Tissue Transplant Surgery in Ankara, Turkey

Composite tissue transplantation is an advanced transplant method that includes multiple tissue types together (such as skin, muscle, bone, blood vessels, and nerves) and is typically performed using microsurgical techniques. The most common applications are face, arm, and hand transplants.

This procedure is preferred for severe tissue losses that cannot be reconstructed with conventional reconstructive surgeries. The transplanted tissue is harvested from a donor, and vascular and nerve connections are reconstructed to match the recipient. In this way, both aesthetic and functional integrity can be achieved.

Composite tissue transplantation requires high technical precision to preserve viability and restore movement and sensation. Lifelong immunosuppressive therapy is mandatory to prevent rejection; this requires careful follow-up and disciplined care.

With successful transplants, not only patients’ physical appearance but also their social and psychological adaptation can improve significantly. Composite tissue transplantation is one of the most advanced applications of reconstructive surgery and is carried out through multidisciplinary teamwork.

What Is Composite Tissue Transplantation?

Composite tissue transplantation is the transfer of anatomical structures that include multiple tissue types—such as skin, muscle, bone, nerves, and blood vessels—as a single unit. It is most commonly applied in face, hand, and arm transplants. This procedure aims to restore function and aesthetic appearance after severe trauma, burns, or congenital deficiencies. Long-term immunosuppressive therapy is required after transplantation to prevent immune rejection.

How has Turkey historically developed in the field of composite tissue transplantation?

Our country is not only a regional powerhouse in organ transplantation but also a globally recognized reference center. This success was not achieved overnight; it is built upon decades of microsurgical expertise and bold steps. Although organ transplantation efforts in Turkey began in the late 1960s, the transition to composite tissue transplantation became possible with the refinement of microsurgical techniques and the development of immunosuppressive therapies. Foundations laid in the 1970s began to bear fruit from 2010 onward, leading to successive achievements that entered world medical history.

Long-established institutions such as Akdeniz University, Hacettepe University, and Gazi University have been the driving forces of this process. The short period between 2010 and 2012, in particular, can be regarded as a golden era when Turkish plastic surgery proved its maturity. The operations performed during this time were not only technical successes; they also became milestones that shaped ethical debates, legal regulations, and immunologic protocols. Antalya’s rise to the status of a “transplant city” and the academic depth of universities in Ankara have made Turkey a beacon of hope for international patients as well.

Key dates and events in Turkey’s process include:

• 25 September 2010
• 9 August 2011
• 21 January 2012
• 24 February 2012
• 17 March 2012

Which patients are considered suitable candidates for composite tissue transplantation?

These operations are not suitable for every patient with limb loss or facial deformity. For a plastic surgeon, these procedures are not “life-saving” operations that eliminate an immediate life-threatening condition; rather, they are “quality-of-life enhancing” procedures that elevate the patient’s living standard. This fine line is the most important criterion in patient selection. There must be a rational balance between the risks the patient will take and the benefits they will gain. Considering the side effects of immunosuppressive drugs, this risk is not taken for losses that can be managed with a simple scar revision or a functional prosthesis.

Candidates must be ready for this process both physically and mentally. Those with a history of malignant tumors, active infection, or psychological issues that would undermine post-transplant adherence cannot be included in this program. The goal is not merely to attach a new organ to a patient, but to reintegrate them into social life, work life, and human relationships.

Key criteria sought in upper extremity transplantation include:

• Bilateral arm loss
• Below-elbow amputation level
• Need for immunosuppressive medication use
• Loss of the dominant side
• Asymmetric amputations
• Insufficiency of conventional methods

What is considered when evaluating composite tissue for face transplantation?

Face transplantation is a procedure with deep functional and social goals far beyond aesthetic concerns. The concept of “cosmetic surgery” is insufficient here. A patient with severe facial damage not only avoids looking in the mirror; they may also be unable to eat, speak properly, close their eyelids, or breathe comfortably. These patients are often individuals who have become completely isolated from society and confined to their homes.

