1
|
Huelsboemer L, Knoedler L, Kochen A, Yu CT, Hosseini H, Hollmann KS, Choi AE, Stögner VA, Knoedler S, Hsia HC, Pomahac B, Kauke-Navarro M. Cellular therapeutics and immunotherapies in wound healing - on the pulse of time? Mil Med Res 2024; 11:23. [PMID: 38637905 PMCID: PMC11025282 DOI: 10.1186/s40779-024-00528-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Abstract
Chronic, non-healing wounds represent a significant challenge for healthcare systems worldwide, often requiring significant human and financial resources. Chronic wounds arise from the complex interplay of underlying comorbidities, such as diabetes or vascular diseases, lifestyle factors, and genetic risk profiles which may predispose extremities to local ischemia. Injuries are further exacerbated by bacterial colonization and the formation of biofilms. Infection, consequently, perpetuates a chronic inflammatory microenvironment, preventing the progression and completion of normal wound healing. The current standard of care (SOC) for chronic wounds involves surgical debridement along with localized wound irrigation, which requires inpatient care under general anesthesia. This could be followed by, if necessary, defect coverage via a reconstructive ladder utilizing wound debridement along with skin graft, local, or free flap techniques once the wound conditions are stabilized and adequate blood supply is restored. To promote physiological wound healing, a variety of approaches have been subjected to translational research. Beyond conventional wound healing drugs and devices that currently supplement treatments, cellular and immunotherapies have emerged as promising therapeutics that can behave as tailored therapies with cell- or molecule-specific wound healing properties. However, in contrast to the clinical omnipresence of chronic wound healing disorders, there remains a shortage of studies condensing the current body of evidence on cellular therapies and immunotherapies for chronic wounds. This review provides a comprehensive exploration of current therapies, experimental approaches, and translational studies, offering insights into their efficacy and limitations. Ultimately, we hope this line of research may serve as an evidence-based foundation to guide further experimental and translational approaches and optimize patient care long-term.
Collapse
Affiliation(s)
- Lioba Huelsboemer
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Leonard Knoedler
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
- School of Medicine, University of Regensburg, 93040, Regensburg, Germany
| | - Alejandro Kochen
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
- Regenerative Wound Healing Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Catherine T Yu
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Helia Hosseini
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Katharina S Hollmann
- School of Medicine, University of Wuerzburg, 97070, Würzburg, Germany
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Ashley E Choi
- California University of Science and Medicine, Colton, CA, 92324, USA
| | - Viola A Stögner
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Samuel Knoedler
- School of Medicine, University of Regensburg, 93040, Regensburg, Germany
| | - Henry C Hsia
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
- Regenerative Wound Healing Center, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Bohdan Pomahac
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Martin Kauke-Navarro
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, 06510, USA.
| |
Collapse
|
2
|
Knoedler L, Dean J, Diatta F, Thompson N, Knoedler S, Rhys R, Sherwani K, Ettl T, Mayer S, Falkner F, Kilian K, Panayi AC, Iske J, Safi AF, Tullius SG, Haykal S, Pomahac B, Kauke-Navarro M. Immune modulation in transplant medicine: a comprehensive review of cell therapy applications and future directions. Front Immunol 2024; 15:1372862. [PMID: 38650942 PMCID: PMC11033354 DOI: 10.3389/fimmu.2024.1372862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Balancing the immune response after solid organ transplantation (SOT) and vascularized composite allotransplantation (VCA) remains an ongoing clinical challenge. While immunosuppressants can effectively reduce acute rejection rates following transplant surgery, some patients still experience recurrent acute rejection episodes, which in turn may progress to chronic rejection. Furthermore, these immunosuppressive regimens are associated with an increased risk of malignancies and metabolic disorders. Despite significant advancements in the field, these IS related side effects persist as clinical hurdles, emphasizing the need for innovative therapeutic strategies to improve transplant survival and longevity. Cellular therapy, a novel therapeutic approach, has emerged as a potential pathway to promote immune tolerance while minimizing systemic side-effects of standard IS regiments. Various cell types, including chimeric antigen receptor T cells (CAR-T), mesenchymal stromal cells (MSCs), regulatory myeloid cells (RMCs) and regulatory T cells (Tregs), offer unique immunomodulatory properties that may help achieve improved outcomes in transplant patients. This review aims to elucidate the role of cellular therapies, particularly MSCs, T cells, Tregs, RMCs, macrophages, and dendritic cells in SOT and VCA. We explore the immunological features of each cell type, their capacity for immune regulation, and the prospective advantages and obstacles linked to their application in transplant patients. An in-depth outline of the current state of the technology may help SOT and VCA providers refine their perioperative treatment strategies while laying the foundation for further trials that investigate cellular therapeutics in transplantation surgery.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Jillian Dean
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fortunay Diatta
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Noelle Thompson
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Richmond Rhys
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Khalil Sherwani
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Tobias Ettl
- Department of Dental, Oral and Maxillofacial Surgery, Regensburg, Germany
| | - Simon Mayer
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Katja Kilian
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Jasper Iske
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ali-Farid Safi
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Siba Haykal
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bohdan Pomahac
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kauke-Navarro
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
3
|
Kauke-Navarro M, Sadigh S, Lee CAA, Panayi AC, Knoedler L, Knoedler S, Stoegner V, Huelsboemer L, Jamil A, Ko C, Lian CG, Murphy GF, Pomahac B. Lymphadenopathy and lymph node rejection following facial vascularized composite allotransplantation. J Plast Reconstr Aesthet Surg 2024; 91:268-275. [PMID: 38430863 DOI: 10.1016/j.bjps.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Apart from the skin, little is known about the immunological processes in deeper tissues, which are typically not accessible to biopsy and inspection, of vascularized composite allografts (VCAs). Face transplant patients develop prominent adenopathy shortly after transplantation that resolves over time. The mechanisms underlying this process are not understood. MATERIALS AND METHODS A retrospective cohort study was conducted on 9 patients who underwent 10 facial VCAs at the Brigham and Women's Hospital, Boston, MA, between April 2009 and July 2019. Clinical, radiological, and histological data related to lymphadenopathy of the head and neck were reviewed. RESULTS Patients who received donor-derived lymph nodes (LNs) developed bilateral lymphadenopathy of the submental or submandibular superficial LNs. Median time of presentation was POD18 (range POD6-POM3). Notably, bilateral adenopathy of the neck was not observed in later stages of follow-up (mean follow-up, 115 months). Histology of 3 LNs showed increased histiocytes and apoptosis, with the features reminiscent of necrotizing histiocytic lymphadenitis, and B and T lymphocytes (mostly CD8 + T) admixed with CD163 + histiocytes and dendritic cells. Molecular chimerism analysis in one case showed the coexistence of donor (81%) and recipient (19%) derived lymphocytes. Granzyme B (GZMB) expression confirmed the presence of increased cytotoxic T cells in this LN sample. CONCLUSION Our data suggested the involvement of an immunological process within the donor-derived LNs after facial allotransplantation between the recipient and donor cells. GZMB expression suggested LN rejection that can occurred independently of skin rejection. This finding supports the need to better define the role of donor-derived immune cells in the context of allograft rejection.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Sam Sadigh
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine A A Lee
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adriana C Panayi
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viola Stoegner
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Lioba Huelsboemer
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Azzi Jamil
- Department of Medicine, Transplantation Research Center, Renal Division, Brigham and Women's Hospital and Children's Hospital, 221 Longwood Ave, Boston, MA, USA
| | - Christine Ko
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
4
|
Wessel KJ, Stögner VA, Yu CT, Pomahac B, Hirsch T, Ayyala HS, Kueckelhaus M. Preclinical Performance of the Combined Application of Two Robotic Systems in Microsurgery: A Two-center Study. Plast Reconstr Surg Glob Open 2024; 12:e5775. [PMID: 38689940 PMCID: PMC11057809 DOI: 10.1097/gox.0000000000005775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/12/2024] [Indexed: 05/02/2024]
Abstract
Background Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial. Methods Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score. Results All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants. Conclusions The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.
Collapse
Affiliation(s)
- Kai J. Wessel
- From the Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Muenster, Muenster, Germany
| | - Viola A. Stögner
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
- Hannover Medical School, Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover, Germany
| | - Catherine T. Yu
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Tobias Hirsch
- From the Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Muenster, Muenster, Germany
| | - Haripriya S. Ayyala
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Maximilian Kueckelhaus
- From the Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
5
|
Knoedler L, Knoedler S, Alfertshofer M, Hansen FJ, Schenck T, Sofo G, Obed D, Hollmann K, Siegwart LC, Vollbach FH, Bigdeli AK, Kauke-Navarro M, Pomahac B. Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes. Aesthetic Plast Surg 2024:10.1007/s00266-024-03927-0. [PMID: 38528130 DOI: 10.1007/s00266-024-03927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/09/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Frederik J Hansen
- Department of Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Giuseppe Sofo
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, 30625, Hannover, Germany
| | - Katharina Hollmann
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Laura C Siegwart
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Felix H Vollbach
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
6
|
Hauc SC, Stögner VA, Ihnat JM, Hosseini H, Huelsboemer L, Kauke-Navarro M, Rivera JC, Williams M, Glahn JZ, Savetamal A, Pomahac B. Understanding the Drivers of Cost and Length of Stay in a Cohort of 21,875 Patients with Severe Burn. J Burn Care Res 2024; 45:425-431. [PMID: 37882472 DOI: 10.1093/jbcr/irad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 10/27/2023]
Abstract
Burn management has significantly advanced in the past 75 years, resulting in improved mortality rates. However, there are still over one million burn victims in the United States each year, with over 3,000 burn-related deaths annually. The impacts of individual patient, hospital, and regional demographics on length of stay (LOS) and total cost have yet to be fully explored in a large nationally representative cohort. Thus, this study aimed to examine various hospital and patient characteristics using a sample of over 20,000 patients. Inpatient data from the National Inpatient Sample from 2008 to 2015 were analyzed, and only patients with an ICD-9 code for second- or third-degree burns were included. In addition, a major operating room procedure must have been indicated on the discharge summary for patients to be included in the final dataset, ensuring that only severe burns requiring complex care were analyzed. Analysis of covariance models was used to evaluate the impact of various patient, hospital, and regional variables on both LOS and cost. The study found that skin grafts and fasciotomy significantly increased the cost of hospitalization. Having burns on the face, neck, and trunk significantly increased costs for patients with second-degree burns, while burns on the trunk resulted in the longest LOS for patients with third-degree burns. Infections in the hospital and additional procedures, such as flaps and skin grafts, also led to longer stays. The study also found that the prevalence of postoperative complications, such as electrolyte imbalance, was high among patients with burn surgery.
