Publications by authors named "Eduardo D Rodriguez"

215 Publications

Establishing Photographic Standards for Facial Transplantation: A Systematic Review of the Literature.

Plast Reconstr Surg Glob Open 2020 May 14;8(5):e2834. Epub 2020 May 14.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Photography provides a means for objective assessment and dissemination of clinical information. The American Society of Plastic Surgeons (ASPS) and Plastic Surgery Foundation (PSF) published photography guidelines in 2006 to optimize its clinical use. However, photographic documentation of outcomes in facial transplantation (FT) continues to lack standardization. We therefore appraised the current state of FT photography in the peer-reviewed literature.

Methods: A PubMed search was conducted from July 2005 to July 2019. Studies containing photographs of partial or full FT recipients were included. Non-English language articles, cadaveric and animal studies, technique papers, and case reports were excluded. Data were extracted from 91 articles. Adherence rates were calculated to determine whether published FT photographs followed ASPS/PSF guidelines. Proposed photographic standards particular to FT were then formulated to guide standardization of practice.

Results: Only 28.6% (26/91) of articles adhered to the photographic conventions of preparation, positioning, and views. Of 162 patient appearances in the 91 articles, 95% (154/162) met the criteria for preparation, 98.8% (160/162) met the criteria for positioning, but only 24.7% (40/162) met the criteria for views.

Conclusions: Photographic documentation of FT outcomes in the peer-reviewed literature is limited, with inconsistent adherence to ASPS/PSF guidelines. There is substantial deficiency in provision of alternative views, with the majority of publications only depicting the frontal view. FT photography standards should specifically incorporate alternative views, proper lighting and framing, and elimination of distractions, and accommodate for remote patient self-photography. This will promote a transparent and consistent longitudinal evaluation of the surgical results.
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http://dx.doi.org/10.1097/GOX.0000000000002834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605848PMC
May 2020

The Plastic Surgery Residency Interview Revisited: Virtual Interviews and Beyond.

Plast Reconstr Surg 2020 11;146(5):1209-1211

From the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Hospital; the Division of Plastic Surgery, University of California, San Diego; the Division of Plastic Surgery, Baylor College of Medicine; the Department of Plastic Surgery, New York University Langone Medical Center; and the Dallas Plastic Surgery Institute.

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http://dx.doi.org/10.1097/PRS.0000000000007321DOI Listing
November 2020

Have We Achieved Optimal Skin Color Matching in Partial Facial Transplantation? A Survey Study of the General Public and Medical Professionals.

J Craniofac Surg 2020 Nov/Dec;31(8):2213-2216

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY.

Background: Skin color matching is an essential factor in achieving optimal aesthetic outcome in partial facial transplantation. However, there is no published literature evaluating the success of color matching to date. Furthermore, a medical professional's perception of an optimal color match may not necessarily translate to that of the general public. The purpose of our study was to evaluate skin color matching between the donor allograft and recipient native tissue in partial facial transplantations to determine the level of success perceived by the general public and medical professionals.

Methods: Published photographs of partial face transplant recipients were used to create a survey where recipient native and donor allograft skin samples were juxtaposed. Thirty-three members of the general public and 30 medical professionals were asked to rate skin color match on a scale from "excellent match" to "not a match."

Results: Overall, 47% of given ratings were positive, indicating an "excellent" or "good match," and 53% of ratings were negative, indicating a "poor match" or "lack of match" between the skin sample pairings shown. Of the 19 partial face transplant patients who were rated, 9 patients received >50% positive ratings, and 10 patients received <50% positive ratings. Medical professionals consistently gave more positive ratings, with statistically significant differences in 7 of the 19 rated patients (P < 0.05).

Conclusion: The results suggest that there is need for improvement in color matching in partial facial transplantation, and that the general public is more critical of skin color matching compared to medical professionals.
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http://dx.doi.org/10.1097/SCS.0000000000006895DOI Listing
November 2020

Feasibility and Perception of Cross-sex Face Transplantation to Expand the Donor Pool.

Plast Reconstr Surg Glob Open 2020 Sep 24;8(9):e3100. Epub 2020 Sep 24.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Background: A major challenge in face transplantation (FT) is the limited donor allograft pool. This study aimed to investigate the feasibility of cross-sex FT (CSFT) for donor pool expansion by: (1) comparing craniomaxillofacial metrics following CSFT versus same-sex FT (SSFT); and (2) evaluating the public and medical professionals' perception of CSFT.

