Reconstructive Transplantation

Preface
Contents
Contributors
Part I: Introduction
1: History of Vascularized Composite Allotransplantation
1.1 Introduction
1.2 VCA Records in the Ancient History
1.2.1 Transplantation in the Antient Times
1.2.2 Transplantation During Modern History
1.2.3 History of Transplant Biology
1.2.4 Brief History of Immunosuppression
1.3 History of Experimental VCA
1.3.1 Rat Hindlimb Allotransplantation Model
1.3.2 Rat Face Transplantation Models
1.3.3 Immunomodulatory VCA Models
1.3.4 Large Animal Models
1.3.5 Other VCA Models
1.4 History of Clinical VCA
1.4.1 Other Clinical VCA Applications
1.5 History to Be Made in the Field of VCA
1.5.1 Solving the Chronic Rejection
1.5.2 Overcoming Organ Shortage
References
2: Immunosuppression Protocols in VCA Transplantation
2.1 Introduction
2.2 Historical Perspectives
2.3 Immunosuppression in VCA
2.3.1 Induction Regimes
2.3.1.1 Recombinant Anti-thymocyte Globulin
2.3.1.2 Basiliximab
2.3.1.3 Alemtuzumab
2.3.2 Maintenance Regimes
2.3.2.1 Tacrolimus
2.3.2.2 Cyclosporin
2.3.2.3 Mycophenolate Mofetil
2.3.2.4 mTOR Inhibitors
2.3.2.5 Steroids
2.3.2.6 Belatacept
2.3.2.7 Topical Immunosuppression
2.3.2.8 Immunosuppression Minimization Protocols
2.4 Rejection
2.4.1 Acute Rejection
2.4.1.1 Diagnosis and Grading of Acute Rejection
2.4.1.2 Treatment
ACR
AMR
TPE
IVIG
Rituximab
Bortezomib
Eculizumab
2.4.2 Chronic Rejection
2.5 Desensitization and Tolerance Induction Protocols
2.6 Conclusions
References
Part II: Face Transplantation
3: Face Transplantation: Cleveland Clinic Experience
3.1 Introduction
3.2 Case 1 [5, 6]
3.2.1 Patient Presentation
3.2.2 Pretransplant Planning and Flap Design
3.2.3 Donor
3.2.4 Immunologic Characteristics
3.2.5 Operative Course
3.2.6 Immunosuppression
3.2.7 Initial Postoperative Course
3.2.8 Physical Therapy and Rehabilitation
3.2.9 Psychosocial Care
3.2.10 Functional and Neurosensory Outcome
3.2.11 Rejection Episodes and Long-Term Complications
3.3 Case 2 [7–9]
3.3.1 Patient Presentation
3.3.2 Transplant Preparation and Flap Design
3.3.3 Donor
3.3.4 Immunologic Characteristics
3.3.5 Operative Course
3.3.6 Immunosuppression
3.3.7 Initial Postoperative Course
3.3.8 Physical Therapy, Rehabilitation, Psychosocial Care
3.3.9 Functional and Neurosensory Outcomes
3.3.10 Rejection Episodes and Long-Term Complications
3.4 Lessons Learned
3.5 Conclusion
References
4: Orthognathic Outcomes and Technical Considerations in Vascularized Composite Facial Allotransplantation
4.1 Introduction
4.2 Techniques for Cephalometric Analysis
4.3 Skeletal Outcomes to Date
4.3.1 Mandible-Only Transplantation
4.3.2 Midface-Only Transplantation
4.3.3 Midface and Mandible Transplantation
4.4 Dental Outcomes to Date
4.5 The Cleveland Clinic Facial Vascularized Composite Allotransplantation Program
4.6 Complications, Considerations, and Strategies for the Future
4.7 Concluding Thoughts
References
5: Facial Composite Vascularized Allotransplantation: Barcelona Experience
5.1 The Spanish Model of Accreditation
5.2 Organization of Facial Tissue Donation at UHVH
