Immunologic Outcomes in Cross-Sex Solid Organ Transplants: A Systematic Review and Meta-Analysis to Inform Vascularized Composite Allotransplantation.

BACKGROUND: Of nearly 90 hand and 50 face transplant recipients, only five have received a cross-sex vascularized composite allotransplantation (CS-VCA). CS-VCA has the potential to expand the donor pool and has been proven anatomically feasible and ethically acceptable in previous studies. However, there is a lack of immunologic data. This study evaluated the immunologic feasibility of CS-VCA through analysis of the solid organ transplant literature, given the paucity of CS-VCA data. The authors hypothesize that rates of acute rejection (AR) and graft survival (GS) in CS versus same-sex (SS) solid organ transplantation are similar. METHODS: A systematic review and meta-analysis were performed. Studies comparing GS or AR episodes in CS and SS adult kidney (KT) and liver transplant (LT) populations were included. Odds ratios were calculated for overall GS and AR for all SS and CS transplant combinations [male-to-female (MTF), female-to-male, and overall]. RESULTS: A total of 693 articles were initially identified with 25 included in the meta-analysis. No significant difference in GS was noted between SS-KT versus CS-KT [OR, 1.04 (95% CI, 1.00 to 1.07); P = 0.07), SS-KT versus MTF-KT [OR, 0.97 (95% CI, 0.90 to 1.04); P = 0.41), and SS-LT versus MTF-LT [OR, 0.95 (95% CI, 0.91 to 1.00); P = 0.05). No significant difference in AR was noted between SS-KT versus MTF-KT [OR, 0.99 (95% CI, 0.96 to 1.02); P = 0.57), SS-LT versus CS-LT [OR, 0.78 (95% CI, 0.53 to 1.16); P = 0.22], or SS-LT versus female-to-male LT [OR, 1.03 (95% CI, 0.95 to 1.12); P = 0.47]. For the remaining pairings, GS was significantly increased and AR was significantly decreased in the SS transplants. CONCLUSIONS: Published data suggest immunologic feasibility of CS-KT and CS-LT with the potential for generalization to the VCA population. CLINICAL RELEVANCE STATEMENT: In theory, CS-VCA could expand the potential donor pool, ultimately leading to decreased wait times for recipients and improve the likelihood of establishing a immunologically favorable donor-recipient match.

Gender-affirming hysterectomy in the United States: A comparative outcomes analysis and potential implications for uterine transplantation.

PURPOSE: Hysterectomy is a gynecological procedure sometimes performed as part of the gender-affirming process for transgender and gender-expansive patients assigned female at birth. Our goal was to compare surgical outcomes between patients undergoing gender-affirming hysterectomy and patients undergoing hysterectomy for benign menstrual disorders. We then explored the implications of gender-affirming hysterectomy for uterine transplantation. METHODS: We performed a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2009 through 2018. We identified patients undergoing hysterectomy in the United States based on Current Procedural Terminology code. We used the International Classification of Diseases 9 or 10 codes to identify patients with benign menstrual disorders (non-gender-affirming group) and gender dysphoria (gender-affirming group). We compared patient characteristics and surgical complications. RESULTS: Of the 40,742 patients that met inclusion criteria, 526 (1.3%) patients were individuals with gender dysphoria. Compared to patients who underwent hysterectomy for benign menstrual disorders, gender-affirming patients were younger, were healthier, had a lower prevalence of diabetes, and were more likely to undergo surgery in the outpatient setting, with shorter time to discharge. Complication rates were similar between groups. Logistic regression controlling for the American Society of Anesthesiology classification determined the difference of return to the operating room was not statistically significant (OR 1.082; 95% CI, 0.56-2.10; p = 0.816). CONCLUSION: Gender-affirming hysterectomy has a safety profile similar to hysterectomy performed for benign menstrual disorders. Researchers should further explore the possibility of uterus donation among these patients as they may be suitable candidates.

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.

Evolution of a Plastic Surgery Summer Research Program: Lessons Learned from Programmatic Evaluation and Quality Enhancement.

