A survey of North American burn and plastic surgeons on their current attitudes toward facial transplantation.

BACKGROUND: Feasibility of composite tissue allotransplantation (CTA) has been substantiated by transplantations of the hand, abdominal wall, and face. CTA has the potential to reconstruct "like with like," but the risk-to-benefit ratio and clinical indications have yet to be determined. We sought to examine the current attitudes about the emerging field of CTA from those who treat complex facial injuries. STUDY DESIGN: In 2007, a Web-based blinded survey was sent to both burn and plastic surgeons involved in facial reconstruction. We examined the practice profile with regard to complex facial injuries and asked respondents to assess the level of risk in CTA and indications for facial transplantation. Surgeons were asked to evaluate three clinical cases (two closely mirroring clinical face transplantations) for suitability for treatment with CTA. RESULTS: One hundred sixty-four surgeons responded (54% response rate) and averaged 17.3 years in practice. They saw 12.1 severe facial-injury patients per year. A total of 78.7% agreed that current techniques do not provide adequate reconstruction for severe facial injuries, and 26.2% were in favor of performing CTA on immunosuppression. Acceptable indications for CTA were multiple failed reconstructions (70%), total facial burn (59%), and absence of remote tissue (55%). Ten percent saw no acceptable indication for CTA. The scenarios that mimicked recent transplantations had moderate support in favor of CTA (20.7% for the Chinese patient and 29.3% for the French patient). CONCLUSIONS: This survey demonstrates support for use of CTA to reconstruct complex facial deformities. Surgeons continue to be wary of immunosuppression and chronic rejection, and many want to wait for better immunologic treatment options.

A survey of north american hand surgeons on their current attitudes toward hand transplantation.

PURPOSE: Although composite tissue allotransplantation (CTA) is unparalleled in its potential to reconstruct "like with like," the risk-benefit ratio and clinical indications are difficult to determine. We examined current attitudes regarding the emerging field of CTA from those who treat complex hand injuries. METHODS: A web-based survey regarding CTA was sent to members of the American Society for Surgery of the Hand, which identified their demographic data and practice profiles. Respondents' support for CTA and their assessment of the level of risk associated with these procedures were addressed. Additional questions focused on the clinical application of CTA with current immunosuppression, ethical issues surrounding CTA, and the indications for hand transplantation. Finally, 2 clinical situations that closely mirrored past hand transplantations were presented, and members evaluated their suitability for allotransplantation. RESULTS: A total of 474 surgeons responded to the survey (22% response rate), who were divided in their opinion of hand transplantation with 24% in favor, 45% against, and 31% undecided. The majority (69%) consider this surgery to be a high-risk endeavor; however, a large percentage (71%) still believe it to be an ethical procedure when performed on properly selected patients. The most accepted indications for hand transplantation were loss of bilateral hands (78%) and amputation of a dominant hand (32%). Only 16% were in favor of performing transplants with the immunosuppression available today. In response to the clinical situation, 66% would offer transplantation to a bilateral hand amputee, whereas only 9% would offer transplantation to a patient with diabetes who had lost his or her dominant hand. CONCLUSIONS: This survey demonstrates support for hand allotransplantation as a solution for dominant-hand and bilateral hand amputees. However, surgeons continue to be concerned about the adverse effects of immunosuppression and the risks of acute and chronic rejection, and many want to wait for the development of better immunologic treatment options.

Comparison of computed tomographic imaging measurements with clinical findings in children with unilateral lambdoid synostosis.

BACKGROUND: In this study, the authors retrospectively reviewed 12 children with unilateral lambdoid synostosis to compare and contrast clinical findings and associated computed tomographic scan measurements for consistency. METHODS: Multidisciplinary chart records were reviewed for descriptive findings of unilateral lambdoid synostosis. The preoperative computed tomographic scans underwent quantitative analysis of craniofacial morphology. The described clinical findings were compared with the associated computed tomographic measurements for consistency. RESULTS: Clinical findings of unilateral lambdoid synostosis that were consistent with computed tomographic measurements included mastoid cant and bulge, and inferior ear position. Ipsilateral posterior ear position was clinically noted in half of the cases but was anterior in all cases on computed tomographic analysis. Trapezoid head shape was recorded in 11 of the 12 children but present in only eight computed tomographic scans. Median skull base deviation was 9 degrees for the posterior cranial fossa, 10 degrees for the middle cranial fossa, 6 degrees for mastoid cant, and 1 degree for facial twist. There was no correlation between degree of deformity and extent of suture fusion. CONCLUSIONS: Mastoid bossing, skull base cant, and inferior ear deviation ipsilateral to the fused sutures were clinical findings that were consistent with computed tomographic measurements in these patients. Trapezoid head shape and posterior ear deviation were not. Radiographic suture fusion was observed in all cases; however, the extent of fusion did not correlate with the degree of deformity.

Direct microvascular repair of an infant's transected coronary artery: case report.

The authors report the direct, microvascular repair of a right coronary artery transected during reoperation fOr complications of arterial switch operation (ASO) in a 3 month-old child. This is the first documented use of direct microsurgical anastamosis in the repair of an infant's transected coronary artery. Deviation from standard coronary bypass graft repair was permitted by vessel characteristics, as well as close collaboration between plastic surgery and cardiac surgery services. Patency of repair was confirmed intraoperatively with Doppler ultrasound and through postoperative echocardiograms documenting stable right ventricular function. This case highlights the benefit of a multidisciplinary approach to an emergent clinical problem using microsurgical techniques.

Early composite cranioplasty in infants with severe aplasia cutis congenita: a report of two cases.

OBJECTIVE: Severe cutis aplasia congenita has traditionally been treated with initial soft tissue coverage and delayed cranioplasty. We advocate the technique of early composite reconstruction of both bone and soft tissues. METHODS: Two cases of cutis aplasia congenita with large skull defects (6 x 10 cm, 8 x 8 cm) of superficial layers, skull, and dura are presented. In each case, composite reconstruction was undertaken before 2 weeks of age with restoration of bony and soft tissue coverage through autologous, full-thickness cranial bone grafts and scalp flaps. Both children have been followed up over 2 years with clinical examination and computed tomography (CT) scans. RESULTS: In both cases, defects were completely repaired postoperatively and remained closed 2 years later. Complete regeneration of calvarial bone graft donor sites were documented by CT scan. Head shape and circumference were normal at 2-year follow up.