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This canine study examines the structural stability of extensive laryngotracheal reconstruction with the sternohyoid myocutaneous rotary door flap (RDF) and modifications of the RDF with subdermal collagen and collagen hydroxyapatite matrix. The postreconstruction stability of the RDF and these modifications were tested and compared by measuring immediate postmortem airway stability during application of negative intraluminal pressures. Comparisons between controls and experimental specimens demonstrated that the RDF provides structural stability to secure airway patency under physiologic pressures. Biocompatible matrix adds further structural support in maintenance of the reconstructed lumen. This study validates that the RDF provides adequate rigid support for extensive laryngotracheal reconstruction without the requirement of skeletal support. [ABSTRACT FROM AUTHOR]

Background: Feminizing genioplasty warrants chin modification to achieve feminine characteristics. This study compared female and male facial skeletal dimensions and shape to guide feminizing genioplasty., Methods: Skulls stored at the Cleveland Museum of Natural History were analyzed. Sex, age, and race were documented. Heights and widths of the face and chin were measured, normalized, and compared., Results: Forty-three male (43.58±12.52-y-old) and 43 female (40.48±12.04-y-old) skulls were included. Within each group, 25 skulls were of African American (AA) origin and 18 were of Caucasian (C) origin. Absolute chin heights were larger in AA and C males compared with females (P<0.05). After normalization to lower facial height, there was a trend toward greater chin height in AA males compared with females (P=0.07). Parasagittal chin width in AA males was significantly larger than AA females (P=0.0006). Interforaminal chin width in C males trended toward being significantly larger than females (P=0.08). Following normalization of chin widths, no significant sex-based differences were noted for AA skulls except for the interforaminal/intergonial ratio, which was smaller in AA males (P=0.04). For C skulls, most normalized ratios were significantly smaller in males (P<0.05). C females had wider angles at the point of maximum chin projection (P=0.007) and wider symphyseal inclinations (P<0.0001). These differences were not present in AA skulls (P>0.05). Regardless of race, male chins appeared square, whereas female chins were round., Conclusions: While chin width reduction is not needed for most patients, height reduction could be considered. Chin contouring is the most central component of feminizing genioplasty., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

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

Introduction: Above elbow transplants represent 19% of the upper extremity transplants. Previous large-animal models have been too distal or heterotopic, did not use immunosuppression and had short survival. We hypothesize that an orthotopic forelimb transplant model, under standard immunosuppression, is feasible and can be used to address questions on peri-transplant ischemia reperfusion injury, and post-transplantation vascular, immunologic, infectious, and functional outcomes., Materials and Methods: Four forelimbs were used for anatomical studies. Four mock transplants were performed to establish technique/level of muscle/tendon repairs. Four donor and four recipient female Yucatan minipigs were utilized for in-vivo transplants (endpoint 90-days). Forelimbs were amputated at the midarm and preserved through ex vivo normothermic perfusion (EVNP) utilizing an RBC-based perfusate. Hourly perfusate fluid-dynamics, gases, electrolytes were recorded. Contractility during EVNLP was graded hourly using the Medical Research Council scale. EVNP termination criteria included systolic arterial pressure ≥115 mmHg, compartment pressure ≥30 mmHg (at EVNP endpoint), oxygen saturation reduction of 20%, and weight change ≥2%. Indocyanine green (ICG) angiography was performed after revascularization. Limb rejection was evaluated clinically (rash, edema, temperature), and histologically (BANFF classification) collecting per cause and protocol biopsies (POD 1, 7, 30, 60 and endpoint). Systemic infections were assessed by blood culture and tissue histology. CT scan was used to confirm bone bridging at endpoint., Results: Animals 2, 4 reached endpoint with grade 0-I rejection. Limbs 1, 3 presented grade III rejection on days 6, 61. CsA troughs averaged 461 ± 189 ng/mL. EVNLP averaged 4.3 ± 0.52 h. Perfusate lactate, PO 2 , and pH were 5.6 ± 0.9 mmol/L, 557 ± 72 mmHg and 7.5 ± 0.1, respectively. Muscle contractions were 4 [1] during EVNLP. Transplants 2, 3, 4 showed bone bridging on CT., Conclusion: We present preliminary evidence supporting the feasibility of an orthotopic, mid-humeral forelimb allotransplantation model under standard immunosuppression regimen. Further research should validate the immunological, infectious, and functional outcomes of this model., (© 2024 The Authors. Microsurgery published by Wiley Periodicals LLC.)

Competing Interests: Conflict of Interest The authors have no conflict of interests to disclose.

Competing Interests: The authors declare no conflicts of interest.

Competing Interests: Conflict of Interest The authors have no conflict of interests to disclose.