Early surgical exposure and research fellowships can influence medical students' specialty choice, increase academic productivity, and impact residency match. However, to our knowledge, there is no published guidance on the programmatic evaluation and quality enhancement necessary for the sustainability of formal plastic surgery summer research programs for first year medical students. We present seven years (2013-2020) of institutional experience in an effort to inform program development at other institutions. Methods: From 2013 to 2016, a sole basic science research arm existed. In 2017, a clinical research arm was introduced, with several supplemental activities, including surgical skills curriculum. A formalized selection process was instituted in 2014. Participant feedback was analyzed annually. Long-term outcomes included continued research commitment, productivity, and residency match. Results: The applicant pool reached 96 applicants in 2019, with 85% from outside institutions. Acceptance rate reached 7% in 2020. With adherence to a scoring rubric for applicant evaluation, good to excellent interrater reliability was achieved (intraclass correlation coefficient = 0.75). Long-term outcomes showed that on average per year, 28% of participants continued involvement in departmental research and 29% returned for dedicated research. Upon finishing medical school, participants had a mean of 7 ± 4 peer-reviewed publications. In total, 62% of participants matched into a surgical residency program, with 54% in integrated plastic surgery. Conclusions: A research program designed for first year medical students interested in plastic surgery can achieve academic goals. Students are provided with mentorship, networking opportunities, and tools for self-guided learning and career development.

Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery?

BACKGROUND: No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs. METHODS: The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database. RESULTS: Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure. CONCLUSIONS: Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.

Patient-centred outcomes and dental implant placement in computer-aided free flap mandibular reconstruction: a systematic review and meta-analysis.

Computerised surgical planning (CSP) and computer-aided design and manufacturing (CAD/CAM) have been demonstrated to increase surgical accuracy and reduce operative time in free flap mandibular reconstruction, but evidence is lacking as to their impact on patient-centred outcomes. Implant-supported dental prostheses, however, have been associated with improved quality of life outcomes following free flap mandibular reconstruction. We aim to review reported patient-centred outcomes in mandibular reconstruction with CSP and CAD/CAM and determine whether use of these technologies is associated with higher rates of dental implant placement following free flap mandibular reconstruction. On December 20, 2020, a systematic review and meta-analysis were conducted according to PRISMA guidelines for studies reporting quality of life, functional outcomes, and rates of dental implant placement in computer-aided free flap mandibular reconstruction. A random-effects meta-analysis was performed to compare dental implant placement rates between surgeries using CSP and those using conventional freehand techniques. A total of 767 articles were screened. Nine articles reporting patient-centred outcomes and 16 articles reporting dental implant outcomes were reviewed. Of those reporting dental implant outcomes, five articles, representing a total of 302 cases, were included in the meta-analysis. Use of CSP was associated with a significant increase in the likelihood of dental implant placement, with an odds ratio of 2.70 (95% CI 1.52 to 4.79, p = 0.0007). Standardised reporting methods and controlled studies are needed to further investigate the impact of CSP and CAD/CAM technologies on functional outcomes and patient-reported quality of life in free flap mandibular reconstruction. Use of CSP and CAD/CAM technologies is associated with higher rates of dental implant placement in patients undergoing free flap mandibular reconstruction when compared to conventional freehand techniques.

Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes.

Purpose: Gender-affirming surgery (GAS) has become an important component of the treatment of gender dysphoria. Although the frequency of these procedures is on the rise, a complete safety profile has yet to be established. The goal of our study is to analyze the trends and outcomes of these surgical procedures. Methods: All patients with a primary diagnosis of gender dysphoria undergoing GAS were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between the years 2009 and 2018. Patient demographics and 30-day postoperative outcomes were recorded. We performed a multivariate logistic regression for postoperative complications, controlling for several confounding variables. Results: We identified 2956 patients, of which 1767 (59.78%) were transgender men and 1189 (40.22%) were transgender women. The number of patients undergoing GAS per year increased from 7 in 2010 to 1069 in 2018, a 152-fold increase. For patients undergoing top surgery, Black race (odds ratio [OR] = 2.255, 95% confidence interval [CI] 1.189-4.277, p = 0.013) and diabetes (OR = 4.156, 95% CI 1.571-10.999, p = 0.004) were independent predictors of 30-day postoperative complications. For patients undergoing bottom surgery, total operative time in minutes (OR = 1.005, 95% CI 1.003-1.007, p = 0.001) was an independent predictor of 30-day postoperative complications. Conclusion: The demand for GAS has increased exponentially since 2014. While postoperative complication rates are acceptable, Black race was shown to be an independent predictor of postoperative morbidity in patients undergoing top surgery, a finding that calls for further investigation of racial disparities among transgender patients.

Measurements of motor functional outcomes in facial transplantation: A systematic review.

