International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer.

BACKGROUND: In recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines. METHODS: This retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively. RESULTS: In the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU-LOS) were 20 days (range 7-79) and 6 days (range 1-32), and in the ERAS group 13 days (range 3-70) and 5 days (range 1-24), respectively. Both LOS (p < 0.001) and ICU-LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery. CONCLUSIONS: We found reduced LOS, ICU-LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

The Second Helsinki Face Transplantation and the World Experience of Revision Surgery During the First Posttransplantation Year.

INTRODUCTION: We conducted a review of all surgical interventions performed during the first postoperative year in published face transplantation (FT) cases. In addition, we herein present our second FT patient, a full-face composite FT with an emphasis on surgical revisions after transplantation. MATERIALS AND METHODS: A literature review was conducted and resulted in 376 publications of which 33 included reference to surgical interventions during the first post-FT year. For our second FT patient, a thorough review of all medical records was performed. RESULTS: Among the first 41 FTs, 32 FT patients had reports with reference to corrective surgery during the first year (22 composite and 10 soft-tissue FTs). Soft-tissue FTs had a median of 2 procedures (range, 1-8 procedures), and composite FTs, 3 procedures per patient (range, 1-9 procedures). Nearly all early interventions (<1 month) were performed in composite FT patients (anastomotic occlusion, hematoma, sialocele, palatinal dehiscence). The most common late interventions were scar corrections, tissue suspensions, periorbital corrections, osseal and dental procedures, and interventions for palatinal dehiscence and sialocele. Our second FT patient has recovered well and has undergone 3 surgical interventions during the first year. CONCLUSIONS: Surgical interventions are very common during the first postoperative year after FT, and composite FTs are more prone to complications necessitating surgical intervention than soft-tissue FTs. There is a wide variety of complications reflecting the heterogeneity of FT allografts. Corrective surgery in FT patients appears safe with only a few reported complications.

Olfactory and gustatory functions after free flap reconstruction and radiotherapy for oral and pharyngeal cancer: a prospective follow-up study.

BACKGROUND: The senses of smell and taste can be adversely affected by both tumour- and treatment-related factors amongst head and neck cancer patients. The consequences may negatively impact nutritional status as well as quality of life in this patient population. PATIENTS AND METHODS: This prospective longitudinal follow-up study is consisted of 44 patients treated for oral cavity, oropharyngeal or hypopharyngeal cancer with tumour resection and microvascular free tissue transfer reconstruction at the Helsinki University Hospital, Helsinki, Finland. Thirty-nine (89%) of them also received radiotherapy. The senses of smell (odour detection, identification and threshold test) and taste (electrogustometry) and quality of life (UW-QOL) were evaluated preoperatively, and at 6 weeks, 3 months, 6 months and 12 months, postoperatively. RESULTS: There were higher scores in the odour detection values in the 6-week and 3-month tests compared with preoperative values for the tumour side. Other detection scores did not differ statistically from the preoperative values neither in the tumour nor the contralateral side. However, in the odour identification test, all posttreatment values were statistically significantly higher than pretreatment ones. In the olfactory threshold test, no statistically significant differences were found between pre- and posttreatment values. Electrogustometry values for the taste on the tumour side were statistically significantly impaired at 6 weeks (p < 0.05) and at 3 months (p < 0.01) compared with the pretreatment results. They were also impaired at 6 months and at 12 months, although the differences were not statistically significant. The quality of life was impaired after treatment in this patient series. However, the correlation between quality of life and sense of taste was found only at one time point (3 months) and only with contralateral side measurements. CONCLUSIONS: We conclude that in oral and pharyngeal cancer patients the postoperative taste problems are related to the impairment on the taste sensation in the tongue but not with the sense of smell. Moreover, the impairment in the quality of life is not clearly related to the impaired sense of taste.

More than just the helix: A series of free flaps from the ear.

AIM: We herein present our experience using free flaps harvested from the ear region in facial, nasal and intraoral reconstruction. PATIENTS AND METHODS: Between 2011 and 2016, 19 patients underwent reconstruction using 20 free flaps from the ear region based on the superficial temporal vessels. There were 10 males and 9 females with a mean age of 57 years. Defect aetiology consisted of post-tumour ablation (n = 15), trauma (n = 2) and burn scar (n = 2). Defect location involved the nose (n = 13), floor of mouth (n = 3), tongue (n = 1), lower eyelid (n = 1), and lower lip (n = 1). RESULTS: Twelve helical, seven temporal artery posterior auricular skin (TAPAS), and one hemiauricular flap were performed. One patient required venous re-anastomosis but complete flap necrosis eventually occurred. This patient later underwent successful contralateral helix flap reconstruction. Overall flap survival was 95%. Follow-up ranged from 12 to 69 months. A moderate to excellent aesthetic and functional outcome was achieved in all cases, but most (13/19) required later minor refinement surgery. CONCLUSION: As a versatile source of free flap options, the ear can provide more than just the helix.

