Francis A. Papay

The world's experience with facial transplantation: What have we learned thus far?

The objective of this review article is to summarize the published details and media citations for all seven face transplants performed to date to point out deficiencies in those reports so as to provide the basis for examining where the field of face transplantation stands, and to act as a stimulus to enhance the quality of future reports and functional outcomes. Overall long-term function of facial alloflaps has been reported satisfactorily in all seven cases. Sensory recovery ranges between 3 and 6 months, and acceptable motor recovery ranges between 9 and 12 months. The risks and benefits of facial composite tissue allotransplantation, which involves mandatory lifelong immunosuppression analogous to kidney transplants, should be deliberated by each institution’s multidisciplinary face transplant team. Face transplantation has been shown thus far to be a viable option in some patients suffering severe facial deficits which are not amenable to modern-day reconstructive technique.

Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas

The advent of functional transnasal endoscopic sinus surgery has brought new opportunities in the repair of difficult cerebro‐spinal fluid leaks of the paranasal sinuses. The following four case reports illustrate the repair of cerebrospinal fluid leaks with the use of rigid transnasal endoscopy for enhanced angled visualization and illumination. A description of surgical techniques and instrumentation involving transnasal endoscopy in repair of sphenoidal and ethmoidal cerebrospinal fluid fistulas is reported. A discussion of etiology, diagnoses, and conservative versus surgical management of cerebrospinal fluid rhinorrhea is presented.

Prospective analysis of the outcome of subpectoral breast augmentation: Sensory changes, muscle function, and body image

This study is a prospective analysis of the outcome of subpectoral breast augmentation. Forty-seven patients undergoing breast augmentation were studied. They were assessed for pectoralis muscle function, breast sensation, and body image before and after subpectoral breast augmentation with saline implants. The patients were evaluated as follows: Pectoralis function was determined by measuring maximal voluntary isometric force. Sensation was evaluated by two means: vibration and pressure. The patient’s body image was assessed using the Multidimensional Body-Self Relations Questionnaire. Results indicated a significant change in breast sensation at 3 months postoperatively but not at 6 months. Pectoralis muscle function did not significantly change during the study period. Body image was significantly improved at both postoperative measuring periods. The authors conclude that breast augmentation results in improved body image with negligible effect on muscle or nerve function.

Optic nerve decompression in cranial base fibrous dysplasia

Fibrous dysplasia of the anterior cranial base involves the bony orbit and optic canal. Although fibrous dysplasia is benign, it may produce a mass effect along the course of the optic nerve, inducing visual disturbances. Optic canal decompression in patients without clinical signs of optic neuropathy is controversial. We describe five patients with extensive fibrous dysplasia of the anterior cranial base involving the orbit and optic canal. These patients underwent transcranial optic canal decompression before signs of severe visual loss during correction of dystopias and craniofacial deformity induced by fibrous dysplasia. Cranial orbital reconstruction was performed by means of split rib and cranial bone grafts. Postoperative follow-up did not reveal disturbances in visual function, extraocular motility, or evidence of cerebrospinal fluid fistulas. This suggests that early, radical resection of orbital fibrous dysplasia with optic canal decompression may be effective in preventing visual loss with minimal risk of other neurological sequelae. Subsequent orbital reconstruction involving split-thickness rib and cranial bone grafting yields satisfactory cosmetic results.

Diced cartilage grafts wrapped in alloderm for dorsal nasal augmentation

Dorsal nasal augmentation is commonly performed for various aesthetic deficiencies and/or reconstructive defects such as the saddle nose deformity. However, the optimal technique for volume augmentation has yet to be identified. The senior author (F.P.) has since developed a new modified technique using wrapped diced cartilage within an AlloDerm. This novel construct provides the plastic surgeon a smooth, convenient, pliable option with similar operative times as compared with other popular techniques. In summary, this technique has been proven to be successful in achieving attractive, safe, and acceptable outcomes in nasal dorsal configuration and overall patient satisfaction.

Donor facial composite allograft recovery operation: Cleveland and boston experiences

Background: Complexity of logistic issues related to facial transplantation includes donor tissue recovery, recipient preparation, and operative execution. Limited information is available on the intricate process associated with facial allograft procurement in the United States. Methods: The face transplant teams at the Cleveland Clinic and Brigham and Womens Hospital have combined their experiences regarding collaboration with organ procurement organizations and institutional review boards, and outlined technical and logistic challenges encountered during the process of facial allograft procurement and compared them with those of solid organ procurement. Results: In a collaborative effort, both programs have created comprehensive guidelines for all aspects involved in donor facial allograft procurement. Conclusions: The authors suggest that every face transplant team should develop a thorough understanding of the local and regional legislative issues related to organ and tissue donation and ethical concerns surrounding this procedure. The recovery plan has to be communicated extensively among all members of the team. The Cleveland and Boston teams hope their experiences may help other teams in the process of building new face transplant programs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A Comparison of Dermabond Tissue Adhesive and Sutures in the Primary Repair of the Congenital Cleft Lip