Although the ethical and technical feasibility of face transplant (FT) has been established, current literature lacks consensus on functional outcomes monitoring for recipients. This systematic review aims to appraise and summarize the current literature on tools used to assess motor functional outcomes in FT. This study complied with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). On September 15, 2020, two reviewers conducted independent electronic searches using medical literature databases, without language or time frame limitations. Eligibility criteria included studies reporting on the evaluation of motor functional outcomes in face transplant recipients. Of 451 papers found in the literature, 12 fulfilled the study inclusion criteria. The reported tools included clinical scales/examinations, electromyography, optical movement tracking devices, muscle volumetric measurement using magnetic resonance imaging, and software-based video and photo analyses. The frequency of data collection varied from every three months to every year. Publications reporting on motor functional outcomes tracking tools vary broadly and demonstrate a lack of consensus. Although quantitative measurements are desirable, adapted clinical scales are still the current standard of care.

The First Successful Combined Full Face and Bilateral Hand Transplant.

BACKGROUND: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS: A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS: Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS: Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Techniques and Trends of Facial Feminization Surgery: A Systematic Review and Representative Case Report.

BACKGROUND: Facial feminization surgery is composed of a variety of craniomaxillofacial surgical procedures that are increasingly sought after by male-to-female transgender patients and by those seeking feminization of the face. Facial feminization surgery can play a prominent role in alleviating gender dysphoria. In consideration of an observed increase in gender-affirming procedures performed in recent years, a broad knowledge base in the techniques, outcomes, and challenges of facial feminization surgery should be established by surgeons offering these procedures. Our review was designed to critically appraise the current literature and inform future advancements in gender-affirming surgical practice. In addition, we detail a representative case to illustrate the senior author's approach to full facial feminization. METHODS: A comprehensive literature search of the PubMed, EMBASE, and Cochrane databases was conducted for studies published through June 2020 using following the search terms: "Face" OR "facial" OR "craniofacial" AND "Feminization" OR "Feminization Surgery" OR "Gender Reassignment" OR "Gender Affirming Surgery" OR "Gender Confirmation Surgery." Data on procedures, outcomes, patient age, follow-up time, complications, and patient satisfaction were collected. The data were categorized by facial thirds and then further stratified by facial feature. RESULTS: Our search yielded 388 articles. Thirty articles fit our inclusion criteria, and of these, 23 articles were included in the review. We extracted primary data pertaining to 3554 patients with an age range of 18 to 73 who underwent 8506 total procedures. Most of the procedures addressed the upper facial third (hairline, forehead, and brow), comprising 49.1% of total procedures performed. Further categorization by facial feature revealed that the most commonly addressed feature was the forehead (34.6% of procedures), followed by the nose (12.8%) and the chin (12.2%). In studies that used quantitative measures to gauge patient-reported outcomes, satisfaction was high. CONCLUSIONS: Facial feminization surgery seems to be safe, whether it is conducted in a single stage or as a staged procedure. Patients report high satisfaction and better gender congruency after facial feminization procedures. Further research is needed to establish best surgical practice and gauge patient satisfaction beyond the length of average follow-up and determine the frequency with which adjunctive procedures are sought out.

Imaging of Facial Reconstruction and Face Transplantation.

Pre- and postoperative imaging is increasingly used in plastic and reconstructive surgery for the evaluation of bony and soft tissue anatomy. Imaging plays an important role in preoperative planning. In the postoperative setting, imaging is used for the assessment of surgical positioning, bone healing and fusion, and for the assessment of early or delayed surgical complications. This article will focus on imaging performed for surgical reconstruction of the face, including orthognathic surgery, facial feminization procedures for gender dysphoria, and face transplantation.

Trends, Gaps, and Collaboration in Facial Transplantation: A Bibliometric Study.

Facial transplantation (FT) has advanced extensively over the past two decades, with over 40 transplants performed to date. Over this time, the FT literature has evolved as well, from early discussions on ethics and feasibility of FT to functional outcomes reports more recently. We aimed to evaluate the entire body of FT literature to identify trends in publications over time in addition to current existing gaps in the field. Methods: We conducted a comprehensive bibliometric analysis of the published FT literature from 1994, the first year FT was mentioned in the literature, through July 2020. Co-authorship and keyword information were analyzed using VOSviewer. Articles were manually categorized based on keywords and their aim to provide insight on trends. Results: A total of 2182 articles were identified. Analysis identified the top 50 publishing authors in the field and demonstrated co-authorship linkage between 84.8% of the top 1000 authors. Clinical surgical techniques, protocols, and experiments were the most frequently published category. Within clinical outcomes, immunologic outcomes were most frequent, while psychosocial were the lowest. Gaps were identified in long-term outcomes reporting and patient-reported outcomes, with physician-reported outcomes heavily outweighing patient-reported outcomes. Conclusions: As the field continues to evolve, rigorous tracking of publication patterns over time will encourage development of a more robust evidence base, identify gaps in the published literature, and highlight opportunities to enhance collaboration in the field. This data will provide surgeons and research institutions with information to further improve this life-changing procedure.

