Comparative Rheology of Hyaluronic Acid Fillers, Poly-l-lactic Acid, and Varying Dilutions of Calcium Hydroxylapatite.

Background: This study examines the rheological properties of various dermal fillers, including hyaluronic acid (HA) fillers, poly-L-lactic acid (PLLA), and calcium hydroxylapatite-carboxymethylcellulose (CaHA-CMC) gels, with a particular focus on the impact of aqueous dilution on CaHA-CMC's rheology and potential clinical implications. Methods: Using standardized rheological analysis, we measured and compared the elastic modulus (G'), viscous modulus (G″), and the tan δ values of different dilutions of CaHA-CMC against published values of HA and PLLA fillers. The study aimed to determine the potential clinical use of application-specific CaHA-CMC hydrogel dilutions along a range of gel strength and cohesion for hydrogel fillers in current use. Results: The findings demonstrate that CaHA-CMC's rheological properties can be tailored across a broad spectrum of viscoelastic parameters through titrated dilution, ranging from high elasticity to low cohesion. Varying the aqueous volume allows for the rheomodulation of CaHA-CMC, potentially matching the entire rheological spectrum of HA fillers and suggesting an expanded range of clinical applications. Conclusions: The versatility of CaHA-CMC through dilution may offer a customizable approach for clinical applications, providing practitioners with the ability to fine-tune the properties of fillers to meet specific patient needs and treatment goals. This study lays the groundwork for the potential future use of filler dilutional rheomodulation in clinical practice, tailored to patient- and application-specific needs.

BreastGAN: Artificial Intelligence-Enabled Breast Augmentation Simulation.

BACKGROUND: Managing patient expectations is important to ensuring patient satisfaction in aesthetic medicine. To this end, computer technology developed to photograph, digitize, and manipulate three-dimensional (3D) objects has been applied to the female breast. However, the systems remain complex, physically cumbersome, and extremely expensive. OBJECTIVES: The authors of the current study wish to introduce the plastic surgery community to BreastGAN, a portable, artificial intelligence (AI)-equipped tool trained on real clinical images to simulate breast augmentation outcomes. METHODS: Charts of all patients who underwent bilateral breast augmentation performed by the senior author were retrieved and analyzed. Frontal before and after images were collected from each patient's chart, cropped in a standardized fashion, and used to train a neural network designed to manipulate before images to simulate a surgical result. AI-generated frontal after images were then compared with the real surgical results. RESULTS: Standardizing the evaluation of surgical results is a timeless challenge which persists in the context of AI-synthesized after images. In this study, AI-generated images were comparable to real surgical results. CONCLUSIONS: This study features a portable, cost-effective neural network trained on real clinical images and designed to simulate surgical results following bilateral breast augmentation. Tools trained on a larger dataset of standardized surgical image pairs will be the subject of future studies.

Using Big Data to Assess Legitimacy of Plastic Surgery Information on Social Media.

BACKGROUND: The proliferation of social media in plastic surgery poses significant difficulties for the public in determining legitimacy of information. This work proposes a system based on social network analysis (SNA) to assess the legitimacy of information contributors within a plastic surgery community. OBJECTIVES: The aim of this study was to quantify the centrality of individual or group accounts on plastic surgery social media by means of a model based on academic plastic surgery and a single social media outlet. METHODS: To develop the model, a high-fidelity, active, and legitimate source account in academic plastic surgery (@psrc1955, Plastic Surgery Research Council) appearing only on Instagram (Facebook, Menlo Park, CA) was chosen. All follower-followed relationships were then recorded, and Gephi (https://gephi.org/) was used to compute 5 different centrality metrics for each contributor within the network. RESULTS: In total, 64,737 unique users and 116,439 unique follower-followed relationships were identified within the academic plastic surgery community. Among the metrics assessed, the in-degree centrality metric is the gold standard for SNA, hence this metric was designated as the centrality factor. Stratification of 1000 accounts by centrality factor demonstrated that all of the top 40 accounts were affiliated with a plastic surgery residency program, a board-certified academic plastic surgeon, a professional society, or a peer-reviewed journal. None of the accounts in the top decile belonged to a non-plastic surgeon or non-physician; however, this increased significantly beyond the 50th percentile. CONCLUSIONS: A data-driven approach was able to identify and successfully vet a core group of interconnected accounts within a single plastic surgery subcommunity for the purposes of determining legitimate sources of information.

