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Since 1998, vascularized composite allotransplantation (VCA) has been a growing area of research in the field of reconstructive surgery. Although conditions treated with VCA often result from a traumatic injury, there has been limited emphasis on incorporating trauma-informed care (TIC) models in VCA. Considering the importance of psychosocial well-being in VCA candidates and recipients, applying best practices in TIC to the face, upper extremity, and penile transplantation may be critical in minimizing retraumatization throughout the perioperative process. There are six main principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical, and gender issues, which may be further incorporated in care for VCA patients. Evaluating for PTSD and incorporating TIC may have substantial benefit to postoperative outcomes., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: In properly selected patients, combined face and whole eye transplantation (FWET) may offer a more optimal aesthetic and potentially functional outcome while avoiding the complications and stigma of enucleation and prosthetics. This study presents the most comprehensive cadaveric assessment for FWET to date, including rehearsal allograft procurement on a brain-dead donor., Methods: Over a 2-year period, 15 rehearsal dissections were performed on 21 cadavers and one brain-dead donor. After identification of a potential recipient, rehearsals assessed clinical feasibility and enabled operative planning, technical practice, refinement of personalized equipment, and improved communication among team members. Operative techniques are described., Results: Facial allograft procurement closely followed previously described face transplant techniques. Ophthalmic to superficial temporal (O-ST) vessel anastomosis for globe survival was assessed. Craniectomy allowed for maximal optic nerve and ophthalmic vessel pedicle length. Appropriate pedicle length and vessel caliber for O-ST anastomosis was seen. Research procurement demonstrated collateral blood flow to the orbit and surrounding structures from the external carotid system as well as confirmed the feasibility of timely O-ST anastomosis. Personalized cutting guides enabled highly accurate bony inset., Conclusions: This study formalizes an approach to FWET, which is feasible for clinical translation in judiciously selected patients. O-ST anastomosis seems to minimize retinal ischemia time and allow perfusion of the combined allograft on a single external carotid pedicle. Although restoration of vision likely remains out of reach, globe survival is possible., Competing Interests: Eduardo D. Rodriguez has received speaker Honoria from DePuy Synthes for work unrelated to this study. All the other authors have no financial interest to declare in relation to the content of this article. This study was funded by the Reconstructive Transplantation Research Award (W81XWH-15-2-0036) from the Department of Defense, with institutional support from New York University Langone Health., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

There are over 43 million individuals in the world who are blind. As retinal ganglion cells are incapable of regeneration, treatment modalities for this condition are limited. Since first incepted in 1885, whole-eye transplantation (WET) has been proposed as the ultimate cure for blindness. As the field evolves, different aspects of the surgery have been individually explored, including allograft viability, retinal survival, and optic nerve regeneration. Due to the paucity in the WET literature, we aimed to systematically review proposed WET surgical techniques to assess surgical feasibility. Additionally, we hope to identify barriers to future clinical application and potential ethical concerns that could be raised with surgery., Methods: We conducted a systematic review of PubMed, Embase, Cochrane Library, and Scopus from inception to June 10, 2022, to identify articles pertaining to WET. Data collection included model organisms studied, surgical techniques utilized, and postoperative functional outcomes., Results: Our results yielded 33 articles, including 14 mammalian and 19 cold-blooded models. In studies performing microvascular anastomosis in mammals, 96% of allografts survived after surgery. With nervous coaptation, 82.9% of retinas had positive electroretinogram signals after surgery, indicating functional retinal cells after transplantation. Results on optic nerve function were inconclusive. Ocular-motor functionality was rarely addressed., Conclusions: Regarding allograft survival, WET appears feasible with no complications to the recipient recorded in previous literature. Functional restoration is potentially achievable with a demonstrated positive retinal survival in live models. Nevertheless, the potential of optic nerve regeneration remains undetermined., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Early surgical exposure and research fellowships can influence medical students' specialty choice, increase academic productivity, and impact residency match. However, to our knowledge, there is no published guidance on the programmatic evaluation and quality enhancement necessary for the sustainability of formal plastic surgery summer research programs for first year medical students. We present seven years (2013-2020) of institutional experience in an effort to inform program development at other institutions., Methods: From 2013 to 2016, a sole basic science research arm existed. In 2017, a