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Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.
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Fenda Labial , Fissura Palatina , Procedimentos Ortopédicos , Procedimentos de Cirurgia Plástica , Lactente , Humanos , Fenda Labial/cirurgia , Fissura Palatina/cirurgiaRESUMO
INTRODUCTION: Paravertebral block (PVB) has emerged as a viable strategy for improving postoperative outcomes in breast surgery; however, it is unclear whether these benefits extend to recipients of post-mastectomy reconstruction (PMR). METHODS: A systematic search of the PubMed, EMBASE, Web of Science and Cochrane Library electronic databases was conducted for all studies matching the a priori inclusion criteria (inception to 1 March 2017). Independent assessment by two reviewers, in stages, of the title/abstract and full text was performed. Data relating to study design, patient characteristics, PVB medications and technique, and outcomes, including pain, opioid consumption, length of stay (LOS), postoperative nausea and vomiting (PONV), and PVB-related complications was abstracted. RESULTS: Of the 1243 identified articles, nine met the inclusion criteria, accounting for 936 patients (PVB, n = 518; non-PVB, n = 418) in two randomized controlled trials (RCT) and seven retrospective cohort studies. Of these studies, six described PVB for prosthetic PMR, and three described PVB for autologous PMR. Overall, there is a subtle trend towards improved pain control, less opioid requirement and shorter LOS, while PONV was largely unchanged in patients receiving PVB for PMR. In two studies, technical failure was reported at 7.4 and 10%, although no study reported a PVB-related complication. Study quality varied, and risk of bias in the included studies was high. Heterogeneity precluded a meta-analysis. CONCLUSIONS: Although recent reports and RCTs advocate for PVB use in PMR, our review highlights significant heterogeneity and knowledge gaps that must be addressed in order for PVB to become part of the optimal anesthetic protocol in PMR.
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Neoplasias da Mama/cirurgia , Mastectomia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Procedimentos de Cirurgia Plástica , Náusea e Vômito Pós-Operatórios/prevenção & controle , Cuidados Pré-Operatórios , Feminino , Humanos , PrognósticoRESUMO
OBJECTIVE: This study was designed to examine the comparative effectiveness of oromandibular defect reconstruction via anterolateral thigh flap and bridging plate (ALT only) versus simultaneous soft tissue and vascularized bone flap (DFF), with regards to long-term plate exposure and complications. METHODS: A propensity score-matched analysis of patients with an oncologic head and neck defect who underwent microvascular reconstruction was performed. Two surgical groups, i.e., ALT only and DFF, were created. Incidence and subsequent management strategies for postoperative plate exposure were evaluated along with complications, overall survival, and postoperative quality of life (QoL). RESULTS: Sixty-two patients were 1:1 propensity matched (31 per group). The DFF group had a significantly larger soft tissue and bone defect than the single-flap group. The 5-year probability of not having a plate exposure was 45.5 and 47.4% for the double-flaps and single-flap groups, respectively (p = 0.186). The ALT-only group had a significantly higher rate of wound infections (38.7% vs. 12.9%, p = 0.02). The incidence of flap loss, reexploration, inpatient mortality, plate fracture, medical complications, and overall survival were not significantly different. Although mean score for pain was significantly worse in the ALT-only group (75.2 vs. 88.5, p < 0.001), the remainder of our QoL assessments (cosmesis, swallow, employment, and speech) were comparable. CONCLUSIONS: The utilization of an ALT with plate strategy is associated with competitive rates of plate exposure and overall survival relative to DFF but higher wound infections and long-term pain. These results have considerable salience for patient-counseling regarding expectations for functional and clinical outcomes.
