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Background: Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy. Methods: A retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database for patients over the age of 65 years who underwent a panniculectomy between 2010 and 2015 was conducted. The mFI-5 score was calculated for each patient based on the presence of diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status, and an mFI-5 score of 2 was used as a cutoff. Multivariate logistic and linear regression analysis was used to determine the validity of the mFI-5 as a predictor of postoperative complications. Results: A total of 575 patients were analyzed. Patients with an mFI-5 score of 2 or more (421; 73.2%) had significantly higher rates of wound complications (19.5% versus 12.8%; P = 0.03), overall complications (33.8% versus 19.5%; P < 0.001), and significantly longer hospital length of stay (3.6±5.0 versus 1.9±3.0; P < 0.001). mFI-5 score of 2 or more was an independent risk factor for wound complications (odds ratio, 1.26; 95% confidence interval, 1.08–2.20; P = 0.04) and overall complications (odds ratio, 1.34; 95% confidence interval, 1.09–2.15; P = 0.02). Conclusions: Frailty, as measured by the mFI-5, holds a predictive value regarding outcomes of wound complications and overall complications in elderly patients after panniculectomy. The mFI-5 score can be used to identify high-risk patients before surgery.

Learning Objectives: After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. Summary: This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.

Summary Over the past 15 years, landmark achievements have established facial transplantation (FT) as a feasible reconstructive option for otherwise irreparable craniofacial defects. However, as the field matures and long-term outcomes begin to emerge, FT teams around the world are now facing new challenges. Data for this review were identified by searches of the PubMed/MEDLINE database from inception through August 2020. All English-language articles pertaining to FT were included. Significant advances in candidate selection, technology, operative technique, posttransplant care, and immunosuppressive management have contributed to the tremendous expansion of the field, culminating in the execution in the past 3 years of 2 facial re-transplantations, and most recently the world’s first successful combined face and double hand transplant in August 2020. Despite these achievements, the allograft donor pool remains limited, with long wait times, requiring surgical experimentation with cross-sex FT. Immunosuppressive management has improved, but significant adverse events continue to be reported. Most recently, the COVID-19 pandemic has placed an unprecedented strain on the healthcare system, with various implications for the practice of reconstructive transplantation. In this article, we provide the most comprehensive and up-to-date FT review, highlighting fundamental lessons learned and recent advancements, while looking toward the challenges ahead. Over the past 15 years, extensive multidisciplinary efforts have been instrumental to the establishment of FT as a feasible reconstructive option. As novel challenges are beginning to emerge, continued collaborative and multispecialty research efforts are needed to further this field.