Objective:To compare the long-term cosmesis of Dermabond (octyl-2-cyanoacrylate) and traditional skin sutures among patients undergoing primary cleft lip ± palate repair. Materials and Methods:Eleven patients underwent photographic analysis following primary cleft lip ± palate repair, including the use of Dermabond. Eleven age-matched controls who underwent cleft lip ± palate repair with traditional suture closure served as controls. Cosmesis was assessed by 3 blinded plastic surgeons using a visual analogue scale (VAS) and the Hollander Wound Evaluation Scale (HWES). Results:The overall mean VAS score for the patients treated with and without Dermabond was 70.0 (SD, 9.5) and 68.3 (SD, 13.4), respectively (P = 0.46). The overall mean HWES score for the patients treated with and without Dermabond was 1.7 (SD 1.7) (P = 0.92). Conclusions:Dermabond tissue adhesive offers equivalent mature wound cosmesis as traditional suture closure in the repair of the congenital cleft lip ± palate.

Evaluation of syncope from head and neck cancer

Five patients suffering from recurrent syncope in association with metastatic squamous cell carcinoma of the head and neck were examined. Two patients had exhaustive diagnostic work‐up for syncope, which eventually disclosed previously undiagnosed, recurrent squamous cell carcinoma. Case reports describe glossopharyngeal neuralgia, a well recognized cause of syncope in the head and neck cancer patient, characterized by acute unilateral head or neck pain preceding each syncopal episode. The literature on the diagnosis of syncope is reviewed, and the syncopal mechanisms unique to the head and neck cancer patient are analyzed and discussed. A diagnostic approach to syncope in head and neck cancer is proposed.

Cosmetic Surgery Volume and Its Correlation With the Major US Stock Market Indices

BACKGROUND As a consumer-driven industry, cosmetic plastic surgery is subject to ebbs and flows as the economy changes. There have been many predictions about the short, intermediate, and long-term impact on cosmetic plastic surgery as a result of difficulties in the current economic climate, but no studies published in the literature have quantified a direct correlation. OBJECTIVES The authors investigate a possible correlation between cosmetic surgery volume and the economic trends of the three major US stock market indices. METHODS A volume analysis for the time period from January 1992 to October 2008 was performed (n = 7360 patients, n = 8205 procedures). Four cosmetic procedures-forehead lift (FL), rhytidectomy (Rh), breast augmentation (BA), and liposuction (Li)-were chosen; breast reduction (BRd), breast reconstruction (BRc), and carpal tunnel release (CTR) were selected for comparison. Case volumes for each procedure and fiscal quarter were compared to the trends of the S&P 500, Dow Jones (DOW), and NASDAQ (NASD) indices. Pearson correlation statistics were used to evaluate a relationship between the market index trends and surgical volume. P values <.05 were considered statistically significant. RESULTS Three of the four cosmetic surgery procedures investigated (Rh, n = 1540; Li, n = 1291; BA, n = 1959) demonstrated a direct (ie, positive) statistical correlation to all three major market indices. FL (n =312) only correlated to the NASD (P = .021) and did not reach significance with the S&P 500 (P = .077) or DOW (P = .14). BRd and BRc demonstrated a direct correlation to two of the three stock market indices, whereas CTR showed an inverse (ie, negative) correlation to two of the three indices. CONCLUSIONS This study, to our knowledge, is the first to suggest a direct correlation of four cosmetic and two reconstructive plastic surgery procedures to the three major US stock market indices and further emphasizes the importance of a broad-based plastic surgery practice in times of economic recession.

Pediatric vascularized composite allotransplantation.

BackgroundVascularized composite allotransplantation (VCA) has experienced a growing acceptance, which has led to a debate centered on extending the indications of the procedure to include pediatric patients. The aim of this article was to discuss such indications based on the evidence in pediatric solid organ transplantation, reconstructive surgery in children, and VCA in adult patients. MethodsPapers published on the outcomes of pediatric solid organ transplantation, growth after replantation of extremities, vascularized autologous tissue transfer, craniofacial surgery, orthognathic procedures, facial fractures, and outcomes after repair of peripheral nerves in children were reviewed. ResultsAlthough the outcomes of solid organ transplantation in children have improved, the transplanted organs continue to have a limited lifespan. Long-term immunosuppressive therapy exposes the patients to an increased lifetime risk of infections, diabetes, hypertension, dyslipidemia, cardiovascular disease, and malignancy. Growth impairment and learning disabilities are other relevant drawbacks, which affect the pediatric recipients. Nonadherence to medication is a common cause of graft dysfunction and loss among the adolescent transplant recipients. Rejection episodes, hospitalizations, and medication adverse effects contribute negatively to the quality of life of the patients. Although normal growth after limb transplantation could be expected, pediatric facial transplant recipients may present with arrest of growth of transplanted midfacial skeleton. ConclusionsConsidering the non–life-threatening nature of the conditions that lead to eligibility for VCA, it is suggested that it is premature to extend the indications of VCA to include pediatric patients under the currently available immunosuppressive protocols.