Accuracy of Orbital Shape Reconstruction-Comparative Analysis of Errors in Implant Shape Versus Implant Positioning: A Cadaveric Study.

INTRODUCTION: Orbital blowout fractures are commonly reconstructed with implants shaped to repair orbital cavity defects, restore ocular position and projection, and correct diplopia. Orbital implant shaping has traditionally been performed manually by surgeons, with more recent use of computer-assisted design (CAD). Accuracy of implant placement is also key to reconstruction. This study compares the placement accuracy of orbital implants, testing the hypothesis that CAD-shaped implants indexed to patient anatomy will better restore orbit geometry compared with manually shaped implants and manually placed implants. METHODS: The placement accuracy of orbital implants was assessed within a cadaveric blowout fracture model (3 skulls, 6 orbits) via 3-dimensional CT analysis. Defects were repaired with 4 different techniques: manually placed-manually shaped composite (titanium-reinforced porous polyethylene), manually placed CAD composite, indexed placed CAD composite, and indexed placed CAD titanium mesh. RESULTS: Implant placement accuracy differed significantly with the implant preparation method ( P =0.01). Indexing significantly improved the placement accuracy ( P =0.002). Indexed placed titanium mesh CAD implants (1.42±0.33 mm) were positioned significantly closer to the intact surface versus manually placed-manually shaped composite implants (2.12±0.39 mm). DISCUSSION: Computer-assisted design implants indexed to patient geometry yielded average errors below the acceptable threshold (2 mm) for enophthalmos and diplopia. This study highlights the importance of adequately indexing CAD-designed implants to patient geometry to ensure accurate orbital reconstructions.

Penile inversion vaginoplasty outcomes: Complications and satisfaction.

Penile inversion vaginoplasty helps to alleviate gender dysphoria and improve quality of life in many transgender individuals. Overall, the procedure is associated with high post-operative satisfaction, even when complications occur. Adverse events related to vaginoplasty are commensurate with other genitourinary reconstructive procedures performed for other diagnoses (ie, cancer or congenital issues). Here, we explore the incidence of complications following vaginoplasty, emphasizing the challenges in defining and managing these adverse events. In addition, outcome measures to assess patient satisfaction will be reviewed.

Guiding the conversation-types of regret after gender-affirming surgery and their associated etiologies.

BACKGROUND: A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. METHODS: This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. RESULTS: The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. CONCLUSIONS: In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Perioperative Transgender Hormone Management: Avoiding Venous Thromboembolism and Other Complications.

SUMMARY: This review discusses the current evidence regarding perioperative hormone therapy for transgender individuals, with an emphasis on strategies to reduce the risk of perioperative venous thromboembolism. Historically, surgeons routinely discontinued estrogen therapy in the perioperative period with the goal of reducing the risk of venous thromboembolism. However, abrupt estrogen cessation may also lead to adverse emotional and physiologic effects, including an exacerbation of one's gender dysphoria. The data on the relationship of feminizing hormones and venous thromboembolism in the perioperative setting are largely based on extrapolation of hormone regimens that are no longer in use and may not accurately reflect the actual risk of venous thromboembolism. Future studies will allow surgeons to engage in evidence-based, patient-centered, informed consent while also minimizing the risk of complications, such as venous thromboembolism.

Primary orbital fracture repair: development and validation of tools for morphologic and functional analysis.

