Orthotopic forelimb transplantation in a Yucatan minipig model: Anatomic and in vivo study

INTRODUCTION

Above elbow transplants represent 19% of the upper extremity transplants. Previous large-animal models have been too distal or heterotopic, did not use immunosuppression and had short survival. We hypothesize that an orthotopic forelimb transplant model, under standard immunosuppression, is feasible and can be used to address questions on peri-transplant ischemia reperfusion injury, and post-transplantation vascular, immunologic, infectious, and functional outcomes.

MATERIALS AND METHODS

Four forelimbs were used for anatomical studies. Four mock transplants were performed to establish technique/level of muscle/tendon repairs. Four donor and four recipient female Yucatan minipigs were utilized for in-vivo transplants (endpoint 90-days). Forelimbs were amputated at the midarm and preserved through ex vivo normothermic perfusion (EVNP) utilizing an RBC-based perfusate. Hourly perfusate fluid-dynamics, gases, electrolytes were recorded. Contractility during EVNLP was graded hourly using the Medical Research Council scale. EVNP termination criteria included systolic arterial pressure ≥115 mmHg, compartment pressure ≥30 mmHg (at EVNP endpoint), oxygen saturation reduction of 20%, and weight change ≥2%. Indocyanine green (ICG) angiography was performed after revascularization. Limb rejection was evaluated clinically (rash, edema, temperature), and histologically (BANFF classification) collecting per cause and protocol biopsies (POD 1, 7, 30, 60 and endpoint). Systemic infections were assessed by blood culture and tissue histology. CT scan was used to confirm bone bridging at endpoint.

RESULTS

Animals 2, 4 reached endpoint with grade 0-I rejection. Limbs 1, 3 presented grade III rejection on days 6, 61. CsA troughs averaged 461 ± 189 ng/mL. EVNLP averaged 4.3 ± 0.52 h. Perfusate lactate, PO2 , and pH were 5.6 ± 0.9 mmol/L, 557 ± 72 mmHg and 7.5 ± 0.1, respectively. Muscle contractions were 4 [1] during EVNLP. Transplants 2, 3, 4 showed bone bridging on CT.

CONCLUSION

We present preliminary evidence supporting the feasibility of an orthotopic, mid-humeral forelimb allotransplantation model under standard immunosuppression regimen. Further research should validate the immunological, infectious, and functional outcomes of this model.

Artificial Intelligence for Perioperative Medicine: Perioperative Intelligence

The anesthesiologist's role has expanded beyond the operating room, and anesthesiologist-led care teams can deliver coordinated care that spans the entire surgical experience, from preoperative optimization to long-term recovery of surgical patients. This expanded role can help reduce postoperative morbidity and mortality, which are regrettably common, unlike rare intraoperative mortality. Postoperative mortality, if considered a disease category, will be the third leading cause of death just after heart disease and cancer. Rapid advances in technologies like artificial intelligence provide an opportunity to build safe perioperative practices. Artificial intelligence helps by analyzing complex data across disparate systems and producing actionable information. Using artificial intelligence technologies, we can critically examine every aspect of perioperative medicine and devise innovative value-based solutions that can potentially improve patient safety and care delivery, while optimizing cost of care. In this narrative review, we discuss specific applications of artificial intelligence that may help advance all aspects of perioperative medicine, including clinical care, education, quality improvement, and research. We also discuss potential limitations of technology and provide our recommendations for successful adoption.

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis

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

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

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

Cost analysis of conventional facial reconstruction procedures followed by face transplantation

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

Near-total human face transplantation for a severely disfigured patient in the USA

BACKGROUND

Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results.

METHODS

On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society.

FINDINGS

After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup.

INTERPRETATION

We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients.

FUNDING

None.

