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Xu et al. Plast Aesthet Res 2022;9:33 Plastic and
DOI: 10.20517/2347-9264.2021.116
Aesthetic Research

Review Open Access

Ethical challenges in vascularized composite
allotransplantation of the lower extremity: lessons

learned from hand transplantation and implications
for the future

1
Amy L. Xu , Casey Jo Humbyrd 2
1
Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
2
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19106, USA.
Correspondence to: Dr. Casey Jo Humbyrd, Department of Orthopaedic Surgery, The University of Pennsylvania, 230 West
Washington Square, 5th Floor Farm Journal Building, Philadelphia, PA 19106, USA. E-mail:
casey.humbyrd@pennmedicine.upenn.edu

How to cite this article: Xu AL, Humbyrd CJ. Ethical challenges in vascularized composite allotransplantation of the lower
extremity: lessons learned from hand transplantation and implications for the future. Plast Aesthet Res 2022;9:33.
https://dx.doi.org/10.20517/2347-9264.2021.116
Received: 27 Oct 2021 First Decision: 6 Jan 2022 Revised: 19 Jan 2022 Accepted: 21 Apr 2022 Published: 6 May 2022

Academic Editors: Matthew L Iorio, Marten Basta Copy Editor: Jia-Xin Zhang Production Editor: Jia-Xin Zhang

Abstract
Vascularized composite allotransplantation (VCA) is a novel surgical practice that involves the transplantation of
multiple tissue types as a functional unit without the primary purpose of extending life. While VCA of the upper
extremity is becoming increasingly accepted and performed, VCA of the lower extremity remains largely
unexplored despite its acknowledged potential value. There are inherent ethical concerns surrounding VCA that
are dominated by a conflict between the principles of beneficence and maleficence. The primary question is
whether the quality-of-life benefits to the patient outweigh the risks associated with long-term
immunosuppression for a non-lifesaving procedure. In addition, the ethical conversation involves concerns
regarding informed consent, donor autonomy, patient privacy and public disclosure, patient selection, and unique
considerations in the pediatric patient. Lower extremity VCA has additional ethical issues compared to upper
extremity VCA, as current lower limb prostheses provide excellent, near baseline function that upper limb
constructs have not yet been able to achieve. In this review, we discuss the ethical challenges of lower extremity
VCA using available evidence for the upper extremity. We also compare ethical considerations of VCA of the
extremity with other surgical alternatives to limb loss - namely, limb salvage and replantation - and address how
the conversation may be altered with further advancements in immunosuppression and prosthetic technology.

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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