Examination of the Wrist.

LEARNING OBJECTIVES: After reading this article and reviewing the supplemental videos, the participant should be able to: 1. Identify common wrist conditions that may be encountered on evaluation. 2. Describe provocative maneuvers used to confirm a diagnosis of wrist disorder. 3. Develop a systematic approach to examination of the wrist. 4. Determine appropriate diagnostic maneuvers for radial, central, and ulnar wrist pain. SUMMARY: The wrist is a complex structure, and providers caring for hand and upper extremity conditions need to have an understanding of the wrist examination and provocative maneuvers for conditions that are encountered. Fractures, tendonitis, arthritis, and instabilities are all commonly encountered, and the provider should have an idea of the diagnosis based on clinical examination and use imaging as needed to confirm or stage a diagnosis.

Ethical Issues in Aesthetic and Reconstructive Surgical Innovation: Perspectives of Plastic Surgeons.

Innovative surgery is defined as a novel procedure, a significant modification of a standard technique, or a new application of an established technique. Although innovation is a crucial part of improving patient care in plastic surgery, there are various ethical considerations and dilemmas in performing unvalidated techniques and procedures, especially for non-life-threatening indications. The aim of this study was to gain a better understanding regarding the motivations and ethical considerations of plastic surgeons in their decision to perform innovative operations. An anonymous, institutional review board-approved, online survey was sent to members of the American Society of Plastic Surgeons and other international plastic surgeons worldwide. The survey asked respondents to rank various factors that influence their decisions to perform innovative plastic surgery, both reconstructive and aesthetic, on a five-point Likert scale. Seven hundred thirty-three of 26,028 plastic surgeons (response rate, 2.9 percent) responded to the survey. Although similar factors were considered to be important for both reconstructive and aesthetic operations, only approximately 50 percent of respondents considered institutional review board approval to be an important factor when considering innovation in both reconstructive (50 percent) and aesthetic surgery (51 percent), suggesting that respondents do not consider innovation a form of research that ought be subject to standard research protections. Overall, the authors' survey suggests that more effort must be extended to ethical training in plastic surgery to create a stronger professional atmosphere regarding innovation and, possibly, to the creation of a more formal group charged with oversight of innovation.

Primary Residency Training and Clinical Practice Profiles Among Board-Certified Hand Surgeons.

PURPOSE: This study seeks to identify the relationship between the type of residency training (general, plastic, or orthopedic surgery) and the clinical practice profiles of hand surgeons in the United States. METHODS: Membership applications to the American Society for Surgery of the Hand (ASSH) from 2011 to 2015 were analyzed. Data on type of residency training, practice type, the percentage of hand surgery in practice, and the time to application were collected. Total cases and the number of cases in each key clinical category were collected from surgical case logs. RESULTS: From 2011 to 2015, a total of 451 hand surgeons applied for ASSH membership. Of these, 73.8% were orthopedic surgeons, 16.0% plastic surgeons, and 10.2% general surgeons. The median times to application after fellowship graduation and completion of the Certificate of Added Qualifications (CAQ) were 5 and 1 years, respectively and were similar between groups. Orthopedic surgeons are more likely to be in a private practice and perform the highest volume of cases. Plastic surgeons are most likely to be in an academic practice but perform nearly 20% of their cases outside of the field of hand surgery. Failure to meet the minimum case requirement in the joint contracture (40.7%), congenital (80.5%), and microvascular surgery (47.6%) categories were the most common for all applicants. Orthopedic surgeons were most likely to perform bone and joint, nerve, tendon and muscle, and tumor cases. Plastic surgeons were the most likely to perform skin and wound, congenital, and microvascular cases. CONCLUSIONS: Orthopedic-, plastic-, and general surgery-trained hand surgeons early in their career have varied practice types and have different clinical case profiles. Differences in case profiles may be due to surgeon interest and/or training experience. CLINICAL RELEVANCE: Promoting a collaborative relationship between hand surgeons of varied backgrounds is crucial to the training of future hand surgeons and the continued advancement of the field.

Disappearing Digits: Analysis of National Trends in Amputation and Replantation in the United States.