#Botox 101: Subgroup Analysis of Twitter's Top 101 Neurotoxin Influencers.

BACKGROUND: Recent studies demonstrate that board-certified plastic surgeons and dermatologists are underrepresented in posting public-directed marketing content about botulinum toxin A on YouTube. However, educational content and peer-to-peer social media influence regarding the topic of neurotoxins has not been studied. Twitter is a social media platform that has emerged as a unique network for public education and for the exchange of ideas among physicians. OBJECTIVE: The purpose of this study is to identify Twitter's top social media influencers on #botox, to describe their characteristics and to relate their social media influence to academic influence. METHODS: Twitter influence scores for the topic search #botox were collected in January 2019 with Right Relevance software. #Botox was the only neurotoxin term with sufficient activity to generate an influencer list. The user accounts associated with top influencers were connected to individual names, identification as a plastic surgeon or dermatologist, board certification status, location, and academic h-index. RESULTS: The top 101 Twitter influencers on #botox are presented. Seventy-five percent of influencers are physically located in the United States. Academic h-index of #botox social media influencers ranged from 0 to 62 (mean, 8.6). CONCLUSION: This study shows that the top #botox social media influencers on Twitter and primarily board-certified or eligible plastic surgeons located in the United States. This study also elucidates the influencer network within which other plastic surgeons and dermatologists can interact to augment their own influence within the social media network. This is the first study to describe social media influencers in this way.

The Development and Commercialization of Medical Technologies.

It is not uncommon for physicians to think of ways to improve the delivery of care, which may take the form of a new medical device, drug, test, or service. In recent years, structured approaches to the identification of unmet needs and the development of solutions have been introduced to the medical community. Yet, due to gaps in exposure and training, there remains an opportunity to improve the level of understanding within the medical community regarding how to develop an innovation, once conceived, to the point of commercialization. The purpose of this article, therefore, is to provide an overview of some of the relevant considerations and requirements when bringing an idea for a new medical technology to market.

Data-Driven Insights on the Effects of COVID-19 on Aesthetics: Part I (Passive Analysis).

BACKGROUND: Since COVID-19 was declared to be a worldwide pandemic and US national emergency in March (week 11), it has significantly changed aesthetic plastic surgery. As plastic surgeons now move towards reopening practices, understanding public interest in medical aesthetics will be critical to maximize efforts and resource allocation in procedures and treatments that patients want. OBJECTIVES: In this study, the authors sought to passively query public interest in aesthetics utilizing Google Trends search data. METHODS: Google Trends was utilized to quantify relative search volumes over the past 4 years for a variety of categories: patient-related, surgery-related, injectables, breast procedures, face procedures, and body procedures. Data were deseasonalized and represented graphically. Z-scores of each time-point differing from the expected values were determined utilizing least squares regression. RESULTS: Of the 204 significantly anomalous search term data points in 2020, 172 (84.0%) occurred after week 11 (pandemic/national emergency declaration). Sixty percent of searches in all time-points after week 11 significantly differed, and 25/26 (96.0%) search terms experienced significant changes after week 11. There was decreased interest for 18 terms with variable recovery. Procedural nadirs for decreased search volume troughs occurred between weeks 11 and 14. Six patient-related chief complaints saw increased search interest after COVID-19, with peak interest between weeks 11 and 17. CONCLUSIONS: This is the first study, to the authors' knowledge, to assess real-time, national data about the impact of COVID-19 on public interest in aesthetics.

Insta-Grated Plastic Surgery Residencies: 2020 Update.

