Faculty Bibliography

Reconstruction in head and neck surgery requires restoration of complex functions, including speech, swallowing, and breathing, while preserving as much facial form and patient identity as possible. Over the past decade, advances in preoperative digital planning, intraoperative technologies, and robotic platforms have reshaped reconstructive strategies, giving rise to the concept of hybrid reconstruction. Hybrid approaches integrate free tissue transfer with computer-aided design and manufacturing (CAD/CAM), virtual surgical planning, intraoperative navigation, and robot-assisted microsurgery to enhance precision, reproducibility, and functional outcomes. This narrative review examines the principles and applications of hybrid reconstruction in head and neck surgery with particular emphasis on osseous reconstruction of the mandible, maxilla, and midface. The roles of intraoperative navigation and robotic assistance as enabling tools are discussed, along with their potential benefits and current limitations. Functional and morphologic outcomes, patient-reported quality of life, and challenges related to cost, access, training, and evidence heterogeneity are critically reviewed. Hybrid reconstruction represents an advancement toward outcomes-driven, patient-centered care; however, thoughtful integration of emerging technologies and continued emphasis on rigorous outcome assessment are essential to guide responsible adoption in contemporary head and neck reconstructive surgery.

Vascularized composite allotransplantation (VCA) is increasingly recognized as a reconstructive option that offers substantial benefits for patients with severe tissue loss, including injuries affecting the face and hand. Despite its clinical promise, VCA remains limited by surgical complexity, the need for long-term immunosuppression, and associated morbidity. Preclinical models are therefore essential for refining surgical techniques, testing novel immunomodulatory approaches, and investigating ischemia/reperfusion injury. Compared with large-animal models, rodent models offer advantages in accessibility and cost while adhering more closely to the 3Rs principles of Replacement, Reduction, and Refinement. Among them, the mouse offers unique advantages, including the availability of humanized strains, a broad panel of well-characterized antibodies, and compatibility with advanced immunological assays. These features make the mouse particularly valuable for translational VCA research. Murine VCA, however, requires demanding supermicrosurgical skills, as vascular anastomoses are performed on vessels measuring approximately 0.3-0.5 mm in diameter. To enhance reproducibility, we provide technical tips that have proven critical to the success of these procedures. These include the insertion of a nylon filament into the vessel lumen to stabilize the anastomosis, careful separation of the artery and vein over a sufficient distance along the pedicle, precise anesthetic dosing, and specific maneuvers to prevent pedicle twisting. We also highlight common pitfalls and errors, offering practical guidance to improve outcomes. Here, we describe a comprehensive, stepwise protocol for mouse heterotopic hindlimb-to-neck transplantation, accompanied by instructional video material. This non-functional model minimizes postoperative morbidity compared with orthotopic transplantation while providing robust and reproducible results. It is ideally suited for training in supermicrosurgery and for addressing key experimental questions in VCA, including immune tolerance, graft preservation, and ischemia/reperfusion mechanisms. This methodology provides investigators with a reliable murine platform to advance translational VCA research and to develop innovative strategies aimed at improving outcomes in reconstructive transplantation.

Despite the growing demand for hyaluronic acid (HA) lip fillers, there is a paucity of robust, quantitative data across high-powered studies. This systematic review and meta-analysis aims to assess the efficacy and safety of HA lip fillers as reported by randomized controlled trials (RCTs). A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, utilizing PubMed, Embase, and Cochrane, and eligible studies included RCTs with human subjects utilizing HA filler for lip augmentation. Meta-analysis evaluated rates of improvement in lip fullness, aesthetic appearance, patient satisfaction, and adverse events. A comprehensive review initially identified 2,038 articles. Following screening by title and abstract, full-text review, and risk of bias assessment with the Cochrane risk-of-bias tool for randomized trials (RoB 2), sixteen articles were included in the study. Meta-analysis demonstrated that 60% (95% CI: 44-76%) had improvement in lip fullness, 82% (95% CI: 67-92%) had improvement in aesthetic appearance, 68% (95% CI: 58-78%) reported satisfaction, 50% (95% CI: 27-73%) had adverse events, and 1.5% (95% CI: 1.9-4.0%) had serious adverse events requiring treatment, needing follow-up, or lasting beyond 30 days. The most common adverse events were swelling (78%), firmness (48%), bruising (34%), and tenderness (33%). Across studies with the highest level of evidence, HA filler efficacy and patient satisfaction is moderate to high. Severe adverse reactions are rare, but adverse events are common.