Background: The efficacy of virtual visits in converting new patients into established patients undergoing surgical treatment has not been demonstrated. The aim of this study was to evaluate patient retention and surgical conversion rate after an initial virtual plastic surgery consultation., Methods: An IRB-approved retrospective review of all new plastic surgery patients seen between May and August 2020 at a single institution was conducted. The initial encounter type, chief complaint, demographics, treatment recommendation, insurance approval rate, number and modality of pre- and postoperative visits, time to procedure, follow up, and complications were recorded. Patient retention and surgery conversion rate were calculated. Statistical analysis was performed with Chi-squared test, Fisher's exact test, and unpaired t-test., Results: In total, the records of 1889 new patients were reviewed (1635 in-person, 254 virtual). Virtual patients were younger (44.5 ± 19.0 versus 49.5 ± 20.7 years, p < 0.001), and nearly half resided greater than 50 miles away (42% versus 16%, p < 0.001). Virtual patients more frequently presented for cosmetic surgery (14% versus 7%, p < 0.001), lymphedema (15% versus 3%, p < 0.001), and gender dysphoria (11% versus 2%, p < 0.001). In-person patients presented more often for trauma (18% versus 5%, p < 0.001), elective hand complaints (16% versus 3%, p < 0.001), and breast reconstruction (9% versus 4%, p < 0.01). There were no differences in patient retention (p = 0.45) and procedure conversion rate (p = 0.21) between the groups., Conclusion: Telemedicine provides an opportunity to increase the practice catchment area and is as effective as in-person first encounters for establishing care and transition to surgery., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to disclose., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The anesthesiologist's role has expanded beyond the operating room, and anesthesiologist-led care teams can deliver coordinated care that spans the entire surgical experience, from preoperative optimization to long-term recovery of surgical patients. This expanded role can help reduce postoperative morbidity and mortality, which are regrettably common, unlike rare intraoperative mortality. Postoperative mortality, if considered a disease category, will be the third leading cause of death just after heart disease and cancer. Rapid advances in technologies like artificial intelligence provide an opportunity to build safe perioperative practices. Artificial intelligence helps by analyzing complex data across disparate systems and producing actionable information. Using artificial intelligence technologies, we can critically examine every aspect of perioperative medicine and devise innovative value-based solutions that can potentially improve patient safety and care delivery, while optimizing cost of care. In this narrative review, we discuss specific applications of artificial intelligence that may help advance all aspects of perioperative medicine, including clinical care, education, quality improvement, and research. We also discuss potential limitations of technology and provide our recommendations for successful adoption., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Purpose: There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP., Methods: Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain., Results: EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047)., Conclusions: Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP., (© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: The field of face transplantation continues to evolve, with more complex defects being addressed, and, at the same time, increased outcome expectations. Given our unique long-term experience in this field, we consented one of the youngest patients to undergo a full-face transplant., Methods: An 18-year-old woman presented with complete destruction of her central face and craniofacial structures. She had coexisting major injuries, including pituitary gland, visual axis, and motor control. After extensive rehabilitation and reconstruction techniques, the patient underwent face transplant on May 4, 2017, at the age of 21 years., Results: The total operative time for the recipient was 26 hours. There were no major perioperative complications. Since transplant, the patient has undergone 3 revision surgeries. She is near completely independent from a daily life activity standpoint. She has had 1 episode of rejection above grade II that was successfully treated with a short-term increased in immunosuppression., Conclusions: Contrary to data in solid organ transplantation where youth is associated with increased risk of rejection, our current algorithm in immunosuppression, combined with this patient's compliance, has led to only 1 rejection episode beyond grade II. This successful transplant can serve as a model for future vascularized composite transplants in younger populations., Competing Interests: Conflicts of interest and sources of funding: This face transplant was supported by the Department of Defense Armed Forces Institute of Regenerative Medicine, grant number W81XWH-08-2-0034., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Ischemia-reperfusion injury remains a primary concern in upper extremity transplantation. Ex vivo normothermic perfusion (EVNP) enables near-physiological organ preservation, avoiding the deleterious effects of hypoxia and cooling. We investigated the effectiveness of human limb EVNP compared with static cold storage (SCS)., Methods: Twenty human upper extremities were procured. Ten were perfused at 38 °C with an oxygenated red blood cell-based solution, and contralateral limbs served as SCS control (4 °C). EVNP was terminated with systolic arterial pressure ≥115 mm Hg, compartment fullness, or a 20% decline in oxygen saturation. Weight, contractility, compartment pressure, tissue oxygen saturation, and uptake rates were assessed. Perfusate fluid dynamics, gases, electrolytes, and metabolites were measured. Myocyte injury scores and liquid chromatography-mass spectrometry analysis were performed., Results: EVNP duration was 41.6 ± 9.4 h. Vascular resistance averaged 173.0 ± 29.4 mm Hg × min/L. Weight change and compartment pressures were 0.4 ± 12.2% ( P  = 0.21) and 21.7 ± 15.58 mm Hg ( P  = 0.003), respectively. Arterial and venous carbon dioxide partial pressure, oxygen saturation, and pH were 509.5 ± 91.4 mm Hg, 15.7 ± 30.2 mm Hg, 87.4 ± 11.4%, and 7.3 ± 0.2, respectively. Oxygen uptake rates averaged 5.7 ± 2.8 mL/min/g. Lactate reached 20 mmol/L after 15 (interquartile range = 6) h. Limb contractility was preserved for 30.5 (interquartile range = 15.8) h ( P  < 0.001) and negatively correlated with perfusate potassium (ρ = -0.7, P  < 0.001). Endpoint myocyte injury scores were 28.9 ± 11.5% (EVNP) and 90.2 ± 11.8% (SCS) ( P  < 0.001). A significant increase in taurine ( P  = 0.002) and decrease in tryptophan ( P  = 0.002) were detected. Infrared thermography and indocyanine green angiography confirmed the presence of peripheral perfusion., Conclusions: EVNP can overcome the limitations of cold preservation by extending preservation times, enabling limb quality assessment, and allowing limb reconditioning before transplantation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no funding or conflicts of interest.

