Composite Tissue Allograft

The emerging field of reconstructive transplantation offers the opportunity to reconstruct patients after devastating injuries. However, the transplantation of composite tissue allograft (CTA) is a complex endeavor requiring collaborations between plastic and reconstructive surgeons and multiple other fields such as transplant surgery, transplant medicine, anesthesia, psychiatry, otolaryngology, and medical ethicists to name a few. This special issue was inspired, in part, by the collaboration between the American Society of Reconstructive Microsurgery (ASRM) and American Society of Reconstructive Transplantation (ASRT) that has produced a special session devoted entirely to the topic of CTA at each annual meeting of the ASRM. Several of the papers presented here are based or inspired by topics that have been presented at these sessions. In this issue we have gathered many of the original presenters to discuss important areas related to this emerging field.

The issue begins with an article by Pomahac on the fundamentals of establishing a composite tissue allotransplant program. Their program has been highly successful and has performed the second, third, and fourth face transplants done in the United States. This is followed by an article by Chang et al on a critical issue of immunosuppression and CTA. The article examines the impact that data from immunosuppression in renal transplantation has on both the present and future strategies in immunosuppression regimens in CTA. The next series of articles are devoted to the clinical aspects of the transplantation of hand and face. Dr. Banegas et al explore the critical issues in harvesting the donor hand based on their experience at Louisville. This is followed by an article by Azari et al on the technical aspects in the recipient operation based on the experience garnered at the University of Pittsburgh. Drs. Siemionow and Ozturk discuss the technical aspects regarding the donor harvest for facial transplantation based on their work at the Cleveland Clinic. Finally, in terms of the recipient operation, Cavadas et al from Valencia, Spain present their recent experience with the surgical transplantation of lower face, mandible, and tongue in a high-risk patient.

An equally important issue in the arena of reconstructive transplantation has surrounded the indications for the transplantation of the face or hand. Several surgeons have suggested that in facial reconstruction autologous options can address the majority of problems encountered after severe facial trauma. To address this issue, Drs. Gottlieb and Agarwal explore the autologous alternatives to facial transplantation based on the experience and pioneering work of Dr. Gottlieb at the University of Chicago. A similar case against hand transplantation has been proposed by some that suggest that the increasingly sophisticated myo-electric prosthesis will soon be able to restore function after amputation. This topic is discussed by Agew et al in their article that compares targeted reinnervation with limb transplantation based on the on-going work by Dr. Dumanian and his colleagues at Northwestern University.

The issue concludes with an instructive article from Sacks et al providing an important experimental technique that can facilitate the rapid and reliable transplantation of the hind-limb for use in experimental protocols. These articles explore issues that are familiar to those involved in the arena of reconstructive transplantation but represent important topics for all those involved in making CTA a clinical reality beyond the experimental venue. I also hope that this series of articles provides those interested in joining the field of composite tissue allotransplantation an introduction to some of the philosophical and technical issues faced by those involved.