Perioral wrinkles: histologic differences between men and women

BACKGROUND

Women tend to develop more and deeper wrinkles in the perioral region than men. Although much is known about the complex mechanisms involved in skin aging, previous studies have described histologic differences between men and women with respect to skin aging only incidentally and have not investigated the perioral region.

OBJECTIVE

The purpose of this study was to investigate gender-specific differences in the perioral skin.

METHODS

To determine wrinkle severity, skin surface replicas of the upper lip region in 10 male and 10 female fresh cadavers were analyzed by using the dermaTOP blue three-dimensional digitizing system (Breuckmann, Meersburg, Germany). In 30 fresh male and female cadavers, three full-thickness lip resections were investigated in a blinded fashion for specific histologic features. All results were statistically analyzed in a linear regression model with SPSS software (version 15.0; SPSS, Chicago, IL).

RESULTS

The female replicas showed more and deeper wrinkles than the male replicas (P < .01). Histologic analysis revealed that the perioral skin of men displayed a significantly higher number of sebaceous glands (P = .000; 95% confidence interval [CI] 23.6-53.2), sweat glands (P = .002; 95% CI 2.1-8.1), and a higher ratio between vessel area and connective tissue area in the dermis (P = .009; 95% CI 0.003-0.021). The amount of hair follicles did not significantly differ between men and women, although the average number of sebaceous glands per hair follicle was greater in men (P = .002; 95% CI 0.33-1.28).

CONCLUSIONS

Women exhibit more and deeper wrinkles in the perioral region and their skin contains a significantly smaller number of appendages than men, which could be a feasible explanation for why women are more susceptible to development of perioral wrinkles.

Contractile and morphological properties of hamster retractor muscle following 16 h of cold preservation

INTRODUCTION

Cold hypoxia is a common factor in cold tissue preservation and mammalian hibernation. The purpose of this study was to determine the effects of cold preservation on the function of the retractor (RET) muscle of the hamster in the non-hibernating state and compare these with previously published data (van der Heijden et al., 2000) on the rat cutaneus trunci (CT) muscle.

MATERIALS AND METHODS

After cold storage (16 h at 4 degrees C), muscles were stimulated electrically to measure maximum tetanus tension (P(0)) and histologically analyzed. The protective effects of addition of the antioxidants trolox and deferiprone and the calcium release inhibitor BDM to the storage fluid were determined.

RESULTS

After storage, the twitch threshold current was increased (from 60 to 500 microA) and P(0) was decreased to 27% of control. RET morphology remained unaffected. RET muscle function was protected by trolox and deferiprone (P(0), resp., 43% and 59% of control). Addition of BDM had no effect on the RET.

CONCLUSIONS

The observed effects of cold preservation and of trolox and deferiprone on the RET were comparable to those on CT muscle function, as reported in a previously published study (van der Heijden et al., 2000). Both hamster RET and rat CT muscles show considerable functional damage due to actions of reactive oxygen species. In contrast to the CT, in the RET cold preservation-induced functional injury could not be prevented by BDM and was not accompanied by morphological damage such as necrosis and edema. This suggests that the RET myocytes possess a specific adaptation to withstand the Ca(2+) overload induced by cold ischemia.

Different models of training and certification in plastic surgery

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Hammering K-wires is superior to drilling with irrigation

Cooling during drilling Kirschner wires is not always effective in preventing thermal related damage. In this study, we used a human in vitro model and compared temperature elevation, insertion time, and extraction force between three Kirschner wire insertion methods-drilling with and without irrigation and pneumatic hammering. Forty five Kirschner wires were inserted into 15 fresh human cadaver metacarpals. All three insertion methods were applied in each metacarpal. Drilling without irrigation resulted in a temperature elevation of 67.25 +/- 5.4 degrees C with significantly lower values for drilling with irrigation (4.15 +/- 0.6 degrees C) and pneumatic hammering (31.52 +/- 3.4 degrees C). The insertion time for pneumatic hammering (47.63 +/- 8.8 s) was significantly lower compared to drilling without irrigation (263.16 +/- 36.5 s) and drilling with irrigation (196.10 +/- 28.5 s). Extraction forces after drilling without irrigation, drilling with irrigation, and pneumatic hammering were 39.85 +/- 4.1 N, 57.81 +/- 6.5 N, and 62.23 +/- 6.7 N, respectively. Pneumatic hammering is superior to drilling without irrigation, especially when irrigation is not possible.