Abstract: Hand transplantation for upper extremity amputation provides a unique treatment that restores form and function, which may not be achieved by traditional reconstruction and prosthetics. However, despite enhancing quality of life, hand transplantation remains controversial, because of immunological complications, transplant rejection, and medication effects. This systematic literature review sought to collect information on current experiences and outcomes of hand transplants to determine the efficacy and utility of hand transplants. The databases PubMed, Scopus, and Embase were analyzed with combinations of "hand" or "upper extremity" or "arm" and "transplant" or "allograft," with information collected on recipient characteristics, details of transplant, immunological outcomes, functional outcomes, and complications. Functional outcomes, as measured by Disabilities of Arm, Shoulder and Hand score, were compared between patient groups using Wilcoxon signed-rank test or 1-way analysis of variance test and post hoc Tukey test. Within the 108 articles that fulfilled inclusion and exclusion criteria, there were 96 patients with 148 hand transplants. There were 57 patients who experienced acute rejection and 5 patients with chronic rejection. Disabilities of the Arm, Shoulder and Hand scores significantly decreased after hand transplantation and were significantly lower for distal transplants compared with proximal transplants. There were 3 patients with concurrent face transplantation and 2 patients with simultaneous leg transplants. Sixteen patients experienced amputation of the hand transplant, and there were 5 deaths. This study found that hand transplantation provides significant restoration of function and form, especially for proximal transplants. Reduction in complications, such as rejection and amputation, can be achieved by decreasing medication cost and patient education., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Severe burns are traumatic and physically debilitating injuries with a high rate of mortality. Bacterial infections often complicate burn injuries, which presents unique challenges for wound management and improved patient outcomes. Currently, pigs are used as the gold standard of pre-clinical models to study infected skin wounds due to the similarity between porcine and human skin in terms of structure and immunological response. However, utilizing this large animal model for wound infection studies can be technically challenging and create issues with data reproducibility. We present a detailed protocol for a porcine model of infected burn wounds based on our experience in creating and evaluating full thickness burn wounds infected with Staphylococcus aureus on six pigs. Wound healing kinetics and bacterial clearance were measured over a period of 27 d in this model. Enumerated are steps to achieve standardized wound creation, bacterial inoculation, and dressing techniques. Systematic evaluation of wound healing and bacterial colonization of the wound bed is also described. Finally, advice on animal housing considerations, efficient bacterial plating procedures, and overcoming common technical challenges is provided. This protocol aims to provide investigators with a step-by-step guide to execute a technically challenging porcine wound infection model in a reproducible manner. Accordingly, this would allow for the design and evaluation of more effective burn infection therapies leading to better strategies for patient care., (© 2013-2022 The Journal of Biological Methods, All rights reserved.)

