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
|
Knoedler L, Dean J, Knoedler S, Kauke-Navarro M, Hollmann K, Alfertshofer M, Helm S, Prantl L, Schliermann R. Hard shell, soft core? Multi-disciplinary and multi-national insights into mental toughness among surgeons. Front Surg 2024; 11:1361406. [PMID: 38645505 PMCID: PMC11027567 DOI: 10.3389/fsurg.2024.1361406] [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: 12/25/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Background With the prevalence of burnout among surgeons posing a significant threat to healthcare outcomes, the mental toughness of medical professionals has come to the fore. Mental toughness is pivotal for surgical performance and patient safety, yet research into its dynamics within a global and multi-specialty context remains scarce. This study aims to elucidate the factors contributing to mental toughness among surgeons and to understand how it correlates with surgical outcomes and personal well-being. Methods Utilizing a cross-sectional design, this study surveyed 104 surgeons from English and German-speaking countries using the Mental Toughness Questionnaire (MTQ-18) along with additional queries about their surgical practice and general life satisfaction. Descriptive and inferential statistical analyses were applied to investigate the variations in mental toughness across different surgical domains and its correlation with professional and personal factors. Results The study found a statistically significant higher level of mental toughness in micro-surgeons compared to macro-surgeons and a positive correlation between mental toughness and surgeons' intent to continue their careers. A strong association was also observed between general life satisfaction and mental toughness. No significant correlations were found between the application of psychological skills and mental toughness. Conclusion Mental toughness varies significantly among surgeons from different specialties and is influenced by professional dedication and personal life satisfaction. These findings suggest the need for targeted interventions to foster mental toughness in the surgical community, potentially enhancing surgical performance and reducing burnout. Future research should continue to explore these correlations, with an emphasis on longitudinal data and the development of resilience-building programs.
Collapse
Affiliation(s)
- Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Jillian Dean
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Samuel 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
| | - Katharina Hollmann
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sabrina Helm
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Rainer Schliermann
- Faculty of Social and Health Care Sciences, Regensburg University of Applied Sciences, Regensburg, Germany
| |
Collapse
|
4
|
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
|
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
|
Kauke-Navarro M, Knoedler L, Deniz C, Knoedler S, Safi AF. Early outcomes and risk factors for complications after facial alloplastic implant surgery: An ACS-NSQIP study. J Plast Reconstr Aesthet Surg 2024; 90:209-214. [PMID: 38387417 DOI: 10.1016/j.bjps.2024.02.021] [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: 12/15/2023] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Facial implantology (FI) is a growing field in facial surgery that focuses on harmonizing and balancing facial features. Despite its increasing popularity, larger-scale studies on FI outcomes and risks are scarce. METHODS The ACS-NSQIP (2008-2021) was queried to identify patients who underwent combined/isolated alloplastic FI surgery of the malar/mandibular region. Based on CPT codes (21125; 21270), procedures were subdivided into combined or isolated FI surgery of the malar or the mandibular region. RESULTS The study population included 84 patients, of which n = 19 (23%), n = 10 (12%), n = 33 (39%), and n = 22 (26%) underwent combined malar, isolated malar, combined mandibular, and isolated mandibular FI surgery, respectively. Isolated malar (total n = 10) and mandibular FI surgery (total n = 22) patients had relatively high comorbidity rates with up to n = 6 (60%) active smokers and n = 9 (41%) with hypertension, respectively. Combined malar (n = 19) and mandibular FI surgeries (n = 33) had the highest complication rates with n = 3 (16%) and n = 5 (15%) patients experiencing any complications. For both isolated malar and mandibular FI procedures, n = 1 (10% and 4.5%) patient reported any complications. CONCLUSION In this study, we accessed the ACS-NSQIP database and found alloplastic augmentation for zygoma and mandible to be safe. Patients who underwent combined procedures and mandibular augmentation were more likely to show complications or require inpatient stay. Most alloplastic augmentations of mandible or zygoma were combined with other procedures (62%) which suggests that alloplastic facial implants (in the academic setting) are often used as an adjunct in the treatment of complex craniofacial disorders.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA; Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland.