Collapse
Affiliation(s)
- Sacha C Hauc
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Viola Antonia Stögner
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Jacqueline M Ihnat
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Helia Hosseini
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Lioba Huelsboemer
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Martin Kauke-Navarro
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Jean C Rivera
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Mica Williams
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Joshua Z Glahn
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Alisa Savetamal
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| | - Bohdan Pomahac
- Department of Surgery, Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, 06511, CT, USA
| |
Collapse
|
7
|
Yu Z, Vieyra-Garcia P, Benezeder T, Crouch JD, Kim IR, O'Malley JT, Devlin PM, Gehad A, Zhan Q, Gudjonsson JE, Sarkar MK, Kahlenberg JM, Gerard N, Teague JE, Kupper TS, LeBoeuf NR, Larocca C, Tawa M, Pomahac B, Talbot SG, Orgill DP, Wolf P, Clark RA. Phototherapy Restores Deficient Type I IFN Production and Enhances Antitumor Responses in Mycosis Fungoides. J Invest Dermatol 2024; 144:621-632.e1. [PMID: 37716650 PMCID: PMC10922223 DOI: 10.1016/j.jid.2023.06.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 09/18/2023]
Abstract
Transcriptional profiling demonstrated markedly reduced type I IFN gene expression in untreated mycosis fungoides (MF) skin lesions compared with that in healthy skin. Type I IFN expression in MF correlated with antigen-presenting cell-associated IRF5 before psoralen plus UVA therapy and epithelial ULBP2 after therapy, suggesting an enhancement of epithelial type I IFN. Immunostains confirmed reduced baseline type I IFN production in MF and increased levels after psoralen plus UVA treatment in responding patients. Effective tumor clearance was associated with increased type I IFN expression, enhanced recruitment of CD8+ T cells into skin lesions, and expression of genes associated with antigen-specific T-cell activation. IFNk, a keratinocyte-derived inducer of type I IFNs, was increased by psoralen plus UVA therapy and expression correlated with upregulation of other type I IFNs. In vitro, deletion of keratinocyte IFNk decreased baseline and UVA-induced expression of type I IFN and IFN response genes. In summary, we find a baseline deficit in type I IFN production in MF that is restored by psoralen plus UVA therapy and correlates with enhanced antitumor responses. This may explain why MF generally develops in sun-protected skin and suggests that drugs that increase epithelial type I IFNs, including topical MEK and EGFR inhibitors, may be effective therapies for MF.
Collapse
Affiliation(s)
- Zizi Yu
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pablo Vieyra-Garcia
- Research Unit for Photodermatology, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Theresa Benezeder
- Research Unit for Photodermatology, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Jack D Crouch
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ira R Kim
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John T O'Malley
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Phillip M Devlin
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmed Gehad
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Qian Zhan
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mrinal K Sarkar
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - J Michelle Kahlenberg
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nega Gerard
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica E Teague
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas S Kupper
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Cutaneous Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Cutaneous Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Cecilia Larocca
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Cutaneous Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Marianne Tawa
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Simon G Talbot
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis P Orgill
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Wolf
- Research Unit for Photodermatology, Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria.
| | - Rachael A Clark
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
8
|
Knoedler S, Knoedler L, Geldner B, Ghanad I, Kim BS, Alfertshofer M, Machens HG, Broer PN, Pomahac B, Kauke-Navarro M, Paik AM. Isolated and combined breast augmentation in transgender patients: Multi-institutional insights into early outcomes and risk factors. J Plast Reconstr Aesthet Surg 2024; 90:149-160. [PMID: 38367411 DOI: 10.1016/j.bjps.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/23/2024] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The increasing demand for gender-affirming surgery (GAS) in transgender and gender-diverse healthcare highlights the importance of breast augmentation surgery (BAS) for transfeminine patients. Despite its significance, there is a lack of research on postoperative outcomes of BAS. METHODS We analyzed the multi-institutional American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) (2008-2021) database to identify female transgender individuals (TGIs) who underwent BAS surgery, both isolated and combined with concurrent GAS procedures. We evaluated 30-day outcomes, including the incidence of mortality, reoperation, readmission as well as surgical and medical complication occurrence. RESULTS Of 1699 female TGIs, 92% underwent isolated BAS and 7.7% underwent combined BAS. The mean age and body mass index (BMI) were 36 ± 12 years and 27 ± 6.6 kg/m2, respectively. Isolated BAS showed a 2.8% complication rate, while combined BAS had a higher rate with 9.1%. Specifically, all complications occurred in patients undergoing BAS with concurrent genitourinary surgery (n = 85; 14%), whereas no adverse events were recorded after combined BAS and facial feminization (n = 19) or chondrolaryngoplasty (n = 19). In patients seeking combined BAS, advanced age (p = 0.05) and nicotine abuse (p = 0.004) were identified as risk factors predisposing to adverse events, whereas American Society of Anesthesiology class 1 was found to be protective (p = 0.02). CONCLUSIONS Isolated BAS in TGIs demonstrates a positive safety profile. Combined surgeries, particularly with genitourinary procedures, pose higher risks. Identifying risk factors such as smoking and advanced age is crucial for patient selection and surgical planning. These findings can aid in refining patient eligibility and inform surgical decision-making for BAS.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benedikt Geldner
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Iman Ghanad
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany.
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Angie M Paik
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
9
|
Knoedler S, Kauke-Navarro M, Knoedler L, Friedrich S, Matar DY, Diatta F, Mookerjee VG, Ayyala H, Wu M, Kim BS, Machens HG, Pomahac B, Orgill DP, Broer PN, Panayi AC. Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study. Int J Surg 2024; 110:684-699. [PMID: 38052017 PMCID: PMC10871660 DOI: 10.1097/js9.0000000000000909] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/02/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. STUDY DESIGN The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. RESULTS The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. CONCLUSION The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg, Germany
| | - Dany Y. Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fortunay Diatta
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Vikram G. Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Haripriya Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P. Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
10
|
Knoedler S, Kauke-Navarro M, Knoedler L, Friedrich S, Ayyala HS, Haug V, Didzun O, Hundeshagen G, Bigdeli A, Kneser U, Machens HG, Pomahac B, Orgill DP, Broer PN, Panayi AC. The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis. J Plast Reconstr Aesthet Surg 2024; 89:40-50. [PMID: 38134626 DOI: 10.1016/j.bjps.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg, Germany
| | - Haripriya S Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Oliver Didzun
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany.
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
| |
Collapse
|
11
|
Glahn JZ, Huelsboemer L, Pomahac B. Face Transplantation, Social Death, and Bias in Healthcare Resource Allocation. Ann Surg 2024:00000658-990000000-00740. [PMID: 38214163 DOI: 10.1097/sla.0000000000006195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Joshua Zev Glahn
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | | |
Collapse
|
12
|
Noel OF, Dumbrava MG, Daoud D, Kammien AJ, Kauke-Navarro M, Pomahac B, Colen D. Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome. Ann Plast Surg 2024; 92:100-105. [PMID: 37962243 DOI: 10.1097/sap.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT In the past decade, vascularized composite allotransplantation (VCA) has become clinical reality for reconstruction after face and hand trauma. It offers patients the unique opportunity to regain form and function in a way that had only been achieved with traditional reconstruction or with the use of prostheses. On the other hand, prostheses for facial and hand reconstruction have continued to evolve over the years and, in many cases, represent the primary option for patients after hand and face trauma. We compared the cost, associated complications, and long-term outcomes of VCA with prostheses for reconstruction of the face and hand/upper extremity. Ultimately, VCA and prostheses represent 2 different reconstructive options with distinct benefit profiles and associated limitations and should ideally not be perceived as competing choices. Our work adds a valuable component to the general framework guiding the decision to offer VCA or prostheses for reconstruction after face and upper extremity trauma.
Collapse
Affiliation(s)
- Olivier F Noel
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | | | - Deborah Daoud
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alexander J Kammien
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Martin Kauke-Navarro
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Bohdan Pomahac
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - David Colen
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| |
Collapse
|
13
|
Knoedler S, Knoedler L, Patel H, Diatta FH, Camacho JM, Sofo G, Perozzo FAG, Evans B, Mookerjee VG, Ayyala HS, Pomahac B, Kauke-Navarro M. Surgical management of breast fat necrosis: Multi-institutional data analysis of early outcomes and risk factors for complications. J Plast Reconstr Aesthet Surg 2024; 88:292-295. [PMID: 38029475 DOI: 10.1016/j.bjps.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/06/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Breast fat necrosis (BFN) is a non-cancerous condition affecting the adipose tissue. Despite incidence rates of up to 25% after breast surgery, little is known about risk factors and postoperative outcomes following the surgical treatment of BFN. METHODS The National Surgical Quality Improvement Program of the American College of Surgeons (2008-2021) was queried to identify female patients diagnosed with and surgically treated for BFN. Outcomes of interest included 30-day surgical and medical complications, reoperation, and readmission. We performed confounder-adjusted multivariable analyses to determine risk factors. RESULTS The study population included 1179 female patients (mean age: 55.8 ± 13.8 years), of whom 96% (n = 1130) underwent direct excision and 4.2% (n = 49) received debridement of necrotic tissue. The majority of cases were operated on by general surgeons (n = 867; 74%) in the outpatient setting (n = 1107; 94%). Overall, 74 patients (6.3%) experienced postoperative adverse events, most of which were surgical complications (n = 43; 3.7%). Twenty-one (1.8%) women had to return to operating room, while readmission was reported in 18 (1.5%) cases. Adverse events were significantly more likely to occur in patients with chronic heart failure (p = 0.002) and higher wound classes (p = 0.033). CONCLUSION Complication rates following the surgical management of BFN were found to be relatively high and seen to correlate with the setting. We identified chronic heart failure and wound contamination as risk factors for complication occurrence. These evidence-based insights may sensitize surgeons to critically balance patients' eligibility for BFN surgery and refine perioperative algorithms.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Heli Patel
- Nova Southeastern University Dr. Kiran C Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA.
| | - Fortunay H Diatta
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | | | - Giuseppe Sofo
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Filippo A G Perozzo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Brogan Evans
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Vikram G Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Haripriya S Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
14
|
Longo B, Alberti FB, Pomahac B, Pribaz JJ, Meningaud JP, Lengelé B, Özkan Ö, Özkan Ö, Barret JP, Lassus P, Blondeel P, Roche N, Gurunian R, Infante-Cossio P, Lindford A, Brandacher G, Giovanoli P, Plock J, Gorantla VS, Herrington ER, Saleh D, Natalwala I, Cardillo M, Jowsey-Gregoire S, La Padula S, Manas D, Benedict J, Nuccitelli G, Bosc R, Morello R, Farías-Yapur A, Giacalone M, Hall S, D'Orsi G, Cervelli V. International consensus recommendations on face transplantation: A 2-step Delphi study. Am J Transplant 2024; 24:104-114. [PMID: 37666457 PMCID: PMC10881406 DOI: 10.1016/j.ajt.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/03/2023] [Accepted: 08/18/2023] [Indexed: 09/06/2023]
Abstract
Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.