BACKGROUND: Significantly fewer replantations have been performed at the authors' institution in recent years, with similar trends observed across the United States. A study of three national databases was performed to evaluate this trend, its possible cause, and national health care implications. METHODS: The National Electronic Injury Surveillance System, Bureau of Labor Statistics, and National Inpatient Sample databases were queried for cases with a diagnosis of finger amputation over available years from 2000 to 2011. Data were weighted and analyzed to give appropriate national estimates of amputations, replantations, and related clinical variables. Trend analysis was performed using modified Poisson regression. RESULTS: Although workplace finger amputation rates decreased 40 percent from 2000 to 2010 (p < 0.0001), the overall finger amputation incidence did not change significantly (26,668 versus 24,215; p = 0.097). Compared with 930 replantations in 2001, only 445 were performed in 2011, more than a 50 percent decrease (p < 0.001). In all years, the majority of hospitals performing replantation performed only one (49.3 to 64.1 percent) each year, with a small minority (2.2 to 8.1 percent) performing more than 10 per year. In 2000, 120 hospitals (12.1 percent) performed at least one replantation, compared with only 80 hospitals (7.6 percent) in 2010, a 4.6 percent annual decline (p = 0.002). CONCLUSIONS: There has been a striking decline in digital replantations being performed, despite a relatively stable incidence of amputations. Apparently independent of declining work-related injuries, evolving clinical decision-making may be responsible for this trend. Decreasing replantation experience among hand surgeons lends credence to the development of specialized regional centers designed to treat these complex injuries.

Analysis of Flap Weight and Postoperative Complications Based on Flap Weight in Patients Undergoing Microsurgical Breast Reconstruction.

Background Higher body mass index (BMI) has been shown to increase postoperative complications in autologous breast reconstruction. However, the correlation with flap weight is unknown. Here, we explore the relationship of flap weights and complication rates in patients undergoing microvascular breast reconstruction. Methods Retrospective chart review identified all patients undergoing microvascular breast reconstruction with abdominally based flaps at a single institution between November 2007 and April 2013. Breasts with documented flap weight and 1-year follow-up were included. Patients undergoing stacked deep inferior epigastric perforator flaps were excluded. Breasts were divided into quartiles based on flap weight and examined by demographics, surgical characteristics, complications, and revisions. Results A total of 130 patients undergoing 225 flaps were identified. Patients had a mean age of 50.4 years, mean BMI of 27.1 kg/m2, and mean flap weight of 638.4 g (range: 70-1640 g). Flap weight and BMI were directly correlated. Flaps were divided into weight-based quartiles: first (70-396 g), second (397-615 g), third (616-870 g), and fourth (871-1640 g). There were no associations between flap weight and incidences of venous thrombosis, arterial thrombosis, hematoma, flap loss, fat necrosis, or donor site hernia. However, increased flap weight was associated with increased rate of donor site wound healing problems in both univariate and multivariate analysis. Conclusions Increased flap weight is not associated with added flap complications among patients undergoing microvascular breast reconstruction, however, patients with flaps of 667.5 g or more are more likely to have donor site healing problems. The success and evidence contrary to previous studies may be attributed to surgeon intraoperative flap choice.

Current Trends in Facial Rejuvenation: An Assessment of ASPS Members' Use of Fat Grafting during Face Lifting.

BACKGROUND: Fat grafting can be used to improve the results of face lifting. The extent to which plastic surgeons use fat grafting in their face-lift practices is unknown. The goals of this study were to understand the current use of fat grafting during facial rejuvenation surgery and identify the most common techniques used. METHODS: A 28-item questionnaire was formulated for distribution to a randomized cohort of American Society of Plastic Surgeons members. Data were collected and statistically analyzed using Pearson chi-square and Fisher's exact tests. RESULTS: A total of 309 questionnaires were collected. The questionnaire revealed that 85.2 percent of respondents use fat grafting during face lifts. Currently, the most common techniques used include abdominal harvest, centrifuge processing, blunt cannula injection without pretunneling, and placing less than 0.1 cc per pass. The deep central malar, lower lid cheek junction, and nasolabial folds are the most commonly injected areas. CONCLUSIONS: Combining surgical repositioning of fat with fat grafting offers surgeons a greater degree of aesthetic control for correcting contour in the aging face. Although there is controversy regarding the best method to surgically reposition fat, there is a growing consensus that volume augmentation is preferred by most face-lift surgeons.

