Faculty Bibliography

Facial disfigurement can significantly affect personal identity and access to social roles. Although conventional reconstruction can have positive effects with respect to identity, these procedures are often inadequate for more severe facial defects. In these cases, facial transplantation (FT) offers patients a viable reconstructive option. However, FT's effect on personal identity has been less well examined, and ethical questions remain regarding the psychosocial ramifications of the procedure. This article reviews the literature on the different roles of the face as well as psychological and social effects of facial disfigurement. The effects of facial reconstruction on personal identity are also reviewed with an emphasis on orthognathic, cleft, and head and neck surgery. Finally, FT is considered in this context, and future directions for research are explored.

Background/Purpose: Outpatient primary cleft palate surgery (PCPS) has been implemented in many cleft centers; however, the prevalence of this procedure is unknown and its safety has been called into question. We queried the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIPPediatric) to evaluate perioperative complications associated with PCPS. Methods/Description: The ACS NSQIP-Pediatric database was reviewed from 2012 to 2015 using Current Procedure Terminology (CPT) codes for PCPS. Patients undergoing concurrent bone grafting or cleft lip surgery were excluded. Patients aged 5 years or younger were included. The goal of our study was to compare 30-day perioperative complications following outpatient vs inpatient PCPS. Statistical analyses were carried out using SPSS (Version 21.0. Armonk, NY: IBM Corp).
Result(s): We identified 4191 (2760 inpatient vs 1431 outpatient) eligible patients. The majority of patients were males (52.6%). Plastic surgeons performed these procedures most frequently (80.3%) followed by otolaryngologists (18.7%). Tympanostomy tube insertion was the most common concurrent procedure (17.1%). Mean age in days and weight in kilograms at surgery were 485.5 +/- 319.2 and 9.7 +/- 3.8, respectively. Mean age (509.3 +/- 346.9 vs 473.2 +/- 303.1; P < .001) and weight (9.9 +/- 4.0 vs 9.6 +/- 3.8; P = .01) were significantly higher in the outpatient group. The inpatient group included a significantly higher proportion of patients with congenital abnormalities (25.0% vs 21.2%; P = .01), history of stroke (1.0% vs 0.3%; P = .02), cardiac risk factors (14.4% vs 11.7%; P = .02) and oxygen dependence (1.8%vs 0.8%; P = .01). Univariate analysis showed that rates of superficial (3.5% vs 2.0%; P = .01) and deep (2.2% vs 1.0%; P = .003) wound dehiscence were significantly higher in the outpatient group. The rates of reoperation (1.2 vs 0.4; P = .02) and readmission (3.2 vs 1.5; P = .01) were significantly higher in the inpatient group. Mortality at 30 days was comparable between groups. After controlling for confounders, rates of superficial (OR = 1.99, P = .01, 95% CI [1.22, 3.24]) and deep (OR = 2.22, P = .01, 95% CI [1.25, 3.95]) wound dehiscence remained significantly higher in the outpatient group, whereas reoperation (OR = 2.8, P=.04, 95%CI [1.04, 7.14]) and readmission (OR=1.92, P= .02, 95% CI [1.14, 3.23]) rates were significantly higher in the inpatient group.
Conclusion(s): Outpatient PCPS is a common practice and appears to have an acceptable safety profile in appropriately selected patients. Outpatient surgery has a higher risk for wound complications. Inpatient surgery is associated with greater reoperation and readmission. Preoperative evaluation of patient risk factors and comorbidities is critical for optimal outcomes

