In spite of an enormous amount of new experimental laboratory data based on evolving neuroscientific concepts during the last 25 years peripheral nerve injuries still belong to the most challenging and difficult surgical reconstructive problems. Our understanding of biological mechanisms regulating posttraumatic nerve regeneration has increased substantially with respect to the role of neurotrophic and neurite-outgrowth promoting substances, but new molecular biological knowledge has so far gained very limited clinical applications. Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement and new concepts are needed to further increase the results from nerve repair. For bridging gaps in nerve continuity little has changed during the last 25 years. However, evolving principles for immunosuppression may open new perspectives regarding the use of nerve allografts, and various types of tissue engineering combined by bioartificial conduits may also be important. Posttraumatic functional reorganizations occurring in brain cortex are key phenomena explaining much of the inferior functional outcome following nerve repair, and increased knowledge regarding factors involved in brain plasticity may help to further improve the results. Implantation of microchips in the nervous system may provide a new interface between biology and technology and developing gene technology may introduce new possibilities in the manipulation of nerve degeneration and regeneration.

A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance.

Livebirth after uterus transplantation

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(06)68935-6.pdf

First human face allograft: early report

The first hand transplantation was performed in Lyon, France, on 23 September 1998 by an international team of surgeons [1]. Since then, hand transplantation programmes have been launched in the United States, Austria, China, Italy, Belgium and Poland [2, 3, 4, 5, 6], and the teams felt the need to create a worldwide registry to provide a basis for cooperation and to share their experiences (Fig. 1). Since May 2002, all groups [7] performing hand transplantations have supplied detailed information to the International Registry on Hand and Composite Tissue Transplantation (IRHCTT; www.handregistry.com). Follow-up period ranged from 2 to 85 months (Table 1). A good number of composite tissue transplantations other than the hand have been performed around the world in the period 1994–2006, including the femoral diaphysis, the knee, the larynx, the uterus, the abdominal wall, a lower limb in conjoined twins, and most recently, the face in two centres.

The international registry on hand and composite tissue transplantation

Background: We performed the first human partial face allograft on November 27, 2005. Here we report outcomes up to 18 months after transplantation. Methods: The postsurgical induction immunosuppression protocol included thymoglobulins combined with tacrolimus, mycophenolate mofetil, and prednisone. Donor hematopoietic stem cells were infused on postoperative days 4 and 11. Sequential biopsy specimens were taken from a sentinel skin graft, the facial skin, and the oral mucosa. Functional progress was assessed by tests of sensory and motor function performed monthly. Psychological support was provided before and after transplantation. Results: Sensitivity to light touch, as assessed with the use of static monofilaments, and sensitivity to heat and cold had returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred on days 18 and 214 after transplantation and were reversed. A decrease in inulin clearance led to a change in immunosuppressive regimen from tacrolimus to sirolimus at 14 months. Extracorporeal photochemotherapy was introduced at 10 months to prevent recurrence of rejection. There have been no subsequent rejection episodes. At 18 months, the patient is satisfied with the aesthetic result. Conclusions: In this patient who underwent the first partial face transplantation, the functional and aesthetic results 18 months after transplantation are satisfactory.

https://www.medpagetoday.com/upload/2007/12/13/2451.pdf

Outcomes 18 Months after the First Human Partial Face Transplantation

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(99)02062-0.pdf

Human hand allograft: report on first 6 months

First human hand transplantation. Case report.

Hand transplantation is a model of composite tissue allografting ( a A ) . The immunological issues in CTA are extremely complex, as different tissues are involved, each of which has to be considered both individually and as a part of a unit while each has a different time and intensity of rejection. Cartilage, ligaments and fat present low antigenicity, and consequently they lead to a weak rejection; bone, muscles, nerves and vessels show a moderate rejection profile in spite of various degrees of immunogenicity; skin, a complex immunological structure, is the component that develops the most severe rejection, because of the abundance of dentritic cells within epidermis and dermis. Finally, bone marrow, a source of immunocompetent cells, is a major target for rejection, but also a source of contaminating donor T cells that could induce a graft-versus-host disease in a strongly immunosuppressed recipient, and a source of stem cells that might contribute to the development of a microchimerism. Limb transplantation, the most common experimental model of CTA, has met with varying degrees of success; however, results have improved with the introduction of new immunosuppressants, especially tacrolimus and mycophenolic acid [l-71. In humans few cases of isolated muscle [8], bone, joint [9, lo], nerve [ l l ] or vascular allografts [12] have been reported. The first vascularized human hand transplantation was performed on 23 September 1998 in Lyon, and it is described in the present report [13].

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1432-2277.2000.tb02095.x

Guillaume Herzberg

Papers

Human hand allograft: report on first 6 months

First human hand transplantation. Case report.

First human hand transplantation