Facing Allograft Failure: A Systematic Review of Explantation and Retransplantation in Vascularized Composite Allotransplantation
In brief
Chronic rejection led 44% of reported graft removals in a 25-patient review
Across 19 studies, 25 recipients underwent 22 graft removals and three retransplants; chronic rejection was the most common reason for removal, followed by perfusion problems and medication non-compliance. These last-line procedures were feasible, but retransplantation was technically harder because of scarring and altered anatomy, underscoring the need to prevent irreversible graft failure.
- Journal
- Journal of reconstructive microsurgery (Q1)
- Published
- 5 October 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Alexis Katie Gursky, Y Edward Wen, Anandhini D Narayanan, Shaina M Staffenberg, Hailey P Wyatt, Sergio A Segrera, et al.
- PMID
- 42833276
- DOI
- 10.1055/a-2972-6379
Why clinicians should know about it
- Picked for Plastic and Reconstructive Surgery (paper of the day, 9 October 2026): Explantation and retransplantation in VCA, not within typical plastic reconstructive
Abstract
BACKGROUND: Vascularized composite allotransplantation (VCA) can restore form and function beyond conventional reconstruction, but acute (AR) and chronic rejection (CR) limit long-term allograft survival. When allograft failure becomes irreversible, explantation or retransplantation may be necessary. This review evaluates the indications, management, and operative considerations associated with explantation and retransplantation in VCA. METHODS: A systematic review of PubMed, PubMed Central, MEDLINE, Scopus, and Web of Science was conducted to identify studies reporting patient-level data on VCA recipients who underwent allograft explantation or retransplantation. Extracted data included recipient demographics, immunologic characteristics, rejection history, and explantation or retransplantation outcomes. RESULTS: Nineteen studies reporting 25 VCA recipients were included, comprising 22 explants and three retransplants (two face, one abdominal wall). The most common VCA types were uterus (32%), face (24%), and hand (16%). The leading indications for graft removal were CR (44%), perfusion-related complications (32.0%), medication non-compliance (24.0%), and patient request (12.0%). The median time to explant was 12.5 months, and to retransplant was 7.3 years. Management of CR included pulse steroids, increased immunosuppression, plasmapheresis, and biologic agents. Retransplantation was more technically challenging than the primary transplant due to scarring, distorted anatomy, and vessels affected by CR, requiring more proximal vascular anastomoses and nerve coaptations. CONCLUSION: Explantation and retransplantation in VCA are feasible but last-line interventions. The leading cause of graft loss was CR, though perfusion-related and patient-related factors also contributed. Earlier recognition and management of AR, clearer definitions of CR, and overall improved strategies to prevent progression to irreversible graft failure are needed.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.