Free temporal artery posterior auricular skin (TAPAS) flap: A new option in facial and intra-oral reconstruction.

BACKGROUND: There is a limited availability of suitable microvascular free flap options for the reconstruction of small to medium-sized facial and intraoral defects. The purpose of this report is to present a new free temporal artery based posterior auricular skin (TAPAS) flap in facial and intraoral reconstruction. PATIENTS AND METHODS: Four patients were deemed suitable for TAPAS flap reconstruction and consisted of two males and two females with a mean age of 43 years (range 22-66). Defect aetiology and location comprised of post-traumatic lower eyelid scarring, late lower lip scarring post tumour resection, and floor of mouth and tongue defects following tumour resection. The dimensions of the resultant defects ranged from 25 × 50 mm (smallest) to 40 × 70 mm (largest). All patients underwent microvascular reconstruction using a free fasciocutaneous TAPAS flap raised from the retroauricular region based on the superficial temporal vessels. RESULTS: The maximal pedicle length was 60 mm and the maximum flap size measured 40 mm by 70 mm. The latter patient required skin grafting of the postauricular donor site. Postoperatively, there was one case of mild transient venous congestion that spontaneously resolved after 2 days and one case of minor partial flap dehiscence that required re-suturing. Follow-up time ranged from 6 to 14 months. Overall, all flaps survived with good aesthetic and functional outcome. CONCLUSION: The TAPAS flap is a small flap with exceptional qualities and may be a useful addition to the armamentarium of free flaps in facial and oral reconstructions. © 2016 Wiley Periodicals, Inc. Microsurgery 37:525-530, 2017.

Paraumbilical perforator flap for reconstruction of the external auditory meatus: A case report.

We herein present a technique of using the umbilical stalk for reconstruction of the external auditory meatus. A 49-year-old female presented with locally aggressive melanoma affecting her mastoid region. She underwent radical excision including the skin and soft tissues around the external ear with simultaneous lymph node clearance. The resultant defect measured 15 cm × 8 cm in diameter and was 2.5 cm deep. This was reconstructed with a similarly sized microvascular paraumbilical perforator flap that included the umbilical stalk. In the post-operative course there was complete flap survival but a prolonged wound dehiscence near the auditory meatus that required revision surgery. At 15-months follow-up, the patient was melanoma-free and the auditory meatus was patent. Hearing was also preserved. The umbilical stalk is one of the few skin covered tubed structures in the human body that may be used without major donor morbidity to "replace like with like," the auditory channel.

Finnish translation, validation, and reproducibility of BREAST-Q modules relevant to breast cancer treatment.

BACKGROUND AND OBJECTIVE: Breast cancer and its treatments can have a marked impact on the patient health-related quality of life. The aim of this study was to produce and validate Finnish versions of the breast-conserving treatment, mastectomy and breast reconstruction modules of the BREAST-Q, a patient-reported outcome tool designed specifically for women undergoing treatment for breast cancer. METHODS: The relevant BREAST-Q modules were translated to Finnish according to established guidelines. Altogether 777 preoperative women were recruited at the Breast Surgery Unit and the Plastic Surgery Unit of Helsinki University Hospital between December 2019 and March 2021. This included 541 patients scheduled for breast-conserving surgery, 86 for mastectomy, and 150 for breast reconstruction. Postoperative patients were recruited through a postal survey, approaching 500 women operated for breast cancer in 2017, including 250 women who had undergone breast-conserving surgery and 250 women who had undergone mastectomy, as well as 339 women who had undergone breast reconstruction between August 2017 and July 2019. The patients were invited to fill the BREAST-Q modules relevant to their treatment and the general health-related quality-of-life instrument SF-36. A repeat administration of the BREAST-Q was done 2 weeks later. RESULTS: A total of 665 (41%) women participated in the study, 339 (44%) preoperatively and 326 (39%) postoperatively. The BREAST-Q subscales showed high internal consistency with most Cronbach's alphas > 0.8. The repeatability of the subscales was excellent with most intra-class correlation coefficients > 0.75. Low or negligible correlation was observed between BREAST-Q subscales and SF-36 domains. CONCLUSIONS: The Finnish version of the BREAST-Q modules breast-conserving treatment, mastectomy, and breast reconstruction performs well in assessing the health-related quality of life of women undergoing surgery for breast cancer or breast reconstruction.

