Chin Dysmorphology in the Primary Rhinoplasty Population: Prevalence, Objective Analysis, and Implications.

BACKGROUND: Chin flaws are far more common than recognized. Denial of genioplasty by parents or adult patients can present a surgical planning enigma, especially in patients with microgenia and chin deviation. This study aims to investigate the frequency of chin imperfections on patients seeking rhinoplasty, review the conundrum they generate, and offer management suggestions based on over 40 years of the senior author's experience. METHODS: This review included 108 consecutive patients presenting for primary rhinoplasty. Demographics, soft tissue cephalometrics, and surgical details were obtained. Exclusion criteria included prior orthognathic or isolated chin surgery, mandiblular trauma, or congenital craniofacial deformities. RESULTS: Of the 108 patients, 92 (85.2%) were female. Mean age was 30.8 years (SD±13, range 14-72). Ninety-seven (89.8%) patients exhibited some degree of objective chin dysmorphology. Fifteen (13.9%) had Class I deformities (macrogenia), 63 (58.3%) Class II (microgenia), and 14 (12.9%) Class III (combined macro and microgenia in the horizontal or vertical vectors). Forty-one (38%) patients had Class IV deformities (asymmetry). While all patients were offered the opportunity to correct chin flaws, only 11 (10.1%) underwent such procedures. Five (4.6%) patients had simultaneous osseous genioplasty (mean advancement 7.8mm, range 5-9mm); 7 (6.5%) received fat grafting to the chin (mean volume 4.4cc, range 1-9cc). CONCLUSIONS: A considerable proportion of primary rhinoplasty patients possess quantifiable chin dysmorphology on circumspect examination, high-resolution photographs and cephalometric analysis. Only a small number agree to surgical interventions that pursue full facial harmony. Potential reasons for these findings, patient aversion, and mitigation strategies will be discussed. 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 .

Distinguishing Authentic Voices in the Age of ChatGPT: Comparing AI-Generated and Applicant-Written Personal Statements for Plastic Surgery Residency Application.

BACKGROUND: ChatGPT, a generative artificial intelligence model, may be used by future applicants in the plastic surgery residency match. METHODS: Ten personal statements (5 generated by ChatGPT, 5 written by applicants) were rated by 10 reviewers, blinded to the source of the essay. RESULTS: A total of a 100 evaluations were collected. There was no significant difference in ratings for readability, originality, authenticity, and overall quality (all P > 0.05) when comparing computer-generated and applicant essays. CONCLUSION: Personal statements prepared by ChatGPT are indistinguishable from essays written by actual applicants. This finding suggests that the current plastic surgery application format be reevaluated to better aid in holistic evaluation of students.

Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction.

BACKGROUND: Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making. MATERIALS AND METHODS: This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed. RESULTS: One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value. CONCLUSIONS: We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.

Prospective Assessment of the Abdominal Hernia-Q (AHQ)-Patient Burden, Reliability, and Longitudinal Assessment of Quality of Life in Hernia Repair.

OBJECTIVE: This study assesses the user burden, reliability, and longitudinal validity of the AHQ, a novel VH patient-reported outcomes measure (PROM). BACKGROUND: We developed and psychometrically validated the AHQ as the first VH-specific, stakeholder-informed PROM. Yet, there remains a need to assess the AHQ's clinical applicability and further validate its psychometric properties. METHODS: To assess patient burden, pre- and postoperative patients were timed while completing the corresponding AHQ form. To measure test-retest reliability, a subset of patients completed the AHQ within a week of initial completion, and consecutive responses were correlated. Lastly, patients undergoing VH repair were prospectively administered the pre- and postoperative AHQ forms, the Hernia-Related Quality of Life Survey and the Short Form-12 both preoperatively and at postoperative intervals, up to over a year after surgery. Quality-of-Life scores were correlated from the 3 PROMs and effect sizes were compared using analysis of normal variance. RESULTS: Median response times for the pre- and postoperative AHQ were 1.1 and 2.7 minutes, respectively. The AHQ demonstrates high test-retest reliability coefficients for pre- and postoperative instruments ( r = 0.91, 0.89). The AHQ appropriately and proportionally measures expected changes following surgery and significantly correlates with all times points of theHernia-Related Quality of Life Survey and Short Form-12 MS and 4/5 (80%) SF12-PS. CONCLUSION: The AHQ is a patient-informed, psychometrically-validated, clinical instrument for measuring, quantifying, and tracking PROMs in VH patients. The AHQ exhibits low response burden, excellent reliability, and effectively measures hernia-specific changes in quality-of-Life following ventral hernia repair.

Abdominal Body Contouring: Does Body Mass Index Affect Clinical and Patient Reported Outcomes?

BACKGROUND: Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. OBJECTIVES: We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI <35 kg/m2 to highlight key differences in clinical and patient-reported-outcomes (PROs). METHODS: Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m2). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed. RESULTS: 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. CONCLUSION: There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.

Calibration of Hernia-Specific Patient-Reported Outcome Measures.