Methods: Seven cadaveric FTs were performed, resulting in both CSFT and SSFT. Precision of bony and soft tissue inset was evaluated by comparing pre- versus post-operative cephalometric and anthropometric measurements. Fidelity of the FT compared to the virtual plan was assessed by imaging overlay techniques. Surveys were administered to medical professionals, medical students, and general population to evaluate opinions regarding CSFT.

Results: Five CSFTs and 2 SSFTs were performed. Comparison of recipients versus post-transplant outcomes showed that only the bigonial and medial intercanthal distances were statistically different between CSFT and SSFT ( = 0.012 and = 0.010, respectively). Of the 213 survey participants, more were willing to donate for and undergo SSFT, compared with CSFT (donate: 59.6% versus 53.0%, = 0.001; receive: 79.5% versus 52.3%, < 0.001). If supported by research, willingness to receive a CSFT significantly increased to 65.6% ( < 0.001). On non-blinded and blinded assessments, 62.9% and 79% of responses rated the CSFT superior or equal to SSFT, respectively.

Conclusions: Our study demonstrates similar anthropometric and cephalometric outcomes for CSFT and SSFT. Participants were more reticent to undergo CSFT, with increased willingness if supported by research. CSFT may represent a viable option for expansion of the donor pool in future patients prepared to undergo transplantation.
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http://dx.doi.org/10.1097/GOX.0000000000003100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544392PMC
September 2020

Equity in access to facial transplantation.

J Med Ethics 2020 Oct 15. Epub 2020 Oct 15.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States.

We examine ethical considerations in access to facial transplantation (FT), with implications for promoting health equity. As a form of vascularised composite allotransplantation, FT is still considered innovative with a relatively low volume of procedures performed to date by a small number of active FT programmes worldwide. However, as numbers continue to increase and institutions look to establish new FT programmes, we anticipate that attention will shift from feasibility towards ensuring the benefits of FT are equitably available to those in need. This manuscript assesses barriers to care and their ethical implications across a number of considerations, with the intent of mapping various factors relating to health equity and fair access to FT. Evidence is drawn from an evolving clinical experience as well as published scholarship addressing several dimensions of access to FT. We also explore novel concerns that have yet to be mentioned in the literature.
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http://dx.doi.org/10.1136/medethics-2020-106129DOI Listing
October 2020

Perceptions of Quality of Life among Face Transplant Recipients: A Qualitative Content Analysis.

Plast Reconstr Surg Glob Open 2020 Aug 17;8(8):e2956. Epub 2020 Aug 17.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

The aim of facial transplantation (FT) was to enhance quality of life (QoL) for individuals living with severe facial disfigurement. Yet QoL has proved challenging to assess, as the field lacks a unified approach for incorporating FT recipients' perspectives into meaningful QoL measures. In this study, we review FT recipients' self-reported QoL through a qualitative analysis of publicly available posttransplant interviews to identify the aspects of QoL they report as meaningful.

Methods: A conventional qualitative content analysis was conducted through a comprehensive review of publicly available interviews with FT recipients. Data sources included English language audio, video, and online print interviews from 2008 to 2019. Recipient interview data were obtained for both partial and full FT recipients located in North America through Google and YouTube searches. Audio and video interviews were transcribed, and an inductive content analysis was used to develop and apply a coding scheme to all interview transcripts. Codes were subsequently grouped into categories and interpreted into themes.

Results: In total, 81 interviews representing 12 North American, English-speaking face transplant recipients were collected from internet sources, of which 74 interviews remained after exclusion criteria were applied. Three themes emerged representing the dimensions of QoL emphasized by FT recipients: (1) reconstitution and re-embodiment of physical/corporeal selfhood, (2) integrity of cognitive/emotional selfhood, and (3) social selfhood and the importance of social integration.

Conclusions: This study provides an insight into North American FT recipients' experiences, values, and goals and illuminates critical aspects of QoL that are meaningful to this unique patient population, which may not be fully captured by currently available assessment tools. The themes developed in this study link facets of QoL to the overall significance of embodied selfhood among FT recipients and will help inform the future development of FT-specific patient-reported QoL outcome measures.
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http://dx.doi.org/10.1097/GOX.0000000000002956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489701PMC
August 2020

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review.