5.3 Organ Procurement Protocol
5.4 Funding of Programs
5.5 Program Development
5.6 Patients
5.6.1 Patient 1
5.6.2 Patient 2
5.7 Lessons Learned
References
6: Facial Transplantation: First Canadian Experience
6.1 Introduction
6.2 Patient
6.3 Donor
6.4 Preparation
6.5 Allograft Procurement
6.6 Recipient Debridement
6.7 Allo-transplantation
6.8 Immunosuppression
6.9 Rejection Monitoring
6.10 Prophylactic Antimicrobial Therapy
6.11 Postoperative Course
6.12 Complications
6.12.1 Infectious
6.12.2 Rejections
6.12.3 Metabolic
6.13 Functional Outcomes
6.14 Ancillary Procedures
6.15 Lessons Learned
References
7: Facial Allotransplantation: Outcomes and Results of the Amiens/Lyon Team
7.1 Introduction
7.2 Patients
7.2.1 Pretransplant Evaluation
7.2.2 Transplantation
7.2.3 Rehabilitation Protocol
7.2.4 Follow-Up
7.2.5 Patient #1
7.2.6 Patient #2
7.2.7 Patient #3
7.2.8 Patient and Graft Survival
7.2.9 Acute and Chronic Rejection
7.2.10 Functional Results
7.2.11 Complications
7.3 Learned Lessons
References
8: VCA in Head and Neck Region
8.1 Introduction
8.2 Face Transplantation (FTx)
8.2.1 Qualification and Preparation of Recipients
8.2.1.1 Detailed Psychological Qualification
8.2.2 Donor Selection
8.2.3 Surgical Procedures
8.2.3.1 Planning of Bone Components
8.2.3.2 Sensory and Motor Innervation
8.2.3.3 Chewing Function Restoration
8.2.3.4 Speech and Swallowing Function Restoration
8.2.3.5 Continuity of the Respiratory Tract Restoration
8.2.3.6 Vascular Aspect
8.2.4 Postoperative Management
8.2.5 Immunosuppression and Pharmacotherapy
8.2.6 Managing Patients After the Face Transplant
8.2.7 Complications After Face Transplant
8.2.8 Results of the Face Transplant Program in Poland
8.3 Neck Organ Transplantation (NTx)
8.3.1 Qualification and Preparation of Recipient
8.3.2 Selection of Donors and Coordination of Donation
8.3.3 Surgical Procedure
8.3.4 Postoperative Management
8.3.5 Immunosuppression and Pharmacotherapy
8.3.6 Managing Patients After Complex Neck Organ Allotransplantation
8.3.7 Complications After Complex Neck Organ Allotransplantation
8.3.8 Outcomes of the Neck Organ Transplant Program
8.4 Perspectives of the Development of the Face and Neck Organ Transplantation Program
References
9: Face Transplantation by Ozkan Team (Turkey)
9.1 Introduction
9.2 Status of the Program
9.3 Screening Process
9.3.1 Obstacles to the Expansion of the Program
9.4 Patients
9.4.1 Patient 1
9.4.2 Patient 2
9.4.3 Patient 3
9.4.4 Patient 4
9.4.5 Patient 5
9.5 Surgical Technique
9.5.1 Immunosuppression Protocol
9.5.2 Monitoring Protocol
9.5.3 Rehabilitation Protocol
9.5.4 Unique Problems or Challenges Encountered
9.6 Lessons Learned
9.6.1 Challenges
9.6.2 What Did You Change Over Time?
9.6.3 What Will You Not Repeat in the Future?
9.6.4 How Do You See the Future of VCA?
References
10: Facial Transplantation: Nonimmune-Related Hyperacute Graft Failure
10.1 Introduction
10.2 Patient
10.3 Lesson Learned
References
11: The Helsinki Vascularized Composite Allograft Program
11.1 Building the Helsinki Vascular Composite Allotransplantation Program
