New Kid on the Block: A Systematic Review of the Quadratus Lumborum Block in Plastic and Reconstructive Surgery.

Background: Although the transversus abdominal plane (TAP) block is commonly used in abdominal surgery as part of enhanced recovery after surgery pathways, the quadratus lumborum (QL) block has been hypothesized as an effective alternative to the TAP block in some areas. This review evaluates the current literature, as it relates to the QL block in plastic and reconstructive surgery. Methods: A systematic review using PubMed searched for all original, peer-reviewed articles, including the term "quadratus lumborum block." In total, 509 articles were identified for review by two independent reviewers. Original articles evaluating the use of a QL block in any plastic surgery operation were included. Articles evaluating pediatric patients, animal trials, and the use of a QL block in any nonplastic surgery operation were excluded. Results: Three articles met inclusion criteria. One trial demonstrated decreased subjective pain scores and total opioid use, whereas the second found no statistically significant difference. A case study described the use of a QL block for unilateral breast reconstruction with minimal opiate use and reduced pain scores postoperatively. Limitations include the limited number of studies and the heterogeneity in study type and design, making analysis difficult. Conclusions: Despite its demonstrated efficacy in other surgical subspecialties, there are limited data evaluating the use of the QL block in plastic and reconstructive surgery. Additional research is needed to evaluate the role of the QL block in plastic surgery and how it compares to the more widely utilized TAP block.

Sports participation after craniosynostosis repair: the critical role of post-operative guidance in parental decision-making.

PURPOSE: Despite previous research supporting patient safety in sports after craniosynostosis surgery, parental anxiety remains high. This study sought to evaluate the role of healthcare providers in guiding patients and families through the decision-making process. METHODS: Parents of children with repaired craniosynostosis were asked to assess sports involvement and parental decision-making in children ages 6 and older. Questions were framed primarily on 5-point Likert scales. Sport categorizations were made in accordance with the American Academy of Pediatrics. Chi-squared, linear regression, and Pearson correlation tests were used to analyze associations between the questions. RESULTS: Forty-three complete parental responses were recorded. Mean ages at surgery and time of sports entry were 7.93 ± 4.73 months and 4.76 ± 2.14 years, respectively. Eighty-two percent of patients participated in a contact sport. Discussions with the primary surgeon were more impactful on parental decisions about sports participation than those with other healthcare providers (4.04 ± 1.20 vs. 2.69 ± 1.32). Furthermore, children whose parents consulted with the primary surgeon began participating in sports at a younger age (4.0 ± 1.0 vs. 5.8 ± 2.7 years, p = 0.034). The mean comfort level with contact sports (2.8 ± 1.4) was lower than that with limited-contact (3.8 ± 1.1, p = 0.0001) or non-contact (4.4 ± 1.3, p < 0.0001) sports. CONCLUSION: This study underscores the critical role that healthcare professionals, primarily surgeons, have in guiding families through the decision-making process regarding their children's participation in contact sports.

A diffusion tensor imaging comparison of white matter development in nonsyndromic craniosynostosis to neurotypical infants.

PURPOSE: Nonsyndromic craniosynostosis (NSC) is associated with neurocognitive deficits, and intervention at infancy is standard of care to limit the negative effects of NSC on brain development. In this study, diffusion tensor imaging (DTI) was implemented to investigate white matter microstructure in infants with NSC undergoing cranial vault remodeling, and a comparison was made with white matter development in neurotypical controls. METHODS: Infants presenting with NSC (n = 12) underwent DTI scans before and after cranial vault remodeling. Neurotypical infants (n = 5), age matched to NSC patients at preoperative scans, were compared to preoperative DTI scans. Pre- and postoperative NSC scans were compared in aggregate, and the sagittal synostosis (n = 8) patients were evaluated separately. Finally, neurotypical infants from the University of North Carolina/University of New Mexico Baby Connectome Project (BCP), who underwent DTI scans at timepoints matching the NSC pre- and postoperative DTI scans, were analyzed (n = 9). Trends over the same time period were compared between NSC and BCP scans. RESULTS: No significant differences were found between preoperative NSC scans and controls. White matter development was more limited in NSC patients than in BCP patients, with microstructural parameters of the corpus body and genu and inferior and superior longitudinal fasciculi consistently lagging behind developmental changes observed in healthy patients. CONCLUSION: Infant white matter development appears more limited in NSC patients undergoing cranial vault remodeling relative to that in neurotypical controls. Further investigation is needed to explore these differences and the specific effects of early surgical intervention.

Understanding the Drivers of Cost and Length of Stay in a Cohort of 21,875 Patients with Severe Burn.

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.

Evaluating the Impact of Residency Research Productivity on Craniofacial Surgeons' Career Trajectory.

