The first abdominal wall VCA was performed by Tzakis and colleagues in 2003 in recipients of intestinal or multivisceral transplants with loss of abdominal domain [61].These VCAs were unique as the patients were already on immunosuppression for SOT. Since then 38 full-thickness vascularized abdominal wall transplants, six partial-thickness vascularized, and 17 partial-thickness nonvascularized rectus fascia grafts have been reported worldwide [62]. Despite failures in some patients, these grafts have been used to facilitate primary, tension free closure of abdominal wall in SOT patients with visceral coverage and reduced complications [63, 64]. Taken together, despite mixed success, the numbers of abdominal wall transplantations exceeds that of craniofacial VCA.

Kluyskens and Ringoir performed the first laryngeal transplant in 1969 for reconstruction after tumor extirpation [65, 66]. However, the tumor recurred leading to death at 8 months and the graft was lost to rejection when immunosuppression was withdrawn. Following this early attempt, Strome and colleagues performed the first successful laryngotracheal VCA (including thyroid and parathyroid glands) in 1998 in Cleveland prior to the first upper extremity transplantation in Louisville [67, 68]. The patient who suffered from laryngeal trauma recovered swallowing and phonation with excellent quality of life outcomes until this graft was lost to chronic rejection 14 years later [69]. Following this, Tintinago et al. from Medellin, Colombia performed over 18 laryngotracheal VCA, including the first esophageal VCA [70–72]. Majority of patients were weaned from tracheostomies. There is a report of two graft losses, but this experience remains mostly unpublished with long-term outcomes unknown.

Hofmann and colleagues performed the first series of knee joint and femur VCAs in Munich between 1996 and 2006 [73]. These include six human vascularized allogeneic knee transplantations and three femoral diaphyseal transplants for long segmental bone defects [74]. All of these grafts were successful in the short term but were lost within the first 56 months due to reasons including infections, non-adherence to medications and chronic graft rejection [75, 76].

In 2003, Ewers and colleagues performed the first total tongue VCA in Vienna, Austria in a recipient following carcinoma resection [77]. Following a short period of success, the patient succumbed to tumor recurrence. In 2004, Hui and team transplanted both ears bridged by cephalocervical scalp skin in a recipients following extirpation of melanoma [78]. Again, the patient succumbed to tumor recurrence. More recently, in 2015, a team from MD Anderson Cancer Center performed a combined partial calvarial and scalp transplant in a SOT recipient suffering from a wound defect secondary to tumor removal from the scalp. Long-term outcomes remain to be seen.

Hu et al. performed the first penis allotransplantation in Guangzhou, China in 2006, in a patient suffering from traumatic penile amputation [79]. After a short course of success with normal urination, the transplant was electively removed at 2 weeks due to psychosocial rejection experienced by the recipient and his spouse [80]. More recently, in 2014, a team lead by Andre van der Merve from South Africa performed a penis transplant in a recipient suffering from complicated circumcision [81]. A year later, this patient is reported to have ejaculatory and erectile sexual function, although it is unclear if erogenous sensation has recovered. Two programs have recently received OPTN approval to perform penile transplants in the USA.

The earliest attempt at uterine transplantation was in Saudi Arabia by Fageeh et al. in 2000 [82]. The graft failed at 99 days due to ischemic uterine torsion. This attempt was followed by another transplant in Antalya, Turkey, in 2013, lead by Ozkan et al. [83–85]. Both these early attempts were based on deceased donors. Despite survival of the transplant, pregnancy was not accomplished in this recipient. In 2014, Brannstrom and colleagues achieved the first successful pregnancy in uterine transplantation in a recipient with absolute uterine infertility (AUI) . This team performed a total of 9 deceased donor uterine transplants with four live births [86, 87].

Uterus transplantation may be the first available treatment for AUI, which is caused by absence of the uterus or the presence of a nonfunctional uterus. Similar to abdominal wall transplants, where the patient is usually on immunosuppression for the SOT, uterine transplants benefit from reduced immunosuppressive drug exposure (coverage only needed during gestation) [88–91].

Four cases of lower extremity VCA have been reported (two bilateral and two unilateral) [92]. In 2006, Zuker and colleagues performed the first unilateral lower limb VCA in ischiopagus conjoined twin infants [93]. Given that this was a twin–twin VCA, postoperative immunosuppression was not needed. Over a 6-year period, the patient recovered motor and sensory function to allow ambulation with assistance [93].

In 2010, Cavadas and colleagues performed the first bilateral above knee lower extremity VCA in a 21-year-old recipient in Valencia, Spain [94, 95]. At 1 year, there was recovery of knee flexion and extension with some ankle function. In 2012, Ozkan and colleagues performed a simultaneous bilateral upper limb VCA in combination with a unilateral lower extremity VCA in Antalya, Turkey. Both the Spanish and Antalya patients succumbed after transplant, one to post transplant lymphoma and the other to post transplant end organ failure secondary to disseminated aspergillosis. In the same year, Nasir and coworkers performed a bilateral lower extremity VCA in combination with upper extremity VCA in Ankara, Turkey. The patient died perioperatively due to surgical complications [96].

Other simultaneous complex transplants have been reported across the world involving combination face and upper extremity or upper and lower extremity VCA (bilateral or unilateral) [97]. Three of four of these reported tandem transplants have died due to operative or perioperative complications that include overwhelming sepsis or shock [98, 99]. One patient survived but had to undergo removal of both upper extremities only to preserve a face transplant. Uniformly, quadruple VCA and triple VCA have been associated with very high failure. There are risks of the large antigenic burden, overwhelming ischemia–reperfusion injury, large volume resuscitation requirements, extended anesthesia times among a host of surgical and technical challenges [100].

In July 2015, the world’s first bilateral pediatric hand transplant was performed by Levin and team in an 8 year old boy at University of Pennsylvania. The recipient was a SOT patient and thus already under immunosuppression [101, 102].