11.1.1 Program Setup
11.1.1.1 Finnish National Solid Organ Transplantation Center
11.1.1.2 Legal Issues
11.1.1.3 Helsinki University Hospital Permission
11.1.1.4 Organ Donation
11.1.1.5 Ethical Issues
11.1.1.6 Financial Issues
11.1.2 Helsinki VCA Team
11.1.2.1 Surgical Team
11.1.2.2 SOT Team
11.1.2.3 H&N Cancer Team
11.2 Face Transplantation Patient Evaluation
11.2.1 Patient Selection and Screening
11.2.1.1 Indications and Contraindications
11.2.1.2 Facial Analysis
11.2.1.3 General Checkup
11.2.1.4 Microbial Examinations
11.2.1.5 Immunological Evaluations
11.2.1.6 Psychiatric Evaluation
11.2.1.7 Health-Related Quality of Life (HRQoL)
11.2.1.8 Social Impairment
11.2.1.9 Esthetic Evaluation
11.2.1.10 Decision-Making for FT
11.2.2 Radiology and 3D Planning in FT
11.2.2.1 3D Planning for the Recipient
11.2.2.2 3D Planning for the Donor
11.2.2.3 Donor Funeral Mask
11.2.3 FT Candidates in Helsinki
11.3 Helsinki Face Transplantation Patients and Transplantation Surgery
11.3.1 First Helsinki FT Patient (Transplanted in 2016)
11.3.2 Second Helsinki FT Patient (Transplanted in 2018)
11.3.2.1 Donors
11.3.3 Face Transplantation Surgery
11.3.3.1 Face Donation Surgery
11.3.3.2 Recipient Face Debridement
11.3.3.3 Restoration of the Face
11.4 Follow-Up Protocol
11.4.1 Immunosuppression Protocol
11.4.2 Rejection Monitoring Protocol
11.4.2.1 Biopsies
11.4.2.2 HLA Antibodies
11.4.3 Antimicrobial Protocol
11.4.4 Rehabilitation Protocol
11.4.4.1 Early Recovery Period
11.4.4.2 Psychological Support
11.4.4.3 Surgical Controls
11.4.4.4 Dental Follow-Up
11.5 Results
11.5.1 Functional Outcomes
11.5.1.1 Motor Recovery
11.5.1.2 Sensory Recovery
11.5.1.3 Oral Recovery
11.5.1.4 Breathing
11.5.1.5 Dental and Intraoral Recovery
11.5.1.6 Eyelids
11.5.1.7 Bone Ossification
11.5.2 3D Planning, Prediction, and Bone Stability
11.5.3 Psychosocial Results
11.5.4 Immunological Results
11.5.5 Complications
11.5.5.1 Surgical Complications
11.5.5.2 Immunosuppression-Related Complications
11.5.5.3 Infections
11.6 Lessons Learned
11.6.1 Program Update
11.6.2 Strengths of Helsinki VCA Team
11.6.3 Obstacles to Expansion of the Program
11.6.4 The Future of VCAs
References
Part III: Laryngeal Transplantation
12: Laryngeal Transplantation, I
12.1 Introduction
12.2 The First Human Composite Laryngeal Transplant
12.3 The Unpublished Colombian Experience
12.4 Second Published Human Composite Laryngeal Transplant
12.4.1 Third Published Human Composite Laryngeal Transplant
12.4.2 Surgical Details
12.5 Immunosuppression Reduction
12.6 Immunosuppression in the Cancer Patient
12.7 Immunomodulation
12.8 Reinnervation Research in Laryngeal Transplantation
12.9 Explantation
12.10 Conclusion
References
13: Laryngotracheal Transplant
13.1 Introduction
13.1.1 University of California-Davis (UCD) Laryngeal Transplantation Program
13.1.1.1 Patients
13.1.1.2 Surgical Technique
13.1.2 Rejection
13.1.3 Laryngeal Anatomical Complexity and Associated Challenges in Autologous Rehabilitation of ­End-Stage Laryngeal Dysfunction or Laryngotracheal Stenoses