Collapse
Affiliation(s)
- Benedetto Longo
- Chair of Plastic Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy.
| | - Fay Bound Alberti
- Director of Interface and Director of the Centre for Technology and the Body, King's College London
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Julian Joseph Pribaz
- Department of Plastic and Reconstructive Surgery, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, and Maxillofacial Surgery, Henri Mondor Hospital, University of Paris, Créteil, France
| | - Benoît Lengelé
- Department of Plastic and Reconstructive Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Ömer Özkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Özlenen Özkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Juan Pere Barret
- Department of Plastic Surgery and Burns, Vall d'Hebron Barcelona Hospital Campus, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Patrik Lassus
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Phillip Blondeel
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Roche
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Raffi Gurunian
- Department of Plastic Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Pedro Infante-Cossio
- Department of Oral and Maxillofacial Surgery, Virgen del Rocio University Hospital, University of Seville, Seville, Spain
| | - Andrew Lindford
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jan Plock
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Vijay S Gorantla
- Department of Surgery, Wake Forest School of Medicine, Wake Forest Institute of Regenerative Medicine, Winston Salem, North Carolina, USA
| | | | - Daniel Saleh
- Department of Plastic and Reconstructive Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Massimo Cardillo
- Director of National Transplants Center, National Institute of Health, Italian Ministry of Health, Rome, Italy
| | | | - Simone La Padula
- Department of Plastic, Reconstructive, and Maxillofacial Surgery, Henri Mondor Hospital, University of Paris, Créteil, France; Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Derek Manas
- NHS Blood and Transplant, Stoke Gifford, Bristol, UK; Liver Transplant Unit, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle, UK
| | - James Benedict
- Center for Global Health Ethics, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Gloria Nuccitelli
- Division of Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Romain Bosc
- Department of Plastic, Reconstructive, and Maxillofacial Surgery, Henri Mondor Hospital, University of Paris, Créteil, France
| | - Roberto Morello
- Department of Maxillofacial Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Anneke Farías-Yapur
- School of Psychology, Universidad Panamericana, Benito Juárez, Mexico City, Mexico
| | - Martina Giacalone
- Chair of Plastic Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| | | | - Gennaro D'Orsi
- Chair of Plastic Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| | - Valerio Cervelli
- Chair of Plastic Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| |
Collapse
|
15
|
Huelsboemer L, Stögner VA, Hosseini H, Hauc S, Boroumand S, Parikh N, Blood A, Mookerjee V, Kauke-Navarro M, Nizzi MC, Pomahac B. An update on long-term mental health in eight face transplant recipients - A single center experience. Int J Psychiatry Med 2023:912174231225764. [PMID: 38152028 DOI: 10.1177/00912174231225764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Face transplantation is a groundbreaking and complex surgical intervention offering profound physical and psychological benefits to patients with severe facial disfigurements. This report provides an update on the long-term psychosocial outcome of eight face transplant recipients. METHOD All transplant recipients were initially transplanted at Brigham and Women´s Hospital (Boston, USA) between 2011 and 2020 and are seen as outpatient patients at Yale New Haven Hospital (New Haven, USA). A mixed-methods approach was used to assess the psychological well-being of these patients. The Short-Form 12, Brief-COPE, EQ-VAS and CES-D were administered between October 2022 and October 2023. RESULTS Older age of face transplant recipients was significantly and positively associated with better mental health and increased use of both emotional and instrumental support (Brief-COPE). The initial enhancement in patients' self-reported quality of life, as assessed by the EQVAS, declined on the EQ-VAS score at the last follow-up period. Similarly, an increase in depression score was observed (CES-D score) up through the last follow-up assessment. Both of the latter results, however, did not reach statistical significance. CONCLUSIONS These results underscore the importance of ongoing psychological support throughout the long-term journey of recovery for face transplant recipients. They emphasized the need for a comprehensive, patient-centered approach that also addresses the complex psychological dimensions and contributes to our understanding of the mental health dynamics involved in face transplantation, underscoring the need for guidelines and continued research in this evolving field.
Collapse
Affiliation(s)
- Lioba Huelsboemer
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Viola A Stögner
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Helia Hosseini
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sacha Hauc
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sam Boroumand
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Neil Parikh
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
- University of Boston, Boston, MA, USA
| | - Alexa Blood
- Transplant Department, Yale New Haven Hospital, New Haven, CT, USA
| | - Vikram Mookerjee
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
16
|
Knoedler S, Schliermann R, Knoedler L, Wu M, Hansen FJ, Matar DY, Obed D, Vervoort D, Haug V, Hundeshagen G, Paik A, Kauke-Navarro M, Kneser U, Pomahac B, Orgill DP, Panayi AC. Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis. Int J Surg 2023; 109:4238-4262. [PMID: 37696253 PMCID: PMC10720826 DOI: 10.1097/js9.0000000000000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties. METHODS The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design. RESULTS A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001). CONCLUSION Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Rainer Schliermann
- Faculty of Social and Health Care Sciences, University of Applied Sciences Regensburg, Regensburg
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Mengfan Wu
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, People’s Republic of China
| | - Frederik J. Hansen
- Department of General and Visceral Surgery, Friedrich-Alexander University Erlangen, Erlangen
| | - Dany Y. Matar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Angie Paik
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Dennis P. Orgill
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| |
Collapse
|
17
|
Longo B, Pomahac B, Giacalone M, Cardillo M, Cervelli V. 18 years of face transplantation: Adverse outcomes and challenges. J Plast Reconstr Aesthet Surg 2023; 87:187-199. [PMID: 37879143 DOI: 10.1016/j.bjps.2023.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 08/19/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Since the first procedure performed in 2005, face transplantation has been debated as viable approach for the treatment of severe craniofacial defects. Despite the benefits provided, the experience in face allotransplantation has brought to light a significant risk of complications, including allograft removal or loss, and mortality. The present study is intended to provide an updated review on complications and major challenges witnessed over 18 years of experience in the field. METHODS A systematic review of PubMed, MEDLINE, Cochrane, Google, and Google Scholar databases on face transplantation was conducted according to PRISMA guidelines up to April 2023. Articles providing details on cases of face allograft loss, removal, and patient death were included. Online articles and media reports were assessed to include information not disclosed in peer-reviewed literature. Face transplant centers were contacted to have updated follow-up information on single-face transplant cases. RESULTS The search yielded 1006 reports, of which 28 were included. On a total of 48 procedures performed in 46 patients, adverse outcomes were gleaned in 14 cases (29%), including seven allograft losses (14.6%), and the death of ten patients (21.7%). Chronic rejection was the leading cause of allograft loss, with a median time from transplant to irreversible rejection of 90 months (IQR 88.5-102). The main causes of death were infectious complications, followed by malignancies, non-compliance to immunosuppression, and suicide. The median time to death was 48.5 months (IQR 19-122). CONCLUSIONS To the best of our knowledge, this is the first study providing a comprehensive review of adverse outcomes in face transplantation. Considering the high rate of major complications, the heterogeneity of cases and single-center approaches, and the absence of published standards of care, the development of a consensus by face transplant teams holds the key to the field's advancement.
Collapse
Affiliation(s)
- Benedetto Longo
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy.
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martina Giacalone
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| | - Massimo Cardillo
- National Transplants Center, National Institute of Health, Italian Ministry of Health, Rome, Italy
| | - Valerio Cervelli
- Chair of Plastic and Reconstructive Surgery, Department of Surgical Sciences, Tor Vergata University of Rome, Rome, Italy
| |
Collapse
|
18
|
Kauke-Navarro M, Noel OF, Knoedler L, Knoedler S, Panayi AC, Stoegner VA, Huelsboemer L, Pomahac B. Novel Strategies in Transplantation: Genetic Engineering and Vascularized Composite Allotransplantation. J Surg Res 2023; 291:176-186. [PMID: 37429217 DOI: 10.1016/j.jss.2023.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/18/2023] [Accepted: 04/30/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Despite the clinical success in vascularized composite allotransplantation (VCA), systemic immunosuppression remains necessary to prevent allograft rejection. Even with potent immunosuppressive regimens (tacrolimus, mycophenolate mofetil, and steroids), most patients experience several rejection episodes, often within the same year. The risk of systemic side effects must constantly be weighed against the risk of under-immunosuppression and, thus, acute and chronic rejection. In this context, genomic editing has emerged as a potential tool to minimize the need for toxic immunosuppressive regimens and has gained attention in the fields of solid organ transplantation and xenotransplantation. This strategy may also be relevant for the future of VCA. METHODS We discuss the topic of genetic engineering and review recent developments in this field that justify investigating tools such as clustered regularly interspaced short palindromic repeats/Cas9 in the context of VCA. RESULTS We propose specific strategies for VCA based on the most recent gene expression data. This includes the well-known strategy of tolerance induction. Specifically, targeting the interaction between antigen-presenting cells and recipient-derived T cells by CD40 knockout may be effective. The novelty for VCA is a discovery that donor-derived T lymphocytes may play a special role in allograft rejection of facial transplants. We suggest targeting these cells prior to transplantation (e.g., by ex vivo perfusion of the transplant) by knocking out genes necessary for the long-term persistence of donor-derived immune cells in the allograft. CONCLUSION Despite the demonstrated feasibility of VCA in recent years, continued improvements to immunomodulatory strategies using tools like clustered regularly interspaced short palindromic repeats/Cas9 could lead to the development of approaches that mitigate the limitations associated with rejection of this life-giving procedure.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Olivier F Noel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Samuel Knoedler
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adriana C Panayi
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viola A Stoegner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut; Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Lioba Huelsboemer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut; Institute of Musculoskeletal Medicine, University Hospital Muenster, Münster, Germany
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.
| |
Collapse
|
19
|
Knoedler L, Knoedler S, Allam O, Remy K, Miragall M, Safi AF, Alfertshofer M, Pomahac B, Kauke-Navarro M. Application possibilities of artificial intelligence in facial vascularized composite allotransplantation-a narrative review. Front Surg 2023; 10:1266399. [PMID: 38026484 PMCID: PMC10646214 DOI: 10.3389/fsurg.2023.1266399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/26/2023] [Indexed: 12/01/2023] Open
Abstract
Facial vascularized composite allotransplantation (FVCA) is an emerging field of reconstructive surgery that represents a dogmatic shift in the surgical treatment of patients with severe facial disfigurements. While conventional reconstructive strategies were previously considered the goldstandard for patients with devastating facial trauma, FVCA has demonstrated promising short- and long-term outcomes. Yet, there remain several obstacles that complicate the integration of FVCA procedures into the standard workflow for facial trauma patients. Artificial intelligence (AI) has been shown to provide targeted and resource-effective solutions for persisting clinical challenges in various specialties. However, there is a paucity of studies elucidating the combination of FVCA and AI to overcome such hurdles. Here, we delineate the application possibilities of AI in the field of FVCA and discuss the use of AI technology for FVCA outcome simulation, diagnosis and prediction of rejection episodes, and malignancy screening. This line of research may serve as a fundament for future studies linking these two revolutionary biotechnologies.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Omar Allam
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Katya Remy
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maximilian Miragall
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University Munich, Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
20
|
Knoedler S, Knoedler L, Kauke-Navarro M, Rinkevich Y, Hundeshagen G, Harhaus L, Kneser U, Pomahac B, Orgill DP, Panayi AC. Regulatory T cells in skin regeneration and wound healing. Mil Med Res 2023; 10:49. [PMID: 37867188 PMCID: PMC10591349 DOI: 10.1186/s40779-023-00484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
As the body's integumentary system, the skin is vulnerable to injuries. The subsequent wound healing processes aim to restore dermal and epidermal integrity and functionality. To this end, multiple tissue-resident cells and recruited immune cells cooperate to efficiently repair the injured tissue. Such temporally- and spatially-coordinated interplay necessitates tight regulation to prevent collateral damage such as overshooting immune responses and excessive inflammation. In this context, regulatory T cells (Tregs) hold a key role in balancing immune homeostasis and mediating cutaneous wound healing. A comprehensive understanding of Tregs' multifaceted field of activity may help decipher wound pathologies and, ultimately, establish new treatment modalities. Herein, we review the role of Tregs in orchestrating the regeneration of skin adnexa and catalyzing healthy wound repair. Further, we discuss how Tregs operate during fibrosis, keloidosis, and scarring.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, 85764, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Yuval Rinkevich
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, 85764, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany.