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Can Deniz
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland; Faculty of Medicine, University of Bern, Bern, Switzerland.
| |
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
|
Kauke-Navarro M, Knoedler L, Knoedler S, Deniz C, Stucki L, Safi AF. Balancing beauty and science: a review of facial implant materials in craniofacial surgery. Front Surg 2024; 11:1348140. [PMID: 38327548 PMCID: PMC10847330 DOI: 10.3389/fsurg.2024.1348140] [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: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 02/09/2024] Open
Abstract
Facial reconstruction and augmentation, integral in facial plastic surgery, address defects related to trauma, tumors infections, and congenital skeletal deficiencies. Aesthetic considerations, including age-related facial changes, involve volume loss and diminished projection, often associated with predictable changes in the facial skeleton. Autologous, allogeneic, and alloplastic implants are used to address these concerns. Autologous materials such as bone, cartilage, and fat, while longstanding options, have limitations, including unpredictability and resorption rates. Alloplastic materials, including metals, polymers, and ceramics, offer alternatives. Metals like titanium are biocompatible and used primarily in fracture fixation. Polymers, such as silicone and polyethylene, are widely used, with silicone presenting migration, bony resorption, and visibility issues. Polyethylene, particularly porous polyethylene (MedPor), was reported to have one of the lowest infection rates while it becomes incorporated into the host. Polyether-ether-ketone (PEEK) exhibits mechanical strength and compatibility with imaging modalities, with custom PEEK implants providing stable results. Acrylic materials, like poly-methylmethacrylate (PMMA), offer strength and is thus mostly used in the case of cranioplasty. Bioceramics, notably hydroxyapatite (HaP), offer osteoconductive and inductive properties, and HaP granules demonstrate stable volume retention in facial aesthetic augmentation. Combining HaP with other materials, such as PLA, may enhance mechanical stability. 3D bioprinting with HaP-based bioinks presents a promising avenue for customizable and biocompatible implants. In conclusion, various materials have been used for craniofacial augmentation, but none have definitively demonstrated superiority. Larger randomized controlled trials are essential to evaluate short- and long-term complications comprehensively, potentially revolutionizing facial balancing surgery.
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, United States
- Craniologicum, Center for Craniomaxillofacial Surgery, Bern, Switzerland
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Can Deniz
- Craniologicum, Center for Craniomaxillofacial Surgery, Bern, Switzerland
| | - Lars Stucki
- Faculty of Medicine and Dentistry, Danube Private University, Krems, Austria
| | - Ali-Farid Safi
- Craniologicum, Center for Craniomaxillofacial Surgery, Bern, Switzerland
- Medical Faculty, University of Bern, Bern, Switzerland
| |
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, Hoch CC, Kauke-Navarro M, Kehrer A, Friedman L, Prantl L, Machens HG, Orgill DP, Panayi AC. An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell's Palsy. J Craniofac Surg 2024; 35:23-28. [PMID: 37695075 PMCID: PMC10841222 DOI: 10.1097/scs.0000000000009739] [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: 05/22/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND There exists a paucity of large-scale, multi-institutional studies that investigate the outcomes of surgery for Bell's palsy (BP). Here, we utilize a large, multi-institutional database to study the risk factors and early-stage outcomes following surgical procedures in BP. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2019) to identify patients who underwent surgery for the diagnosis of BP. We extracted data on comorbidities and preoperative blood values, and 30-day postoperative outcomes. RESULTS Two hundred fifty-seven patients who underwent surgery for BP symptoms over the 12-year review period were identified. Muscle grafts (n=50; 19%) and fascial grafts (n=48; 19%) accounted for the majority of procedures. The most common comorbidities were hypertension (n=89; 35%) and obesity (n=79; 31%). Complications occurred in 26 (10.1%) cases. Additionally, length of hospital stay was significantly associated with both surgical and medical complications (3.9±4.7 versus 1.5±2.0; P <0.01) and (3.2±3.8 versus 1.4±2.0; P <0.01), respectively. Preoperative creatinine, blood urea nitrogen, and alkaline phosphatase were identified as potential predictors of poor postoperative outcomes. CONCLUSION Based on multi-institutional analysis, complication rates following surgery for BP were found to be overall low and seen to correlate with length of hospital stay. Reoperations and readmissions were the most frequent complications after surgery for BP. The preoperative evaluation of routine laboratory values may help refine patient eligibility and risk stratification. In addition, our findings call for future large-scale prospective studies in the field of facial palsy surgery to further improve the quality of care and optimize perioperative protocols.
