Summary Overall, more than 60 hand/forearm/arm transplantations and 16 face transplantations have been performed in the past 12 years. In the European experience summarized here, three grafts have been lost in response to a vascular thrombosis (n = 1), rejection and incompliance with immunosuppression (n = 1) and death (n = 1). The overall functional and esthetic outcome is very satisfactory, but serious side effects and complications related to immunosuppression are challenges hindering progress in this field. The high levels of immunosuppression, skin rejection, nerve regeneration, donor legislation and the acceptance level need to be addressed to promote growth of this promising new field in transplantation and reconstructive surgery.

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With respect to social and psychologic effects, performance of the procedure is extremely worthwhile because it not only provides complete limb preservation, but also has excellent potential for a favorable functional outcome.

Cartilage tissue engineering shows to have tremendous potential for the reconstruction of three-dimensional cartilage defects. To ensure survival, shape, and function, in vitro cartilage-engineered constructs must be revascularized. This article presents an effective method for neovascularization and free microsurgical transfer of these in vitro constructs. Twelve female Chinchilla Bastard rabbits were used. Cartilage-engineered constructs were created by isolating chondrocytes from auricular biopsies, amplifying in monolayer culture, and then seeding them onto polycaprolactone scaffolds. In each prefabricated skin flap, three in vitro cartilage-engineered constructs (2 x 2 x 0.5 cm) and one construct without cells (served as the control) were implanted beneath an 8 x 15 cm random-pattern skin flap, neovascularized by implantation of an arteriovenous vascular pedicle with maximal blood flow. Six weeks later, the neovascularized flaps with embedded cartilage-engineered constructs were completely removed based on the newly implanted vascular pedicle, and then freely retransferred into position using microsurgery. Macroscopic observation, selective microangiography, histology, and immunohistochemistry were performed to determine the construct vitality, neovascularization, and new cartilage formation. The results showed that all neovascularized skin flaps with embedded constructs were successfully free-transferred as free flaps. The implanted constructs were well integrated and protected within the flap. All constructs were well neovascularized and showed histologically stability in both size and form. Immunohistology showed the existence of cartilage-like tissue with extracellular matrix neosynthesis.

IV.

Reconstruction of an irreparably amputated thumb in multiple digit amputations using amputated fingers can considerably improve hand function and allows creation of a newly transplanted thumb with acceptable cosmetic and functional attributes. However, the surgery is challenging and rarely reported. We report six cases using this procedure in patients with crushed thumbs unsuitable for replantation. In four of the patients, the remnant of the index finger was replanted on the thumb stump and in another two patients, an amputated middle finger and ring finger were used. The patients had a minimum followup of 12 months (mean, 18 months; range, 12-45 months). All newly transplanted thumbs survived resulting in the patients having satisfactory postoperative hand function and appearance.

Thin, large, well-vascularized, and axial-pattern flaps are often desired in the clinical practice of defect reconstruction to maximize esthetic and functional results. Flap prefabrication based on the neovascularization development following vascular pedicle implantation allows surgeons to create such flaps as required. Using different types of implanted vascular pedicles, the aim of the study was to identify the most effective and suitable types of pedicles for clinical use. Five models of implanted vascular pedicles in Chinchilla Bastard rabbits were investigated as follows: model 1, arteriovenous (AV) pedicle with end ligation (minimal blood flow in the implanted vascular pedicle); model 2, AV pedicle with end anastomosis (new shunt formation between vein and artery stump for creating maximal blood flow in the implanted vascular pedicle); model 3, purely isolated arterialized venous loop; model 4, purely isolated arterial loop; model 5, AV pedicle with end anastomosis (similar to model 2) combined with flap expansion. These different types of vascular pedicles were implanted into a random-pattern abdominal skin flap as large as 8 x 15 cm. Neovascularization in the various prefabricated flaps was evaluated macroscopically, scintigraphically, microangiographically, and histologically. A total of 150 prefabricated flaps were investigated and randomly assigned to 5 models with 30 flaps each. Each model contained 5 groups of 6 flaps corresponding to the various retention times of 4, 8, 12, 16, and 20 days after vascular pedicle implantation. Six flaps were also designated to the control group. Neovascularization was best in model 5, followed by comparable results for models 2, 3, and 4, with the worst results found in model 1, especially for the time intervals of 8, 12, and 16 days. Twenty days remains the minimal length of time required for matured neovascularization in all models (P < 0.05). Models 2 and 3 both appear to be particularly promising for clinical application.

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