Hammering versus drilling of sharp and obtuse trocar-point k-wires

Kirschner wire characteristics affect the heating of bone during insertion and the subsequent strength of fixation. We inserted 90 sharp and 90 obtuse trocar-tip K-wires into 90 fresh frozen human cadaver metacarpals using either a drill or a pneumatic hammer. The temperature elevation, insertion time and extraction force were measured for four K-wire insertion combinations: drilling sharp; drilling obtuse; hammering sharp; hammering obtuse. Hammering resulted in significantly lower temperature elevations than drilling. Hammering sharp K-wires resulted in the highest extraction forces. The first and fifth metacarpals showed significantly lower temperature elevations than the other metacarpals, while the insertion time was significantly higher in the second and third metacarpal than in the other metacarpals. Hammering sharp trocar-tip K-wires minimises thermal damage to bone and gives the strongest fixation.

Vascular anatomy of the hamster retractor muscle with regard to its microvascular transfer

BACKGROUND

The hamster retractor muscle (RET) is used as an in vivo model in studies of skeletal muscle ischemia-reperfusion injury. The RET is unique in that the muscle can be isolated while preserving the primary vascular supply so that its contractile function can be measured simultaneously with local microvascular responses to experimental interventions. The goal of this study was to understand the anatomical origin of the vascular supply to the RET and determine whether the RET can be used as a free flap after surgical isolation of the thoracodorsal vessels.

METHODS

Microdissection was performed to determine the anatomy of the vasculature that supplies and drains the RET.

RESULTS

Distinct numbers and patterns of feed arteries (2-4) and collecting veins (1-3) were identified (n = 26 animals). Dye injection (n = 8) of the thoracodorsal artery demonstrated that the RET remains perfused following its isolation on the thoracodorsal pedicle. Heterotopic allograft transplantation of the RET (n = 2) was performed by anastomosing the thoracodorsal vessels to the femoral vessels using the end-to-side technique.

CONCLUSIONS

The anatomical relationships indicate that the RET can be used as a free flap model for evaluating the effect of preservation strategies and transplantation on skeletal muscle microcirculation and contractile function.

A rat model of saliva secretory immunoglobulin: a suppression caused by intense exercise

We aimed to develop a valid model of immunosuppression induced by intense exercise in rats. Rats were divided into three groups. In the rest (Rest) group, saliva was collected from resting rats on 4 consecutive days. In the exercise (Ex) group, rats ran on a treadmill until exhaustion (exercise time: 60.0 +/- 3.7 min), and their saliva was collected before and after exercise; the salivary glands were removed after exercise. In the control (Con) group, saliva collection and gland removal were also performed, but the rats did not exercise. Secretory immunoglobulin A (SIgA) concentrations in saliva and polymeric immunoglobulin receptor (pIgR) mRNA expression in the glands were measured. There was no significant change in SIgA concentration in the Rest group over 4 days. In the Ex group, SIgA concentration decreased significantly after exercise compared with before, whereas there was no significant change in the Con group. The expression of pIgR mRNA was significantly lower in the Ex group post-exercise than in the Con group. Our procedure for saliva collection appeared suitable, and the exercise-induced SIgA suppression was probably caused by a decline in pIgR mRNA expression. We propose to use this reproducible and reliable rat model of exercise-induced SIgA suppression in future studies.