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 and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Cosima C. Hoch
- Department of Otolaryngology, Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Leigh Friedman
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Hans-Guenther Machens
- Department of Plastic and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
14
|
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
|
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
|
Knoedler L, Ruppel F, Kauke-Navarro M, Obed D, Wu M, Prantl L, Broer PN, Panayi AC, Knoedler S. Hair Transplantation in the United States: A Population-based Survey of Female and Male Pattern Baldness. Plast Reconstr Surg Glob Open 2023; 11:e5386. [PMID: 37964923 PMCID: PMC10642908 DOI: 10.1097/gox.0000000000005386] [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: 02/09/2023] [Accepted: 07/20/2023] [Indexed: 11/16/2023]
Abstract
Background Androgenetic alopecia, the most common type of hair loss, can impair the patient's overall mental health. Although there are pharmaceutical and surgical treatments available, little is known about the public standpoint toward hair transplantation (HT). Methods A sample of individuals living in the United States (n = 1000; male and female participants were equally distributed) was asked to fill out the questionnaire. The online survey was conducted in June 2022. Results Most participants (42%; n = 416) were between 41 and 60 years of age. Study participants frequently reported that, with their hair loss progressing, they would not feel attractive anymore (n = 400; 40%), nor as confident as before (n = 330; 33%). Although women with minimal hair loss were willing to spend a median price of $4000 [interquartile range (IQ) IQR $1000-$5000], women with extensive hair loss were willing to spend significantly more (median = $5000; IQR $3600-$6375; P = 0.011). This was reproducible in men (P = 0.033). Although significantly fewer women considered undergoing HT (430 women versus 447 men; P < 0.001), female participants were willing to pay more for their HT compared with men (P = 0.039). Conclusions Individuals living in the United States consider hair loss to impair their attractiveness and regard HT as a valuable therapeutic option. More affordable and gender-specific HT should be subject to future research work.
Collapse
Affiliation(s)
- Leonard Knoedler
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Felix Ruppel
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Lukas Prantl
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - 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, Mass
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Samuel Knoedler
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| |
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
|
Miragall MF, Knoedler S, Kauke-Navarro M, Saadoun R, Grabenhorst A, Grill FD, Ritschl LM, Fichter AM, Safi AF, Knoedler L. Face the Future-Artificial Intelligence in Oral and Maxillofacial Surgery. J Clin Med 2023; 12:6843. [PMID: 37959310 PMCID: PMC10649053 DOI: 10.3390/jcm12216843] [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: 10/06/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023] Open
Abstract
Artificial intelligence (AI) has emerged as a versatile health-technology tool revolutionizing medical services through the implementation of predictive, preventative, individualized, and participatory approaches. AI encompasses different computational concepts such as machine learning, deep learning techniques, and neural networks. AI also presents a broad platform for improving preoperative planning, intraoperative workflow, and postoperative patient outcomes in the field of oral and maxillofacial surgery (OMFS). The purpose of this review is to present a comprehensive summary of the existing scientific knowledge. The authors thoroughly reviewed English-language PubMed/MEDLINE and Embase papers from their establishment to 1 December 2022. The search terms were (1) "OMFS" OR "oral and maxillofacial" OR "oral and maxillofacial surgery" OR "oral surgery" AND (2) "AI" OR "artificial intelligence". The search format was tailored to each database's syntax. To find pertinent material, each retrieved article and systematic review's reference list was thoroughly examined. According to the literature, AI is already being used in certain areas of OMFS, such as radiographic image quality improvement, diagnosis of cysts and tumors, and localization of cephalometric landmarks. Through additional research, it may be possible to provide practitioners in numerous disciplines with additional assistance to enhance preoperative planning, intraoperative screening, and postoperative monitoring. Overall, AI carries promising potential to advance the field of OMFS and generate novel solution possibilities for persisting clinical challenges. Herein, this review provides a comprehensive summary of AI in OMFS and sheds light on future research efforts. Further, the advanced analysis of complex medical imaging data can support surgeons in preoperative assessments, virtual surgical simulations, and individualized treatment strategies. AI also assists surgeons during intraoperative decision-making by offering immediate feedback and guidance to enhance surgical accuracy and reduce complication rates, for instance by predicting the risk of bleeding.
