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Composite Tissue Allografts: Should We Reconsider the Terminology?

Gordon, Chad R., D.O.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 464e-465e
doi: 10.1097/PRS.0b013e3181bf7fd1
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Department of Plastic Surgery, The Cleveland Clinic, 9500 Euclid Avenue, Desk A-60, Cleveland, Ohio 44195, drchadrgordon@hotmail.com

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Sir:

Composite tissue allotransplantation is a rapidly progressing field of reconstructive transplant surgery. This surgical specialty refers specifically to the transplantation of composite tissue allografts. The first successful transplant involving a composite tissue allograft was performed in 1957 by Dr. Peacock. This operation involved the transplantation of a human flexor tendon allograft in a 47-year-old woman suffering from tenosynovitis of her index finger.1 Since then, numerous allografts have followed, which include hand, partial face, knee (vascularized joint), abdominal wall, larynx, uterus, vascularized nerve, and scalp.2

The objective of this letter is to acknowledge my personal disliking of the descriptive term, “composite tissue allograft.” As one of the editors for the textbook entitled Transplantation of Composite Tissue Allografts,2 I feel compelled to report my dissatisfaction. Personally, the term “composite tissue allograft” is misleading, and plastic surgeons, transplantologists, physicians, immunologists, and scientists alike may need to revise this terminology.

For example, the word “graft” is used to describe “tissue that has been removed from the body, is completely devascularized, and is relocated to another location dependent on recipient neo-vascular ingrowth for survival.”3 As for the definition of an allograft, it is defined as “tissue transplanted between unrelated individuals of the same species.”4 Furthermore, “a group of two or more tissues containing more than one germinal layer” is known as a “composite graft.”5

Therefore, in summary, a composite tissue allograft, by the strictest sense of the aforementioned definitions, would accurately describe “devascularized tissue(s) transplanted from a donor to an unrelated recipient, and whose survival/function is solely dependent upon recipient neo-angiogenesis.” This definition does not, and should not, allude to transplanted tissue(s) possessing inherent vessels and/or nerves requiring microsurgical anastomoses, such as in the case of many composite tissue allografts.

Hand transplantation, for instance, is often described as being a “composite tissue allograft.”5 Obviously, the hand allograft is not dependent on the recipient for establishing neurovascularity and that, in fact, it is accompanied by its own nerves (i.e., median, ulnar, and radial) and vessels (i.e., radial/ulnar arteries, cephalic/basilic veins) requiring microanastomoses. Therefore, I propose that we use a more accurate term such as “composite tissue allotransplant,” or for more detail, refer to this particular composite tissue allotransplantation subtype as a “composite tissue limb allotransplant.”

Another great example is the partial face allograft, which has been performed recently in both France and China.2 These successful “allografts” contain skin, subcutaneous tissue, muscle, and of course, their own inherent nervous tissue (i.e., facial nerve) and blood supply (i.e., external carotid artery, external jugular/facial veins), and again require microsurgical anastomoses during transplantation, unlike a typical graft. Perhaps, instead of using the term “facial composite tissue allograft” to describe this type of reconstructive surgery, we should be using a term more analogous, such as “facial composite tissue alloflap” or “free composite allotissue transfer” instead.

In conclusion, no matter which terminology is chosen, composite tissue allotransplantation is a uniquely fascinating subspecialty, and I look forward to witnessing many unprecedented clinical achievements in the near future.

Chad R. Gordon, D.O.

Department of Plastic Surgery

The Cleveland Clinic

9500 Euclid Avenue, Desk A-60

Cleveland, Ohio 44195

drchadrgordon@hotmail.com

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REFERENCES

1.Peacock EE Jr, Madden JW. Human composite flexor tendon allografts. Ann Surg. 1967;166:624–629.
2.Gordon CR, Serletti JM, Black KS, Hewitt CW. The evolution and current status of composite tissue allotransplantation: The twentieth century realization of “Cosmas and Damian.” In: Hewitt CW, Lee WPA, Gordon CR, eds. Transplantation of Composite Tissue Allografts. New York: Springer; 2008:13–25.
3.Thorne CH. Techniques and principles in plastic surgery. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott-Raven; 2007:8.
4.Lee WPA, Feili-Hariri M, Butler PEM. Transplant biology and applications to plastic surgery. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott-Raven; 2007:53.
5.Baker DC. Composite grafts. In: Georgiade GS, Riefkohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial and Reconstructive Surgery. 3rd ed. Baltimore: Williams & Wilkins; 1997:34.

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