The purpose of this study was to develop and validate a technique for objective quantitative evaluation of outcomes of orbital reconstruction. Facial three-dimensional images were captured using a Vectra three-dimensional camera. Morphometric analysis was based on interactive anthropometric identification. The analysis was applied to a population of healthy adults (n = 13) and a population of patients following primary repair of unilateral orbital fractures (n = 13). Morphologic results following reconstruction were evaluated by identifying residual asymmetries. All subjects further completed the Derriford Appearance Questionnaire and the Orbital Appearance and Function Questionnaire.Normative reference values for periorbital asymmetry were determined in a reference population. The mean asymmetry was less than 1.6 mm for each measured morphologic feature. In the trauma population, primary orbital reconstruction effectively restored normal periorbital symmetry in 16 of 20 measured parameters. The fracture population showed no significant differences in the degree of asymmetry in globe projection, lower eyelid position, or ciliary margin length.The overall DAS59 scores were significantly higher in the fracture population (P = 0.04). This was due to significantly higher physical distress and dysfunction scores (P = 0.02), as well as a trend toward higher general and social self-consciousness scores (P = 0.06). No significant difference in facial self-consciousness was noted (P = 0.21). Thus, although primary orbital reconstruction was effective in restoring periorbital morphology, patients still experienced a higher level of physical distress and dysfunction than their nontraumatized counterparts. This was in accordance with patient self-report, which indicated that a greater percentage of patients were significantly bothered by functional outcomes postoperatively as opposed to appearance.

Cognitive dietary restraint: impact on bone, menstrual and metabolic status in young women.

We compared bone mineral density (BMD) and content (BMC), menstrual and metabolic status between physically active women with 1) high cognitive dietary restraint (High-CDR) (score > or = 9, n=38) and Normal-CDR (score<9, n=46) and 2) across quartiles of CDR scores. Eighty-four physically active (500+/-35 min wk(-1)) premenopausal women participated and were categorized according to their CDR score. Primary outcomes included, BMD, BMC, menstrual status, estrone-3-glucuronide (E1G) and pregnanediol-3-glucuronide (PdG) area under the curve (AUC). Secondary outcomes included resting energy expenditure (REE), total triiodothyronine, and ghrelin. Measures of body mass (59.2+/-1.1 vs. 58.5+/-1.0 kg) and percent body fat (24.7+/-1.2 vs. 23.7+/-0.7%) were similar between women with Normal-CDR and High-CDR, however the High-CDR group had lower total body (1.140+/-0.011 vs. 1.179+/-0.010 g cm(-2); p=0.015) and lumbar spine (1.114+/-0.019 vs. 1.223+/-0.022 g cm(-2); p=0.001) BMD. The prevalence of oligo-amenorrhea was higher in the High-CDR group and became increasingly greater across the CDR quartiles. There were no differences in metabolic characteristics between the High-CDR and Normal-CDR groups, however REE and the ratio of measured to predicted REE were lower in the fourth quartile (CDR scores > or = 13) compared to the second and third quartiles. Our results provide evidence that high CDR scores are associated with reduced lumbar spine and total body BMD in physically active premenopausal women. A greater frequency of menstrual disturbances in women with higher CDR scores likely played a role in the reduced total body and lumbar spine BMD.

Drive for thinness score is a proxy indicator of energy deficiency in exercising women.

The purpose of this study was to determine the association between drive for thinness (DT) and adaptations to energy deficiency in exercising women. This observational study evaluated psychometric and metabolic factors in sedentary (n=9, 27.9+/-2.0 yr) and exercising women (n=43, 24.0+/-1.1 yr). Volunteers were retrospectively grouped according to exercise status (sedentary or exercising) and a DT score of normal (sedentary or exercising) or high (exercising only). Resting energy expenditure (REE) and metabolic hormones (triiodothyronine, (TT3), ghrelin, leptin, insulin) were measured repeatedly over a 2-3 month period. The DT subscale successfully discriminated the groups based on energy status. Although the groups did not differ in body weight, the high DT group exhibited adaptations to chronic energy deficiency, including a REE below 90% of their predicted REE (86+/-3.0%), significantly lower TT3 levels and significantly higher ghrelin levels than the normal DT groups. Since energy deficiency plays a causal role in the Female Athlete Triad, DT may serve as a proxy indicator of underlying energy deficiency and may be useful for identifying individuals at risk for Triad disorders prior to the development of serious clinical sequelae.