Youngest Composite Full-Face Transplant: A Model for Vascularized Composite Allograft in Younger Populations.

BACKGROUND: The field of face transplantation continues to evolve, with more complex defects being addressed, and, at the same time, increased outcome expectations. Given our unique long-term experience in this field, we consented one of the youngest patients to undergo a full-face transplant. METHODS: An 18-year-old woman presented with complete destruction of her central face and craniofacial structures. She had coexisting major injuries, including pituitary gland, visual axis, and motor control. After extensive rehabilitation and reconstruction techniques, the patient underwent face transplant on May 4, 2017, at the age of 21 years. RESULTS: The total operative time for the recipient was 26 hours. There were no major perioperative complications. Since transplant, the patient has undergone 3 revision surgeries. She is near completely independent from a daily life activity standpoint. She has had 1 episode of rejection above grade II that was successfully treated with a short-term increased in immunosuppression. CONCLUSIONS: Contrary to data in solid organ transplantation where youth is associated with increased risk of rejection, our current algorithm in immunosuppression, combined with this patient's compliance, has led to only 1 rejection episode beyond grade II. This successful transplant can serve as a model for future vascularized composite transplants in younger populations.

First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery.

Uterus transplantation is the only known potential treatment for absolute uterine factor infertility. It offers a unique setting for the investigation of immunologic adaptations of pregnancy in the context of the pharmacologic-induced tolerance of solid organ transplants, thus providing valuable insights into the early maternal-fetal interface. Until recently, all live births resulting from uterus transplantation involved living donors, with only 1 prior birth from a deceased donor. The Cleveland Clinic clinical trial of uterus transplantation opened in 2015. In 2017, a 35 year old woman with congenital absence of the uterus was matched to a 24 year old parous deceased brain-dead donor. Transplantation of the uterus was performed with vaginal anastomosis and vascular anastomoses bilaterally from internal iliac vessels of the donor to the external iliac vessels of the recipient. Induction and maintenance immunosuppression were achieved and subsequently modified in anticipation of pregnancy 6 months after transplant. Prior to planned embryo transfer, ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, with histology interpreted as grade 3 rejection suspicious for an antibody-mediated component. Aggressive immunosuppressive regimen targeting both cellular and humoral rejection was initiated. After 3 months of treatment, there was no histologic evidence of rejection, and after 3 months from complete clearance of rejection, an uneventful embryo transfer was performed and a pregnancy was established. At 21 weeks, central placenta previa with accreta was diagnosed. A healthy neonate was delivered by cesarean hysterectomy at 34 weeks' gestation. In summary, this paper highlights the first live birth in North America resulting from a deceased donor uterus transplant. This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate. This is the first delivery from our ongoing clinical trial in uterus transplantation, including the first reported incidence of severe mixed cellular/humoral rejection as well as the first reported placenta accreta.

Characterization of Face Transplant Candidates Evaluated at Cleveland Clinic and Algorithm to Maximize Efficacy of Screening Process.

INTRODUCTION: As a high-volume referral center for facial transplantation, we have learned significantly from the screening, evaluation, and enrollment process. This report analyzes our algorithm for the assessment of potential face transplant candidates referred to our institution. METHODS: After institutional review board approval in 2004, a prospectively maintained database was created for patients who were referred face transplant. Records were reviewed for the nature of tissue defect, functional deficit, surgical and medical history, and expert recommendations.Our algorithm begins with a review of a patient's file with a focus on institutional review board criteria. After screening, a phone interview is conducted, and transplantation is discussed. Patients are presented to the team to analyze the medical, psychiatric, and surgical history; support network; and geographic location. Eligible patients are invited for an in-person evaluation, and the case is reviewed again with the team. If approved, the patient can provide consent for transplantation. RESULTS: More than 200 patients were referred for transplant evaluation at the Cleveland Clinic from 2004 to 2016. Sixty were eligible for further evaluation for face transplantation based on preliminary screening. Thirteen (6.5% of original cohort) were invited for in-person evaluation and physical examination. Five (2.5% of original cohort, 38.4% invited cohort) of these 13 patients underwent face transplantation, of whom, 3 (1.5% of original cohort, 23.1% invited cohort) underwent face transplantation at our institution. All 3 patients who were ultimately transplanted were referred by a physician. DISCUSSION: As the availability of public information on face transplant increases, it is likely that an increase in self-referral for face transplantation will occur. Thus, it is critical that institutions adopt a systematic approach to triage in order to identify appropriate patients. Our algorithm allowed for a high enrollment and transplantation ratio to save patient and institution time and resources. This could be easily adopted by other institutions to save time, money, and resources.