Role of allogeneic placental tissues in penile inversion vaginoplasty.

Background: The role of allogeneic placental tissue (APT) in genital gender-affirming surgery (GAS) is not well understood. Penile inversion vaginoplasty (PIV), the most common genital GAS, often results in tissue healing- or wound-related complications, including scarring and neovaginal stenosis. Surgical reoperation and revision vaginoplasty are common. The aim of this study was to evaluate the contribution of APT to postoperative outcomes in PIV. Methods: The authors performed a retrospective analysis of consecutive adult patients undergoing primary PIV during a 6-year period (September 1, 2014 to September 1, 2020). Subjects receiving intraoperative application of an APT biomaterial were compared to those undergoing primary PIV without APT. Postoperative outcomes-including wound healing morbidity and reoperation-were compared between groups. Short- and long-term complications were classified using Clavien-Dindo. Results: A total of 182 primary PIV cases were reviewed (115 conventional PIV; 67 PIV-APT). The postoperative follow-up time for the population averaged 12.7 months. All-cause and wound related complications were significantly lower amongst PIV-APT patients when compared to conventional PIV (P=0.002 and P=0.004, respectively). The rate of long-term complications was significantly lower in PIV-APT subjects: prolonged pain (P=0.001), prolonged swelling (P=0.047), and neovaginal stenosis (P<0.001). The PIV-APT group required significantly less reoperation for vaginal depth enhancement (P=0.007). Conclusions: Though its use in urogenital reconstruction has been limited, this study indicates that the placement of APT during PIV significantly lowered the risk of complications associated with poor wound healing. This supports a novel use for placental tissues in reducing complications in genital GAS.

Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Background: Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. Methods: We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. Results: A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. Conclusions: A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis.

Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.

Techniques and Applications of Lower Extremity Feminization and Masculinization.

Background: Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals. Methods: A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected. Results: A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "ideal" for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others. Conclusions: Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

Conscientious Objection to Gender-Affirming Surgery: Institutional Experience and Recommendations.

SUMMARY: As more academic institutions with surgical residency training programs begin to offer gender-affirming surgery, issues of trainee conscientious objection related to participation in these patient encounters may arise. In this article, the authors discuss their institutional experience with residents' conscientious objection to involvement in gender-affirming surgery. Although there are ethical arguments for and against conscientious objection, current U.S. federal policy grants all health care workers conscientious objector status upon their request. Recommendations are offered for other institutions that may experience similar situations regarding conscientious objection to gender-affirming care or to other aspects of plastic and reconstructive surgery.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

BACKGROUND: Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair. METHODS: A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated. RESULTS: Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed. CONCLUSIONS: The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Negative Impact of COVID-19 on Medical Education amongst Medical Students Interested in Plastic Surgery: A Cross-sectional Survey Study.

BACKGROUND: The COVID-19 pandemic has resulted in unpreceded changes to medical education. Medical students interested in urology and neurosurgery have reported concerns regarding COVID-19's effects on clinical experience and the residency application process; however, the impact amongst students interested in plastic surgery is unknown. We hypothesized that students applying into plastic surgery may experience much distress as a result of the COVID-19 pandemic. METHODS: An electronic survey was developed by 3 plastic surgery residents and 2 academic plastic surgeons and later refined by 4 fourth-year medical students. Questions focused on medical education curricular changes, perceived impact on medical education, and demographics. From April-May 2020 the survey was distributed to medical students who were interested in plastic surgery. Participants were identified through plastic surgery residency program personnel and social media platforms. RESULTS IN TOTAL: 130 of the 140 respondents reported interest in plastic surgery careers. An estimated 67% were in their clinical years or completing research year(s) before residency applications. Of the respondents, 80% believed that the COVID-19 pandemic had a negative impact on their medical education. Clinical-level students compared with preclinical-level students, and students applying to residency during the 2020-2021 match cycle compared with students not applying during the 2020-2021 match cycle were significantly more likely to perceive the COVID-19 pandemic as having a negative impact on their medical education (P = 0.04 and 0.03, respectively). CONCLUSION: Medical students interested in plastic surgery perceive the COVID-19 pandemic as having a negative impact on their education, likely due to a reduction in clinical exposure.

Facial Hair Transplantation for Transgender Patients: A Literature Review and Guidelines for Practice.

BACKGROUND: Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients. OBJECTIVES: This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients. METHODS: A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction. RESULTS: We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations. CONCLUSIONS: Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density.

Defining Aesthetic Preferences for the Penis: A Photogrammetric and Crowdsourcing Analysis.

