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Is Skin the Most Allogenic Tissue in Vascularized Composite Allotransplantation and a Valid Monitor of the Deeper Tissues?

Robbins, Nicholas L., D.O.; Wordsworth, Matthew J., M.A., M.R.C.S.; Parida, Bijaya K., Ph.D.; Kaplan, Bruce, M.D.; Gorantla, Vijay S., M.D., Ph.D.; Weitzel, Erik K., M.D.; Breidenbach, Warren C., M.D., M.S.

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 880e–886e
doi: 10.1097/PRS.0000000000005436
Plastic Surgery Focus: Special Topics

Summary: Since the 1960s, skin has been considered to be the most allogenic tissue in humans. This tenet has remained unquestioned in the reconstructive transplant arena, which has led to skin serving as the sole monitor for early rejection in vascularized composite allotransplantation. In this article, the authors question the validity of this belief. The authors’ hypothesis is that skin is not always an accurate monitor of rejection in the deep tissues, thus questioning the positive and negative predictive value of the punch biopsy for suspected vascularized composite allotransplantation rejection. A search was carried out identifying vascularized composite allotransplantation publications where the allogenicity of transplanted skin was evaluated. Eighteen publications claimed skin was found to be the most allogenic tissue in humans, justifying its use as a superior monitor for rejection. Eight publications demonstrated skin to be a poor monitor of rejection deeper to the skin. Two vascularized composite allotransplantation animal studies reported skin rejecting simultaneously with the deeper tissues. Finally, three publications discussed a skin and kidney allograft, transplanted simultaneously, indicating skin allogenicity was equivalent to the that of the kidney allograft. Much of the literature in human vascularized composite allotransplantation claims skin to be an excellent monitor of the deep tissues. The conclusion from this study is that skin does not always function as a good monitor for what could be rejecting in the deep tissues. The authors believe continued research is necessary to focus on expanding novel monitoring techniques and technologies to accurately diagnose vascularized composite allotransplantation rejection without tissue destruction.

Lackland Air Force Base, Fort Sam Houston, San Antonio, and Temple, Texas; and Winston-Salem, N.C.

From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; the University of Texas Health at San Antonio; Baylor Scott & White Health; and Wake Forest Institute for Regenerative Medicine.

Received for publication February 1, 2018; accepted September 14, 2018.

Disclaimer: The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components.

Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. No funding was received for this article.

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Warren C. Breidenbach, M.D., M.S., 300 Convent Street, Suite 1330, San Antonio, Texas 78205,

©2019American Society of Plastic Surgeons