Clinical Pearls and Pitfalls in Reconstructive Transplantation

Abstract

The techniques of reconstructive transplantation are based on the experience of microsurgeons, orthopedic surgeons, and plastic surgeons in the field of replantation and plastic reconstructive surgery. Our center has focused on the transplantation of the hand and forearm. Our approach to hand transplantation has evolved over the past 15 years, based on decades of replantation experience at our center and the types of patients and outcomes we have encountered. While a transplant is much like a replant, there are clear differences. First, unlike a replant, the length and availability of recipient muscles, tendons, vessels, and nerves are often shorter than suggested by the level of amputation. Second, while the donor allograft supplies more than adequate amounts of tissue, this may not match the recipient and care must be taken to match bony length, and attach tendons with the proper tension of flexors and extensors in order to optimize good function post transplant. Finally, the challenges of allograft rejection and the currently required systemic immunosuppression mandate close monitoring by a multidisciplinary team for the life of the graft. This chapter highlights the experience of the nine transplants performed in eight recipients, and the most important clinical considerations for good outcome in a vascularized composite allotransplantation (VCA) hand recipient.