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The complex three-dimensional (3D) anatomy in facial allotransplantation creates a unique challenge for surgical reconstruction. Evolution of virtual surgical planning (VSP) through computer-aided design and computer-aided manufacturing has advanced reconstructive outcomes for many craniomaxillofacial indications. Surgeons use VSP, 3D models, and surgical guides to analyze and to trial surgical approaches even prior to entering the operating room. This workflow allows the surgeon to plan osteotomies and to anticipate challenges, which improves surgical precision and accuracy, optimizes outcomes, and should reduce operating room time. We present the development, evolution, and utilization of VSP and 3D-printed guides in facial allotransplantation at our institution, from guide conception to first clinical case.

Background Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. Methods Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. Results A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm2) compared with that in the fourth (mean 26,474 ± 38,626 µm2), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p Conclusion This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Dermal filler injections, one of the most commonly performed procedures in facial esthetic surgery, are rising in popularity. This has also led to an increase in nonmedical grade filler injections performed by nonmedical personnel, including that of injectable silicone. Surgical removal of silicone fillers is challenging, as the hydrophobic material often disperses within the soft tissue as droplets. This can lead to a systemic inflammatory reaction requiring steroid treatment. MRI localization of the filler material does not enable intraoperative guidance, and palpitation of the material is challenging since the filler droplets are often too small to palpate and located in multiple planes. We present a case demonstrating the advantages of utilizing intraoperative ultrasound to localize and silicone filler material. Utilizing this technique, we were able to achieve a high degree of excision of silicone filler material and the patient was able to stop her previous necessary immunosuppressive steroid regimen successfully.

SUMMARY Advances in virtual surgical planning and three-dimensionally-printed guides have enabled increased precision in vascularized free fibula flap reconstruction of the mandible and valuable preoperative planning. However, virtual surgical planning currently requires high-resolution computed tomographic scans, exposing patients to ionizing radiation. The aim of this study was to determine whether black bone magnetic resonance imaging can be used for accurate surgical planning and three-dimensionally-printed guide creation, thus reducing patient radiation exposure. This study included 10 cadaver heads and 10 cadaver lower extremities. A mock fibula free flap for mandible reconstruction was performed. Five operations were planned with guides created using black bone magnetic resonance imaging, whereas the other five were planned and performed using guides created with computed tomographic scan data. All specimens underwent a postoperative computed tomographic scan, and three-dimensional reconstruction of scans was performed and surgical accuracy to the planned surgery was assessed. Guides created from black bone magnetic resonance imaging demonstrated high accuracy to the surgical plan. There was no statistically significant difference in postoperative deviation from the plan when black bone magnetic resonance imaging versus computed tomographic scanning was used for virtual surgical planning and guide creation. Both modalities led to a postoperative positive or negative deviation from the virtual plan within 0.8 mm. This study demonstrates that virtual surgical planning and three-dimensionally-printed guide creation for free fibula flaps for mandible reconstruction can be performed using black bone magnetic resonance imaging with comparable accuracy to computed tomographic scanning. This could reduce radiation exposure for patients and enable a more streamlined imaging process for head and neck cancer patients.

Face transplantation is a life-transforming surgery for patients with complex and devastating facial injuries who have exhausted the traditional armamentarium of plastic surgery. The ultimate success of this procedure is dependent upon the regeneration of the recipient’s facial nerves into donor tissue, restoring the complex movement of facial musculature to enable optimal results. Goals of facial reanimation in face transplant are similar to those in facial paralysis; dependent on the recipient defect, these include spontaneous smile, ability to blink, restoration of oral commissure integrity, and capacity to show facial expression. These goals can be reached through careful preoperative assessment of donor and recipient facial nerve function and intraoperative nerve mapping of donor and recipient nerve branches. We also advocate for distal nerve branch coaptation to reduce potential aberrant reinnervation and synkinesis and to shorten the distance required for regeneration to target muscles. We also recognize the need for standardized assessment of facial nerve motor function among face transplant patients to further improve outcomes in this innovative field. Face transplant success and patient satisfaction with postoperative quality of life is largely dependent upon the degree of nerve regeneration and reanimation. Thus, careful assessment of this aspect of the procedure is paramount.

Background Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques. Methods Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry. Results Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups. Conclusions This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.

