Faculty Bibliography

IMPORTANCE/UNASSIGNED:Since 2005, a total of 50 face transplants have been reported from 18 centers in 11 countries. The overall survival of the grafts has not yet been established. OBJECTIVE/UNASSIGNED:To assess the survival of the face transplant grafts and evaluate factors potentially influencing it. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Data on all the transplants included in this multicenter cohort study were collected at participating transplant centers for updated nonpublished data, supplemented with literature review for nonparticipating centers. Data from 2005 until September 2023, were included. Data were analyzed from November 11, 2005, through September 18, 2023. Patients included the first 50 patients in the world to have received a face transplant. EXPOSURE/UNASSIGNED:Face transplant graft. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the overall survival of the face transplant graft, defined as either transplant loss or patient death. The secondary outcome was the number of acute rejection episodes per year. RESULTS/UNASSIGNED:The 50 transplants were performed on 39 men (81%) and 9 women (19%) with a median age of 35 (range, 19-68) years at the time of the transplant. The median follow-up time was 8.9 (range, 0.2-16.7) years. During the follow-up, 6 transplants were lost with 2 patients retransplanted. There were 10 patients who died, 2 of whom had lost a transplant. The 5- and 10-year survival of the transplants was 85% (SD, 5%) and 74% (SD, 7%), respectively. The sequential number of the transplant in the world was a significant predictor of survival (hazard ratio, 95; 95% CI, 90-100; P < 05). The median number of acute rejection episodes per year was 1.2 (range, 0-5.3) for the transplants that were lost and 0.7 (range, 0-4.6) for the transplants that survived. No correlation with patient and transplant variables was detected for either the transplant survival or the number of rejection episodes. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, the overall survival of the face transplants is encouraging. These data suggest that the acceptable long-term survival of face transplants makes them a reconstructive option for extensive facial defects.

PURPOSE/OBJECTIVE:Merit-based incentive payment system (MIPS) is a payment model implemented to promote high-value care through performance-based adjustments of Medicare reimbursements. Higher scores indicate superior performance in healthcare quality, efficiency, and interoperability, which can result in financial advantages. Given the paucity of literature, we aimed to characterize plastic surgery performance in MIPS. METHOD/METHODS:The Centers for Medicare and Medicaid Services (CMS) online data repository was queried for data on MIPS performance of plastic surgeons from 2019-2021. Descriptive analyses and multivariable logistic regression were conducted to identify predictors of receiving bonus payment for exceptional performance. RESULTS:Approximately 1400 surgeons were sampled in each year. The median number of Medicare beneficiaries and percent of dually eligible beneficiaries-eligible for Medicare and Medicaid-were higher in 2019 (p<0.001). Beneficiary median HCC risk score, which measures expected healthcare costs and needs based on health status, was lower in 2021 (p<0.001). The most common reporting schema was reporting as a group. Total MIPS score increased from 2019 to 2020 to 2021 (90.2 vs 96.4 vs 98.3, p<0.001), but quality score progressively decreased (98.8 vs 95.5 vs 89.90, p<0.001). Fewer physicians received positive adjustment and bonus payments in 2020 and 2021. Predictors of receiving bonus payments were reporting as an alternative payment model, practice size >24, and having 10-49% of dually eligible beneficiaries (p<0.05). CONCLUSION/CONCLUSIONS:Understanding performance of plastic surgeons in MIPS can guide future policy direction and ensure that high-quality care translates into improved patient outcomes across all fields and levels of social vulnerability.

PURPOSE/OBJECTIVE:The purpose of this study was to compare the dimensional accuracy, translucency, and biaxial flexural strength of milled zirconia (MZ) versus 3D-printed zirconia (PZ) discs. MATERIALS & METHODS/METHODS:A circular disc measuring 14.0 mm in diameter and 1.20 mm in thickness was designed using computer-aided design (CAD) software. The resulting standard tessellation language (STL) file was used both as a control and to fabricate 36 zirconia (3Y-TZP) disc specimens (n = 36): 18 were milled (group MZ) and 18 were 3D-printed (group PZ). The diameter and thickness of each disc were measured using a digital caliper. Translucency was evaluated using a calibrated dental colorimeter. The flexural strength was determined using the piston-on-three-ball biaxial flexure test. All measurements were done by one blinded examiner. The statistical significance level was set to α = 0.05. RESULTS:The MZ discs had significantly more accurate dimensions than the PZ discs in both diameter and thickness when compared to the control CAD software-designed disc. The MZ discs exhibited significantly higher translucency (translucency parameter (TP) = 16.95 ±0.36 vs. 9.24 ±1.98) and biaxial flexural strength (996.16 ±137.37 MPa vs. 845.75 ±266.16 MPa) than the PZ discs. Finally, MZ possessed a significantly higher Weibull modulus relative to PZ. CONCLUSIONS:The results showed that the milled specimens achieved better dimensional accuracy and were more translucent, stronger, and less prone to failure than printed specimens.