Trends and drivers of the aesthetic market during a turbulent economy.

BACKGROUND: Aesthetic procedures are significant sources of revenue for plastic surgeons. With the popularity of nonsurgical aesthetic procedures, many plastic surgeons question how to best tailor their aesthetic practice. METHODS: Revenue generated from surgical and minimally invasive aesthetic procedures performed in the United States between 2000 and 2011 was calculated from the American Society of Plastic Surgeons' annual reports. Regression analysis was performed against six commonly cited economic indicators. RESULTS: In 2011, revenue from minimally invasive procedures increased from $3.0 billion to $5.7 billion (90 percent growth), whereas revenue from surgical procedures decreased from $6.6 billion to $6.0 billion (10 percent decline). Between 2000 and 2011, minimally invasive procedure market share grew from 30 percent to nearly 50 percent. Linear regression analysis revealed significant correlations between surgical procedure revenue and indicators of macroeconomic climate: Dow Jones Industrial Average (R = 0.72; p < 0.01), Standard & Poor's 500 Index (R = 0.64, p < 0.05), and unemployment rate (R = -0.81; p < 0.001). Minimally invasive procedure revenue was significantly correlated with indicators related to microeconomic decision trends: disposable income per capita (R = 0.93; p < 0.001), real gross domestic product per capita (R = 0.88; p < 0.001), and home price index (R = 0.63; p < 0.05). No economic indicator in this study was found to be significantly correlated with both surgical and minimally invasive revenue. CONCLUSION: Despite economic turbulence, minimally invasive procedures are the most rapidly growing source of revenue and are poised to be the dominant source of revenue in the aesthetic market.

Chairs and chiefs of plastic surgery: is it an insider job?

PURPOSE: There is no more important decision an academic Plastic Surgery Department or Division can make than naming a chair or chief. Externally recruited leadership brings fresh perspectives and connections. Critics, however, argue that they lack the in-depth knowledge of the institution's culture and history that may be needed to succeed. The ability and skill of an internal candidate is already known and can increase the odds of that person's success in the leadership position. Finally, external recruitment can be a more costly process. Ultimately, the decision is really a litmus test for a Plastic Surgery program. The authors aim to evaluate factors influencing ascent in Plastic Surgery leadership, including training history, internal promotion, and external recruiting. METHODS: All Plastic Surgery residency programs accredited by the Accreditation Council for Graduate Medical Education were noted (n = 71). Academic departmental chairs or divisional chiefs of these residency programs were identified at the time of study design (October 1, 2011). For each chair or chief, gender, training history, and faculty appointment immediately prior to the current leadership position was recorded. RESULTS: There were 71 academic chairs or chiefs of Plastic Surgery residency programs at the time of data collection. The majority (62%) had done fellowship training following Plastic Surgery residency. Fellowships included hand (43%), craniofacial (29%), microsurgery (18%), and other types (10%). The majority (73%) of leaders were internal hires (P < 0.01), having faculty appointments at their institutions prior to promotion. However, only a fraction (22%) of these internal hires had done Plastic Surgery residency or fellowship training at that institution (P < 0.01). External recruits consisted of 27% of all 71 academic hires (P < 0.01). CONCLUSIONS: Many factors influence the decision to recruit leadership from internally or to hire an external candidate. These include the time to fill the position, program culture, candidate experience, and cost. These results support that the insider/outsider hire decision is ultimately one of duality. That dichotomy is achieved with an emphasis on internal promotion, but always with an eye towards the advantages of bringing in external talent as a valuable contribution to increase organizational success.

Measuring quality of life and patient satisfaction after body contouring: a systematic review of patient-reported outcome measures.