Plast Reconstr Surg Glob Open 2020 Aug 17;8(8):e2955. Epub 2020 Aug 17.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.

Methods: An institutional "FT Anesthesia Protocol" was developed and applied to 2 face transplants. A systematic review of 3 databases captured FTs in the peer-reviewed literature up to February 2020. Two reviewers independently screened titles and abstracts to include all clinical articles with FT recipient and/or donor-specific preoperative, intraoperative, and relevant postoperative anesthetic variables. Data charting guided a narrative synthesis, and quantitative synthesis reported variables as median (range).

Results: Our institutional experience emphasizes the importance of on-site rehearsals, anticipation of patient-specific anesthetic and resuscitative requirements, and long-term pain management. Systematic search identified 1092 unique records, and 129 met inclusion criteria. Reports of 37 FTs in the literature informed the following anesthetic axes: donor pre- and intraoperative management during facial allograft procurement, recipient perioperative care, immunotherapy, antimicrobial prophylaxis, and pain management. Quantitative synthesis of 30 articles showed a median operative time of 18 hours (range, 9-28) and fluid replacement with 13 L (5-18) of crystalloids, 13 units (0-66) of packed red blood cells, 10 units (0-63) of fresh frozen plasma, and 1 unit (0-9) of platelets.

Conclusions: Anesthetic considerations in FT span the continuum of care. Future efforts should guide standard reporting to establish evidence-based strategies that promote quality improvement and patient safety.
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http://dx.doi.org/10.1097/GOX.0000000000002955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489595PMC
August 2020

Enhancing Face Transplant Outcomes: Fundamental Principles of Facial Allograft Revision.

Plast Reconstr Surg Glob Open 2020 Aug 17;8(8):e2949. Epub 2020 Aug 17.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author's experience with 3 FTs.

Methods: A literature review was performed, with 2 reviewers independently conducting title and abstract screening, followed by a full-text review. All articles mentioning FT revision surgeries were evaluated. The medical records of the senior author's 3 FT recipients were additionally reviewed.

Results: Initially, 721 articles were captured and 37 were included in the final analysis. Thirty-two FTs were reported to have involved posttransplant allograft revisions, with FT recipients undergoing a mean of 4.8 ± 4.6 revision procedures. The mean duration between FT and the first revision procedure was 149 ± 179 days. A wide spectrum of revisions was identified and categorized as involving the soft tissues, craniofacial skeleton, dentition, oronasal cavity, salivary glands, facial nerve, or ocular region. In the senior author's experience, when indicated, posttransplant occlusal changes and integrity of the donor-recipient intraoral interface were successfully addressed with secondary procedures without allograft compromise or loss.

Conclusions: The worldwide experience shows that secondary procedures are nearly ubiquitous after FT and can be safely performed at various timepoints. The authors thereby establish 5 distinct categories of facial allograft revisions and define 7 critical principles to optimize posttransplant procedures.
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http://dx.doi.org/10.1097/GOX.0000000000002949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489753PMC
August 2020

A Comparison of Immunosuppression Regimens in Hand, Face, and Kidney Transplantation.

J Surg Res 2021 02 23;258:17-22. Epub 2020 Sep 23.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York. Electronic address:

Background: Authors have speculated that vascularized composite allotransplantation (VCA) recipients may require greater maintenance immunosuppression than solid organ transplant (SOT) recipients due to the higher antigenicity of skin. However, detailed comparisons of VCA and SOT immunosuppression regimens have been limited.

Methods: Hand and face VCA recipient immunosuppression data were collected through a systematic literature review. Kidney recipient data were obtained through a retrospective chart review of the authors' institution. Prednisone and mycophenolate mofetil (MMF) doses were compared between VCA and kidney recipients at predefined follow-up intervals (<1, 1-5, and >5 y). Tacrolimus target trough levels (TTTL) were compared at follow-up intervals of 1-5 and >5 y, and stratified into our institution's kidney transplant risk-based target ranges (4-6 ng/mL, 6-8 ng/mL) or higher (>8 ng/mL).

