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
Correction to: Face Transplantation: Cleveland Clinic Experience
	Correction to: Chapter 3 in: R. Gurunian et al. (eds.), Reconstructive Transplantation, https://doi.org/10.1007/978-3-031-21520-9_3
Index