Keeping osteocytes alive: a comparison of drilling and hammering k-wires into bone

In this study, the insertion time and histological effects of drilling and hammering K-wires into bone are described. The insertion time was measured while drilling or hammering K-wires into the femurs and tibias of ten rabbits. Four K-wires, inserted into one hind limb, were used for histological examination directly after insertion and four K-wires inserted into the contralateral hind limb were used for the same measurements 4 weeks later. The specimens were scored for presence, or absence, of osteocytes, fragmentation of the bone edges, haemorrhage, microfractures, cortical reaction and callus formation around the pin track. The insertion time needed for drilling in K-wires was significantly longer than that of hammering. Drilling also resulted in the disappearance of the osteocytes in almost all sections while hammering did not have this effect but did result in more microfractures. Hammering K-wires may be a superior technique because it prevents osteonecrosis and requires a shorter insertion time.

Delayed skin allograft rejection following matrix membrane pretreatment

INTRODUCTION

No solution has been offered to induce long-term skin allograft survival in burn patients. We investigated whether transplant acceptance could be improved by a nonsystemic pretreatment of the graft and recipient wound surfaces with a bioengineered interface consisting of an acellular matrix membrane.

METHODS

Group 1 (n=30): Crosstransplants of untreated skin grafts between BALB/c and C57BL/6 mice. Group 2 (n=30): Crosstransplants of matrix-treated skin grafts between BALB/c and C57BL/6 mice. Group 3 (n=30): Retransplantation of skin grafts from the original donor on to the sensitised recipients. Sensitisation was accomplished by prior transplantation of an untreated skin allograft from the same donor (Group 1 mice). Two skin grafts were transplanted: one treated and one untreated.

RESULTS

Rejection occurred in the untreated group after a mean of 6.8 days (+/-1.5 days). In contrast, treatment with the bioengineered matrix membrane was found to substantially prolong allograft survival with a mean of 28 days (+/-3.8 days). Graft survival between the two groups reached statistical significance (P<0.05). In the sensitised mice, the untreated skin regrafts were all rejected in an accelerated fashion with an onset of less than 4 days (mean+/-1 days). However, the matrix membrane-treated skin regrafts were maintained for a mean of 18 days (+/-3 days).

CONCLUSION

These results show that treatment with the bioengineered matrix membrane greatly delays the onset of acute allograft rejection. The described topical application to the wound surfaces of both the graft and the recipient may offer a new and readily available source of wound coverage in patients with extensive burns.

Ear piercing techniques and their effect on cartilage, a histologic study

BACKGROUND

The popularity of high ear piercing has led to an increased incidence of perichondritis. Damage to the relatively avascular cartilage will make the ear prone to infection. The literature suggests that a piercing gun, mainly used by jewellers to pierce the lobule, may give excessive cartilaginous damage. Therefore some authors favour the piercing needle, as used in piercing studios. But until now, no comparative histological studies have been performed.

PURPOSE OF STUDY

To evaluate the extent of damage to ear cartilage using different piercing techniques.

METHODS

Twenty-two fresh human cadaver ears were pierced using two spring loaded piercing guns (Caflon and Blomdahl), one hand force system (Studex) and a piercing needle (16G i.v. catheter). Extent of damage to the perichondrium and cartilage was quantified using a transverse section along the pin tract and compared between the different methods.

RESULTS

The pattern of injury was similar in all techniques, showing perichondrium stripped from the cartilage around the pin tract, with most damage present on the exit site (mean length of 0.43 mm). Cartilage fractures and loose fragments were present over a mean length of 0.21 mm. No significant difference in the amount of injury between the different techniques was observed.

CONCLUSIONS

In contradiction with assumptions in the literature, all piercing methods give the same extent of damage to cartilage and perichondrium. Each method is expected to have the same risk for perichondritis, thus in the prevention of post-piercing perichondritis focus should be on other factors such as hygiene and after-care.

Drilling K-wires, what about the osteocytes? An experimental study in rabbits

INTRODUCTION

The function of osteocytes regarding osteonecrosis has been underestimated for a long time. Recently it has been suggested that apoptosis of osteocytes results in strong osteoclastic bone resorption. Death of osteocytes due to drilling may therefore increase the risk of K-wire loosening. The purposes of our in vivo study were to assess the minimal drill time needed to notice disappearance of osteocytes and to measure the distance of the empty osteocyte lacunae surrounding the drill tract in relation with the insertion time, directly and 4 weeks after drilling Kirschner (K-) wires into the femur and tibia of rabbits.