OBJECTIVE: To elucidate trends in publication productivity over the past 50 years and how they correlate with the stage of training as well as the competitiveness of residency and fellowship programs. The authors hypothesize that research qualifications play an important role in obtaining a competitively ranked craniofacial surgery fellowship and that over the past 50 years, there has been an upward shift in the research qualifications held by applicants at the time of application. DESIGN: A cross-sectional study was performed involving all 121 academic craniofacial surgeons in the United States for whom sex, years since fellowship, current institution rank, current academic position, and years since graduation were available. MAIN OUTCOME MEASURES: The relationship between research qualifications, as determined by the overall number of publications, number of first authorship publications, H-index scores, and years since fellowship completion, was examined. The study also analyzed the placement of surgeons at programs ranked in the top 25 versus the lower 25. RESULTS: As the number of decades since beginning craniofacial fellowship decreased, the average number of first authorship publications and average H-index increased. Those who attended higher-ranking residency and fellowship programs had a higher average number of publications, number of first authorship publications, and H-index. CONCLUSIONS: Over the past 5 decades, research productivity at all stages of medical training has surged, potentially fueled by the trend toward pass/fail grading in medical school evaluations and standardized exams and the need to differentiate oneself in an increasingly competitive field.

Perceived Age and Gender Perception Using Facial Recognition Software Following Facial Feminization Surgery.

Measures of success for facial feminization surgery (FFS) have previously included improved rates of external gender perception as female and patient-reported outcome measures. In this study, we used artificial intelligence facial recognition software to objectively evaluate the effects of FFS on both perceived gender and age among male-to-female transgender patients, as well as their relationship with patient facial satisfaction. Standardized frontal preoperative and postoperative images of 27 transgender women undergoing FFS were analyzed by Amazon's AI facial recognition software to determine gender, femininity confidence score, and perceived age. Female gender-typing, improvement in gender-typing (preoperatively to postoperatively), and femininity confidence scores were analyzed. To assess patient satisfaction, FACE-Q modules were completed postoperatively. Preoperatively, FFS images were perceived as female 48.1% of the time, and postoperatively, this improved to 74.1% ( P =0.05). Femininity confidence scores improved from a mean score of 0.04 preoperatively to 0.39 postoperatively ( P =0.003). FFS was associated with a decrease in perceived age relative to the patient's true age (-2.4 y, P <0.001), with older patients experiencing greater reductions. Pearson correlation matrix found no significant relationship between improved female gender typing and patient facial satisfaction. Undergoing surgery at a younger age was associated with higher overall facial satisfaction ( r =-0.6, P =0.01). Transfeminine patients experienced improvements in satisfaction with facial appearance, perceived gender, and decreases in perceived age following FFS. Notably, patient satisfaction was not directly associated with improved AI-gender typing, suggesting that other factors may influence patient satisfaction.

Quantitative Analysis of Morphometric Changes in Feminization Rhinoplasty Utilizing a Standardized Forehead-Rhinoplasty Technique.

Background: Rhinoplasty is one of the most commonly performed facial gender-affirming surgeries (FGASs) for transgender females, but well-established morphometric parameters describing feminizing nasal changes do not exist. Objectives: Describe the author's technique for feminization rhinoplasty, analyze the changes in 3-dimensional nasal anthropomorphic parameters, and describe patient-reported outcomes. Methods: Three-dimensional photogrammetric evaluation was performed both preoperatively and postoperatively in transgender female patients who underwent FGAS. Measurements assessed included the nasofrontal angle, nasolabial angle, dorsal height, mid-dorsal width, alar width, nasal tip width, and tip projection. Patients were surveyed preoperatively and postoperatively using the FACE-Q Nose module. Paired t-tests were utilized to assess changes in postoperative measurements and FACE-Q Nose satisfaction scores. Results: Twenty patients underwent FGAS during the study period. The average time between surgery and postoperative 3-dimensional images was 13.6 ± 6.8 months. The nasofrontal angle increased by 8.2° (148.0 ± 7.4° to 156.1 ± 6.7°, P < .001) and tip projection increased by 0.017 (0.58 ± 0.03 to 0.60 ± 0.04, P < .01). Dorsal height, mid-dorsal width, and tip width all decreased significantly (P < .05). There were significant improvements in patients' "Satisfaction with Nose," "Satisfaction with Facial Appearance Overall," "Psychological Function," and "Social Function" on FACE-Q. One revision rhinoplasty was performed, and no documented surgical complications were reported. Conclusions: There were statistically significant changes in the nasofrontal angle, tip projection, dorsal height, mid-dorsal width, and tip width in patients receiving feminization rhinoplasty. These data may help surgeons with preoperative planning and intraoperative decision making.

Pediatric Facial Burns and Consumer Products: A Nationwide Analysis.