The primary goal in face transplantation is to achieve an appearance that allows the patient to “go out among people” and to restore basic vital functions. Restoring mouth opening means the patient can move from being fed with a straw to eating solid foods. Reconstructing the eyelids prevents the cornea from drying out and avoids blindness. Creating nasal structures enables comfortable breathing. Perhaps most importantly, restoring the facial muscles is critical. A patient who can express emotions—smile or show sadness—feels human again.

Key gains targeted in face transplantation include:

• Restoring mouth opening
• Regaining eating function
• Improving speech ability
• Eyelid function
• Corneal protection
• Nasal airway patency
• Facial expression control
• Ability to express emotions
• Social integration
• Psychosocial recovery

How is composite tissue compatibility ensured between recipient and donor?

For a successful transplant, it is not enough for medical tests to be compatible; visual and structural compatibility must also be achieved. This is not required in other organ transplants. The color or shape of a liver is not visible from the outside, but in a face or hand transplant, the new tissue must integrate with the patient’s body. Therefore, when a donor is found, doctors examine the match with the meticulousness of an artist.

On the biological side, blood group is the most basic determinant. While Rh factor compatibility may not be strictly required, the ABO system must match. Tissue type compatibility (HLA) is not as strictly regulated as in classic organ transplants, but it is closely monitored to manage rejection risk. The most challenging process is matching physical characteristics. The size of the transplanted hand, bone thickness, skin color, and hair pattern should be compatible with the recipient’s other hand or body structure. In face transplantation, factors such as age, sex, and cranial structure come into play.

Main parameters evaluated for recipient–donor compatibility include:

• Blood group
• Sex
• Age range
• Skin color
• Tissue tone
• Hair density
• Bone structure
• Extremity size
• Anthropometric measurements
• Viral serology

What stages does composite tissue transfer go through during surgery?

Composite tissue transplantation operations are the peak of surgery and truly a marathon. These operations usually last 8 to 12 hours, but can sometimes reach 24 hours. Multiple teams work simultaneously in the operating room. While one team removes the tissue from the donor without damage—preserving vascular and nerve pedicles—the other team prepares the recipient. Timing is everything; the shorter the ischemia time (the period without blood flow), the higher the chance of success.

During the operation, the principle of “structure first, then function” is followed. First, bones are fixed with plates and screws—like establishing the framework of a building. After the skeletal system is secured, the most delicate microsurgical phase begins. Arteries and veins are connected under the microscope with sutures far thinner than a hair. When blood flow is restored, seeing the pale, lifeless tissue suddenly turn pink and warm is a mesmerizing moment for everyone in the operating room. But it does not end there: muscles, tendons, and nerves are repaired one by one. Nerve repair is critical for future movement and sensation.

Key steps in the surgical procedure include:

• Tissue harvest
• Recipient site preparation
• Osteosynthesis
• Arterial anastomosis
• Venous anastomosis
• Nerve coaptation
• Tendon repair
• Muscle group transfer
• Skin coverage
• Drain placement

How does the immune system respond to transplanted composite tissue?

Our defense system distinguishes perfectly between “self” and “foreign.” Composite tissue transplantation is among the most provocative procedures for the immune system. The main reason is the skin. Because skin is a barrier that protects us from microbes in the outside world, it is rich in immune cells (such as Langerhans cells). When these cells encounter foreign tissue, they sound the alarm very quickly. Therefore, acute rejection episodes can occur more frequently and more severely in face or arm transplant patients compared to liver or kidney transplantation.

To manage this, patients must take lifelong immunosuppressive medications. These drugs “quiet” the immune system and prevent it from attacking the new tissue. However, this also makes the body more vulnerable to infections and other illnesses. Doctors constantly adjust dosages to maintain the balance—neither too little (risking rejection) nor too much (making the patient ill). Signs of rejection often first appear as redness or rash on the skin, which can be an advantage for early detection.

Elements used in immunologic monitoring and treatment include:

• Calcineurin inhibitors
• Antimetabolites
• Corticosteroids
• Skin biopsies
• Banff grading system
• T-lymphocyte counting
• Cytokine profile monitoring
• Drug blood-level measurement

How do patients psychologically integrate with composite tissue in this process?

A person’s face is their window to the world; their hands are the tool through which they establish physical contact with the world. Changing such personal and visible regions can have profound effects on mental health. After surgery, the patient must integrate parts that once belonged to someone else into their own body when looking in the mirror or at their hands. This process is called “integration of the sense of bodily integrity.”

