Incidence of Venous Thromboembolism Based on Caprini Score in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction. METHODS: This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE. RESULTS: This study included 524 patients (mean age 51.2 ± 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001). CONCLUSION: In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Oncologic safety of axillary lymph node dissection with immediate lymphatic reconstruction.

PURPOSE: Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates. METHODS: Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed. RESULTS: A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9 months (range 6-63 months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified. CONCLUSION: Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.

Breast Implant-Related Outcomes After Cardiothoracic Surgeries and Electrophysiologic Procedures.

BACKGROUND: Outcomes related to preexisting breast implants after cardiothoracic procedures are poorly characterized. This study evaluated complications after minimally invasive cardiac surgery (MICS), median sternotomy (MS), and electrophysiologic procedures (EP) in patients with preexisting breast implants. METHODS: A retrospective review of patients with prior breast implants who underwent MICS, MS, or EP from 1994 to 2019 was performed. Demographic, treatment, and outcome characteristics were recorded. χ 2 Test and analysis of variance were used to perform statistical comparisons. RESULTS: In total, 78 patients (37 MICS, 21 MS, and 20 EP) were identified. Mean breast implant age was 13.3, 11.7, and 10.2 years, respectively ( P = 0.235). Intraoperative plastic surgeon involvement was present in 26 (70.3%) MICS cases, compared with 2 (9.5%) MS and 0% EP ( P < 0.001). Intraoperative rupture occurred in 5 (13.5%) MICS cases and no MS or EP cases ( P < 0.001). Postoperative implant complications occurred in 6 (16.2%) MICS, 8 (38.1%) MS, and 5 (25.0%) EP ( P = 0.350) cases, with median time to complication of 5.9, 5.4, and 38.9 months, respectively ( P = 0.596). Revision surgery was performed in 5 (13.5%) MICS, 7 (33.3%) MS, and 5 (25.0%) EP ( P = 0.246) cases. On multivariate analysis, lack of intraoperative plastic surgeon involvement ( P = 0.034) and breast implant age ( P = 0.001) were significant predictors of postoperative complications. CONCLUSIONS: Long-term complication rates are highest among patients with breast implants undergoing MS. Plastic surgeon involvement was significantly associated with fewer postoperative complications. Our results support a multidisciplinary approach to managing breast implants during cardiothoracic procedures.

Youngest Composite Full-Face Transplant: A Model for Vascularized Composite Allograft in Younger Populations.

BACKGROUND: The field of face transplantation continues to evolve, with more complex defects being addressed, and, at the same time, increased outcome expectations. Given our unique long-term experience in this field, we consented one of the youngest patients to undergo a full-face transplant. METHODS: An 18-year-old woman presented with complete destruction of her central face and craniofacial structures. She had coexisting major injuries, including pituitary gland, visual axis, and motor control. After extensive rehabilitation and reconstruction techniques, the patient underwent face transplant on May 4, 2017, at the age of 21 years. RESULTS: The total operative time for the recipient was 26 hours. There were no major perioperative complications. Since transplant, the patient has undergone 3 revision surgeries. She is near completely independent from a daily life activity standpoint. She has had 1 episode of rejection above grade II that was successfully treated with a short-term increased in immunosuppression. CONCLUSIONS: Contrary to data in solid organ transplantation where youth is associated with increased risk of rejection, our current algorithm in immunosuppression, combined with this patient's compliance, has led to only 1 rejection episode beyond grade II. This successful transplant can serve as a model for future vascularized composite transplants in younger populations.

Maxillary and Mandibular Healing After Facial Allotransplantation.