OBJECTIVE:Assess the use of video otoscopy (VO) as a tool for teaching Emergency Department (ED) residents and remote Otolaryngology consultation. STUDY DESIGN/METHODS:Survey and retrospective chart review. SETTING/METHODS:Tertiary care center. METHODS:Emergency Medicine resident physicians completed an otologic skill self-assessment and pathology followed by an interactive training on VO and postintervention assessment after 9 months of use. Outcomes compared change in pre- to posttraining scores. ED consultations using VO during this time period were reviewed to detect differences between the presumed diagnosis/treatment based only on phone consultation and VO image compared to the final diagnosis/treatment after in-person Otolaryngology consultation. RESULTS:Forty-six (63.1%) ED residents participated. Diagnostic accuracy improved by 20.7% overall. The most improved diagnoses were of a normal ear canal (+75%), tympanosclerosis (+58.4%), and ear canal foreign body (+57.1%); most challenging were external auditory canal cyst (-13.6%), hemotympanum (-11.3%), and cerumen (-1.9%). Cholesteatoma did not improve because all responses were incorrect; neither did tympanic membrane perforation because all were correct. Confidence in the otologic exam and anatomy also increased (P < .01). Thirteen consults used VO and 3 (23.1%) had a change in diagnosis/treatment after in-person Otolaryngology evaluation. CONCLUSION/CONCLUSIONS:Training on the use of VO significantly improves the confidence and diagnostic skills of ED providers for many pathologies. This application suggests the efficacy of an otologic e-consultation model.

Nerve growth factor (NGF) monoclonal antibodies inhibit chronic pain, yet failed to gain approval due to worsened joint damage in osteoarthritis patients. We report that neuropilin-1 (NRP1) is a coreceptor for NGF and tropomyosin-related kinase A (TrkA) pain signaling. NRP1 was coexpressed with TrkA in human and mouse nociceptors. NRP1 inhibitors suppressed NGF-stimulated excitation of human and mouse nociceptors and NGF-evoked nociception in mice. NRP1 knockdown inhibited NGF/TrkA signaling, whereas NRP1 overexpression enhanced signaling. NGF bound NRP1 with high affinity and interacted with and chaperoned TrkA from the biosynthetic pathway to the plasma membrane and endosomes, enhancing TrkA signaling. Molecular modeling suggested that the C-terminal R/KXXR/K NGF motif interacts with the extracellular "b" NRP1 domain within a plasma membrane NGF/TrkA/NRP1 of 2:2:2 stoichiometry. G α interacting protein C-terminus 1 (GIPC1), which scaffolds NRP1 and TrkA to myosin VI, colocalized in nociceptors with NRP1/TrkA. GIPC1 knockdown abrogated NGF-evoked excitation of nociceptors and pain-like behavior. Thus, NRP1 is a nociceptor-enriched coreceptor that facilitates NGF/TrkA pain signaling. NRP binds NGF and chaperones TrkA to the plasma membrane and signaling endosomes via the GIPC1 adaptor. NRP1 and GIPC1 antagonism in nociceptors offers a long-awaited nonopioid alternative to systemic antibody NGF sequestration for the treatment of chronic pain.

This study explores the novel application of pyronin Y for fluorescently labeling extracellular matrices (ECMs) and gelatin cryogels, providing a simple and reliable method for laser scanning confocal microscopy. Pyronin Y exhibited remarkable staining ability of the porous structures of gelatin cryogels, indicating its potential as a reliable tool for evaluating such biomaterials. Confocal imaging of pyronin Y-stained cryogels produced high signal-to-noise ratio images suitable for quantifying pores using Fiji/Image J. Importantly, pyronin Y enabled effective dual-color imaging of cryogel-labeled mesenchymal stem cells, expanding its utility beyond traditional RNA assays. Traditional staining methods like Mason's trichrome and Sirius Red have limitations in cryogel applications. Pyronin Y emerges as a powerful alternative due to its water solubility, minimal toxicity, and stability. Our results demonstrate pyronin Y's ability to specifically stain gelatin cryogel's porous structures, surpassing its weak staining of ECMs in 2D. Confocal imaging revealed enduring staining even under rigorous scanning, with no notable photobleaching observed. Furthermore, pyronin Y's combination with Alexa Fluor 647 for dual-color imaging showed promising results, validating its versatility in fluorescence microscopy. In conclusion, this study establishes pyronin Y as a cost-effective and rapid option for fluorescent staining of gelatin cryogels. Its simplicity, efficacy, and compatibility with confocal microscopy make it a valuable tool for characterizing and evaluating gelatin-based biomaterials, contributing significantly to the field of cryogel imaging. The study opens new avenues for dual-color imaging in biomaterial research and tissue engineering, advancing our understanding of cellular interactions within scaffolds. Key features • Fluorescent staining of gelatin-based cryogels with an inexpensive yet less time-consuming protocol. • Pyronin Y staining is suitable for dual-color confocal imaging by combining with far-red fluorophores (such as Alexa Fluor 647). • The method is conducted routinely. Graphical overview Gelatin cryogel staining using pyronin Y.

