Vascularized Composite Upper Limb Allograft Harvesting for Proximal Arm Allotransplantation

In vascularized composite allograft (VCA) for upper limb reconstruction, upper arm-level or transhumeral transplantations are performed less frequently than forearm and hand transplantations. Transplantation is technically more feasible at this proximal level, largely owing to the use of macrovascular anastomoses. Despite these challenges, the outlook for arm allotransplantation remains encouraging, and this protocol provides a standardized technique for harvesting a vascularized upper arm composite allograft, ensuring both optimal outcomes and minimal tissue trauma. In the case of upper arm transplant, the technique varies according to the level of transplantation: supracondylar, transhumeral at a proximal arm level, or through the shoulder with the donor humeral head. A circumferential skin incision at mid-arm, or depending on the level at the origin of the upper limb, is made. A skin flap, such as a deltoid flap, can be harvested from the donor for skin closure at proximal levels. Dissection of the cephalic vein and deeper the brachial or axillary artery and veins is required. Then, the surgeon must identify the nerves depending on the level (terminal branches of brachial plexus or anteromedial and anterolateral cords for proximal transplantation) and transect the biceps, brachialis, and triceps muscles. The coracobrachialis and the deltoid muscles may also be dissected depending on the amputation level. Finally, the surgeon must make a transhumeral osteotomy or, if needed, harvest the donor humeral head for shoulder reconstruction. In this case, a peroneus longus graft for the suspension ligamentoplasty can also be harvested. The goal of this protocol is to standardize the procedure of harvesting and preparing an upper arm allotransplant.