Challenges and perspectives of composite tissue allotransplantation in reconstructive surgery for very severe burns

Despite advances in reconstructive surgery since the "Gueules cassees" ("Broken faces") at the beginning of the 20th century, some exceptional clinical situations still remain true therapeutic impasses such as major facial charring and mutilation disfigurement, with com-plete destruction of the labial strap and/or bilateral hand amputation. Vascularized Composite Tissue Allotransplantation (VCA) represents a new approach in reconstructive surgery, reconci-ling the rules of microsurgery and inter-human transplantation whose aim is not to save life, as is the case with organ transplantation, but to improve quality of life, thus offering real hope for severely mutilated patients without a truly satisfactory therapeutic solution. In spite of long-term uncertainties regarding the risks of chronic immunosuppression and the possible alteration of functional outcomes over time, similar to organ transplants; the first human cases of VCA proved the feasibility of these procedures and the quality of the functional results obtained, although incomplete, subject to "lifelong immunosuppressive treatment". Acute care of very serious burns poses specific problems (massive repeated unavoidable blood transfusions and use of skin allografts) that can all lead to HLA sensitization and limitation to transplant access including VCA. 100 years after the birth of "Broken Faces", the activity of a military trauma center confronts us with the difficulties encountered in such situations, from acute care to reconstruction stage. (c) 2022 l'Acad acute accent emie nationale de m acute accent edecine. Published by Elsevier Masson SAS. All rights reserved.