Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA; formerly Wegener's granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten-year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1-year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Technical and surgical aspects of the sphenopalatine ganglion (SPG) microstimulator insertion procedure.

Cluster headache (CH) is a debilitating, severe form of headache. A novel non-systemic therapy has been developed that produces therapeutic electrical stimulation to the sphenopalatine ganglion (SPG). A transoral surgical technique for inserting the Pulsante SPG Microstimulator into the pterygopalatine fossa (PPF) is presented herein. Technical aspects include detailed descriptions of the preoperative planning using computed tomography or cone beam computed tomography scans for presurgical digital microstimulator insertion into the patient-specific anatomy and intraoperative verification of microstimulator placement. Surgical aspects include techniques to insert the microstimulator into the proper midface location atraumatically. During the Pathway CH-1 and Pathway R-1 studies, 99 CH patients received an SPG microstimulator. Ninety-six had a microstimulator placed within the PPF during their initial procedure. Perioperative surgical sequelae included sensory disturbances, pain, and swelling. Follow-up procedures included placement of a second microstimulator on the opposite side (n=2), adjustment of the microstimulator lead location (n=13), re-placement after initial unsuccessful placement (n=1), and removal (n=5). This SPG microstimulator insertion procedure has sequelae comparable to other oral cavity procedures including tooth extractions, sinus surgery, and dental implant placement. Twenty-five of 29 subjects (86%) completing a self-assessment questionnaire indicated that the surgical effects were tolerable and 90% would make the same decision again.

Cost analysis of conventional facial reconstruction procedures followed by face transplantation.

For the first time, this study analyzes the cost of multiple conventional reconstructions and face transplantation in a single patient. This patient is a 46-year-old female victim of a shotgun blast resulting in loss of multiple functional and aesthetic subunits. For over 5 years, she underwent multiple conventional reconstructions with suboptimal results. In December 2008, she became the recipient of the first U.S. face transplant. This has provided the unique opportunity to present the cost of 23 separate conventional reconstructive procedures and the first face transplant in the United States. The combined cost of conventional reconstructive procedures and the first U.S. face transplant was calculated to be $353 480 and $349 959, respectively. The combined cost posttransplant totaled $115 463. The direct cost pretransplant was $206 646, $232 893 peritransplant and $74 236 posttransplant. The two largest areas of cost utilization were surgical ($79 625; 38.5%) and nursing ($55 860; 27%), followed by anesthesia ($24 808; 12%) and pharmacy ($16 581; 8%). This study demonstrates that the cost of the first U.S. face transplant is similar to multiple conventional reconstructions. Although the cost of facial transplantation is considerable, the alleviation of psychological and physiological suffering, exceptional functional recovery and fulfillment of long-lasting hope for social reintegration may be priceless.

Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers.

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.

Relationship of obesity and specimen weight to complications in reduction mammaplasty.

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

Orbital extension of a frontal sinus osteoma in a thirteen-year-old girl.

Osteomas are uncommon, slow-growing, benign osteogenic neoplasms that arise most frequently in the craniofacial skeleton. (1,2) Osteoma is the most common benign tumor of the nose and paranasal sinuses and the most common neoplasm of the frontal sinus. (3-5) Paranasal sinus osteomas originate in the sinus wall, fill the lumen with well-defined mature osseous tissue, and occasionally extend into the orbit where they give rise to orbital signs and symptoms. Osteomas most commonly become symptomatic in the second to fifth decade in life, but orbital involvement has rarely been reported in patients aged 18 years and younger. (2,6-10) We report a case of a frontal sinus osteoma with orbital extension in a 13-year-old girl.

Lip augmentation with AlloDerm acellular allogenic dermal graft and fat autograft: A comparison with autologous fat injection alone.

Many surgical options exist for lip augmentation, none of which consistently provide safe, lasting, and predictable volume gains. We describe and evaluate the use of AlloDerm acellular allogenic dermal graft in combination with fat autograft and compare the postoperative results with those of autologous fat injection alone. Analysis of the preoperative and 1- and 3-month postoperative photographs was done using digital imaging software. Outcome measures included vermilion show and horizontal lip projection from the soft tissue pogonion-subnasale plane. A 61% mean increase in vermilion show was observed in lips augmented with AlloDerm/fat injection, in comparison to a mean increase of 13% in lips augmented with fat injection alone. Lip projection demonstrated a mean increase of 1 mm in AlloDerm/fat lips at 3 months. Postoperatively, no evidence of resorption was seen in lips augmented with AlloDerm/fat between the 1- and the 3-month follow-ups, however, a 9% decrease in vermilion show occurred in lips augmented with fat injection over the same period. No complications occurred in either group. We conclude that AlloDerm in conjunction with autologous fat injection constitutes a safe, reliable, and lasting method of lip augmentation providing increased vermilion show compared to that with autologous fat injection alone.

Reconstruction of the irradiated contracted socket with an expanded superficial temporalis fascial flap.

PURPOSE: To describe the reconstruction of an irradiated contracted socket with an expanded superficial temporalis fascial flap and oral mucosa. METHODS: A superficial temporalis fascial flap was first expanded with tissue expansion techniques and then rotated into the orbit to revascularize the socket. The mucosal surface of the socket was secondarily grafted with buccal and hard palate mucosa. RESULTS: The expanded superficial temporalis fascial flap was used to revascularize the socket for grafting with hard palate and buccal mucosa. This resulted in the successful retention of an ocular prosthesis. CONCLUSION: The expanded superficial temporalis fascial flap is a useful technique in reconstruction of the contracted socket.

The microdissection cautery needle versus the cold scalpel in bicoronal incisions.