Consideration of Human Immunodeficiency Status in Patients Seeking Facial Feminization Surgery.

ABSTRACT: Facial feminization surgery (FFS) with its proven safety and efficacy has become a mainstay surgical approach for those desiring gender-specific perceived feminine facial aesthetics. To date, specific characteristics of patients seeking FFS have been limited, with no studies investigating the role of the Human Immunodeficiency Virus (HIV) on FFS outcomes. The potential clinical implications of HIV and more specifically HIV-associated lipodystrophy, which can cause facial lipoatrophy, require further investigation. Given the importance of midface projection in feminizing the face, the authors aimed to investigate any associations HIV or Highly Active Antiretroviral Therapy may have on outcomes, including clinical consequences of facial lipoatrophy. The authors performed a retrospective chart review of all patients with a diagnosis of gender dysphoria referred to the senior author (EDR) for FFS between 2017 and 2020. Patients were grouped based on HIV status and demographics, history, and outcomes were assessed. Seventy-seven patients were included, with 28 patients (36.4%) having a diagnosis of HIV. A total of 25 (32.5%) and 23 (29.9%) patients underwent malar fat grafting and cheek implants, respectively. No significant difference was found between HIV-positive and HIV-negative patients when looking at the use of malar fat grafting, cheek implants, age, or complication rates. To the best of our knowledge, this study presents the largest cohort of HIV status assessment of FFS patients to date. Future studies, particularly on the long-term outcomes, are warranted, as is continued information sharing among providers and centers performing FFS, in order to continue advancing the literature and subsequently patient care.

Comparative Outcomes of Partial and Full Facial Feminization Surgery: A Retrospective Cohort Study.

BACKGROUND: The demand for facial feminization surgery (FFS) amongst transgender women is on the rise, and requests for a single-stage full FFS (F-FFS) are becoming more frequent. The specific aim of this article is to present our institutional experience with both partial-FFS (P-FFS) and F-FFS with a specific emphasis on safety of each approach. METHODS: We examined the electronic medical record of all patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation at our institution, between June 2017 and October 2020. Patients were sub-grouped into those who underwent F-FFS (upper, middle, and lower facial thirds in a single anesthetic event) and those who underwent P-FFS. Univariate analysis was used to assess for difference in postoperative complications. RESULTS: We identified 77 patients who underwent 382 total procedures. The mean follow-up time was 7.5 months (Sd = 7.3) (interquartile range 1.75-12.0 months). Fifty-one (71.4%) patients underwent F-FFS and 21 (28.6%) patients underwent P-FFS. Compared to P-FFS, F-FFS was not associated with an increase in postoperative complication (1 out of 21 [4.8%] versus 4 out of 51 [7.8%]) ( P < 0.556). When comparing characteristics of patients with postoperative complications to patients with no postoperative complications, the average body mass index was significantly higher (30.9 versus 25.4, respectively). ( P < 0.029). CONCLUSIONS: Full-FFS is a set of procedures that has gained increased popularity among male-to-female transgender patients. Our results support the understanding that F-FFS is a safe and reliable approach, which may be preferable to patients and providers alike.

Is Digital Animation Superior to Text Resources for Facial Transplantation Education? A Randomized Controlled Trial.

BACKGROUND: Facial transplantation is a complex surgical procedure that requires education of medical professionals, patients, and the general public. The objective of this randomized controlled trial was to compare the educational efficacy of facial transplantation digital animation versus text resources for teaching medical students a complex surgical procedure and its applicable anatomical and surgical principles. METHODS: Medical student volunteers were recruited and prospectively randomized to an animation or a text group. Students completed preintervention and postintervention assessments of confidence and knowledge of head and neck anatomy and facial transplantation. Student Evaluations of Educational Quality survey assessed student satisfaction with both tools following study crossover. Knowledge assessment was developed using National Board of Medical Examiners guidelines and content validated by four experts. The Cohen d statistic was used to measure the effect size of each intervention. RESULTS: Thirty-six students were assigned randomly to the animation group (n = 19) or the text (n = 17) group. Postintervention analysis demonstrated significantly higher performance scores in the animation group compared to the text group (p = 0.029). The animation group had a larger effect size (Cohen d = 1.96 versus 1.27). Only students in the animation group reported significantly improved confidence in head and neck anatomy after the intervention (p = 0.002). Both groups demonstrated significantly increased postintervention confidence in knowledge of facial transplantation (p < 0.001). Satisfaction scores revealed that students significantly favored the animation resource (p < 0.001). CONCLUSIONS: Animation can be an effective tool for facial transplantation education and results in improved student knowledge, confidence, and satisfaction compared to text resources. Facial transplantation can also be used as an educational framework for teaching medical students anatomical and surgical principles.