Results: Immunosuppression data were available for 57 VCA and 98 kidney recipients. There were no significant differences in prednisone doses between groups at all follow-up intervals. VCA recipient mean MMF dose was significantly greater at <1-y (1.71 ± 0.58 versus 1.16 ± 0.55 gm/d; P = 0.01). For VCA recipients, there was a significant difference (P = 0.02) in TTTL distribution over the three predefined therapeutic ranges (4-6 ng/mL, 6-8 ng/mL, and >8 ng/mL) between 1 and 5 y (24.0%, 20.0%, 56.0%, respectively) and >5 y (28.6%, 42.9%, 28.6%).

Conclusions: At longer follow-up, VCA and kidney recipients receive comparable MMF/prednisone doses, and most VCA recipients are treated with TTTL similar to kidney recipients. Further research may improve our understanding of VCA's complex risk/benefit ratio, and enhance informed consent.
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http://dx.doi.org/10.1016/j.jss.2020.08.006DOI Listing
February 2021

Guiding Strategies for the Future of Vascularized Composite Allotransplantation: A Systematic Review of Organ Donation Campaigns.

Plast Reconstr Surg 2020 10;146(4):922-934

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health.

Background: Since the 1990s, the field of vascularized composite allotransplantation has gained momentum, offering unprecedented solutions for patients with defects not amenable to autologous reconstruction. As with solid organ donation, the vascularized composite allotransplant donor pool remains limited. This systematic review identifies past successes and failures in organ donation campaigns to guide future strategies for expanding vascularized composite allotransplant donation.

Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed/MEDLINE, PsycINFO, and Embase) were searched through July 31, 2019. The study compiled solid organ and vascularized composite allotransplant campaigns that aimed to increase donor registration. Articles depicting the current state of vascularized composite allotransplant donation were also assessed.

Results: Of an initial 3318 articles identified, 40 were included. Six articles described direct mail or print interventions, 10 depicted Web-based interventions, 13 dealt with interpersonal interventions, and seven used multimodal interventions. Four articles described the current state of vascularized composite allotransplant donation. A qualitative synthesis was conducted. The authors found that social media campaigns can have a robust but fleeting effect on registration trends and that interpersonal interventions are effective at increasing registration rates. In addition, the opportunity for participants to immediately register as organ donors, by means of either return mail, in-person, or online, is vital to campaign success.

Conclusions: Public organ donation campaigns have had success in increasing organ donor registration rates, particularly through the use of social media and interpersonal interventions that allow for immediate registration. Synthesizing this information, we propose a multimodal campaign to expand the vascularized composite allotransplant donor pool.
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http://dx.doi.org/10.1097/PRS.0000000000007187DOI Listing
October 2020

Development of Donor Family-Oriented Resources to Facilitate Authorization for Reconstructive Transplantation.

Prog Transplant 2020 12 10;30(4):398-399. Epub 2020 Sep 10.

Hansjörg Wyss Department of Plastic Surgery, 12297NYU Langone Health, NY, USA.

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http://dx.doi.org/10.1177/1526924820958122DOI Listing
December 2020

A case of facial composite tissue allograft rejection.

JAAD Case Rep 2020 Sep 12;6(9):845-847. Epub 2020 Jul 12.

Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York.

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http://dx.doi.org/10.1016/j.jdcr.2020.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452299PMC
September 2020

Breaking Down Silos: Collaboration in Head and Neck Reconstruction Research.

J Reconstr Microsurg 2021 Feb 1;37(2):161-166. Epub 2020 Sep 1.

Department of Plastic and Reconstructive Surgery, NYU Langone Health, New York, New York.

Background:  Collaboration has been shown to be beneficial when we have complex problems and highly specialized groups, such as in head and neck reconstruction. Otolaryngology, plastic surgery, and oral maxillofacial surgeons perform head and neck reconstruction research. While the specialties represent unique backgrounds, the degree of interdisciplinary collaboration and subtopic focus is unknown. We sought to describe the frequency of interinstitutional interdisciplinary collaboration and examine the association of specialty with research subtopics.

Methods:  Oral presentations from 2014 to 2018 focused on head and neck reconstruction or associated principles at the main reconstructive academic meetings in otolaryngology (American Head and Neck Society), plastic surgery (American Society for Reconstructive Microsurgery), and oral maxillofacial surgery (American Association of Oral and Maxillofacial Surgeons) were reviewed. Author specialty and institution data were recorded. All abstracts were assigned a research subtopic, chosen based on identified themes. Subtopic frequencies among the specialties were compared.