| |
Collapse
|
21
|
Haug V, Peng Y, Tchiloemba B, Wang AT, Buerger F, Romfh P, Kneser U, Polizzotti BD, Pomahac B. Normothermic Ex Situ Machine Perfusion of Vascularized Composite Allografts with Oxygen Microcarriers for 12 Hours Using Real-Time Mitochondrial Redox Quantification. J Clin Med 2023; 12:6568. [PMID: 37892706 PMCID: PMC10607057 DOI: 10.3390/jcm12206568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Normothermic ex situ perfusion of vascularized composite allografts (VCAs) necessitates high oxygen demand and, thus, increased metabolic activity, which, in turn, requires the use of blood-based perfusion solutions. However, blood-derived perfusates, in turn, constitute an antigenic load. To circumvent this immunogenic problem, we used a perfusate enriched with acellular dextrane oxygen microcarriers to perfuse rat hindlimbs. METHODS Rat hindlimbs (n = 11) were perfused with either (non-), oxygenated dextrane-enriched Phoxilium, or Phoxilium enriched with dextrane oxygen microcarriers (MO2) for 12 h at 37 °C or stored on ice. Oxygenation of the skeletal muscle was assessed with Raman spectroscopy, tissue pO2-probes, and analysis of the perfusate. Transmission electronic microscopy was utilized to assess the ultrastructure of mitochondria of the skeletal muscle. RESULTS For all evaluated conditions, ischemia time until perfusion was comparable (22.91 ± 1.64 min; p = 0.1559). After 12 h, limb weight increased significantly by at least 81%, up to 124% in the perfusion groups, and by 27% in the static cold storage (SCS) group. Raman spectroscopy signals of skeletal muscle did not differ substantially among the groups during either perfusion or static cold storage across the duration of the experiment. While the total number of skeletal muscle mitochondria decreased significantly compared to baseline, mitochondrial diameter increased in the perfusion groups and the static cold storage group. CONCLUSION The use of oxygen microcarriers in ex situ perfusion of VCA with acellular perfusates under normothermic conditions for 12 h facilitates the maintenance of mitochondrial structure, as well as a subsequent recovery of mitochondrial redox status over time, while markers of muscle injury were lower compared to conventional oxygenated acellular perfusates.
Collapse
Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (V.H.)
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Yifeng Peng
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bianief Tchiloemba
- Division of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Alice T. Wang
- Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (V.H.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Florian Buerger
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Brian D. Polizzotti
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT 06510, USA
| |
Collapse
|
22
|
Mookerjee VG, Kauke-Navarro M, Hauc SC, Huelsboemer L, Formica RN, Pomahac B. "Advancing Face Transplantation: A Critical Analysis of Revisions and Long-Term Surgical Outcomes in Ten Cases". Plast Reconstr Surg 2023:00006534-990000000-02113. [PMID: 37699110 DOI: 10.1097/prs.0000000000011058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Face transplantation has emerged as a viable solution for reconstructing the most complex facial injuries. Prior work has demonstrated that surgical revisions are necessary to optimize outcomes. The authors' group has updated the previous report of revisions in their cohort, quantified and described which revisions were performed for functional, aesthetic, or mixed indications, and described the rationale, safety, and long-term outcomes of these revisions. METHODS A retrospective analysis of the authors' ten face transplants was performed from April 2009 to February 2023. The patients' medical records, preoperative facial defects, and operative reports (index and secondary revisions) were reviewed. RESULTS Nine patients were included. One patient underwent irreversible acute on chronic allograft rejection and received a second face transplant. The average number of revisions was 5.2 per patient (range, 2 to 11 procedures). The median time interval from transplantation to first revision was 4 months (range, 1 to 21 months). Median follow-up was 106 months (range 39 to 142 months). Most interventions consisted of debulking the allograft or revising the periorbital tissues. CONCLUSIONS In the current study, we report longer term data on revision surgeries needed in face transplant recipients. Patients should expect to undergo revisions for both functional and aesthetic considerations. Although the majority of revisions are performed within two years following transplantation, revisions can be safely performed at any time point. Shared decision-making between the patient and provider team is essential in deciding which revisions are performed and when.
Collapse
Affiliation(s)
- Vikram G Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sacha C Hauc
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Lioba Huelsboemer
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
23
|
Knoedler S, Matar DY, Friedrich S, Knoedler L, Haug V, Hundeshagen G, Kauke-Navarro M, Kneser U, Pomahac B, Orgill DP, Panayi AC. The surgical patient of yesterday, today, and tomorrow-a time-trend analysis based on a cohort of 8.7 million surgical patients. Int J Surg 2023; 109:2631-2640. [PMID: 37788019 PMCID: PMC10498871 DOI: 10.1097/js9.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/14/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Global healthcare delivery is challenged by the aging population and the increase in obesity and type 2 diabetes. The extent to which such trends affect the cohort of patients the authors surgically operate on remains to be elucidated. Comprising of 8.7 million surgical patients, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database can be analyzed to investigate the echo of general population dynamics and forecast future trends. MATERIAL AND METHODS The authors reviewed the ACS-NSQIP database (2008-2020) in its entirety, extracting patient age, BMI, and diabetes prevalence. Based on these data, the authors forecasted future trends up to 2030 using a drift model. RESULTS During the review period, median age increased by 3 years, and median BMI by 0.9 kg/m2. The proportion of patients with overweight, obesity class I, and class II rates increased. The prevalence of diabetes rose between 2008 (14.9%) and 2020 (15.3%). The authors forecast the median age in 2030 to reach 61.5 years and median BMI to climb to 29.8 kg/m2. Concerningly, in 2030, eight of ten surgical patients are projected to have a BMI above normal. Diabetes prevalence is projected to rise to 15.6% over the next decade. CONCLUSION General population trends echo in the field of surgery, with the surgical cohort aging at an alarmingly rapid rate and increasingly suffering from obesity and diabetes. These trends show no sign of abating without dedicated efforts and call for urgent measures and fundamental re-structuring for improved future surgical care.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Dany Y. Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Adriana C. Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| |
Collapse
|
24
|
Knoedler S, Broichhausen S, Guo R, Dai R, Knoedler L, Kauke-Navarro M, Diatta F, Pomahac B, Machens HG, Jiang D, Rinkevich Y. Fibroblasts - the cellular choreographers of wound healing. Front Immunol 2023; 14:1233800. [PMID: 37646029 PMCID: PMC10461395 DOI: 10.3389/fimmu.2023.1233800] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023] Open
Abstract
Injuries to our skin trigger a cascade of spatially- and temporally-synchronized healing processes. During such endogenous wound repair, the role of fibroblasts is multifaceted, ranging from the activation and recruitment of innate immune cells through the synthesis and deposition of scar tissue to the conveyor belt-like transport of fascial connective tissue into wounds. A comprehensive understanding of fibroblast diversity and versatility in the healing machinery may help to decipher wound pathologies whilst laying the foundation for novel treatment modalities. In this review, we portray the diversity of fibroblasts and delineate their unique wound healing functions. In addition, we discuss future directions through a clinical-translational lens.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Sonja Broichhausen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ruiji Guo
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Ruoxuan Dai
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Fortunay Diatta
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dongsheng Jiang
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Yuval Rinkevich
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, Germany
| |
Collapse
|
25
|
Kauke-Navarro M, Knoedler L, Knoedler S, Diatta F, Huelsboemer L, Stoegner VA, Mookerjee VG, Panayi AC, Butler PD, Pomahac B. Ensuring Racial and Ethnic Inclusivity in Facial Vascularized Composite Allotransplantation. Plast Reconstr Surg Glob Open 2023; 11:e5178. [PMID: 37577247 PMCID: PMC10419650 DOI: 10.1097/gox.0000000000005178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023]
Abstract
Facial vascularized composite allotransplantation (fVCA) represents a valuable surgical option for reconstruction of the most devastating facial defects. There is a mounting body of evidence suggesting that healthcare disparities exist for a variety of other surgical and nonsurgical procedures. We aimed to investigate the potential existence of racial and ethnic disparities in the field of fVCA. Methods A comprehensive literature review was conducted by the authors of this review on PubMed/MEDLINE, and Embase databases from database inception to December 1, 2022 for studies published in the English and French languages. The search terms were (1) "face" OR "facial" AND (2) "transplant" OR "VCA" OR "vascularized composite allotransplantation" OR "vascularized composite allograft" OR "graft." Results Upon assessment of the racial and ethnic demographics of the 47 global cases of fVCA between 2005 and 2020, 36 were White, 10 were Asian, and one was Black. Sixteen of the 17 fVCA procedures performed in the United States involved White patients. The other patient self-identified as Black, equaling 6% of all US fVCA recipients. Conclusion Our analysis showed that the ethnic and racial distribution of fVCA has not proportionally reflected the racial and ethnic demographics of the general US population, underscoring the risk of such healthcare imbalances. Although large-scale studies are needed before drawing definitive conclusions, leaders in the field should take preventive steps to avoid potential disparities. Further investigations into the factors that facilitate or prohibit access to fVCA referral and surgery will be necessary moving forward.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Leonard Knoedler
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Technical University of Munich, Munich, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Fortunay Diatta
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Lioba Huelsboemer
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Viola A. Stoegner
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Vikram G. Mookerjee
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Burn Center, Microsurgery, University of Heidelberg, Ludwigshafen, Germany
| | - Paris D. Butler
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Bohdan Pomahac
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| |
Collapse
|
26
|
Dorante MI, Wang AT, Kollar B, Perry BJ, Ertosun MG, Lindford AJ, Kiukas EL, Özkan Ö, Özkan Ö, Lassus P, Pomahac B. Facial Expression after Face Transplant: An International Face Transplant Cohort Comparison. Plast Reconstr Surg 2023; 152:315e-325e. [PMID: 36727808 DOI: 10.1097/prs.0000000000010242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Assessment of motor function restoration following face transplant (FT) is difficult, as standardized, bilateral tests are lacking. This study aims to bolster support for software-based analysis through international collaboration. METHODS FaceReader (Noldus, Wageningen, The Netherlands), a facial expression analysis software, was used to analyze posttransplant videos of eight FT patients from Boston, Massachusetts (range, 1 to 9 years after transplant), two FT patients from Helsinki, Finland (range, 3 to 4 years after transplant), and three FT patients from Antalya, Turkey (range, 6.5 to 8.5 years after transplant). Age-matched healthy controls from respective countries had no history of prior facial procedures. Videos contained patients and controls performing facial expressions evaluated by software analysis using the Facial Action Coding System. Facial movements were assigned intensity score values between 0 (absent) and 1 (fully present). Maximum values were compared with respective healthy controls to calculate percentage restoration. RESULTS Of 13 FT patients, eight patients were full FT, five patients were partial FT, and two patients were female patients. Compared with healthy controls, the median restoration of motor function was 36.9% (interquartile range, 28.8% to 52.9%) for all patients with FT ( P = 0.151). The median restoration of smile was 37.2% (interquartile range, 31.5% to 52.7%) for all patients with FT ( P = 0.065). When facial nerve coaptation was performed at the distal branch level, average motor function restoration was 42.7% ± 3.61% compared with 27.9% ± 6.71% at the proximal trunk coaptation level ( P = 0.032). Use of interpositional nerve grafts had no influence on motor outcomes. CONCLUSIONS Software-based analysis is suitable to assess motor function after FT. International collaboration strengthens outcome data for FT. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Miguel I Dorante
