Faculty Bibliography

BACKGROUND:Congestive heart failure affects 6.2 million people in the United States. Patients have a decreased cardiopulmonary reserve and often suffer from peripheral edema, important considerations in lower extremity reconstructive surgery. In this study, the authors sought to determine the impact of congestive heart failure on postoperative outcomes following lower extremity pedicled flap reconstruction using a national multi-institutional database. METHODS:The authors isolated all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent lower extremity pedicled flap reconstruction from 2010 to 2016. Preoperative, intraoperative, and postoperative variables were compared between patients with and without congestive heart failure. Multivariable regressions were performed to determine the independent effect of congestive heart failure on postoperative outcomes. RESULTS:The authors identified 1895 patients who underwent lower extremity pedicled flap reconstruction, of whom 34 suffered from congestive heart failure. No significant difference was observed between patients with versus without congestive heart failure in postoperative wound complications (superficial wound infection, deep wound infection, and wound dehiscence), renal failure, or readmission. On multivariable analysis, congestive heart failure was independently associated with increased cardiopulmonary complications (i.e., myocardial infarction, cardiac arrest, pneumonia, reintubation, and failed ventilator weaning) (OR, 3.92; 95 percent CI, 1.53 to 9.12), septic events (OR, 4.65; 95 percent CI, 2.05 to 10.02), and length of hospital stay (β, 0.37; 95 percent CI, 0.01 to 0.72). CONCLUSIONS:In patients undergoing lower extremity pedicled flap reconstruction, congestive heart failure independently predicts a four-fold increase in postoperative sepsis and cardiopulmonary complications and a significantly increased length of hospital stay. The authors' findings highlight the need for heightened perioperative vigilance and medical optimization in this high-risk population. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.

BACKGROUND:The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.). METHODS:Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally-printed facial masks (n = 3) were captured with each device and compared. RESULTS:For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally-printed facial mask comparison, average root mean square difference was 0.28 mm. CONCLUSIONS:The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.

Unveiling the molecular mechanisms underlying tissue regeneration provides new opportunities to develop treatments for diabetic ulcers and other chronic skin lesions. Here, we show that Ccl2 secretion by epidermal keratinocytes is directly orchestrated by Nrf2, a prominent transcriptional regulator of tissue regeneration that is activated early after cutaneous injury. Through a unique feedback mechanism, we find that Ccl2 from epidermal keratinocytes not only drives chemotaxis of macrophages into the wound but also triggers macrophage expression of EGF, which in turn activates basal epidermal keratinocyte proliferation. Notably, we find dysfunctional activation of Nrf2 in epidermal keratinocytes of diabetic mice after wounding, which partly explains regenerative impairments associated with diabetes. These findings provide mechanistic insight into the critical relationship between keratinocyte and macrophage signaling during tissue repair, providing the basis for continued investigation of the therapeutic value of Nrf2.

BACKGROUND:Skin color matching is an essential factor in achieving optimal aesthetic outcome in partial facial transplantation. However, there is no published literature evaluating the success of color matching to date. Furthermore, a medical professional's perception of an optimal color match may not necessarily translate to that of the general public. The purpose of our study was to evaluate skin color matching between the donor allograft and recipient native tissue in partial facial transplantations to determine the level of success perceived by the general public and medical professionals. METHODS:Published photographs of partial face transplant recipients were used to create a survey where recipient native and donor allograft skin samples were juxtaposed. Thirty-three members of the general public and 30 medical professionals were asked to rate skin color match on a scale from "excellent match" to "not a match." RESULTS:Overall, 47% of given ratings were positive, indicating an "excellent" or "good match," and 53% of ratings were negative, indicating a "poor match" or "lack of match" between the skin sample pairings shown. Of the 19 partial face transplant patients who were rated, 9 patients received >50% positive ratings, and 10 patients received <50% positive ratings. Medical professionals consistently gave more positive ratings, with statistically significant differences in 7 of the 19 rated patients (P < 0.05). CONCLUSION/CONCLUSIONS:The results suggest that there is need for improvement in color matching in partial facial transplantation, and that the general public is more critical of skin color matching compared to medical professionals.

BACKGROUND:Cross-sex vascularized composite allotransplantation has been performed in cadaveric facial transplantation and clinical extremity transplantation. Understanding the challenge of appropriate donor-recipient matching, this study sought to characterize the public's perception of cross-sex vascularized composite allotransplantation. METHODS:Participants were surveyed in New York City. Data collected included demographics and willingness to donate vascularized composite allografts (VCAs) of various types. Similar questions were asked in the context of same-sex and cross-sex donation. RESULTS:A total of 101 participants (male: 56.4%; age ≤35 years: 62.4%) were surveyed. The majority expressed willingness to donate to recipients of a different sex (hand: 78.2%, face: 56.4%, penis or uterus: 69.3%, lower limb: 81.2%, abdominal wall: 80.2%, larynx: 81.2%, and solid organs: 85.2%). Among VCAs, willingness to donate facial allografts was significantly different in same-sex versus cross-sex contexts (64.4% vs 56.4%; P = 0.008). Participants were also significantly more likely to donate VCAs to same-sex recipients on behalf of themselves versus loved ones (P < 0.05). There was significantly lower willingness to receive cross-sex versus same-sex facial (P = 0.022) and genital allografts (P = 0.022). Education on the preservation of recipient masculinity or femininity in cross-sex facial transplantation increased participants' willingness to receive a cross-sex face transplant from 56.4% to 71.3% (P = 0.001). CONCLUSIONS:This study highlights the urban public's acceptance of VCA donation or reception regardless of sex mismatch. There is increased willingness to receive a cross-sex face transplant after education, highlighting opportunities for future focused interventions to increase public awareness and ultimately the donor pool.