UNLABELLED: EVIDENCE-BASED BACKGROUND: In both cosmetic and postbariatric body contouring populations, the primary determinants of success are patient satisfaction and quality of life (QOL). These patient-reported outcomes (PRO) are ideally measured with specially-designed, procedure- or condition-specific questionnaires. OBJECTIVE: The authors identify and appraise all patient-reported outcome (PRO) measures (questionnaires) developed for patients undergoing body contouring surgery. METHODS: MEDLINE, EMBASE, PsychINFO, Ebase, CINAHL, HAPI, Science Citation Index/Social Sciences Citation Index, Ovid Evidence Based Medicine databases were searched from the inception of each database through August 2010. Articles included in the study described the development and/or psychometric evaluation of a PRO measure developed for body contouring patients. Each measure was then appraised for adherence to internationally-recommended guidelines for item generation, item reduction, and psychometric evaluation. RESULTS: The following five PRO questionnaires were identified by our search: one liposuction (the Freiburg Questionnaire on Aesthetic Dermatology and Cosmetic Surgery, FQAD), one general plastic surgery (Derriford Appearance Scale, DAS-59/24), and three breast reduction measures (the Breast Reduction Assessed Severity Scale Questionnaire, BRASSQ; Breast Related Symptoms questionnaire, BRS; and the BREAST-Q reduction module. Detailed examination of these measures revealed that the FQAD, DAS-59, and BRS are limited by both their content range and psychometric properties. The BRASSQ and BREAST-Q both have strong psychometric properties, and the BREAST-Q is unique in its inclusion of items covering specific postoperative issues such as scarring. CONCLUSIONS: While instruments are available for measuring outcomes in breast reduction patients, reliable, valid, and responsive PRO measures are lacking for the majority of body contouring procedures. To demonstrate the unique outcomes of body contouring surgery, future research to rigorously develop and validate new PRO measures in this population is necessary.

A randomized controlled trial of skin care protocols for facial resurfacing: lessons learned from the Plastic Surgery Educational Foundation's Skin Products Assessment Research study.

BACKGROUND: The Skin Products Assessment Research Committee was created by the Plastic Surgery Educational Foundation in 2006. The Skin Products Assessment Research study aims were to (1) develop an infrastructure for Plastic Surgery Educational Foundation-conducted, industry-sponsored research in facial aesthetic surgery and (2) test the research process by comparing outcomes of the Obagi Nu-Derm System versus conventional therapy as treatment adjuncts for facial resurfacing procedures. METHODS: The Skin Products Assessment Research study was designed as a multicenter, double-blind, randomized, controlled trial. The study was conducted in women with Fitzpatrick type I to IV skin, moderate to severe facial photodamage, and periocular and/or perioral fine wrinkles. Patients underwent chemical peel or laser facial resurfacing and were randomized to the Obagi Nu-Derm System or a standard care regimen. The study endpoints were time to reepithelialization, erythema, and pigmentation changes. RESULTS: Fifty-six women were enrolled and 82 percent were followed beyond reepithelialization. There were no significant differences in mean time to reepithelialization between Obagi Nu-Derm System and control groups. The Obagi Nu-Derm System group had a significantly higher median erythema score on the day of surgery (after 4 weeks of product use) that did not persist after surgery. Test-retest photographic evaluations demonstrated that both interrater and intrarater reliability were adequate for primary study outcomes. CONCLUSIONS: The authors demonstrated no significant difference in time to reepithelialization between patients who used the Obagi Nu-Derm System or a standard care regimen as an adjunct to facial resurfacing procedures. The Skin Products Assessment Research team has also provided a discussion of future challenges for Plastic Surgery Educational Foundation-sponsored clinical research for readers of this article.

Better preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions.

BACKGROUND: Traditional resections for benign and low-grade malignant neoplasms of the mid pancreas result in loss of normal parenchyma that can cause pancreatic endocrine and exocrine insufficiency. Central pancreatectomy (CP) is a parenchyma-sparing option for such lesions. This study evaluates a single institution's experience with CP and compares outcomes with distal pancreatectomy (DP). METHODS: We retrospectively collected data on CP patients from 1997 through 2009 and evaluated outcomes. In a subset of 50 patients, we performed a matched-pairs analysis to directly compare the short- and long-term outcomes of CP and DP. RESULTS: Seventy-three patients underwent CP with a median operating room time of 254 minutes. Overall morbidity was 41.1% with pancreatic fistula in 20.5%. Mortality was 0%. There were no differences in fistula, morbidity, and mortality rates between the CP and DP groups. The CP group had resected for smaller lesions. CP patients had a lower rate of new-onset and worsening diabetes than DP patients (14% vs 46%; P = .003). Of new-onset and worsening diabetics, only 1 CP patient required insulin compared with 14 DP patients (P = .002). CONCLUSION: CP is safe and effective for select neoplasms of the mid pancreas. Patients undergoing CP have markedly decreased insulin requirements compared with DP patients.

Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older.

BACKGROUND: Surgery offers the only chance for cure in patients with pancreatic cancer, and a growing number of elderly patients are being offered resection. We examined outcomes after pancreaticoduodenectomy in patients 80 years and older. METHODS: We retrospectively collected data on pancreaticoduodenectomy patients from 1992 to 2009 to compare outcomes between patients older and younger than 80 years. Variables were compared using t-, Wilcoxon rank-sum, or Fisher's exact tests. Survival was compared using Kaplan-Meier analysis and log-rank test. RESULTS: Patients 80 years and older who underwent pancreaticoduodenectomy were similar with respect to sex, race, blood loss, operative times, reoperation, length of stay, and readmission compared to younger patients. There were no differences in overall complications (47% vs. 51%, p = 0.54), major complications (19% vs. 25%, p = 0.25), and mortality (5% vs. 4%, p = 0.53) when comparing older to younger patients. In a subset who underwent pancreaticoduodenectomy for ductal adenocarcinoma, older patients (n = 45) had a median survival time of 11.6 months compared to 18.1 months in younger patients (n = 346; p < 0.01). CONCLUSION: Pancreaticoduodenectomy can be performed safely in select patients 80 years and older. Age alone should not dissuade surgeons from offering patients resection, though elderly patients with pancreatic ductal adenocarcinoma appear to have shorter survival than younger patients with the same disease.

One hundred thirty resections for pancreatic neuroendocrine tumor: evaluating the impact of minimally invasive and parenchyma-sparing techniques.

BACKGROUND: Increasingly, surgeons apply minimally invasive and parenchyma-sparing techniques to the management of pancreatic neuroendocrine tumor (PNET). The aim of this study was to evaluate the impact of these approaches on patient outcomes. METHODS: We retrospectively collected data on patients with PNET and compared perioperative and pathologic variables. Survival was analyzed using the Kaplan-Meier method. Factors influencing survival were evaluated using a Cox proportional hazards model. RESULTS: One hundred thirty patients underwent resection for PNET. Traditional resections included 43 pancreaticoduodenectomies (PD), 38 open distal pancreatectomies (DP), and four total pancreatectomies. Minimally invasive and parenchyma-sparing resections included 25 laparoscopic DP, 11 central pancreatectomies, five enucleations, three partial pancreatectomies, and one laparoscopic-assisted PD. Compared to traditional resections, the minimally invasive and parenchyma-sparing resections had shorter hospital stays. By univariate analysis of neuroendocrine carcinoma, liver metastases and positive resection margins correlated with poor survival. There was an increase in minimally invasive or parenchyma-sparing resections over the study period with no differences in morbidity, mortality, or survival. CONCLUSION: In this series, there has been a significant increase in minimally invasive and parenchyma-sparing techniques for PNET. This shift did not increase morbidity or compromise survival. In addition, minimally invasive and parenchyma-sparing operations yielded shorter hospital stays.

Laparoscopic distal pancreatectomy offers shorter hospital stays with fewer complications.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study was to investigate short-term outcomes after LDP compared to open distal pancreatectomy (ODP) at a single, high-volume institution. METHODS: We reviewed records of patients who underwent distal pancreatectomy (DP) and compared perioperative data between LDP and ODP. Continuous variables were compared using Student's t or Wilcoxon rank-sum tests. Categorical variables were compared using chi-square or Fisher's exact test. RESULTS: A total of 360 patients underwent DP. Beginning in 2001, 95 were attempted, and 71 were completed laparoscopically with a 25.3% conversion rate. Compared to ODP, LDP had similar rates of splenic preservation, pancreatic fistula, and mortality. LDP had lower blood loss (150 vs. 900 mL, p < 0.01), smaller tumor size (2.5 vs. 3.6 cm, p < 0.01), and shorter length of resected pancreas (7.7 vs. 10.0 cm, p < 0.01). LDP had fewer complications (28.2% vs. 43.8%, p = 0.02) as well as shorter hospital stays (5 vs. 6 days, p < 0.01). CONCLUSIONS: LDP can be performed safely and effectively in patients with benign or low-grade malignant neoplasms of the distal pancreas. When feasible in selected patients, LDP offers fewer complications and shorter hospital stays.