clinical research arm was introduced, with several supplemental activities, including surgical skills curriculum. A formalized selection process was instituted in 2014. Participant feedback was analyzed annually. Long-term outcomes included continued research commitment, productivity, and residency match., Results: The applicant pool reached 96 applicants in 2019, with 85% from outside institutions. Acceptance rate reached 7% in 2020. With adherence to a scoring rubric for applicant evaluation, good to excellent interrater reliability was achieved (intraclass correlation coefficient = 0.75). Long-term outcomes showed that on average per year, 28% of participants continued involvement in departmental research and 29% returned for dedicated research. Upon finishing medical school, participants had a mean of 7 ± 4 peer-reviewed publications. In total, 62% of participants matched into a surgical residency program, with 54% in integrated plastic surgery., Conclusions: A research program designed for first year medical students interested in plastic surgery can achieve academic goals. Students are provided with mentorship, networking opportunities, and tools for self-guided learning and career development., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: 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: 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: 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: 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., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Facial transplantation (FT) has advanced extensively over the past two decades, with over 40 transplants performed to date. Over this time, the FT literature has evolved as well, from early discussions on ethics and feasibility of FT to functional outcomes reports more recently. We aimed to evaluate the entire body of FT literature to identify trends in publications over time in addition to current existing gaps in the field., Methods: We conducted a comprehensive bibliometric analysis of the published FT literature from 1994, the first year FT was mentioned in the literature, through July 2020. Co-authorship and keyword information were analyzed using VOSviewer. Articles were manually categorized based on keywords and their aim to provide insight on trends., Results: A total of 2182 articles were identified. Analysis identified the top 50 publishing authors in the field and demonstrated co-authorship linkage between 84.8% of the top 1000 authors. Clinical surgical techniques, protocols, and experiments were the most frequently published category. Within clinical outcomes, immunologic outcomes were most frequent, while psychosocial were the lowest. Gaps were identified in long-term outcomes reporting and patient-reported outcomes, with physician-reported outcomes heavily outweighing patient-reported outcomes., Conclusions: As the field continues to evolve, rigorous tracking of publication patterns over time will encourage development of a more robust evidence base, identify gaps in the published literature, and highlight opportunities to enhance collaboration in the field. This data will provide surgeons and research institutions with information to further improve this life-changing procedure., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Over the past 15 years, landmark achievements have established facial transplantation (FT) as a feasible reconstructive option for otherwise irreparable craniofacial defects. However, as the field matures and long-term outcomes begin to emerge, FT teams around the world are now facing new challenges. Data for this review were identified by searches of the PubMed/MEDLINE database from inception through August 2020. All English-language articles pertaining to FT were included. Significant advances in candidate selection, technology, operative technique, posttransplant care, and immunosuppressive management have contributed to the tremendous expansion of the field, culminating in the execution in the past 3 years of 2 facial re-transplantations, and most recently the world's first successful combined face and double hand transplant in August 2020. Despite these achievements, the allograft donor pool remains limited, with long wait times, requiring surgical experimentation with cross-sex FT. Immunosuppressive management has improved, but significant adverse events continue to be reported. Most recently, the COVID-19 pandemic has placed an unprecedented strain on the healthcare system, with various implications for the practice of reconstructive transplantation. In this article, we provide the most comprehensive and up-to-date FT review, highlighting fundamental lessons learned and recent advancements, while looking toward the challenges ahead. Over the past 15 years, extensive multidisciplinary efforts have been instrumental to the establishment of FT as a feasible reconstructive option. As novel challenges are beginning to emerge, continued collaborative and multispecialty research efforts are needed to further this field., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Chronic facial paralysis can lead to significant functional and psychosocial impairment. Treatment often involves free muscle flap-based facial reanimation surgery. Although surgical techniques have advanced considerably over the years, consensus has yet to be reached for postoperative outcome evaluation. To facilitate outcome comparison between the various techniques for free muscle-flap-based reanimation, a standardized, widely accepted functional outcomes assessment