population Health, NYU Langone Health, New York, NY, United States
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Gustave K Diep
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Zoe P Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
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28
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Haug V, Kollar B, Obed D, Kiwanuka H, Turk M, Wo L, Tasigiorgos S, Kueckelhaus M, Riella LV, Pomahac B. The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation. JAMA FACIAL PLAST SU 2020; 21:278-285. [PMID: 30998810 DOI: 10.1001/jamafacial.2019.0076] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Acute rejection is one of the most frequent complications in facial transplantation, with potentially severe consequences for the recipient if overlooked. Clinical signs, such as erythema or edema, are helpful to diagnose acute rejection in the early follow-up stage; however, it is not well known whether these clinical signs remain reliable markers of acute rejection beyond the second posttransplant year. Objective To determine the diagnostic value of clinical signs of acute rejection after facial transplantation over time. Design, Setting, and Participants A retrospective, single-center cohort study was conducted of patients who underwent facial transplantation at Brigham and Women's Hospital between April 2009 and October 2014, with up to an 8-year follow-up. Medical records were reviewed until September 30, 2017. The medical records from 104 encounters with 7 patients who underwent partial or full facial transplantation were analyzed for symptoms of rejection, immunosuppressive therapy, and histopathologic findings. Main Outcomes and Measures The occurrence of 5 clinical signs of acute rejection were evaluated: erythema, edema, exanthema, suture line erythema, and mucosal lesions. Odds ratios (ORs) were calculated to determine the statistically significant association of these signs with the histopathologic diagnosis of rejection. In addition, tacrolimus blood levels, as a surrogate marker of immunosuppressive therapy, were evaluated. Results Of the 7 patients included in the study, 5 were men. The mean follow-up was 66 months (range, 35-101). Of 104 clinical encounters, 46 encounters (44.2%) represented rejection episodes and 58 encounters (55.8%) represented no-rejection episodes. Beyond 2 years posttransplantation, only erythema (OR, 6.53; 95% CI, 1.84-20.11; P = .004) and exanthema (OR, ∞; 95% CI, 2.2-∞; P = .004) were demonstrated to be reliable clinical signs of acute rejection in facial transplantation. There was also a statistically significant association of subtherapeutic tacrolimus levels with late rejection episodes (OR, 3.79; 95% CI, 1.25-12.88; P = .03). In addition, the occurrence of subclinical rejection was more frequent during later follow-up times (7 [24.1%] late rejections vs 1 [5.9%] early rejection). Five of 8 subclinical rejections (62.5%) were associated with subtherapeutic tacrolimus levels. Conclusions and Relevance Clinical signs of acute rejection in facial transplantation appear to be of limited diagnostic value, particularly after the second postoperative year. Until alternative biomarkers for rejection are identified, protocol skin biopsies will remain necessary for guiding assessments of allograft rejection. Level of Evidence 3.
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Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Doha Obed
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marvee Turk
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maximillian Kueckelhaus
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Schuster Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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29
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Wilks DJ, Clark B, Kay SPJ. The histocompatibility and immunogenetics of hand transplantation. Int J Immunogenet 2019; 47:24-27. [PMID: 31867873 DOI: 10.1111/iji.12469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/25/2019] [Accepted: 11/28/2019] [Indexed: 12/01/2022]
Abstract
This short review will be concerned with the literature that has developed connected with the immunogenetic and tissue compatibility aspects of hand transplantation and will also draw on connected work in the more general area of vascularized composite allotransplantation (VCA) which includes face, abdominal wall uterus and larynx.
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Affiliation(s)
- Daniel J Wilks
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
| | - Brendan Clark
- Transplant Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - Simon P J Kay
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
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30
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Clark B, Carter C, Wilks DJ, Lobb M, Hughes P, Baker R, Kay SPJ. The Leeds hand transplant programme: Review of the laboratory management of the first six cases. Int J Immunogenet 2019; 47:28-33. [PMID: 31840432 DOI: 10.1111/iji.12466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/21/2019] [Accepted: 11/28/2019] [Indexed: 11/30/2022]
Abstract
The UK hand transplantation programme is hosted by the Department of Plastic and Reconstructive Surgery at Leeds Teaching Hospitals under the leadership of Professor Simon Kay. Since programme launch in 2013, ten procedures in six individuals have been performed involving unilateral or bilateral transplants. The multi-disciplinary team that delivers the programme includes the transplant immunology service. The laboratory experience in programme support is reported here.