BACKGROUND: Achieving an aesthetic phalloplasty result is important for patients with acquired or congenital defects of the penis, or with genital-related dysphoria. However, aside from length and girth, the aesthetic proportions of the male penis have not been defined. OBJECTIVES: This study aimed to determine proportions of the male penis through photogrammetric analysis of nude male photographs and to verify these proportions with a crowdsourcing-based survey. METHODS: Nude male photographs (n = 283) were analyzed to define aesthetic proportions of the male penis. Photographs were analyzed for the position of the penis on the torso in relation to the umbilicus and for the ratio of the dorsal and ventral glans of the penis in relation to the entire shaft length. Proportions were then further studied by crowdsourcing 1026 respondents with Amazon mechanical Turk. RESULTS: The ideal position of the penis below the umbilicus is about 55% (6/11th) of the distance from the jugular notch to the umbilicus (measured average, 53.6%; survey-weighted average, 58.9%). The dorsal glans of the penis is about 33% (1/3rd) of the length of the entire shaft (measured average, 32.1%; survey-weighted average, 37.5%). The ventral glans of the penis is about 12.5% (1/8th) of the length of the entire shaft (measured average, 12.6%; survey-weighted average, 11.7%). CONCLUSIONS: Measured proportions of the human penis follow exact fractions. Crowdsourcing data helped support photogrammetric analysis, with survey-preferred ratios within 5% of measured ratios. With further validation, these data can aid surgeons performing phalloplasty.

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction.

BACKGROUND: Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. METHODS: A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. RESULTS: Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I 2 = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication. CONCLUSION: A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty.

BACKGROUND: Estrogen therapy and penile inversion vaginoplasty (PIV) are necessary, life-saving interventions for many transfeminine patients. Patients undergoing PIV are generally at low baseline risk for venous thromboembolism (VTE) based on Caprini Score. Estrogen therapy may increase VTE risk in surgical patients, but its cessation may be psychiatrically dysphoric for transfeminine patients. AIM: This study examines whether perioperative estrogen cessation impacts VTE risk in patients undergoing PIV. METHODS: This was a pre-post study of patients undergoing PIV. From 2014 through 2018, all patients stopped estrogen therapy for 2 weeks before surgery and resumed 1 week postoperatively (group 1). Starting in 2019, all patients continued estrogen therapy perioperatively, with dose reductions for those whose dose was >6 mg/day (group 2). OUTCOMES: The primary outcome was 90-day VTE rate. RESULTS: 178 patients were included in the study, with 117 in group 1 and 61 in group 2. Median Caprini Score was 4 in group 1 (interquartile range: 3-6) and 3 in group 2 (interquartile range: 3-4) (P = .011). Complications per patient were higher in group 1 (2.2 vs 0.9, P < .001), with a longer follow-up (14.1 vs 10.2 months, P < .001). Rates of 90-day VTE were not different between groups (0.0% vs 1.6%, P = .166). CLINICAL IMPLICATIONS: Patients undergoing PIV are generally at low risk for VTE, based on 2005 Caprini Scores. This study provides preliminary evidence that perioperative estrogen therapy continuation does not appear to substantially increase VTE risk in transfeminine patients undergoing PIV with low Caprini Scores, although more investigation is needed to establish true safety. STRENGTHS & LIMITATIONS: Strengths include the pre-post design and single-surgeon experience, high proportion of patients with 90-day follow-up, and relatively large series to understand baseline VTE risk by Caprini Score in a PIV population. The main weakness of this study is its limited power to measure true differences in VTE risk based on estrogen continuation. CONCLUSIONS: This study suggests that perioperative estrogen continuation may be safe for patients undergoing PIV, the overwhelming majority of whom are at low baseline VTE risk. However, clinicians should weigh the magnitude of the risks and benefits of estrogen cessation on a case-by-case basis. Nolan IT, Haley C, Morrison SD, et al. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med 2021;18:193-200.

A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy.

INTRODUCTION: Anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care. METHODS: The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population. RESULTS: From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation. CONCLUSION: There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. 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. .

Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction.

BACKGROUND: Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS: A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS: The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION: Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

Current State of Transgender Medical Education in the United States and Canada: Update to a Scoping Review.

BACKGROUND: The published literature on education about transgender health within health professions curricula was previously found to be sporadic and fragmented. Recently, more inclusive and holistic approaches have been adopted. We summarize advances in transgender health education. METHODS: A 5-stage scoping review framework was followed, including a literature search for articles relevant to transgender health care interventions in 5 databases (Education Source, LGBT Source, MedEd Portal, PsycInfo, PubMed) from January 2017 to September 2019. Search results were screened to include original articles reporting outcomes of educational interventions with a transgender health component that included MD/DO students in the United States and Canada. A gray literature search identified continuing medical education (CME) courses from 12 health professional associations with significant transgender-related content. RESULTS: Our literature search identified 966 unique publications published in the 2 years since our prior review, of which 10 met inclusion criteria. Novel educational formats included interdisciplinary interventions, post-residency training including CME courses, and online web modules, all of which were effective in improving competencies related to transgender health care. Gray literature search resulted 15 CME courses with learning objectives appropriate to the 7 professional organizations who published them. CONCLUSIONS: Current transgender health curricula include an expanding variety of educational intervention formats driven by their respective educational context, learning objectives, and placement in the health professional curriculum. Notable limitations include paucity of objective educational intervention outcomes measurements, absence of long-term follow-up data, and varied nature of intervention types. A clear best practice for transgender curricular development has not yet been identified in the literature.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications.

BACKGROUND: The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. PATIENTS AND METHODS: Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. RESULTS: A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. CONCLUSION: ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.