Collapse
Affiliation(s)
- Maximilian F. Miragall
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Samuel 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
| | - Rakan Saadoun
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Alex Grabenhorst
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Florian D. Grill
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Lucas M. Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Andreas M. Fichter
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, 3011 Bern, Switzerland;
- Faculty of Medicine, University of Bern, 3010 Bern, Switzerland
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT 06510, USA
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| |
Collapse
|
21
|
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
|
22
|
Baecher H, Hoch CC, Knoedler S, Maheta BJ, Kauke-Navarro M, Safi AF, Alfertshofer M, Knoedler L. From bench to bedside - current clinical and translational challenges in fibula free flap reconstruction. Front Med (Lausanne) 2023; 10:1246690. [PMID: 37886365 PMCID: PMC10598714 DOI: 10.3389/fmed.2023.1246690] [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: 06/24/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023] Open
Abstract
Fibula free flaps (FFF) represent a working horse for different reconstructive scenarios in facial surgery. While FFF were initially established for mandible reconstruction, advancements in planning for microsurgical techniques have paved the way toward a broader spectrum of indications, including maxillary defects. Essential factors to improve patient outcomes following FFF include minimal donor site morbidity, adequate bone length, and dual blood supply. Yet, persisting clinical and translational challenges hamper the effectiveness of FFF. In the preoperative phase, virtual surgical planning and artificial intelligence tools carry untapped potential, while the intraoperative role of individualized surgical templates and bioprinted prostheses remains to be summarized. Further, the integration of novel flap monitoring technologies into postoperative patient management has been subject to translational and clinical research efforts. Overall, there is a paucity of studies condensing the body of knowledge on emerging technologies and techniques in FFF surgery. Herein, we aim to review current challenges and solution possibilities in FFF. This line of research may serve as a pocket guide on cutting-edge developments and facilitate future targeted research in FFF.
Collapse
Affiliation(s)
- Helena Baecher
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Cosima C. Hoch
- Medical Faculty, Friedrich Schiller University Jena, Jena, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, 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
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bhagvat J. Maheta
- College of Medicine, California Northstate University, Elk Grove, CA, 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
| | - 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
| | - 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
| |
Collapse
|
23
|
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
|
24
|
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
|
25
|
Knoedler S, Knoedler L, Wu M, Haug V, Broer PN, Kauke-Navarro M, Hundeshagen G, Prantl L, Orgill DP, Panayi AC. Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis. J Craniofac Surg 2023; 34:1722-1726. [PMID: 37487058 DOI: 10.1097/scs.0000000000009553] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/24/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values. RESULTS We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events. CONCLUSION Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine; New Haven, CT
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
| |
Collapse
|
26
|
Bernasconi M, Bilic A, Kauke-Navarro M, Safi AF. Nodal tumor volume as a prognostic factor for oral squamous cell carcinoma-a systematic review. Front Oral Health 2023; 4:1229931. [PMID: 37654649 PMCID: PMC10467257 DOI: 10.3389/froh.2023.1229931] [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: 05/27/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Oral squamous cell carcinoma (OSCC) is a complex disease with a high potential for lymph node metastasis and poor survival rates. Accurate nodal staging is crucial for prognostic assessment and treatment planning in OSCC. Recent research has suggested that nodal tumor volume (NTV) may be a more accurate indicator of nodal disease burden than traditional staging methods. However, the prognostic significance of NTV in OSCC remains unclear. This systematic review aims to evaluate the existing evidence on the relationship between NTV and prognosis in OSCC. A comprehensive search of electronic databases was conducted, and studies meeting inclusion criteria were critically appraised and synthesized. Our review identified 23 studies that investigated the prognostic significance of NTV in OSCC. The majority of studies reported that larger NTV was associated with poorer survival outcomes, although the strength of the association varied. The review also identified several areas for future research, including the standardization of NTV measurement and the integration of NTV into the broader landscape of OSCC management. In conclusion, our review suggests that NTV holds promise as a novel prognostic factor in OSCC, but more research is needed to fully elucidate its potential and inform clinical decision-making.