BACKGROUND/UNASSIGNED:Our objective is to evaluate the utilization fraction (UF) of surgical instruments during a commonly performed ambulatory hand surgery case as an avenue for cost reduction, increased operating room efficiency, and systems quality improvement. METHODS/UNASSIGNED:The total number of instruments opened at the start of the case was recorded followed by instruments being divided into those used and not used during the procedure. Total sterile processing costs were estimated at $1.56 per instrument according to data from our institution's central sterilization processing (CSP) department. RESULTS/UNASSIGNED:Nineteen hand procedures performed by 2 surgeons were included in this study. An average of 120.1 ± 10.9 instruments were opened at the start of each case, while an average of 12.6 ± 5.4 instruments were used per case (Figure 1). This yielded an UF of 10.7% ± 4.8%. Using our internal CSP estimate, we calculated an annual cost of $16 863 to reprocess the current hand tray (Figure 2). Using literature data, this cost ranged from $5 513 to $34 484 annually. The same cost calculations were performed for the theoretical optimized tray (incorporating instruments used at least 20% of the time when opened) containing 23.2 instruments. The annual reprocessing cost of this new tray according to CSP data was $3 260, demonstrating a cost-reduction of $13 603 or 80.7% (Figure 2). CONCLUSIONS/UNASSIGNED:Evaluation of pre- and peri-operative processes is a valuable technique to mitigate increasing healthcare costs and reduce unnecessary healthcare spending, with broad applicability to multiple surgical subspecialties and procedures.

BACKGROUND:The iPhone (Apple Inc, Cupertino, California) contains a high-fidelity 3D-scanner and is widely distributed in the United States. Presently, 3D analysis of the breast necessitates ownership of cost-prohibitive cameras and software packages such as the Vectra system. OBJECTIVES/OBJECTIVE:We compared the accuracy of 3D photos of the breast obtained with the iPhone X 3D scanner against the Canfield Vectra H2 (Canfield Scientific Inc. Parsippany, NJ) in an effort to expand access to 3D technology in plastic surgery. METHODS:Twenty breasts (n=20) were 3D-photographed with iPhone X and the Vectra H2 and compared with color map analysis and by measuring distances across the model between key anatomical landmarks. These distances included sternal notch to nipple (SN-N), mid-chest to nipple (M-N), nipple to mid-inframammary fold (N-IMF), and inframammary fold width (IMF). Statistical tests included the Bland-Altman Plot analysis. RESULTS:When comparing absolute differences in distances between key anatomical landmarks, the average discrepancy in measurements between iPhone and Vectra image pairs were the following: SN-N: 0.94mm, M-N: 0.70mm, N-IMF 0.81mm, and IMF 0.96mm. Colormap analysis demonstrated an average error of 1.53mm, mean of 0.53mm, and standard deviation of ±1.81mm. Bland-Altman Plot revealed a mean difference of 0.13mm and an agreement interval between -1.90 and 2.17mm. CONCLUSIONS:The iPhone is capable of capturing 3D-photographs with a high level of fidelity when compared to Vectra. 3D-scans obtained with the iPhone may be useful for planning nipple position, measuring the breast footprint, choosing implants, and performing other functions using 3D technology that are typically performed using the more expensive systems.

IMPORTANCE/UNASSIGNED:Catastrophic facial injury with globe loss remains a formidable clinical problem with no previous reports of reconstruction by whole eye or combined whole eye and facial transplant. OBJECTIVE/UNASSIGNED:To develop a microsurgical strategy for combined whole eye and facial transplant and describe the clinical findings during the first year following transplant. DESIGN, SETTING, AND PARTICIPANT/UNASSIGNED:A 46-year-old man who sustained a high-voltage electrical injury with catastrophic tissue loss to his face and left globe underwent combined whole eye and face transplant using personalized surgical devices and a novel microsurgical strategy at a specialized center for vascularized composite allotransplantation. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Reperfusion and viability of the whole eye and facial allografts, retinal function, and incidence of acute rejection. RESULTS/UNASSIGNED:The patient underwent a combined whole eye and face transplant from an immunologically compatible donor with primary optic nerve coaptation and conventional postoperative immunosuppression. Globe and retinal perfusion were maintained throughout the immediate postoperative period, evidenced by fluorescein angiography. Optical coherence tomography demonstrated atrophy of inner retinal layers and attenuation and disruption of the ellipsoid zone. Serial electroretinography confirmed retinal responses to light in the transplanted eye. Using structural and functional magnetic resonance imaging, the integrity of the transplanted visual pathways and potential occipital cortical response to light stimulation of the transplanted eye was demonstrated. At 1 year post transplant (postoperative day 366), there was no perception of light in the transplanted eye. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This is the first report of whole eye transplant combined with facial transplant, demonstrating allograft survival including rejection-free graft survival and electroretinographic measurements indicating retinal response to light stimuli. These data highlight the potential for clinical allotransplantation for globe loss.