Vascularized Composite Allotransplantation in a Post-COVID-19 Pandemic World.

Sir:

It was with great interest that we read the Viewpoint article by distinguished plastic surgeons led by Dr. Eduardo Rodriguez.[1] The authors reported how the vascularized composite allotransplantation community has been affected by the coronavirus disease of 2019 (COVID-19) pandemic. We would also like to share our experience with COVID-19 in the preparation for our next vascularized composite allotransplantation surgery. We hope to provide some insights for future vascularized composite allotransplantation management in this uncertain period.

Vascularized composite allotransplantation is a very challenging procedure on different levels:

Surgery: Each case has to be thoroughly planned based on the defect being restored.

Immunology: The immunosuppression regimen must be optimized to prevent immune rejection.

Psychiatric condition: Long-term follow-up is mandatory.

Multidisciplinary approach: Many plastic surgeons in a wide range of subspecialties intervene to perform this surgery.

Despite 20 years of experience in vascularized composite allotransplantation worldwide, constant improvement in surgical technique is still required from the surgeon[2] thanks to newly available technologies (e.g., three-dimensional printing). Moreover, 80 percent of the effort required to perform vascularized composite allotransplantation is estimated to be due to time-consuming perioperative preparation.[3]

In our experience, the cadaver transplant training sessions planned monthly for vascularized composite allotransplantation had to be suspended. On the other hand, we report positive feedback for the preparation because of the reduction of our clinical activities. This freed up more time for us to finalize crucial steps, such as the elaboration of cutting guides, webinars to train new members of the team, computed tomography scan analysis, and coordination of the teams (“nonsurgical steps”).

This time savings must, however, be balanced with the new requirements imposed by COVID-19, as the authors pointed out very well.[1] This time should be allocated to implementation of infection precautions, optimization of patient safety, and updating operative and perioperative quality assurance protocols in the specific vascularized composite allotransplantation field. This could be reduced by sharing the protocols currently being developed among the various vascularized composite allotransplantation centers. A recent study[4] based on a cohort of 80 patients with COVID-19 showed that the immunosuppression regimen was frequently associated (38 percent) with poor outcomes (intensive care unit hospitalization and/or deaths). Thus, we need to closely monitor the emerging literature on the consequences of COVID-19 in immunosuppressed patients to determine the necessity of developing enhanced safety protocols tailored to our vascularized composite allotransplantation patients compared to nonimmunosuppressed patients.

Finally, this period emphasizes the fact that vascularized composite allotransplantation, more than a surgical challenge, requires major preoperative preparation and organizational work. Thus, one of the additional solutions in response to the changes in plastic surgery related to COVID-19[5] is the possibility of continuing vascularized composite allotransplantation surgery, despite COVID-19, by carrying out the major preparation steps required via remote work that does not necessitate a physical meeting of a group of people.

DISCLOSURE

The authors declare there is no conflict of interest regarding the publication of this communication. The authors received no specific funding or grants for this work.