INTRODUCTION: Facial transplantation has emerged as a viable option in treating devastating facial injuries.Despite the high healing rate of Le Fort III and bilateral sagittal split osteotomies (BSSO) in nontransplant patients, few studies have reported assessment of maxillary and mandibular healing in face transplant patients compared with nontransplant patients. The aim of this study was to examine differences in bone healing in our patients. PATIENTS AND METHODS: A retrospective chart review was conducted of facial allotransplantation patients at the Cleveland Clinic from December 2008 to inception. Demographics such as age, date of birth, and sex were recorded. Additional variables included procedures, revisions, reoperations, medications, and bone stability and healing. Computed tomography (CT) images assessed the alignment of skeletal components, bony union quality, and stability of fixation. RESULTS: Three patients were included: 2 had Le Fort III segment transplantation, and 1 had transplantation of both a Le Fort III segment and mandibular BSSO. The Le Fort III segment in all patients exhibited mobility and fibrous union at the Le Fort III osteotomy on CT. In contrast, the BSSO healed uneventfully after transplantation and revision surgery, with bony union confirmed by both CT and histology of the fixation area between the donor and recipient mandible bilaterally. No patients with midfacial fibrous union required revision of the nonunion as they were clinically asymptomatic. CONCLUSION: Le Fort osteotomy demonstrates inferior healing in facial transplantation compared with the nontransplant population. In contrast, the successful healing in the mandible is likely owing to the high density of rich cancellous bone.

Neurotization Does not Prolong Operative Time in Free Flap Breast Reconstruction.

BACKGROUND: Neurotization during the breast reconstruction process can improve patient quality-of-life and satisfaction with reconstructive outcomes. One concern with neurotization is increased total operative time due to the need for additional dissection and nerve coaptation. The purpose of this study was to compare total operative time between neurotized and non-neurotized abdominal-based, free flap breast reconstruction. METHODS: A retrospective review was conducted of consecutive patients who underwent unilateral, abdominal-based, free flap breast reconstruction between 2016 and 2018 at a single tertiary care center. Data were collected on patient demographics, surgical techniques, and length of surgery. Data analysis was performed using chi-square test, independent t-test, and multivariate linear regression analysis. A p-value ≤0.05 was considered statistically significant. RESULTS: Seventy-three patients were included in this study. Twenty-three patients (31.50%) underwent flap neurotization (N group) and 50 (68.49%) underwent standard breast reconstruction without neurotization (NO group). The groups were similar in age, BMI, smoking status, and ASA class. No difference was found between the two groups in timing of reconstruction (p = 0.388). Average operative times were 467.73 ± 145.52 minutes and 455.28 ± 111.19 minutes for the N and NO groups, respectively, with no significant difference between the two groups (two-tailed p-value = 0.72). CONCLUSION: Seamless integration of neurotization in abdominal-based, free flap breast reconstruction is possible without significant prolongation of total operative time. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Sparing Mastectomy: Are We Providing Proper Prophylactic Antibiotic Coverage?

BACKGROUND: Infection after nipple-sparing mastectomy (NSM) and implant-based reconstruction (IBR) can be a devastating complication. The retained nipple may act as a portal or nidus for different ductal organisms, and as such, the bacteriology of surgical-site infections (SSIs) in this setting may not be adequately covered by current antibiotic recommendations. This study sought to evaluate SSI and reconstruction outcomes in relation to antibiotic choice and identify the different microbial species implicated. METHODS: A prospective database was reviewed for patients who underwent NSM with IBR from 2010 to 2019. Patient characteristics, operative details, antibiotic regimens, and subsequent treatment details were evaluated. The study analyzed SSI incidence, timing, and type of causative organisms. RESULTS: The study analyzed 571 NSMs with IBR performed for 347 patients (55% with direct implants and 45% with tissue expanders). The preoperative antibiotics consisted of cephalosporin alone for 65% of the patients, a more broad single-antibiotic use for 12% of the patients, and dual-coverage antibiotics for 20% of the patients. During a median follow-up of 1.7 years, SSI developed in 12% of the reconstructions, with 6% requiring prosthesis removal. The most common SSI organism cultured was Staphylococcal species. Neither pre- nor postoperative antibiotic choice was associated with incidence of infection, type of bacteria, or need for prosthetic explanation. CONCLUSION: For patients undergoing NSM with IBR, a more aggressive antibiotic choice is not associated with an improved SSI rate. Patient and treatment factors continue to carry the highest risk for SSI.

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction.

BACKGROUND: Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch. METHODS: Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin. RESULTS: Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps. CONCLUSIONS: This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

Lymphedema Prevention Surgery: Improved Operating Efficiency Over Time.