A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation.

BACKGROUND: Patient satisfaction and improved quality of life are the predominant considerations determining success in cosmetic surgery. However, few studies have examined patients' perceptions of their appearance following cosmetic facial surgery and/or nonsurgical facial rejuvenation. This study identified patient-reported outcome measures developed and validated for use in patients undergoing surgical and/or nonsurgical cosmetic procedures. METHODS: A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and/or quality of life following surgical and/or nonsurgical cosmetic procedures were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation. RESULTS: From 442 articles, 47 patient-reported outcome measures assessing facial appearance after a cosmetic procedure were identified. Only nine questionnaires satisfied inclusion and exclusion criteria. These measures were subdivided into the following categories: rhinoplasty (Rhinoplasty Outcomes Evaluation, Glasgow Benefit Inventory, Facial Appearance Sorting Test), skin rejuvenation (Facial Lines Treatment Satisfaction Questionnaire, Skin Rejuvenation Outcomes Evaluation, Facial Lines Outcomes Questionnaire), face lift (Facelift Outcomes Evaluation), blepharoplasty (Rhinoplasty Outcomes Evaluation), and general appearance (Derriford Appearance Scale 59). None of these measures satisfied all guidelines. All measures were limited by either their development, their validation, or their content. CONCLUSIONS: Valid, reliable, and responsive instruments designed to measure patient-reported outcomes following surgical and nonsurgical facial rejuvenation are lacking. A patient-reported outcome measure that represents perceptions of facial cosmetic surgery patients and satisfies accepted health measurement criteria is needed. It would facilitate comparison of techniques and quantification of positive effects, and aid surgeons seeking to quantify outcomes in their own practices.

Measuring patient outcomes in breast augmentation: introducing the BREAST-Q Augmentation module.

The Breast-Q Augmentation module is a new and unique questionnaire for measuring patient-reported outcomes following breast augmentation. It has undergone a rigorous development and validation process and is currently the only questionnaire for breast augmentation that meets international and federal standards for questionnaire development. The Breast-Q Augmentation module covers a comprehensive set of concerns of breast augmentation patients, including satisfaction with breasts and impact on quality of life. With its excellent psychometric properties, the Breast-Q Augmentation module can provide clinicians and researchers with a wealth of essential data to improve the field of breast augmentation from the perspectives of both surgeons and patients.

A soft-tissue approach to midfacial hypoplasia associated with Treacher Collins syndrome.

INTRODUCTION: Treacher Collins syndrome is an autosomal dominant mandibulofacial dysostosis with characteristic hard- and soft-tissue facial abnormalities. These include ocular malformations, ear malformations, and hypoplasia of the facial skeleton, especially of the malar bones and mandible. Traditionally, surgical correction of the facial abnormalities has focused on skeletal reconstruction to restore facial form and symmetry. In this report, we describe the use of customized parascapular free flaps, after standard reconstructive surgeries, for the correction of defects of facial contour in Treacher Collins patients. In most cases, bony reconstruction of the zygoma or periorbita is not required. METHODS: From June 1995 to December 2003, 8 patients with Treacher Collins syndrome underwent microsurgical correction of facial contour using 16 free flaps. In all patients, staged parascapular free flaps were used for reconstruction. The microvascular technique involved a 2-team approach with simultaneous ipsilateral parascapular flap harvest and facial pocket dissection. The flaps were contoured, revascularized (14 superficial temporal vessels, 2 facial vessels), and inset. No vein grafts were used. The patients were followed for a minimum of 1 year, and postoperative evaluation included medical photography, visual assessment, and evaluation by the patient and family. RESULTS: Seven patients had previous facial skeleton correction using craniofacial techniques. The age at operation ranged from 4-19 years. Sixteen parascapular free flaps were used in the 8 patients. Postoperative complications were limited to 1 hematoma. There were no partial or total flap losses. All of the patients had improved facial contour and symmetry. Overlying skin tone and color similarly improved. CONCLUSION: After traditional skeletal reconstruction for the complex craniofacial defects of Treacher Collins syndrome, deficiencies in facial contour and symmetry usually persist. Customized soft-tissue free flaps can be employed to differentially resurface these defects and achieve optimal esthetic results in these challenging patients.