- From the Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Lahey Hospital and Medical Center
| | - Alice T Wang
- From the Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Branislav Kollar
- From the Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Bridget J Perry
- Speech and Feeding Disorders Lab, Massachusetts General Hospital Institute of Health Profession
| | - Mustafa G Ertosun
- Department of Plastic and Reconstructive Surgery, Akdeniz University School of Medicine
| | - Andrew J Lindford
- Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki
| | - Emma-Lotta Kiukas
- Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki
| | - Ömer Özkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University School of Medicine
| | - Özlenen Özkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University School of Medicine
| | - Patrik Lassus
- Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki
| | - Bohdan Pomahac
- From the Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine
| |
Collapse
|
27
|
Nguyen M, Gonzalez L, Newman A, Cannon A, Zarebski SA, Chaudhry SI, Pomahac B, Boatright D, Dardik A. Rates of National Institutes of Health Funding for Surgeon-Scientists, 1995-2020. JAMA Surg 2023; 158:756-764. [PMID: 37195709 PMCID: PMC10193263 DOI: 10.1001/jamasurg.2023.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/17/2023] [Indexed: 05/18/2023]
Abstract
Importance Surgeon-scientists are uniquely positioned to facilitate translation between the laboratory and clinical settings to drive innovation in patient care. However, surgeon-scientists face many challenges in pursuing research, such as increasing clinical demands that affect their competitiveness to apply for National Institutes of Health (NIH) funding compared with other scientists. Objective To examine how NIH funding has been awarded to surgeon-scientists over time. Design, Setting, and Participants This cross-sectional study used publicly available data from the NIH RePORTER (Research Portfolio Online Reporting Tools Expenditures and Results) database for research project grants awarded to departments of surgery between 1995 and 2020. Surgeon-scientists were defined as NIH-funded faculty holding an MD or MD-PhD degree with board certification in surgery; PhD scientists were NIH-funded faculty holding a PhD degree. Statistical analysis was performed from April 1 to August 31, 2022. Main Outcome National Institutes of Health funding to surgeon-scientists compared with PhD scientists, as well as NIH funding to surgeon-scientists across surgical subspecialties. Results Between 1995 and 2020, the number of NIH-funded investigators in surgical departments increased 1.9-fold from 968 to 1874 investigators, corresponding to a 4.0-fold increase in total funding (1995, $214 million; 2020, $861 million). Although the total amount of NIH funding to both surgeon-scientists and PhD scientists increased, the funding gap between surgeon-scientists and PhD scientists increased 2.8-fold from a $73 million difference in 1995 to a $208 million difference in 2020, favoring PhD scientists. National Institutes of Health funding to female surgeon-scientists increased significantly at a rate of 0.53% (95% CI, 0.48%-0.57%) per year from 4.8% of grants awarded to female surgeon-scientists in 1995 to 18.8% in 2020 (P < .001). However, substantial disparity remained, with female surgeon-scientists receiving less than 20% of NIH grants and funding dollars in 2020. In addition, although there was increased NIH funding to neurosurgeons and otolaryngologists, funding to urologists decreased significantly from 14.9% of all grants in 1995 to 7.5% in 2020 (annual percent change, -0.39% [95% CI, -0.47% to -0.30%]; P < .001). Despite surgical diseases making up 30% of the global disease burden, representation of surgeon-scientists among NIH investigators remains less than 2%. Conclusion and Relevance This study suggests that research performed by surgeon-scientists continues to be underrepresented in the NIH funding portfolio, highlighting a fundamental need to support and fund more surgeon-scientists.
Collapse
Affiliation(s)
- Mytien Nguyen
- MD-PhD Program, Yale School of Medicine, New Haven, Connecticut
| | - Luis Gonzalez
- MD-PhD Program, Yale School of Medicine, New Haven, Connecticut
| | - Ashley Newman
- Howard University School of Medicine, Washington, DC
| | - Ashley Cannon
- Technical Resources International, Bethesda, Maryland
| | | | - Sarwat I. Chaudhry
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Dowin Boatright
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Surgery, Veterans Affairs Connecticut Healthcare System, West Haven
| |
Collapse
|
28
|
Mookerjee VG, Stögner VA, Alper DP, Evans BG, Pomahac B. Single Stitch Vicryl Mesh Wrap for Prepectoral Implant Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e5058. [PMID: 37313479 PMCID: PMC10259646 DOI: 10.1097/gox.0000000000005058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/13/2023] [Indexed: 06/15/2023]
Abstract
Acellular dermal matrices are commonly used in prepectoral breast reconstruction for implant coverage and support, but they are associated with significant costs. The authors describe a technique for prepectoral breast reconstruction in which the implant is completely wrapped in a knitted Vicryl mesh and then positioned on the chest, without the need for any tacking sutures. A retrospective review was performed on all consecutive prepectoral breast reconstructions, using this technique at a single institution. A separate cohort undergoing prepectoral reconstruction with a conventional acellular dermal matrix technique was also reviewed for comparison. Patient demographics, oncologic and reconstruction characteristics, outcomes, complications, and materials cost were analyzed. Twelve patients (23 breasts) underwent prepectoral reconstruction with Vicryl mesh, and 34 patients (55 breasts) underwent prepectoral reconstruction with acellular dermal matrices. Overall complication rates in the Vicryl group were low (two infections, one case of skin necrosis, one hematoma) and did not differ statistically from the acellular dermal matrix group. Operative time per breast was nearly twice as fast (35.7 versus 68.0 min, P < 0.01). Calculated materials cost savings was $8273 per breast. Prepectoral breast reconstruction with Vicryl mesh only is a safe technique that is much faster and significantly cheaper compared with conventional reconstructive techniques utilizing acellular dermal matrices.
Collapse
Affiliation(s)
- Vikram G. Mookerjee
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Viola A. Stögner
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - David P. Alper
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Brogan G.A. Evans
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Bohdan Pomahac
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| |
Collapse
|
29
|
Knoedler L, Knoedler S, Panayi AC, Lee CAA, Sadigh S, Huelsboemer L, Stoegner VA, Schroeter A, Kern B, Mookerjee V, Lian CG, Tullius SG, Murphy GF, Pomahac B, Kauke-Navarro M. Cellular activation pathways and interaction networks in vascularized composite allotransplantation. Front Immunol 2023; 14:1179355. [PMID: 37266446 PMCID: PMC10230044 DOI: 10.3389/fimmu.2023.1179355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is an evolving field of reconstructive surgery that has revolutionized the treatment of patients with devastating injuries, including those with limb losses or facial disfigurement. The transplanted units are typically comprised of different tissue types, including skin, mucosa, blood and lymphatic vasculature, muscle, and bone. It is widely accepted that the antigenicity of some VCA components, such as skin, is particularly potent in eliciting a strong recipient rejection response following transplantation. The fine line between tolerance and rejection of the graft is orchestrated by different cell types, including both donor and recipient-derived lymphocytes, macrophages, and other immune and donor-derived tissue cells (e.g., endothelium). Here, we delineate the role of different cell and tissue types during VCA rejection. Rejection of VCA grafts and the necessity of life-long multidrug immunosuppression remains one of the major challenges in this field. This review sheds light on recent developments in decoding the cellular signature of graft rejection in VCA and how these may, ultimately, influence the clinical management of VCA patients by way of novel therapies that target specific cellular processes.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Catherine A. A. Lee
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sam Sadigh
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Lioba Huelsboemer
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Viola A. Stoegner
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Andreas Schroeter
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Barbara Kern
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Vikram Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Christine G. Lian
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - George F. Murphy
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
30
|
Kauke-Navarro M, Knoedler S, Panayi AC, Knoedler L, Haller B, Parikh N, Huelsboemer L, Stoegner VA, Kiefer J, Eisenhardt SU, Azzi J, Pomahac B. Correlation between facial vascularized composite allotransplantation rejection and laboratory markers: Insights from a retrospective study of eight patients. J Plast Reconstr Aesthet Surg 2023; 83:155-164. [PMID: 37276734 DOI: 10.1016/j.bjps.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The field of facial vascularized composite allotransplantation (fVCA) is still new and a limited number of patients have undergone the procedure. This has led to a lack of understanding about the impact of fVCA rejection on standard laboratory markers (e.g., CBC, BMP, CRP) for the acute management of these patients. It is not clear if rejection elicits a systemic inflammatory response that influences common inflammatory markers such as WBC and CRP. A comprehensive understanding of changes in these markers could help in the management of fVCA patients in the acute setting. METHODS The medical records of 8 fVCA patients with a total of 9 transplants were reviewed retrospectively, and data on standard laboratory values (CBC, BMP, LFTs, CRP) and vital signs were extracted. To examine the relationship between laboratory values and rejection status, linear mixed models were used to analyze the data, taking into account their longitudinal nature (repeated measures). RESULTS A statistically significant relationship was found between the Banff grade of rejection and the relative number of basophils in the patient's blood during rejection (p = 0.005). In addition, in patients with clinical signs of rejection (e.g., facial erythema, edema) and skin biopsy showing Banff ≥ II, CRP was found to be significantly elevated (p = 0.03). The WBC count remained stable during rejection, and the relative number of neutrophils was lower at the time of rejection, indicating possible consumption at the site of rejection. CONCLUSION During fVCA rejection, most standard laboratory parameters and vital signs appear to be stable. However, the levels of CRP and basophils were elevated during rejection, while the neutrophil count was lower. Leukocytosis can likely be used as a marker of microbial infection in fVCA patients, as WBC does not seem to increase at the time of allograft rejection.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adriana C Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, Munich, Germany
| | - Neil Parikh
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lioba Huelsboemer
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Viola Antonia Stoegner
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA; Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Jamil Azzi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital and Children's Hospital, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
31
|
Lee CAA, Wang D, Kauke-Navarro M, Russell-Goldman E, Xu S, Mucciarone KN, Sohrabi S, Lian CG, Pomahac B, Murphy GF. Insights from Immunoproteomic Profiling of a Rejected Full Face Transplant. Am J Transplant 2023:S1600-6135(23)00405-7. [PMID: 37037378 DOI: 10.1016/j.ajt.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/24/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
Vascularized composite allografts (VCAs) of faces and extremities are subject to chronic rejection that is incompletely understood. Here we report on immunoproteomic evaluation of a full facial VCA removed 88 months after transplantation due to chronic rejection. CD8-positive T cells of donor (graft) origin infiltrating deep intragraft arteries in apposition to degenerating endothelium of chimeric recipient origin in association with arteriosclerotic alterations. Digital spatial proteomic profiling highlighted proteins expressed by activated cytotoxic T cells and macrophages as well as pathway components involved in atherogenic responses, including IDO1 and STING. Chronic facial VCA rejection thus involves T cell/macrophage-mediated accelerated arteriosclerosis not normally represented in punch biopsies and potentially driven by persistent graft-resident effector T cells and recipient target endothelium that chimerically repopulates graft arteries.
