Faculty Bibliography

BACKGROUND:Vascularized composite allotransplantation (VCA) can restore form and function beyond conventional reconstruction, but acute (AR) and chronic rejection (CR) limit long-term allograft survival. When allograft failure becomes irreversible, explantation or retransplantation may be necessary. This review evaluates the indications, management, and operative considerations associated with explantation and retransplantation in VCA. METHODS:A systematic review of PubMed, PubMed Central, MEDLINE, Scopus, and Web of Science was conducted to identify studies reporting patient-level data on VCA recipients who underwent allograft explantation or retransplantation. Extracted data included recipient demographics, immunologic characteristics, rejection history, and explantation or retransplantation outcomes. RESULTS:Nineteen studies reporting 25 VCA recipients were included, comprising 22 explants and three retransplants (two face, one abdominal wall). The most common VCA types were uterus (32%), face (24%), and hand (16%). The leading indications for graft removal were CR (44%), perfusion-related complications (32.0%), medication non-compliance (24.0%), and patient request (12.0%). The median time to explant was 12.5 months, and to retransplant was 7.3 years. Management of CR included pulse steroids, increased immunosuppression, plasmapheresis, and biologic agents. Retransplantation was more technically challenging than the primary transplant due to scarring, distorted anatomy, and vessels affected by CR, requiring more proximal vascular anastomoses and nerve coaptations. CONCLUSION/CONCLUSIONS:Explantation and retransplantation in VCA are feasible but last-line interventions. The leading cause of graft loss was CR, though perfusion-related and patient-related factors also contributed. Earlier recognition and management of AR, clearer definitions of CR, and overall improved strategies to prevent progression to irreversible graft failure are needed.

Outcome assessment after face transplantation remains heterogeneous, limiting comparison of recovery, patient benefit, and treatment burden across programs. We sought to define a face-specific core outcome set for longitudinal postoperative assessment, informed by the NYU Langone experience and its published outcome literature. We performed a methodological inventory of postoperative assessments used across 4 NYU Langone face transplant recipients treated between 2015 and 2023 and reviewed face-relevant peer-reviewed publications available through September 2026. Recipient-level outcome values were not reanalyzed. Measures were prioritized for clinical relevance, repeatability, and suitability for longitudinal comparison. Twenty-three relevant publications from the NYU program informed the framework. The proposed core outcome set comprises 6 domains: (1) allograft integrity and surgical outcomes; (2) rejection, immunologic surveillance, and immunosuppression-related morbidity; (3) facial sensory and motor recovery; (4) speech, swallowing, and oral function; (5) structural and region-specific facial outcomes; and (6) patient-reported outcomes, rehabilitation, and treatment burden. This face-specific framework provides a clinically focused minimum data set for longitudinal outcome assessment after face transplantation. Consistent use may improve patient tracking and facilitate more meaningful comparison across programs, while prospective multicenter implementation will be necessary to refine and validate the proposed core set.