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Retalhos de Tecido Biológico , Neoplasias Mandibulares/cirurgia , Reconstrução Mandibular/métodos , Neoplasias Bucais/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Pontuação de Propensão , Coxa da Perna/cirurgia , Placas Ósseas , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Qualidade de Vida , Estudos Retrospectivos , Retalhos CirúrgicosRESUMO
BACKGROUND: Ischemia-reperfusion injury remains the major limiting factor for limb replantation and transplantation. Static cold storage (SCS) on ice currently represents the standard mode of preservation but is limited to 6 h of duration. Ex vivo machine perfusion has evolved as a potential alternative to safely extend the duration of ex vivo preservation by providing continuous supply of oxygen and nutrients. This study aims to evaluate underlying molecular mechanisms of both preservation modalities. METHODS: We assessed molecular changes in amputated porcine forelimbs stored on ice at 4°C for 2 h (n = 2) and limbs perfused with Perfadex solution at 10°C for 2 h (n = 3) or 12 h (n = 3) before replantation. Muscle biopsies were examined for histological changes and gene expression levels using H&E staining and a hypoxia-related PCR gene array, respectively. RESULTS: Histology revealed only minor differences between the ice (SCS) and perfusion groups after 2 h of preservation, with decreased muscle fiber disruption in the perfusion groups compared with the ice (SCS) group. Perfused limbs demonstrated downregulation of genes coding for glycolytic pathways and glucose transporters after 2 h and 12 h when compared with SCS after 2 h. Similarly, genes that induce angiogenesis and those that are activated on DNA damage were downregulated in both perfusion groups as compared with SCS. CONCLUSIONS: Perfusion of porcine limbs resulted in less activation of hypoxia-related gene families when compared with SCS. This may indicate a state more closely resembling physiological conditions during perfusion and potentially limiting ischemic injury. Our study confirms ex vivo perfusion for up to 12 h as a viable alternative for preservation of vascularized composite tissues.
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Extremidades/cirurgia , Hipóxia/metabolismo , Preservação de Órgãos , Reimplante , Animais , Temperatura Baixa , Dano ao DNA , Feminino , Glucose/metabolismo , Perfusão , Suínos , Transcriptoma , Fator A de Crescimento do Endotélio Vascular/genéticaRESUMO
BACKGROUND: Inadequate anatomic knowledge has been cited as a major contributor to declining surgical resident operative competence. We analyzed the impact of a comprehensive, procedurally oriented cadaveric procedural anatomy dissection laboratory on the operative performance of surgery residents, hypothesizing that trainees' performance of surgical procedures would improve after such a dissection course. MATERIALS AND METHODS: Midlevel general surgery residents (n = 9) participated in an 8 wk, 16-h surgery faculty-led procedurally oriented cadaver simulation course. Both before and after completion of the course, residents participated in a practical examination, in which they were randomized to perform one of nine Surgical Council on Resident Education-designated "essential" procedures. The procedures were recorded using wearable video technology. Videos were deidentified before evaluation by six faculty raters blinded to examinee and whether performances occurred before or after an examinee had taken the course. Raters used the validated Operative Performance Rating System and Objective Structured Assessment of Technical Skill scales. RESULTS: After the course residents had higher procedure-specific scores (median, 4.0 versus 2.4, P < 0.0001), instrument-handling (4.0 versus 3.0, P = 0.006), respect for tissue (4.0 versus 3.0, P = 0.0004), time and motion (3.0 versus 2.0, P = 0.0007), operation flow (3.0 versus 2.0, P = 0.0005), procedural knowledge (4.0 versus 2.0, P = 0.0001), and overall performance scores (4.0 versus 2.0, P < 0.0001). Operative Performance Rating System and Objective Structured Assessment of Technical Skill scales averaged by number of items in each were also higher (3.2 versus 2.0, P = 0.0002 and 3.1 versus 2.2, P = 0.002, respectively). CONCLUSIONS: A cadaveric procedural anatomy simulation course covering a broad range of open general surgery procedures was associated with significant improvements in trainees' operative performance.
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Anatomia/educação , Cirurgia Geral/educação , Treinamento por Simulação , Cadáver , Competência Clínica , Humanos , Gravação em VídeoRESUMO
BACKGROUND: Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation. METHODS: We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes. RESULTS: Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant. CONCLUSIONS: Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.
