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challenges that may necessitate deviations or conversions to secondary options, such as tendon grafting or
use of alternative donor nerves. Intraoperatively, success is contingent not simply upon meticulous
microsurgical dissection and anastomosis of the vessels and nerves but upon correct positioning of the
muscle and tensioning of tendons to enable their excursion and provide the desired movement. In the early
postoperative period, careful monitoring of the transferred muscle is critical to ensure its survival and
successful healing of the recipient and donor sites. If all the above are accomplished, the final and most
important component will involve the rehabilitation and retraining process, which will demand intimate
and coordinated collaboration with hand and occupational therapy colleagues to achieve a meaningful
functional outcome.

VASCULARIZED COMPOSITE ALLOTRANSPLANTATION
In keeping with the oft-cited surgical principle of replacing “tissue losses in kind” , VCA of the hand and
[47]
upper extremity seeks to restore form and function following limb loss in a manner that is not possible with
other reconstructive modalities. Although fewer than 25 years have passed since the first successful hand
transplant, the procedure has now been performed in at least a dozen countries and on more than 100
patients. High mortality and devastating graft loss rates have been reported for combination VCA
procedures that involve upper extremity transplantation in conjunction with a craniofacial or lower
extremity transplant; however, isolated unilateral or bilateral upper extremity VCA has proven to be a more
reliably attainable goal. The patient survival rate has been reported to be 99%, while overall long-term graft
survival is approximately 85% across all recipients and more than 95% with stringent adherence to an
immunosuppressive medication regimen [48,49] .

However, it is that same regimen of immunosuppressive agents that underpins the shortcomings and
drawbacks of VCA. Since its inception, the field of transplantation has been plagued by the need for lifelong
use of these medications. Their well-described toxicities leading to both graft and organ damage as well as
increased susceptibility to infection and malignancy are certainties that all transplant recipients accept.
While much progress has been made towards inducing chimerism and tolerance [50,51] , at present, these
remain theoretical goals, the promise of which has yet to be fully realized. Until the ability to minimize or
eliminate immune responses to transplanted tissue in the absence of pharmacologic intervention becomes a
reality, constant diligence will remain necessary to balance the harmful effects of immunosuppressants
against the risk of graft rejection.

With respect to VCA specifically, discussions of its ethics and risk-benefit profile often cite that, unlike
transplantation of a solid organ, such as a liver or kidney, VCA involving the face or an upper extremity is
life-changing but not life-saving. Nonetheless, the psychosocial benefits of VCA demonstrate the substantial
impact that transplantation can have on an individual’s life, in many circumstances easing the burdens of
isolation, loneliness, and loss of personhood that may accompany the “social death” experienced following a
disfiguring injury [52,53] . In 2016, Breidenbach et al. performed a statistical analysis of hand transplantation
with the aim of discerning whether the procedure met the necessary threshold to be deemed the standard of
[54]
care . The group concluded that when considered against solid organ transplants, hand transplantation
demonstrates a superior ability to attain adequate immunosuppression and has a lower risk of chronic graft
rejection and a decreased incidence of renal failure. This finding, in combination with a functional ability
that was superior to that of the prosthetic devices available at the time, suggested that hand and upper
extremity VCA had merits.

Despite the wealth of literature published on the subject and the growing number of centers globally that are
offering the procedure, assessment of functional outcomes following hand transplantation has proven