BACKGROUND: Lymphedema prevention surgery (LPS), which identifies, preserves, and restores lymphatic flow via lymphaticovenous bypasses (LVB), has demonstrated potential to decrease lymphedema in breast cancer patients requiring axillary lymph node dissection. Implementing this new operating technique requires additional operating room (OR) time and coordination. This study sought to evaluate the improvement of LPS technique and OR duration over time. METHODS: A prospective database of patients who underwent LPS at our institution from 2016 to 2019 was queried. Type of breast and reconstruction surgery, number of LVB performed, and OR times were collected. LPS details were compared by surgical group and year performed. RESULTS: Ninety-four patients underwent LPS, and 88 had complete OR time data available for analysis. Average age was 51 years, body mass index of 28, with an average of 15 lymph nodes removed. Reconstructive treatment groups included prosthetic reconstruction 56% (49), oncoplastic reduction 10% (9), and no reconstruction 34% (30). The number of patients undergoing LPS increased significantly from 2016 to 2019, and average number of LVB per patient doubled. In patients without reconstruction, the average time for LPS improved significantly from 212 to 87 min from 2016 to 2019 (p = 0.015) and similarly in patients undergoing LPS with prosthetic reconstruction from 238 to 160 min (p = 0.022). CONCLUSIONS: LVB is an emerging surgical lymphedema prevention technique. While requiring additional surgical time, our results show that with refinement of technique, over 4 years, we were able to perform double the number of LVB per patient in half the OR time.

Collaboration between breast and reconstructive surgery in optimizing outcomes for women with breast cancer.

Performing successful breast reconstruction after mastectomy requires communication and collaboration between the breast and reconstruction surgery teams. This allows for oncologic safety while providing esthetic and functional reconstruction. In this article, we discuss the numerous techniques we have adopted successfully into our breast reconstructive practice that were possible due to this collaboration including prophylactic lymphaticovenous bypass (LVB), tumor ultrasound-guided incision (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve identification at time of mastectomy to allow for sensate reconstruction, and the prevention of chronic pain and strategic oncoplasty.

Technical considerations in nonreconstructive mastectomy patients.

BACKGROUND: Not all women undergo post-mastectomy breast reconstruction due to medical comorbidities or personal preference. An aesthetically pleasing closure and contour of the chest wall is still desired, though may be technically difficult to achieve in some patients. By combining techniques and lessons learned from breast reductions and female-to-male mastectomies (FTTM), we present a technical approach to aesthetic primary closure post-mastectomy that can be utilized in patients regardless of preoperative breast size. METHODS: After mastectomy, excess cranial/caudal tissue is determined and the lower flap is de-epithelialized to allow for bulk in the reconstructed breast. Excess tissue in the horizontal plane is assessed, and axillary, nonbreast tissue is medialized. Excess skin in the horizontal plane is removed with a small lateral incision similar to a wise-pattern closure. RESULTS: We have performed this technique with good aesthetic results and satisfied patients postoperatively. CONCLUSION: When performing post-mastectomy closure without reconstruction, attention to tissue excess, medialization of axillary tissue and providing bulk with lateral and caudal tissue allows for an easy, reproducible, and aesthetic closure.

Characterization of Face Transplant Candidates Evaluated at Cleveland Clinic and Algorithm to Maximize Efficacy of Screening Process.