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Affiliation(s)
- Brendan Clark
- Departments of Transplant Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - Clive Carter
- Departments of Transplant Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - Daniel J Wilks
- Departments of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
| | - Mark Lobb
- Departments of Transplant Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - Pamela Hughes
- Departments of Transplant Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - Richard Baker
- Departments of Renal Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - Simon P J Kay
- Departments of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
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31
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Shubin AV, Kollar B, Dillon ST, Pomahac B, Libermann TA, Riella LV. Blood proteome profiling using aptamer-based technology for rejection biomarker discovery in transplantation. Sci Data 2019; 6:314. [PMID: 31819064 PMCID: PMC6901551 DOI: 10.1038/s41597-019-0324-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/04/2019] [Indexed: 12/24/2022] Open
Abstract
Face transplantation is a promising solution for patients with devastating facial injuries who lack other satisfactory treatment options. At the same time, this type of transplantation is accompanied with high risks of acute transplant rejection. The limitations of traditional skin biopsy and the need to frequently monitor the condition of face transplant call for less invasive biomarkers to better diagnose and treat acute rejection. Discovery of peripheral serum proteins accurately reflecting the transplant status would represent a reasonable solution to meet this demand. However, to date, there is no clinical data available to address the feasibility of this approach. In this study, we used the next generation aptamer-based SOMAscan proteomics platform to profile 1305 proteins of peripheral blood serum in twenty-four samples taken from 6 patients during no-rejection, nonsevere rejection, and severe rejection episodes. Also, we provide a detailed description of biosample processing and all steps to generate and analyze the SOMAscan dataset with hope it will assist in performing biomarker discovery in other transplantation centers using this platform.
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Affiliation(s)
- Andrey V Shubin
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, 02138, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Simon T Dillon
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Towia A Libermann
- Beth Israel Deaconess Medical Center Genomics, Proteomics, Bioinformatics and Systems Biology Center, Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.
| | - Leonardo V Riella
- Schuster Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
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32
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Rotman S, Koch N, Wiesner L, Aubert V, Rosales IA, Colvin RB, Raffoul W, Pascual M. Nonvascularized human skin chronic allograft rejection. Am J Transplant 2019; 19:3191-3196. [PMID: 31344327 DOI: 10.1111/ajt.15542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 01/25/2023]
Abstract
A 65-year-old man had extensive burns of the lower legs in 1991, at the age of 40 years. He was treated by nonvascularized and de-epithelialized, allogeneic split-thickness skin allograft and cyclosporine monotherapy for 2 months. Ulcers developed between 10 and 25 years after transplantation and a surgical debridement on the lower extremities was required. Analyses of the removed tissue allografts showed chronic antibody-mediated and cellular rejection with extensive and dense fibrosis, and diffuse capillary C4d deposits. An anti-DRB1*08:01, donor-specific antibody was present. A unique clinical condition with late immunopathological features of human skin chronic allograft rejection is reported.
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Affiliation(s)
- Samuel Rotman
- Service of Clinical Pathology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nathalie Koch
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Lucie Wiesner
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Vincent Aubert
- Service of Immunology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert B Colvin
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wassim Raffoul
- Service of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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33
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Rifkin WJ, David JA, Plana NM, Kantar RS, Diaz-Siso JR, Gelb BE, Ceradini DJ, Rodriguez ED. Achievements and Challenges in Facial Transplantation. Ann Surg 2019; 268:260-270. [PMID: 29489486 DOI: 10.1097/sla.0000000000002723] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
: The first facial transplantation in 2005 ushered in a new era in reconstructive surgery, offering new possibilities for the repair of severe disfigurements previously limited by conventional techniques. Advances in allograft design, computerized preoperative planning, surgical technique, and postoperative revisions have helped push the boundaries in this new frontier of vascularized composite allotransplantation. Over the past 12 years, 40 of these procedures have been performed across the world, offering the field the opportunity to reflect on current outcomes. Successes achieved in the brief history of facial transplantation have resulted in a new set of obstacles the field must now overcome. In this review, we aim to highlight the achievements, major challenges, and future directions of this rapidly evolving field.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Joshua A David
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Natalie M Plana
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Bruce E Gelb
- Division of Transplant Surgery, NYU Langone Health, New York, NY
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
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34
