Facial Transplantation: Principles and Evolving Concepts.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. SUMMARY: This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.

[50 Years ago: First Successful Treatment of Acute Allograft Rejection after a Human Heart Transplantation]. / Vor 50 Jahren: Erste erfolgreiche Behandlung einer akuten Herztransplantat-Abstoßungskrise.

The first clinical use of the "Munich antilymphocyte globulin" (ALG) at the occasion of the first successful human heart transplantation is briefly described. The cardiac transplantation was carried out by Christiaan Barnard and his team in Cape Town, South Africa, in 1968. The patient developed an acute allograft rejection which could be successfully reversed within three weeks using the intravenous administration of ALG. This event can be regarded as the beginning of a success story of ALG in its use as a powerful immunosuppressive agent in all categories of clinical organ transplantation.

The emergence and pitfalls of international tissue banking.

The rapid growth of tissue banking and associated international organisations following the fall of the Berlin wall in 1991 is described. This surge in collaboration led to a world-wide constructive movement to use and to produce human tissues. As the years progressed industrialisation, led by the USA, improved the quality of tissue allografts but led higher costs and consolidation within the developing industry. The growth of litigation more than kept pace with the industrial progress. One landmark case is described, the outcome of which could revolutionise the current practices now applied to eliminate possible viral contamination of implanted tissue grafts.

History of osteochondral allograft transplantation.

Osteochondral defects or injuries represent the most challenging entities to treat, especially when occur to young and active patients. For centuries, it has been recognized that such defects are almost impossible to treat. However, surgeons have never stopped the effort to develop reliable methods to restore articular cartilage and salvage the endangered joint function. Osteochondral allograft transplantation in human was first introduced by Eric Lexer in 1908. Since that era, several pioneers have been worked in the field of osteochondral allotransplantation, presenting and developing the basic research, the methodology and the surgical techniques. Herein we present in brief, the history and the early clinical results of osteochondral allograft transplantation in human.

Development of homologous skin, bone and other soft tissues transplantation in Slovenia.

In Slovenia, transplantation of tissues such as skin and bone was successfully following global trends throughout its history. First documented homologous skin graft was already mentioned back in 1901. Alongside with new discoveries in immunology and advancements in burn surgery, skin transplantation development surged in the second half of 20th century. Slovenia's first and currently the only skin bank was established in 1973, in Ljubljana. Throughout its existence it always managed to supply skin grafts for patients that were in vast majority burn victims. The bone bank was established twenty years earlier, in 1952. Homologous bone grafts helped patients with trauma injuries and tumour resections. Besides skin and bone grafts, cartilage and other soft tissues have also been used for transplantation - tympanic membrane and cartilage transplants being used in ear surgery. International inclusion of Slovenian physicians allowed comparable results and introduction of new methods at home and around the world.

Hallmarks in the Therapeutic Approach of Aortic Aneurysms: The Main Contributors.

Abstract: Deriving from the Greek word for "widening", aneurysms have been a well known entity since antiquity. In the 2nd century AD, Antyllos, the Greek born surgeon who practiced in Rome, described a method for aneurysms' surgical removal that remained a standard procedure till the 19th century. In 18th century John Hunter proposed a limb saving operation method for treating peripheral aneurysms paving thus the way for the modern surgery of aneurysms and Rudolph Matas, carried out the first aneurysmorrhaphy. During the 20th century two eminent surgeons laid the foundations of vascular surgery: Charles Dubost, who utilized the first homograft for aneurysm repair and Michael DeBakey, who performed the first radical treatment of a thoracic aneurysm.

Personal glimpses into the evolution of truncus arteriosus repair.

Truncus arteriosus (common arterial trunk) is an uncommon but complex congenital heart anomaly. Until the early 1970s, typically, patients died between the age of a few weeks to six months. Congestive heart failure owing to large pulmonary blood flow and truncal valve regurgitation was the major cause of death until innovative surgical techniques were discovered. In 1963, Herbert Sloan at the University of Michigan completed the first repair using a nonvalved conduit with long-term survival (not reported until 1974). At the Mayo Clinic, Rastelli and McGoon studied and completed the first repair with a valved homograft in 1967. In 1976, Ebert used the 12-mm Hancock valved conduit in infants under six months of age (University of California, San Francisco). In Boston (mid-1980s), Jonas and Castañeda used aortic homografts, which greatly reduced bleeding as a postoperative complication. In the early 1990s, Bove (University of Michigan) reported outstanding results with an approach based on primary repair within the first few days of life for patients with truncus arteriosus. Improved prognosis for patients with truncus arteriosus resulted from these corrective operations by analyzing the natural history of this condition while applying innovative ideas, improved technology, and perioperative care.

