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.

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.

Ethical considerations in facial transplantation have been widely discussed for more than twenty years, preceding the technical realization of the procedure in 2005. With more than 50 face transplants performed to date in adults worldwide, considerations are evolving beyond risks and benefits toward questions of equity and sustainability. Yet, issues of informed consent, the risk of lifelong immunosuppression, graft lifespan, and metrics for success continue to prompt dialogue, especially for certain patient populations. In this Perspective, we combine our clinical experience with a synthesis of the existing evidence and propose that emerging adults, characterized as individuals aged 18-25, be given particular consideration. Emerging adults occupy a middle ground between adolescence and established adulthood. This formative life stage has a profound impact on an individual's sense of identity and social integration. Emerging adults stand to benefit significantly from facial transplantation precisely because of the key developmental nature of this stage, yet ongoing cognitive development presents challenges for judgement and decision-making that can complicate care for this population and impact outcomes. Given the complexity of facial transplantation and lifelong commitment to follow up required for face transplant recipients, it is critical to understand potential challenges for decision-making and obstacles to adherence that individuals may face in this developmental life stage. Recognizing emerging adults as a patient population with specific support needs will enable face transplant programs to offer tailored supports to improve outcomes for this transformative procedure in emerging adulthood.

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.

INTRODUCTION/BACKGROUND:Vascularized Composite Allotransplantation (VCA) is a reconstructive technique that restores form and function in patients with severe tissue loss from trauma, burns, tumors, or congenital anomalies. Despite improving clinical outcomes, public understanding and acceptance remain barriers to widespread public acceptance. This systematic review examines global public perceptions of VCA, focusing on demographic, cultural, religious, and educational influences on donation. METHODS:A PRISMA-guided systematic review was conducted in June 2025 across PubMed, Embase, MEDLINE, Scopus, and Web of Science. Eligible studies included original surveys or mixed-methods research involving nonexpert participants who reported willingness to donate to VCA. Excluded were studies limited to experts, discussion articles, reviews, abstracts, or commentaries. RESULTS:Twenty studies met the inclusion criteria, representing 19,023 respondents from 8 countries. Overall, there was a lower pooled willingness to donate facial VCA than hand VCA, with pooled willingness estimates of 47.9% and 54.8%, respectively. In contrast, willingness to receive VCA was higher overall, with pooled willingness estimates of 65.6% for facial transplantation and 72.4% for hand transplantation. Religious differences were evident: Christian and agnostic respondents were generally more willing to donate, whereas Muslim respondents were less willing. Racial differences were also noted, with White respondents more likely to donate. In contrast, Black and Asian respondents were less likely to indicate willingness to donate. CONCLUSIONS:This systematic review provides the first comprehensive synthesis of global survey data on public perceptions of VCA. Nearly half of the respondents reported willingness to donate, with higher acceptance of hand donation than of face donation. Racial, ethnic, and religious factors shape attitudes, underscoring the need for culturally tailored educational strategies to improve donation acceptance.

BACKGROUND/UNASSIGNED:During the last 20 years, the novel and highly visible nature of facial transplantation (FT) has posed a dual and potentially conflicting obligation for FT programs: to disseminate findings for scientific advancement while respecting recipients' preferences for privacy, given the significant public and media attention. The individually identifying nature of FT is not present in other forms of vascularized composite allotransplantation, making it unique. Despite extensive ethical discourse on FT, implications for privacy are largely absent from ethical analyses. METHODS/UNASSIGNED:This conceptual analysis assesses the complex ethical implications associated with privacy in FT and offers guidance to FT programs for navigating concerns related to donors, recipients, and their families. A literature review was performed and supplemented by our institutional experience. RESULTS/UNASSIGNED:Ethical approaches to privacy require balancing the conflicting ethical principles at the center of this dual obligation. Patient-centered strategies should include comprehensive psychological screening to understand patients' goals for care, informed consent that clearly addresses the dissemination of information and media involvement, and control of media coverage until the recipient is ready and willing. Public relations support for recipients has been helpful in our institution's experience. Additional community-based strategies include educational outreach interventions to satisfy public curiosity. CONCLUSIONS/UNASSIGNED:Findings from published reports alongside our institution's experience suggest that a nuanced, multifaceted approach is essential to navigate the ethical complexities of privacy in FT. Aligning key stakeholders to support FT recipients' well-being while maintaining scientific integrity reflects the ethical tension between duties to patients and obligations to advance transplant science.

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) 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.

BACKGROUND/UNASSIGNED:Advancements in surgical techniques and immunosuppressive therapies have transformed care for patients through vascularized composite allotransplantation (VCA). However, lifelong systemic immunosuppression (SI) carries significant risks, specifically during acute rejection (AR), which typically requires increasing SI dosages. Mitigating such risks may be achieved through topical tacrolimus (TT). Although TT shows promise for VCA in preclinical studies, robust clinical data are lacking. This systematic review aims to evaluate the clinical use of TT in VCA. METHODS/UNASSIGNED:A systematic review was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines using Cochrane, PubMed, Scopus, and Web of Science. Studies included patients who underwent VCA and received TT treatment. Study details, patient demographics, VCA characteristics, Banff grade, induction and SI maintenance protocols, complications, AR episodes, and treatment plans following these episodes were collected. RESULTS/UNASSIGNED:The search yielded 271 articles; 11 met inclusion criteria, encompassing 15 VCA recipients (mean age 39.9 y). Thirty-two AR episodes were reported; 22 (68.8%) involved TT. TT was mostly used in Banff grade I-II AR episodes. Resolution occurred in 65.5% of TT-treated episodes, though this finding was not statistically significant. TT was frequently used with steroids and adjunct therapies. CONCLUSIONS/UNASSIGNED:This systematic review highlights the potential role that TT may play in mitigating the need for increased doses of SI during AR episodes. As clinical data continue to grow, further research is essential to establish the potential benefits and efficacy of TT use in VCA.