Plastic Surgery Research Council
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Presenter: Margot Den Hondt, MD
Co-Authors: Vranckx JJ; Delaere P
UZ Leuven

Introduction: There are few therapeutic options for repairing tracheal defects longer than 5 cm since no autologous donor fibrocartilagenous framework is available for reconstruction and trachea lacks an identifiable vascular pedicle that would enable direct anastomosis to vessels of the recipient.

Materials and Methods: Based on our experimental and clinical experience with tracheal auto- and allotransplantation, we reconstructed 6 long-segment tracheal defects using an allograft that was revascularized by heterotopic wrapping in radial forearm fascia. The patients received immunosuppressive therapy. After revascularization, the mucosal lining was replaced progressively using recipient buccal mucosa, creating a chimera of donor respiratory epithelium and recipient buccal mucosa. The chimera allowed for gradual withdrawal of immunosuppressive therapy. Four to ten months after implantation, the tracheal allograft was dissected with its new vascular pedicle and brought into its orthotopic location by microvascular techniques.

Results: In all patients immunosuppressive therapy was withdrawn. However, in one patient long-term vascularization problems of the inner mucosal lining occurred in the transplant. Shortening the time span for the orthotopic transplantation in the 2nd stage limits the quality of outcome. There is a fragile balance between the immunologic parameters and the vascularization of the internal lining of the trachea. The time points in this protocol had to be modified based on the internal mucosal healing of the allogenic trachea.

Discussion: We report the world s first 6 tracheal allotransplantations following initial indirect revascularization of the graft in a heterotopic position by prefabrication. Tracheal allotransplantation can occur without lifelong immunosuppression. The vascularization process of the mucosal lining of the trachea determines the quality of outcome and time of treatment.
We currently analyze from bed to bench the impact of pro-angiogenic strategies for the mucosal lining based on growth factors and tissue engineering techniques in a rabbit model under immunosuppression.

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