Soft tissue augmentation in the oral cavity is limited by mechanical loading, salivary enzymes, and rapid degradation of collagen-based biomaterials. Porcine-derived collagen membranes (PDCMs) may provide an alternative to autografts, but their clinical performance is influenced by membrane architecture, crosslinking, and the surgical environment. This study evaluated the long-term biocompatibility, degradation behavior, and soft tissue healing outcomes of two novel crosslinked PDCMs compared with an established noncrosslinked bilayer membrane in a canine mandibular defect model. Standardized full-thickness mandibular soft tissue defects were created in n=24 beagles and treated with a bilayer PDCM with high crosslinking (HXL), a bilayer PDCM with low crosslinking (LXL), or a predicate bilayer membrane (Mucograft, MG). Untreated defects served as controls. Animals were euthanized at 4, 8, and 12 weeks. Qualitative and semiquantitative analyses assessed membrane presence, inflammation, and subepithelial healing, while membrane thickness was quantified across timepoints. All membranes supported successful healing with decreasing inflammation over time. At 4 weeks, MG demonstrated greater membrane thickness (p = 0.023) and inflammation (p = 0.004) than LXL. At 8 weeks, both HXL and LXL showed reduced membrane presence relative to MG (p = 0.001), and this difference persisted at 12 weeks (p = 0.018). At 12 weeks, LXL achieved superior subepithelial healing compared with MG (p = 0.047), with more organized collagen and improved integration. Overall, LXL provided a favorable balance of stability, integration, and biocompatibility, supporting coordinated soft tissue remodeling.

Presurgical lip, alveolus, and nose approximation (PLANA) is a novel form of presurgical infant orthopedics (PSIO) involving a prefabricated silicone intranasal device combined with hydrocolloid adhesive lip taping. Early studies have demonstrated favorable nasolabial morphologic outcomes using PLANA and a reduction in the burden of care on infants and their caregivers relative to nasoalveolar molding (NAM). However, the efficacy of PLANA in reducing cleft severity to facilitate surgical repair has not been comprehensively assessed from the perspective of the cleft surgeon. This study, therefore, compared surgeon ratings of PSIO outcomes in infants with unilateral cleft lip treated with PLANA and NAM. Two expert surgeons blindly evaluated PSIO outcomes in 10 patients treated with PLANA and 10 patients treated with NAM using standardized pre- and post-PSIO photographs. Surgeons used a 4-point Likert scale to assess improvement in lip approximation, lateral displacement of the subnasale from the midsagittal plane, nasal deviation, alar base width symmetry, alar base height symmetry, columellar angle, columellar length, nostril width symmetry, nostril height symmetry, and nasal tip projection, as well as overall morphologic improvement. The PLANA cohort received statistically significantly greater scores for alar base width symmetry (3.45 versus 2.35, P<0.001), alar base height symmetry (3.40 versus 2.55, P=0.02), columellar angle (3.70 versus 3.10, P=0.05), nostril width symmetry (3.65 versus 2.20, P<0.001), and overall outcome (3.65 versus 2.90, P=0.02). The 2 cohorts received similar ratings across all other parameters. Surgeons consistently rated PSIO outcomes as equivalent or superior with PLANA relative to NAM.

Rhinoplasty is the fifth most commonly performed cosmetic surgery globally. While surgical techniques used for rhinoplasty have evolved significantly in the past century, the creation of precise osteotomies remains a cornerstone of the procedure. Recently, piezotomes have been associated with reduced postoperative pain, edema, ecchymosis, complications, and revision rates in rhinoplasty. Despite these clinically significant benefits, there remains a paucity of histologic analysis of osteotomies performed with piezotomes in a large translational preclinical model. In this study, n=12 adult sheep underwent lateral rhinoplasty of the posterior maxilla using each of the three surgical devices: piezotome, manual osteotome, and oscillatory saw. Subjects were randomized to heal for either 3 or 12 weeks postoperatively (n = 6 animals per cohort). En bloc samples were processed and analyzed histologically. A semiquantitative healing scale was used to quantify bony ingrowth into the osteotomy. Wilcoxon signed-rank tests were used to analyze the outcome variable. No statistically significant differences in semiquantitative grades were observed among groups (p > 0.05) at either time point. However, the piezotome was associated with more uniform, reproducible, and smoother osteotomy walls, and smaller bone chips at 3 weeks. At 12 weeks, all osteotomy techniques had complete or near-complete osteogenesis. Use of the piezotome did not completely prevent soft tissue injury. Some osteotomies demonstrated full-thickness penetration and injury to the underlying cartilage. All groups demonstrated comparable healing outcomes after 12 weeks. However, histologic results indicate that reliance solely on device technology may not be sufficient. Clinical judgement of these techniques and relevant case presentations is required to minimize unintended tissue injury.