Bone transplantation and tissue engineering. Part II: bone graft and osteogenesis in the seventeenth, eighteenth and nineteenth centuries (Duhamel, Haller, Ollier and MacEwen).

In the 18th century, the fate of allografts and their role in bone formation became of interest to many orthopaedic surgeons. A controversy over the science of osteogenesis, the formation of bone, had emerged following the opposing views of Duhamel and von Haller. Duhamel noted that the periosteum had a deep osteogenic layer, which he termed the "cambium layer". However, von Haller claimed the opposite: the periosteum was not osteogenic. In the 19th century, Ollier performed comprehensive studies on the periosteum. Ollier's experiments were published in two volumes entitled "Traite Experimental et clinique de la regeneration des os" in 1867. His conclusion was that transplanted periosteum and bone survived and could become osteogenic under proper conditions. The controversy was furthered by MacEwen who believed, contrary to Duhamel and Ollier, that the periosteum had no osteogenetic power and was purely a limiting membrane giving direction to bone growth but taking no active part in it. This manuscript describes this period of controversies about the osteogenesis of the transplanted bone, marrow and periosteum that would eventually die or not and be replaced by surrounding tissue or be active for osteogenesis. Whether bone grafts are a form of passive scaffolding or active in osteogenesis was the main question about auto and allografts in the 18th and 19th centuries. In response to this challenge, many papers were written to defend each side of the argument.

The reconstructive microsurgery ladder in orthopaedics.

Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.

The next frontier in composite tissue allotransplantation.

Solid organ transplantations became a clinical option in the 1950s. The hand allograft was the pioneer of composite tissue allotransplantation (CTA), successfully started near the end of the last century despite arguments over the practicality and methods. Since then, CTA such as hand and face has continued to progress from the theoretical to clinical reality. The treatment principles, drug combinations, and mechanisms of the immunosuppression medications on which contemporary transplant surgeries have been based continue to develop as researchers and physicians gain more experience in the CTA field. It could be argued that the ethical issues associated with CTA have prevented evolution of the field rather than surgical or technical skill. This is particularly true for allo-head and body reconstruction (AHBR). How can leaders in the field of CTA develop a model that would satisfy ethical concerns? Bolstered by recent successes in the field, is it time to traverse the next frontier? Can AHBR ever be a feasible option in the clinical setting? The reader will be provided with a brief history of CTA from theory to research to clinical practice. A concise description of AHBR as it pertains to the critical procedure (i.e., surgery design) will also be discussed.

Allograft tympanoplasty: a historical perspective.

OBJECTIVE: To present the rise and decline of allograft tympanoplasty and investigate how the challenges it has faced may inform us of its future. DATA SOURCES: Articles and books published over the last 48 years that refer to allograft tympanoplasty or its historical roots. HISTORY: The first published account of allograft tympanoplasty is by Ned Chalat in 1964; however, whether he was the first to use the technique is controversial. In 1966, Jean Marquet published the first clinically successful use of allograft tympanic membranes. Since that time, a number of surgeons have trialed both en bloc tympano-ossicular techniques and tympanomeatal techniques with separate ossicle interposition or columellar reconstruction, often with considerable success. The advent of the human immunodeficiency virus and Creutzfeldt-Jakob's disease resulted in a reduction in its application; however, a number of centers are still successfully using the technique in their current practice. CONCLUSION: Whether allograft tympanoplasty will have a place in the future of otology remains to be seen, but an understanding of the history of this technique is essential in evaluating its merit.

Harvey Cushing's use of a transplanted human vein to treat hydrocephalus in an infant in the early 1900s. Historical vignette.

A review of the Johns Hopkins Hospital surgical records from 1896 to 1912 revealed a case from 1908 wherein Dr. Harvey Cushing attempted to treat hydrocephalus in a 4-month-old infant by constructing a shunt for which he used a venous segment harvested from the patient's father. Prior to this procedure, surgeons used shunts constructed from various often highly immunogenic materials. In addition to addressing the limitations of these materials, Cushing's technique allowed the inclusion of valves within the shunt, preventing the retrograde flow of CSF. Despite the success of this procedure in canine models, the child's postoperative death prevented an assessment of its success in a human. It is possible that Cushing's approach would meet with more success today, given the modern benefits of human leukocyte antigen tissue typing and immunosuppressant agents.