Scoring of skin rejection in a swine composite tissue allograft model

Marty Zdichavsky, Jon W. Jones, E. Tuncay Ustuner, Xiaoping Ren, Jean Edelstein, Claudio Maldonado, Warren Breidenbach, Scott A. Gruber, Mukunda Ray, John H. Barker

Research output: Contribution to journalArticlepeer-review

64 Scopus citations


Background. For the first time, we define and correlate visual and histologic grading systems of composite tissue allograft (CTA) skin rejection in a large-animal model and determine the utility of these grading systems for early diagnosis and monitoring of rejection. Materials and methods. Sixteen pairs of outbred swine underwent transplant of a forelimb osteomyocutaneous free flap. Group I (n = 6) did not receive immunosuppressive therapy. Group II (n = 10) received oral cyclosporin A, mycophenolate mofetil, and prednisone. The flap was visually inspected and protocol skin biopsies were taken at frequent intervals over a 90-day period. Visual Grades 0 (no rejection) to 4 (severe rejection) were assigned based on skin color, bleeding from biopsy site, and blister formation. Histologic Grades 0 to 4 were assigned based on the degree of vasculitis, folliculitis, dermal inflammation, and epidermal degeneration present. Results. All Group I animals progressively rejected their graft by Day 7. Group II grafts survived from 19 and 90 days; 93% of 115 biopsy specimens were read to be within ±1 histologic score of their assigned flap visual grade. Visual assessment carried an 8% false positive and 39% false negative rate with regard to biopsy-proven rejection. However, 81% of missed rejection specimens were histologic Grade 1. Biopsy, when visually indicated, would detect all rejection episodes when histologically Grade 1 or 2 and still potentially reversible. Conclusions. Visual scoring of CTA skin serves as a useful tool for initially detecting rejection, but repeated histologic evaluation is necessary for monitoring the subsequent course of the graft.

Original languageEnglish (US)
Pages (from-to)1-8
Number of pages8
JournalJournal of Surgical Research
Issue number1
StatePublished - Jul 1999
Externally publishedYes


  • Composite tissue allograft
  • Cyclosporin A
  • Mycophenolate mofetil
  • Skin rejection
  • Swine

ASJC Scopus subject areas

  • Surgery


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