Daniel E. Borsuk

Total face, double jaw, and tongue transplantation: An evolutionary concept

Background: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result. Methods: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised. The strategy involved the foundation of a basic science laboratory, the cultivation of a supportive institutional clinical environment, the innovative application of technologies, cadaveric simulations, a real-time clinical rehearsal, and an informed and willing recipient who had the characteristic deformity. Results: After institutional review board and organ procurement organization approval, a total face, double jaw, and tongue transplantation was performed on a 37-year-old man with a central face high-energy avulsive ballistic injury. Conclusions: This facial transplant represents the most comprehensive transplant performed to date. Through a systematic approach and clinical adherence to fundamental principles of aesthetic surgery, craniofacial surgery, and microsurgery and the innovative application of technologies, restoration of human appearance and function for individuals with a devastating composite disfigurement is now a reality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Total face, double jaw, and tongue transplant simulation: a cadaveric study using computer-assisted techniques.

Background: With the transplantation of more extensive facial vascularized composite allografts, fundamental craniofacial and aesthetic principles become increasingly important. In addition, computer-assisted planning and intraoperative navigation may improve precision and efficiency in these complex procedures. Methods: Ten mock face transplants were performed in 20 cadavers. The vascularized composite allograft consisted of all facial skin, mimetic muscles, the tongue, the midface by means of a Le Fort III osteotomy, and the mandible by means of sagittal split osteotomies. Craniofacial computed tomographic scans were obtained before and after the mock transplants. Surgical planning software was used to virtually plan the osteotomies, and a surgical navigation system guided the osteotomies intraoperatively. Cephalometric analyses were compared between the virtually planned transplants and the actual postoperative results. Results: The combination of preoperative computerized planning and intraoperative guidance consistently produced a vascularized composite allograft that could be easily fixated to the prepared recipient, with only minimal burring of osteotomy sites necessary. Satisfactory occlusion was maintained, and postoperative computed tomography confirmed accurate skeletal fixation. Insignificant differences with regard to cephalometric analyses were noted when predicted and actual postoperative data were compared. Conclusions: The authors’ experience treating severe craniofacial injury allowed consistent transfer of facial vascularized composite allografts, maintaining proper occlusion. Preoperative computer planning and intraoperative navigation ensured precise osteotomies and a good donor-recipient skeletal match, which greatly reduced the need for intraoperative adjustments and manipulation. This total facial vascularized composite allograft represents one of the most extensive described and is intended to represent a typical central facial demolition pattern.

Total face, double jaw, and tongue transplant research procurement: an educational model.

Background: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery. Methods: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified. The family graciously consented to donation of a total face, double jaw, and tongue allograft and multiple solid organs. Results: A craniofacial computed tomographic angiogram was obtained preoperatively to define the vascular anatomy and facilitate virtual computerized surgical planning. The allograft was procured in 10 hours, with an additional 2 hours required for an open tracheostomy and silicone facial impression. The donor was coagulopathic throughout the recovery, resulting in an estimated blood loss of 1500 ml. Fluorescence angiography confirmed adequate perfusion of the entire allograft based on lingual and facial arterial and external jugular and thyrolinguofacial venous pedicles. The solid organ transplant team initiated abdominal organ isolation while the facial allograft procurement was in progress. After completion of allograft recovery, the kidneys and liver were recovered without complication. Conclusions: Before conducting a clinical face transplant, adequate preparation is critical to maximize vascularized composite allotransplantation outcomes and preserve solid organ allograft function. As more centers begin to perform facial transplantation, research procurement of a facial vascularized composite allograft offers a unique educational opportunity for the surgical and anesthesia teams, the organ procurement organization, and the institution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Dental manifestations of dermatologic conditions

BACKGROUND Cutaneous disorders can be associated with a wide variety of dental manifestations that should be familiar to dermatologists. OBJECTIVE We sought to describe the development of the teeth, explain current dental terms, and review the dental manifestations of some dermatologic conditions. METHODS A MEDLINE search (1966-May 2007) was performed to find relevant articles pertaining to dental manifestations of dermatologic conditions. RESULTS Dental manifestations are associated with a wide variety of skin diseases that include genetic, infectious, inflammatory, and immune disorders. LIMITATIONS The review is broad and focuses on commonly described manifestations. CONCLUSIONS An appreciation and understanding of dental signs can aid in the diagnosis and treatment of many skin conditions.

Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

Aesthetic and functional facial transplantation: a classification system and treatment algorithm.

Background: As of July of 2013, 27 facial vascularized composite allotransplantations have been performed. The authors developed a classification system and treatment algorithm that is practical and surgically applicable. Methods: The majority of the transplants have been described in the surgical literature and the media, and a review of the data was performed. A classification system and a treatment algorithm were designed. Skeletal defects were defined by craniofacial osteotomies and soft-tissue defects by aesthetic facial subunits. The soft-tissue defect was subdivided into the following subunits: oral-nasal (type 1), oronasal-orbital (type 2), and full facial (type 3). The bony defects were subdivided into mandibular involvement (M), Le Fort 1 (A), Le Fort 3 (B), and monobloc (C). Results: The mechanisms of injury included trauma (n = 13), burns (n = 8), congenital deformity (n = 3), oncologic resection (n = 1), and unreported (n = 2). According to the proposed classification system: one was type 1; one was type 1-M; one was type 1-MB; two were type 2; two were type 2-B; two were type 2-MB; six were type 3; one was type 3-B; and three were type 3-MB; eight could not be classified due to a lack of data. The treatment algorithm designed a vascularized composite allotransplantation that addressed the bony and soft-tissue components. Conclusions: Patient selection for these complicated procedures, currently dependent on lifelong immunosuppression, is crucial to their success. The authors describe a classification system and treatment algorithm for facial defects that may be ideally suited for facial transplantation. The proposed classification and algorithm may help centers define indications and ideally improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A novel application of computer-aided design and manufacturing for reduction cranioplasty.