13.1.3.1 Lessons Learned
13.1.4 Shift in the Transplant Surgery Ethical Paradigm
13.1.5 Evolving Indications for Laryngeal Transplantation and Attitudes Toward Laryngeal Transplant and Malignancy
13.1.6 Lessons Learned from Explantation of First Laryngeal Transplant
13.1.7 How Do You See the Future of VCA?
References
Part IV: Upper Extremity Transplantation
14: Hand and Upper Extremity Transplantation
14.1 Introduction
14.2 Indications and Patient Selection
14.3 Patient Expectations
14.4 Surgical Technique
14.4.1 Incising the Skin
14.4.2 Dissecting and Identifying the Neurovascular Structures and Tendon-Muscle Units
14.4.3 Hemostasis
14.4.4 Transplantation
14.4.4.1 Osteosynthesis
14.4.4.2 Vessel Anastomosis
14.4.4.3 Muscle-Tendon Suture/Transfer
14.4.4.4 Definite Vessel Anastomosis
14.4.4.5 Nerve Suture
14.4.4.6 Soft Tissue Closure
14.4.4.7 Dressing
14.4.5 Postoperative Care
14.4.5.1 Observation
Circulation Checks
14.4.5.2 Medication
14.5 Outcomes of Hand Transplantation
14.6 Upper Extremity Amputations and Prosthetics
14.7 Activities of Daily Living
14.8 Definition
14.9 Types and Functions of the Upper Limb Prosthetic
14.10 Upper Extremity Prostheses Controls and Components
14.11 Indications and Appropriate Prescription
14.12 Lessons Learned
14.13 Conclusion
References
15: Hand Transplantation Program at Amrita Institute of Medical Sciences, Kochi, India: Technical Considerations (Part 1)
15.1 Introduction
15.2 Case Series
15.3 Surgical Technique
15.3.1 Distal Forearm Level Hand Transplantation
15.3.1.1 Donor Hand Retrieval and Preparation
15.3.1.2 Recipient Limb Preparation and Transplantation
15.3.2 Proximal Forearm Level Hand Transplantation
15.3.2.1 Donor Hand Retrieval and Preparation
15.3.2.2 Recipient Limb Preparation and Transplantation
15.3.3 Supra-Condylar Level Hand Transplantation
15.3.3.1 Donor Hand Retrieval and Preparation
15.3.3.2 Recipient Limb Preparation and Transplantation
15.3.4 Mid-Arm Level
15.4 Conclusion
References
16: Hand Transplantation Program at Amrita Institute of Medical Sciences, Kochi, India: Postsurgical Management, Outcomes, and Special Considerations (Part 2)
16.1 Immunosuppression
16.1.1 Induction Therapy
16.1.2 Maintenance Therapy
16.2 Monitoring Protocol
16.3 Rehabilitation Protocol
16.3.1 Distal-Level Transplants
16.3.2 Proximal-Level Transplants
16.3.3 Supracondylar-Level Transplants
16.4 Outcome Assessment
16.4.1 Functional Outcomes
16.4.2 Immunological Outcomes
16.5 Complications, Unique Problems, and Challenges Encountered
16.5.1 Recipient 1: Bilateral Distal Forearm Level Transplant
16.5.2 Recipient 2: Bilateral Distal Forearm Level Transplant
16.5.3 Recipient 3: Bilateral Forearm Level Transplant
16.5.4 Recipient 4: Bilateral Supracondylar Level Transplant
16.5.5 Recipient 5: Bilateral Proximal Forearm Level Transplant
16.5.6 Recipient 6: Right Proximal Forearm Level and Left Proximal Arm Level Transplant
16.5.7 Recipient 7: Bilateral Mid-Arm Level Transplant
16.5.8 Recipient 8: Bilateral Proximal Forearm Level Transplant
16.6 The Future
16.7 Conclusion
References
17: Hand Transplantation CM Kleinert Institute for Hand and Microsurgery Experience
17.1 The Beginning
17.2 Criteria and Protocols
17.3 Donor Considerations
17.4 Donor Procurement
17.5 Recipient Selection
17.6 Recipient Surgery
17.7 Postoperative Care
17.8 Immunosuppression
17.9 Antimicrobial Prophylaxis
17.10 Rehabilitation Protocol
17.11 Functional Assessment
17.12 Immunological Monitoring
17.13 Monitoring Vasculopathy