Craniofacial procedures commonly use scalp incisions to optimize surgical access and aesthetic results. Although the use of traditional electrocautery instruments on hair-bearing tissue has been limited secondary to the width of resulting alopecia, needle-tipped electrocautery devices with decreased energy transmission have been developed. This study investigates the cosmetic effect of such instruments on scalp incisions. Twelve children undergoing craniosynostotic correction via bicoronal incisions were included. One side of the incision was completed with the cold scalpel whereas the contralateral portion was effected using the Colorado MicroDissection Needle (Colorado Biomedical Inc., Evergreen, CO, U.S.A.) according to optimal usage instructions. At the conclusion of the study period, precise measurements of the resultant width of alopecia were obtained from the parietal and temporal regions bilaterally, and were analyzed statistically. Also, parents completed a questionnaire concerning subjective observations of the surgical incision and its healing. The portions of the incision completed with the Colorado MicroDissection Needle demonstrated a wider area of peri-incisional alopecia (5.8 +/- 1.8 mm) than that produced by the cold scalpel (3.5 +/- 0.87 mm). Not only was this increased width significant statistically (P < 0.05), in addition the disparity was noted by the majority of parents (10 of 12) either on the patient questionnaire or with nonsuggestive verbal questioning. The benefit of the hemostatic incisional technique of electrocautery with even needle-tipped instruments must be weighed carefully against its cosmetic consequences.

Structural stability of the rotary door myocutaneous flap.

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.

Expanded superficial temporalis fascial flap for orbital reconstruction in a postirradiated orbit: a patient report.

The temporalis musculofascial flap can be pre-expanded to increase its area prior to transfer. The large size of the preexpanded flap enabled orbital reconstruction to be carried out in a postirradiated orbit in a three-year-old girl. The flap was split, transferred in two parts, and covered with a buccal mucosal graft. A prosthetic shell was satisfactorily fitted postoperatively.

Complex regional pain syndrome of the breast in a patient after breast reduction.

Complex regional pain syndrome (CRPS) is characterized by devastating pain, swelling, and cutaneous discoloration that result from vasomotor dysfunction caused by an abnormally accelerating sympathetic loop reflex after trauma or surgery. Although in the extremities CRPS is well documented as reflex sympathetic dystrophy, it only has been reported anecdotally in the breast after modified radical mastectomy and never reported after breast reduction. We report CRPS in the right breast of a 27-year-old woman after revision breast reduction surgery. The patient had signs of CRPS and symptoms of pain, swelling, epidermal scaling, and cutaneous temperature changes lasting more than 1 year. Liquid crystal thermographic scanning revealed a persistent, clinically significant hypothermic region in the affected breast. Intravenous phentolamine temporarily relieved the symptoms. Subsequent sympathetic blockade of the stellate ganglion alleviated chronic CRPS symptoms. Surgeons should be alert that CRPS may need to be considered in the differential diagnosis of chronic disproportionate pain after breast surgery. Early identification and treatment will help alleviate persistent CRPS symptoms and avoid soft-tissue changes.

Transnasal transseptal endoscopic approach to the sphenoid sinus.

A modified transseptal approach to the sphenoid sinus and pituitary gland utilizing rigid endoscopy has been developed by the Departments of Otolaryngology, Plastic Surgery, and Neurosurgery at The Cleveland Clinic Foundation. When compared with alternate approaches or the nonendoscopic transseptal procedure, the modified approach provides better visualization and increased illumination of the surgical sites. Other advantages include a decrease in operating time, dissection, bleeding, and postoperative morbidity without compromising nasal function in the postoperative period.

Endoscopic approach for benign tumor ablation of the forehead and brow.

Resection of benign tumors of the forehead and brow raises aesthetic concerns. An endoscopic subperiosteal approach to benign bony and soft-tissue tumors in the supraorbital and frontotemporal regions permits extirpation of these masses without producing visible facial scars. Therefore, this technique was used for tumor resection in 4 patients. This procedure demonstrated magnified visualization of the masses, and safe access for excisional biopsy and bony contouring. In addition to more acceptable surgical scars, patients experienced no significant postoperative morbidity and a reduced incidence of swelling, discomfort, and scalp anesthesia. Therefore, we conclude that the endoscopic subperiosteal approach is a favorable alternative for resection of suitable tumors.

Treatment of recurrent cerebrospinal fluid rhinorrhea with a free vascularized omental flap: a case report.

Cerebrospinal fluid fistulas after pericranial surgery are a major source of morbidity. A patient who underwent transsphenoidal sinus surgery for a recurrent pituitary adenoma was presented. The patient developed a chronic CSF leak despite standard management, including subarachnoid CSF drainage and transnasal endoscopic closure of the dura. Successful closure of the CSF fistula was obtained using a free omental flap to the sphenoid sinus. This case is the first reported use of a free microvascularized omental flap in an intracranial position for treating chronic CSF rhinorrhea. A description of the indications and the surgical technique for free omental closure of CSF fistulas was provided. The etiology, diagnosis, and management of CSF rhinorrhea are reviewed for the reconstructive surgeon.

Comparison of ossification of demineralized bone, hydroxyapatite, Gelfoam, and bone wax in cranial defect repair.

Demineralized bone allografts in the repair of calvarial defects are compared with other common bone fillers. This study uses a video-digitizing radiographic analysis of calvarial defect ossification to determine calcification of bone defects and its relation to postoperative clinical examination and regional controls. The postoperative clinical results at 3 months demonstrated that bony healing was greatest in bur holes filled with demineralized bone and hydroxyapatite. Radiographic analysis demonstrated calcification of demineralized bone-filled defects compared to bone wax- and Gelfoam-filled regions. Hydroxyapatite granules are radiographically dense, thus not allowing accurate measurement of true bone healing. The results suggest that demineralized bone and hydroxyapatite provide better structural support via bone healing to defined calvarial defects than do Gelfoam and bone wax.