Vascularized composite allotransplantation (VCA), including hand, face, penis, uterus, lower extremity, etc., have been technical success. However, the risks of lifelong immunosuppression have limited these procedures to a select group of patients for whom nontransplant alternatives have resulted in unsatisfactory outcomes. Recent reports of facial allograft failure, and subsequent reconstruction using autologous tissues, have reinforced the idea that a surgical contingency plan must be in place in case this devastating complication occurs.
Hand transplantation is the most common form of modern composite tissue allotransplantation, with 100 cases reported worldwide since 1998. The procedure is a treatment option for complex injuries that leave patients with structural, functional, and aesthetic deficits that cannot be addressed by other means. Successful application of this technology requires a multidisciplinary approach, incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and so on. Its long-term results depend on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection.
Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation. Our understanding of VCA is still evolving, and ongoing research is needed to improve functional outcomes and to decrease the morbidity associated with long-term immunosuppression. Further translational studies should promote the development of new strategies to justify broader application and the development of safe, effective tolerance induction protocols for clinical trials of VCA.