Vascularised composite allotransplantation (VCA) includes transplantation of multiple tissues in a single vascularised unit, such as the upper limb, or most dramatically the face. Truly remarkable results have been achieved, such as the one illustrated in this article. More than 70 hand transplants have been registered internationally since 1998 and 25 partial or total facial transplants since 2005. One patient in China died two years after the transplant due to liver failure associated with Chinese traditional medicine substituted for regular immunosuppressive therapy. The other patient received both a facial transplant and also bilateral upper limb transplants and died from overwhelming infection 45 days after surgery. The most controversial component of this treatment is the necessity for patients to undergo lifelong immunosuppression postoperatively and this is discussed in this article and also in the invited comment – which also suggests that collaboration, concentrating experience in a single centre, should be a prerequisite for such procedures. The largest number of these procedures (nine) has been in France, seven of these in Paris, which takes the lead from Boston in the USA who have performed five. There is no doubt that these operations will continue to be performed and, like craniofacial procedures, the greatest success will be associated with those centres where cooperation and familiarity with the problems is greatest.