Re-cognizing the new self: The neurocognitive plasticity of self-processing following facial transplantation.

The face is a defining feature of our individuality, crucial for our social interactions. But what happens when the face connected to the self is radically altered or replaced? We address the plasticity of self-face recognition in the context of facial transplantation. While the acquisition of a new face following facial transplantation is a medical fact, the experience of a new identity is an unexplored psychological outcome. We traced the changes in self-face recognition before and after facial transplantation to understand if and how the transplanted face gradually comes to be perceived and recognized as the recipient's own new face. Neurobehavioral evidence documents a strong representation of the pre-injury appearance pre-operatively, while following the transplantation, the recipient incorporates the new face into his self-identity. The acquisition of this new facial identity is supported by neural activity in medial frontal regions that are considered to integrate psychological and perceptual aspects of the self.

A Comparison of Immunosuppression Regimens in Hand, Face, and Kidney Transplantation.

BACKGROUND: Authors have speculated that vascularized composite allotransplantation (VCA) recipients may require greater maintenance immunosuppression than solid organ transplant (SOT) recipients due to the higher antigenicity of skin. However, detailed comparisons of VCA and SOT immunosuppression regimens have been limited. METHODS: Hand and face VCA recipient immunosuppression data were collected through a systematic literature review. Kidney recipient data were obtained through a retrospective chart review of the authors' institution. Prednisone and mycophenolate mofetil (MMF) doses were compared between VCA and kidney recipients at predefined follow-up intervals (<1, 1-5, and >5 y). Tacrolimus target trough levels (TTTL) were compared at follow-up intervals of 1-5 and >5 y, and stratified into our institution's kidney transplant risk-based target ranges (4-6 ng/mL, 6-8 ng/mL) or higher (>8 ng/mL). RESULTS: Immunosuppression data were available for 57 VCA and 98 kidney recipients. There were no significant differences in prednisone doses between groups at all follow-up intervals. VCA recipient mean MMF dose was significantly greater at <1-y (1.71 ± 0.58 versus 1.16 ± 0.55 gm/d; P = 0.01). For VCA recipients, there was a significant difference (P = 0.02) in TTTL distribution over the three predefined therapeutic ranges (4-6 ng/mL, 6-8 ng/mL, and >8 ng/mL) between 1 and 5 y (24.0%, 20.0%, 56.0%, respectively) and >5 y (28.6%, 42.9%, 28.6%). CONCLUSIONS: At longer follow-up, VCA and kidney recipients receive comparable MMF/prednisone doses, and most VCA recipients are treated with TTTL similar to kidney recipients. Further research may improve our understanding of VCA's complex risk/benefit ratio, and enhance informed consent.

Total Eyelid Transplantation in a Face Transplant: Analysis of Postoperative Periorbital Function.

BACKGROUND: Prolonged impairment of protective ocular functions can compromise vision and lead to blindness if uncorrected. Several facial transplants have incorporated periorbital structures with variable eyelid preservation, but objective assessment of post-transplant periorbital function has been limited. MATERIALS AND METHODS: Kinematic data were collected from a full-face recipient that included the fist total eyelid transplantation at 5 separate pre-transplant (PRE) and post-transplant time points (T1-T4). Using optical facial tracking, eyelid movements were tracked during involuntary blinking and compared with controls. RESULTS: There was significant improvement in right eye aperture from PRE to T1 (ß = 5.54, P < 0.001), with no change between T1 and T4. Aperture fluctuated in the left eye, with a temporary decrease between T2 and T3 corresponding with revision brow lift (ß = -4.57, P < 0.001). Although improved from the pre-transplantation, right and left eye apertures remained significantly smaller than controls at T1 and T4 (P < 0.001). Similarly, spatial coupling increased from PRE to T1 (ß = 0.63, P < 0.001) and remained high at T4, albeit significantly less than controls (P < 0.001). Temporal coupling improved from PRE to T2 (ß = 2.29, P < 0.02) and was sustained at subsequent time points, with no difference relative to controls at T4. Considerable improvement was observed on clinical examination, with full functional status. CONCLUSIONS: Application of a novel method for assessing functional eyelid recovery using facial tracking technology to the first total eyelid transplantation in the setting of a full facial transplant shows clear functional improvement after transplantation and suggests revisions can be performed safely to optimize aesthetic outcomes without permanent negative functional impact.