BACKGROUND: Recent evidence shows accelerating worldwide adoption of social media and suggests a commensurate increase in social media use by integrated plastic surgery residency programs in the United States. Programs nationwide are now making strides to include a longitudinal social media component in their plastic surgery curriculum. OBJECTIVES: The aim of this study was to investigate the use of Instagram by plastic surgery residency programs and to describe trends in adoption, volume, and content. METHODS: Current active Instagram accounts affiliated to integrated plastic surgery residency programs were surveyed to identify date of first post, number of posts, number of followers, number of followings, engagement rate, most-liked posts, and content of posts. All data were collected on May 12, 2020. RESULTS: Sixty-nine out of 81 (85.2%) integrated plastic surgery residency programs had Instagram accounts, totaling 5,544 posts. This represents an absolute increase in program accounts of 392% since 2018. The 100 most-liked posts were categorized as: promotion of the program/individual (46), resident life (32), promotion of plastic surgery (14), and education (8). CONCLUSIONS: Instagram use by plastic surgery residency programs has drastically increased since it was first evaluated in 2018. This trend will continue as we reach near saturation of residency programs with accounts. We remain steadfast in our belief that the advantages of social media use by plastic surgeons and trainees are far outweighed by the potential community-wide impacts of violations of good social media practice on peers, patients, and the general public.

Interstitial Cystitis/Bladder Pain Syndrome as Referred Pain From Injured T12/L1 Nerves: Symptomatic Improvement With Resection of Ilioinguinal and Iliohypogastric Nerves.

OBJECTIVE: To evaluate the specific contribution of ilioinguinal (II) and iliohypogastric (IH) nerve injury and referred pain to interstitial cystitis/bladder pain syndrome and patient-reported chronic pelvic pain, and to enumerate the effects of II and IH nerve resection on the pain and voiding symptoms in patients with IC/BPS. MATERIALS AND METHODS: This was a prospective cohort study of 8 patients with ICS/BPS who had prior abdominal surgery. All patients received diagnostic image guided T12/L1 nerve blocks, followed by II and IH nerve resections. Validated O'Leary-Sant ICS symptom indices (OSPI) and pelvic pain and urgency/frequency patient symptoms scale (PUF) scores were collected at specified intervals pre- and post-operatively. RESULTS: Median scores at pre-operative (OSPI 13.9, PUF 20.4) and 1 week time points (OSPI 5.9, PUF 11), as well as differences between pre-operative and 10 month time points (OSPI 3.7, PUF 6) were all statistically significant (P = .008 and .009 at 1 week, and .007 and .008 at 10 months, for OSPI and PUF respectively). The mean difference in score from pre-operative to longest follow-up as measured by the OSPI was -14.4 (P < .001) and by PUF -10.3 (P < .001). All time points registered demonstrated improvement in pain scores. There were no surgical complications or adverse events. CONCLUSION: II and IH nerve resection may be an effective and durable treatment option for those with prior abdominal surgery who have referred interstitial cystitis/bladder pain syndrome pain from these injured nerves.

Data-Driven Insights on the Effects of COVID-19 on Public Interest in Medical Aesthetics: Part II (Active Analysis).

BACKGROUND: The COVID-19 pandemic significantly affected financial and psychosocial factors that influence plastic surgery demand. OBJECTIVES: The authors sought to actively assess public interest changes and the reasons underlying these shifts. METHODS: Using Amazons' Mechanical Turk, we crowdsourced public opinions regarding aesthetic interventions from April 30 to May 3, 2020. The survey assessed prior experience with and interest in 6 aesthetic interventions before and during the pandemic and reasons for changing interest. United States residents aged 18 years and over who passed the attention check were included. RESULTS: We included 704 of 838 total responses. One-half of respondents were female; the median age group was 25 to 34 years. During the pandemic, 21% of respondents had increased and 33% decreased interest in at least one intervention. Non-invasive procedures (7.3%), facial aesthetic surgery (6.6%), and medical-grade skincare (5.9%) elicited the greatest interest increase. Seeing themselves in the mirror more often (43.2%), desire to look better after the crisis (41.8%), and increased time on social media (40.4%) were the top reasons for increased interest. The most common reasons for decreased interest were changing spending priorities (58%), focusing on other health aspects (49.8%), and worrying about infection in medical facilities (46.3%). Almost one-half of respondents considered virtual consultations for interventions of increased interest. CONCLUSIONS: The COVID-19 pandemic significantly affected interest in medical aesthetics. Offering telemedicine and discussing detailed COVID-19 infection control policies with patients will be critical to address patient needs and concerns. These findings can be used to improve patient outreach, advertisement, and counseling as practices focus on reopening.

