American Association of Plastic Surgeons

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Chronic Clinico-Pathologic Changes in Skin of Face Transplant Recipients
Sotirios Tasigiorgos, MD1, George Murphy, MD1, Nicco Krezdorn, MD2, Elazer Edelman, MD, PhD3, Luccie Wo, MD1, Branislav Kollar, MD1, Ericka M. Bueno, PhD1, Christine G. Lian, MD1, Bohdan Pomahac, MD1.
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA, 2Hannover Medical School, Hannover, Germany, 3Harvard Medical School, Massachusetts Institute of Technology, Boston, MA, USA.

PURPOSE: Face vascularized composite allograft (FVCA) represents a single, complex procedure to correct severe disfigurement. Chronic clinico-pathologic changes may accompany FVCA over time and relate to chronic rejection (CR). Here we report possible CR in three patients based on defined and correlative clinical and histopathological assessments.
METHODS: Seven patients were studied who received FVCA at our Institution. "Protocol biopsies" were performed every 6 months until 5 years post-surgery, with yearly biopsies thereafter; "clinical biopsies" were performed at times of suspected acute rejection and during resolution phases during therapy. In addition to clinical parameters, histologic samples were assessed by H&E staining for acute rejection (AR; Banff criteria), histochemistry for type I collagen using the Herovici stain, and immunohistochemistry for CD31 reactivity.
RESULTS: Clinical evidence of chronicity included nostril dry notch, apparent premature ageing, white demarcation of suture lines, and telangiectasias. Histologic alterations occurred in both protocol and clinical biopsies; involved later time points; and included epidermal atrophy, hyperkeratosis, follicular ectasia, and interface/lichenoid lymphocytic infiltrates along the dermal-epidermal junction. Papillary dermal sclerosis and thickening correlated with deposition of mature, type I collagen, as determined by Herovici stain; CD31 immunohistochemistry revealed microvascular prominence.
CONCLUSION: The finding of interface/lichenoid immune infiltrates in association with clinical and histologic evidence of chronicity (atrophy, sclerosis) in both protocol and clinical biopsies is consistent with chronic, low-grade alloreactivity (CR) in some patients. Close monitoring for such alterations may be required to maximize therapeutic responses in predisposed individuals.


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