Zygomatic Rotation-Advancement: A New Concept for the Correction of Exorbitism in Patients With Syndromic Craniosynostosis.

BACKGROUND: The exophthalmos and class III malocclusion seen in Crouzon syndrome can be treated by Le Fort III advancement/distraction. However, reconstructive options for zygomatic retrusion are limited. The authors describe the repair of isolated exorbitism in a patient with Crouzon syndrome, via bilateral zygomatic rotation-advancement. METHODS: A 34-year-old woman with Crouzon syndrome complained of exorbitism and malar hypoplasia. Four years prior, she declined Le Fort III advancement and underwent orthodontic/orthognathic correction of malocclusion. Radiographs were used to develop a computerized surgical plan. Bilateral periorbital osteotomy with advancement/rotation of the zygomatic process was performed using custom osteotomy guides and plates. Images obtained immediately postoperative and 3- and 19-month postoperative were compared to assess surgical stability, accuracy, and soft tissue changes. RESULTS: Decreased globe exposure and increased malar prominence have improved facial balance. Superimposed pre- and postoperative radiographs demonstrate bilateral advancement of the zygomatic body and inferior orbital rim. Superimposition of immediate postoperative and 19-month radiographs showed no relapse. Soft tissue histogram showed increased prominence of the malar eminence, lateral orbital rim, and cheek. CONCLUSIONS: Zygomatic rotation-advancement proved a safe, effective, stable, and predictable treatment for isolated malar hypoplasia in a patient with Crouzon syndrome. Virtual planning can enhance novel complex craniofacial procedures.

Educational Resources in Craniofacial Surgery: The Case for User-Friendly Digital Simulators.

INTRODUCTION: Digital simulators are potential solutions to challenges facing surgical education. The authors sought to evaluate the reach and utilization of a freely-accessible craniofacial surgery digital educational simulator. More importantly, we compare usage patterns between web-based and mobile-based platforms. METHODS: A 3-way collaboration between academic, non-profit (myFace, New York, NY), and biotechnology (Biodigital, New York, NY) stakeholders in 2015 produced the Craniofacial Interactive Virtual Assistant Pro (CIVA-Pro). CIVA-Pro is a freely-accessible craniofacial surgery digital educational simulator. In addition to the web-based platform, a mobile-based platform was launched in 2017. Usage analytics were collected and analyzed. RESULTS: Since its launch, 751 registered users from 117 countries had accessed CIVA-Pro. The total number of sessions was 9531, including 7500 web and 2031 mobile sessions. The total screen time was 403.9 hours, 290.3 for the web and 113.6 for the mobile platform. Comparison of the mean monthly screen time and number of monthly sessions between platforms since 2017 demonstrated a significantly higher mean monthly screen time (60.1 ±â€Š33.2 versus 29.4 ±â€Š16.5 hours; P = 0.002) and number of sessions (110.2 ±â€Š36.1 versus 58.1 ±â€Š31.9; P < 0.0001) for the mobile-based platform. The mean screen time per session was comparable (P = 0.86). CONCLUSION: A freely available digital craniofacial surgery educational simulator designed for surgical trainees can achieve significant global reach. Significantly higher utilization of the mobile-based platform of the simulator as compared to the web-based platform reinforces the need to invest in user-friendly, easily accessible, and widely available digital educational resources by key stakeholders to ensure optimal plastic surgery trainee education.

Communication Efficiency in a Face Transplant Recipient: Determinants and Therapeutic Implications.

We longitudinally assessed speech intelligibility (percent words correct/pwc), communication efficiency (intelligible words per minute/iwpm), temporal control markers (speech and pause coefficients of variation), and formant frequencies associated with lip motion in a 41-year-old face transplant recipient. Pwc and iwpm at 13 months post-transplantation were both higher than preoperative values. Multivariate regression demonstrated that temporal markers and all formant frequencies associated with lip motion were significant predictors (P < 0.05) of communication efficiency, highlighting the interplay of these variables in generating intelligible and effective speech. These findings can guide us in developing personalized rehabilitative approaches in face transplant recipients for optimal speech outcomes.

Levels of Evidence in Plastic Surgery Research: A 10-Year Bibliometric Analysis of 18,889 Publications From 4 Major Journals.

