Vascularised composite allotransplantation (VCA) has an evolving role in the reconstruction of complex functional and aesthetic deficits non-amenable to autologous or implant-based reconstructive modalities. International applications of VCA span upper extremity, face, abdominal wall, uterus, and penile transplantation, with more than 300 procedures performed worldwide. Among these, abdominal wall transplantation has uniquely contributed to the development of the sentinel skin flap (SSF) concept, in which solid organ transplant patients undergo simultaneous transplantation of a solid organ and a donor-derived vascularised skin flap, with the skin component of the SSF being trialled internationally as a means of monitoring for rejection within the solid organ allograft. Despite growing clinical success, VCA continues to face substantial barriers to wider adoption. Acute rejection remains highly prevalent, affecting up to 89% of recipients, with significant morbidity linked to intensive systemic immunosuppression. Challenges are further amplified by the unique immunological heterogeneity of composite grafts, ethical concerns surrounding identity-linked tissues, and the lack of standardised outcomes reporting across VCA subtypes. Advances in machine perfusion technologies and emerging cellular and biomaterial-based immunomodulation strategies show promise in reducing immunosuppression burden and improving graft longevity. This review outlines the current state of VCA, including clinical applications, outcomes, and mechanistic insights from pre-clinical studies, while highlighting key ethical considerations and evolving regulatory frameworks. Future progress will depend on standardised reporting systems, improved donor–recipient matching, better understanding of ischemia–reperfusion injury, and the development of next-generation immunosuppressive/immuno-modulatory therapies. Collectively, these innovations position VCA as a rapidly advancing field with significant potential to redefine reconstructive and transplant surgery.

Acral melanoma (AM) is a rare, biologically distinct melanoma subtype arising on the palms, soles, and nail apparatus that is frequently diagnosed late and carries a worse prognosis than non-acral cutaneous melanoma. Population-specific AM data remain limited outside North America and East Asia, and Ireland’s comparatively homogeneous population has not previously been described. We performed a retrospective, bi-institutional cohort study of 41 AM patients treated at two Dublin tertiary referral centres (2017–2023), using data from prospectively maintained melanoma databases, medical records, and pathology reports. Patients were predominantly older adults (median age 73, range 39–88) with a long delay before presentation: 80.5% reported an enlarging lesion for six months or more before seeking care. Lesions were predominantly located on the foot (73.2%), and acral lentiginous melanoma was the predominant histological subtype (82.9%). Median Breslow Thickness was 3.0 mm, and 75.6% presented with T stage ≥ 3. Amputation was required in 65.9% of patients to achieve adequate margins, 47.4% of those assessed had confirmed nodal disease, and 36.6% developed recurrence. Mutation testing, performed in a subset of tumours, identified BRAF, NRAS, and KIT alterations in a minority of cases, with a substantial proportion classified as triple-wild-type. Despite Ireland’s unique germline background reported in cutaneous melanoma, this Irish cohort’s mutational profile and advanced stage at presentation were broadly consistent with international cohorts. Earlier clinical recognition, standardised nail-unit biopsy technique, and a national melanoma registry could improve outcomes for this rare, high-risk subtype.