In face transplantation, this is even more delicate. The new face is neither the donor’s former face nor the recipient’s original face. Donor tissue placed onto the recipient’s bone structure creates a completely new, hybrid appearance. The patient must accept and learn to love this “new self.” This adaptation process can be as long and challenging as surgical healing. Reactions from family and the environment play a key role in the patient embracing this new identity. Therefore, preoperative psychiatric evaluations are strict. Suicidal tendencies, personality disorders, or unrealistic expectations are absolute contraindications.

Components of psychological evaluation and support include:

• Body image perception
• Identity adaptation
• Realistic expectation analysis
• Family support system
• Social phobia assessment
• Depression screening
• History of addiction
• Ability to adhere

Why is rehabilitation vital after composite tissue transplantation?

The final stitch placed on the operating table is not the end of the process—it is actually only the beginning. If surgical success is 50%, the remaining 50% depends entirely on rehabilitation. It is not enough for a transplanted hand or face to simply remain in place; it must move, feel, and live. However, nerve healing takes time. Nerve ends advance at an average rate of about 1 millimeter per day. This means that in an elbow-level transplant, it can take months for signals to reach the fingertips.

This waiting period is not passive. Physical therapy begins immediately after discharge and can continue for years. The brain’s “hand” or “face” map must be redrawn. Thanks to brain plasticity, the patient retrains the brain by repeatedly attempting movements they cannot yet perform. Passive stretching, electrical stimulation, and mirror therapy help prevent muscle wasting and joint stiffness. Without full adherence, even the most perfect surgery can result in a stiff, nonfunctional limb.

Main stages of rehabilitation include:

• Passive joint movements
• Active-assisted exercises
• Muscle strengthening
• Fine motor skill training
• Sensory re-education
• Hot and cold perception training
• Grasping exercises
• Facial expression training
• Activities of daily living
• Occupational therapy

How is composite tissue transplantation regulated legally and ethically in Turkey?

Turkey has not left such a complex medical procedure solely to surgeons’ initiative; it has established a strong legal and ethical framework at world standards. Regulations issued by the Ministry of Health clearly define in which centers, by whom, and under which rules these operations can be performed. “Composite Tissue Transplant Councils” established in licensed centers convene for each case and make joint decisions. These councils include not only surgeons, but also psychiatrists and other specialists:

Ethically, the most important principle is “do no harm.” While aiming to improve a patient’s quality of life, one must not place them under the lifelong burden of severe disease risks. Privacy is also extremely sensitive. The donor family’s identity and the recipient’s images should not be used as advertising material, and the patient’s dignity must be protected. Debates following extreme cases—such as four-extremity transplantation at Hacettepe University—have helped clarify these ethical boundaries further and contributed to an approach centered on patient safety.

Main pillars of the legal and ethical framework include:

• Composite Tissue Transplant Council approval
• Requirement of a licensed center
• Bioethics Association principles
• Do no harm principle
• Protection of privacy
• Fair organ allocation
• National Coordination System
• Informed consent

Which other specialized composite tissue transplants can be performed besides face and arm?

Expertise in this field is not limited to the face and hand. Turkish surgeons—and world medicine—have demonstrated that other tissues and organs can also be transplanted. These specialized transplants are typically performed for very specific and rare indications, but their contribution to medical literature is significant.

For example, intestinal transplantation can be life-saving in patients with multiple organ failure involving the intestines along with organs such as the stomach and pancreas. These operations restore continuity of the digestive system and free the patient from intravenous nutrition. Another important area is uterus transplantation. This procedure, which gives women who were born without a uterus or lost it the chance of motherhood, is among the most miraculous achievements of reconstructive transplantation. Penile transplantation, performed to restore both sexual function and the urinary system in patients who have lost the organ due to trauma or cancer, can also have a tremendous impact on psychological recovery.

Other types of composite tissue transplantation include:

• Intestinal transplantation
• Uterus transplantation
• Penile transplantation
• Abdominal wall transplantation
• Larynx transplantation
• Trachea transplantation
• Lower extremity transplantation