Background The use of magnetic resonance imaging (MRI) for virtual surgical planning has not yet been described. In the United States, over 600,000 computed tomographic (CT) scans are performed annually on children, who are at higher risk than adults of developing cancer caused by ionizing radiation. The aim of this study was to demonstrate whether three-dimensionally-printed craniofacial surgical guides created from "black bone" MRI are comparable in accuracy to those created from CT scans. Methods A mock craniosynostosis surgery translocating four calvarial segments was virtually planned and performed in 10 cadavers. For five specimens, planning was performed and three-dimensionally-printed guides were created using black bone MRI scans. Five specimens underwent standard planning using CT scans. Reconstructed skulls underwent CT scans and three-dimensional reconstruction. Accuracy was compared to that of virtually planned surgeries. Results The preoperative black bone MRI scan had an average deviation from the preoperative CT scan of 1.37 mm. There was no statistically significant difference in the fit accuracy of MRI versus CT-created guides. Average deviation of postoperative anatomy from preoperative plan was within 1.5 mm for guides created from either scanning modality, with no statistically significant difference in accuracy between the two methods. Planned versus postoperative skull volume was not statistically significantly different when MRI versus CT was used. Conclusions This study demonstrates that virtual surgical planning and three-dimensional craniofacial surgical guide creation can be performed using black bone MRI with accuracy comparable to that of CT. This could dramatically reduce radiation exposure of craniofacial reconstruction patients.

The purpose of this study was to evaluate the time to diagnosis and management of hook of hamate fractures in an era of advanced imaging. We performed a retrospective study of 51 patients treated for hook of hamate fractures. Patients were sent a quickDASH questionnaire regarding the outcomes of their treatment. Hook of hamate fractures were diagnosed with advanced imaging at a median of 27 days. Clinical findings of hook of hamate tenderness had better sensitivity than carpal tunnel-view radiographs. Nonunion occurred in 24% of patients with non-operative treatment and did not occur in the operative group. Both treatment groups achieved good clinical results, with a grip strength of 80% compared with the non-injured hand and a median quickDASH score of 2. Advanced imaging improved the time to diagnosis and treatment compared to historical case series. Nonunion is common in patients treated non-operatively.Level of evidence: IV

Head and neck reconstructive microsurgery is constantly innovating because of a combination of multidisciplinary advances. This article examines recent innovations that have affected the field as well as presenting research leading to future advancement. Innovations include the use of virtual surgical planning and three-dimensional printing in craniofacial reconstruction, advances in intraoperative navigation and imaging, as well as postoperative monitoring, development of minimally invasive reconstructive microsurgery techniques, integration of regenerative medicine and stem cell biology with reconstruction, and the dramatic advancement of face transplant.

Background Face transplantation can offer functional and aesthetic restoration to patients who have exhausted their reconstructive options, improving quality of life and psychosocial integration. Ethical issues in face transplantation abound, including questions of patient selection and evaluation before transplantation. To date, there has been no study of ethicists' opinions regarding face transplantation. Methods An online survey of attendees of the 2015 International Conference on Clinical Ethics Consultation (n = 401) assessed ethicists' opinions about face transplantation. Questions examined the risk-to-benefit ratio of immunosuppression; permissibility of face transplantation in subpopulations (including children and blind patients); donor-recipient age, sex, and ethnicity mismatches; and ethical oversight. Results Most ethicists (84 percent) agreed that it is permissible to perform a face transplantation on an adult in the absence of clear medical contraindications. Most respondents also agreed that it is permissible to perform a face transplantation on a child (62 percent) or a blind patient (61 percent), yet demonstrated less consensus regarding the permissibility of performing a face transplantation on patients with an increased risk of immune rejection. Respondents were generally supportive of age, sex, and ethnicity mismatches, with 43 percent indicating that it is permissible to have a sex mismatch. The majority answered that face transplantation should be covered by federal insurance (74 percent). Conclusions This study provides insight into clinical ethicists' views regarding face transplantation. Most ethicists support the ethical permissibility of face transplantation, and did not have concerns about age, sex, and ethnicity mismatches. These findings highlight emerging areas of consensus regarding the ethical permissibility of face transplantation.

Vascularized composite allotransplant (VCA) offers functional, social, and quality of life improvements for patients who have exhausted traditional reconstructive options. Unlike solid organ transplant, VCA success is not only based upon the quality of perfusion and level of immunosuppression, but also on the success of nerve regeneration within the transplanted part. This paper will summarize the present state of peripheral nerve regeneration in the context of VCA and will explore the latest research advances that will affect the future of the field. These advances offer promising future strategies to improve patient outcomes in VCA.

