Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports

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.

Smartphone-based thermography in flap surgery: A systematic review and meta-analysis of perforator identification

Background

Thermography can be used in pre-operative planning of free perforator flap surgeries. Thermography assesses skin temperature by measuring the quantity of infrared radiation observed. In this meta-analysis, authors assess the sensitivity of smartphone-based thermal imaging (SBTI) in the detection of perforators and analyze the difference between static and dynamic imaging.

Materials and methods

Authors followed the PRISMA guidelines for systematic reviews and meta-analyses. The meta package in R was used to conduct the meta-analysis. The "metaprop" function was used to calculate the overall sensitivity estimate and 95% confidence interval. The "metaprop.one" function was used to calculate subgroup estimates for static and dynamic study types. The "metareg" function was used to conduct meta-regression analyses to explore sources of heterogeneity.

Results

This study includes seven articles with 1429 perforators being evaluated. The overall proportion of the sensitivities was estimated to be 0.8754 (95% CI: 0.7542; 0.9414) using a random effects model. The heterogeneity of the studies was high, as indicated by the tau^2 value of 1.2500 (95% CI: 0.4497; 8.4060) and the I^2 value of 92.6% (95% CI: 88.1%; 95.4%). The pooled sensitivity for static imaging was 0.8636 (95%CI: 0.6238-0.9603) with a tau^2 of 2.0661 and a tau of 1.4374, while the pooled sensitivity for dynamic imaging was slightly higher (p = 0.7016) at 0.8993 (95%CI: 0.7412-0.9653) with a smaller tau^2 of 0.8403 and a tau of 0.9167.

Conclusion

Further studies need to confirm that SBTI is a reliable and convenient technique for detecting perforators for the pre-operative planning of free perforator flap surgeries.

[Bilateral breast reconstruction by DIEP flap in two stages: Technical note]

With the rise of risk prevention surgery, more and more bilateral mastectomies are performed. These present a challenge when patients desire autologous reconstruction. Some surgeons perform reconstructions using a double DIEP flap, but this technique, which requires rapid operation and extensive experience, can sometimes be difficult to implement. Other factors may also favor a two-stage reconstruction, one breast after the other. We present here our technique to harvest two hemi-DIEP during two distinct operating times, by modifying the design of the first flap and by performing a prior autonomization of the second.