Primary Distal Interphalangeal Joint Tenosynovial Chondromatosis of the Small Finger: A Case Report With Literature Review.

Primary synovial chondromatosis is a rare, benign proliferative disease of the joint synovium, tenosynovium, or bursal lining, in which cartilage metaplasia leads to the development of multiple intra-articular and periarticular loose osteocartilaginous bodies. This disease usually involves larger joints (knee, hip, elbow, and shoulder), but it has also rarely been reported in the hand. Patients with this disease complain of pain, swelling, nodules, and decreased range of motion of the affected joint. Due to its nonspecific symptoms and low prevalence, this disease often goes misdiagnosed, leading to delays in patient treatment. In the literature to date, there are only a few reports of primary synovial chondromatosis. In this case report, we present a patient with a rare case of primary synovial chondromatosis localized to right small finger distal interphalangeal joint.

LDB1 Enforces Stability on Direct and Indirect Oncoprotein Partners in Leukemia.

The LMO2/LDB1 macromolecular complex is critical in hematopoietic stem and progenitor cell specification and in the development of acute leukemia. This complex is comprised of core subunits of LMO2 and LDB1 as well as single-stranded DNA-binding protein (SSBP) cofactors and DNA-binding basic helix-loop-helix (bHLH) and GATA transcription factors. We analyzed the steady-state abundance and kinetic stability of LMO2 and its partners via Halo protein tagging in conjunction with variant proteins deficient in binding their respective direct protein partners. We discovered a hierarchy of protein stabilities (with half-lives in descending order) as follows: LDB1 > SSBP > LMO2 > TAL1. Importantly, LDB1 is a remarkably stable protein that confers enhanced stability upon direct and indirect partners, thereby nucleating the formation of the multisubunit protein complex. The data imply that free subunits are more rapidly degraded than those incorporated within the LMO2/LDB1 complex. Our studies provided significant insights into LMO2/LDB1 macromolecular protein complex assembly and stability, which has implications for understanding its role in blood cell formation and for therapeutically targeting this complex in human leukemias.

The "Crumple Zone" hypothesis: Association of frontal sinus volume and cerebral injury after craniofacial trauma.

PURPOSE: The paranasal sinuses are complex anatomical structures of unknown significance. One hypothesis theorizes that the sinuses, in the event of a traumatic injury, function as a crumple zone to distribute and absorb energy to protect the brain and other critical structures. The current study investigates the association between frontal sinus (FS) volume and the severity of cerebral insults following craniofacial trauma. METHODS: All patients with FS fracture admitted to a level 1 trauma center from 2011 to 2014 were retrospectively reviewed. FS volumes were measured from computed tomography (CT) on admission using a proprietary region growing segmentation tool. Head injuries were classified based on the presence of specific types of intracranial pathology and their corresponding Marshall Score. RESULTS: FS fracture was identified on the admission CT in 165 patients. Male patients had significantly larger FS volume compared to females (8.4 ± 6.3 vs. 4.0 ± 2.9 cm3, p < 0.001). Smaller FS volume was significantly associated with a worse Marshall Score (p = 0.041) and a higher incidence of cerebral contusion (p = 0.016) independent of age, gender, mechanism, ISS, and admission GCS. The inverse correlation between FS volume and the Marshall Score was also statistically significant (Spearman correlation coefficient r = -0.19, p = 0.015). Smaller FS volume was observed in patients who suffered intracranial insults, underwent neurosurgical interventions, and had worse clinical outcomes and trended towards significance with respect to an association with subarachnoid hemorrhage (p = 0.074) and subdural hematoma (p = 0.080), and had a statistically significant association with longer length of stay (p < 0.001). CONCLUSION: FS volume is inversely correlated with the severity of intracranial pathology following craniofacial trauma. Our findings are consistent with the "crumple zone" hypothesis and suggest that the FS likely plays a role in mitigating intracranial injury. Furthermore, FS volume is significantly different between male and female patients. This is a novel finding that warrants further validation.

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations.

UNLABELLED: Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury. METHODS: Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed. RESULTS: A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels). CONCLUSIONS: Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

A Novel Microsurgical Model for Heterotopic, En Bloc Chest Wall, Thymus, and Heart Transplantation in Mice.