17.14 Tolerization of VCA with Adipose SVF
17.15 Patient Profiles and Outcomes
17.15.1 Patient #1
17.15.2 Patient #2
17.15.3 Patient #3
17.15.4 Patient #4
17.15.5 Patient #5
17.15.6 Patient #6
17.15.7 Patient #7
17.15.8 Patient #8
17.15.9 Patient #9
17.15.10 Patient #10
17.16 Complications
17.17 Current Status of the Program
References
18: Hand Allotransplantation: The Penn Experience
18.1 Introduction
18.2 Protocols
18.2.1 Surgical Technique
18.2.2 Immunosuppression
18.2.3 Monitoring
18.2.4 Rehabilitation
18.3 Patients
18.3.1 Patient #1—9/21/2011
18.3.2 Functional Outcomes
18.3.3 Immunologic Outcomes
18.3.4 Other Outcomes and Challenges
18.3.5 Patient #2—7/7/2015
18.3.6 Functional Outcomes
18.3.7 Immunologic Outcomes
18.3.8 Other Outcomes and Challenges
18.3.9 Patient #3—8/22/2016
18.3.10 Functional Outcomes
18.3.11 Immunologic Outcomes
18.3.12 Other Outcomes and Challenges
18.3.13 Patient #4—2/17/2019
18.3.14 Functional Outcomes
18.3.15 Immunologic Outcomes
18.3.16 Other Outcomes and Challenges
18.4 Lessons Learned
Reference
19: Upper Extremity Transplantation: The Massachusetts General Hospital Experience
19.1 Introduction
19.2 Patients
19.3 Lessons Learned
19.4 Perspective in VCA
References
20: Upper Extremity Allotransplantation: Our Long-Term Experience in Lyon
20.1 Introduction
20.2 Patients
20.2.1 Single Hand Transplantation
20.2.2 Bilateral UET Cohort
20.2.2.1 Pretransplant Investigations
20.2.2.2 Transplantation
20.2.2.3 Rehabilitation Protocol
20.2.2.4 Follow-Up
Patient #1
Patient #2
Patient #3
Patient #4
Patient #5
Patient #6
Patient #7
20.2.2.5 Acute and Chronic Rejection
20.2.2.6 Functional Recovery
20.2.2.7 Complications
20.2.2.8 Patient and Graft Survival
20.3 Lessons Learned
References
21: Hand Transplantation: The Brigham and Women’s Hospital Experience
21.1 Introduction
21.1.1 Program Inception
21.1.2 Funding
21.1.3 Patient Screening
21.1.3.1 Patient Approval and Current Waitlist
21.1.3.2 Obstacles to Program Expansion
21.2 Patients
21.2.1 Surgical Technique
21.2.2 Rehabilitation Protocol
21.2.3 Immunosuppression Protocol
21.2.4 Patients
21.2.4.1 Recipient #1
21.2.4.2 Recipient #2
21.2.4.3 Recipient #3
21.2.4.4 Recipient #4
21.3 Lessons Learned
21.3.1 Program Strengths
21.3.2 Modifications
21.3.3 Future of VCA
References
22: Double Hand Transplant Monza
22.1 Introduction
22.2 Patient 1
22.2.1 Donor
22.2.2 Recipients
22.3 Surgical Technique
22.4 Multipotent Mesenchymal Stromal Cells
22.4.1 The Active Principle of Multipotent Mesenchymal Stromal Cells (MSCs)
22.5 MSC Protocol
22.6 Immunosuppression Protocol
22.7 Treatment of Rejection
22.8 Antibiotic Prophylaxis
22.9 Monitoring Protocol (Table 22.1)
22.10 Rehabilitation Protocol
22.11 Problems Encountered
22.12 Lessons Learned
References
23: United States Military Hand Allotransplantation
23.1 Introduction
23.2 Donor
23.3 Recipient
23.4 Surgical Technique
23.5 Immunosuppression Protocol
23.6 Episodes of Acute Rejection
23.7 Monitoring
23.8 Rehabilitation Protocol
23.8.1 Starting 3 Days Post-Op
23.8.2 At 3 Weeks Post-Op
23.8.3 At 6 Weeks Post-Op
23.8.4 At 9–12 Weeks Post-Op
23.8.5 Other Considerations
23.9 Follow-Up
23.10 Sensory Function
23.11 Motor Function
23.12 Complications
23.12.1 CMV Reactivation
23.12.2 Acute Renal Failure
23.12.3 Return to Operating Room
23.12.4 Unrelated Injuries
23.13 Unique Challenges
23.14 Lessons Learned
References
Part V: Lower Extremity Transplantation
24: Lower Extremity Transplantation by Ozkan Team (Turkey)