Breast-conserving therapy (BCT), consisting of lumpectomy followed by adjuvant radiation, provides oncologic outcomes equivalent to mastectomy for many patients with breast cancer. As survivorship increases, the demand for aesthetic restoration after BCT has grown; however, reconstructive strategies in this setting remain less standardized than those following mastectomy. Reconstruction after BCT presents distinct challenges due to partial tissue loss, nonuniform radiation injury, progressive fibrosis, and wide variability in patient expectations and tolerance for revision surgery. Consequently, mastectomy-based reconstructive algorithms are often insufficient for guiding care in this population. This review synthesizes contemporary reconstructive options following BCT through a personalized medicine framework, emphasizing patient-specific risk factors that influence technique selection, timing, and long-term outcomes. Key determinants include radiation exposure, breast morphology, comorbid conditions, prior breast surgery, and psychosocial preferences. Oncoplastic volume displacement, implant-based augmentation, fat grafting, and autologous reconstruction each demonstrate distinct risk profiles in the post-BCT tissue environment and require individualized application. Timing of reconstruction and willingness to undergo staged procedures play a central role in outcome durability and patient satisfaction. Across reconstructive strategies, revision burden emerges as a clinically meaningful, patient-centered outcome that is not adequately captured by traditional short-term complication metrics. A risk-informed approach that integrates individualized risk assessment with transparent counseling and shared decision-making may improve alignment between reconstructive planning and patient goals. Personalized reconstruction after BCT requires moving beyond technique-driven paradigms toward flexible, longitudinal care pathways. Future efforts should focus on developing BCT-specific predictive models and incorporating patient-reported outcomes to advance personalized reconstructive care.

BACKGROUND:Facial transplantation offers transformative solutions for patients with severe facial disfigurements. Minimizing ischemia time is critical for preserving tissue viability, and prioritizing facial allograft recovery during multiorgan procurement aims to optimize outcomes. This study evaluates whether prioritizing facial allograft procurement affects the outcomes of non-vascularized composite allotransplantation (VCA) organ transplants. METHODS:This retrospective study analyzed 4 VCA donor recoveries and face transplants at our center. Perioperative data, including operation times, blood pressure, oxygenation, urine output, and blood product administration, were recorded. Donor data were verified using the United Network for Organ Sharing database, institutional records, and data from LiveOnNY and Gift of Life organ procurement organizations to assess recipient and graft survival. RESULTS:Twenty-one allografts (VCAs and organs) were transplanted into 16 patients. The 1-year patient survival rate was 92% (11 of 12) among non-VCA recipients. One patient died during surgery, and 2 patients died more than 3 years after transplantation from unrelated causes. Three non-VCA graft failures occurred within the first year, resulting in an 87% graft survival rate. The median ischemia time for face transplants was 3 hours 18 minutes. Preoperative planning, including cadaveric rehearsals, computerized surgical plans, and 3-dimensionally printed cutting guides, contributed to stable perioperative parameters and reduced blood loss. CONCLUSIONS:This study suggests that prioritizing facial allograft procurement is feasible and does not appear to compromise non-VCA organ transplant outcomes. Further multicenter studies are needed to validate these findings and further refine protocols.

BACKGROUND:Composite allotransplantation has become a viable reconstructive option for selected patients, but preservation remains a major barrier to broader clinical application. Static cold storage is the current gold standard, yet ischemia reperfusion injury and limited preservation times restrict its effectiveness. Recent advances in machine perfusion and subzero nonfreezing storage (or supercooling) have prompted renewed interest in optimizing graft viability. METHODS:Following PRISMA guidelines, we systematically searched PubMed, EMBASE, and Cochrane, covering studies published from June 2022 to August 2025 for studies on ex vivo preservation of vascularized composite allotransplantations. Eligible articles included original studies in English evaluating postharvest, pretransplant preservation strategies. Data extracted were study design, preservation methods, perfusates, and primary outcomes. Risk of bias was assessed using SYRCLE for animal studies and Joanna Briggs Institute for human/cadaver studies. RESULTS:Seventeen studies met the inclusion criteria: 1 on static cold storage, 13 on machine perfusion, and 3 on supercooling. Static cold storage research has declined, with the only recent study investigating subnormothermic machine perfusion as a recovery adjunct. Machine perfusion studies focused on the optimization of perfusion parameters, perfusate composition, and circuit design. Red blood cell-based perfusates remained common, but alternative oxygen carriers such as polymerized hemoglobin-based oxygen carrier-201 and dextran oxygen microcarriers showed promise despite edema-related challenges. Supercooling studies demonstrated the feasibility of multiday preservation in rodent and porcine models. Overall, risk of bias was high or unclear across animal studies, mainly due to selection and performance bias, whereas the single human ex vivo study showed low risk of bias. CONCLUSIONS:The field of vascularized composite allograft preservation is expanding rapidly, with a combination of static and dynamic techniques emerging as a promising option to extend graft viability beyond the current limits. However, translation to clinical setting remains limited by small preclinical studies, methodological heterogeneity, and the paucity of functional endpoints. Standardized protocols, robust large-animal models, and eventual human feasibility trials are needed to establish clinically applicable preservation strategies.