tool must be adopted., Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the PubMed, Cochrane, and Embase databases to identify the reported functional outcome measurement tools used in the free muscle flap-based reanimation literature., Results: The search yielded 219 articles, 43 of which met our inclusion and exclusion criteria. We noted an increase in publications reporting the utilization of objective measures over time, particularly software-based tools, as well as increased utilization of patient reported outcomes measures., Conclusions: Based on the trends identified in the literature, we suggest standardization of outcome measures following facial reanimation surgery with free muscle-flap using a combination of the Facial Assessment by Computer Evaluation (FACEgram) software and the Facial Clinimetric Evaluation (FaCE) Scale., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: A major challenge in face transplantation (FT) is the limited donor allograft pool. This study aimed to investigate the feasibility of cross-sex FT (CSFT) for donor pool expansion by: (1) comparing craniomaxillofacial metrics following CSFT versus same-sex FT (SSFT); and (2) evaluating the public and medical professionals' perception of CSFT., Methods: Seven cadaveric FTs were performed, resulting in both CSFT and SSFT. Precision of bony and soft tissue inset was evaluated by comparing pre- versus post-operative cephalometric and anthropometric measurements. Fidelity of the FT compared to the virtual plan was assessed by imaging overlay techniques. Surveys were administered to medical professionals, medical students, and general population to evaluate opinions regarding CSFT., Results: Five CSFTs and 2 SSFTs were performed. Comparison of recipients versus post-transplant outcomes showed that only the bigonial and medial intercanthal distances were statistically different between CSFT and SSFT ( P = 0.012 and P = 0.010, respectively). Of the 213 survey participants, more were willing to donate for and undergo SSFT, compared with CSFT (donate: 59.6% versus 53.0%, P = 0.001; receive: 79.5% versus 52.3%, P < 0.001). If supported by research, willingness to receive a CSFT significantly increased to 65.6% ( P < 0.001). On non-blinded and blinded assessments, 62.9% and 79% of responses rated the CSFT superior or equal to SSFT, respectively., Conclusions: Our study demonstrates similar anthropometric and cephalometric outcomes for CSFT and SSFT. Participants were more reticent to undergo CSFT, with increased willingness if supported by research. CSFT may represent a viable option for expansion of the donor pool in future patients prepared to undergo transplantation., Competing Interests: Disclosure: Dr. Rodriguez has received speaker honoraria for unrelated activities from DePuy Synthes CMF and KLS Martin. All the other authors have no financial interest to declare. This work was supported by the Office of Naval Research (Grant N00014-10-1-0868), the US Department of Defense—Congressionally Directed Medical Research Programs (under Reconstructive Transplant Research Award W81XWH15-2-0036), and New York University Langone Health., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field., Methods: An institutional "FT Anesthesia Protocol" was developed and applied to 2 face transplants. A systematic review of 3 databases captured FTs in the peer-reviewed literature up to February 2020. Two reviewers independently screened titles and abstracts to include all clinical articles with FT recipient and/or donor-specific preoperative, intraoperative, and relevant postoperative anesthetic variables. Data charting guided a narrative synthesis, and quantitative synthesis reported variables as median (range)., Results: Our institutional experience emphasizes the importance of on-site rehearsals, anticipation of patient-specific anesthetic and resuscitative requirements, and long-term pain management. Systematic search identified 1092 unique records, and 129 met inclusion criteria. Reports of 37 FTs in the literature informed the following anesthetic axes: donor pre- and intraoperative management during facial allograft procurement, recipient perioperative care, immunotherapy, antimicrobial prophylaxis, and pain management. Quantitative synthesis of 30 articles showed a median operative time of 18 hours (range, 9-28) and fluid replacement with 13 L (5-18) of crystalloids, 13 units (0-66) of packed red blood cells, 10 units (0-63) of fresh frozen plasma, and 1 unit (0-9) of platelets., Conclusions: Anesthetic considerations in FT span the continuum of care. Future efforts should guide standard reporting to establish evidence-based strategies that promote quality improvement and patient safety., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The aim of facial transplantation (FT) was to enhance quality of life (QoL) for individuals living with severe facial disfigurement. Yet QoL has proved challenging to assess, as the field lacks a unified approach for incorporating FT recipients' perspectives into meaningful QoL measures. In this study, we review FT recipients' self-reported QoL through a qualitative analysis of publicly available posttransplant interviews to identify the aspects of QoL they report as meaningful., Methods: A conventional qualitative content analysis was conducted through a comprehensive review of publicly available interviews with FT recipients. Data sources included English language audio, video, and online print interviews from 2008 to 2019. Recipient interview data were obtained for both partial