Collapse
Affiliation(s)
| | - Ante Bilic
- Faculty of Medicine, University of Berne, Berne, Switzerland
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Ali-Farid Safi
- Faculty of Medicine, University of Berne, Berne, Switzerland
- Craniologicum, Center for Craniomaxillofacial Surgery, Berne, Switzerland
| |
Collapse
|
27
|
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
|
28
|
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
|
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
|
Knoedler L, Knoedler S, Kauke-Navarro M, Knoedler C, Hoefer S, Baecher H, Gassner UM, Machens HG, Prantl L, Panayi AC. Three-dimensional Medical Printing and Associated Legal Issues in Plastic Surgery: A Scoping Review. Plast Reconstr Surg Glob Open 2023; 11:e4965. [PMID: 37124385 PMCID: PMC10145872 DOI: 10.1097/gox.0000000000004965] [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: 12/05/2022] [Accepted: 03/09/2023] [Indexed: 05/02/2023]
Abstract
Three-dimensional printing (3DP) represents an emerging field of surgery. 3DP can facilitate the plastic surgeon's workflow, including preoperative planning, intraoperative assistance, and postoperative follow-up. The broad clinical application spectrum stands in contrast to the paucity of research on the legal framework of 3DP. This imbalance poses a potential risk for medical malpractice lawsuits. To address this knowledge gap, we aimed to summarize the current body of legal literature on medical 3DP in the US legal system. By combining the promising clinical use of 3DP with its current legal regulations, plastic surgeons can enhance patient safety and outcomes.
Collapse
Affiliation(s)
- Leonard Knoedler
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
| | - Christoph Knoedler
- Faculty of Applied Social and Health Sciences, Regensburg University of Applied Sciences, Regensburg, Germany
| | - Simon Hoefer
- Faculty of Law, University of Regensburg, Regensburg, Germany
| | - Helena Baecher
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | | | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lukas Prantl
- From the Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| |
Collapse
|
33
|
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
|
34
|
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]
|
35
|
Huelsboemer L, Kauke-Navarro M, Reuter S, Stoegner VA, Feldmann J, Hirsch T, Kueckelhaus M, Dermietzel A. Tolerance Induction in Vascularized Composite Allotransplantation-A Brief Review of Preclinical Models. Transpl Int 2023; 36:10955. [PMID: 36846605 PMCID: PMC9946984 DOI: 10.3389/ti.2023.10955] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 10/05/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023]
Abstract
Pre-clinical studies are an obligatory tool to develop and translate novel therapeutic strategies into clinical practice. Acute and chronic rejection mediated by the recipient's immune system remains an important limiting factor for the (long-term) survival of vascularized composite allografts (VCA). Furthermore, high intensity immunosuppressive (IS) protocols are needed to mitigate the immediate and long-term effects of rejection. These IS regiments can have significant side-effects such as predisposing transplant recipients to infections, organ dysfunction and malignancies. To overcome these problems, tolerance induction has been proposed as one strategy to reduce the intensity of IS protocols and to thereby mitigate long-term effects of allograft rejection. In this review article, we provide an overview about animal models and strategies that have been used to induce tolerance. The induction of donor-specific tolerance was achieved in preclinical animal models and clinical translation may help improve short and long-term outcomes in VCAs in the future.
Collapse
Affiliation(s)
- Lioba Huelsboemer
- Division of Plastic and Reconstructive Surgery, School of Medicine, Yale University, New Haven, CT, United States
- Institute of Musculoskeletal Medicine, University Hospital Münster, Münster, Germany
| | - Martin Kauke-Navarro
- Division of Plastic and Reconstructive Surgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Stefan Reuter
- Division of General Internal Medicine, Nephrology and Rheumatology, Department of Medicine D, University Hospital Münster, Münster, Germany
| | - Viola A. Stoegner
- Division of Plastic and Reconstructive Surgery, School of Medicine, Yale University, New Haven, CT, United States
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hanover, Germany
| | - Jan Feldmann
- Institute of Musculoskeletal Medicine, University Hospital Münster, Münster, Germany
| | - Tobias Hirsch
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Münster, Münster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Münster, Germany
| | - Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Münster, Münster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Münster, Germany
| | - Alexander Dermietzel
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University Hospital Münster, Münster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Münster, Germany
| |
Collapse
|
36
|
Knoedler L, Odenthal J, Prantl L, Oezdemir B, Kehrer A, Kauke-Navarro M, Matar DY, Obed D, Panayi AC, Broer PN, Chartier C, Knoedler S. Artificial Intelligence-Enabled Simulation of Gluteal Augmentation: A Helpful Tool in Preoperative Outcome Simulation? J Plast Reconstr Aesthet Surg 2023; 80:94-101. [PMID: 37001299 DOI: 10.1016/j.bjps.2023.01.039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/14/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND While the buttock region is considered an esthetic hallmark, the Brazilian butt lift (BBL) remains controversially discussed in the plastic surgery community. This is due to its contentious safety profile. Thus, informed consent and patient education play a key role in preoperative planning. To this end, we aimed to program an easy-to-use, widely accessible, and low-budget algorithm that produces reliable outcome simulations. METHODS The conditional generative adversarial network (GAN) was trained using pre- and postoperative images from 1628 BBL patients. To validate outcome simulation, 25 GAN-generated images were assessed deploying 67 Amazon Mechanical Turk Workers (Mturks). RESULTS Mturks could not differentiate between GAN-generated and real patient images in approximately 49.4% of all trials. CONCLUSION This study presents a free-to-use, widely accessible, and reliable algorithm to visualize potential surgical outcomes that could potentially be applied in other fields of plastic surgery.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Jan Odenthal
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Berkin Oezdemir
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Dany Y Matar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Doha Obed
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Adriana C Panayi
- Department of Surgery, Division of Plastic 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
| | | | - Samuel Knoedler
- Department of Surgery, Division of Plastic 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.