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Kollar B, Kamat P, Klein H, Waldner M, Schweizer R, Plock J. The Significance of Vascular Alterations in Acute and Chronic Rejection for Vascularized Composite Allotransplantation. J Vasc Res 2019; 56:163-180. [DOI: 10.1159/000500958] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
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35
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Kaufman CL, Cascalho M, Ozyurekoglu T, Jones CM, Ramirez A, Roberts T, Tien HY, Moreno R, Galvis E, Tsai TM, Palazzo M, Farner S, Platt JL. The role of B cell immunity in VCA graft rejection and acceptance. Hum Immunol 2019; 80:385-392. [DOI: 10.1016/j.humimm.2019.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 12/12/2022]
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36
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Krezdorn N, Lian CG, Wells M, Wo L, Tasigiorgos S, Xu S, Borges TJ, Frierson RM, Stanek E, Riella LV, Pomahac B, Murphy GF. Chronic rejection of human face allografts. Am J Transplant 2019; 19:1168-1177. [PMID: 30312535 PMCID: PMC6433509 DOI: 10.1111/ajt.15143] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/14/2018] [Accepted: 09/23/2018] [Indexed: 01/25/2023]
Abstract
Face vascularized composite allografts (FVCAs) have helped patients with severe facial disfigurement, with acute rejection now largely controlled through iatrogenic immunosuppression. However, little is known regarding the incidence and mechanism(s) of more long-term pathologic alterations in FVCAs that may affect function and graft durability. Protocol surveillance biopsy specimens for up to an 8-year interval in 7 patients who received FVCAs at our institution revealed histopathologic evidence of chronic rejection. Clinical manifestations included features of premature aging, mottled leukoderma accentuating suture lines, telangiectasia, and dryness of nasal mucosa. Pathologic changes consisted of epidermal thinning accompanied by discrete foci of lymphocyte-mediated cytotoxicity, hyperkeratosis, follicular plugging, vascular ectasia, and sclerosis beneath the epidermal layer associated with collagen type I deposition. Genomic interrogation and immunohistochemistry of sclerotic zones revealed upregulation of the AP-1 pathway components, JunB and c-Fos, previously implicated in overproduction of type I dermal collagen in the setting of systemic sclerosis. We conclude that some patients develop chronic rejection in FVCAs with striking similarities to alterations seen in certain autoimmune cutaneous disorders (lupus erythematosus and scleroderma/chronic sclerodermoid graft-versus-host disease). Identification of relevant pathways and genes, such as JunB and c-Fos, may provide new targets for preventative therapies for chronic immune-mediated changes in vascularized composite allografts.
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Affiliation(s)
- Nicco Krezdorn
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA,Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Christine G. Lian
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Michael Wells
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Shuyen Xu
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Thiago J. Borges
- Transplant Research Center, Renal Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Rayven M. Frierson
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Ewelina Stanek
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Leonardo V. Riella
- Transplant Research Center, Renal Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - George F. Murphy
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, 75 Francis St, 02115 Boston, MA, USA
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Abstract
PURPOSE OF REVIEW For patients with devastating injuries in whom standard reconstruction is not an option, vascularized composite allotransplantation (VCA) has become a viable means of restoring form and function. However, immunological rejection continues to be a problem in VCA and has not yet been fully characterized. As the field is relatively new, much of the data on rejection and immunosuppression have been extrapolated from that of solid organ transplantation. In this review, we cover the basic mechanisms of rejection as they relate specifically to VCA with analysis of recent literature and future directions. RECENT FINDINGS Recent clinical studies have supported previously postulated T-cell-mediated mechanism of acute rejection and have also made strides in differentiating rejection from inflammation from other skin conditions and with different treatment regimens. Antibody-mediated rejection has been described in recent cases as well as treatment of presensitized patients receiving VCAs. With more long-term grafts, chronic changes, including vasculopathy, are being reported. SUMMARY Clinically observed types of rejection in VCA include mainly cell-mediated, antibody-mediated and chronic rejection. Advances in diagnosis and treatment of rejection have been made, but there is still much to be learned about VCA-specific rejection.
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Novel immunological and clinical insights in vascularized composite allotransplantation. Curr Opin Organ Transplant 2019; 24:42-48. [DOI: 10.1097/mot.0000000000000592] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ozkan O, Ertosun MG, Ozkan O. Technical, Immunological, and Ethical Similarities and Differences Between Vascularized Composite Allotransplantation and Solid Organ Transplantation in Current Practice. Transplant Proc 2018; 50:3775-3782. [PMID: 30577269 DOI: 10.1016/j.transproceed.2018.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/19/2018] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation (SOT) is a surgical method used as the gold standard in end-term organ failure. Following SOT, successful results have also been achieved in vascularized composite tissue transplantation, which improves the quality of life with the success of solid organ transplants and the development of modern immunosuppressive regimens. This review discusses the preoperative, operative, postoperative, and immunological differences between vascularized tissue transplantation and SOT.