OBJECTIVES/GOALS: Face transplant can offer functional and aesthetic restoration to patients who have exhausted reconstructive options. Ethical issues in face transplant still abound, including that of patient selection. The goal of this study was to assess ethicists’ viewpoints on face transplant. METHODS/STUDY POPULATION: A large-scale online survey of attendees of the International Conference on Clinical Ethics Consultation (N = 401) was performed to assess ethicists’ opinions on issues in face transplant. Questions were asked regarding the risk-benefit ratio of immunosuppression, permissibility of face transplant for more recipient subpopulations (including children and blind patients), donor-recipient age, gender, and ethnicity mismatches, and ethics committee make-up. RESULTS/ANTICIPATED RESULTS: Among 84 respondents, 84% agreed it is permissible to perform a face transplant on an adult with no medical contraindications. The majority of respondents agreed that it is permissible to perform a face transplant on a child or blind recipient. An issue of continued concern was risk of immunosuppression. Respondents had a high threshold of permissibility for ethnic mismatches between donor and recipient, and 43% reported it is permissible to have a gender mismatch. A 10 year age difference between donor and recipient was the most commonly accepted. Questions regarding the ideal composition of a face transplant ethics committee demonstrated consensus on the roles that should be represented. DISCUSSION/SIGNIFICANCE OF IMPACT: This study provides insight into ethicists’ viewpoints on face transplant, which demonstrates a high level of permissibility towards the procedure. This may be due to the early success of face transplants and the shifting ethical issues in the field to practical aspects of the procedure. This research also provides guidance to programs regarding questions of donor and recipient selection, ethics committee composition, and offers insight into strengthening the ethical framework of the field.

WOS: 000455067400017, PubMed: 30589807, Background: Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle. Methods: Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted. Results: An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it. Conclusions: The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

Introduction Face transplantation can offer patients with severe facial deformities a better quality of life, but questions of donor suitability remain unanswered. The aim of this study is to determine how an obesity mismatch between donor and recipient affects facial fat graft retention and cellular properties, potentially increasing the donor pool substantially. We hypothesized that facial fat would respond to the microenvironment of the recipient and developed an animal model to evaluate this hypothesis. Methods This study utilized 30 C57BL/6J wild-type (WT) and 30 diet-induced obese (DIO), immunologically identical mice. One hundred seventy-five micrograms of perigonadal fat was harvested from 10 mice from each group and transplanted to the subcutaneous scalp of the remaining mice. Ten DIO mice were implanted with DIO donor fat and 10 with WT donor fat. The 10 WT mice were implanted with DIO fat and 10 with WT fat. Recipients underwent micro-CT scans at 2 days and 2, 4, 6, 8, 10, and 12 weeks postoperation. Scans were 3D-reconstructed to assess transplanted fat volume. At 12 weeks, the transplanted fat was analyzed by hematoxylin–eosin staining. Results Volume retention of the transplanted fat depended on recipient phenotype, which was confirmed through ANOVA and Student–Newman–Keuls test. Graft volume with a DIO recipient increased with both a DIO (25.6%) and a WT (24.4%) donor from 2 days to 12 weeks postoperation. In a WT recipient, graft volume decreased when the donor was WT (54.0%) and DIO (53.0%). Average cellular volume was also dependent on the recipient phenotype. Conclusion This study demonstrates that fat transplanted to the facial region responds to the surrounding microenvironment both macroscopically and microscopically. This study has large implications in donor suitability in face transplant, as it indicates that a donor–recipient obesity mismatch may be acceptable.

The initiation of DNA replication is tightly regulated in order to ensure that the genome duplicates only once per cell cycle. In vertebrate cells, the unstable regulatory protein Geminin prevents a second round of DNA replication by inhibiting the essential replication factor Cdt1. Cdt1 recruits mini-chromosome maintenance complex (MCM2-7), the replication helicase, into the pre-replication complex (pre-RC) at origins of DNA replication. The mechanism by which Geminin inhibits MCM2-7 loading by Cdt1 is incompletely understood. The conventional model is that Geminin sterically hinders a direct physical interaction between Cdt1 and MCM2-7. Here, we describe an inactive missense mutant of Geminin, GemininAWA, which binds to Cdt1 with normal affinity yet is completely inactive as a replication inhibitor even when added in vast excess. In fact, GemininAWA can compete with GemininWT for binding to Cdt1 and prevent it from inhibiting DNA replication. GemininAWA does not inhibit the loading of MCM2-7 onto DNA in vivo, and in the presence of GemininAWA, nuclear DNA is massively over-replicated within a single S phase. We conclude that Geminin does not inhibit MCM loading by simple steric interference with a Cdt1-MCM2-7 interaction but instead works by a non-steric mechanism, possibly by inhibiting the histone acetyltransferase HBO1.

Despite having a long tradition and over 25,000 yearly scientific conferences organized within the US alone, to the best of our knowledge little quantitative work has been performed to rigorously a...