and full FT recipients located in North America through Google and YouTube searches. Audio and video interviews were transcribed, and an inductive content analysis was used to develop and apply a coding scheme to all interview transcripts. Codes were subsequently grouped into categories and interpreted into themes., Results: In total, 81 interviews representing 12 North American, English-speaking face transplant recipients were collected from internet sources, of which 74 interviews remained after exclusion criteria were applied. Three themes emerged representing the dimensions of QoL emphasized by FT recipients: (1) reconstitution and re-embodiment of physical/corporeal selfhood, (2) integrity of cognitive/emotional selfhood, and (3) social selfhood and the importance of social integration., Conclusions: This study provides an insight into North American FT recipients' experiences, values, and goals and illuminates critical aspects of QoL that are meaningful to this unique patient population, which may not be fully captured by currently available assessment tools. The themes developed in this study link facets of QoL to the overall significance of embodied selfhood among FT recipients and will help inform the future development of FT-specific patient-reported QoL outcome measures., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author's experience with 3 FTs., Methods: A literature review was performed, with 2 reviewers independently conducting title and abstract screening, followed by a full-text review. All articles mentioning FT revision surgeries were evaluated. The medical records of the senior author's 3 FT recipients were additionally reviewed., Results: Initially, 721 articles were captured and 37 were included in the final analysis. Thirty-two FTs were reported to have involved posttransplant allograft revisions, with FT recipients undergoing a mean of 4.8 ± 4.6 revision procedures. The mean duration between FT and the first revision procedure was 149 ± 179 days. A wide spectrum of revisions was identified and categorized as involving the soft tissues, craniofacial skeleton, dentition, oronasal cavity, salivary glands, facial nerve, or ocular region. In the senior author's experience, when indicated, posttransplant occlusal changes and integrity of the donor-recipient intraoral interface were successfully addressed with secondary procedures without allograft compromise or loss., Conclusions: The worldwide experience shows that secondary procedures are nearly ubiquitous after FT and can be safely performed at various timepoints. The authors thereby establish 5 distinct categories of facial allograft revisions and define 7 critical principles to optimize posttransplant procedures., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Photography provides a means for objective assessment and dissemination of clinical information. The American Society of Plastic Surgeons (ASPS) and Plastic Surgery Foundation (PSF) published photography guidelines in 2006 to optimize its clinical use. However, photographic documentation of outcomes in facial transplantation (FT) continues to lack standardization. We therefore appraised the current state of FT photography in the peer-reviewed literature., Methods: A PubMed search was conducted from July 2005 to July 2019. Studies containing photographs of partial or full FT recipients were included. Non-English language articles, cadaveric and animal studies, technique papers, and case reports were excluded. Data were extracted from 91 articles. Adherence rates were calculated to determine whether published FT photographs followed ASPS/PSF guidelines. Proposed photographic standards particular to FT were then formulated to guide standardization of practice., Results: Only 28.6% (26/91) of articles adhered to the photographic conventions of preparation, positioning, and views. Of 162 patient appearances in the 91 articles, 95% (154/162) met the criteria for preparation, 98.8% (160/162) met the criteria for positioning, but only 24.7% (40/162) met the criteria for views., Conclusions: Photographic documentation of FT outcomes in the peer-reviewed literature is limited, with inconsistent adherence to ASPS/PSF guidelines. There is substantial deficiency in provision of alternative views, with the majority of publications only depicting the frontal view. FT photography standards should specifically incorporate alternative views, proper lighting and framing, and elimination of distractions, and accommodate for remote patient self-photography. This will promote a transparent and consistent longitudinal evaluation of the surgical results., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Skin color matching in vascularized composite allotransplantation (VCA) is an important determinant of aesthetic outcomes. The process of color matching is infrequently described in the literature. The Pantone SkinTone Guide (PSTG) is a handheld tool comprised of realistic skin tone swatches with a corresponding virtual swatch system. A color match acceptability threshold (AT) is defined as the point beyond which >50% of observers deem a given skin tone pairing as unacceptable. In this study, color match acceptability thresholds were developed using the PSTG to help standardize donor-recipient color matching. Four representative colors were chosen across the skin tone spectrum. These standard colors were used to develop a survey asking participants to determine the acceptability of color pairings. Using survey results, ATs were determined for changes in lightness, undertone, and