Evaluation of lymphatic and vascular system restructuring inreplantation and bilateral upper extremity transplant patients

Patients who have composite tissue loss that disrupts body integrity and causes loss of function; replantation surgeries with vascularised composite tissue transplantation, which are applied to restore physical appearance and improve function, increase the quality of life. There is limited information about the changes in the vascular structure and the remodeling of the lymphatic structures following anatomical integrity in these patients. Three bilateral hand allotransplants and three unilateral major upper extremity replantations performed at Akdeniz University Faculty of Medicine between 01.01.2012 and 01.01.2022 were included in the study. Of the major upper extremity replantation patients, 2 had forequarters and 1 had elbow replantation. ICG lymphography findings were evaluated to examine the lymphatic system in patients with bilateral hand transplant and major upper extremity replantation. In addition, arterial doppler USG data before and after anastomosis were evaluated in this patient groups. As the ICG lymphography control group, six patients with malignancy in the upper extremity but who had not undergone any previous procedure on the extremity were included in the study. When ICG lymphography findings were evaluated, it was shown that spontaneous lymphatic connections were formed in the recipient and donor tissues, although lymphatic anastomosis was not performed in bilateral hand transplant patients. The situation was similar in the patients with elbow replantation history. However, the superficial lymphatic flow seen in the upper hand in bilateral hand transplant patients could not be seen in forequarter replantation patients. Although it is speculative, the lymphatic flow to the axillary area was interrupted as a result of the mismatch of the upper extremity lymphatic pathways with reverse flow at the suture line of the forequarter patients. Therefore, the superficial lymphatic pathways in the upper hand may undergo fibrosis, which leads the lymphatic flow through the deep lymphatic system. In addition, less muscle movements and contractions compared to transplanted patients may have caused the difference between the two groups. The fact that tacrolimus caused an increase in superficial lymphatics may also have caused the ICG lymphography differences between these two groups. In Doppler USG examinations, intima thickening, irregularity and calcification were detected in the donor artery wall compared to the recipient artery in a patient with a history of bilateral hand transplantation, and ischemic changes of the allograft were not observed. In other patients with bilateral hand transplants and major upper extremity replantation, the data in the donor and recipient arteries were consistent with each other. We think that patient follow-up with doppler USG is useful for allograft follow-up. Key words: Hand transplantation, replantation, ICG lymphography, doppler USG