24.1 Introduction
24.2 Patients
24.3 Surgical Technique
24.4 Immunosuppression Protocol (Induction, Maintenance, and Variations; Treatment of Rejection)
24.5 Monitoring Protocol
24.6 Unique Problems or Challenges
24.7 Lessons Learned
24.7.1 What Are the Strengths of Your Program?
24.7.2 What Will you Not Repeat in the Future?
References
25: Quadruple Extremity Transplantation
25.1 Introduction
25.2 Case Presentation
25.2.1 Transplant Procurement
25.2.2 Irradiation of the Procured Extremities
25.2.3 Immunosuppression
25.2.4 Operative Details
25.3 Discussion and Lessons Learned
References
26: Vascularized Knee Joint Allotransplantation
26.1 Introduction
26.2 Patients and Methods
26.3 Bone Allograft Procurement
26.4 Back-Table Allograft Preparation
26.5 Transplantation Procedure
26.6 Histocompatibility and Immunosuppression
26.7 Postoperative Follow-up
26.8 Results
26.9 Patient 1
26.10 Patient 2
26.11 Patient 3
26.12 Patient 4
26.13 Patient 5
26.14 Patient 6
26.15 Discussion
26.15.1 Surgical Technique
26.15.2 Psychological Assessment
26.15.3 Lifelong Immunosuppression and its Consequences
26.15.4 Late Rejection and Sentinel Skin Graft (SSG)
26.15.5 Allograft Vasculopathy
26.15.6 Osteochondral Allograft (OCA) Transplantation to Reconstruct Focal Osteochondral Defects
26.16 Conclusion
References
Part VI: Abdominal Wall Transplantation
27: Abdominal Wall Transplantation
27.1 Introduction and History
27.2 Surgical Considerations
27.2.1 Abdominal Wall Anatomy
27.2.2 Surgical Allograft Harvest
27.2.3 Revascularization of Abdominal Wall Allografts
27.2.4 Technical Considerations
27.3 Case Report
27.3.1 Postoperative Course
27.4 Future Directions
27.4.1 Defining Indications
27.4.2 Neurotization
27.4.3 Immunosuppression
27.5 Conclusion
References
28: Abdominal Wall Transplantation with Microsurgical Technique
28.1 Introduction
28.1.1 Procurement of AWTx Graft
28.1.2 Microsurgical Technique for AWTx
28.1.3 Immunosuppressive Protocol
28.1.3.1 Monitoring Protocol
28.2 Future Perspectives
28.3 Conclusions
References
Part VII: Uterus Transplantation
29: Deceased Donor Uterus Transplantation
29.1 Introduction
29.2 Cleveland Clinic Protocol
29.2.1 Recipient Selection
29.2.2 Donor Selection
29.2.3 Post-Transplant Process for Pregnancy
29.2.4 Operative Management and Surgical Technique
29.2.4.1 Procurement
29.2.4.2 Transplant
29.2.5 Immunosuppression
29.2.6 Follow-Up
29.2.7 Ethical Problems in Cadaveric Uterus Donation
References
30: Uterus Transplant: The Dallas Experience
30.1 Introduction
30.1.1 Patients
30.1.1.1 Donor and Recipient Selection
30.1.1.2 Donor Hysterectomy and Complications
30.1.1.3 Recipient Uterine Transplant and Complications
30.1.1.4 Immunosuppression Protocol
30.1.1.5 Monitoring Protocol
30.1.1.6 Embryo Transfer
30.1.1.7 Live Births
30.1.2 Lessons Learned
References
31: Live Birth from the World’s First-Ever Successful Uterus Transplant and the Following Second Case from Turkey: Technical Aspects, Surgical and Obstetric Outcomes
31.1 Introduction
31.2 Patients
31.3 Surgical Technique
31.4 Immunosuppression Protocol
31.5 Monitoring Protocol
31.6 Remarks
31.7 Lessons Learned
31.7.1 What Are the Strengths of Your Program?
31.7.2 What Did You Change Over Time?
31.7.3 What Will You Not Repeat in the Future?
31.7.4 How Do You See the Future of VCA?
31.8 Conclusion
References
Part VIII: Penis Transplantation
32: Conventional Surgical Techniques and Emerging Transplantation in Complex Penile Reconstruction
32.1 Introduction
32.1.1 Conventional Surgical Techniques
32.1.2 History of Penis Transplantation
32.2 Technical Considerations
32.2.1 Indications
32.2.2 Patient Selection and Pre-Operative Evaluation
32.2.3 Donor Considerations
32.2.4 Surgical Technique
32.2.5 Antimicrobial Therapy
32.2.6 Immunosuppression Protocol
32.2.7 Donor Bone Marrow Transfusion and Chimerism Analysis
32.3 Lessons Learned
32.3.1 Clinical Outcomes
32.3.2 Building a Successful Program
32.3.3 Conclusion
References
Part IX: Miscellaneous Special
33: Future Directions of Vascularized Composite Allotransplantation
33.1 Introduction
33.2 Rejection
33.3 Immunosuppression
33.4 Ischemia-Reperfusion Injury (IRI)
33.5 Strategies Proposed to Improve VCA Outcomes
33.6 Machine Perfusion Technique and Cryopreservation
33.7 Modulating Immunosuppression
33.8 Innovative Strategies to Regulate the Immune System to a Mitigate VCA Rejection
33.9 Nerve Regeneration
33.10 Eye Transplantation
33.11 Limitations
33.12 Conclusions
References
34: Ethical Considerations of Living Donation in Vascularized Composite Allotransplantation
34.1 Introduction
34.2 Analysis of Vascularized Composite Allotransplantation Using Four-Quadrant Approach to Ethical Decision-Making
34.2.1 Medical Indications
34.2.2 Patient Preferences
34.2.3 Quality of Life
34.2.4 Contextual Features
34.3 Conclusions
References
Index