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Techniques and Trends of Facial Feminization Surgery: A Systematic Review and Representative Case Report

Siringo, Nicolette V; Berman, Zoe P; Boczar, Daniel; Chaya, Bachar F; Diep, Gustave K; Trilles, Jorge; Mazzei, Sara; Rodriguez Colon, Ricardo; Rodriguez, Eduardo D
BACKGROUND:Facial feminization surgery is composed of a variety of craniomaxillofacial surgical procedures that are increasingly sought after by male-to-female transgender patients and by those seeking feminization of the face. Facial feminization surgery can play a prominent role in alleviating gender dysphoria. In consideration of an observed increase in gender-affirming procedures performed in recent years, a broad knowledge base in the techniques, outcomes, and challenges of facial feminization surgery should be established by surgeons offering these procedures. Our review was designed to critically appraise the current literature and inform future advancements in gender-affirming surgical practice. In addition, we detail a representative case to illustrate the senior author's approach to full facial feminization. METHODS:A comprehensive literature search of the PubMed, EMBASE, and Cochrane databases was conducted for studies published through June 2020 using following the search terms: "Face" OR "facial" OR "craniofacial" AND "Feminization" OR "Feminization Surgery" OR "Gender Reassignment" OR "Gender Affirming Surgery" OR "Gender Confirmation Surgery." Data on procedures, outcomes, patient age, follow-up time, complications, and patient satisfaction were collected. The data were categorized by facial thirds and then further stratified by facial feature. RESULTS:Our search yielded 388 articles. Thirty articles fit our inclusion criteria, and of these, 23 articles were included in the review. We extracted primary data pertaining to 3554 patients with an age range of 18 to 73 who underwent 8506 total procedures. Most of the procedures addressed the upper facial third (hairline, forehead, and brow), comprising 49.1% of total procedures performed. Further categorization by facial feature revealed that the most commonly addressed feature was the forehead (34.6% of procedures), followed by the nose (12.8%) and the chin (12.2%). In studies that used quantitative measures to gauge patient-reported outcomes, satisfaction was high. CONCLUSIONS:Facial feminization surgery seems to be safe, whether it is conducted in a single stage or as a staged procedure. Patients report high satisfaction and better gender congruency after facial feminization procedures. Further research is needed to establish best surgical practice and gauge patient satisfaction beyond the length of average follow-up and determine the frequency with which adjunctive procedures are sought out.
PMID: 34270469
ISSN: 1536-3708
CID: 5160352

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery

Trilles, Jorge; Chaya, Bachar F; Brydges, Hilliard; Parker, Augustus; Kimberly, Laura L; Boczar, Daniel; Rodriguez Colon, Ricardo; Rodriguez, Eduardo D
PMID: 35451878
ISSN: 2325-8306
CID: 5218602

Adapting Existing Conduits to Secure Data From Smart Devices in Plastic Surgery

Boczar, Daniel; Brydges, Hilliard; Trilles, Jorge; Rodriguez Colon, Ricardo; Rodriguez, Eduardo D
PMID: 35502950
ISSN: 1536-3708
CID: 5216022

Cytomegalovirus-related Complications and Management in Facial Vascularized Composite Allotransplantation: An International Multicenter Retrospective Cohort Study