An Algorithm for the Prevention and Treatment of Pain Complications of the Radial Forearm Free Flap Donor Site.

BACKGROUND: The radial forearm free flap (RFFF) is a staple of microsurgical reconstruction. Significant attention has been paid to donor-site morbidity, particularly vascular and aesthetic consequences. Relatively few authors have discussed peripheral nerve morbidity such as persistent hypoesthesia, hyperesthesia, or allodynia in the hand and wrist or neuroma formation in the wrist and forearm. Here, we present a diagnostic and therapeutic algorithm for painful neurologic complications of the RFFF donor site. MATERIALS AND METHODS: The peripheral nerves that can be involved with the RFFF are reviewed with respect to the manner in which they may be involved in postoperative pain manifestations. A method for prevention and for treatment of each of these possibilities is also presented. RESULTS: Nerves from the forearm that can be harvested with the RFFF will have the most likelihood for injury and these include the lateral antebrachial cutaneous nerve, the radial sensory nerve, and the medial antebrachial cutaneous nerve. A nerve that may be injured at the distal juncture of the skin graft to the forearm is the palmar cutaneous branch of the median nerve. The "prevention" portion of the algorithm suggests that each nerve divided to become a recipient nerve should have its proximal end implanted into a muscle to prevent painful neuroma. The "treatment" portion of the algorithm suggests that if a neuroma does form, it should be resected, not neurolysed, and the proximal portion should be implanted into an adjacent muscle. The diagnostic role of nerve block is emphasized. CONCLUSION: Neurological complications following RFFF can be prevented by an appropriate algorithm as described by devoting attention to the proximal end of recipient nerves. Neurological complications, once present, can be difficult to diagnose accurately. Nerve blocks are critical in this regard and are employed in the treatment algorithm presented.

Pioneers in Modern Craniofacial Surgery: Assessing the Academic Impact of Drs. Joseph Gruss and Paul Manson.

BACKGROUND: The authors conducted this study to assess the impact that Drs. Joseph Gruss and Paul Manson have had on craniofacial surgery through their individual contributions and through their trainees. METHODS: This was a retrospective analysis of fellows trained by either Dr. Gruss or Dr. Manson. Demographic and bibliometric measures were recorded for each fellow. Demographic factors included years since completion of fellowship training, current practice of craniomaxillofacial surgery, academic practice, and academic leadership roles. Bibliometric measures included number of publications, number of citations, and h-index. To adjust for scholarly activity before fellowship training, only contributions published after fellowship training were included. RESULTS: Over a 39-year period, a total of 86 surgeons completed fellowship training with either of the two principal surgeons. The mean time since completion of training was 18.7 ± 11.4 years. Seventy-nine percent of surgeons had active practices in craniomaxillofacial surgery; 54 percent had academic practices. The mean number of publications was 26.4 ± 69.3, the mean number of citations was 582 ± 2406, and the average h-index was 6.7 ± 10.6. Among academic surgeons, the average h-index was 10.7 ± 13.1, 89 percent practiced in North America, 89 percent had active practices in craniomaxillofacial surgery, and nearly 50 percent had achieved a leadership role. CONCLUSIONS: Modern craniofacial reconstruction has evolved from principles used in trauma and correction of congenital differences. The extensive impact that Drs. Paul Manson and Joseph Gruss have had on the field, and plastic surgery at large, is evident through their primary contributions and the immense impact their trainees have had on the field.

A Practical Approach to Artificial Intelligence in Plastic Surgery.

Understanding the intersection of technology and plastic surgery has been and will be essential to positioning plastic surgeons at the forefront of surgical innovation. This account of the current and future applications of artificial intelligence (AI) in reconstructive and aesthetic surgery introduces us to the subset of issues amenable to support from this technology. It equips plastic surgeons with the knowledge to navigate technical conversations with peers, trainees, patients, and technical partners for collaboration and to usher in a new era of technology in plastic surgery. From the mathematical basis of AI to its commercially viable applications, topics introduced herein constitute a framework for design and execution of quantitative studies that will better outcomes and benefit patients. Finally, adherence to the principles of quality data collection will leverage and amplify plastic surgeons' creativity and undoubtedly drive the field forward.