MATERIALS AND METHODS

Trocar tipped K-wires (70 mm length and 0.6 mm thickness) were drilled into the femur and tibia of 14 New Zealand white rabbits [mean body weight 2.81 kg (2.66-3.09 kg)]. Six rabbits were terminated following surgery (t = 0) and eight rabbits were terminated 4 weeks (t = 4) after surgery. Following termination, hematoxylin and eosin stained sections were cut from femur and tibia until the drill hole was visible. The sections were evaluated under a light microscope for the presence or absence of osteocytes in osteocyte lacunae surrounding the drill holes.

RESULTS

All osteocyte lacunae were empty around the K-wires in 50 and 87% of the cases, directly and 4 weeks after the surgery, respectively. The osteocytes disappeared especially beyond a drilling time of 37 s (P = 0.011) and 27 s (P = 0.008) at t = 0 and t = 4, respectively. Furthermore, a significantly positive correlation was seen between the distances of the empty osteocyte lacunae surrounding the drill holes in relation with time at t = 0 (P = 0.008) and t = 4 (P = 0.000).

CONCLUSION

Although only drilling without cooling was studied, short drilling times may prevent the disappearance of osteocytes in case cooling is not used in clinical practice as is the case in percutaneous K-wire insertion.

Risk Assessment of Immunosuppressive Therapy in Facial Transplantation

BACKGROUND

Immunosuppression-related risks are foremost among ethical concerns regarding facial transplantation. However, previous risk estimates are inaccurate and misleading, because they are based on data from studies using different immunosuppression regimens, health status of the transplant recipients, tissue composition, and antigenicity. This review provides a comprehensive risk assessment for facial transplantation based on comparable data of immunosuppression, recipient health status, and composition and antigenicity of the transplanted tissue.

METHODS

The risk estimates for face transplantation presented here are based on data reported in clinical kidney (10-year experience) and hand transplantation (5-year experience) studies using tacrolimus/mycophenolate mofetil/corticosteroid therapy. Mitigating factors including ease of rejection diagnosis, rejection reversibility, infection prophylaxis, patient selection, and viral serologic status are taken into account.

RESULTS

Estimated risks include acute rejection (10 to 70 percent incidence), acute rejection reversibility (approximating 100 percent with corticosteroid therapy alone), chronic rejection (<10 percent over 5 years), cytomegalovirus disease (1 to 15 percent), diabetes (5 to 15 percent), hypertension (5 to 10 percent), and renal failure (<5 percent).

CONCLUSIONS

A review of these data indicates that previously reported estimates of immunosuppression-related risks are outdated and therefore should no longer be used. These updated risk estimates should be used by facial transplant teams, institutional review boards, and potential recipients when considering the immunologic risks associated with facial transplantation.

Use of tissue expanders in adult postpneumonectomy syndrome

OBJECTIVE

Mediastinal shift and rotation after pneumonectomy can lead to severe symptomatic airway compression. Historically, a variety of treatments, such as muscle-flap transposition, pericardial fixation, and plombage, have been used. In this study we retrospectively evaluated the effectiveness of intrathoracic tissue expansion in postpneumonectomy syndrome.

METHODS

Since 1990, our center has used tissue expanders as plombage in patients with postpneumonectomy syndrome. Between 1990 and 2005, a total of 20 patients were treated. The outcome was evaluated by using preoperative, perioperative, and postoperative bronchoscopy and imaging studies. Patient satisfaction was determined with a validated questionnaire.

RESULTS

In 19 of the 20 patients, up to 3 tissue expanders were placed and filled within the pleural cavity. Access to the pleural cavity could not be obtained in 1 patient because of adhesions. Perioperative and postoperative bronchoscopic scans demonstrated decompression of the left main bronchus in 16 (84%) of 19 patients. On discharge, all patients reported improvement of their respiratory symptoms. Six (32%) patients required reoperation because of herniation (n = 2), luxation (n = 1), inadequate positioning (n = 2), and leakage of the tissue expander (n = 4). In 4 patients additional filling was performed in the outpatient clinic, with immediate improvement of respiratory distress.

