PROBLEMS IN THE USE OF COMPOSITE TISSUE TRANSPLANTATION IN BURNS AND GUIDELINES TO IMPROVE POTENTIAL USE

Laurent Lantieri¹, Patrice Duhamel², Mikael Hivelin¹, Caroline Superbielle³, Marc David Benjoar¹.

¹Department of plastic surgery, CHU Henri Mondor, UPEC, Créteil, France; ²Burn Unit, Percy Military Hospital, Clamart, France; ³Department of immunology, St Louis Hospital, Paris, France.

Composite Tissue Allotransplantation (CTA) open new surgical prospects in the field of deep and extensive burns, particularly in cases of face carbonization and/or bilateral hand amputation. The initial treatment of deep and extensive burns is a complex surgical challenge. Multiple blood transfusions are unavoidable and the use of skin allografts can increase the incidence of HLA alloimmunization. This may lead to a complex histocompatibility tests in a transplantation program. Moreover, in the hand and face transplants performed to date, sepsis-related complications are the most commonly seen such as in burn deaths. We are reporting here four cases of complexe burned patient where CTA was integrated in the treatment process and failed to give to the patient a potential alternative to conventional treatment.

Case 1: Was a 39 years old patient who suffered an electrical burn in 1998 with corneal destruction and reduced vision. The patient was on waiting list for 18 months for face transplant but no compatible donor was found due to high level of positive reactive antibodies.

Case 2: Was a 52 years old patient who suffered frome a burn injury in 2003 Orbicularis oris was destroyed conducting to indication of face transplant. High level of PRA was found and predictive analysis found that only one potential donor every two years would be possible. The patient was then not put on waiting list.

Case 3: Was a 37 year-old man with burns mostly third degree burns, over 80% of his body. All ten fingers were amputated, and the upper face and skull had been covered by a free omental flap. This patient benefit of bilateral hand and face transplant but died 2 months after surgery due to infection

Case 4: A 22 years old patient was admitted with extensive burn which necessitate massive excision of the face and amputation of all fingers thus leading to investigate opportunity of CTA; Initial coverage by was completed at 6 weeks but the patient died at 4 months post trauma in a pseudo septic status without any positive culture.

Following these cases we are proposing practical guidelines for burn centers in prevision of future CTA to help limiting both infectious and immunological risks.