Translation of SCAR-Q into Finnish and psychometric validation of the Finnish version.

BACKGROUND: An effective patient-reported outcome measure for scars is needed to assess scar treatments and thus improve scar management. The recently developed SCAR-Q questionnaire for all scar types, which consists of the Appearance, Symptom, and Psychosocial impact scales, has been developed with patients' input. The aim of this study was to translate the SCAR-Q into Finnish and to assess its psychometric properties in burn patients. METHODS: The translation protocol followed the International Society for Pharmacoeconomics and Outcomes Research guidelines. Participants for the psychometric validation of the Finnish SCAR-Q were adults with deep second or third degree burns treated with skin grafting in the Helsinki Burn Centre between 2006 and 2017. Internal consistency was assessed by using Crohnbach's alpha and reliability by using ICC, SEM, R values, and Mann-Whitney U-test. The internal structure of each SCAR-Q subscale was investigated by using exploratory factor analysis. RESULTS: 190 burn patients participated in the psychometric validation of the Finnish SCAR-Q. 135 (71.1 %) of the participants were male. Ceiling effect was present in all subscales. Internal consistency was excellent with all subscales, Crohnbach's alpha 0.97, 0.91, and 0.94. Reliability was good in all subscales, ICC 0.84, 0.88, and 0.91. The parallel analysis suggested inclusion of one factor into factor analysis for the Appearance scale and the Psychosocial impact scale, whereas two factors for the Symptom scale. CONCLUSION: The Finnish version of the SCAR-Q is equivalent with the original scale, showed excellent internal consistency, factor analysis confirmed it for the Appearance and Psychosocial impact scale, and demonstrated good reliability with all subscales when used in assessing burn scars.

Effect of delayed autologous breast reconstruction on breast cancer recurrence and survival.

BACKGROUND: The goal of the present study was to evaluate the impact of delayed autologous breast reconstruction on disease relapse in breast cancer patients treated with mastectomy. MATERIAL AND METHODS: The study was based on 503 consecutive patients younger than 70 years of age who underwent mastectomy between January 2000 and December 2003. Overall, 391 (78 %) received mastectomy alone and 112 (22 %) underwent a delayed breast reconstruction. The median time from mastectomy to delayed breast reconstruction was 34 months. The median duration of follow-up was 102 months. RESULTS: There were no locoregional recurrences (LRR) in patients who underwent delayed reconstruction (0.0 %); 21 LRR developed in patients treated with mastectomy only (5.4 %), P = 0.011. Distant metastases occurred less frequently in the reconstruction group (12.5 %) than in the patients who underwent mastectomy alone (21.5 %); P = 0.0343. The 8-year breast cancer specific survival in the reconstruction group was 98.2 and 85.7 % for the mastectomy only group, P = 0.000. CONCLUSIONS: Delayed autologous breast reconstruction does not appear to adversely influence disease progression when compared to patients treated with mastectomy only.

Sauna contact burns in adults in the Helsinki Burn Centre during 2006-2018.

INTRODUCTION: Within Finish culture is a strong tradition of sauna bathing. This special environment predisposes the persons refreshing in the sauna to different kind of burns with varying etiologies. Despite the high prevalence of sauna related burns in Finland, there is paucity on the sauna related burns literature. METHODS: In this 13-year retrospective study, all sauna-related contact burns in the adult population treated at the Helsinki Burn Centre were analyzed. Altogether 216 patients were included in this study. RESULTS: The incidence of sauna-related contact burns was significantly higher in males; they accounted for 71.8% of patients. In addition to male gender, another risk factor was high age, with the elderly also being more prone to have a longer length of stay in hospital and more often receiving operative treatment. Despite most burns being relatively small, they were deep and more than one-third (36.6%) of patients underwent surgery. A strong seasonal variation in the injuries was recorded; over 40% of the burns took place during the summer months. CONCLUSION: Sauna contact burns are common, and despite their small size, they frequently cause deep injuries indicating operative treatment. There is a clear male predominance in the patient population. Most probably the cultural aspects of sauna bathing at summer cottages explain the strong seasonal variation in the incidence of these burns. The long latency between initial injury and presentation at the Helsinki Burn Centre should be highlighted to health care centres and central hospitals.

Translation and validation of a Finnish version of the Facial Clinimetric Evaluation (FaCE) Scale.