Background: Ex vivo normothermic limb perfusion (EVNLP) preserves amputated limbs under near-physiologic conditions. Perfusates containing red blood cells (RBCs) have shown to improve outcomes during ex vivo normothermic organ perfusion, when compared with acellular perfusates. To avoid limitations associated with the use of blood-based products, we evaluated the feasibility of EVNLP using a polymerized hemoglobin-based oxygen carrier-201 (HBOC-201)., Methods: Twenty-four porcine forelimbs were procured from Yorkshire pigs. Six forelimbs underwent EVNLP with an HBOC-201-based perfusate, six with an RBC-based perfusate, and 12 served as static cold storage (SCS) controls. Ex vivo normothermic limb perfusion was terminated in the presence of systolic arterial pressure of 115 mm Hg or greater, fullness of compartments, or drop of tissue oxygen saturation by 20%. Limb contractility, weight change, compartment pressure, tissue oxygen saturation, oxygen uptake rates (OURs) were assessed. Perfusate fluid-dynamics, gases, electrolytes, metabolites, methemoglobin, creatine kinase, and myoglobin concentration were measured. Uniformity of skin perfusion was assessed with indocyanine green angiography and infrared thermography., Results: Warm ischemia time before EVNLP was 35.50 ± 8.62 minutes (HBOC-201), 30.17 ± 8.03 minutes (RBC) and 37.82 ± 10.45 (SCS) (p = 0.09). Ex vivo normothermic limb perfusion duration was 22.5 ± 1.7 hours (HBOC-201) and 28.2 ± 7.3 hours (RBC) (p = 0.04). Vascular flow (325 ± 25 mL·min-1 vs. 444.7 ± 50.6 mL·min-1; p = 0.39), OUR (2.0 ± 1.45 mL O2·min-1·g-1 vs. 1.3 ± 0.92 mL O2·min-1·g-1 of tissue; p = 0.80), lactate (14.66 ± 4.26 mmol·L-1 vs. 13.11 ± 6.68 mmol·L-1; p = 0.32), perfusate pH (7.53 ± 0.25 HBOC-201; 7.50 ± 0.23 RBC; p = 0.82), flexor (28.3 ± 22.0 vs. 27.5 ± 10.6; p = 0.99), and extensor (31.5 ± 22.9 vs. 28.8 ± 14.5; p = 0.82) compartment pressures, and weight changes (23.1 ± 3.0% vs. 13.2 ± 22.7; p = 0.07) were not significantly different between HBOC-201 and RBC groups, respectively. In HBOC-201 perfused limbs, methemoglobin levels increased, reaching 47.8 ± 12.1% at endpoint. Methemoglobin saturation did not affect OUR (ρ = -0.15, r2 = 0.022; p = 0.45). A significantly greater number of necrotic myocytes was found in the SCS group at endpoint (SCS, 127 ± 17 cells; HBOC-201, 72 ± 30 cells; RBC-based, 56 ± 40 cells; vs. p = 0.003)., Conclusion: HBOC-201- and RBC-based perfusates similarly support isolated limb physiology, metabolism, and function., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Metopic craniosynostosis is the second most frequent type of craniosynostosis. When the phenotypic presentation has been deemed severe the treatment is surgical in nature and is performed in infancy with fronto-orbital advancement and cranial vault remodeling. At the time of this writing, there is no consensus regarding an objective evaluation system for severity, diagnostic criteria, or indications for surgery. This study aims to review the anthropometric cranial measurements and the relative diagnostic criteria/classification of severity/surgical indications proposed so far for this skull malformation, and to investigate if there is any scientific support for their utility., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

A novel multimodal, multiscale imaging system with augmented reality capability were developed and characterized. The system offers 3D color reflectance imaging, 3D fluorescence imaging, and augmented reality in real time. Multiscale fluorescence imaging was enabled by developing and integrating an in vivo fiber-optic microscope. Real-time ultrasound-fluorescence multimodal imaging used optically tracked fiducial markers for registration. Tomographical data are also incorporated using optically tracked fiducial markers for registration. Furthermore, we characterized system performance and registration accuracy in a benchtop setting. The multiscale fluorescence imaging facilitated assessing the functional status of tissues, extending the minimal resolution of fluorescence imaging to ~17.5 µm. The system achieved a mean of Target Registration error of less than 2 mm for registering fluorescence images to ultrasound images and MRI-based 3D model, which is within clinically acceptable range. The low latency and high frame rate of the prototype system has shown the promise of applying the reported techniques in clinically relevant settings in the future.

