Upper limb amputations are a real medical and surgical challenge. The ideal treatment should restore function, sensation, and body image. At present, neither traditional reconstructions nor prostheses meet all these criteria. However, Vascularized Composite Allografts (VCA) offers a unique option for restoring form and function satisfactorily despite harmful immunosuppression.

This protocol presents a systematized procedure for harvesting a vascularized forearm composite allograft to ensure optimal results and minimize tissue damage during harvesting.

A circumferential incision is made halfway up the shark's mouth arm, and then the brachial artery and vein, median, ulnar, and radial nerve are located and dissected. The biceps, brachioradialis, and triceps muscles are isolated and sectioned, and then an osteotomy of the humerus is performed a few centimeters above the elbow.

The brachial artery is cannulated, and the graft is irrigated with a preservative solution until a clear venous return is obtained. Preparation of the graft then begins with two incisions, anterior and posterior, to raise two lateral skin flaps. A medial skin flap exposes the basilic vein, medial ante-brachial cutaneous nerve, medial epicondylar muscles, ulnar nerve, median nerve, brachial artery, and vein. A lateral skin flap, including the cephalic vein, the lateral ante-brachial cutaneous nerve, the radial nerve up to its division, the brachioradialis muscle, and the lateral epicondylar, completes graft preparation.

This article outlines a surgical protocol for forearm transplantation, emphasizing key steps such as precise skin flap planning to avoid excess tissue and ensure distal perfusion. Targeted nerve anastomosis is recommended to minimize axonal loss and reduce reinnervation distance. Two procurement methods are compared: the MGH method, which reduces ischemia time but is logistically complex, and the faster Penn “cut and run” method, which starts ischemia earlier. The level of amputation influences nerve and muscle dissection strategies. Graft preparation differs by level, affecting function and reinnervation time. The protocol is based on cadaveric studies and requires adaptation for clinical use.

Intraoperative optimizations for nerves, vessels, and lymphatics repair will be discussed to enhance the functional result.

This protocol provides a forearm graft ready to be transplanted.