Faculty Bibliography

The aim of facial transplantation (FT) was to enhance quality of life (QoL) for individuals living with severe facial disfigurement. Yet QoL has proved challenging to assess, as the field lacks a unified approach for incorporating FT recipients' perspectives into meaningful QoL measures. In this study, we review FT recipients' self-reported QoL through a qualitative analysis of publicly available posttransplant interviews to identify the aspects of QoL they report as meaningful.

Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author's experience with 3 FTs.

Photography provides a means for objective assessment and dissemination of clinical information. The American Society of Plastic Surgeons (ASPS) and Plastic Surgery Foundation (PSF) published photography guidelines in 2006 to optimize its clinical use. However, photographic documentation of outcomes in facial transplantation (FT) continues to lack standardization. We therefore appraised the current state of FT photography in the peer-reviewed literature.

Background/Purpose: Le Fort I advancement surgery is challenging in patients with clefts because of the palatal scar tissues. In this study, we investigated the outcome of Le Fort I advancement surgery (mild, moderate, and severe groups) and 1-year skeletal stability in patients with cleft lip and palate. Methods/Description: A retrospective chart review was performed to identify patients with nonsyndromic unilateral or bilateral cleft lip and palate who underwent maxillary Le Fort I advancement at skeletal maturity from 2013 to 2019. To satisfy the inclusion criteria, all patients had to have diagnostic quality cone beam computed tomography (CBCT) prior to surgery (T0), immediately postoperative (T1), and at 1-year follow-up (T2). A total of 59 patients (unilateral n = 34, bilateral n = 25) who underwent Le Fort I advancement was identified. Nineteen of these 59 patients were excluded due to insufficient radiographic records; thus, 40 patients with complete records were included in the study. The sample was comprised of 9 females and 31 males, with an average age of 19.1 +/- 3.21 years at the time of the surgery. Lateral cephalograms were extracted, traced, and superimposed using Dolphin Imaging software (V 11.95). Horizontal surgical movement (T0-T1) and postoperative relapse (T1-T2) at skeletal and dental level were quantified as linear changes at point A and upper incisor edge (U1-tip), respectively. Patients were divided into 3 groups according to the severity of surgical movement: mild (<5 mm, n = 9), moderate (5-10 mm, n = 20), and severe (>10 mm, n = 11). The statistical analysis was performed using 2-way repeated-measures ANOVA to test the difference of surgical movements and postoperative relapse between groups.
Result(s): The mean advancement (T0-T1) of all patients at point A was 8.1+/-2.8 mm and at U1-tip was 7.7+/-2.6 mm. In the mild, moderate, and severe groups, the mean advancement at point A were 4.6 +/- 1.3 mm, 7.7+/-1.1 mm, and 11.6+/-1.2 mm, and at U1-tip were 5.7+/-2.9 mm, 7.4 +/- 1.3 mm, and 10 +/- 2.6 mm, respectively. There were significant skeletal and dental advancements in all the 3 groups following Le Fort I surgery (P < .0001). At 1-year follow-up, the mean relapse (T1-T2) at point A was 1.2 +/- 1.1 mm and at U1-tip was 0.07 +/- 1.9 mm. When analyzed within the mild, moderate, and severe groups, the mean relapse at point A were 0.8 +/- 0.7 mm, 1.2 +/- 0.9 mm, and 1.9+/-1.5 mm and at U1-tip were -0.4+/-1.6 mm, 0.4+/-2.1 mm, and -0.2 +/- 1.5 mm, respectively. There was no significant difference in the relapse amount between the mild, moderate, and severe groups at skeletal and dental components (P > .05).
Conclusion(s): Le Fort I advancement surgery successfully corrected maxillary hypoplasia in patients with cleft lip and palate in all the 3 groups. This study also demonstrated that larger advancement in the severe group can result in equivalent skeletal stability when compared to the mild and moderate advancement. Though mild skeletal relapse was observed in all the 3 groups, none of the patients had to be reoperated