Introduction: As a high-volume referral center for facial transplantation, we have learned significantly from the screening, evaluation, and enrollment process. This report analyzes our algorithm for the assessment of potential face transplant candidates referred to our institution., Methods: After institutional review board approval in 2004, a prospectively maintained database was created for patients who were referred face transplant. Records were reviewed for the nature of tissue defect, functional deficit, surgical and medical history, and expert recommendations.Our algorithm begins with a review of a patient's file with a focus on institutional review board criteria. After screening, a phone interview is conducted, and transplantation is discussed. Patients are presented to the team to analyze the medical, psychiatric, and surgical history; support network; and geographic location. Eligible patients are invited for an in-person evaluation, and the case is reviewed again with the team. If approved, the patient can provide consent for transplantation., Results: More than 200 patients were referred for transplant evaluation at the Cleveland Clinic from 2004 to 2016. Sixty were eligible for further evaluation for face transplantation based on preliminary screening. Thirteen (6.5% of original cohort) were invited for in-person evaluation and physical examination. Five (2.5% of original cohort, 38.4% invited cohort) of these 13 patients underwent face transplantation, of whom, 3 (1.5% of original cohort, 23.1% invited cohort) underwent face transplantation at our institution. All 3 patients who were ultimately transplanted were referred by a physician., Discussion: As the availability of public information on face transplant increases, it is likely that an increase in self-referral for face transplantation will occur. Thus, it is critical that institutions adopt a systematic approach to triage in order to identify appropriate patients. Our algorithm allowed for a high enrollment and transplantation ratio to save patient and institution time and resources. This could be easily adopted by other institutions to save time, money, and resources.

Introduction: Cranial vault surgery in children with ventricular shunts is more complex due to the possible interference of shunt location with surgical planning and increased risk of shunt related complications. The study evaluated the management of ventricular shunts during cranial vault remodeling (CVR) and subsequent outcomes and complications following CVR., Methods: An IRB-approved retrospective chart review was performed including patients who underwent CVR in presence of a ventricular shunt. Measured outcomes were number of shunt revisions following CVR, 30-day complication rate, 3-month complication rate, and post-CVR Whitaker classification. Finally, a review of the literature was performed, and our results were compared to previous reports., Results: Eleven patients met the inclusion criteria. Ventricular shunt was not exposed in 18%; exposed and not revised in 54%; exposed and left on a bone peninsula in 18% and simultaneously exposed and revised in 18%. Two patients experienced complications within 30-days. Three additional patients experienced complications within 3-months. An average of 2.2 shunt revisions per patient were performed following CVR. Whitaker classification was I in 7 patients, II in 1 patient and III in 2 patients. Shunt revision rate for patients undergoing CVR for hydrocephalic macrocephaly was on average of 1.2 and 1.9 for shunt-induced craniosynostosis in literature., Conclusions: Cranial vault abnormalities in the presence of a ventricular shunt can be effectively treated with CVR. The presence of a shunt does not seem to interfere with final head shape. While leaving the shunt unexposed may appear less morbid, shunt related complications can still occur with this approach.

Background: Infraorbital foramen (IOF) is an important anatomical landmark in cleft lip surgery. The location of IOF within the maxilla of infants is different from adults. However, little information about anatomy of IOF in infants exists in the literature. This study aims to determine the location of IOF in infant dry skulls based on key surgical landmarks., Methods: All dry skulls under age 2 years old were selected from the Hamann-Todd Human Osteological Collection at the Cleveland Museum of Natural History (Cleveland, OH). Specimens without cranial bones or complete maxilla were excluded. Seven anatomical measurements were taken on each side of the face for each individual skull (14 measurements for each skull). Anatomical landmarks used for the measurements included infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary buttress, anterior nasal spine (ANS), and inferolateral corner of the aperture piriformis., Results: Twenty-seven halves of 14 dry skulls were included in the final analysis. The mean age of specimens was 0.57 years. Mean distances from infraorbital foramen to infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary, and ANS buttress were 4.11 ± 0.82, 9.4 ± 1.62, 12.7 ± 2.71, 11.7 ± 1.54, and 18.4 ± 2.11 mm, respectively., Conclusion: This study also shows that the infraorbital foramen in infants is located at the level of the ANS or within 2 mm higher and that the distance between the infraorbital rim and foramen is only 3 to 4 mm. These findings should be applied to the cleft population with discretion.

Background: Although the natural history of nonsyndromic unilateral coronal craniosynostosis has been extensively described, optimal management remains controversial due to lack of Level 1 evidence. This study aims to assess the current state of practice among craniofacial surgeons., Methods: Ninety-four craniofacial surgeons were approached to complete a survey consisting of 15 questions. Data were collected assessing surgeons' primary surgical indication, timing of intervention, preoperative imaging, and choice of technique for patients presenting with nonsyndromic unilateral coronal craniosynostosis. Choice of technique and timing of intervention in case of recurrence were also investigated., Results: After 5 mailings, the response rate was 61%. The combination of both appearance and raised intracranial pressure was the primary indication for treatment for 73.2% of surgeons. Preoperative CT scan of the skull was "always" performed by 70.1% of respondents. Open surgical management was most commonly performed at 8-10 months of age (38.6%). Bilateral frontal craniectomy with remodeling of the supraorbital bandeau and frontal bone was the most common choice of procedure (84.2%). In case of mild to moderate and moderate to severe recurrences at 1 year of age, 89.5% and 47.4% of surgeons opted for conservative management, respectively. Optimal timing for repeat cranioplasty was after 4 years of age (65.5%). Overall, 43.4% quoted lack of evidence as the greatest obstacle to clinical decision-making when dealing with unilateral synostosis., Conclusion: This survey exposes the lack of consensus and the disparity of opinion among craniofacial surgeons regarding the management of nonsyndromic coronal synostosis, particularly in the setting of recurrence.

