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Immunosuppression For Upper-Extremity Vascular Composite Allotransplantation
Sammy Othman, BA1, Niv Milbar, MD1, L. Scott Levin, MD2, Matthew Levine, MD3, Stephen J. Kovach, MD1.
1Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA, 2Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA, 3Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE:
Upper extremity vascularized composite allografts (VCA) at the level of the hand or forearm can dramatically improve patients' quality of life through functional, aesthetic, and psychiatric improvements. While surgical technique has been refined, the proper post-operative immunosuppressive regimen has not been adequately described, with some advocating for standard solid organ transplantation triple-therapy maintenance and others presenting tailored approaches. We detail our experience with induction and maintenance therapy.
METHODS:
Four patients received bilateral VCAs at the level of forearm or hand. Immunological workup, including matched HLA type, was completed pre-operatively. Patients were induced using thymoglobulin and maintained with standard triple-therapy (Tacrolimus, Mycophenolic Acid, Prednisone) according to solid-organ transplantation (SOT) protocol. Rejection was managed with topical tacrolimus, rapamycin, steroid boluses, and adjustment of tacrolimus and/or rapamycin through trough-based dosing.
RESULTS:
All patients experienced salvage of their VCAs with varying episodes of low-level rejection according to the Banff Criteria. All patients reported good function which was confirmed on physical examination through functional wrist/elbow measures. Patients reported satisfactory aestheticism on last follow-up post-operatively (range: 6 - 95 months).
CONCLUSION:
The standard induction and maintenance therapy for SOT is an adequate regimen for upper extremity VCAs. Patients experience strong functional and aesthetic outcomes, and can achieve long-term transplantation salvage even after short-term low-level rejection.


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