BACKGROUND/UNASSIGNED:Plastic surgery training has evolved into 2 main pathways: independent and integrated, yet their future directions remain largely unaddressed in the literature. This study examines trends during the past decade in program numbers, positions, and competitiveness of the 2 training models, to better guide the mentorship of prospective plastic surgeons. METHODS/UNASSIGNED:² greater than 0.5 indicating a strong linear trend. RESULTS/UNASSIGNED: = 0.76). CONCLUSIONS/UNASSIGNED:Plastic surgery training has shifted predominantly to favor the integrated pathway, with the independent pathway offering fewer positions despite steady interest. As a result, early exposure, research, and mentorship are essential, and applicants should be counseled that the integrated pathway is now the primary model.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) restores form and function in patients with severe disfigurement, yet acute rejection remains common within the first year. In solid organ transplantation, rituximab, a B cell-depleting agent, has been shown to reduce rejection in highly sensitized recipients, and donor-specific antibodies (DSAs) are established biomarkers of rejection. The impact of rituximab and DSAs in VCA remains unclear. This study examined rejection-free survival following rituximab induction and the relationship between positive DSA levels and rejection in VCA recipients. METHODS/UNASSIGNED:This retrospective review analyzed 4 patients who underwent facial transplantation between 2015 and 2023 at our institution. All patients received rituximab and antithymocyte globulin as part of their induction immunosuppression. Rejection-free survival was the primary outcome, with DSA levels assessed at baseline and throughout follow-up. A generalized linear mixed-effects model was used to evaluate the relationship between DSA positivity and rejection. RESULTS/UNASSIGNED:= 0.693). Some patients were DSA-negative during clinical rejection, and some were DSA-positive without signs of rejection. CONCLUSIONS/UNASSIGNED:This is the first study to evaluate rituximab-based induction in a cohort of VCA recipients, demonstrating median rejection-free survival exceeding one and a half years. Although some patients were DSA-positive during rejection episodes, no significant correlation was observed, challenging the predictive value of DSAs as seen in solid organ transplantation and highlighting the need to explore alternative biomarkers for rejection in VCA.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) restores complex defects when conventional reconstruction is not feasible. However, lifelong immunosuppression introduces substantial risks, including posttransplant malignancies. This study aims to characterize the incidence, timing, management, and outcomes of posttransplant malignancies in VCA recipients to inform future surveillance and management guidelines. METHODS/UNASSIGNED:A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines using PubMed, Scopus, Web of Science, and Cochrane. Eligible studies included patients who underwent VCA and developed a subsequent malignancy. Collected data included demographics, transplant and malignancy details, and survival. RESULTS/UNASSIGNED:Fifteen studies comprising 15 unique VCA recipients were included. Transplants involved the face (37.5%), upper extremity (37.5%), scalp (12.5%), lower extremity (6.25%), and abdominal wall (6.25%). Median time to first malignancy was 1.89 years posttransplant. Across all cases, 24 malignancies were reported, most commonly nonmelanoma skin cancer (60%) and posttransplant lymphoproliferative disorder (33%). Notably, 85% of skin cancers developed at nonallograft sites. Overall survival was 53.3%. All patients with skin cancer alone survived, whereas posttransplant lymphoproliferative disorder carried a 50% mortality rate. Median time from malignancy to death was 5.5 years, and from transplant to death, 10.1 years. CONCLUSIONS/UNASSIGNED:Recipients of VCA demonstrate increased malignancy risk, particularly nonmelanoma skin cancers and lymphoma, with a typical onset of 2 years posttransplant. Dermatologic surveillance focusing on native skin, Epstein-Barr virus viral load monitoring in high-risk recipients, and regular follow-up are essential and may aid early detection.

BACKGROUND/UNASSIGNED:Concomitant ocular and facial trauma (COFT) can result in devastating functional, aesthetic, and psychosocial consequences, including vision loss. Standard reconstructive techniques often fall short in addressing the intricate needs of these injuries, making advanced techniques, such as combined facial transplantation and whole-eye transplantation (FT-WET), promising solutions. This study characterizes COFT patients to define a population that may benefit from FT-WET. METHODS/UNASSIGNED:A retrospective analysis of the National Trauma Data Bank (2018-2022) was conducted to identify COFT patients using International Classification of Diseases, Tenth Revision diagnosis codes. Patients were stratified into surgical and nonsurgical cohorts based on the presence of major surgical interventions targeting the face or eye. Characteristics of each group were compared. RESULTS/UNASSIGNED:< 0.001) were also more common in this group. CONCLUSIONS/UNASSIGNED:Surgical COFT patients represent a younger population with more complex injuries, aligning with favorable characteristics for potential FT-WET candidates. This study identified a distinct population of COFT patients who may benefit from FT-WET, providing critical insights into candidate selection and injury patterns.

BACKGROUND/UNASSIGNED:Vascularized composite allotransplantation (VCA) has achieved significant advancements in reconstructive surgery through pioneering efforts in face, upper extremity, and whole-eye transplantations. The VCA program at New York University Langone Health has pursued these efforts since its inception in 2013. METHODS/UNASSIGNED:This review documents the evolution of the VCA program, highlighting 4 critical cases that demonstrate the program's innovative approach to surgical challenges and patient care. Each case study reveals the integration of computerized surgical planning, meticulous preoperative preparations, postoperative outcomes, and key institutional metrics. RESULTS/UNASSIGNED:Notable achievements include the first successful combined face and bilateral hand transplantation, and the first combined face and whole-eye transplantation, with improved procedural efficiencies such as reduced hospital and intensive care unit length of stay and operative durations over time. Furthermore, the program's focus on multidisciplinary collaboration has enhanced patient outcomes and operational procedures. CONCLUSIONS/UNASSIGNED:These efforts not only mark significant milestones in VCA but also contribute to the broader surgical and microsurgical fields by refining techniques that minimize resource use and optimize patient recovery and quality of life.