Collapse
Affiliation(s)
- Catherine A A Lee
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Diana Wang
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | | | | | - Shuyun Xu
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Kyla N Mucciarone
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Sadaf Sohrabi
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Bohdan Pomahac
- Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA.
| |
Collapse
|
32
|
Murakami N, Borges TJ, Win TS, Abarzua P, Tasigiorgos S, Kollar B, Barrera V, Ho Sui S, Teague JE, Bueno E, Clark RA, Lian CG, Murphy GF, Pomahac B, Riella LV. Low-dose interleukin-2 promotes immune regulation in face transplantation: A pilot study. Am J Transplant 2023; 23:549-558. [PMID: 36740193 PMCID: PMC10318113 DOI: 10.1016/j.ajt.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
Face transplantation is a life-changing procedure for patients with severe composite facial defects. However, it is hampered by high acute rejection rates due to the immunogenicity of skin allograft and toxicity linked to high doses of immunosuppression. To reduce immunosuppression-associated complications, we, for the first time in face transplant recipients, used low-dose interleukin 2 (IL-2) therapy to expand regulatory T cells (Tregs) in vivo and to enhance immune modulation, under close immunological monitoring of peripheral blood and skin allograft. Low-dose IL-2 achieved a sustained expansion (∼4-fold to 5-fold) of circulating Tregs and a reduction (∼3.5-fold) of B cells. Post-IL-2 Tregs exhibited greater suppressive function, characterized by higher expression of TIM-3 and LAG3co-inhibitory molecules. In the skin allograft, Tregs increased after low-dose IL-2 therapy. IL-2 induced a distinct molecular signature in the allograft with reduced cytotoxicity-associated genes (granzyme B and perforin). Two complications were observed during the trial: one rejection event and an episode of autoimmune hemolytic anemia. In summary, this initial experience demonstrated that low-dose IL-2 therapy was not only able to promote immune regulation in face transplant recipients but also highlighted challenges related to its narrow therapeutic window. More specific targeted Treg expansion strategies are needed to translate this approach to the clinic.
Collapse
Affiliation(s)
- Naoka Murakami
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Thiago J Borges
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA; Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Thet Su Win
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA; Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Phammela Abarzua
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA; Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Victor Barrera
- Bioinformatics Core, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Maryland, USA
| | - Shannan Ho Sui
- Bioinformatics Core, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Maryland, USA
| | - Jessica E Teague
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Ericka Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Rachael A Clark
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA; Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Leonardo V Riella
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA; Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Maryland, USA.
| |
Collapse
|
33
|
Wang AT, Panayi AC, Fischer S, Diehm YF, Tapking C, Hundeshagen G, Kneser U, Mastroianni M, Pomahac B, Haug V. Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis. Aesthet Surg J 2023; 43:NP231-NP241. [PMID: 36411260 DOI: 10.1093/asj/sjac293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The BREAST-Q questionnaire reduction module is an established tool for outcomes after reduction mammoplasty. OBJECTIVES This systematic review and meta-analysis assess key parameters affecting pre- and postoperative scores, with specific foci on patient characteristics and tissue resection weights. METHODS This study was conducted per PRISMA guidelines. PUBMED (National Institutes of Health; Bethesda, MD), Google Scholar (Google; Mountain View, CA), and Web of Science (Clarivate Analytics; Philadelphia, PA) were searched. All studies published before August 1, 2021, were assessed for eligibility by 2 independent reviewers. Inclusion criteria were prospective or retrospective studies in 6 languages that reported quality of life after reduction mammoplasty employing the BREAST-Q questionnaire reduction module. Quality of included studies was assessed employing the Newcastle-Ottawa-Scale. Analysis was performed per Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines. RESULTS A total of 28 papers were included in the systematic review, 13 for preoperative meta-analysis, and 17 for postoperative meta-analysis. Postoperative scores in all 3 quality of life domains (psychosocial, physical, and sexual well-being) and satisfaction with breasts increased significantly after reduction mammoplasty compared with preoperative scores. Satisfaction with breasts showed the greatest improvement, from 22.9 to 73.0. Preoperative scores were lower than normative data, with improvement to comparable scores as the healthy population postoperatively. Improvements in BREAST-Q scores did not correlate with patient comorbidities, complication rates, or amount of breast tissue resected. CONCLUSIONS Reduction mammoplasty provides marked improvement in BREAST-Q patient-reported quality of life as well established in literature. However, these improvements do not correlate with tissue resection weights, warranting further inquiry of insurance-defined resection requirements. LEVEL OF EVIDENCE: 3
Collapse
|
34
|
Knoedler S, Kauke-Navarro M, Haug V, Broer PN, Pomahac B, Knoedler L, Panayi AC. Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis. Aesthet Surg J 2023; 43:433-451. [PMID: 36472232 DOI: 10.1093/asj/sjac320] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction. OBJECTIVES The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care. METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed. RESULTS In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications. CONCLUSIONS This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.
Collapse
|
35
|
Panayi AC, Knoedler S, Kauke-Navarro M, Haug V, Obed D, Pomahac B. Face transplantation: a bibliometric analysis of the top 100 most cited articles. Eur J Plast Surg 2023. [DOI: 10.1007/s00238-023-02045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
36
|
Nguyen M, Gonzalez L, Chaudhry SI, Ahuja N, Pomahac B, Newman A, Cannon A, Zarebski SA, Dardik A, Boatright D. Gender Disparity in National Institutes of Health Funding Among Surgeon-Scientists From 1995 to 2020. JAMA Netw Open 2023; 6:e233630. [PMID: 36939702 PMCID: PMC10028489 DOI: 10.1001/jamanetworkopen.2023.3630] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/30/2023] [Indexed: 03/21/2023] Open
Abstract
Importance Surgical diseases account for approximately 30% of the global burden of disease. Gender diversity in biomedical research is critical to generate innovative patient-centered research in surgery. Objective To examine the distribution of biomedical research funding by the National Institutes of Health (NIH) among women and men surgeon-scientists during a 25-year period. Design, Setting, and Participants This cross-sectional study used publicly available data from the NIH RePORTER (Research Portfolio Online Reporting Tools: Expenditures and Results) database for research project grants awarded to women and men surgeon-scientists who were principal investigators between 1995 and 2020. Data were retrieved between January 20 and March 20, 2022. The representation of women surgeon-scientists among academic surgeons was compared with the representation of men surgeon-scientists over time. Main Outcomes and Measures Distribution of NIH funding to women and men surgeon-scientists was examined via 2 metrics: holding a large-dollar (ie, R01-equivalent) grant and being a super principal investigator (SPI) with $750 000 or more in total annual research funding. Statistical analysis was performed between April 1 and August 31, 2022. Results Between 1995 and 2020, 2078 principal investigator surgeons received funding from the NIH. The proportion of women academic surgeons who were surgeon-scientists remained unchanged during this same period (1995, 14 of 792 [1.8%] vs 2020, 92 of 3834 [2.4%]; P = .10). Compared with their men counterparts, women surgeon-scientists obtained their first NIH grant earlier in their career (mean [SD] years after first faculty appointment, 8.8 [6.2] vs 10.8 [7.9] years; P < .001) and were as likely to obtain large-dollar grants (aRR, 0.99 [95% CI, 0.95-1.03]) during the period 2016 to 2020. Despite this success, women surgeon-scientists remained significantly underrepresented among SPIs and were 25% less likely to be an SPI (aRR, 0.75 [95% CI, 0.60-0.95] during the period 2016 to 2020). Conclusions and Relevance The findings of this cross-sectional study of NIH-funded surgeons suggest that women surgeons remained underrepresented among surgeon-scientists over a 25-year period despite early career success in receiving NIH funding. This is concerning and warrants further investigation to increase the distribution of NIH funding among women surgeon-scientists.
Collapse
Affiliation(s)
| | | | - Sarwat I. Chaudhry
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
- Department of Biological and Biomedical Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Bohdan Pomahac
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ashley Newman
- Howard University School of Medicine, Washington, DC
| | - Ashley Cannon
- Technical Resources International, Bethesda, Maryland
| | | | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Department of Biological and Biomedical Sciences, Yale School of Medicine, New Haven, Connecticut
- Department of Surgery, VA Connecticut Healthcare System, West Haven
| | - Dowin Boatright
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York, New York
| |
Collapse
|
37
|
Knoedler S, Hoch CC, Huelsboemer L, Knoedler L, Stögner VA, Pomahac B, Kauke-Navarro M, Colen D. Postoperative free flap monitoring in reconstructive surgery-man or machine? Front Surg 2023; 10:1130566. [PMID: 36911625 PMCID: PMC9992807 DOI: 10.3389/fsurg.2023.1130566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Free tissue transfer is widely used for the reconstruction of complex tissue defects. The survival of free flaps depends on the patency and integrity of the microvascular anastomosis. Accordingly, the early detection of vascular comprise and prompt intervention are indispensable to increase flap survival rates. Such monitoring strategies are commonly integrated into the perioperative algorithm, with clinical examination still being considered the gold standard for routine free flap monitoring. Despite its widespread acceptance as state of the art, the clinical examination also has its pitfalls, such as the limited applicability in buried flaps and the risk of poor interrater agreement due to inconsistent flap (failure) appearances. To compensate for these shortcomings, a plethora of alternative monitoring tools have been proposed in recent years, each of them with inherent strengths and limitations. Given the ongoing demographic change, the number of older patients requiring free flap reconstruction, e.g., after cancer resection, is rising. Yet, age-related morphologic changes may complicate the free flap evaluation in elderly patients and delay the prompt detection of clinical signs of flap compromise. In this review, we provide an overview of currently available and employed methods for free flap monitoring, with a special focus on elderly patients and how senescence may impact standard free flap monitoring strategies.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - Cosima C. Hoch
- Department of Otolaryngology, Head and Neck Surgery, Rechts der Isar Hospital, Technical University Munich, Munich, Germany
| | - Lioba Huelsboemer
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Viola A. Stögner
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - David Colen
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| |
Collapse
|
38
|
Perry BJ, Eshghi M, Stipancic KL, Richburg B, Ventresca H, Pomahac B, Green JR. Longitudinal Recovery of Speech Motor Function Following Facial Transplantation: A Prospective Observational Study. Laryngoscope 2022; 132:2359-2367. [PMID: 35218215 PMCID: PMC9402794 DOI: 10.1002/lary.30068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/10/2022] [Accepted: 02/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Although facial transplantation is considered effective for restoring facial appearance, research on speech outcomes following surgery is limited. More research is critically needed to inform patients of expected rates and extent of recovery, and to develop interventions aimed at improving speech outcomes. METHODS Four patients in early recovery (3 weeks-24 months postsurgery) and three patients in late recovery (36-60 months postsurgery) were included. Clinical measures of speech recovery, including speech intelligibility measured using the Sentence Intelligibility Test, a lip strength testing device (Iowa Oral Performance Instrument), and kinematic measures of lip and jaw function measured using high-resolution 3D optical motion capture were used to describe the rate and extent of functional speech and lip recovery, describe and compare the rate of functional speech recovery and kinematic lip and jaw changes in early and late stages of recovery, and explore the association between kinematic measures and functional speech. RESULTS Speech intelligibility, speaking rate, and lip strength were below normative values in the first 2 years of postsurgery. Participants in the first 2 years of recovery demonstrated steeper slopes of improvement in clinical and kinematic measures than participants in the later stages of recovery (36-64 months). Gains in jaw range of movement and gains in lip speed and range of movement were significantly correlated with rates of sentence intelligibility improvement. Gains in lip strength were not associated with functional speech improvement. CONCLUSIONS These findings motivate ongoing work aimed at developing interventions for improving motor speech function in this population. LEVEL OF EVIDENCE 3 Laryngoscope, 132:2359-2367, 2022.