Autologous fat grafting is an important tool for plastic surgeons treating the aging face. Malar augmentation with fat is often targeted to restore the youthful facial contour and provides support to the lower eyelid. The existence of distinct facial fat compartments suggests that a stepwise approach may be appropriate in this regard. The authors describe a three-step approach to malar augmentation using targeted deep malar fat compartmental augmentation, termed the "boomerang lift." Clinical patients undergoing autologous fat grafting for malar augmentation were injected in three distinct deep malar fat compartments: the lateral sub-orbicularis oculi fat, the medial sub-orbicularis oculi fat, and the deep medial cheek (n = 9). Intraoperative three-dimensional images were taken at baseline and following compartmental injections (Canfield VECTRA H1). Images were overlaid between the augmented and baseline captures, and the three-dimensional surface changes were analyzed, which represented the resulting "augmentation zone." Three-dimensional analysis demonstrated a unique pattern for the augmentation zone consistent across patients. The augmentation zone resembled a boomerang, with the short tail supporting the medial lower lid and the long tail extending laterally along the zygomatic arch. The upper border was restricted by the level of the nasojugal interface, and the lower border was defined medially by the nasolabial fold and laterally by the level of the zygomaticocutaneous ligament. Lateral and medial sub-orbicularis oculi fat injections defined the boundaries of the boomerang shape, and injection to the deep medial cheek provided maximum projection. This is the first description of deep malar augmentation zones in clinical patients. Three-dimensional surface imaging was ideal for analyzing the surface change in response to targeted facial fat grafting. The authors' technique resulted in a reproducible surface shape, which they term the boomerang lift.

Background/Purpose:Management of patientswith cleft lip and palate is complex and requires a multidisciplinary team with several treatment interventions. Proper sequencing and timing of orthodontic and surgical treatment is important for successful long-term outcome and reducing the burden of care on the families. This presentation will focus on orthodontic management of patients born with cleft lip and palate from infancy to skeletal maturity. Methods/Description: The management of patients with cleft lip and cleft palate requires extended orthodontic treatment and an interdisciplinary approach in providing these patients with optimal aesthetics, function, and stability. Orthodontic or orthopedic management in infancy, primary, mixed, and permanent dentition and after the completion of facial growth will be discussed with a proper interdisciplinary approach to treatment planning and treatment sequencing during each phase of orthodontic and surgical treatment. This presentation will discuss the presurgical infant orthopedic, pre and post bone graft orthodontics, phase II comprehensive orthodontic treatment, and LeFort I distraction and orthognathic surgery at skeletal maturity. Long-term outcome of treatment will be presented of patients treated from birth to adulthood

Vascular malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result, resections of large VMs are often performed in a multistage approach. This article introduces a new hybrid approach for the management of head and neck VMs entailing the use of an endovascular operating room where a neuroendovascular surgeon performs embolization or sclerotherapy intraoperatively as needed in conjunction with surgical excision. Three patients with large VMs in the facial region underwent successful use of the hybrid approach. The hybrid approach improved visualization, leading to complete resection in 1 patient and nearly complete resections (70% and 90%) in the other patients. The technique also helped minimize blood loss because only the youngest patient (23 months old) required a blood transfusion. Implications of these findings include the transition from a multistaged approach for large VMs to a single-stage approach. In addition, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

Background/Purpose: Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with a bilateral cleft. The nasoalveolar molding (NAM) technique is a unique approach to presurgical infant orthopedics to reduce the severity of the initial cleft of the alveolar and the nasal deformity, particularly in patients with bilateral cleft lip and palate. Methods/Description: In infants with bilateral cleft lip and palate, the premaxilla may be protrusive, mobile, and may show varying degree of asymmetrical displacement and rotation. In some instances, the premaxilla may be everted placed on top of the nasal tip with a very short columella length. Protruded premaxilla and the associated nasal deformity present a special challenge for the surgeon in achieving optimal repair during primary reconstructive surgery. This study session will demonstrate the NAM technique to treat patients with severe bilateral cleft lip and palate. The technique of correcting the protruded and asymmetrically displaced premaxilla, molding the alar cartilage and nonsurgical columella elongation will be discussed. Appliance design and weekly adjustment of the NAM appliance to accomplish the desired result will be presented. Special emphasis will be placed on leveling the premaxilla in asymmetric cases; retracting premaxilla in incomplete bilateral clefts and management of complications during the course of the NAM therapy will be discussed. For the successful outcome, the surgeon has to take the advantage of the NAM therapy during the primary repair. Surgical technique of 1-stage lip nose and alveolus surgery utilizing the presurgical preparation of infants with bilateral cleft lip and palate with NAM therapy will be discussed in detail. Long-term outcome of patients treated with NAM and primary reconstruction of nose lip and alveolus will be presented

Background/UNASSIGNED:Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality. Methods/UNASSIGNED:In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed. Results/UNASSIGNED:There was no flap loss. The hands were sensate with effective simple prehensile function. Conclusion/UNASSIGNED:Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.