Plastic Surgery amidst the Pandemic: The New York University Experience at the Epicenter of the COVID-19 Crisis.

SUMMARY: The coronavirus disease of 2019 pandemic became a global threat in a matter of weeks, with its future implications yet to be defined. New York City was swiftly declared the epicenter of the pandemic in the United States as case numbers grew exponentially in a matter of days, quickly threatening to overwhelm the capacity of the health care system. This burgeoning crisis led practitioners across specialties to adapt and mobilize rapidly. Plastic surgeons and trainees within the New York University Langone Health system faced uncertainty in terms of future practice, in addition to immediate and long-term effects on undergraduate and graduate medical education. The administration remained vigilant and adaptive, enacting departmental policies prioritizing safety and productivity, with early deployment of faculty for clinical support at the front lines. The authors anticipate that this pandemic will have far-reaching effects on the future of plastic surgery education, trends in the pursuit of elective surgical procedures, and considerable consequences for certain research endeavors. Undoubtedly, there will be substantial impact on the physical and mental well-being of health care practitioners across specialties. Coordinated efforts and clear lines of communication between the Department of Plastic Surgery and its faculty and trainees allowed a concerted effort toward the immediate challenge of tempering the spread of coronavirus disease of 2019 and preserving structure and throughput for education and research. Adaptation and creativity have ultimately allowed for early rebooting of in-person clinical and surgical practice. The authors present their coordinated efforts and lessons gleaned from their experience to inform their community's preparedness as this formidable challenge evolves.

Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style.

BACKGROUND: Facial feminization surgery (FFS) plays an instrumental role in the process of gender affirmation. These procedures are becoming increasingly appreciated for their ability to improve patient satisfaction and gender identity in a way that alleviates gender dysphoria and improves the quality of life. Despite the recent surge in popularity across the US, the current literature lacks evidence on the safety profile of combined facial feminization procedures. Our goal was to determine the safety profile of facial feminization procedures registered on a national surgical database. METHODS: Patients with a primary diagnosis of gender dysphoria undergoing facial surgical procedures were identified from the National Surgical Quality Improvement Program database between the years 2013 and 2018. Demographic characteristics along with 30-day postoperative complications were recorded. Logistic regression models adjusted for confounders were used to determine the independent predictors of postoperative complications. RESULTS: A cohort of 77 patients who underwent a total of 220 procedures was identified. The number of patients undergoing surgery per year increased from three (3.9%) in 2013 to 41 (53.2%) in 2018, a 13.6-fold increase. The most commonly performed procedure was forehead contouring/frontal sinus setback, performed on 52 patients (67.5%), followed by orbital contouring (n = 37, 48%), rhinoplasty (n = 34, 44%), mandibuloplasty (n = 34, 44%), chondrolaryngoplasty (n = 27, 35.1%), genioplasty (n = 11, 14%), brow lift (n = 9, 11.7%), cheek augmentation (n = 9, 11.7%), and lip lift (n = 7, 9.1%). The number of patients who underwent 5 or more procedures in a single anesthetic event was 41 (53.2%). The complication rate was 3.9%. Univariate analysis suggested an association between older age and postoperative morbidity (P  < 0.02). However, this was not found to be an independent predictor on multivariate analysis adjusted for confounders (P < 0.083). Additionally, an increase in operative time and the number of procedures performed during a single anesthetic were not independent predictors of 30-day postoperative complications (P < 0.317 and P  < 0.19, respectively). CONCLUSIONS: FFS can be safely performed and has a low risk of postoperative morbidity. The number of patients seeking FFS surgery has risen exponentially, with the highest demand seen for the reconstruction of the upper facial third. These findings should guide expectations for patients seeking FFS, as well as for plastic surgeons looking to perform multiple procedures per anesthetic event.