Exploration of novel strategies in organ transplantation to prolong allograft survival and minimizing the need for long-term maintenance immunosuppression must be pursued. Employing vascularized bone marrow transplantation and co-transplantation of the thymus have shown promise in this regard in various animal models. Vascularized bone marrow transplantation allows for the uninterrupted transfer of donor bone marrow cells within the preserved donor microenvironment, and the incorporation of thymus tissue with vascularized bone marrow transplantation has shown to increase T-cell chimerism ultimately playing a supportive role in the induction of immune regulation. The combination of solid organ and vascularized composite allotransplantation can uniquely combine these strategies in the form of a novel transplant model. Murine models serve as an excellent paradigm to explore the mechanisms of acute and chronic rejection, chimerism, and tolerance induction, thus providing the foundation to propagate superior allograft survival strategies for larger animal models and future clinical application. Herein, we developed a novel heterotopic en bloc chest wall, thymus, and heart transplant model in mice using a cervical non-suture cuff technique. The experience in syngeneic and allogeneic transplant settings is described for future broader immunological investigations via an instructional manuscript and video supplement.

Which Factors Are Associated with Open Reduction of Adult Mandibular Condylar Injuries?

BACKGROUND: The purpose of this study was to identify factors associated with the decision to perform open reduction and internal fixation of mandibular condylar fractures. METHODS: This was a retrospective cohort study of patients with mandibular condylar fractures managed by the plastic and reconstructive surgery, oral and maxillofacial surgery, and otorhinolaryngology services over a 15-year period. Bivariate associations and a multiple logistic regression model were computed for injury characteristics that were associated with open reduction and internal fixation. For all analyses, a value of p ≤ 0.05 was considered significant. RESULTS: Six hundred fifty-four condylar injuries were identified in 547 patients. The sample's mean age was 36.0 ± 16.5 years, 20.5 percent were women, and 63 percent were Caucasian. The most common mechanisms of injury were motor vehicle collisions (49 percent), 53.4 percent involved the subcondylar region and 20 percent were bilateral injuries. Associated noncondylar mandibular fractures were present in 60 percent of cases; 20.7 percent were managed with open reduction and internal fixation. The overall complication rate was 21.6 percent. In a multiple logistic regression model, factors associated with an increased likelihood of open reduction and internal fixation were the presence of extracondylar mandibular injuries, condylar neck or subcondylar region injuries, increasing dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery (p ≤ 0.04). CONCLUSIONS: Increasing severity of mandibular injury, lower level of fracture, joint dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery are associated with open reduction and internal fixation of mandibular condylar injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Defining Population-Specific Craniofacial Fracture Patterns and Resource Use in Geriatric Patients: A Comparative Study of Blunt Craniofacial Fractures in Geriatric versus Nongeriatric Adult Patients.

BACKGROUND: This study investigates the hypothesis that mechanisms of injury, fracture patterns, and burden to the health care system differ between geriatric and nongeriatric populations sustaining blunt-force craniofacial trauma. METHODS: A 5-year retrospective chart review of patient records and computed tomographic imaging was performed. Demographic and outcome data were extracted for equally numbered samples of blunt-mechanism facial fracture patients aged 60 years or older (geriatric), and adult patients aged 18 to 59 years (adult nongeriatric). Comparisons were made between these two populations using t tests and multivariable logistic regression. RESULTS: One thousand eighty-seven geriatric and 1087 nongeriatric patients were included. Geriatric patients were significantly more likely to be Caucasian, female, and have sustained fractures as the result of falling. They also had significantly longer hospital stays, were more likely to die, and were more likely to be discharged to home with services. Mandible fractures and panfacial fractures were significantly more common in the nongeriatric population. Geriatric age was associated with doubled length of hospitalization for patients with midface fractures. Logistic regression revealed that significantly higher incidences of orbital floor, maxillary, and condylar fractures in geriatric patients were dependent on geriatric age status, rather than mechanism of injury alone. CONCLUSIONS: Resource allocation for geriatric patients with craniofacial trauma should differ from that of their nongeriatric adult counterparts, with more resources allocated to supportive care during hospitalization and assistive care after discharge. The authors' data indicate that structural and biological changes in the craniofacial skeleton contribute to differences in fracture location independent of mechanism of injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Treatment Outcomes following Traumatic Optic Neuropathy.