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Affiliation(s)
- O Ozkan
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey
| | - M G Ertosun
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey
| | - O Ozkan
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey.
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40
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Increased levels of circulating MMP3 correlate with severe rejection in face transplantation. Sci Rep 2018; 8:14915. [PMID: 30297859 PMCID: PMC6175842 DOI: 10.1038/s41598-018-33272-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022] Open
Abstract
Face transplantation is a viable treatment option for carefully selected patients with devastating injuries to the face. However, acute rejection episodes occur in more than 80% of recipients in the first postoperative year. Unfortunately, neither a correlation between histological grades of rejection and anti-rejection treatment nor systemic surrogate markers of rejection in face transplantation are established in clinical routine. Therefore, we utilized next generation aptamer-based SOMAscan proteomics platform for non-invasive rejection biomarker discovery. Longitudinal serum samples from face transplant recipients with long-term follow-up were included in this study. From the 1,310 proteins analyzed by SOMAscan, a 5-protein signature (MMP3, ACY1, IL1R2, SERPINA4, CPB2) was able to discriminate severe rejection from both no-rejection and nonsevere rejection samples. Technical validation on ELISA platform showed high correlation with the SOMAscan data for the MMP3 protein (rs = 0.99). Additionally, MMP3 levels were significantly increased during severe rejection as compared to no-rejection (p = 0.0009) and nonsevere rejection (p = 0.0173) episodes. Pathway analyses revealed significant activation of the metallopeptidase activity during severe face transplant rejection. This pilot study demonstrates the feasibility of SOMAscan to identify non-invasive candidate biomarkers of rejection in face transplantation. Further validation in a larger independent patient cohort is needed.
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Local Injections of Tacrolimus-loaded Hydrogel Reduce Systemic Immunosuppression-related Toxicity in Vascularized Composite Allotransplantation. Transplantation 2018; 102:1684-1694. [DOI: 10.1097/tp.0000000000002283] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lindford AJ, Mäkisalo H, Jalanko H, Lauronen J, Anttila VJ, Juteau S, Ämmälä AJ, Eskola A, Saarni S, Isoniemi H, Mäkitie A, Lassus P. The Helsinki approach to face transplantation. J Plast Reconstr Aesthet Surg 2018; 72:173-180. [PMID: 30279107 DOI: 10.1016/j.bjps.2018.08.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/12/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
AIM We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases. METHODS & PATIENTS The Helsinki VCA program initially required the fulfillment of legal, hospital, financial, and ethical requirements. Thereafter, the assembling of a multidisciplinary team commenced. A team of Plastic, maxillofacial and ENT surgeons comprise the facial VCA team. The protocol involves collaboration with the Solid Organ Transplant (SOT) team, transplant immunology, immunosuppression, microbiology, psychiatric evaluation, well-defined VCA indications and informed consent. Between 2011 and 2017 two patients were selected for transplantation. Both patients had a severe composite facial deformity involving the maxilla and mandible following earlier ballistic injury. RESULTS Patient 1 was a 35 year-old male who underwent successful near total face transplantation in February 2016 and at 30 months he has a good aesthetic outcome with symmetrical restoration of the central face and good sensory and symmetrical motor functional outcomes. Patient 2 was a 58 year-old male who underwent full face transplantation in March 2018 and at 5 months he has recovered without major problems. CONCLUSION A successful facial VCA program requires a well-prepared research protocol, experts from multiple specialties and careful patient selection. The establishment of the Helsinki VCA program required long and thorough planning and resulted in the first two Nordic face transplantation cases. This protocol now forms the platform (as a proof of concept) for other types of vascularized composite allotransplantations.