Novel Expanded Safe Zone for Reduction of Submental Fullness with ATX-101 Injection.

BACKGROUND: ATX-101 (deoxycholic acid injection; Kybella) provides an approved nonsurgical treatment option for reduction of submental fullness caused by submental fat. Current one-size-fits-all recommendations for the use of ATX-101 limit treatment to a central area, which may not provide complete resolution of submental fat for some patients. An expanded safe zone is described, allowing for individualized, comprehensive treatment of submental fat with ATX-101 according to each patient's anatomy and desired outcomes. METHODS: A retrospective review was conducted of patients treated with ATX-101 for excess submental fat between June of 2015 and December of 2016 at a single plastic surgery practice. The expanded safe zone was developed to isolate the distinct fat compartments of the submental area and includes a no-treatment zone to avoid the marginal mandibular nerve. The extent of ATX-101 treatment required in each zone was determined by assessment of subcutaneous adipose tissue. A 1-cm grid was used to mark the treatment area before injection of ATX-101 (2 mg/cm). Improvement (defined as decreased palpable and/or visible submental fullness) was determined at least 4 months after the final treatment. Adverse events were recorded at each visit and reported by patients by means of telephone. RESULTS: Overall, 167 patients were included in this analysis. Improvement in submental fullness was achieved in 160 of 167 patients (95.8 percent). The majority of adverse events consisted of temporary injection-site edema, numbness, and tenderness. CONCLUSION: An understanding of submental anatomy and careful assessment of each patient's submental fat allows for individualized treatment with ATX-101 beyond the central region of the neck without increased risk of adverse events. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Who should you be following? The top 100 social media influencers in orthopaedic surgery.

BACKGROUND: Social media has been credited with the potential to transform medicine, and Twitter was recently named "an essential tool" for the academic surgeon. Despite this, peer-to-peer and educational influence on social media has not been studied within orthopaedic surgery. This knowledge is important to identify who is controlling the conversation about orthopaedics to the public. We hypothesized that the plurality of top influencers would be sports medicine surgeons, that social media influence would not be disconnected from academic productivity, and that some of the top social media influencers in orthopaedic surgery would not be orthopaedic surgeons. AIM: To identify the top 100 social media influencers within orthopaedics, characterize who they are, and relate their social media influence to academic influence. METHODS: Twitter influence scores for the topic "orthopaedics" were collected in July 2018 using Right Relevance software. The accounts with the top influence scores were linked to individual names, and the account owners were characterized with respect to specialty, subspecialty, practice setting, location, board certification, and academic Hirsch index (h-index). RESULTS: Seventy-eight percent of top influencers were orthopaedic surgeons. The most common locations included California (13%), Florida (8%), New York (7%), United Kingdom (7%), Colorado (6%), and Minnesota (6%). The mean academic h-index of the top influencers (n = 79) was 13.67 ± 4.12 (mean ± 95%CI) and median 7 (range 1-89) (median reported h-index of academic orthopaedic faculty is 5 and orthopaedic chairpersons is 13). Of the 78 orthopaedic surgeons, the most common subspecialties were sports medicine (54%), hand and upper extremity (18%), and spine (8%). Most influencers worked in private practice (53%), followed by academics (17%), privademics (14%), and hospital-based (9%). All eligible orthopaedic surgeons with publicly-verifiable board certification statuses were board-certified (n = 74). CONCLUSION: The top orthopaedic social media influencers on Twitter were predominantly board-certified, sports-medicine subspecialists working in private practice in the United States. Social media influence was highly concordant with academic productivity as measured by the academic h-index. Though the majority of influencers are orthopaedic surgeons, 22% of top influencers on Twitter are not, which is important to identify given the potential for these individuals to influence patients' perceptions and expectations. This study also provides the top influencer network for other orthopaedic surgeons to engage with on social media to improve their own social media influence.