BACKGROUND: Improving the quality of research published in plastic surgery literature has been recognized as a difficult and time-intensive process. Despite significant progress over the last decade, leaders in the field continue to advocate for higher-quality studies to better inform clinical practice. OBJECTIVES: The aim of this study was to evaluate and analyze trends in the levels of evidence (LOEs) of the plastic surgery literature over the last decade in 4 major journals. METHODS: After systematic review of all articles published between 2008 and 2017 in Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Journal of Plastic, Reconstructive, and Aesthetic Surgery, and Aesthetic Surgery Journal (ASJ), included articles were assigned an LOE and classified according to study design and category. RESULTS: In total, 8211 articles were included. Case series and reports represented 36.1% and 13.6% of studies, respectively. Additionally, 27.2% were retrospective cohort studies, 8.2% prospective cohort studies, 3.9% systematic reviews, and 2.9% randomized controlled trials (RCTs). Overall, the percentage of Level I/II studies has increased from 10.9% in 2008 to 17.3% in 2017. ASJ published the greatest proportion of Level I/II studies (23.2%) and RCTs (5.1%) of all the journals. There were significant differences in the distribution of Level I/II studies by journal (P < 0.001) and category (P < 0.001). CONCLUSIONS: Over the past decade, plastic surgery journals have published higher-quality research and a significantly greater proportion of Level I and II studies. The field must continue to strive for robust study designs, while also recognizing the importance of lower-LOE research.

Risk Factors for Wound Complications Following Transmetatarsal Amputation in Patients With Diabetes.

BACKGROUND: The goal of our study was to evaluate risk factors for wound complications in patients with diabetes mellitus undergoing transmetatarsal amputations (TMAs), given the paucity of research on this subject. MATERIALS AND METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database. In this retrospective analysis, all surgical cases with a primary Current Procedural Terminology code for TMA from 2009 to 2015 were reviewed. RESULTS: A total of 2316 patients with diabetes mellitus who underwent TMA were identified. Overall wound complications occurred in 276 (11.9%) of patients. Univariate analysis showed that the operative time was significantly longer in patients who developed complications than those who did not (58.3 ± 39.5 versus 50.6 ± 39.4; P = 0.003). Furthermore, the rate of obesity was significantly higher among patients who developed wound complications than those who did not (47.1% versus 41.5%; P = 0.04). Multivariate analysis demonstrated that a longer operative time (odds ratio = 1.02; 95% confidence interval: 1.01-1.04; P = 0.01) and obesity (odds ratio = 1.60; 95% confidence interval: 1.06-2.40; P = 0.03) were independent risk factors for wound complications in our cohort. CONCLUSIONS: These findings emphasize the importance of having heightened clinical vigilance in obese patients with diabetes mellitus undergoing this procedure, close postoperative follow-up, and limiting operative time when possible.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction.

BACKGROUND: Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS: The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS: Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Preoperative Imaging for Facial Transplant: A Guide for Radiologists.

Facial transplant (FT) is a viable option for patients with severe craniomaxillofacial deformities. Transplant imaging requires coordination between radiologists and surgeons and an understanding of the merits and limitations of imaging modalities. Digital subtraction angiography and CT angiography are critical to mapping vascular anatomy, while volume-rendered CT allows evaluation of osseous defects and landmarks used for surgical cutting guides. This article highlights the components of successful FT imaging at two institutions and in two index cases. A deliberate stepwise approach to performance and interpretation of preoperative FT imaging, which consists of the modalities and protocols described here, is essential to seamless integration of the multidisciplinary FT team. ©RSNA, 2019 See discussion on this article by Lincoln .

Outcomes After Tooth-Bearing Maxillomandibular Facial Transplantation: Insights and Lessons Learned.