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Transplante de Face/efeitos adversos , Procedimentos de Cirurgia Plástica , Complicações Pós-Operatórias , Trismo , Adulto , Face/fisiopatologia , Face/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Amplitude de Movimento Articular , Trismo/etiologia , Trismo/fisiopatologia , Trismo/cirurgia , Ferimentos por Arma de FogoRESUMO
PURPOSE: To date, there have been over 100 upper extremity transplantations (UET) performed worldwide. However, little data are available regarding institutional screening practices or description of the population of patients that seek transplantation as a treatment modality for their upper extremity disabilities. We performed a review of our institutional experience in an attempt to better understand our referral patterns and identify factors that may be associated with successful screening. METHODS: Contact demographic data, injury characteristics, and mode of referral were retrospectively reviewed from 2010 through 2015. Differences in demographic data, injury-related characteristics, and clinical trial outcomes were assessed with the Chi-square test or Fisher exact test. RESULTS: There were a total of 89 UET contacts. The average age was 35.2 years, with most contacts being white (n = 24). The majority were male (n = 66; 75.0%) and the most common indication for referral was trauma (n = 43; 55.8%). Of the 89 contacts, 20 (22.5%) were physician referrals and 69 (77.5%) were self-referrals. Physician referrals led to the most screened and accepted contacts, whereas self-referrals more often led to immediate exclusion. CONCLUSIONS: This study gives an overview of the demographic composition of our UET contacts, with a specific emphasis on mode of referral. We have identified that physician referrals have led to more screened and accepted patients versus self-referred individuals. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.
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Braço/transplante , Transplante de Mão , Encaminhamento e Consulta , Centros Médicos Acadêmicos , Adolescente , Adulto , Distribuição por Idade , Traumatismos do Braço/etnologia , Traumatismos do Braço/cirurgia , Boston , Feminino , Traumatismos da Mão/etnologia , Traumatismos da Mão/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Distribuição por Sexo , Adulto JovemRESUMO
BACKGROUND: Inadequate anatomy training has been cited as a major contributor to declines in surgical resident operative competence and confidence. We report the impact of a procedurally oriented general surgery cadaveric dissection course on trainee-operative confidence and competence. MATERIALS AND METHODS: After obtaining institutional review board approval, postgraduate year 2 and 3 general surgery residents were prospectively enrolled into two cohorts: (1) an intervention group (n = 7) participating in an 8-wk procedurally oriented cadaver course and (2) controls (n = 7) given access to course materials without participation in cadaver dissection. At both the beginning and end of the study, we used two evaluation instruments: (1) an oral examination using standardized templates and (2) a questionnaire assessing operative confidence. RESULTS: There were no intergroup differences in baseline characteristics, including number of operative procedures performed to date. Residents who took the anatomy course had significantly higher improvements in examination scores on common bile duct exploration (mean ± standard error, 33 ± 8% versus 10 ± 7%, P = 0.04), femoral endarterectomy (43 ± 5% versus 11 ± 7%, P = 0.003), fasciotomies (55 ± 10% versus 22 ± 9%, P = 0.04), inguinal hernia repair (20 ± 9% versus -14 ± 5%, P = 0.005), superior mesenteric artery embolectomy (38 ± 10% versus 2 ± 11%, P = 0.04), and in overall examination scores (31 ± 4% versus 8% ± 3%, P = 0.0006). In addition, they reported higher operative confidence on common bile duct exploration (P = 0.008) and superior mesenteric artery embolectomy (P = 0.02), and a trend toward higher overall operative confidence (P = 0.06). CONCLUSIONS: In this study, we demonstrate that a procedurally oriented cadaver course covering a wide range of essential general surgery procedures resulted in significant improvements in self-reported operative confidence and competence as assessed by oral examination.
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Anatomia/educação , Cadáver , Competência Clínica , Cirurgia Geral/educação , Humanos , Estudos ProspectivosRESUMO
The advent of more potent immunosuppressants led to the first successful human upper extremity transplantation in 1998. At this time, >100 upper extremity transplants, 30 face transplants, and a variety of other vascularized composite allotransplantation (VCA) procedures have been performed around the world. VCA recipients present unique challenges for transplantation. The incidence of acute rejection exceeds 80% in hand and face transplantation and is well documented, whereas reports about antibody-mediated rejection and chronic rejection remain scarce. Immunosuppression protocols commonly used at US centers are derived from solid organ transplantation protocols. Novel approaches to minimize rejections in VCA may include improved HLA matching and considerations toward cytomegalovirus infection status. New graft preservation techniques may decrease immunogenicity prior to transplant. Novel monitoring methods such as valid biomarkers, ultrasound biomicroscopy, and sentinel flaps may enable earlier diagnosis of rejection. Cell-based therapies are being explored to achieve immunosuppressive regimen minimization or even tolerance induction. The efficacy of local immunosuppression in clinical VCA remains controversial. In conclusion, although immunosuppressive strategies adapted from SOT have demonstrated good midterm results, focusing on the unique features of VCA grafts may enable additional, more specific treatment strategies in the future and improved long-term graft outcomes.
