Faculty Bibliography

Changes made to the forehead and periorbital region can have dramatic effects in gender-affirmation surgery. Removal of frontal bossing and alteration of orbital shape can result in significant facial feminization. This elective surgical intervention must be safe, reliable, and aesthetically effective. The described technique of frontal and periorbital bone contouring allows for a safe and consistent surgical outcome in properly selected patients. Nuances in specific technical maneuvers in this operation can have profound effects on safety and aesthetic outcomes. In this article, specific points are detailed in text and video describing the senior author's (E.D.R) surgical approach.

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

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/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

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: 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.

Background/Purpose : APS ACTION Registry was created to study long-term outcomes in persistently antiphospholipid antibody (aPL)-positive patients with and without other systemic autoimmune diseases. Our primary objective was to determine whether clinically significant aPL profiles at baseline remain stable over time. Methods : A web-based data capture system is used to store patient demographics and aPL-related medical history. Inclusion criteria are positive aPL, based on the Updated Sapporo APS Classification Criteria, tested at least twice within one year prior to enrollment. Patients are followed every 12+/-3 months with clinical data and blood collection. For this prospective analysis of available follow-up (f/u) aPL tests, clinically significant aPL profile was defined as positive lupus anticoagulant (LA) test and/or aCL/abeta 2 GPI IgG/M > 40U. Stable aPL profile was defined as a clinically significant aPL profile in at least two-thirds of f/u measurements. Univariate and multivariable generalized linear mixed models with logit link were used to assess the effect of time and other variables of interest on odds of clinically significant aPL profile. Wilcoxon rank-sum and Fisher's exact tests were employed to compare clinical characteristics of patients with stable versus unstable aPL profiles. Results : As of January 2019, 796 patients were enrolled from 26 centers worldwide, 482 had f/u visits with aPL results, and 472 patients had a clinically significant aPL profile at baseline. Based on aPL profiles at f/u visits (median follow up: 5.1 years [interquartile range [IR]: 4.3, 5.8]; median number of f/u visits with aPL profiles: 2 [interquartile range: 1, 3]), 366/472 (78%) patients had stable aPL profiles over time (54 [11%] unstable; 52 [11%] inconclusive). Time did not affect odds of maintaining a clinically significant aPL profile at f/u (p=0.906). In multivariable analysis, time, age, concomitant systemic autoimmune disease (mainly lupus), smoking history, and hydroxychloroquine use did not affect odds of maintaining a clinically significant aPL profile at f/u. Based on crude unadjusted comparisons, patients with stable aPL profiles, compared to those with unstable profiles, were more likely to have baseline positive LA test, aCL IgM > 40U (positive trend for IgG), abeta 2 GPI IgG > 40U (positive trend for IgM), two or more positive aPL tests, and history of arterial events and aspirin use (Table). Conclusion : In approximately 80% of patients with a baseline clinically significant aPL profile (LA test and/or aCL/ abeta 2 GPI IgG/M > 40U), aPL profiles remain consistently significant (stable) during five years of follow-up. Further multivariate analysis will investigate predictors of aPL profile stability over time, and guide future validation studies of stored samples through APS ACTION core laboratories