The Ethics of Psychosocial Assessment in Vascularized Composite Allotransplantation: A Call for Transparency of Process to Support the Equitable Selection of Patients.

As the field of vascularized composite allotransplantation (VCA) continues to evolve and technological approaches improve, VCA programs must focus on promoting greater consistency in psychosocial assessment across programs to support the equitable selection of patients. Based on a summary of published reports of VCA, we address the ethical considerations raised by the present heterogeneity of approaches to psychosocial assessment, including weighing risks and benefits, informed consent and the role of decisional capacity, and potential or perceived bias in the assessment process. We propose transparency of process across the field and encourage VCA programs to work collaboratively to share approaches to psychosocial assessment both pre- and post-transplant to promote health equity.

Acceptance of Vascularized Composite Allotransplantation (Face and Hand Transplant) in Singapore.

Recent advancements and innovations in the burgeoning field of vascularized composite allotransplantation has enabled face and hand transplant to become a reality in the Western world. Plastic surgeons from the United States, France, and Spain have since performed vascularized composite allotransplantation as a novel therapeutic option in patients suffering from severe facial disfigurement and limb loss. Results have demonstrated remarkable functional and esthetic outcomes with improvements in the immense psychological, social, and emotional burdens that can arise in these patients. Despite the success of existing national solid organ transplant programs, face and hand transplant has yet to be established in this region. The specific aims of this study were to assess the attitudes and amount of risk Singaporeans are willing to accept towards receiving or donating face and hand transplants; and hence ultimately evaluate the feasibility of establishing such a program in Singapore.

The Ethics of Penile Transplantation: Preliminary Recommendations.

BACKGROUND: For men with significant genitourinary injury, penile transplantation is being considered as an option when reconstruction is not feasible or proves unacceptable to the injured patient. METHODS: A review of the literature was conducted to assess the current state of penile reconstruction and transplantation options, as well as to evaluate scholarly research addressing the ethical dimensions of penile transplantation. RESULTS: The state of penile transplantation is elementary. If reconstruction is not a possibility, proceeding ethically with research on penile vascularized composite allotransplantation will require the articulation of guidelines. To date, very little has been published in the scholarly literature assessing the ethics of penile transplantation. CONCLUSIONS: Guidelines should be developed to address penile transplantation and must cover the donation of tissue, consent, subject selection, qualifications of the surgical team, and management of both failure and patient dissatisfaction. Unless guidelines are established and disseminated, penile transplants should not be undertaken. The preliminary recommendations suggested in this article may help to inform development of guidelines.

The miracle of face transplantation after 10 years.

INTRODUCTION: At the 10th year anniversary of the first face transplantation, there are currently 36 patients worldwide, who are the recipients of faces coming from human donors. AREAS OF AGREEMENT: Despite the initial debates and ethical concerns, face transplantation became a clinical reality with satisfactory functional outcomes. AREAS OF CONTROVERSY: The areas of controversy still include the impact of lifelong immunosuppression on otherwise healthy patients as well as the selection process of face transplant candidates. GROWING POINTS: Other concerns include financial support for this new generation of transplants as well as social reintegration and patients return to work after face transplantation. AREAS TIMELY FOR DEVELOPING RESEARCH: Based on over 20 years of research experience in the field of vascularized composite allotransplantation, and clinical experience as a leading surgeon of the US first face transplantation, this review will summarize the well-known facts as well as unexpected outcomes and challenges of face transplantation.

Standardizing psychosocial assessment for vascularized composite allotransplantation.

PURPOSE OF REVIEW: Vascularized composite allotransplantation (VCA) encompasses hand, face, uterus, penile and lower extremity transplantation. Psychosocial factors are recognized as important, but no standard approach to the evaluation, selection or posttransplant care has been described and thus, the development of a standardized approach is needed. RECENT FINDINGS: Various psychosocial assessment tools have been reported. Body image and the functional impact of hand versus face transplantation are notable issues. Patients with psychiatric, chemical dependence histories and suicide attempts have been transplanted. Loss of graft or decreased function because of nonadherence has occurred. Screening for depression, social adaptation, coping styles and quality of life (QOL) is common. SUMMARY: Although VCA is not a lifesaving procedure, as in solid organ transplantation, the following areas require assessment: psychiatric stability, history of chemical dependence, family support, adherence and understanding of transplantation. VCA requires the incorporation of a visible allograft, lengthy rehabilitation, occupational considerations, prosthetic use, possible screening for posttraumatic stress disorder related to injuries and phantom limb pain. Intense media interest may lead to distress. Development of an instrument to address these areas initially and over time to monitor for changes in QOL and training the psychosocial team is a priority.

BASIC PRINCIPLES OF MODELLIND OF FACIAL COMPOSITE TISSUE ALLOGRAFTS.

The article presents the results of anatomical studies aimed to develop modelling of facial allografts taking into account the peculiarities of blood supply. The allografts should meet both aesthetic and functional needs of the recipient for further use in clinical practice. There were selected 3 facial composite tissue allografts out of 50 modifications, which are more suitable for required parameters. On basis of these data, there was successfully performed the facial composite tissue allograft transplantation on the patient.

Attitudes regarding lower extremity allotransplantation among lower extremity amputees.

BACKGROUND: Lower limb allotransplantation is garnering increasing attention in the vascularized composite allotransplantation community as a potential treatment modality for those suffering from lower limb amputations. Little is known, however, about the level of interest among lower limb amputees regarding this procedure. METHODS: An online survey regarding lower limb allotransplantation was designed in conjunction with and distributed by the Amputee Coalition to lower limb amputees in the United States. Responses from the survey were blinded, tabulated, and analyzed for significance using chi-square or Fisher's exact test. RESULTS: A total of 770 respondents completed the online survey. Forty-three percent of respondents stated they would be interested in being evaluated for lower limb transplantation, 36 percent declined, and 21 percent were uncertain. Those respondents who expressed an interest in allotransplantation tended to be significantly younger, better educated, more recently amputated, and less satisfied with prosthetic outcomes than those who were not interested. The most important criterion for transplantation to be considered a success by respondents was restoration of meaningful knee/ankle joint function, followed by restoration of limb sensibility. If immunosuppression were not required, 32 percent of those who initially declined and 88 percent of those who were uncertain would choose to undergo evaluation for lower limb allotransplantation. CONCLUSION: A significant proportion of lower limb amputees would be interested in undergoing evaluation for lower limb allotransplantation.

Fifteen years later: main lessons from composite tissue allografts.

Composite tissue allografts (CTA) are also called "reconstructive transplantation" as they are a valid alternative approach to repairing complex tissue defects. These procedures are still considered "experimental" and their therapeutic value remains to be validated. An immunosuppressive treatment similar to that used in solid organ transplantation allows CTA survival and function despite a high rate of acute rejection (AR) episodes. Clinical experience seems to confirm that skin is the most antigenic tissue and the first target of AR episodes, which are easy to reverse and do not seem to adversely influence graft survival and function when promptly treated. Chronic rejection can also occur in CTA, although its features are still unclear. Upper-extremity or face-transplanted patients show a relevant sensorimotor recovery. Patients are able to perform the majority of daily activities and to lead normal social lives. Global cortical remodeling occurs in the months following transplantation, reversing the functional reorganization induced by the amputation. Appropriation of the graft occurs in parallel with functional recovery. The patients' compliance is essential for the success of CTAs as well as careful recipient selection and patient follow-up to prevent complications of long-term immunosuppression.