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Affiliation(s)
- Andrew J Lindford
- Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital (HUS), University of Helsinki, Topeliuksenkatu 5, P.O. Box 266, FIN-00029, Helsinki, Finland.
| | - Heikki Mäkisalo
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, University of Helsinki, Finland
| | - Hannu Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital, Finland
| | | | - Veli-Jukka Anttila
- Department of Infectious Diseases, Helsinki University Hospital, University of Helsinki, Finland
| | - Susanna Juteau
- Department of Pathology, Haartman Institute, University of Helsinki & HUSLAB, Helsinki, Finland
| | - Antti-Jussi Ämmälä
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Finland
| | - Anna Eskola
- Department of Psychiatry, Helsinki University Hospital, University of Helsinki, Finland
| | - Samuli Saarni
- Department of Health, Unit of Mental Health, National Institute for Health and Welfare, Helsinki, Finland; Turku University Hospital, University of Turku, Turku, Finland
| | - Helena Isoniemi
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, University of Helsinki, Finland
| | - Antti Mäkitie
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Patrik Lassus
- Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital (HUS), University of Helsinki, Topeliuksenkatu 5, P.O. Box 266, FIN-00029, Helsinki, Finland
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Kollar B, Tasigiorgos S, Dorante MI, Carty MJ, Talbot SG, Pomahac B. Innovations in reconstructive microsurgery: Reconstructive transplantation. J Surg Oncol 2018; 118:800-806. [PMID: 30098294 DOI: 10.1002/jso.25147] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 12/17/2022]
Abstract
In the past 20 years, reconstructive transplantation (RT) has emerged as a viable reconstructive option for carefully selected patients. More than 100 upper extremity and 40 face transplants have been performed worldwide to date. Concomitantly, the portfolio of reconstructive transplantation has been extended by additional procedures such as lower extremities, abdominal wall, neck, uterus, genitourinary, and pediatric transplants. In the present review article, we aim to summarize the current state of knowledge about this exciting field.
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Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Miguel I Dorante
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Carty
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon G Talbot
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hautz T, Grahammer J, Moser D, Eberhart N, Zelger B, Zelger B, Blumer MJ, Drasche A, Wolfram D, Troppmair J, Öfner D, Schneeberger S. Subcutaneous administration of a neutralizing IL-1β antibody prolongs limb allograft survival. Am J Transplant 2018; 18:2029-2042. [PMID: 29633557 PMCID: PMC6100092 DOI: 10.1111/ajt.14765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 01/25/2023]
Abstract
Cytokine-expression profiles revealed IL-1ß highly upregulated in rejecting skin of limb allografts. We investigate the effect of intragraft treatment with a neutralizing IL-1β antibody in limb transplantation. Following allogenic hind-limb transplantation, Lewis rats were either left untreated or treated with anti-lymphocyte serum + tacrolimus (baseline); baseline immunosuppression + anti-IL-1β (1 mg/kg once/week, 6-8 subcutaneous injections) into the transplanted or contralateral limb. Endpoint was rejection grade III or day 100. Graft rejection was assessed by histology, immunohistochemistry, flow cytometry phenotyping of immune cells, and monitoring cytokine expression. Anti-IL-1β injections into the allograft or contralateral limb resulted in a significant delay of rejection onset (controls: 58.60 ± 0.60; group 3: 75.80 ± 10.87, P = .044; group 4: 73.00 ± 6.49, P = .008) and prolongation of graft survival (controls: 64.60 ± 0.87; group 3: 86.60 ± 5.33, P = .002; group 4: 93.20 ± 3.82, P = .002), compared to controls. Although the phenotype of the graft infiltrating immune cells did not differ between groups, significantly decreased skin protein levels of IL-1β, IL-4, IL-13, IP-10, MCP-1, and MCP-3 in long-term-survivors indicate an overall decrease of chemoattraction and infiltration of immune cells as the immunosuppressive mechanism of anti-IL-1β. Inhibition of IL-1β with short-term systemic immunosuppression prolongs limb allograft survival and represents a promising target for immunosuppression in extremity transplantation.