| |
Collapse
|
37
|
Knoedler S, Matar DY, Knoedler L, Obed D, Haug V, Gorski SM, Kim BS, Kauke-Navarro M, Kneser U, Panayi AC, Orgill DP, Hundeshagen G. Association of age with perioperative morbidity among patients undergoing surgical management of minor burns. Front Surg 2023; 10:1131293. [PMID: 36923377 PMCID: PMC10008887 DOI: 10.3389/fsurg.2023.1131293] [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: 12/28/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023] Open
Abstract
Introduction Burn injuries are associated with significant morbidity, often necessitating surgical management. Older patients are more prone to burns and more vulnerable to complications following major burns. While the relationship between senescence and major burns has already been thoroughly investigated, the role of age in minor burns remains unclear. To better understand differences between elderly and younger patients with predominantly minor burns, we analyzed a multi-institutional database. Methods We reviewed the 2008-2020 ACS-NSQIP database to identify patients who had suffered burns according to ICD coding and underwent initial burn surgery. Results We found 460 patients, of which 283 (62%) were male and 177 (38%) were female. The mean age of the study cohort was 46 ± 17 years, with nearly one-fourth (n = 108; 23%) of all patients being aged ≥60 years. While the majority (n = 293; 64%) suffered from third-degree burns, 22% (n = 99) and 15% (n = 68) were diagnosed with second-degree burns and unspecified burns, respectively. An average operation time of 46 min, a low mortality rate of 0.2% (n = 1), a short mean length of hospital stay (1 day), and an equal distribution of in- and outpatient care (51%, n = 234 and 49%, n = 226, respectively) indicated that the vast majority of patients suffered from minor burns. Patients aged ≥60 years showed a significantly prolonged length of hospital stay (p<0.0001) and were significantly more prone to non-home discharge (p<0.0001). In univariate analysis, advanced age was found to be a predictor of surgical complications (p = 0.001) and medical complications (p = 0.0007). Elevated levels of blood urea nitrogen (p>0.0001), creatinine (p>0.0001), white blood cell count (p=0.02), partial thromboplastin time (p = 0.004), and lower levels of albumin (p = 0.0009) and hematocrit (p>0.0001) were identified as risk factors for the occurrence of any complication. Further, complications were more frequent among patients with lower body burns. Discussion In conclusion, patients ≥60 years undergoing surgery for predominantly minor burns experienced significantly more complications. Minor lower body burns correlated with worse outcomes and a higher incidence of adverse events. Decreased levels of serum albumin and hematocrit and elevated values of blood urea nitrogen, creatinine, white blood count, and partial thromboplastin time were identified as predictive risk factors for complications.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.,Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Dany Y Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Doha Obed
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sabina M Gorski
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| |
Collapse
|
38
|
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
|
39
|
Knoedler S, Kauke-Navarro M, Darwish O, Muehlberger T, Orgill DP, Panayi AC. Letter to the Editor: Insights into migraine surgery – An ACS-NSQIP data analysis over a 13- year period. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.10.016] [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: 11/05/2022]
|
40
|
Knoedler L, Baecher H, Kauke-Navarro M, Prantl L, Machens HG, Scheuermann P, Palm C, Baumann R, Kehrer A, Panayi AC, Knoedler S. Towards a Reliable and Rapid Automated Grading System in Facial Palsy Patients: Facial Palsy Surgery Meets Computer Science. J Clin Med 2022; 11:jcm11174998. [PMID: 36078928 PMCID: PMC9457271 DOI: 10.3390/jcm11174998] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 07/23/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Reliable, time- and cost-effective, and clinician-friendly diagnostic tools are cornerstones in facial palsy (FP) patient management. Different automated FP grading systems have been developed but revealed persisting downsides such as insufficient accuracy and cost-intensive hardware. We aimed to overcome these barriers and programmed an automated grading system for FP patients utilizing the House and Brackmann scale (HBS). Methods: Image datasets of 86 patients seen at the Department of Plastic, Hand, and