The Top 100 Social Media Influencers in Plastic Surgery on Twitter: Who Should You Be Following?

BACKGROUND: Recent studies demonstrate that board-certified plastic surgeons are underrepresented amongst individuals posting public-directed marketing plastic surgery-related content on Instagram. However, peer-to-peer and education-based social media influence has not been studied. Twitter is a social media platform has been suggested to be useful for educating the masses and connecting with colleagues. OBJECTIVES: The purpose of this study is to identify the top influencers in plastic surgery on Twitter, characterize who they are, and relate their social media influence to academic influence. METHODS: Twitter influence scores for the topic search "plastic surgery" were collected in July 2017 using Right Relevance software. The accounts associated with the highest influencer scores were linked to individual names, status as a plastic surgeon, board certification, location, and academic h-index. RESULTS: The top 100 Twitter influencers in plastic surgery are presented. Seventy-seven percent of the top influencers are trained as plastic surgeons or facial plastic surgeons. Sixty-one percent of influencers are board-certified plastic surgeons or board-eligible/future eligible trainees. International plastic surgeons made up 16% of influencers. Other medical doctors made up another 10%. The other 13% of influencers were nonphysicians. Three-quarters of social media influencers were physically located in the United States. Academic h-index of social media influencers ranged from 0 to 62 (mean, 8.6). CONCLUSIONS: This study shows that the top plastic surgery social media influencers on Twitter are predominantly board-certified or eligible plastic surgeons and physically based in the United States. This study also provides the influencer network for other plastic surgeons to engage with to improve their own influence within the plastic surgery social media sphere.

Insta-grated Plastic Surgery Residencies: The Rise of Social Media Use by Trainees and Responsible Guidelines for Use.

BACKGROUND: Ethical guidelines for appropriate use of social media are beginning to be delineated. As social media becomes ingrained in plastic surgery culture, education of residents on appropriate use of social media is increasingly important. Recently, plastic surgery residency programs have begun to utilize social media. OBJECTIVES: This study characterized the trends and content of plastic surgery residency-associated Instagram accounts. METHODS: Active individual residency program Instagram accounts were identified for integrated plastic surgery programs. Metrics for each account were retrieved on September 16, 2017, including date of first post, number of posts, and followers. Individual posts were analyzed for content of post. RESULTS: Fourteen of 67 (21%) integrated plastic surgery programs were found to have active Instagram accounts. There has been an exponential growth of programs adopting Instagram since August 2015. A total of 806 posts were created. Thirty-two (3.97%) posts had intraoperative photos and only one (0.12%) showed a patient image. There were 4466 followers of plastic surgery residency programs. A linear correlation was found between number of posts and number of followers, while there was no correlation of number of followers and time since account start. CONCLUSIONS: Instagram use by plastic surgery integrated programs continues to grow exponentially, and programs are appropriately using the platform. Active use of the resident social media results in increased influence. Resident use of social media has many benefits. We propose social media guidelines for plastic surgery trainees and advocate for continued appropriate use and autoregulation by plastic surgery trainees.

Craniofacial Measurements of Donors and Recipients Correlate with Aesthetic Outcome in Virtual Face Transplantation.

BACKGROUND: Face transplantation is an increasingly feasible option for patients with severe disfigurement. Donors and recipients are currently matched based on immune compatibility, skin characteristics, age, and gender. Aesthetic outcomes of the match are not always optimal and not possible to study in actual cases due to ethical and logistical challenges. We have used a reproducible and inexpensive three-dimensional virtual face transplantation (VFT) model to study this issue. METHODS: Sixty-one VFTs were performed using reconstructed high-resolution computed tomography angiographs of male and female subjects aged 20-69 years. Twenty independent reviewers evaluated the level of disfigurement of the posttransplant models. Absolute differences in 9 soft-tissue measurements and 16 bony cephalometric measurements from each of the VFT donor and recipient pretransplant model pairs were correlated to the reviewers' evaluation of disfigurement after VFT through a multivariate logistic regression model. RESULTS: Five soft-tissue measurements and 3 bony measurements were predictive of the rating of disfigurement after VFT (odds ratio; 95% confidence interval): trichion-to-nasion facial height (1.106; 1.066-1.148), endocanthal width (1.096; 1.051-1.142), exocanthal width (1.067; 1.036-1.099), mouth/chelion width (1.064; 1.019-1.110), subnasale-to-menton facial height (1.029; 1.003-1.056), inner orbit width (1.039; 1.009-1.069), palatal plane/occlusal plane angle (1.148; 1.047-1.258), and sella-nasion/mandibular plane angle (1.079; 1.013-1.150). CONCLUSIONS: This study provides early evidence for the importance of soft-tissue and bony measurements in planning of facial transplantation. With future improvements to immunosuppressive regimens and increased donor availability, these measurements may be used as an additional criterion to optimize posttransplant outcomes.