Introduction: Hemifacial microsomia is the most common congenital disorder of the face after cleft lip and palate. While treatment of the bony abnormalities has been well documented, less attention has been paid to correction of the soft tissue deformity. This study aimed to systematically review the literature addressing the techniques utilized to correct the soft tissue deformity in hemifacial microsomia., Materials and Methods: A comprehensive review of peer-reviewed literature regarding the management of soft tissue reconstruction in patients with hemifacial microsomia was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Odds ratio was used to assess differences in complication rates between reconstructions performed with free tissue transfer and fat grafting., Results: The literature search yielded 38 articles that were fully reviewed for data extraction. Articles were grouped into one of 5 reconstructive modalities-pedicled flap, microvascular free tissue transfer, structural fat grafting, alloplastic implant, and functional reconstruction. Microvascular free tissue transfer had a complication rate of 27.1%, while structural fat grafting had a complication rate of 4.2% (odds ratio 6.7, P = 0.0003)., Conclusions: Microvascular free tissue transfer likely provides greater volume than fat grafting at the cost of a higher complication rate. Mild to moderate soft tissue deformity can be corrected with serial fat grafting. However, severe soft tissue deformity is better corrected with microvascular free tissue transfer. When performing free tissue transfer, one should be prepared for recipient vessel anomalies. To provide adequate augmentation with isolated fat grafting, multiple sessions are likely required.

Background: We report new data for a rare face transplant performed 3 years ago. Granulomatosis with polyangiitis (GPA) (Wegener) is a severe autoimmune necrotizing vasculitis and parenchymal inflammatory disease that can affect any organ including those of the craniofacial region. Skin involvement manifests as malignant pyoderma. This account (1) highlights the technical details of face transplantation for this unique indication, (2) reports the 3-year posttransplant outcome, and (3) describes relevant immunological aspects., Methods: A Le Fort III near-total face and near-total scalp transplant was performed after extensive trauma and subsequent bone and soft tissue infection in a patient with GPA. Incisions were planned along facial aesthetic subunits. The vascular pedicle comprised the facial and superficial temporal arteries bilaterally. The functioning left eye was preserved and fitted into the donor tissues., Results: The procedure took 21 hours, and transfusion was limited to 4 units of packed red cells. Early medical and surgical complications were successfully treated. At 3 years, acceptable aesthetic outcome was achieved with adequate color match and scalp hair growth. The patient has recovered light touch, temperature, and 2-point discrimination and has evidence of symmetric cheek elevation albeit with limited eyelid and frontalis function. GPA relapse did not occur. Four acute rejections were fully reversed., Conclusions: This case represents a new underlying disease (trauma + GPA) leading to face transplantation and a unique clinical scenario where allografting was indicated for potentially life-threatening and sight-preserving reasons and not for mere functional and aesthetic concerns. Despite complexity, 3-year clinical outcome is encouraging, and the patient is no longer at risk for dural exposure, meningitis, and related morbidity.

Purpose: In this paper, we present a vein imaging system to combine reflectance mode visible spectrum images (VIS) with transmission mode near-infrared (NIR) images in real time. Clear vessel localization is achieved in this manner with combined NIR-VIS dual-modal imaging., Methods: Transmission and reflectance mode optical instrumentation is used to combine VIS and NIR images. Two methods of displaying the combined images are demonstrated here. We have conducted experiments to determine the system's resolution, alignment accuracy, and depth penetration. Vein counts were taken from the hands of test subjects using the system and compared with vein counts taken by visual analysis., Results: Results indicate that the system can improve vein detection in the human hand while detecting veins of a diameter < 0.5 mm at any working distance and of a 0.25 mm diameter at an optimal working distance of about 30 cm. The system has also been demonstrated to clearly detect silicone vessels with artificial blood of diameter 2, 1, and 0.5 mm diameter under a tissue depth of 3 mm. In a study involving 25 human subjects, we have demonstrated that vein visibility was significantly increased using our system., Conclusions: The results indicate that the device is a high-resolution solution to near-surface venous imaging. This technology can be applied for IV placement, morphological analysis for disease state detection, and biometric analysis.