Pediatric facial burns pose significant challenges in terms of physical, psychological, and social impacts on children. Understanding the causes of these burns is crucial for prevention and appropriate care. This study aims to provide a comprehensive analysis of causes and preventive measures related to pediatric facial burns caused by consumer products. Using data from the National Electronic Injury Surveillance System (NEISS) from 2012 to 2021, we analyzed 130,461 cases of pediatric facial burns. Common causes included household items such as cleaning supplies, hot water, kitchen appliances, and health and beauty products. Differences in burn causes were observed between genders, with boys more prone to burns from welding equipment, gasoline, and grills, while girls were more susceptible to burns from hair curling equipment, candles, and health and beauty products. The mean age of children burned by different items varied, highlighting the need for age-appropriate preventive measures. The authors discuss the importance of caregiver education, safe storage practices, supervision, and clear communication in preventing pediatric facial burns. By raising awareness of potential burn sources and implementing preventive strategies, the incidence of pediatric facial burns can be significantly reduced.

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7 mo versus 13.2±31.1 mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1 h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7 d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

National Trends in Microtia Repair Cost and Hospital Length of Stay.

Microtia can have deleterious impacts on the functional, psychological, and aesthetic outcomes of affected young children. Reconstructive procedures can alleviate these negative outcomes and significantly improve the quality of life for patients; however, the cost and length of hospital stay (LOS) for such procedures and the factors that impact them have not been well-characterized. This study seeks to understand the hospital-level (institution type, size, and geographic region) and patient-level factors (race, age, and insurance status) that impact cost and LOS in patients who undergo microtia reconstructive surgery. A retrospective data analysis was conducted utilizing the National Inpatient Sample (NIS) database for the years 2008 to 2015. Inclusion criteria included patients who had an International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for microtia (744.23) as well as a procedure for microtia correction (186×/187×). A total of 714 microtia repair cases met the inclusion criteria and were sampled from the NIS database. Microtia repair cost was significantly increased on the West Coast compared with the Northeast ($34,947 versus $29,222, P =0.020), increased with patient age ($614/y, P =0.012), and gradually increased from 2008 to 2015 ($25,897-$48,985, P <0.001). Microtia LOS was significantly increased with government-controlled hospitals compared with private hospitals (1.93 versus 1.39 d, P =0.005), increased with patients on Medicaid compared with private insurance (2.33 versus 2.00 d, P =0.036), and overall decreased with patient age (-0.07 d/y, P =0.001). The results not only identify the multifactorial impacts that drive cost and LOS in microtia repair but provide insights into the financial and medical considerations patients and their families must navigate.

Long-term laryngological sequelae and patient-reported outcomes after COVID-19 infection.

PURPOSE: We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection. MATERIALS AND METHODS: 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI). RESULTS: 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS. CONCLUSIONS: Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.

Orthotic Helmet Therapy for Deformational Plagiocephaly: Stratifying Outcomes by Insurance.

OBJECTIVE: Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status. DESIGN: This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states. PATIENTS, PARTICIPANTS: There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy. MAIN OUTCOMES MEASURES: Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success. RESULTS: Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001). CONCLUSIONS: Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.

Resident Burnout and Well-being in Otolaryngology and Other Surgical Specialties: Strategies for Change.

OBJECTIVE: To perform a literature review on burnout prevalence, factors that affect burnout and well-being, and solutions to address burnout in otolaryngology-head and neck surgery (OTO-HNS) residents and residents in other surgical specialties. DATA SOURCES: Ovid Medline, Embase, and article reference lists. REVIEW METHODS: A literature search was performed to identify articles on resident burnout, distress, wellness, well-being, and quality of life. Articles deemed outside the scope of the current work were excluded. Search was limited to the past 5 years. CONCLUSIONS: Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties. IMPLICATIONS FOR PRACTICE: Addressing burnout, which is prevalent in OTO-HNS residents, is critical to improving patient care and physician well-being. Surgical specialties can share strategies to effectively address resident burnout through institutional interventions, which can be essential quality improvement initiatives, to promote well-being.

Predictive Factors of Outcomes in Helmet Therapy for Deformational Plagiocephaly and Brachycephaly.

Deformational plagiocephaly and brachycephaly, or abnormal flattening of the infant skull due to external forces, are often managed with orthotic helmet therapy. Although helmet therapy is widely used, the factors that predict poor outcomes are not well characterized. In this study of over 140,000 patients who received helmet therapy, older age and greater severity at presentation, and noncompliance with treatment were each independently associated with worse craniometric and provider-reported outcomes. Each additional point of cranial vault asymmetry index or cephalic index at a presentation is associated with an increased likelihood of residual brachycephaly at completion [odds ratio (OR): 1.067; 95% Cl: 1.058-1.075; P <0.0001 and OR: 2.043; 95% CI: 2.021-2.065; P <0.0001, respectively], whereas each additional point of cranial vault asymmetry index at a presentation associated with increased likelihood of residual asymmetry at completion (OR: 2.148; 95% Cl: 2.118-2.179; P <0.0001). Patients were more likely to have residual brachycephaly or asymmetry with increasing age at treatment initiation (OR: 1.562; 95% CI: 1.524-1.600; P <0.0001 and OR: 1.673; 95% Cl: 1.634-1.713; P <0.0001, respectively, for each additional month of age at initiation). These results highlight a need for prompt referral for helmeting, especially in cases with severe features or when patients present late to care. Potentially modifiable factors are age at helmeting and compliance with treatment protocols, and consideration of these factors may be important for achieving success in some cases.