AbstractMacrocephaly is a rare presentation of untreated hydrocephalus. In cases where medical management has failed, macrocephaly can be managed with reduction cranioplasty. Traditionally, reduction cranioplasty is highly dependent on intraoperative tailoring of bone segments to obtain the best possible result and involves high risks of associated severe blood loss and mortality. In this clinical report, we describe a patient with hydrocephalus macrocephaly treated with reduction cranioplasty with the innovative use of computer-aided design and manufacturing to reduce intraoperative risks and improve efficiency.We used computer-aided design to plan osteotomy sites and the final positioning of bone segments. We also utilized computer-aided manufacturing to produce cutting guides, positioning guides, and models to increase precision and improve the final positioning of the cranium. Computer-aided design and manufacturing technology has enabled a shift of the planning burden of complicated craniofacial reconstructions from the intraoperative to the preoperative phase. With a completed plan and premade guides and models, it is possible to minimize the risks, improve efficiency, and obtain a precise, aesthetic result.

Surface anatomy of the middle division of the facial nerve: Zuker's point.

Background: The anatomy of the facial nerve and its branches has been well documented. The course of the extratemporal facial nerve, its anatomical planes, and the surface landmarks of the temporal division and marginal mandibular division are well known. However, the surface landmark of the middle division of the facial nerve has not been studied to date. Methods: Eighteen hemifacial dissections in 10 fresh human cadavers were performed through a preauricular face-lift incision. An 18-gauge needle with brilliant green dye was used to mark the nerve through the skin before dissection. The exact location of the middle division branches of the facial nerve was documented in relation to the transcutaneous marking. Results: The middle division branches of the facial nerve were found to lie at a mean of 2.3 mm from the tattooed point, with a range of 0 to 6 mm. A nerve branch was found directly tattooed by the needle seven of 18 times, inferior to the tattoo five of 18 times, and superior to the tattoo six of 18 times. Conclusions: The zygomatic/buccal motor branch that innervates the zygomaticus major muscle can be reliably found at the midway point on a line drawn from the root of the helix and the lateral commissure of the mouth. This study will help guide surgeons to the middle division of the facial nerve as it applies to facial surgery.

Aesthetic microvascular periorbital subunit reconstruction: beyond primary repair.

Background: Reconstructing periorbital defects is challenging because of the simultaneous need for ocular support, corneal protection, and restoration of aesthetic subtleties. In patients with extensive periorbital tissue loss, microvascular free tissue transfer is a reliable reconstructive option for composite defects. Methods: The authors conducted a retrospective review of patients with periorbital craniofacial defects and identified those treated with microvascular reconstruction at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2010. Results: Twenty-four patients underwent free flap reconstruction for periorbital defects secondary to trauma (n = 12), oncologic resection (n = 11), and congenital deformity (n = 1). The majority were men (n = 13), and the average age of the patients was 47 years (range, 19 to 80 years). Microvascular reconstructions included fibula (n = 9), anterolateral thigh (n = 6), ulnar forearm (n = 7), and groin flaps (n = 2). Flap survival rate was 100 percent, with an average follow-up of 26.5 months. Conclusions: Microvascular reconstruction of the periorbit can be accomplished successfully through careful analysis of tissue loss, eye or ocular prosthetic support, donor-site morbidity, and patient preference. Despite the multiple flap options that fulfill periorbital reconstructive needs, the authors find that the fibula, anterolateral thigh, ulnar forearm, and groin flaps can be used reliably to successfully reconstruct these defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Subperiosteal Release of the Floor of the Mouth to Correct Airway Obstruction in Pierre Robin Sequence: Review of 31 Cases

Objective The purpose of this study was to evaluate subperiosteal release of the floor of the mouth (SRFM) musculature to correct neonatal airway obstruction in children with Pierre Robin sequence and to compare this procedure with other surgical options available. Methods A retrospective chart review of patients who underwent a SRFM for neonatal severe airway obstruction unresponsive to conservative management was performed. Preoperative and postoperative oxygenation parameters, sleep studies, feeding difficulties, and long-term evolution were documented. Results Thirty-one consecutive patients between 1995 and 2009, 19 boys and 12 girls, had an SRFM procedure to alleviate severe neonatal airway obstruction. Eight children were syndromic, 15 had associated malformations, and eight had an isolated Pierre Robin sequence. The airway obstruction was corrected with SRFM alone in 26 children (84%), three patients remained dependent on nasopharyngeal airway, and two required subsequent mandibular osteogenic distraction procedures following the SRFM to manage persistent obstruction. No patient required a tracheostomy. The average age at SRFM was 33 days, and the patients were kept intubated for an average of 6 days postoperatively. Average hospital stay after the surgery was 45 days, and 10 patients went home with gavage feeding. Conclusions The SRFM is effective for the treatment of severe airway obstruction in patients with Pierre Robin sequence. The procedure is simple and has fewer complications and secondary procedures than other surgical options for correction of the airway obstruction.