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Aloenxertos , Terapia de Imunossupressão/métodos , Alotransplante de Tecidos Compostos Vascularizados/métodos , Alotransplante de Tecidos Compostos Vascularizados/normas , Animais , Anticorpos/imunologia , Biomarcadores/metabolismo , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Antígenos HLA/imunologia , Humanos , Tolerância Imunológica , Imunossupressores/uso terapêutico , Transplante HomólogoRESUMO
BACKGROUND: Face transplantation (FT) has emerged as a viable option for treating devastating facial injuries. Most reported outcomes have demonstrated satisfactory motor and sensory restoration despite differences in technique. The authors have developed an algorithm of facial nerve management in these challenging patients. Our principles of management are illustrated by 2 specific patients. METHODS: A retrospective analysis of prospectively collected data on 2 full face transplants was performed. Both patients required nerve grafting during full FT. Patient 1 due to short donor facial nerve stumps and patient 2 due to intraoperative soft tissue swelling. Patient 2 required a nerve transfer 11 months after full FT due to impaired motor recovery opposite the side of nerve grafting. Follow-up examinations consisting of manual muscle testing and Sunnybrook Facial Grading System 6 to 42 months after full FT with selected video examinations were critically reviewed. RESULTS: Patient 1 had symmetrical motor recovery with gradual improvements noted throughout. At 6 months, Patient 2 had asymmetrically improving motor function. After nerve transfer, the patient showed gradual improvement in motor recovery, symmetry, and tone. Videos for each patient demonstrate the evolution of the patients' ability to smile from 6 to 42 months. DISCUSSION: The authors describe their assessment of motor recovery and management of facial nerve reconstruction as it pertains to FT. Finally, the authors illustrate the principles of nerve transfer are applicable to FT recipients.
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Nervo Facial/fisiopatologia , Nervo Facial/cirurgia , Transplante de Face/métodos , Transplante de Face/reabilitação , Transferência de Nervo/métodos , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade/organização & administração , Adolescente , Criança , Pré-Escolar , Fenda Labial/complicações , Fenda Labial/cirurgia , Fissura Palatina/complicações , Fissura Palatina/cirurgia , Estudos de Coortes , Comorbidade , Infecção Hospitalar/etiologia , Infecção Hospitalar/prevenção & controle , Infecção Hospitalar/cirurgia , Músculos Faciais/inervação , Feminino , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Masculino , Neurônios Motores/fisiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Risco Ajustado , Sorriso/fisiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/cirurgiaRESUMO
BACKGROUND: Facial vascularized composite allotransplantation (fVCA) is a life-enhancing procedure performed to improve quality of life (QOL). Patient-reported outcome measures (PROMs) are tools used to assess QOL from the patients' perspective, and are increasingly recognized as an important clinical metric to assess outcomes of treatment. A systematic literature review was performed to identify and appraise the content of PROMs used in fVCA. METHODS: We searched PUBMED/Medline, CINAHL, Embase, PsychInfo, and Web of Science from their inception through to June 2020. Included studies used a PROM in candidates and recipients of fVCA of any gender or age. We excluded abstracts, reviews, editorials, and dissertations. Items from each PROM were extracted and coded, using top-level codes and subcodes, to develop a preliminary conceptual framework of QOL concerns in fVCA, and to guide future PROM selection. RESULTS: Title and abstract screening of 6089 publications resulted in 16 studies that met inclusion criteria. Review of the 16 studies identified 38 PROMs, none of which were developed for fVCA. Review of the coded content for each PROM identified six top-level codes (appearance, facial function, physical, psychological and social health, and experience of care) and 16 subcodes, making up the preliminary conceptual framework. CONCLUSION: There are currently no PROMs designed to measure QOL concerns of fVCA candidates and recipients. Findings from this systematic review will be used to inform an interview guide for use in qualitative interviews to elicit and refine important concepts related to QOL in fVCA.