lightness and undertone combined for each of the standard colors. Inter- and intra-rater reliability were determined using Fleiss's Kappa. Participants were more critical of skin tone pairings on the darker versus the lighter end of the spectrum, as evidenced by higher thresholds observed for lighter sample pairs. Additionally, observers were more critical of differences in skin lightness compared with differences in undertone. Intra-rater reliability was fair to substantial, and inter-rater reliability was fair to moderate. The PSTG can be used as a clinical tool to improve the aesthetic outcomes of skin-containing vascularized composite allotransplantation procedures by optimizing donor-recipient skin color matching. This can allow clinicians to complement visual judgment with quantitative reference., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients., Methods: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images., Results: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin ( P < 0.0001). There was a significant increase in nonwhite photographs over time ( r = 0.086, P < 0.001) and association of nonwhite photographs with international authors ( r = 0.12, P < 0.001)., Conclusions: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Face transplantation has evolved into a viable reconstructive option for patients with extensive facial disfigurement. Because the first face transplant procedure was described in 2005, the safety and feasibility of the procedure have been validated, and the focus of the field has shifted toward refining functional and esthetic outcomes. Recovery of muscle function following facial transplantation is critical to achieving optimal facial function and restoring facial expression. Assessment of facial muscle function in face transplant recipients has traditionally relied on clinical evaluation. In this study, we describe longitudinal changes in facial muscle volumes captured through quantitative magnetic resonance imaging in a face transplant recipient and compare these findings with functional outcomes evaluated through clinical assessment., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The technical feasibility and clinical applicability of facial transplantation (FT) have been demonstrated, yet animal models with different technical nuances and allograft compositions continue to be developed. We sought to provide a comprehensive appraisal of the current scope and value of animal models in FT., Methods: A comprehensive review of the literature was performed to identify all studies relevant to preclinical animal FT. Abstracts, texts, and references were screened. Both large and small animal models in studies including survival experimental arms were included. Purely anatomical or cadaveric animal studies were excluded, as were non-English language articles., Results: Twenty-nine unique models were identified, including 10 large (nonhuman primate, swine, and canine) and 19 small (rabbit, rat, and mouse) animal models. Orthotopic models were described in 70% of large and 73.7% of small animal studies. One study described a 2-stage rat FT model. Nerve coaptations were performed in 20.7% of all models (1 canine, 1 rabbit, and 4 rat models). One rat model allowed the study of both functional recovery and cortical reintegration of the allograft. Survival rates and immunological outcomes varied per model and protocol., Conclusions: A comprehensive review of animal models in FT shows redundancy spanning a variety of species, allograft compositions, and experimental designs. Although initial studies have focused on safety and technical feasibility, recent advances present specific opportunities for refining our understanding of functional and immunological challenges. As clinical experience continues to evolve, animal models may play an increasingly modest yet targeted role in FT., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Face transplant (FT) candidates present with unique anatomic and functional defects unsuitable for autologous reconstruction, making the accurate design and transplantation of patient-specific allografts particularly challenging. In this case series, we present our computerized surgical planning (CSP) protocol for FT., Methods: CSP, computer-aided design and manufacturing, intraoperative navigation, and intraoperative computerized tomography have been successfully incorporated into a comprehensive protocol. Three consecutive FTs were performed. CSP and postoperative results were compared using computerized tomography-derived cephalometric measurements, and the literature was reviewed., Results: Two full and 1 partial FT were successfully performed using the CSP protocol. CSP facilitated the execution of FT with minor angular and translational cephalometric variations on immediate postoperative imaging. Our evolving experience was accompanied by a decreased reliance on cadaveric simulation, from 10 mock transplants and a research procurement before the senior author's first clinical FT (2012) to 6 mock transplants and no research procurement before the third FT (2018). Operative time was significantly reduced from 36 to 25 hours, as was the need for major orthognathic surgical revision. This reflects the learning curve and variable case complexity, but it is also representative of improved planning and execution, complemented by the systematic incorporation of CSP into FT., Conclusions: A CSP protocol allows for refinement of operative flow, technique, and outcomes in partial and full FT. Standards for functional and