CONCLUSION

Use of tissue expanders in adults with postpneumonectomy syndrome is an effective means of decompressing the remaining bronchus, thereby leading to a significant improvement in respiratory symptoms. Although 32% of patients required reoperation for complications, each complication was readily correctable.

Publications of plastic surgery research 1972 through 2004: a longitudinal trend analysis of three international journals

BACKGROUND AND PURPOSE OF STUDY

Assessment and benchmarking of research output is becoming a necessity in the quest for research funds and grants. However, reports on the trends in international research output by plastic surgeons over the years are lacking. We longitudinally analysed plastic surgery publications over the last three decades.

MATERIALS AND METHODS

Data on the topic of surgical interest and the anatomical region of research, the country of origin, and the origin and number of collaborating clinics were noted for each original article published in Plastic and Reconstructive Surgery, the British Journal of Plastic Surgery, and the European Journal of Plastic Surgery in 1972, 1980, 1988, 1996, and 2004.

MAIN FINDINGS AND CONCLUSIONS

The number of articles in three international plastic surgery journals has more than doubled over the last three decades. Reconstruction of acquired defects remained the most important topic in all three journals, but an interest in rejuvenation or aesthetic surgery seems to replace that in basic research. The head and neck area remains the anatomical region of most interest to date, but this interest has decreased substantially. Most articles still originate from the USA, but the absolute and relative number of articles originating from Europe and Asia is rapidly increasing. Also, the published output of multi-national scientific collaboration is increasing. Even though authors from larger countries, in general, contribute more publications in absolute numbers, authors from small countries have a more efficient output relative to the number of inhabitants and GDP of their country.

The prognostic value of abnormal findings on radiographic swallowing studies after total laryngectomy

Pharyngocutaneous fistulae are a common complication after total laryngectomy. Our study evaluates the correlation of postoperative radiographic swallowing studies and clinical symptoms. We also propose a grading system to classify leaks radiographically. The records of 45 patients who underwent total laryngectomy were retrospectively reviewed. All patients had a radiographic swallowing study (RSS) on or around the tenth postoperative day. A grading system was developed to classify radiographic findings (grade 0-5). Twenty-two patients had an abnormal RSS (grade 2-5). Three patients (13.6%) had clinical signs of impending fistula whereas radiography showed moderate leakage (grade 3) in one patient and a pharyngocutaneous fistula (grade 5) in two. The other 19 patients with radiographically demonstrated leakage had no clinical signs of anastomotic complications. After total laryngectomy, radiography may reveal anastomotic complications of varying severity. The grading system used in this study enabled us to objectively classify the radiological abnormalities on swallowing studies. Because most radiographic leakages were clinically silent and not all clinically apparent fistula were radiographically visible in our study, the role of routine postoperative radiographic swallowing studies in the absence of clinical signs or fistula remains unclear.

Bibliographic characteristics of plastic surgeons in The Netherlands: a 55-year survey

BACKGROUND

The allotment of grants is increasingly dependent on benchmarking of scientific output. Still, data to benchmark such output for plastic surgeons are lacking. Therefore, we retrieved these data for plastic surgeons in The Netherlands.

METHODS

We analysed the bibliographic and some biographic characteristics of all 223 plastic surgeons registered in The Netherlands from 1950 through 2004, as well as of all 61 trainee plastic surgeons. Biographic characteristics were obtained through the Netherlands Society of Plastic Surgery and bibliographic characteristics were retrieved from PubMed and the Science Citation Index. With these data, we established a trend of publications at various moments in the careers of plastic surgeons.