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Qualidade de Vida , Alotransplante de Tecidos Compostos Vascularizados , Face , Humanos , Medidas de Resultados Relatados pelo PacienteRESUMO
Negative pressure wound therapy (NPWT) has revolutionized the care of complex wounds since 1997. The addition of instillation (NPWTi-d) adds several potential benefits and challenges to clinicians dealing with complex wounds in a hospital setting. We surveyed the literature regarding the mechanism of action of these devices and reviewed our clinical experience to date. Potential mechanisms of action include the removal of microorganisms from the wound surface, dilution of cytotoxic molecules, upregulation of angiogenesis pathways, and maintenance of a moist wound environment. As we have extended our use of these devices to more complex wounds, we have taken advantage of and observed potential mechanisms of action, including facilitated removal of microorganisms, dilution of inflammatory and cytotoxic macromolecules, additional wound hydration, and enhanced angiogenesis through an intermittent application of NPWT. We have also observed complications, including bleeding, loss of a seal along the wound, and pain. NPWTi-d provides additional options for clinicians caring for complex wounds with favorable responses in wounds with significant contamination and those with poor inherent vascularity. Further studies to clarify the mechanisms of action, better define the wound types that would benefit, and techniques to manage complications using this device should further advance this field.
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INTRODUCTION: Our aim is to examine the correlation between perioperative hyperglycemia and post-operative outcomes following microvascular reconstruction of head and neck defects. PATIENTS AND METHODS: Retrospective review of a prospectively collected database of 350 consecutive patients who underwent microvascular reconstruction of malignant head and neck defects over a 2â¯year period. The relationship between perioperative hyperglycemia (≥â¯180â¯mg/dL) and the incidence of the following complications was evaluated: flap loss, flap-related complications and surgical site infections (SSI). Sub-group analysis based on timing of hyperglycemia was also performed. RESULTS: We identified 313 patients (89.4%) in the normoglycemic group and 37 patients (10.6%) in the hyperglycemic group. Baseline demographics, tumor stage, operative variable were comparable. There were no significant differences in flap-related complications and overall mortality. SSI were significantly higher in the hyperglycemic cohort (48% vs. 28%, pâ¯=â¯0.01). On multivariate analysis, hyperglycemia [OR 2.07; 95% CI, 1.87-4.89], perioperative insulin administration [OR 4.805; 95% CI, 2.18-10.60], prolonged operative time [OR 1.003; 95% CI, 1.002-1.025] and higher Charlson co-morbidity indices [II: OR 2.286 & III: OR 2.284] were independent predictors of SSI. On sub-group analysis, only patients with early (POD 1) post-operative hyperglycemia had a significant OR for SSI (OR 1.88; 95% CI, 1.07-3.29). CONCLUSION: Our findings suggest that perioperative hyperglycemia, specifically during the first 24â¯h post-operatively, is associated with SSI in microvascular head and neck reconstruction. This association highlights the need for strict screening of head and neck patients for hyperglycemia especially in the immediate post-operative period.
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Neoplasias de Cabeça e Pescoço/cirurgia , Hiperglicemia/etiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto , Idoso , Estudos Transversais , Feminino , Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço/irrigação sanguínea , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Face transplantation has emerged as a clinical reality for the restoration of complex facial defects. Critical to the advancement of the burgeoning field of reconstructive transplantation is the quality of the methods used to measure and report the impact of face transplantation on quality of life. METHODS: A systematic search using PubMed and EMBASE was conducted for all studies matching the a priori inclusion criteria from 2005 through 2015. Bibliographies of included studies were also reviewed. Two authors (M.A.A and H.K) independently performed screening of titles. RESULTS: The authors identified 17 articles reporting on quality-of-life outcomes among 14 face transplant recipients. Combinations of objective and subjective measures were used to assess quality of life. Instruments used to assess quality of life after face transplantation included over 25 different instruments. Four centers, comprising eight patients, have reported using prospective, systematic data with validated instruments. Overall, there is reported improvement in quality of life after face transplantation. Heterogeneity and a paucity of data between articles preclude a quantitative analysis. CONCLUSIONS: Anecdotal and subjective reports of improvements in quality of life after face transplantation constitute the majority of reported outcomes in the English peer-reviewed literature. Improved efforts in methods and standardization of collection and reporting of quality-of-life data after face transplantation are needed to better appreciate the impact of face transplantation on quality of life and justify lifelong immunosuppression and its attendant risks and morbidity.