Collapse
Affiliation(s)
- Bridget J. Perry
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,Brigham and Women's HospitalDepartment of Plastic and Reconstructive Surgery, BostonBostonMassachusettsU.S.A.
| | - Marziye Eshghi
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,Massachusetts General HospitalAthinoula A. Martinos Center for Biomedical Imaging, MGHBostonMassachusettsU.S.A.
| | - Kaila L. Stipancic
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,University at BuffaloDepartment of Communication Sciences and DisordersBuffaloNew YorkU.S.A.
| | - Brian Richburg
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
| | - Hayden Ventresca
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
| | - Bohdan Pomahac
- Brigham and Women's HospitalDepartment of Plastic and Reconstructive Surgery, BostonBostonMassachusettsU.S.A.
| | - Jordan R. Green
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
| |
Collapse
|
39
|
Nizzi MC, Pomahac B. In the face of change: Which coping strategies predict better psychosocial outcomes in face transplant recipients? Front Psychol 2022; 13:995222. [PMID: 36467137 PMCID: PMC9712221 DOI: 10.3389/fpsyg.2022.995222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/25/2022] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVES Face transplantation aims to improve patients' quality of life and psychosocial functioning in patients with a disfiguring injury. With 40 cases worldwide, little is known about coping strategies predicting resilient outcomes. DESIGN Six patients followed in Boston, completed the Brief COPE (Carver, 1997) along with validated measures of depression, self-esteem, and quality of life - every 3 months during the first year post-transplant and every 6 months thereafter, up to 36 months post-transplant. ANALYSES Due to sample size and distribution of the data, nonparametric tests were used to characterize the relation of coping strategies with psychosocial outcomes. RESULTS As expected, active coping strategies were associated with better mental health pre-transplant, while avoidant coping strategies were associated with poorer mental health. Patients using support-based strategies reported better mental health at baseline. Post-transplant, the pattern reversed such that avoidant strategies appeared protective, when looking at mental health trajectories over 18 months. Importantly, trends identified during the first 18 months matched the trajectories of all patients with existing data up to 36 months post-transplant, for all outcomes measured. CONCLUSION Different coping strategies support optimal outcomes in the pre-versus post-transplant phases. Pre-transplant data may better inform interventions supporting mental health of transplant candidates than predict post-transplant behavior. Early post-transplant data seems to provide promising insight in long term psychosocial outcomes. CLINICAL IMPLICATIONS Our data stresses the need for pre-transplant assessment of coping and post-transplant coping training. Research aiming to optimize post-transplant psychosocial outcomes should consider coping as a promising target for intervention.
Collapse
Affiliation(s)
- Marie-Christine Nizzi
- Dartmouth College, Hanover, MD, United States
- UCLA Health System, Los Angeles, CA, United States
- Chapman University, Los Angeles, CA, United States
| | | |
Collapse
|
40
|
Rodrigue JR, Shenkel J, Boger M, Pomahac B, Fleishman A. Video Messaging to Increase Vascularized Composite Allograft Donation Willingness in United States Military Veterans. Transplant Direct 2022; 8:e1355. [PMID: 36204186 PMCID: PMC9531254 DOI: 10.1097/txd.0000000000001355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022] Open
Abstract
Expansion of vascularized composite allograft (VCA) transplantation depends on the public's willingness to donate VCA organs, including face, extremities, and genitourinary organs. This study evaluated the effectiveness of video messaging on VCA donation willingness in US military veterans, a key stakeholder in VCA transplantation. Methods Participants (n = 556) were randomized to 1 of 3 VCA video messaging interventions (informational, testimonial, or blended), a general (non-VCA) organ donation video message, or a control (nondonation) video message. Questionnaires were completed at pre- and postintervention and at 3-wk follow-up. Results Veterans exposed to any VCA video messaging were more likely to express VCA donation willingness (69%, n = 203/296) than those exposed to general donation messaging (53%, n = 47 of 89; P = 0.006) or No Donation Messaging (37%, n = 36 of 97; P < 0.001). A significantly higher proportion of participants who received Blended VCA Messaging were willing to be VCA donors, compared with the Informational VCA Messaging group (79% versus 61%, P = 0.006). Each VCA messaging video resulted in a significant pre- to postintervention increase in the proportion of participants willing to donate their own face, hands, and legs (P < 0.03). Conclusions Brief educational videos focused on VCA transplantation can have a demonstrable and verifiable impact on rates of VCA donation willingness in veterans.
Collapse
Affiliation(s)
- James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Jessica Shenkel
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Bohdan Pomahac
- Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| |
Collapse
|
41
|
Eskandari SK, Allos H, Al Dulaijan BS, Melhem G, Sulkaj I, Alhaddad JB, Saad AJ, Deban C, Chu P, Choi JY, Kollar B, Pomahac B, Riella LV, Berger SP, Sanders JSF, Lieberman J, Li L, Azzi JR. mTORC1 Inhibition Protects Human Regulatory T Cells From Granzyme-B-Induced Apoptosis. Front Immunol 2022; 13:899975. [PMID: 35757726 PMCID: PMC9229986 DOI: 10.3389/fimmu.2022.899975] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/05/2022] [Indexed: 01/17/2023] Open
Abstract
Regulatory T cells (Tregs) have shown great promise as a means of cellular therapy in a multitude of allo- and auto-immune diseases—due in part to their immunosuppressive potency. Nevertheless, the clinical efficacy of human Tregs in patients has been limited by their poor in vivo homeostasis. To avert apoptosis, Tregs require stable antigenic (CD3ζ/T-cell-receptor-mediated), co-stimulatory (CD28-driven), and cytokine (IL-2-dependent) signaling. Notably, this sequence of signals supports an activated Treg phenotype that includes a high expression of granzymes, particularly granzyme B (GrB). Previously, we have shown that aside from the functional effects of GrB in lysing target cells to modulate allo-immunity, GrB can leak out of the intracellular lysosomal granules of host Tregs, initiating pro-apoptotic pathways. Here, we assessed the role of inhibiting mechanistic target of rapamycin complex 1 (mTORC1), a recently favored drug target in the transplant field, in regulating human Treg apoptosis via GrB. Using ex vivo models of human Treg culture and a humanized mouse model of human skin allotransplantation, we found that by inhibiting mTORC1 using rapamycin, intracytoplasmic expression and functionality of GrB diminished in host Tregs; lowering human Treg apoptosis by in part decreasing the phosphorylation of S6K and c-Jun. These findings support the already clinically validated effects of mTORC1 inhibition in patients, most notably their stabilization of Treg bioactivity and in vivo homeostasis.
Collapse
Affiliation(s)
- Siawosh K Eskandari
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Hazim Allos
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Basmah S Al Dulaijan
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gandolina Melhem
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ina Sulkaj
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Graduate Program in Immunology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Juliano B Alhaddad
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Anis J Saad
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christa Deban
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Philip Chu
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - John Y Choi
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Branislav Kollar
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Division of Plastic and Reconstructive Surgery, Smilow Cancer Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Leonardo V Riella
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Center of Transplantation Sciences, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Stefan P Berger
- Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jan S F Sanders
- Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Judy Lieberman
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Li Li
- Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jamil R Azzi
- Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
42
|
Panayi AC, Foroutanjazi S, Parikh N, Haug V, Kauke-Navarro M, Diehm YF, Pomahac B. The modified 5-item frailty index is a predictor of perioperative risk in breast reconstruction: An analysis of 40,415 cases. J Plast Reconstr Aesthet Surg 2022; 75:2941-2954. [PMID: 35599223 DOI: 10.1016/j.bjps.2022.04.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 02/23/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aging population has presented surgeons with new challenges as they increasingly must operate on greater numbers of frail patients. The modified frailty index 5 (mFI-5) is a concise comorbidity-based scale that has been shown to accurately predict adverse surgical outcomes. In this study, we sought to evaluate the ability of the mFI-5 to predict the risk of postoperative outcomes in breast reconstruction patients. METHODS Utilizing the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 40,415 patients who underwent breast reconstruction, of which 29,562 were implant-based reconstructions and 10,853 were autologous breast reconstructions. Demographic and preoperative variables as well as 30-day postoperative outcomes, including mortality, operation duration, length of hospital stay, medical and surgical complications, and discharge destination, were extracted. RESULTS Increases in the mFI score correlated with higher rates of reoperation (mFI≥3: 13.5% vs. mFI=0: 5.9%), unplanned readmission (mFI≥3: 10.8% vs. mFI=0: 3.6%), surgical (mFI≥3: 12.2% vs. mFI=0: 4.3%) and medical complications (mFI≥3: 6.8% vs. mFI=0: 1.2%), and lower rates of home discharge (mFI≥3: 96% vs. mFI=0: 99.5%). Multivariate analysis to control for confounders verified significantly higher rates of reoperation (OR=0.01, 95%CI 0.005-0.016), unplanned readmission (OR=0.009, 95%CI 0.005-0.014), and occurrence of surgical complications (OR=0.014, 95%CI 0.009-0.019) and medical complications (OR=0.005, 95%CI 0.002-0.008). Stratification by age showed that the mFI-5 was a stronger risk predictor in younger patients who are frail. Stratification by type of reconstruction showed that increased mFI scores significantly correlated with complications in both autologous and implant-based reconstruction, but the correlation was greater in autologous procedures. CONCLUSION The mFI-5 is identified as a powerful risk predictor in breast reconstruction. The application of this easily accessible tool in the preoperative risk stratification of patients undergoing breast reconstruction can enhance treatment planning and support, optimizing patient counseling, informed consent, and decision-making.