Sociodemographic Disparities in Access to Cleft Rhinoplasty.

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Racial and geographic disparities in reconstructive procedures following melanoma resection.

INTRODUCTION: Melanoma occurs most commonly in non-Hispanic White patients; however, Black and Hispanic patients experience greater morbidity and mortality. This study assesses how race and socioeconomic factors influence rates of reconstructive procedures and hospital-based outcomes in melanoma patients. METHODS: Data were extracted from the National Inpatient Sample database from the years 2010-2015. Patients with melanoma who underwent a reconstructive procedure were identified. Univariate and multivariate logistic regression analysis was used to identify the relationship between dependent variables and various patient/hospital components for patients undergoing reconstructive procedures. RESULTS: Black and Hispanic patients had a greater length of stay (LOS) than non-Hispanic White patients (OR: 2.252, p = 0.0307, and OR: 2.592, p = 0.0014), and Hispanic patients were less likely to receive more complex reconstructive procedures (OR: 0.449, p = 0.0487). Patients living in rural areas were less likely to receive complex reconstructive procedures than those in both urban teaching and non-teaching hospitals (OR: 3.313, p = 0.0135, and OR: 3.505, p = 0.0074). Pedicled or rotational flaps were less likely to be performed at medium- or large-sized hospitals (OR: 0.610, p = 0.0296, and OR: 0.496, p = 0.0002). CONCLUSION: Race and socioeconomic factors are important predictors of access to complex reconstructive procedures and hospital-based outcomes following extirpation in melanoma patients.

Limited Access to Facial Feminization Geographically Despite Nationwide Expansion of Other Gender-Affirming Surgeries.

Facial feminization surgery (FFS) is an integral aspect of gender-affirming surgery (GAS) for individuals seeking to align secondary sex characteristics and gender identity. Despite the importance of FFS in treating gender dysphoria, current trends and prevalence remain unknown. We sought to examine trends in GAS and FFS and investigate the payer status of facial feminization procedures in the United States. Methods: Data was extracted from the National Inpatient Sample from 2008 to 2017 by using International Classification of Diseases Ninth or Tenth diagnosis codes for gender identity disorder and procedure codes for FFS. Results: From 2008 to 2017, 3015 patients underwent GAS. The yearly number of cases increased as did the average cost of GAS, which rose from $13,657 in 2008 to $50,789 in 2017. From 2015 to 2017, when FFS data was available, 110 of 1215 (9.1%) GAS patients had FFS. Most were non-Hispanic White (66.7%) or Black (23.8%). Fifty percent of FFS cases occurred in the West, followed by the Northeast (31.8%), South (13.6%), and Midwest (4.8%) (P = 0.015). By payer the cases were, 36.4% self-pay, 31.8% Medicaid, and 27.3% private insurance (P < 0.0001). Approximately, 18% of patients undergoing male-to-female transition received FFS. Conclusions: From 2008 to 2017, GAS cases increased nationwide while the average cost of surgery rose steeply. FFS cases were primarily in the Western and Northeast United States. Despite high cost, roughly 18% of transgender women in our sample received FFS, highlighting the importance of FFS in gender transition.

EphA7 promotes myogenic differentiation via cell-cell contact.

The conversion of proliferating skeletal muscle precursors (myoblasts) to terminally-differentiated myocytes is a critical step in skeletal muscle development and repair. We show that EphA7, a juxtacrine signaling receptor, is expressed on myocytes during embryonic and fetal myogenesis and on nascent myofibers during muscle regeneration in vivo. In EphA7-/- mice, hindlimb muscles possess fewer myofibers at birth, and those myofibers are reduced in size and have fewer myonuclei and reduced overall numbers of precursor cells throughout postnatal life. Adult EphA7-/- mice have reduced numbers of satellite cells and exhibit delayed and protracted muscle regeneration, and satellite cell-derived myogenic cells from EphA7-/- mice are delayed in their expression of differentiation markers in vitro. Exogenous EphA7 extracellular domain will rescue the null phenotype in vitro, and will also enhance commitment to differentiation in WT cells. We propose a model in which EphA7 expression on differentiated myocytes promotes commitment of adjacent myoblasts to terminal differentiation.