Background/Purpose: Our study quantifies changes in skeletal, soft tissue profile, and globe position in patients with syndromic craniosynostosis after Le Fort I + III (LF I + III) surgery. Methods/Description: Patients with syndromic craniosynostosis who underwent LF I + III at the time of facial maturity were followed for at least 1 year. Each lateral cephalometric radiograph was traced using Dolphin Imaging software and superimposed at the sella. Changes in positions of the different landmarks at T0 (preoperatively), T1 (immediate postoperatively), and T2 (1 year postoperatively) were measured by the software. Sixty-seven soft tissue and skeletal landmarks were digitized and measured. LF III skeletal changes were measured by changes in lateral orbit and orbitale. LF I skeletal changes were measured at the A point and U1. Corresponding soft tissue profile and globe position were studied. All data were measured along the x-axis.
Result(s): Twelve patients included in our study have the following syndromes: Crouzon (n = 6), Pfeiffer (n = 2), Apert (n = 1), Antley-Bixler (n = 1), cleidocranial dysplasia (n = 1) and frontonaso dysplasia (n = 1). Nine patients had previous history of LF III distraction. Standard descriptive statistics was used. Data were analyzed using paired T test. Lateral orbit advanced 5.49 mm (T0-T1) on average, with a P value of 1.3-5, and 5.94 mm (T0-T2) on average; 0.45 mm (T1-T2) change with a P value of .96 suggests the lateral orbit is stable. Similar advancement at orbitale is observed at 5.68 mm (T0-T1) and 6.42 mm (T0-T2). The globe moved anteriorly by 1.98 mm (T0-T1) with a P value of .025 and anteriorly by 0.944mm(T0-T2). The change between T2 and T1 is 1.04 mm (P value: .26), which suggests the globe moved backward after postsurgical swelling subsided. The ratios of movement (globe to lateral orbit) between T0-T1 and T0-T2 are 31% and 16%, respectively. The decrease in ratio can be attributed to the reduction in soft tissue swelling at T2. Restoring position of the globe relative to the lateral orbit decreases the risk of exposure keratitis, keratoconjunctivitis sicca, and corneal ulceration. Anterior nasal spine and point A were advanced by 9.38 and 10.08 mm, respectively, between T0 and T1, and 9.01 mm and 8.51 mm, respectively, between T1 and T2. At the occlusal level, U1 advanced 10 mm and L1 moved back 1.45 mm between T0 and T1. Menton moved back 1.25 mm (T0-T1) but advanced by 2.48 mm (T0-T2). This change in direction is due to splint use at T1 as it rotates mandible clockwise.
Conclusion(s): In our cohort, LFI + III surgery improved both midface deficiency and proptosis in those with syndromic craniosynostosis.Combined Le Fort I + III surgery allows surgeons to perform differential corrections of the midface at the orbital and the dentition level. This is ideal for proptosis correction and establishing optimal jaw relationship

BACKGROUND: The lateral femoral circumflex artery (LFCA) system, which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction. METHODS: Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA) to define any muscular, periosteal, and/or osseous branches to the femur. RESULTS: Six thighs in four cadavers were dissected. Consistent in all specimens, there was an isolated branch extending distally, medially, and posteriorly from the proximal LFCA and entering the periosteum of the femur. In five specimens, the identified branch to the femur was located approximately 1-cm distal to the rectus femoris branch of the LFCA and approximately 1-cm proximal to a separate branch entering and supplying the vastus intermedius. In one specimen, there was a common trunk. The length of this branch from the origin at the LFCA to insertion into the femoral periosteum was approximately 6 to 8 cm. CONCLUSION/CONCLUSIONS: There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility, as another option in complex cases requiring composite reconstruction, including bone.

Skin color matching in vascularized composite allotransplantation (VCA) is an important determinant of aesthetic outcomes. The process of color matching is infrequently described in the literature. The Pantone SkinTone Guide (PSTG) is a handheld tool comprised of realistic skin tone swatches with a corresponding virtual swatch system. A color match acceptability threshold (AT) is defined as the point beyond which >50% of observers deem a given skin tone pairing as unacceptable. In this study, color match acceptability thresholds were developed using the PSTG to help standardize donor-recipient color matching. Four representative colors were chosen across the skin tone spectrum. These standard colors were used to develop a survey asking participants to determine the acceptability of color pairings. Using survey results, ATs were determined for changes in lightness, undertone, and lightness and undertone combined for each of the standard colors. Inter- and intra-rater reliability were determined using Fleiss's Kappa. Participants were more critical of skin tone pairings on the darker versus the lighter end of the spectrum, as evidenced by higher thresholds observed for lighter sample pairs. Additionally, observers were more critical of differences in skin lightness compared with differences in undertone. Intra-rater reliability was fair to substantial, and inter-rater reliability was fair to moderate. The PSTG can be used as a clinical tool to improve the aesthetic outcomes of skin-containing vascularized composite allotransplantation procedures by optimizing donor-recipient skin color matching. This can allow clinicians to complement visual judgment with quantitative reference.

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

Background/UNASSIGNED:Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. Methods/UNASSIGNED:for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. Results/UNASSIGNED:< 0.001). Conclusions/UNASSIGNED:Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.