Results:  Thirteen of 88 (15%) US institutions participate in interdisciplinary collaboration in head and neck reconstruction research. Of the remaining institutions, 23 (31%) have researchers performing parallel work and not collaborating. Certain research subtopics were more often presented by each specialty, representing differing interests.

Conclusion:  Collaboration among head and neck reconstruction research at the US institutions is low compared with the potential. Specialties focus on different research subtopics, and therefore can benefit from working together.
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http://dx.doi.org/10.1055/s-0040-1716322DOI Listing
February 2021

Vascularized Composite Allotransplantation 2.0: The Future Is Now.

Plast Reconstr Surg 2020 09;146(3):386e-387e

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007099DOI Listing
September 2020

Technical Pearls in Frontal and Periorbital Bone Contouring in Gender-Affirmation Surgery.

Plast Reconstr Surg 2020 09;146(3):326e-329e

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health.

Changes made to the forehead and periorbital region can have dramatic effects in gender-affirmation surgery. Removal of frontal bossing and alteration of orbital shape can result in significant facial feminization. This elective surgical intervention must be safe, reliable, and aesthetically effective. The described technique of frontal and periorbital bone contouring allows for a safe and consistent surgical outcome in properly selected patients. Nuances in specific technical maneuvers in this operation can have profound effects on safety and aesthetic outcomes. In this article, specific points are detailed in text and video describing the senior author's (E.D.R) surgical approach.
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http://dx.doi.org/10.1097/PRS.0000000000007113DOI Listing
September 2020

Public Perceptions of Cross-Sex Vascularized Composite Allotransplantation.

Ann Plast Surg 2020 12;85(6):685-690

From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY.

Background: Cross-sex vascularized composite allotransplantation has been performed in cadaveric facial transplantation and clinical extremity transplantation. Understanding the challenge of appropriate donor-recipient matching, this study sought to characterize the public's perception of cross-sex vascularized composite allotransplantation.

Methods: Participants were surveyed in New York City. Data collected included demographics and willingness to donate vascularized composite allografts (VCAs) of various types. Similar questions were asked in the context of same-sex and cross-sex donation.

Results: A total of 101 participants (male: 56.4%; age ≤35 years: 62.4%) were surveyed. The majority expressed willingness to donate to recipients of a different sex (hand: 78.2%, face: 56.4%, penis or uterus: 69.3%, lower limb: 81.2%, abdominal wall: 80.2%, larynx: 81.2%, and solid organs: 85.2%). Among VCAs, willingness to donate facial allografts was significantly different in same-sex versus cross-sex contexts (64.4% vs 56.4%; P = 0.008). Participants were also significantly more likely to donate VCAs to same-sex recipients on behalf of themselves versus loved ones (P < 0.05). There was significantly lower willingness to receive cross-sex versus same-sex facial (P = 0.022) and genital allografts (P = 0.022). Education on the preservation of recipient masculinity or femininity in cross-sex facial transplantation increased participants' willingness to receive a cross-sex face transplant from 56.4% to 71.3% (P = 0.001).

Conclusions: This study highlights the urban public's acceptance of VCA donation or reception regardless of sex mismatch. There is increased willingness to receive a cross-sex face transplant after education, highlighting opportunities for future focused interventions to increase public awareness and ultimately the donor pool.
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http://dx.doi.org/10.1097/SAP.0000000000002472DOI Listing
December 2020

Communication Efficiency in a Face Transplant Recipient: Determinants and Therapeutic Implications.

J Craniofac Surg 2020 Sep;31(6):e528-e530

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health.

We longitudinally assessed speech intelligibility (percent words correct/pwc), communication efficiency (intelligible words per minute/iwpm), temporal control markers (speech and pause coefficients of variation), and formant frequencies associated with lip motion in a 41-year-old face transplant recipient. Pwc and iwpm at 13 months post-transplantation were both higher than preoperative values. Multivariate regression demonstrated that temporal markers and all formant frequencies associated with lip motion were significant predictors (P < 0.05) of communication efficiency, highlighting the interplay of these variables in generating intelligible and effective speech. These findings can guide us in developing personalized rehabilitative approaches in face transplant recipients for optimal speech outcomes.
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http://dx.doi.org/10.1097/SCS.0000000000006727DOI Listing
September 2020

Vascularized Composite Allotransplantation in a Post-COVID-19 Pandemic World.