INTRODUCTION: As a high-volume referral center for facial transplantation, we have learned significantly from the screening, evaluation, and enrollment process. This report analyzes our algorithm for the assessment of potential face transplant candidates referred to our institution. METHODS: After institutional review board approval in 2004, a prospectively maintained database was created for patients who were referred face transplant. Records were reviewed for the nature of tissue defect, functional deficit, surgical and medical history, and expert recommendations.Our algorithm begins with a review of a patient's file with a focus on institutional review board criteria. After screening, a phone interview is conducted, and transplantation is discussed. Patients are presented to the team to analyze the medical, psychiatric, and surgical history; support network; and geographic location. Eligible patients are invited for an in-person evaluation, and the case is reviewed again with the team. If approved, the patient can provide consent for transplantation. RESULTS: More than 200 patients were referred for transplant evaluation at the Cleveland Clinic from 2004 to 2016. Sixty were eligible for further evaluation for face transplantation based on preliminary screening. Thirteen (6.5% of original cohort) were invited for in-person evaluation and physical examination. Five (2.5% of original cohort, 38.4% invited cohort) of these 13 patients underwent face transplantation, of whom, 3 (1.5% of original cohort, 23.1% invited cohort) underwent face transplantation at our institution. All 3 patients who were ultimately transplanted were referred by a physician. DISCUSSION: As the availability of public information on face transplant increases, it is likely that an increase in self-referral for face transplantation will occur. Thus, it is critical that institutions adopt a systematic approach to triage in order to identify appropriate patients. Our algorithm allowed for a high enrollment and transplantation ratio to save patient and institution time and resources. This could be easily adopted by other institutions to save time, money, and resources.

Factors Influencing the Aesthetic Outcome and Quality of Life After Breast Reconstruction: A Cross-sectional Study.

BACKGROUND: The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction. METHODS: Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data. RESULTS: Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R = 0.311, P < 0.001). CONCLUSIONS: The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.

Professional Burnout in United States Plastic Surgery Residents: Is It a Legitimate Concern?

BACKGROUND: Physician burnout is intimately associated with institutional losses, substance abuse, depression, suicidal ideation, medical errors, and lower patient satisfaction scores. OBJECTIVES: By directly sampling all US plastic and reconstructive surgery residents, this study examined burnout, medical errors, and program-related factors. METHODS: Cross-sectional study of data collected from current US plastic and reconstructive surgery residents at Accreditation Council for Graduate Medical Education-accredited programs during the 2018 to 2019 academic year. Previously validated survey instruments included the Stanford Professional Fulfillment and Maslach Burnout Indices. Additional data included demographics, relationship status, program-specific factors, and admission of medical errors. RESULTS: A total of 146 subjects responded. Residents from each postgraduate year (PGY) in the first 6 years were well represented. Overall burnout rate was 57.5%, and on average, all residents experienced work exhaustion and interpersonal disengagement. No relation was found between burnout and age, gender, race, relationship status, or PGY. Burnout was significantly associated with respondents who feel they matched into the wrong program, would not recommend their program to students, do not feel involved in program decisions, reported increasing hours worked in the week prior, feel that they take too much call, reported making a major medical error that could have harmed a patient, or reported making a lab error. CONCLUSIONS: This study directly examined burnout, self-reported medical errors, and program suitability in US plastic and reconstructive residents based on validated scales and suggests that burnout and some medical errors may be related to program-specific, modifiable factors, not limited to, but including, involvement in program-related decisions and call structure.

Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow.

BACKGROUND: A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). METHODS: A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. RESULTS: LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow-up of 11.8 months. CONCLUSION: We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Collaboration between the breast and plastic surgeon in restoring sensation after mastectomy.

Breast cancer is the most commonly diagnosed invasive cancer in women worldwide. While hypoesthesia is a known sequela after mastectomy, patients are now inquiring with renewed interest about the degree and timing of sensation after mastectomy. This is a topic that has generated much research interest. However, while there have been advances in the field, there are few, well-done studies that allow for an accurate answer to this question. In this article, relevant breast and donor site anatomy is reviewed for sensate autologous breast reconstruction. Additional donor sites apart from the typically utilized abdomen are analyzed with relevant anatomical discussions. Outcomes are presented; however, due to the heterogeneity of the patient population, surgical approach and postoperative sensory testing, it is difficult to compare results between studies. Future directions and unanswered questions regarding sensate autologous breast reconstruction are highlighted. While great strides have been made in providing sensate autologous breast reconstruction, there are still many unanswered questions. Thus, the collaboration between surgical teams and sharing of outcomes is crucial to allow for optimization of this powerful surgical approach.

Long-term complications and reconstruction failures in previously radiated breast cancer patients receiving salvage mastectomy with autologous reconstruction or tissue expander/implant-based reconstruction.