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Transplante de Face , Qualidade de Vida , Indicadores Básicos de Saúde , HumanosRESUMO
BACKGROUND: One of the major challenges in traumatic amputation is the need to keep ischemia time brief (4 to 6 hours) to avoid ischemic damage and enable successful replantation. The current inability to meet this challenge often leads to traumatic limb loss, which has a considerable detrimental impact on the quality of life of patients. METHODS: The authors' team built a portable extracorporeal membrane oxygenator device for the perfusion of amputated extremities with oxygenated acellular solution under controlled parameters. The authors amputated forelimbs of Yorkshire pigs, perfused them ex vivo with acellular Perfadex solution for 12 hours at 10°C in their device, and subsequently replanted them into the host animal. The authors used limbs stored on ice slurry for 4 hours before replantation as their control group. RESULTS: Clinical observation and histopathologic evaluation both demonstrated that there was less morbidity and less tissue damage to the cells during preservation and after replantation in the perfusion group compared with the standard of care. Significant differences in blood markers of muscle damage and tissue cytokine levels underscored these findings. CONCLUSIONS: The authors demonstrated the feasibility and superiority of ex vivo hypothermic oxygenated machine perfusion for preservation of amputated limbs over conventional static cold storage and herewith a substantial extension of the allowable ischemia time for replantation after traumatic amputation. This approach could also be applied to the field of transplantation, expanding the potential pool of viable donor vascularized composite allografts.
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Amputação Traumática/cirurgia , Extremidades/lesões , Extremidades/cirurgia , Hipotermia Induzida , Isquemia/prevenção & controle , Reperfusão/métodos , Reimplante/métodos , Animais , Modelos Animais de Doenças , Feminino , Suínos , Fatores de TempoRESUMO
BACKGROUND: Current knowledge of the impact of facial vascularized composite allograft (VCA) procurement on the transplantation outcomes of the concomitantly recovered solid organs is limited to isolated case reports and short-term results. Here we report on a nationwide analysis of facial allograft donor surgery experience and long-term outcomes of the concomitantly recovered solid organs and their recipients. METHODS: There were 10 facial VCA procurements in organ donors between December 2008 and October 2014. We identified the population of subjects who received solid organs from these 10 donors using the Scientific Registry of Transplant Recipients. We retrospectively reviewed operative characteristics, intraoperative parameters, and postoperative outcomes. RESULTS: Six of 10 donor surgeries were performed at outside institutions, all on brain-dead donors. Mean operative duration for facial VCA recovery was 6.9 hours (range, 4-13.25 hours). A total of 36 solid organs were recovered and transplanted into 35 recipients. Survival rates for kidney and liver recipients were 100% and 90% at a median follow-up of 33 and 27.5 months, respectively (range, 6-72 months). Graft survival rates for kidneys and livers were 15 of 16 (94%) and 9 of 10 (90%), respectively. Recipient and graft survival rates for hearts and lungs were 75% (n = 4) and 100% (n = 3) at mean follow-up time of 14.75 and 16 months, respectively. A liver recipient died at 22 months from unknown causes and a heart recipient died of leukemia at 10 months. CONCLUSIONS: Facial VCA procurement does not appear to adversely affect the outcomes of transplant recipients of concomitantly recovered solid organ allografts.