Reconstructive Surgery at the University Hospital Regensburg, Germany, between June 2017 and May 2021, were used to train the neural network and evaluate its accuracy. Nine facial poses per patient were analyzed by the algorithm. Results: The algorithm showed an accuracy of 100%. Oversampling did not result in altered outcomes, while the direct form displayed superior accuracy levels when compared to the modular classification form (n = 86; 100% vs. 99%). The Early Fusion technique was linked to improved accuracy outcomes in comparison to the Late Fusion and sequential method (n = 86; 100% vs. 96% vs. 97%). Conclusions: Our automated FP grading system combines high-level accuracy with cost- and time-effectiveness. Our algorithm may accelerate the grading process in FP patients and facilitate the FP surgeon’s workflow.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Correspondence: ; Tel.: +49-151-448-249-58
| | - Helena Baecher
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Hans-Günther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Philipp Scheuermann
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Christoph Palm
- Regensburg Medical Image Computing Lab, Ostbayrische Technische Hochschule Regensburg, 93053 Regensburg, Germany
| | - Raphael Baumann
- Regensburg Medical Image Computing Lab, Ostbayrische Technische Hochschule Regensburg, 93053 Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
41
|
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
|
42
|
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]
|
43
|
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
|
44
|
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
|
45
|
Kauke-Navarro M, Tchiloemba B, Haug V, Kollar B, Diehm Y, Safi AF, Treister NS, Annino DJ, Marty FM, Lian CG, Murphy GF, Pomahac B. Pathologies of oral and sinonasal mucosa following facial vascularized composite allotransplantation. J Plast Reconstr Aesthet Surg 2020; 74:1562-1571. [PMID: 33376080 DOI: 10.1016/j.bjps.2020.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/18/2020] [Revised: 10/28/2020] [Accepted: 11/22/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cutaneous changes of facial vascularized composite allotransplants (fVCAs) are extensively described in the literature. Parts of the nose, nasal, and oral cavities are included in most fVCAs. Distinctively, the nose and mouth are lined by mucosa. Little is known about the histopathology and complications of the mucosa involved in fVCA patients. METHODS The study constitutes a retrospective cohort study of nine fVCA patients. Medical records were reviewed for information about changes of oral and nasal mucous membranes. Types of mucosal lesions were recorded and analyzed. Uni- and multivariate generalized estimating equation (GEE) models were used to assess the odds of developing mucosal inflammation in the presence of clinico-pathologic variables. RESULTS A total of 186 clinical encounters with examination of oral and nasal mucous membranes were included. Membranes were devoid of clinical pathology in 101 instances (53% of all clinical assessments). Ulcerations/erosions (27%), edema (18%), and erythema (14%) were the most common lesions. Oral lesions affected the lips (58%), buccal mucosa (38%), and palate (5%). Sinonasal processes predominantly affected nasal vestibules and septae. In univariate analysis, sirolimus, skin rejection, and skin Banff grade were associated with the presence of an acute inflammatory mucosal lesion (p<0.05). In multivariate analysis, skin Banff grade and sirolimus were independent predictors of mucosal inflammation. CONCLUSION Pathologies of fVCA mucous membranes are more common than previously reported. Mucosal assessment plays an important role in the pleomorphic allograft rejection process evaluation rather than diagnosis and treatment based on cutaneous pathology. A closer look at the pathophysiology of fVCA mucosal rejection and inflammation is warranted.
Collapse
Affiliation(s)
- Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Bianief Tchiloemba
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Yannick Diehm
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Nathaniel S Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, United States
| | - Donald J Annino
- Division of Otolaryngology, Department of Surgery, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, United States
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, United States
| | - Christine G Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - George F Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|