RESULTS

The age at graduation from medical school (27 years) and at the defence of PhD before registration (32 years) did not differ between specialists and residents. Eighteen residents (0.30) had already obtained a PhD, compared to the 34 specialists (0.15) who obtained their PhD prior to registration. Specialists made 2396 contributions to 1758 PubMed-indexed articles and residents made 327 contributions to 323 articles. Sixty percent of the specialists had published by the time of registration, whereas 79% of the current residents had already done so. The resident-authors had contributed to more articles (mean 6.8) than their predecessors had done at the moment of their registration (mean 4.7). Surgeons and residents published the greater part of their work in plastic surgery journals with relatively high impact factors. Sixty percent of the articles by residents and 45% of the articles by specialists had been cited by others, and articles by residents obtained a mean of 3.8 citations as compared to 4.3 citations to articles by specialist. Most specialists published until six years after registration.

CONCLUSIONS

The quantity and quality of publications by plastic surgeons and residents from The Netherlands increased over the studied 55-year period. Most specialists published from the moment of their graduation at medical school until six years after their registration as plastic surgeon. The residents of 2004 published more and better than their predecessors.

Function of the Clavicular Part of the Pectoralis Major Muscle After Transplantation of Its Sternocostal Part

BACKGROUND

Muscle-sparing transplantation of the sternocostal part of the pectoralis major muscle while preserving the clavicular part of the muscle may reduce donor-site morbidity, particularly in cases where dissection of the lymph nodes of the neck has been performed. The nerve supply and motor function of the clavicular part is alleged to be preserved when the sternocostal part is transposed through the deltopectoral groove. This study aims to objectify such preservation.

METHODS

Muscle activity of the remaining clavicular and abdominal muscle parts was determined electromyographically, dynamometrically, and goniometrically on 17 sides in 16 patients after head and neck reconstruction. Subjective assessment was obtained by use of a structured questionnaire.

RESULTS

The electromyogram proved preservation of innervation of 16 of 17 clavicular parts. The electromyogram of the abdominal part showed no signs of denervation on 10 sides and normal, full interference patterns at maximum voluntary effort in all patients. Selective functional testing of the clavicular part revealed decreased force in horizontal adduction in 11 out of 15 patients. Still, the isolated effect of the pectoralis major transposition on shoulder function could not be objectified statistically. Subjective evaluation yielded that shoulder disability was more likely to have been correlated with loss of trapezius muscle function.

CONCLUSION

We conclude that the innervation of the clavicular part, indeed, is preserved by transposition of the sternocostal part through the deltopectoral groove. This supports the validity, effectiveness, and functional acceptability of our muscle-sparing technique of partial pectoralis major transplantation.

Osteopetrosis complicated by osteomyelitis of the mandible: a case report including characterization of the osteopetrotic bone

A case of a 53-year-old Japanese man with osteopetrosis complicated by osteomyelitis of the mandible is presented. The patient experienced frequent exacerbations and remissions of osteomyelitis of the mandible, despite undergoing several surgical debridements and sequesterectomies with appropriate antimicrobial therapy, for 3 years. Finally, the patient underwent mandibular segmental resection followed by reconstruction with a titanium reconstruction plate. Fifty-one months after surgery there is no evidence of recurrent osteomyelitis of the mandible, suggesting that a more radical surgical approach is preferable for patients with severe complications resulting from osteopetrosis. Also presented here are the histopathological and biochemical features of the osteopetrotic bone. The osteopetrotic cortical bone was morbidly sclerotic with compact and irregular laminations. Degradation of osteocytes in the osteopetrotic bone was due to hypoxia and lack of nutrition resulting from osteosclerosis. There were no significant differences between osteopetrotic and normal bone according to X-ray diffraction, Fourier transform infrared spectroscopy, collagen content or mineral content. Micro-Vickers hardness measurements showed that osteopetrotic bone was significantly harder than normal bone, and the standard deviation of hardness was greater in osteopetrotic bone. Such a loss of integrity in osteopetrotic bone is considered to be a primary reason for the greater risk of a variety of complications such as pathological fracture and refractory osteomyelitis.

Investigation of Risk Acceptance in Facial Transplantation

BACKGROUND

The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant.

METHODS

To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures.

RESULTS

The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures.

CONCLUSIONS

This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.