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Aloenxertos Compostos , Transplante de Face/métodos , Sobrevivência de Enxerto , Transplante de Órgãos/métodos , Doadores de Tecidos , Coleta de Tecidos e Órgãos/métodos , Adulto , Transplante de Face/efeitos adversos , Transplante de Face/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Transplante de Órgãos/efeitos adversos , Transplante de Órgãos/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/mortalidade , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Face transplantation has been shown to improve the functional and aesthetic deficits of facially disfigured individuals. Given promising short-term results, it is important to examine whether face transplantation centers are effectively reaching the targeted facial disfigurement population. The authors' center reviewed their face transplantation contacts to assess patient recruitment and outreach performance. METHODS: The authors performed a retrospective review of their face transplantation contacts from the time of their institutional review board protocol approval (February of 2008) to October of 2015. They investigated the relationship between referral pattern (i.e., physician versus self) with the contact's demographic characteristics (i.e., age, sex, race, mechanism of injury, and geographic location) and clinical trial status. RESULTS: There were a total of 72 face transplantation contacts. The average age of the contacts was 38 years, and the majority were men [n = 41 (56.9 percent)]. Most were white (n = 33), and the most prevalent mechanism of injury was burns (46.4 percent). The majority of the contacts resided within the United States (n = 47), with most from the Northeastern United States (n = 21). Of the 72 contacts, 35 (48.6 percent) were physician referrals and 37 (51.4 percent) were self-referrals. Physician referrals have led to the most screened and transplanted contacts in their center, whereas self-referral often led to immediate exclusion. CONCLUSIONS: The authors show the diversity of patient characteristics and referral patterns in their clinical trial. Furthermore, they describe the relationship of characteristics to outcomes in their cohort and identify areas of improvement, such as patient and physician education. Lastly, they are reminded of the potential impact on the burn community.
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Queimaduras/cirurgia , Traumatismos Faciais/cirurgia , Transplante de Face/métodos , Satisfação do Paciente , Seleção de Pacientes , Encaminhamento e Consulta , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Face transplantation has emerged as a viable option for certain patients in the treatment of devastating facial injuries. However, as with autologous free tissue transfer, the need for secondary revisions in face transplantation also exists. The authors' group has quantified the number of revision operations in their cohort and has assessed the rationale, safety, and outcomes of posttransplantation revisions. METHODS: A retrospective analysis of prospectively collected data of the authors' seven face transplants was performed from April of 2009 to July of 2015. The patients' medical records, preoperative facial defects, and all operative reports (index and secondary revisions) were critically reviewed. RESULTS: The average number of revision procedures was 2.6 per patient (range, zero to five procedures). The median time interval from face transplantation to revision surgery was 5 months (range, 1 to 10 months). Most interventions consisted of debulking of the allograft, superficial musculoaponeurotic system plication and suspension, and local tissue rearrangement. There were no major infections, allograft skin flap loss, or necrosis. One patient suffered a postoperative complication after autologous fat grafting in the form of acute rejection that resolved with pulse steroids. CONCLUSIONS: Secondary revisions after face transplantation are necessary components of care, as they are after most conventional free tissue transfers. Secondary revisions after face transplantation at the authors' institution have addressed both aesthetic and functional reconstructive needs, and these procedures have proven to be safe in the context of maintenance immunosuppression. Patient and procedure selection along with timing are essential to ensure patient safety, optimal function, and aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
Assuntos
Traumatismos Faciais/cirurgia , Transplante de Face/métodos , Reoperação/métodos , Adulto , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Facial self-inflicted gunshot wounds (SIGSWs) cause a devastating midfacial defect and pose a challenging problem to the reconstructive surgeon. Face transplantation (FT) has the potential for near-normal restoration in otherwise non-reconstructible defects. Two out of 7 FT recipients at Brigham and Women's Hospital (BWH) sustained SIGSWs. In this study, we illustrate the role of FT in the management of SIGSWs through an aesthetic, functional, and psychosocial examination of outcomes. METHODS: We performed a retrospective analysis of individuals with SIGSWs who were screened at BWH between 2008 and 2015. We then collected data of the injuries, modes of conventional reconstruction (CR), and deficits. For the FT recipients, we critically reviewed the psychosocial screening process and post-transplantation aesthetic, functional, and psychosocial outcomes. RESULTS: A total of six individuals post-SIGSWs were screened for FT. All of them had undergone CR, with five receiving loco-regional flaps and free tissue transfers, and one undergoing serial debridement and primary soft-tissue repair. Following CR, all suffered from residual functional and aesthetic deficits. Two underwent partial FT and one is currently undergoing FT screening. We describe the pre-transplant psychosocial screening process and the aesthetic, functional, and psychosocial outcomes of the SIGSW FT recipients. CONCLUSIONS: We examined the facial SIGSW injury, outcomes of CR, and the mechanism of FT to offer a potential solution to the shortcomings of CR. More importantly, we highlight the critical nature of the psychosocial component of the multidisciplinary evaluation given the history of mental illness and suicidal behavior in this subset of patients.