Vascularized composite allotransplantation (VCA) is increasingly recognized as a reconstructive option that offers substantial benefits for patients with severe tissue loss, including injuries affecting the face and hand. Despite its clinical promise, VCA remains limited by surgical complexity, the need for long-term immunosuppression, and associated morbidity. Preclinical models are therefore essential for refining surgical techniques, testing novel immunomodulatory approaches, and investigating ischemia/reperfusion injury. Compared with large-animal models, rodent models offer advantages in accessibility and cost while adhering more closely to the 3Rs principles of Replacement, Reduction, and Refinement. Among them, the mouse offers unique advantages, including the availability of humanized strains, a broad panel of well-characterized antibodies, and compatibility with advanced immunological assays. These features make the mouse particularly valuable for translational VCA research. Murine VCA, however, requires demanding supermicrosurgical skills, as vascular anastomoses are performed on vessels measuring approximately 0.3-0.5 mm in diameter. To enhance reproducibility, we provide technical tips that have proven critical to the success of these procedures. These include the insertion of a nylon filament into the vessel lumen to stabilize the anastomosis, careful separation of the artery and vein over a sufficient distance along the pedicle, precise anesthetic dosing, and specific maneuvers to prevent pedicle twisting. We also highlight common pitfalls and errors, offering practical guidance to improve outcomes. Here, we describe a comprehensive, stepwise protocol for mouse heterotopic hindlimb-to-neck transplantation, accompanied by instructional video material. This non-functional model minimizes postoperative morbidity compared with orthotopic transplantation while providing robust and reproducible results. It is ideally suited for training in supermicrosurgery and for addressing key experimental questions in VCA, including immune tolerance, graft preservation, and ischemia/reperfusion mechanisms. This methodology provides investigators with a reliable murine platform to advance translational VCA research and to develop innovative strategies aimed at improving outcomes in reconstructive transplantation.

BACKGROUND:Facial transplantation offers transformative solutions for patients with severe facial disfigurements. Minimizing ischemia time is critical for preserving tissue viability, and prioritizing facial allograft recovery during multiorgan procurement aims to optimize outcomes. This study evaluates whether prioritizing facial allograft procurement affects the outcomes of non-vascularized composite allotransplantation (VCA) organ transplants. METHODS:This retrospective study analyzed 4 VCA donor recoveries and face transplants at our center. Perioperative data, including operation times, blood pressure, oxygenation, urine output, and blood product administration, were recorded. Donor data were verified using the United Network for Organ Sharing database, institutional records, and data from LiveOnNY and Gift of Life organ procurement organizations to assess recipient and graft survival. RESULTS:Twenty-one allografts (VCAs and organs) were transplanted into 16 patients. The 1-year patient survival rate was 92% (11 of 12) among non-VCA recipients. One patient died during surgery, and 2 patients died more than 3 years after transplantation from unrelated causes. Three non-VCA graft failures occurred within the first year, resulting in an 87% graft survival rate. The median ischemia time for face transplants was 3 hours 18 minutes. Preoperative planning, including cadaveric rehearsals, computerized surgical plans, and 3-dimensionally printed cutting guides, contributed to stable perioperative parameters and reduced blood loss. CONCLUSIONS:This study suggests that prioritizing facial allograft procurement is feasible and does not appear to compromise non-VCA organ transplant outcomes. Further multicenter studies are needed to validate these findings and further refine protocols.

PURPOSE/OBJECTIVE:To describe the first successful whole eye transplantation (WET) in a human, performed with concurrent partial face transplantation, and to characterize postoperative outcomes. DESIGN/METHODS:Case report. PARTICIPANT/METHODS:A 46-year-old male with severe facial and ocular deficits following high-voltage electrical injury, including left eye enucleation and extensive soft tissue and aesthetic deformities. METHODS:Comprehensive preoperative evaluation, precise microsurgical techniques including vascular anastomosis and optic nerve coaptation, and serial postoperative assessments with optical coherence tomography (OCT), fluorescein angiography (FA), electroretinography (ERG), and visual evoked potentials (VEP). MAIN OUTCOME MEASURES/METHODS:Sustained globe viability, vascular perfusion, retinal structural integrity, and electrophysiological function. RESULTS:The transplanted globe demonstrated robust vascular perfusion and structural preservation over 12 months. Outer retinal function was maintained, as indicated by ERG, despite retinal nerve fiber layer loss and optic nerve transection. VEP confirmed absence of visual perception. The procedure achieved substantial aesthetic restoration. CONCLUSIONS:This study establishes the feasibility of WET in humans, with sustained globe viability and preserved outer retinal function. These findings serve as a critical step toward future exploration of ocular transplantation.