Plast Reconstr Surg 2020 09;146(3):394e-395e

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007231DOI Listing
September 2020

Establishing a Clinically Applicable Methodology for Skin Color Matching in Vascularized Composite Allotransplantation.

Plast Reconstr Surg Glob Open 2020 Feb 6;8(2):e2655. Epub 2020 Feb 6.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Skin color matching in vascularized composite allotransplantation (VCA) is an important determinant of aesthetic outcomes. The process of color matching is infrequently described in the literature. The Pantone SkinTone Guide (PSTG) is a handheld tool comprised of realistic skin tone swatches with a corresponding virtual swatch system. A color match acceptability threshold (AT) is defined as the point beyond which >50% of observers deem a given skin tone pairing as unacceptable. In this study, color match acceptability thresholds were developed using the PSTG to help standardize donor-recipient color matching. Four representative colors were chosen across the skin tone spectrum. These standard colors were used to develop a survey asking participants to determine the acceptability of color pairings. Using survey results, ATs were determined for changes in lightness, undertone, and lightness and undertone combined for each of the standard colors. Inter- and intra-rater reliability were determined using Fleiss's Kappa. Participants were more critical of skin tone pairings on the darker versus the lighter end of the spectrum, as evidenced by higher thresholds observed for lighter sample pairs. Additionally, observers were more critical of differences in skin lightness compared with differences in undertone. Intra-rater reliability was fair to substantial, and inter-rater reliability was fair to moderate. The PSTG can be used as a clinical tool to improve the aesthetic outcomes of skin-containing vascularized composite allotransplantation procedures by optimizing donor-recipient skin color matching. This can allow clinicians to complement visual judgment with quantitative reference.
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http://dx.doi.org/10.1097/GOX.0000000000002655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159949PMC
February 2020

Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

Plast Reconstr Surg Glob Open 2019 Dec 26;7(12):e2563. Epub 2019 Dec 26.

Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine. Seattle, Washington.

Background: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients.

Methods: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images.

Results: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin ( < 0.0001). There was a significant increase in nonwhite photographs over time ( = 0.086, < 0.001) and association of nonwhite photographs with international authors ( = 0.12, < 0.001).

Conclusions: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.
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http://dx.doi.org/10.1097/GOX.0000000000002563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964926PMC
December 2019

Preclinical Animal Models in Facial Transplantation.

Plast Reconstr Surg Glob Open 2019 Sep 23;7(9):e2455. Epub 2019 Sep 23.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

The technical feasibility and clinical applicability of facial transplantation (FT) have been demonstrated, yet animal models with different technical nuances and allograft compositions continue to be developed. We sought to provide a comprehensive appraisal of the current scope and value of animal models in FT.

Methods: A comprehensive review of the literature was performed to identify all studies relevant to preclinical animal FT. Abstracts, texts, and references were screened. Both large and small animal models in studies including survival experimental arms were included. Purely anatomical or cadaveric animal studies were excluded, as were non-English language articles.

Results: Twenty-nine unique models were identified, including 10 large (nonhuman primate, swine, and canine) and 19 small (rabbit, rat, and mouse) animal models. Orthotopic models were described in 70% of large and 73.7% of small animal studies. One study described a 2-stage rat FT model. Nerve coaptations were performed in 20.7% of all models (1 canine, 1 rabbit, and 4 rat models). One rat model allowed the study of both functional recovery and cortical reintegration of the allograft. Survival rates and immunological outcomes varied per model and protocol.

Conclusions: A comprehensive review of animal models in FT shows redundancy spanning a variety of species, allograft compositions, and experimental designs. Although initial studies have focused on safety and technical feasibility, recent advances present specific opportunities for refining our understanding of functional and immunological challenges. As clinical experience continues to evolve, animal models may play an increasingly modest yet targeted role in FT.
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http://dx.doi.org/10.1097/GOX.0000000000002455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908387PMC
September 2019

Magnetic Resonance Imaging Volumetry of Facial Muscles in a Face Transplant Recipient.