BACKGROUND: The Facial Clinimetric Evaluation (FaCE) scale is a patient-reported health status instrument developed for assessing the health-related quality of life (HRQoL) in patients with facial nerve paralysis. The aim of this study was to translate and validate the FaCE scale for the Finnish-speaking population. METHODS: The FaCE scale was translated according to international guidelines. Sixty patients in an outpatient clinic prospectively completed the translated FaCE scale and generic HRQoL instrument (15D). The objective facial paralysis grading was made using the Sunnybrook and House-Brackmann scales. Repeated FaCE and 15D instruments were mailed to patients 2 weeks later. Total scores of the FaCE instrument and subscales were calculated, and floor and ceiling effects were examined. Exploratory factor analysis was made. Internal consistency, reliability, and repeatability were assessed. Convergence with 15D instrument, Sunnybrook, and House-Brackmann scales was examined. RESULTS: The total internal consistency of the FaCE scale was high (Cronbach's alpha 0.83). There were no statistically significant differences found between mean scores of the subscales in test-retest analysis (p > 0.05). Intra-class correlations coefficients were high, ranging between 0.78 and 0.92, and the correlations were statistically significant (p < 0.001). There were statistically significant correlations observed between the FaCE scale and the 15D, Sunnybrook, and House-Brackmann scores. CONCLUSION: The FaCE scale was successfully translated and validated in Finnish with good validity and reliability. We also demonstrated statistically significant correlations between the generic HRQoL15D instrument and both the Sunnybrook and House-Brackmann physician-based grading scales. The FaCE scale is now ready for use in Finnish facial paralysis patients.

Translation and psychometric validation of the Finnish version of the Patient Scar Assessment Scale for use in patients with burn scars.

BACKGROUND: The aim of this study was to create a Finnish scar assessment scale by translating and evaluating the psychometric properties of the Patient Scar Assessment Scale (PSAS), a part of the Patient and Observer Scar Assessment Scale (POSAS), with burn patients to enable its use in burn care. METHODS: The translation process followed international guidelines with forward and backward translations and cognitive debriefing with patients. Psychometric validation was performed with adult patients with burns who had been treated at the Helsinki Burn Centre between 2006 and 2017 with skin grafting following the excision of deep second- or third-degree burns. To ensure reproducibility, the PSAS was sent to the study participants twice. The correlation between the PSAS and health-related quality of life (HRQL) was also tested. RESULTS: In total, 192 patients, of whom 71 % were male, participated in this study. The mean (SD) age of the participants was 57 (17) years. The internal consistency of the PSAS was good, Cronbach's α 0.89 (95 % CI: 0.86-0.91). The reproducibility was also good concerning all items and the total score, ICC from 0.77 to 0.89. As expected, the total PSAS score correlated negatively with HRQL. CONCLUSION: The PSAS was successfully translated and culturally adapted into Finnish and the newly translated version has good validity and reproducibility for assessing mature burn scars.

Comprehensive outcome analysis in two composite face transplants in Helsinki: Have we succeeded?

INTRODUCTION: There is a need to define what is success after face transplantation (FT). We have previously created a four-component criteria tool to define indications for FT. In this study, we used the same criteria to evaluate the overall outcome of our first two patients after FT. PATIENTS AND METHODS: Preoperative analysis of our two bimaxillary FT patients was compared to the results at four and six years post-transplantation. The facial deficiency impact was divided into four categories: (1) anatomical regions, (2) facial functions (mimic muscles, sensation, oral functions, speech, breathing, periorbital functions), (3) esthetics, and (4) impact on health-related quality of life (HRQoL). Immunological status and complications were also evaluated. RESULTS: For both patients, near-normal anatomical restoration of almost all the facial regions (except the periorbital and intraoral regions) was achieved. The majority of the facial function parameters improved in both patients (patient 2 to a near-normal level). The esthetic score improved from severely disfigured to impaired (patient 1) and to near to normal (patient 2). Quality of life was severely lowered prior to FT and improved after FT but was still affected. Neither patient has experienced acute rejection episodes during follow-up. CONCLUSIONS: We conclude that our patients have benefitted from FT, and we have succeeded. Time will reveal whether we have achieved long-term success.

Facial Expression after Face Transplant: An International Face Transplant Cohort Comparison.