BACKGROUND: Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision. METHODS: Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion. RESULTS: A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 ± 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15). CONCLUSIONS: The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A comprehensive examination of topographic thickness of skin in the human face.

BACKGROUND: Knowledge of topographic skin thickness is important to plastic surgery of the face as it may guide resection and restoration in oncologic, aesthetic, and reconstructive procedures. OBJECTIVE: The purpose of this study is to report the relative thickness of the face throughout 39 distinct subunits. METHODS: Full-thickness punch biopsy samples were obtained at 39 predetermined anatomic locations of the face from 10 human cadaveric heads. Tissue was fixed in paraffin-embedded slides and analyzed using triplicate measurement of dermis and epidermis using computerized measurements. Data were analyzed using univariate statistical analysis and expressed as mean thickness values and relative thickness (RT) values based on the thinnest portion of the face. RESULTS: The area of the face with the thickest dermis was the lower nasal sidewall (1969.2 µm, dRT: 2.59), and the thinnest was the upper medial eyelid (758.9 µm, dRT: 1.00). The area with the thickest epidermis was the upper lip (62.6 µm, eRT: 2.12), and the thinnest was the posterior auricular skin (29.6 µm, eRT: 1.00). Our results confirm that eyelid skin is the thinnest in the face. The thickest portions of the skin appeared to be in the lower nasal sidewall, but the measurements are comparable to those in the ala and posterior auricular skin, which are novel findings. CONCLUSIONS: The greatest epidermal, dermal and total skin thickness are found in the upper lip, right lower nasal sidewall, and left lower nasal sidewall respectively. The least epidermal skin thickness is in the posterior auricular skin. The least dermal skin thickness, and the least total skin thickness, are both in the upper medial eyelid.

Extracapsular Mandibular Condyle Fractures Are Associated with Severe Blunt Internal Carotid Artery Injury: Analysis of 605 Patients.

BACKGROUND: Mandibular condyle fractures are common following facial trauma and carry an increased risk for concomitant blunt carotid artery injuries. Further elucidation of this relationship may improve vascular injury screening and management. METHODS: A retrospective cohort study was performed for all patients sustaining condylar fractures presenting to a large trauma center over twelve years. Fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (1, condylar head; 2, condylar neck; and 3, extracapsular condylar base). Carotid artery injury severity was based on the Biffl scale. Severe vascular injury was defined as a Biffl score greater than I. RESULTS: 605 patients were identified with mandibular condyle fractures consisting of 21.0 percent (n = 127) condylar head; 26.8 percent (n = 162) condylar neck; and 52.2 percent (n = 316) extracapsular condylar base. The incidence of vascular injuries in this population was 5.5 percent (n = 33), of which 75.8 percent (n = 25) were severe. Severe vascular injuries occurred in 1.6 percent (n = 2) of condylar head, 2.5 percent (n = 4) of condylar neck, and 6.0 percent (n = 19) of extracapsular condylar base fractures (p < 0.05). Extracapsular condylar base fractures were independently associated with a 2.94-fold increased risk of a severe blunt carotid artery injury compared with other condyle fractures on multivariable analysis (p < 0.05). CONCLUSIONS: Extracapsular subcondylar fractures should heighten suspicion for concomitant blunt carotid artery injury. The data support a force transmission mechanism of injury in addition to direct injury from bony fragments. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Risk, II.

Manson's point: A facial landmark to identify the facial artery.

