LAUSR

T field of vascularized composite allotransplantation (VCA) is no longer in its infancy. More than 80 upper extremity transplants have been performed world-wide, in addition to 30 patients having received facial transplants. Other composite transplants including abdominal wall, lower extremity, knee, larynx, uterus, and penis transplants have been reported. However, despite expanding numbers of VCA centers (in the United States and abroad) and the slowly expanding volume of procedures, the field is far from achieving widespread adoption that signals maturity. In fact, one may compare the current state of the field to that of late adolescence. Although VCA has established itself as independent from, though still related to, its parent field of solid organ transplantation, it remains young and incompletely defined. Moreover, the combination of a strong desire to surpass expectations in the presence of a relative paucity of adverse outcomes has driven high risk decision-making approaches on the parts of both patients and providers. Although the field longs to be mature, it lacks the credibility earned by other areas of transplantation through decades of history, and sometimes, the heart-breaking experience of failures. Those performing VCA procedures express enthusiastic optimism, temperedwith caution to varying degrees.Overall, the field is encouraged by early successes and promising graft survival rates that suggest that VCA may be a realistic solution for catastrophic injuries or other disfiguring conditions for which conventional reconstruction is insufficient. Overall, VCA may be seen as a platform on the reconstructive ladder (Figure 1), offering a better solution than currently available procedures while potentially providing a ‘jumping off point’ for neurally integrated prosthetics and regenerative medicine/tissue engineering options. Moreover, more recent