Plast Reconstr Surg Glob Open 2019 Nov 22;7(11):e2515. Epub 2019 Nov 22.

The Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York City, N.Y.

Face transplantation has evolved into a viable reconstructive option for patients with extensive facial disfigurement. Because the first face transplant procedure was described in 2005, the safety and feasibility of the procedure have been validated, and the focus of the field has shifted toward refining functional and esthetic outcomes. Recovery of muscle function following facial transplantation is critical to achieving optimal facial function and restoring facial expression. Assessment of facial muscle function in face transplant recipients has traditionally relied on clinical evaluation. In this study, we describe longitudinal changes in facial muscle volumes captured through quantitative magnetic resonance imaging in a face transplant recipient and compare these findings with functional outcomes evaluated through clinical assessment.
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http://dx.doi.org/10.1097/GOX.0000000000002515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908352PMC
November 2019

Beyond Stopping the Bleed: Opportunities for Plastic Surgeons in the Response to Mass Casualty Events.

Plast Reconstr Surg 2019 12;144(6):1133e-1134e

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000006287DOI Listing
December 2019

How to Integrate Lived Experience Into Quality-of-Life Assessment in Patients Considering Facial Transplantation.

AMA J Ethics 2019 11 1;21(11):E980-987. Epub 2019 Nov 1.

The Helen L. Kimmel Professor of Reconstructive Plastic Surgery and chair of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City.

Facial transplantation has gained increasing acceptance as a treatment option to improve quality of life (QoL) for persons suffering from severe facial disfigurement. Despite its growth, the field has yet to establish a consistent approach to assessing QoL in face transplant candidates and recipients that includes integration of meaningful patient-reported outcomes. The published literature suggests that face transplant programs currently use a wide variety of assessment tools and strategies. Moreover, confusion remains as to how best to weigh patients' lived experiences and incorporate them into QoL assessments. Qualitative research can illuminate the dimensions of QoL that are meaningful to face transplant candidates and recipients. Coupled with collaboration and data sharing across face transplant programs, qualitative research will help to bring conceptual clarity and transparency to the assessment process.
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http://dx.doi.org/10.1001/amajethics.2019.980DOI Listing
November 2019

The Rich Get Richer: Osseous Chimeric Versatility to the Anterolateral Thigh Flap.

J Reconstr Microsurg 2020 Mar 25;36(3):171-176. Epub 2019 Oct 25.

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, Bellevue Hospital New York, New York.

Background:  The lateral femoral circumflex artery (LFCA) system, which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction.

Methods:  Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA) to define any muscular, periosteal, and/or osseous branches to the femur.

Results:  Six thighs in four cadavers were dissected. Consistent in all specimens, there was an isolated branch extending distally, medially, and posteriorly from the proximal LFCA and entering the periosteum of the femur. In five specimens, the identified branch to the femur was located approximately 1-cm distal to the rectus femoris branch of the LFCA and approximately 1-cm proximal to a separate branch entering and supplying the vastus intermedius. In one specimen, there was a common trunk. The length of this branch from the origin at the LFCA to insertion into the femoral periosteum was approximately 6 to 8 cm.

Conclusion:  There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility, as another option in complex cases requiring composite reconstruction, including bone.
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http://dx.doi.org/10.1055/s-0039-1698747DOI Listing
March 2020

Noninvasive Monitoring of Allograft Rejection Using a Novel Epidermal Sampling Technique.

Plast Reconstr Surg Glob Open 2019 Aug 8;7(8):e2368. Epub 2019 Aug 8.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Despite promising short- and long-term results to date in vascularized composite allotransplantation (VCA), acute rejection remains the most common major complication in recipients. Currently, diagnosis of acute rejection relies on clinical inspection correlated with histopathological analysis. However, disagreement exists regarding the value of full-thickness skin and mucosal biopsies and histopathology remains semiquantitative, subject to sampling bias, and prone to intra- and inter-observer variabilities. Additionally, biopsies may cause infection, scarring, and/or potentially incite rejection through immune activation after injury. Noninvasive methods to diagnose rejection represent a critical unmet need for the emerging field of VCA. Here, we propose a novel technique utilizing skin stripping of the epidermis and subsequent molecular analysis to detect known markers of acute rejection. Using a small animal VCA model, we sought to validate our epidermal sampling technique as a noninvasive diagnostic test for acute rejection.
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http://dx.doi.org/10.1097/GOX.0000000000002368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756676PMC
August 2019

Computerized Approach to Facial Transplantation: Evolution and Application in 3 Consecutive Face Transplants.