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Affiliation(s)
- Theresa Hautz
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Johanna Grahammer
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Dominik Moser
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Nadine Eberhart
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Bettina Zelger
- Department of PathologyMedical University of InnsbruckInnsbruckAustria
| | - Bernhard Zelger
- Department of DermatologyMedical University of InnsbruckInnsbruckAustria
| | - Michael J. Blumer
- Department of Anatomy, Histology and EmbryologyDivision of Clinical and Functional AnatomyMedical University of InnsbruckInnsbruckAustria
| | - Astrid Drasche
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Dolores Wolfram
- Department of Plastic, Reconstructive and Aesthetic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Jakob Troppmair
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Dietmar Öfner
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
| | - Stefan Schneeberger
- Daniel Swarovski Research Laboratory (DSL)Department of Visceral, Transplant and Thoracic SurgeryCenter of Operative MedicineMedical University of InnsbruckInnsbruckAustria
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Absence of Rejection in a Facial Allograft Recipient with a Positive Flow Crossmatch 24 Months after Induction with Rabbit Anti-Thymocyte Globulin and Anti-CD20 Monoclonal Antibody. Case Rep Transplant 2018; 2018:7691072. [PMID: 29888023 PMCID: PMC5985128 DOI: 10.1155/2018/7691072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/15/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022] Open
Abstract
Background Donor-specific antibodies (DSA) to human leukocyte antigen increase the risk of accelerated rejection and allograft damage and reduce the likelihood of successful transplantation. Patients with full-thickness facial burns may benefit from facial allotransplantation. However, they are at a high risk of developing DSA due to standard features of their acute care. Case Presentation A 41-year-old male with severe disfigurement from facial burns consented to facial allotransplantation in 2014; panel reactive antibody score was 0%. In August of 2015, a suitable donor was found. Complement-dependent cytotoxicity crossmatch was negative; flow cytometry crossmatch was positive to donor B cells. An induction immunosuppression strategy consisting of rabbit antithymocyte globulin, rituximab, tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone taper was designed. Total face, scalp, eyelid, ears, and skeletal subunit allotransplantation was performed without operative, immunological, or infectious complications. Maintenance immunosuppression consists of tacrolimus, MMF, and prednisone. As of posttransplant month 24, the patient has not developed acute rejection or metabolic or infectious complications. Conclusions To our knowledge, this is the first report of targeted B cell agents used for induction immunosuppression in skin-containing vascularized composite tissue allotransplantation. A cautious approach is warranted, but early results are promising for reconstructive transplant candidates given the exceptionally high rate of acute rejection episodes, particularly in the first year, in this patient population.
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Desensitization and Prevention of Antibody-Mediated Rejection in Vascularized Composite Allotransplantation by Syngeneic Hematopoietic Stem Cell Transplantation. Transplantation 2018; 102:593-600. [DOI: 10.1097/tp.0000000000002070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kollar B, Pomahac B. Facial restoration by transplantation. Surgeon 2018; 16:245-249. [PMID: 29490887 DOI: 10.1016/j.surge.2018.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/12/2018] [Indexed: 12/16/2022]
Abstract
Hundred years ago, Sir Harold Gillies laid a foundation to the modern plastic surgery trying to reconstruct facial defects of severely disfigured soldiers of World War I. Some years later, Joseph Murray experimented with rejection of skin grafts aimed for treatment of burned patients who sustained their injuries on battlefields of World War II. In 1954, the acquired expertise and intensive research allowed him to perform the first successful kidney transplantation in the world at Peter Bent Brigham Hospital in Boston. For his achievements in organ transplantation he was awarded Nobel Prize in 1990. The face transplantation appears to be a natural evolution of the work of these two extraordinary plastic surgeons. The first case of partial face transplant from 2005 in France revealed the world that facial restoration by transplantation is superior to conventional reconstruction methods. Since 2009, our team has performed 7 cases of face transplantation at Brigham and Women's Hospital, which is to our best knowledge the largest living single center face transplant cohort in the world. In this article, we want to reflect on the experience with face transplantation at our institution from the past years. We aim to briefly review the key points of the know-how which was given to us from the care of these unique patients.
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Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Tasigiorgos S, Kollar B, Krezdorn N, Bueno EM, Tullius SG, Pomahac B. Face transplantation-current status and future developments. Transpl Int 2018; 31:677-688. [DOI: 10.1111/tri.13130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/21/2017] [Accepted: 02/02/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Sotirios Tasigiorgos
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Branislav Kollar
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Nicco Krezdorn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery; Hannover Medical School; Hannover Germany
| | - Ericka M. Bueno
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Stefan G. Tullius
- Division of Transplant Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Bohdan Pomahac
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
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50
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Lassus P, Lindford A, Vuola J, Bäck L, Suominen S, Mesimäki K, Wilkman T, Ylä-Kotola T, Tukiainen E, Kuokkanen H, Törnwall J. The Helsinki Face Transplantation: Surgical aspects and 1-year outcome. J Plast Reconstr Aesthet Surg 2018; 71:132-139. [DOI: 10.1016/j.bjps.2017.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 09/18/2017] [Accepted: 10/04/2017] [Indexed: 01/10/2023]
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