Airway recovery after face transplantation.

BACKGROUND: Severe facial injuries can compromise the upper airway by reducing airway volume, obstructing or obliterating the nasal passage, and interfering with oral airflow. Besides the significant impact on quality of life, upper airway impairments can have life-threatening or life-altering consequences. The authors evaluated improvements in functional airway after face transplantation. METHODS: Between 2009 and 2011, four patients underwent face transplantation at the authors' institution, the Brigham and Women's Hospital. Patients were examined preoperatively and postoperatively and their records reviewed for upper airway infections and sleeping disorders. The nasal mucosa was biopsied after face transplantation and analyzed using scanning electron microscopy. Volumetric imaging software was used to evaluate computed tomographic scans of the upper airway and assess airway volume changes before and after transplantation. RESULTS: Before transplantation, two patients presented an exposed naked nasal cavity and two suffered from occlusion of the nasal passage. Two patients required tracheostomy tubes and one had a prosthetic nose. Sleeping disorders were seen in three patients, and chronic cough was diagnosed in one. After transplantation, there was no significant improvement in sleeping disorders. The incidence of sinusitis increased because of mechanical interference of the donor septum and disappeared after surgical correction. All patients were decannulated after transplantation and were capable of nose breathing. Scanning electron micrographs of the respiratory mucosa revealed viable tissue capable of mucin production. Airway volume significantly increased in all patients. CONCLUSIONS: Face transplantation successfully restored the upper airway in four patients. Unhindered nasal breathing, viable respiratory mucosa, and a significant increase in airway volume contributed to tracheostomy decannulation.

Facial appearance transfer and persistence after three-dimensional virtual face transplantation.

BACKGROUND: Facial appearance transfer from donor to recipient in face transplantation is a concern. Previous studies of facial appearance transfer and facial appearance persistence (preservation of the recipient's facial likeness) in face transplants simulated using two-dimensional photographic manipulations found low facial appearance transfer (2.6 percent) and high facial appearance persistence (66 percent). Three-dimensional computer simulation of complex facial transplant patterns may improve the accuracy of facial appearance transfer and facial appearance persistence estimations. METHODS: Three-dimensional virtual models of human faces were generated from deidentified computed tomographic angiographs and used as "donors" or "recipients" for virtual face transplantation. Surgical planning software was used to perform 73 virtual face transplantations by creating specific facial defects (mandibular, midface, or large) in the recipient models and restoring them with allografts extracted from the donor models. Twenty independent reviewers evaluated the resemblance of each resulting posttransplant model to the donor (facial appearance transfer) and recipient (facial appearance persistence). The results were analyzed using tests for equal results with one-sample and pairwise Rao-Scott Pearson chi-square testing, correcting for clustering and multiple testing. RESULTS: Overall rates of facial appearance persistence and facial appearance transfer were high (69.2 percent) and low (32.4 percent), respectively. The mandibular pattern had the highest rates of facial appearance persistence and lowest rates of facial appearance transfer. Facial appearance persistence and transfer were similar across sexes. CONCLUSIONS: Facial appearance persistence is high and facial appearance transfer is low after virtual face transplantation. Appearance transfer and persistence after virtual face transplantation are more dependent on the anatomy than on the size of transplanted facial aesthetic units. This information may reassure recipients of partial face transplants and donor families.