Plast Reconstr Surg Glob Open 2019 Aug 19;7(8):e2379. Epub 2019 Aug 19.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y.

Face transplant (FT) candidates present with unique anatomic and functional defects unsuitable for autologous reconstruction, making the accurate design and transplantation of patient-specific allografts particularly challenging. In this case series, we present our computerized surgical planning (CSP) protocol for FT.

Methods: CSP, computer-aided design and manufacturing, intraoperative navigation, and intraoperative computerized tomography have been successfully incorporated into a comprehensive protocol. Three consecutive FTs were performed. CSP and postoperative results were compared using computerized tomography-derived cephalometric measurements, and the literature was reviewed.

Results: Two full and 1 partial FT were successfully performed using the CSP protocol. CSP facilitated the execution of FT with minor angular and translational cephalometric variations on immediate postoperative imaging. Our evolving experience was accompanied by a decreased reliance on cadaveric simulation, from 10 mock transplants and a research procurement before the senior author's first clinical FT (2012) to 6 mock transplants and no research procurement before the third FT (2018). Operative time was significantly reduced from 36 to 25 hours, as was the need for major orthognathic surgical revision. This reflects the learning curve and variable case complexity, but it is also representative of improved planning and execution, complemented by the systematic incorporation of CSP into FT.

Conclusions: A CSP protocol allows for refinement of operative flow, technique, and outcomes in partial and full FT. Standards for functional and esthetic outcomes are bound to evolve with the field's growth, and computerized planning and execution offer a reproducible approach to FT through objective quality assurance.
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http://dx.doi.org/10.1097/GOX.0000000000002379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756666PMC
August 2019

Total Eyelid Transplantation in a Face Transplant: Analysis of Postoperative Periorbital Function.

J Surg Res 2020 01 20;245:420-425. Epub 2019 Aug 20.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York. Electronic address:

Background: Prolonged impairment of protective ocular functions can compromise vision and lead to blindness if uncorrected. Several facial transplants have incorporated periorbital structures with variable eyelid preservation, but objective assessment of post-transplant periorbital function has been limited.

Materials And Methods: Kinematic data were collected from a full-face recipient that included the fist total eyelid transplantation at 5 separate pre-transplant (PRE) and post-transplant time points (T1-T4). Using optical facial tracking, eyelid movements were tracked during involuntary blinking and compared with controls.

Results: There was significant improvement in right eye aperture from PRE to T1 (β = 5.54, P < 0.001), with no change between T1 and T4. Aperture fluctuated in the left eye, with a temporary decrease between T2 and T3 corresponding with revision brow lift (β = -4.57, P < 0.001). Although improved from the pre-transplantation, right and left eye apertures remained significantly smaller than controls at T1 and T4 (P < 0.001). Similarly, spatial coupling increased from PRE to T1 (β = 0.63, P < 0.001) and remained high at T4, albeit significantly less than controls (P < 0.001). Temporal coupling improved from PRE to T2 (β = 2.29, P < 0.02) and was sustained at subsequent time points, with no difference relative to controls at T4. Considerable improvement was observed on clinical examination, with full functional status.

Conclusions: Application of a novel method for assessing functional eyelid recovery using facial tracking technology to the first total eyelid transplantation in the setting of a full facial transplant shows clear functional improvement after transplantation and suggests revisions can be performed safely to optimize aesthetic outcomes without permanent negative functional impact.
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http://dx.doi.org/10.1016/j.jss.2019.07.096DOI Listing
January 2020

Facial Transplantation for an Irreparable Central and Lower Face Injury: A Modernized Approach to a Classic Challenge.

Plast Reconstr Surg 2019 08;144(2):264e-283e

From the Hansjörg Wyss Department of Plastic Surgery and the Transplant Institute, New York University Langone Health.

Background: Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade.

Methods: The authors' team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure.

Results: The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection.

Conclusions: The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000005885DOI Listing
August 2019