BACKGROUND: Assessment of motor function restoration following face transplant (FT) is difficult, as standardized, bilateral tests are lacking. This study aims to bolster support for software-based analysis through international collaboration. METHODS: FaceReader (Noldus, Wageningen, The Netherlands), a facial expression analysis software, was used to analyze posttransplant videos of eight FT patients from Boston, Massachusetts (range, 1 to 9 years after transplant), two FT patients from Helsinki, Finland (range, 3 to 4 years after transplant), and three FT patients from Antalya, Turkey (range, 6.5 to 8.5 years after transplant). Age-matched healthy controls from respective countries had no history of prior facial procedures. Videos contained patients and controls performing facial expressions evaluated by software analysis using the Facial Action Coding System. Facial movements were assigned intensity score values between 0 (absent) and 1 (fully present). Maximum values were compared with respective healthy controls to calculate percentage restoration. RESULTS: Of 13 FT patients, eight patients were full FT, five patients were partial FT, and two patients were female patients. Compared with healthy controls, the median restoration of motor function was 36.9% (interquartile range, 28.8% to 52.9%) for all patients with FT ( P = 0.151). The median restoration of smile was 37.2% (interquartile range, 31.5% to 52.7%) for all patients with FT ( P = 0.065). When facial nerve coaptation was performed at the distal branch level, average motor function restoration was 42.7% ± 3.61% compared with 27.9% ± 6.71% at the proximal trunk coaptation level ( P = 0.032). Use of interpositional nerve grafts had no influence on motor outcomes. CONCLUSIONS: Software-based analysis is suitable to assess motor function after FT. International collaboration strengthens outcome data for FT. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Validation of the Finnish FACE-Q for use in patients undergoing surgery for functional problems or malignancy.

The aim of this study was to produce a Finnish version of the FACE-Q scales Satisfaction with Forehead and Eyebrows, Adverse effects: Forehead, Eyebrows and Scalp, and Adverse effects: Cheeks, Lower face and Neck, and assess the performance of these scales and the Satisfaction with Facial Appearance, Satisfaction with Outcome and Appearance-related Psychosocial Distress in patients who had undergone surgery for functional problems or malignancy affecting the forehead or cheeks. The general health-related outcomes instrument 15 D was used as a reference. Patients who had undergone a frontal lift, a direct brow lift, a facelift or an excision of a facial tumor in Helsinki University Hospital plastic surgery department in 2009-2019 were identified. A postal survey study was conducted with 305 patients, of whom 135 (44%) responded. Diagnoses included facial nerve dysfunction (53%), brow ptosis (21%) and skin, mucosal or salivary gland tumor (20%). The FACE-Q scales displayed high internal consistency (Cronbach's alphas ≥0.80) and good reliability on repeat administration. The exploratory factor analysis revealed unifactorial influences for all scales except the Adverse effects: Forehead, Eyebrows and Scalp. Weak correlations with 15 D dimensions were detected. The FACE-Q scales evaluated here are suitable for use in patients with functional problems or malignancy.

The four category systematic approach for selecting patients for face transplantation.

There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Ten patients with severe facial defects treated between 1995 and 2017 formed the study group. Data was collected from patient charts and clinical, radiological and laboratory examinations. Facial deficiencies were subdivided into four different categories: anatomical region (10 facial subunits), facial function, aesthetic defect (range 0-9-worst), and impact on health-related quality of life (HRQoL) (15D questionnaire, range 0-1). Immunological status and possible contraindications were also evaluated. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 to 10 injured facial subunits. All patients had at least partial loss of facial function. The mean aesthetic disfigurement score was 6.4. The median lowering of 15D score was -0.107. None were significantly sensitized although four patients had relative contraindications and one patient had an absolute contraindication for FT. Three patients with a severe overall facial deficiency were considered as potential FT candidates. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of 4 key categories: anatomical regions affected, facial function, aesthetics, and HRQoL.

Virtual 3D planning and prediction accuracy in two bimaxillary face transplantations in Helsinki.

BACKGROUND: The aim of this study was to describe the 3D planning process used in our two composite face transplantations and to analyze the accuracy of a virtual transplantation in predicting the end-result of face transplantation. METHODS: The study material consists of two bimaxillary composite face transplantations performed in the Helsinki University Hospital in 2016 and 2018. Computed tomography (CT) scans of the recipient and donor were used to define the osteotomy lines and perform the virtual face transplantation and to 3D print customized osteotomy guides for recipient and donor. Differences between cephalometric linear and angular measurements of the virtually simulated and the actual postoperative face transplantation were calculated. RESULTS: No changes to the planned osteotomy lines were needed during surgery. The differences in skeletal linear and angular measurements of the virtually simulated predictions and the actual postoperative face transplantations of the two patients varied between 0.1-5.6 mm and 0.7°-4°. The postoperative skeletal relationship between maxilla and mandible in both patients were almost identical in comparison to the predictions. CONCLUSIONS: 3D planning is feasible and provides close to accurate bone reconstruction in face transplantation. Preoperative virtual transplantation assists planning and improves the outcome in bimaxillary face transplantation.