INTRODUCTION: The anatomy of the facial artery, its tortuosity, and branch patterns are well documented. To date, a reliable method of identifying the facial artery, based on surface landmarks, has not been described. The purpose of this study is to characterize the relationship of the facial artery with several facial topographic landmarks, and to identify a location where the facial artery could predictably be identified. METHODS: Following institutional review board approval, 20 hemifacial dissections on 10 cadaveric heads were performed. Distances from the facial artery to the oral commissure, mandibular angle, lateral canthus, and Manson's point were measured. Distances were measured and confirmed clinically using Doppler examination in 20 hemifaces of 10 healthy volunteers. RESULTS: Manson's point identifies the facial artery with 100% accuracy and precision, within a 3 mm radius in both cadaveric specimens and living human subjects. Cadaveric measurements demonstrated that the facial artery is located 19 mm ± 5.5 from the oral commissure, 31 mm ± 6.8 from the mandibular angle, 92 mm ± 8.0 from the lateral canthus. Doppler examination on healthy volunteers (5 male, 5 female) demonstrated measurements of 18 mm ± 4.0, 50 mm ± 6.4, and 79 mm ± 8.2, respectively. CONCLUSIONS: The identification of the facial artery is critical for the craniofacial surgeon in order to avoid inadvertent injury, plan for local flaps, and in preparation of a recipient vessel for free tissue microvascular reconstruction. Manson's point can aid the surgeon in consistently indentifying the facial artery.

Microsurgical Reconstruction of Complex Scalp Defects: An Appraisal of Flap Selection and the Timing of Complications.

BACKGROUND: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications. METHODS: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed. RESULTS: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2 ± 21.4 years (range, 23-90 years). All free tissue transfers (n = 20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6 ± 67.2 cm(2) (range, 35-285 cm(2)), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1 ± 87.3 cm(2) (range, 42-336 cm(2)). Early complications (<30 days following surgery) occurred in 21.1% of patients and late complications (>30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P = 0.079). CONCLUSIONS: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.

Defining the Role of Skin and Mucosal Biopsy in Facial Allotransplantation: A 2-Year Review and Analysis of Histology.

BACKGROUND: The implications of allograft skin and mucosal biopsy findings on classification of rejection and treatment remain unclear. METHODS: Following facial allotransplantation, scheduled surveillance allograft skin and mucosal biopsy specimens were obtained. Clinical concern for acute rejection prompted biopsies off schedule. Compilation of biopsy results, Banff grading, immunosuppression, and clinical correlation were critically reviewed for a 2-year follow-up. RESULTS: A total of 39 biopsy specimens at 21 time points were obtained for analysis, including allograft skin (n = 21), mucosa (n = 17), and a lesion (n = 1). The patient had three episodes of acute rejection warranting treatment. Discordance between skin and mucosa occurred in 55.6 percent of biopsy specimens (p = 0.01). Mucosa concordance with the clinical evaluation occurred in 38.9 percent of biopsy specimens (p = 0.02), and skin concordance with clinical evaluation was present in 81 percent of biopsy specimens (p = 0.01). CONCLUSIONS: The clinical utility of mucosal biopsy remains elusive. The authors' experience suggests that mucosal or skin biopsy, alone, should not drive the decision-making process in treatment. Skin biopsies are more likely to confirm clinical suspicion of rejection than mucosal histology. Data from other institutions are lacking, and future reporting may help elucidate the role of mucosal and skin biopsy in facial allotransplantation. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Diagnostic, V.

Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice.

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current data.

BACKGROUND: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment. METHODS: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis. RESULTS: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 ± 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm2 (range, 81 to 2500 cm2). The mean age of patients developing a complication was 72.8 ± 6.4 years and patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance. CONCLUSIONS: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.

Physician specialty cost differences of treating nonmelanoma skin cancer.

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.

Eyelid transplantation: lessons from a total face transplant and the importance of blink.