Background: Autologous bone continues to represent the first choice for reconstruction of calvarial defects. However, unanswered questions remain on the natural history of the graft and the influence of patient-related risk factors. This study investigated the outcomes of skull reconstruction with split calvarial bone graft, examining the natural history and stratifying the risk of unfavorable results., Methods: Patients who underwent cranioplasty with split calvarial bone graft between 1982 and 2016 at the Cleveland Clinic were analyzed, recording demographics, comorbidities, indications, size and location of defect, and outcomes including complications and reoperations. Changes in graft thickness were analyzed using computed tomographic and magnetic resonance imaging scans., Results: Forty-one patients with an average age of 33.2 years, cranial defect size of 68 cm, and mean follow-up of 28 months were included. The majority of patients (85 percent) had significant risk factors, with 43 percent suffering prior infection. Seventy-three percent of patients experienced successful restoration. A major complication was recorded in 26.8 percent; resorption occurred in 19.5 percent of patients (in 75 percent only at the recipient site), with 9.8 percent requiring reoperation. Patients with one or more risk factors or a smoking history were more likely to experience a complication. The mean ratio of the graft to the bicortical donor bone thickness was 0.48 ± 0.17 for the recipient site and 0.57 ± 0.10 for the donor site at an average radiographic follow-up of 11.9 ± 10.9 years., Conclusions: This study demonstrated a 73.2 percent first-attempt success rate in a high-risk population. The grafts maintain thickness over time, with no evidence of bone hypertrophy. Defect characteristics and patient systemic factors appear to be important variables influencing success., Clinical Question/level of Evidence: Therapeutic, IV.

Multidrug-resistant bacterial strains are a rapidly emerging healthcare threat; therefore it is critical to develop new therapies to combat these organisms. Prior antibacterial strategies directly target pathogen growth or viability. Host-directed strategies to increase antimicrobial defenses may be an effective alternative to antibiotics and reduce development of resistant strains. In this study, we demonstrated the efficacy of a pyrimidine synthesis inhibitor, N-phosphonacetyl-L-aspartate (PALA), to enhance clearance of methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter baumannii strains by primary human dermal fibroblasts in vitro. PALA did not have a direct bactericidal effect, but enhanced cellular secretion of the antimicrobial peptides human β-defensin 2 (HBD2) and HBD3 from fibroblasts. When tested in porcine and human skin explant models, a topical PALA formulation was efficacious to enhance MRSA, P. aeruginosa, and A. baumannii clearance. Topical PALA treatment of human skin explants also resulted in increased HBD2 and cathelicidin (LL-37) production. The antimicrobial actions of PALA required expression of nucleotide-binding, oligomerization domain 2 (NOD2), receptor-interacting serine/threonine-protein kinase 2 (RIP2), and carbamoyl phosphatase synthase II/aspartate transcarbamylase/dihydroorotase (CAD). Our results indicate that PALA may be a new option to combat multidrug-resistant bacterial infections of the skin through enhancement of an integral pathway of the cutaneous innate immune defense system.

Introduction: Sphincter pharyngoplasty (SP) is becoming increasingly popular for correction of velopharyngeal insufficiency (VPI) after cleft palate repair because of high success rate, low incidence of postoperative obstructive sleep apnea (OSA), and ease of revision in case of failure. This study is a meta-analysis of SP outcomes, reasons for failure, and revision strategies., Methods: A comprehensive review of the literature on SP outcomes was conducted. Sphincter pharyngoplasty failure was defined as persistent hypernasality, incomplete velopharyngeal port (VP) closure on instrumental evaluation with concomitant VPI, or nonresolving hyponasality and/or OSA persisting >3 months after surgery. Two-tailed paired Student t test was used to compare outcomes between syndromic versus nonsyndromic patients and preoperative versus postoperative OSA rates., Results: Forty-four publications evaluating 2402 patients were included. Overall SP success rate was 78.4% (77.3% in nonsyndromic vs 84.8% in syndromic patients, P = 0.11). Overall primary revision rate was 17.8% (20% in nonsyndromic vs 15.4% in syndromic patients P = 0.97). Most failures (89.5%) manifested as persistent VPI with continued hypernasality requiring revision, whereas 10.5% of failures manifested as obstructive symptoms and/or severe hyponasality requiring revision. Causal factors of SP failure were the following: large central port (62.8%), dehiscence (15.5%), tight port (12.1%), and low-inset (9.7%). Primary revision success rate was 75.6%. Obstructive sleep apnea rates increased from 5.1% to 18.4% (P = 0.02)., Conclusions: This study suggests that SP can resolve VPI in 78.4% of patients, which can be increased to 94.7% after one revision. Most failures are technique-dependent; therefore, there could be significant ground for improvement of outcomes.