PURPOSE: To highlight the challenges and lessons learned in tooth-bearing maxillomandibular facial allotransplantation. PATIENTS AND METHODS: Two patients with ballistic composite facial injury underwent tooth-bearing maxillomandibular facial transplantation (FT) after informed consent and institutional review board approval. Patient 1 had undergone total face, double jaw, teeth, and tongue transplantation in March 2012. Patient 2 had undergone partial face, double jaw, and teeth transplantation in January 2018. Le Fort III and bilateral sagittal split skeletal osteotomies were performed in both transplants. Computerized surgical planning was used in both cases, and the allografts were transferred in intermaxillary fixation (IMF) with prefabricated dental splints before rigid skeletal fixation. RESULTS: Normal class I occlusion was achieved at the conclusion of each surgery. Patient 1 had developed a 2 × 2-mm palatal fistula in the early postoperative period and had also gradually developed class III malocclusion. Orthodontic treatment was started at 5 months after transplantation but failed. A Le Fort III advancement was performed 1 month later with successful restoration of class I occlusion. The palatal fistula was successfully repaired at 9 postoperative months. Patient 2 developed a postoperative palate and floor of mouth dehiscence, requiring palatal repair and hyoid and genioglossus advancement on postoperative day (POD) 11. Orthodontic treatment was initiated for Class II malocclusion. On POD 108, left mandibular nonunion was diagnosed. Left coronoidectomy, open reduction, and internal fixation were performed. IMF was maintained for 2 weeks. Orthodontic treatment was then resumed, with normalization of the occlusion by 10 months after FT. CONCLUSIONS: Maxillomandibular transplantation is a viable reconstructive solution for composite midface defects not amenable to autologous reconstruction. Improvement of functional outcomes and prevention of major complications rely on close attention to occlusal relationships, temporomandibular joint dynamics, dental health, and the intraoral donor-recipient soft tissue interface.

Three-Dimensional Affordable Stone Models for Cleft Lip Markings: A Prospective Study of Learner Satisfaction.

INTRODUCTION: Knowledge of surgical markings for unilateral cleft lip (UCL) repair is critical for surgical competency. However, few appropriate models are accessible to residents and affordable and accurately reproduce this 3-dimensional (3D) deformity. We propose that cleft care units have the capability of creating affordable 3D stone models to teach UCL markings. METHODS: Polyvinyl siloxane and SnapStone were used to create UCL stone models. Thirteen plastic surgery residents were prospectively recruited, provided with a textbook chapter and online module for studying surgical markings for UCL repair, and then asked to perform the markings on a UCL stone model and standardized patient photograph. Learner satisfaction was evaluated using a modified survey based on the Student Evaluation of Educational Quality survey. RESULTS: The production time of each model was 10 minutes, whereas the cost was $1.84. Participants reported that the stone model was more stimulating (4.77 ± 0.44 vs 3.92 ± 0.86; U = 38.0; P = 0.008), increased their interest more (4.70 ± 0.48 vs 3.53 ± 1.20; U = 33.5; P = 0.005), allowed better learning (4.61 ± 0.51 vs 3.08 ± 0.86; U = 10.0; P < 0.001), was clearer (4.62 ± 0.51 vs 3.15 ± 0.90; U = 12.5; P < 0.001), and was more effective for learning cleft lip markings (4.77 ± 0.44 vs 3.08 ± 1.04; U = 9.0; P < 0.001). They were also more likely to recommend it (4.85 ± 0.38 vs 3.15 ± 1.07; U = 7.0; P < 0.001). CONCLUSIONS: Plastic surgery residents report that 3D cleft lip stone models are superior training tools to learn cleft lip markings compared with patient photographs. These educational tools have the potential to overcome significant financial, logistic, and time constraints in teaching cleft lip surgery markings.

Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources.

INTRODUCTION: Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources. METHODS: Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison. RESULTS: Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003). CONCLUSIONS: Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

Ocular Considerations in Face Transplantation: Report of 2 Cases and Review of the Literature.

PURPOSE: Periorbital injuries are common in face transplantation (FT) candidates. It is therefore essential that the ophthalmologist play a central role in the multidisciplinary treatment of these patients. In this study, the authors perform a comprehensive review of all procedures involving periorbital components, provide an update for the ophthalmology community regarding the current state of the field, and present 2 cases. METHODS: A comprehensive review of the literature for all FT procedures including periorbital components was performed. The authors also present 2 patients who received FT including periorbital components for extensive facial disfigurement. One patient sustained high-energy avulsive ballistic injury and underwent a total face, double jaw, and tongue transplant in 2012. The second patient received a total face, eyelids, ears, and skeletal subunits transplant for extensive facial burns in 2015. RESULTS: Literature review demonstrated that 22 (54%) of the 41 patients undergoing FT received allografts containing periorbital components. Only 14 cases (64%) reported on the presence of ocular and periocular complications. The most common complications consisted of lower eyelid ectropion and lagophthalmos, and nearly all required revisional procedures. Both patients presented with significant periorbital scarring and demonstrated good visual acuity and aesthetic outcomes at postoperative follow up between 6 and 28 months. CONCLUSIONS: Face transplantation can address extensive facial and periorbital disfigurement with satisfactory functional and aesthetic outcomes. The majority of FT performed to date have included periorbital components, and postoperative ocular and periocular complications are common. It is critical for ophthalmologists to play a central role in the care of these patients.

Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database.

BACKGROUND: Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS: We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (ß = .62; P < .001). CONCLUSIONS: Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.

Fronto-Orbital Advancement: Description of Surgical Technique to Complement the Procedural Cognition Simulation in the Craniofacial Interactive Virtual Assistant-Professional Edition.

The surgical treatment of nonsyndromic craniosynostosis is one of the most common procedures performed by craniofacial surgeons. However, for residents and fellows, the high degree of difficulty and complex anatomy may result in slow progress along a steep learning curve. This is particularly important in the context of contemporary academic practice, where work-hour limits and other factors restrict operative exposure and opportunities for trainees to learn. These issues have prompted the development of surgical simulation modalities that, while prevalent in other surgical specialties, have not been fully adopted in reconstructive surgery.Among these resources is the Craniofacial Interactive Virtual Assistant - Professional Edition (CIVA-Pro), a procedural cognition simulator that is free of charge. By integrating 3-dimensional virtual animation, voice over, and high-definition intraoperative video, CIVA-Pro describes cardinal craniofacial surgery procedures in an engaging platform. In this study, a detailed, step-by-step description of the fronto-orbital advancement surgical technique to complement the corresponding CIVA-Pro module was presented. This synergistic combination of multimedia educational resources provides a unique didactic option for current trainees to prepare for surgery.

Combined Primary Cleft Lip and Palate Repair: Is It Safe?

BACKGROUND: Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS: A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (ß = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (ß = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION: Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

Incidence of Preventable Nonfatal Craniofacial Injuries and Implications for Facial Transplantation.

INTRODUCTION: The number of patients who may benefit from evaluation for face transplantation in the United States (US) remains largely unknown. The goal of our study was to better delineate the pool of patients who might benefit from face transplant evaluation based on the characteristics and mechanisms of injury of previously reported face transplant recipients. METHODS: The authors utilized data from the National Electronic Injury Surveillance System-All Injury Program in this study. The US Census Bureau data were used for population estimates. Inclusion and exclusion criteria were determined based on the characteristics of face transplant recipients to date, and the mechanisms of injury they sustained ultimately necessitating face transplantation. Statistical significance was reached if P <0.05. RESULTS: The estimated annual incidence of preventable craniofacial injuries from firearms (44,266-58,299; 31.7% increase), burns (5712-19,433; 240.2% increase), and animal attacks (5355-14,666; 173.9% increase) increased from 2005 to 2014, whereas the estimated annual incidence of craniofacial injuries from machinery (3927-2933; 25.3% decrease) decreased between 2005 and 2014. The authors estimate the annual incidence rate to fall between 32.1 per 100,000 and 58.1 per 100,000 among individuals aged 20 to 64 in the US. CONCLUSION: In this study, the authors estimate the annual incidence rate of individuals aged 20 to 64 in the US who may benefit from face transplant evaluation and believe that this quantification has the potential to initiate actionable discussions regarding geographical and financial factors affecting access to care in this patient population.

Obesity and Lower Extremity Reconstruction: Evaluating Body Mass Index as an Independent Risk Factor for Early Complications.

BACKGROUND: The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed to identify patients undergoing local- or free-flap reconstruction of the lower extremity between 2010 and 2015. Preoperative variables and outcomes were compared between obese (body mass index ≥ 30) and nonobese patients. Chi-square analysis and Fisher's exact test were used for categorical variables and t-tests for continuous variables. Multivariate regression was performed to control for confounders. RESULTS: Univariate analysis of medical and surgical outcomes revealed that obese patients undergoing local flaps of the lower extremity required a significantly longer operative time (187.7 ± 123.2 vs. 166.2 ± 111.7 minutes; p = 0.003) and had significantly higher rates of superficial surgical site infection (SSI; 7.2% vs. 4.5%; p = 0.04). On univariate analysis, there were no significant differences in any postoperative outcomes between obese and nonobese patients undergoing microvascular free flaps of the lower extremity.On multivariate regression analysis, obesity was not an independent risk factor for superficial SSI (odds ratio = 1.01, p = 0.98) or increased operative time (ß = 16.01, p = 0.14) for local flaps of the lower extremity. CONCLUSION: Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation.

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.