Kauke-Navarro, Martin; Panayi, Adriana C; Formica, Richard; Marty, Francisco; Parikh, Neil; Foroutanjazi, Sina; Safi, Ali-Farid; Mardini, Samir; Razonable, Raymund R; Morelon, Emmanuel; Gelb, Bruce; Rodriguez, Eduardo; Lassus, Patrik; Pomahac, Bohdan
BACKGROUND:There is a paucity of data on the impact of cytomegalovirus (CMV) serostatus and CMV infection on outcomes in facial vascularized composite allotransplantation. METHODS:This international, multicenter, retrospective cohort study presents data on CMV and basic transplant-related demographics, including pretransplant viral D/R serostatus, and duration of antiviral prophylaxis. CMV-related complications (viremia, disease), allograft-related complications (rejection episodes, loss), and mortality were analyzed. RESULTS:We included 19 patients, 4 of whom received CMV high-risk transplants (D+/R-). CMV viremia was noted in 6 patients (all 4 D+/R- patients and 2 D-/R+), mostly within the first-year posttransplant, shortly after discontinuation of antiviral prophylaxis (median 2 mo). CMV disease occurred in 2 D+/R- patients. The high-risk group experienced relatively more rejection episodes per month follow-up. None of D+/R- patients suffered allograft loss due to rejection (longest follow-up: 121 mo). CONCLUSIONS:D+/R- patients were at increased risk of CMV-related complications. Although a higher number of rejections was noted in this group, none of the D+/R- patients lost their allograft or died because of CMV or rejection. Thus, CMV D+/R- face transplantation can likely be safely performed with prophylaxis, active surveillance, and prompt treatment.
PMID: 35389381
ISSN: 1534-6080
CID: 5204982

Frontal Sinus Fractures: Evidence and Clinical Reflections

Lopez, Christopher D; Rodriguez Colon, Ricardo; Lopez, Joseph; Manson, Paul N; Rodriguez, Eduardo D
Background/UNASSIGNED:Despite significant advances in the management of frontal sinus fractures, there is still a paucity of large-cohort data, and a comprehensive synthesis of the current literature is warranted. The purpose of this study was to present an evidence-based overview of frontal sinus fracture management and outcomes. Methods/UNASSIGNED:A comprehensive literature search of PubMed and MEDLINE was conducted for studies published between 1992 and 2020 investigating frontal sinus fractures. Data on fracture type, intervention, and outcome measurements were reported. Results/UNASSIGNED:In total, 456 articles were identified, of which 53 met our criteria and were included in our analysis. No statistically significant difference in mechanism of injury, fracture pattern, form of management, or total complication rate was identified. We found a statistically significant increase in complication rates in patients with nasofrontal outflow tract injury compared with those without. Conclusions/UNASSIGNED:Frontal sinus fracture management is a challenging clinical situation, with no widely accepted algorithm to guide appropriate management. Thorough clinical assessment of the fracture pattern and associated injuries can facilitate clinical decision-making.
PMCID:9015196
PMID: 35450261
ISSN: 2169-7574
CID: 5218562

Using Artificial Intelligence to Measure Facial Expression following Facial Reanimation Surgery

Boczar, Daniel; Rodriguez Colon, Ricardo; Chaya, Bachar F; Trilles, Jorge; Rodriguez, Eduardo D
PMID: 35089270
ISSN: 1529-4242
CID: 5154852

COVID-19: Perspectives from Students Pursuing Plastic Surgery

Rifkin, William J; Boyd, Carter J; Saadeh, Pierre B; Rodriguez, Eduardo D
PMID: 34965219
ISSN: 1529-4242
CID: 5108242

Imaging of Facial Reconstruction and Face Transplantation

Nayak, Gopi K; Berman, Zoe P; Rodriguez, Eduardo D; Hagiwara, Mari
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.
PMID: 34809842
ISSN: 1557-9867
CID: 5063402

Accelerated functional recovery following combined face and bilateral hand transplant [Meeting Abstract]

Gelb, B E; Berman, Z P; Diep, G K; Boczar, D; Trilles, J; Colon, R R; Chaya, B F; Rodriguez, E D
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
EMBASE:637390403
ISSN: 2050-3121
CID: 5177392

Combination B- and T-cell depletion induction confers extended rejection-free intervals post-transplant [Meeting Abstract]

Gelb, B E; Boczar, D; Trilles, J; Berman, Z P; Chaya, B F; Colon, R R; Diep, G K; Rodriguez, E D
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
EMBASE:637390391
ISSN: 2050-3121
CID: 5177402