esthetic outcomes are bound to evolve with the field's growth, and computerized planning and execution offer a reproducible approach to FT through objective quality assurance., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Despite promising short- and long-term results to date in vascularized composite allotransplantation (VCA), acute rejection remains the most common major complication in recipients. Currently, diagnosis of acute rejection relies on clinical inspection correlated with histopathological analysis. However, disagreement exists regarding the value of full-thickness skin and mucosal biopsies and histopathology remains semiquantitative, subject to sampling bias, and prone to intra- and inter-observer variabilities. Additionally, biopsies may cause infection, scarring, and/or potentially incite rejection through immune activation after injury. Noninvasive methods to diagnose rejection represent a critical unmet need for the emerging field of VCA. Here, we propose a novel technique utilizing skin stripping of the epidermis and subsequent molecular analysis to detect known markers of acute rejection. Using a small animal VCA model, we sought to validate our epidermal sampling technique as a noninvasive diagnostic test for acute rejection., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Facial transplantation (FT) experience has grown but success in this innovative and complex field has yet to be defined. The purpose of this study is to determine attitudes regarding the failures in FT and the appropriate management of these failures., Methods: An anonymous, 20-question survey elicited opinions regarding FT failure management. This survey was administered to attendees of 2 FT-focused national meetings. Demographics included sex, age, and personal/institutional FT experience. Attitudes related to FT recipient education, definition of FT failure, and management of complications were gathered., Results: Eighty of 271 attendees completed the survey (29.5%). Respondents were predominantly male (81.3%) and 50 years of age or younger (80.5%). Thirty-eight percentage previously performed an FT and 53.8% were a part of an institution with a vascularized composite allotransplantation (VCA)-related Institutional Review Board (IRB). Respondents almost unanimously agreed it was "absolutely essential" to discuss possibility of FT failure (93.8%), mortality (91.1%), and treatment for chronic rejection (78.8%). However, uncertainty of failure rate existed, with 56.4% citing failure rate as unknown, 25.6% citing <25% and 18.0% citing >25%. 51.2% of those with direct FT experience lacked clear criteria for defining FT success or an institutional protocol for managing chronic rejection. 78.8% believed failed FT patients should be considered for retransplantation, but only about 25% cited functional concerns or esthetic dissatisfaction as appropriate indications., Conclusion: There is a lack of consensus regarding definition of FT failure and rates mortality amongst experts. Even institutions with FT experience lack protocols for managing chronic rejection. Expert consensus and institutional regulations surrounding these issues are warranted.

The unique anatomical characteristics of the forearm region make it especially popular as a free flap donor site for craniofacial soft-tissue reconstruction. The free ulnar forearm flap is less hirsute and allows for better concealment of donor site scar as compared with its radial counterpart. Despite these factors, the free radial forearm flap remains more popular among reconstructive surgeons. Through the presented case series, we hope to emphasize the versatile nature of the free ulnar forearm flap in addressing various craniofacial soft-tissue defects. Following institutional review board approval, a retrospective review of the senior authors' clinical experience performing microvascular free ulnar forearm flap reconstruction of craniofacial soft-tissue defects was performed. A total of 10 patients were identified through our review. Soft-tissue defect locations included lower eyelid (n = 2), tongue and floor of mouth (n = 2), lower lip (n = 2), palatopharyngeal area (n = 1), nose (n = 1), and palate (n = 1). Trauma was the most common defect etiology (n = 5), followed by malignancy (n = 4), and iatrogenic injury in 1 case. All patients demonstrated good aesthetic and functional outcomes related to vision, speech, and oral intake at follow-up when applicable. The free ulnar forearm flap is a versatile reconstructive option that can be used to address a wide spectrum of craniofacial soft-tissue defects and offers numerous advantages over its radial counterpart.

Background: High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author's early and definitive staged reconstructive approach to these challenging patients., Methods: A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes., Results: Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics., Conclusions: Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Background: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions., Methods: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions., Results: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars., Conclusion: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

Unlabelled: Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury., Methods: Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed., Results: A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels)., Conclusions: Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.