Salvage mastectomy (SM) is the standard of care for patients with local recurrence (LR) after breast conservation therapy (BCT), often with immediate reconstruction. Complications of reconstruction are a concern for these patients, and long-term data are limited. We sought to compare rates of complications requiring re-operation (CRR) and reconstruction failure (RF) between autologous reconstruction (AR) and tissue expander/implant reconstruction (TE/I). Patients with locally recurrent breast cancer after BCT, treated with SM and immediate AR or TE/I between 2000 and 2008, were identified. CRR was defined as unplanned return to operating room for wound infection, dehiscence, necrosis (including flap, skin, or fat), hematoma, or hernia (for AR) and extrusion, leak, or capsular contracture (for TE/I). RF was defined as conversion to another reconstruction technique or to flat chest wall. This study included 103 patients with 107 reconstructions. Median follow-up was 6.6 years. CRR and RF were significantly higher with TE/I (n = 34) compared to AR (n = 73) at 5 years (50.9% vs 25.5%; P = 0.02) and (42.1% vs 5.8%; P < 0.001). On univariate analysis (UVA), TE/I (HR = 2.14; P = 0.02) and diabetes (HR = 5.10; P = 0.007) were significant predictors for CRR. On UVA, TE/I (HR = 7.30; P < 0.001) and older age at reconstruction (HR = 1.03; P = 0.003) were significant predictors for RF. In this population of previously irradiated patients, TE/I was associated with significantly higher CRR and RF. Complications continue to occur up to 10 years after TE/I. AR should be considered in appropriately selected patients, though TE/I may remain a reasonable option in patients without high-risk factors for surgical complications.

Anatomic Targets for Breast Reconstruction Neurotization: Past Results and Future Possibilities.

The concept of providing neurotized autologous breast reconstruction is not novel, but the introduction of cadaveric nerve grafts has allowed for the development of new techniques and a resurgence in academic interest. There has been a surge in the number of publications regarding neurotized autologous breast reconstruction. However, recent articles and reviews have focused mainly on autologous, abdominal-based reconstruction. The sensory innervation of the most commonly used autologous tissues has been well described, allowing surgeons to perform accurate and reproducible dissections. However, there are numerous options for autologous breast reconstruction, and not all patients are candidates for abdominally based reconstruction. As more patients inquire to their possible reconstruction options, plastic surgeons will have to be well versed in the different neurotized options and appreciate the technical aspects associated with reconstructive success. In this review, we aim to discuss both established anatomic targets for autologous flap neurotization and future directions.

Face Transplantation for Granulomatosis With Polyangiitis (Wegener Granulomatosis): Technical Considerations, Immunological Aspects, and 3-Year Posttransplant Outcome.

BACKGROUND: We report new data for a rare face transplant performed 3 years ago. Granulomatosis with polyangiitis (GPA) (Wegener) is a severe autoimmune necrotizing vasculitis and parenchymal inflammatory disease that can affect any organ including those of the craniofacial region. Skin involvement manifests as malignant pyoderma. This account (1) highlights the technical details of face transplantation for this unique indication, (2) reports the 3-year posttransplant outcome, and (3) describes relevant immunological aspects. METHODS: A Le Fort III near-total face and near-total scalp transplant was performed after extensive trauma and subsequent bone and soft tissue infection in a patient with GPA. Incisions were planned along facial aesthetic subunits. The vascular pedicle comprised the facial and superficial temporal arteries bilaterally. The functioning left eye was preserved and fitted into the donor tissues. RESULTS: The procedure took 21 hours, and transfusion was limited to 4 units of packed red cells. Early medical and surgical complications were successfully treated. At 3 years, acceptable aesthetic outcome was achieved with adequate color match and scalp hair growth. The patient has recovered light touch, temperature, and 2-point discrimination and has evidence of symmetric cheek elevation albeit with limited eyelid and frontalis function. GPA relapse did not occur. Four acute rejections were fully reversed. CONCLUSIONS: This case represents a new underlying disease (trauma + GPA) leading to face transplantation and a unique clinical scenario where allografting was indicated for potentially life-threatening and sight-preserving reasons and not for mere functional and aesthetic concerns. Despite complexity, 3-year clinical outcome is encouraging, and the patient is no longer at risk for dural exposure, meningitis, and related morbidity.