BACKGROUND: Despite inclusion of periorbital structures in facial transplants, critical assessment of posttransplantation short- and long-term periorbital function has not been reported. The purpose of this article is to report recovery of ocular and periorbital function, with critical appraisal of posttransplant blink in the setting of revision surgery. METHODS: Prospective ocular and periorbital functional assessments were completed at multiple time points in a patient undergoing facial transplantation and subsequent revision operations. Function was evaluated using clinical ocular examinations, visual acuity assessments, photography, and video at various intervals from preoperative baseline to 13.5 months after transplantation. During this period, revision operations involving periorbital structures were performed at 6 and 9 months after transplantation. RESULTS: Before transplantation, volitional blink was 100 percent in both eyes. Involuntary blink was 40 percent in the right eye and 90 percent in the left eye, with occasional full closure. Following face transplantation, voluntary blink was preserved, partial skin sensation was present, and involuntary blink improved to 70 percent in the right eye and 100 percent in the left eye. Following revision surgery, visual acuity and voluntary and involuntary blink were impaired. By 7.5 months after revision, improvement comparable to the pretransplantation assessment was observed. CONCLUSIONS: Adherence to principles of blink preservation is critical in periorbital transplantation. Involuntary blink is essential for preserving vision, and can be improved after transplantation. Revision surgery may temporarily impair advances made with initial allotransplantation. A comprehensive understanding of ocular biomechanics and function is invaluable to the reconstructive surgeon performing facial transplantation involving periorbital structures and posttransplant revision operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Comparison of free fibular flaps with reamer-irrigator-aspirator bone grafts for the reconstruction of critical-sized mandibular defects.

OBJECTIVE: Vascularized bone flaps are currently indicated for reconstructing mandibular defects 6 cm or larger. This technique can result in donor-site morbidity and requires microsurgery. To explore alternative methods of mandibular reconstruction, we sought to compare bone graft obtained with the reamer-irrigator-aspirator (RIA) device with the free fibula (FF) flap for the reconstruction of a critical-sized mandibular defect. METHODS: Sixteen 3-month-old Yorkshire pigs underwent 6-cm full-thickness resection of the left mandible. For the FF group (n = 8), an osseous FF flap was raised from the left leg and placed into the defect. For the RIA group (n = 8), a RIA Instrument Set was used on the ipsilateral femur to ream the femoral canal and harvest RIA putty. This putty containing medullary bone marrow contents and cortical bone was packed into the defect. At the study end point, volumetric, biomechanical, and histologic analyses were performed. RESULTS: Operative times were significantly shorter in the RIA group (RIA,126 [30] min; FF, 346 [50] min; P < 0.05). Biomechanical testing of reconstructed sites showed no significant difference in maximum fracture loads between both groups (RIA, 468 [97] N; FF, 689 [262] N; P = 0.11). Mean (SD) volume ratio of bone growth at the reconstructed sites was comparable between both groups (RIA, 71% [4.5%]; FF, 72% [3.3%]; P = 0.60). Equal bone quality was confirmed histologically. CONCLUSIONS: The RIA technique significantly reduces operative time and provides bone of equal strength and histologic quality to FF flap reconstruction in a large animal model. The RIA method may represent an efficient technique for the reconstruction of craniomaxillofacial defects.

Donor-recipient human leukocyte antigen matching practices in vascularized composite tissue allotransplantation: a survey of major transplantation centers.

BACKGROUND: Vascularized composite tissue allotransplant recipients are often highly sensitized to human leukocyte antigens because of multiple prior blood transfusions and other reconstructive operations. The use of peripheral blood obtained from dead donors for crossmatching may be insufficient because of life support measures taken for the donor before donation. No study has been published investigating human leukocyte antigen matching practices in this field. METHODS: A survey addressing human leukocyte antigen crossmatching methods was generated and sent to 22 vascularized composite tissue allotransplantation centers with active protocols worldwide. Results were compiled by center and compared using two-tailed t tests. RESULTS: Twenty of 22 centers (91 percent) responded to the survey. Peripheral blood was the most commonly reported donor sample for vascularized composite tissue allotransplant crossmatching [78 percent of centers (n=14)], with only 22 percent (n=4) using lymph nodes. However, 56 percent of the 18 centers (n=10) that had performed vascularized composite tissue allotransplantation reported that they harvested lymph nodes for crossmatching. Of responding individuals, 62.5 percent (10 of 16 individuals) felt that lymph nodes were the best donor sample for crossmatching. CONCLUSIONS: A slight majority of vascularized composite tissue allotransplant centers that have performed clinical transplants have used lymph nodes for human leukocyte antigen matching, and centers appear to be divided on the utility of lymph node harvest. The use of lymph nodes may offer a number of potential benefits. This study highlights the need for institutional review board-approved crossmatching protocols specific to vascularized composite tissue allotransplantation, and the need for global databases for sharing of vascularized composite tissue allotransplantation experiences.