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to find ways to provide these patients with means for obtaining better satisfaction and quality of life
postoperatively. Despite the advances in VCA over the last 20 years, there are many challenges that face
this discipline including indications for patient selection, minimizing immunosuppressive regimens,
standardizing outcome measures, and establishing reliable protocols for monitoring, diagnosing, and
managing rejection. The question remains if the risks associated with lifelong immunosuppression justify
the non-lifesaving operation. Continued discussions of the advances, successes, and failures well determine
how rapidly we are able to improve upon the aforementioned reconstructive options.

DECLARATIONS
Acknowledgments
The Authors thank Hansjörg Wyss Foundation for their support.

Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Azoury SC, Bauder A, Souza JM, Stranix JT, Othman S, McAndrew C, Tintle SM, Kovach SJ,
Levin LS
Performed data acquisition, provided administrative, technical, and material support: Azoury SC, Bauder A,
Souza JM, Stranix JT, Othman S, McAndrew C, Tintle SM, Kovach SJ, Levin LS
Reviewed the manuscript for content and grammar/spelling mistakes: Azoury SC, Bauder A, Souza JM,
Stranix JT, Othman S, McAndrew C, Tintle SM, Kovach SJ, Levin LS

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.

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