Coronal-Posterior Approach for Face/Scalp Flap Harvesting in Preparation for Face Transplantation

This report describes the development of a new technique for harvesting facial allograft for facial transplantation. The coronal-posterior surgical approach for facial/scalp flap harvesting from donor cadavers has been developed to allow extended length to the neurovascular bundles utilized in facial composite allograft transplantation. Cadaveric anatomic dissections were performed to harvest facial/scalp flaps via a posterior-coronal approach. Supraorbital and infraorbital neurovascular bundle lengths were extended by osteotomy of the cranial/orbital bone. The mental nerve lengths were extended into the inferior alveolar neurovascular bundle utilizing a sagittal split ramus osteotomy. This surgical approach extends the length of these craniofacial nerves for future neurorrhaphy. The mean length of the supraorbital, infraorbital, and mental nerves was 3.52 +/- 0.31 cm, 4.65 +/- 0.20 cm, 5.6 +/- 0.14 cm, respectively. Based on anatomical dissection in this cadaver study, the authors introduce a new technique for facial/scalp flap harvesting that extends the neurovascular bundles of sensory nerves of the anterior craniofacial skeleton.

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

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

The use of botulinum A toxin to ameliorate facial kinetic frown lines

PURPOSE

External photography and subjective response were used to evaluate the use of botulinum A toxin to diminish glabellar kinetic folds.

METHODS

Eleven patients with glabellar folds and midline forehead wrinkling received one to four injections of 0.1 ml of 100 U/1 ml botulinum A toxin. The injections were given into the procerus or corrugator muscles or both. The number of injections corresponded to the wrinkle lines in each patient. The patients were examined and photographed just before the injections and at 7 to 10 days after the injections. Treatment efficacy was judged by photographic evaluation and by the patient's subjective evaluation of the effect of the treatment.

RESULTS

Photographic evaluation showed objective improvement in the glabellar wrinkling in 6 of 11 patients in relaxed facial position and in all 11 patients during contraction of the periocular mulscles. Ten of the 11 patients reported satisfaction with their cosmetic results and indicated that they would choose to have the procedure done again.

CONCLUSIONS

The results of this study suggest that botulinum A toxin is a safe and effective treatment for glabellar folds.

Keratinocyte allografts accelerate healing of split-thickness donor sites: applications for improved treatment of burns

Grafting with split-thickness autograft skin remains the most effective method for treating burn wounds. When insufficient donor sites are present, decreasing the time required for healing of available donor sites permits more frequent reharvests to continue the grafting process. Cultured human keratinocytes speed wound healing by providing cover and by producing growth factors and extracellular matrix proteins. In this study we compare the rates of healing induced by allografts of cultured keratinocytes applied to split-thickness donor sites with healing by a standard treatment. Sheets of cultured human keratinocytes derived from neonatal foreskins are applied to a portion of a split-thickness donor site while the remainder is covered with a temporary skin substitute. The wound is inspected at 5, 7, 9, 11, 14, 17, 20, and 23 days. Biopsies are obtained at 7 days for light and electron microscopy. In 10 patients the average time to healing for sites covered with keratinocytes was 6.6 +/- 1.96 days compared with 12.6 +/- 4.32 days for control sites (p < 0.002). By day 7 most keratinocyte-covered sites showed reepithelization with the formation of a basement membrane and hemidesmosomes at the dermal-epidermal junction. Control areas were unhealed without epithelial coverage. The reepithelized donor sites from three patients treated with cultured keratinocytes were reharvested. In each case these grafts took, and they were equivalent to skin used from donor sites harvested for the first time. Keratinocyte allografts speed healing of split-thickness donor sites, thereby increasing the availability of autograft skin for burn wound coverage.

Laryngotracheal reconstruction. Extended vertical partial laryngectomy: reconstruction combining epiglottoplasty and the rotary door flap

This article explores various surgical techniques for vertical, partial laryngectomy in the treatment of laryngeal cancer. Potential for reconstruction and broader indications for such surgical procedures may be achieved by combining laryngeal epiglottoplasty with the rotary door sternohyoid myocutaneous flap.

Squamous cell papilloma at the tracheoesophageal puncture stoma

Over 140 tracheoesophageal punctures were performed at the Cleveland Clinic Foundation, Department of Otolaryngology and Communicative Disorders over the last seven years. In all cases the Blom-Singer duckbill prosthesis was utilized for alaryngeal voice restoration. Of these patients, two examples were noted where squamous cell papilloma was found at the tracheoesophageal stoma site. The preoperative evaluation and surgical laser technique for surgical excision of the papilloma with postoperative care are described. The case reports of each of the patients that have been diagnosed as having squamous cell papilloma of the tracheoesophageal puncture site are reviewed.