Background: Vascularized composite allotransplantation offers a new hope for restoration of orbital content and perhaps vision. The aim of this study was to introduce a new composite eyeball-periorbital transplantation model in fresh cadavers in preparation for composite eyeball allotransplantation in humans., Methods: The composite eyeball-periorbital transplantation flap borders included the inferior border, outlined by the infraorbital rim; the medial border, created by the nasal dorsum; the lateral border, created by the lateral orbital rim; and the superior border, created by the superior part of the eyebrow. The pedicle of the flap included the facial artery, superficial temporal artery, and external jugular vein. The skin and subcutaneous tissues of the periorbital region were dissected and the bony tissue was reached. A coronal incision was performed and the frontal lobe of the brain was reached by means of frontal osteotomy. Ophthalmic and oculomotor nerves were also included in the flap. After a "box osteotomy" around the orbit, the dissection was completed. Methylene blue and indocyanine green injection (SPY Elite System) was performed to show the integrity of the vascular territories after facial flap harvest., Results: Adequate venous return was observed within the flap after methylene blue dye injection. Laser-assisted indocyanine green angiography identified a well-defined vascular network within the entire composite eyeball-periorbital transplantation flap., Conclusions: For the first time, a novel composite eyeball-periorbital transplantation model in human cadavers was introduced. Good perfusion of the flap confirmed the feasibility of composite eyeball-periorbital transplantation in the clinical setting. Although harvesting of the flap is challenging, it introduces a new option for reconstruction of the periorbital region including the eyeball.

Background: Ischemia time represents a significant limitation for successful extremity transplantation because of the rapid deterioration of ischemic muscle. Normothermic ex-situ preservation is an emergent method to prolong the organ viability following procurement, by replicating the physiologic conditions. The aim of this study was to develop an ex-situ normothermic limb perfusion system to preserve the viability and function of porcine limbs for 12 hours following procurement., Methods: A total of 18 swine limbs were perfused. Thirteen limbs were used to develop the perfusion protocol. Five limbs were perfused according to the optimized protocol. These limbs were perfused at 39°C for twelve hours using an oxygenated colloid solution containing red blood cells. Glucose and electrolytes were kept within physiologic range by partial perfusate exchange. Limb specific perfusion quality was assessed by muscle contractility upon electrical nerve stimulation, compartment pressure, creatine kinase (CK) and myoglobin concentrations, tissue oxygen saturation (near infrared spectroscopy), indocyanine green angiography, and infrared radiation by thermographic imaging., Results: The last five limbs reached the 12 hours' perfusion target maintaining normal compartment pressure (16.4  ± 8.20 mmHg), minimal weight increase (0.54 ± 7.35%), and mean muscle temperature of 33.6 ± 1.67°C. Myoglobin and CK concentrations were 875 ± 291.4 ng/mL, and 53344 ± 14850.34 U/L, respectively, at the end of perfusion. Muscle contraction was present in all limbs until cessation of perfusion. Differences in uniformity and quality of distal perfusion were identified with thermography and angiography imaging at 12 hours of perfusion., Conclusions: Ex-situ normothermic limb perfusion preserves swine limb physiology and function for at least 12 hours., (© 2017 Wiley Periodicals, Inc.)

Background: LeFort III osteotomies or monobloc advancements, with or without distraction, can be used to treat mid-facial hypoplasia causing exorbitism and obstructive sleep apnea in syndromic patients. This report is a meta-analysis of the complication rates following LeFort III osteotomies or monobloc advancement with or without distraction., Methods: Triple database search was conducted to identify articles addressing mid-facial hypoplasia treated with LeFort III or monobloc in which complications were detailed. Complications were considered major if they required a second operation or were potentially life threatening. Statistical analysis was performed with Student t test., Results: Fifteen studies fit inclusion criteria. This yielded 363 total patients. In patients treated with a monobloc advancement, there was a statistically higher rate of major (P < 0.0001) and minor (P < 0.0001) complications, death (P = 0.02), cerebrospinal fluid (CSF) leaks (P < 0.0001), and meningitis/abscess (P < 0.0001) when distraction was used. In patients treated with a LeFort III, there was a statistically higher rate of reoperation when distraction was used (P = 0.001). In patients treated without distraction, there was a statistically higher rate of major (P < 0.0001) complications, death (P = 0.008), CSF leaks (P = 0.003), and reoperation (P < 0.0001) with a monobloc and a statistically higher rate of minor complications (P < 0.001) with a LeFort III., Conclusion: LeFort III proved to be a safer technique for the treatment of mid-facial hypoplasia. Although distraction was initially introduced to reduce complications, in this review, monobloc with distraction had the highest rate of major complications. There are multiple confounding factors that influence success of mid-face surgery and every patient must be evaluated and treated individually.

Background: Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes., Methods: A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence., Results: Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months., Conclusions: Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.