Faculty Bibliography

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

Introduction: Vascularized composite allotransplantation provides a reconstructive option for patients with otherwise irreparable defects. Despite significant advances in the field, successful multi-vascularized composite allotransplantation has yet to be reported. We herein describe our experience with the first successful combined face and bilateral hand transplant, focusing on the sequence and timing of allograft procurement.
Method(s): The recipient was a 22-year-old male who presented for multi-vascularized composite allotransplantation evaluation after sustaining a motor vehicle accident resulting in 80% total body surface area burns, including his full face and bilateral upper extremities. Following multidisciplinary team evaluation and institutional review board approval, he was deemed an appropriate candidate for combined face and bilateral hand transplant. In defining his expectations for the transplant, the recipient wished to prioritize recovery of hand function above all else.
Result(s): Combined face and bilateral hand transplant was performed over 23 h and 3 min in two adjacent operating rooms. Given the recipient's right-hand dominance, we opted for procurement and transplantation of the right upper extremity first, followed by the left upper extremity, with the facial allograft procured last. The vascular pedicles in the donor left upper extremity allograft were only divided once vascular inflow and outflow was re-established in the right upper extremity. Similarly, the external carotid arteries were clamped and divided after the left upper extremity was reperfused. To minimize ischemia, no tourniquet was used in the donor room, while tourniquet use was limited to <2 h in the recipient room. Total ischemia times were 2 h and 30 min for the right upper extremity; 2 h and 46 min for the left upper extremity; and 2 h and 52 min for the face. Optimization of arterial inflow and venous outflow was ensured with preservation of the muscular perforators and reconstruction of both the deep and superficial venous systems. At 10 months post-transplant, the recipient is demonstrating continuous improvement in functional outcomes.
Conclusion(s): In this report, we describe our approach for procuring three allografts in the first successful face and bilateral hand transplant. In addition to meticulous preparation, this case highlights the importance of understanding and prioritizing the recipient's goals for the transplant

Introduction: Acute rejection is exceptionally common in the first year after vascularized composite allotransplantation. Recipients with burns are at increased risk of developing donor-specific antibodies due to sensitization. Lymphocyte depleting induction with rabbit antithymocyte globulin is commonly utilized. We hypothesized that combination B- and T-cell depletion induction therapy is more efficacious in preventing acute rejection in the early post-transplant period.
Method(s): Our induction protocol calls for intraoperative administration of methylprednisolone (1000 mg) and rabbit antithymocyte globulin beginning intraoperatively (1.5 mg/ kg, cumulative dose 6 mg/kg over the first postoperative week) and rituximab (1000 mg administered on postoperative day 1) for thorough T and mature B-cell depletion. Standard infection prophylaxis is utilized. Donor-specific antibodies are monitored postoperatively with Luminex single-antigen microbeads (mean fluorescence intensity >= 1000 considered clinically significant).
Result(s): Our latest recipient was a 22-year-old male with 80% total body surface area burns. The donor was an ABOidentical, 47-year-old brain dead male. Human leukocyte antigen (HLA) mismatch was 0, 1, 0 (A, B, DR), and 2 HLA-DPB1. Donor-recipient complement-dependent cytotoxicity and flow cytometric T- and B-cell crossmatch were all negative. Abrupt rise in donor-specific antibodies on postoperative days 7 and 8 was treated with two rounds of plasmapheresis and intravenous immunoglobulin. Persistent wound colonization (Acinetobacter baumannii) was treated with meropenem, polymyxin, and tigecycline. The recipient experienced a single episode of acute rejection 9 months post-transplant, successfully treated with pulse doses of methylprednisolone (500 mg intravenous, daily) over 3 days. We suspect this may have been triggered by inflammation induced by revision surgery of all three vascularized composite allotransplantation components in the preceding month
Conclusion(s): We present our third consecutive vascularized composite allotransplantation recipient utilizing this novel immune strategy. In the context of the most extensive vascularized composite allotransplantation performed to date, acute rejection was prevented until 9 months post-transplant in this highly sensitized patient. Two previous recipients remained rejection-free for greater than 1 year post-transplant and have experienced only one rejection episode each to date. Acute rejection in vascularized composite allotransplantation may be better prevented by including rituximab in the induction immunosuppression strategy, and the risk of metabolic or severe infectious complications appears to be manageable

Introduction: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. The field has seen considerable advancement since its inception, with the first successful hand transplant in 1998 and the first partial face transplant in 2005. To date, over 40 bilateral hand transplants have been reported in the literature, along with 47 face transplants. Due to still limited available evidence and the heterogeneity of the sample population, little consensus exists on the anticipated timeline of functional recovery following vascularized composite allotransplantation. We hereby report on the early and accelerated functional recovery of a combined face and bilateral hand transplant recipient.
Method(s): A 21-year-old male was referred with sequelae of an 80% total body surface area burn sustained in a motor vehicle accident 1 year prior. The patient had extensive facial and bilateral upper extremity injuries. Serial debridement and split thickness skin grafting procedures left the patient with proximal digital syndactyly and distal digit amputations. Procurement and transplantation of the face and upper extremities was performed over a 23-h period in August of 2020. Postoperative functional assessment at predetermined time points included active range of motion, grip strength, sensory assessment, Carroll's Upper Extremity Function test, and the Disabilities of the Arm, Shoulder, and Hand questionnaire.
Result(s): Functional assessments were performed at 3 and 6 months post-transplant. Range of motion, grip strength, Carroll's test scores (left = 58 at 6 months post-transplant vs 13 pre-transplant, right = 61 at 6 months post-transplant vs 20 pre-transplant) and Disabilities of the Arm, Shoulder, and Hand evaluation (37 at 6 months post-transplant vs 90 pretransplant) showed substantial improvement. The patient remained rejection-free during the first 9 months post-transplant and has had steady and progressive functional improvement. He is highly motivated and consistently demonstrates functional independence in activities of daily living.
Conclusion(s): Combined face and bilateral hand transplant is a feasible, comprehensive reconstructive solution for composite face and bilateral hand injury in the appropriately selected recipient. Patient motivation, psychosocial support, intensive physical and occupational therapy, and vigilant clinical and immunologic surveillance are essential features of postoperative recovery

The field of vascularized composite allotransplantation (VCA) is evolving, with some procedures poised to transition from highly experimental research toward standard of care. At present, the use of social support as an eligibility criterion for VCA candidacy is at the discretion of individual VCA programs, allowing VCA teams to consider the unique needs of each potential candidate. Yet this flexibility also creates potential for bias during the evaluation process which may disproportionately impact members of certain communities where social configurations may not resemble the model considered "optimal." We examine the extent to which ethical considerations for social support in solid organ transplantation (SOT) may be applied to or adapted for VCA, and the ethically meaningful ways in which VCA procedures differ from SOT. We conclude that VCA programs must retain some flexibility in determining criteria for candidacy at present; however, considerations of equity will become more pressing as VCA procedures evolve toward standard of care, and further empirical evidence will be needed to demonstrate the association between social support and post-operative success. The field of VCA has an opportunity to proactively address considerations of equity and justice and incorporate fair, inclusive practices into this innovative area of transplantation.

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

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