Collapse
Affiliation(s)
- Adriana C Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States.
| | - Sina Foroutanjazi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States; Tufts University School of Medicine, Boston, MA, United States
| | - Neil Parikh
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States
| | - Valentin Haug
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States; Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States
| | - Yannick F Diehm
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston 02115, United States; Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, United States.
| |
Collapse
|
43
|
Petruzzo P, Kanitakis J, Sardu C, Bassiri Gharb B, Morelon E, Amer H, Barret J, Burt J, Brandacher G, Gomez T, Kay S, Kaminska D, Kaufman CL, Kumar DS, Iglesias M, Iyer S, Landin L, Lanzetta M, Lassus P, Levin S, Papay F, Pomahac B, Sassu P, Satbhai NG, Talbot S. VCA in the Era of the COVID-19 Pandemic. Transplantation 2022; 106:690-692. [PMID: 35333847 PMCID: PMC8942593 DOI: 10.1097/tp.0000000000004041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/27/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Palmina Petruzzo
- Department of Transplantation, Hôpital Edouard Herriot, HCL, Lyon, France
- Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Jean Kanitakis
- Department of Dermatology, Hôpital Edouard Herriot, HCL, Lyon, France
| | - Claudia Sardu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Emmanuel Morelon
- Department of Transplantation, Hôpital Edouard Herriot, HCL, Lyon, France
- Université Claude Bernard, Lyon 1, Lyon, France
| | - Hatem Amer
- Division of Nephrology and Hypertension, The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, NY
| | - Juan Barret
- Department of Plastic Surgery and Burns, Hospital Universitari Vall d'Hebron, Department of Surgery, Barcelona, Spain
| | - James Burt
- St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Tomas Gomez
- Virgen del Rocío University Hospital, Andalusian Health Service, and Ibis- Biomedicine Institute of Sevilla, Seville, Spain
| | - Simon Kay
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, United Kingdom
| | - Dorotha Kaminska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Christina L Kaufman
- Department of Cardiovascular and Thoracic Surgery. University of Louisville, Louisville, KY
| | - Dinesh S Kumar
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Martin Iglesias
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán," Mexico City, Mexico
| | - Subramania Iyer
- Plastic/Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Luis Landin
- Plastic and Reconstructive Surgery FIBHULP/IdiPAz Hospital Universitario "La Paz", Madrid, Spain
| | | | - Patrick Lassus
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery (Plastic Surgery), University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Francis Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paolo Sassu
- Department of Hand Surgery, Sahlgrenska University Hospital, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Nilesh G Satbhai
- Department of Plastic, Hand and Reconstructive Microsurgery, Global Hospital, Parel, Mumbai, India
| | - Simon Talbot
- Division of Plastic Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
44
|
Borges TJ, Abarzua P, Gassen RB, Kollar B, Lima-Filho M, Aoyama BT, Gluhova D, Clark RA, Islam SA, Pomahac B, Murphy GF, Lian CG, Talbot SG, Riella LV. T cell-attracting CCL18 chemokine is a dominant rejection signal during limb transplantation. Cell Rep Med 2022; 3:100559. [PMID: 35492875 PMCID: PMC9040185 DOI: 10.1016/j.xcrm.2022.100559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 01/14/2022] [Accepted: 02/12/2022] [Indexed: 11/16/2022]
Abstract
Limb transplantation is a life-changing procedure for amputees. However, limb recipients have a 6-fold greater rejection rate than solid organ transplant recipients, related in part to greater immunogenicity of the skin. Here, we report a detailed immunological and molecular characterization of individuals who underwent bilateral limb transplantation at our institution. Circulating Th17 cells are increased in limb transplant recipients over time. Molecular characterization of 770 genes in skin biopsies reveals upregulation of T cell effector immune molecules and chemokines, particularly CCL18. Skin antigen-presenting cells primarily express the chemokine CCL18, which binds to the CCR8 receptor. CCL18 treatment recruits more allo-T cells to the skin xenograft in a humanized skin transplantation model, leading to signs of accelerated graft rejection. Blockade of CCR8 remarkedly decreases CCL18-induced allo-T cell infiltration. Our results suggest that targeting the CCL18:CCR8 pathway could be a promising immunosuppressive approach in transplantation.
Collapse
Affiliation(s)
- Thiago J. Borges
- Schuster Family Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Phammela Abarzua
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Rodrigo B. Gassen
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, University of Freiburg Faculty of Medicine, 79106 Freiburg, Germany
| | - Mauricio Lima-Filho
- Schuster Family Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bruno T. Aoyama
- Schuster Family Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Diana Gluhova
- DF/HCC Specialized Histopathology Core – Massachusetts General Hospital Site, Boston, MA 02129, USA
| | - Rachael A. Clark
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston MA 02115, USA
| | - Sabina A. Islam
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - George F. Murphy
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Christine G. Lian
- Program in Dermatopathology, Department of Pathology, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Simon G. Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Leonardo V. Riella
- Schuster Family Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| |
Collapse
|
45
|
Haug V, Diehm YF, Kneser U, Pomahac B. Some Like It Hot—a Commentary to Ex Vivo Normothermic Perfusion of Human Upper Limbs. Transplantation 2022; 106:1522-1523. [DOI: 10.1097/tp.0000000000004046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Haug V, Kadakia N, Wang A, Dorante MI, Panayi AC, Kauke-Navarro M, Hundeshagen G, Diehm Y, Fischer S, Hirche C, Kneser U, Pomahac B. “Racial disparities in short-term outcomes after breast reduction surgery - A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching”. J Plast Reconstr Aesthet Surg 2022; 75:1849-1857. [DOI: 10.1016/j.bjps.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/05/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
|
47
|
Panayi AC, Haug V, Kauke-Navarro M, Diehm YF, Pomahac B. The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis. J Plast Reconstr Aesthet Surg 2021; 75:1360-1371. [PMID: 34955390 DOI: 10.1016/j.bjps.2021.11.074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 10/05/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Metabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction. METHODS Review of the 2015-2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge. RESULTS The MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group. CONCLUSION Patients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.
Collapse
Affiliation(s)
- Adriana C Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA
| | - Yannick F Diehm
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, 02115 Boston, USA.
| |
Collapse
|
48
|
Panayi AC, Haug V, Kauke-Navarro M, Foroutanjazi S, Diehm YF, Pomahac B. The modified 5-item frailty index is a predictor of perioperative risk in head and neck microvascular reconstruction: An analysis of 3795 cases. Am J Otolaryngol 2021; 42:103121. [PMID: 34171698 DOI: 10.1016/j.amjoto.2021.103121] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The modified frailty index 5 (mFI-5)-a scale based on the five variables diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and functional dependency-has been shown to be a valid predictor of surgical outcomes. In this study we sought to evaluate the ability of the mFI-5 to predict the postoperative outcomes of head and neck microvascular reconstruction. METHODS Review of the 2015-2019 American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) database identified 5323 cases of microvascular reconstruction, of which 3795 were head and neck cases that provided parameters necessary to calculate the mFI-5. The groups were compared in terms of demographics and comorbidities. Post-operative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and non-home discharge. RESULTS Increases in the mFI were associated with longer hospitalization periods (10.5 ± 7.5 days in mFI 0 vs 14.9 ± 15.4 in mFI ≥ 3; p < 0.0001) higher rates of mortality (1% in mFI 0 vs 3.1% in mFI ≥ 3; p = 0.02), reoperation (15.4% in mFI 0 vs 17.2% in mFI ≥ 3; p = 0.002) and unplanned readmission (7.6% in mFI 0 vs 18.8% in mFI ≥ 3; p = 0.001). Rates of any complications (p < 0.0001), as well as surgical (p < 0.002) and medical (p < 0.0001) complications specifically were higher with greater mFI scores. Higher mFI scores also predicted decreased home discharge (p < 0.0001). Differences remained significant on multivariate analysis and subgroup analysis by age. CONCLUSION The mFI-5 is a significant predictor of risk in microvascular head and neck reconstruction. Subgroup analysis by age highlights that the tool can help identify younger patients who are frail and hence at risk. Through appropriate pre-operative identification of frail patients surgeons can prospectively modify their operative and discharge planning as well as post-operative support.
Collapse
|
49
|
Fullerton ZH, Tsangaris E, DeVries CEE, Klassen AF, Aycart MA, Sidey-Gibbons CJ, Pusic AL, Pomahac B. Patient-reported outcomes measures used in facial vascularized composite allotransplantation: A systematic literature review. J Plast Reconstr Aesthet Surg 2021; 75:33-44. [PMID: 34753682 DOI: 10.1016/j.bjps.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Facial vascularized composite allotransplantation (fVCA) is a life-enhancing procedure performed to improve quality of life (QOL). Patient-reported outcome measures (PROMs) are tools used to assess QOL from the patients' perspective, and are increasingly recognized as an important clinical metric to assess outcomes of treatment. A systematic literature review was performed to identify and appraise the content of PROMs used in fVCA. METHODS We searched PUBMED/Medline, CINAHL, Embase, PsychInfo, and Web of Science from their inception through to June 2020. Included studies used a PROM in candidates and recipients of fVCA of any gender or age. We excluded abstracts, reviews, editorials, and dissertations. Items from each PROM were extracted and coded, using top-level codes and subcodes, to develop a preliminary conceptual framework of QOL concerns in fVCA, and to guide future PROM selection. RESULTS Title and abstract screening of 6089 publications resulted in 16 studies that met inclusion criteria. Review of the 16 studies identified 38 PROMs, none of which were developed for fVCA. Review of the coded content for each PROM identified six top-level codes (appearance, facial function, physical, psychological and social health, and experience of care) and 16 subcodes, making up the preliminary conceptual framework. CONCLUSION There are currently no PROMs designed to measure QOL concerns of fVCA candidates and recipients. Findings from this systematic review will be used to inform an interview guide for use in qualitative interviews to elicit and refine important concepts related to QOL in fVCA.
Collapse
Affiliation(s)
- Zoe H Fullerton
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Elena Tsangaris
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Claire E E DeVries
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Mario A Aycart
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | | | - Andrea L Pusic
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Bohdan Pomahac
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
50
|
Kauke M, Panayi AC, Safi AF, Haug V, Perry B, Kollar B, Nizzi MC, Broyles J, Annino DJ, Marty FM, Sinha I, Lian CG, Murphy GF, Chandraker A, Pomahac B. Full facial retransplantation in a female patient-Technical, immunologic, and clinical considerations. Am J Transplant 2021; 21:3472-3480. [PMID: 34033210 DOI: 10.1111/ajt.16696] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 01/25/2023]
Abstract
There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.
Collapse
Affiliation(s)
- Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget Perry
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, Massachusetts, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie-Christine Nizzi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Justin Broyles
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald J Annino
- Division of Otolaryngology, Department of Surgery, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Indranil Sinha
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anil Chandraker
- Schuster Transplantation Research Center, Renal Division, Boston, Massachusetts, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|