INTRODUCTION: Although there are many patient-reported outcome measures used for ventral hernia (VH), disease-specific instruments, such as the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have shown greater accuracy in capturing all VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling better unification of QoL data. METHODS: Patients with VH were prospectively identified and simultaneously administered both the AHQ and HerQLes pre- and post-operatively. To ensure the validity of the calibration, responses were excluded if patients answered instruments on different dates or if the responses were discordant on corresponding questions within each instrument. The calibration was estimated using a linear mixed effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient. RESULTS: In total, 109 patients were included, responding to 300 pairs of surveys (112 preoperative and 188 postoperative), of which 17 (5.6%) were excluded because of discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre- or post-operatively, with a mean squared error of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a mean squared error of 0.016. CONCLUSIONS: We present a novel and accurate method to convert scores between the AHQ and HerQLes. Being able to unify QoL data from different PROMs supports efforts to more broadly integrate PROMs in surgery and to understand patient-defined measures of success.

The Impact of Virtual Surgical Planning on Orthognathic Surgery: Contributions From Two Specialties.

BACKGROUND: Virtual surgical planning (VSP) has gained popularity for preoperative orthognathic surgery planning and is increasingly being employed by surgeons trained in plastic and reconstructive surgery (PRS) or oral and maxillofacial surgery (OMS). This review assesses the introduction of VSP as a new technology and its impact on orthognathic surgery research and practices based upon surgeon training. METHODS: Two PubMed literature reviews were conducted. The first classified publications on VSP for orthognathic surgery by training (OMS- or PRS-trained surgeons) and compared focuses, timing, and journals of publications from each group of surgeons. The second evaluated how orthognathic surgery publication volumes changed with VSP introduction. English articles published from inception until January 2020 (first review) and November 2020 (second review) were included. RESULTS: The first literature review retrieved 419 unique publications, with 188 studies selected for inclusion: 162 were published by OMS-trained principal investigators (OMS-authored) and 26 by PRS-trained principal investigators (PRS-authored). Plastic and reconstructive surgery-authored publications regarding VSP use in orthognathic surgery increased after the first publication in 2000, but at a significantly slower rate (0.2 new publications/year) than OMS-authored publications ( P < 0.01). Aesthetics was discussed in significantly more PRS-authored publications (76.9% compared to 28.4% of OMS-authored publications). The second review revealed that over 80.6% of orthognathic surgery literature was published after 2008, the year VSP was first integrated into orthognathic surgery workflow. CONCLUSIONS: Following the introduction of VSP, orthognathic surgery research output has differed between PRS and OMS based on publication speed, volume, and research focuses.Further research is necessary to evaluate how VSP has impacted PRS and OMS clinical practice.

The streptococcal multidomain fibrillar adhesin CshA has an elongated polymeric architecture.

The cell surfaces of many bacteria carry filamentous polypeptides termed adhesins that enable binding to both biotic and abiotic surfaces. Surface adherence is facilitated by the exquisite selectivity of the adhesins for their cognate ligands or receptors and is a key step in niche or host colonization and pathogenicity. Streptococcus gordonii is a primary colonizer of the human oral cavity and an opportunistic pathogen, as well as a leading cause of infective endocarditis in humans. The fibrillar adhesin CshA is an important determinant of S. gordonii adherence, forming peritrichous fibrils on its surface that bind host cells and other microorganisms. CshA possesses a distinctive multidomain architecture comprising an N-terminal target-binding region fused to 17 repeat domains (RDs) that are each ∼100 amino acids long. Here, using structural and biophysical methods, we demonstrate that the intact CshA repeat region (CshA_RD1-17, domains 1-17) forms an extended polymeric monomer in solution. We recombinantly produced a subset of CshA RDs and found that they differ in stability and unfolding behavior. The NMR structure of CshA_RD13 revealed a hitherto unreported all ß-fold, flanked by disordered interdomain linkers. These findings, in tandem with complementary hydrodynamic studies of CshA_RD1-17, indicate that this polypeptide possesses a highly unusual dynamic transitory structure characterized by alternating regions of order and disorder. This architecture provides flexibility for the adhesive tip of the CshA fibril to maintain bacterial attachment that withstands shear forces within the human host. It may also help mitigate deleterious folding events between neighboring RDs that share significant structural identity without compromising mechanical stability.

Circulating Tumor DNA Analysis for Detection of Minimal Residual Disease After Chemoradiotherapy for Localized Esophageal Cancer.

BACKGROUND & AIMS: Biomarkers are needed to risk stratify after chemoradiotherapy for localized esophageal cancer. These could improve identification of patients at risk for cancer progression and selection of additional therapy. METHODS: We performed deep sequencing (CAncer Personalized Profiling by deep Sequencing, [CAPP-Seq]) analyses of plasma cell-free DNA collected from 45 patients before and after chemoradiotherapy for esophageal cancer, as well as DNA from leukocytes and fixed esophageal tumor biopsy samples collected during esophagogastroduodenoscopy. Patients were treated from May 2010 through October 2015; 23 patients subsequently underwent esophagectomy, and 22 did not undergo surgery. We also sequenced DNA from blood samples from 40 healthy control individuals. We analyzed 802 regions of 607 genes for single-nucleotide variants previously associated with esophageal adenocarcinoma or squamous cell carcinoma. Patients underwent imaging analyses 6-8 weeks after chemoradiotherapy and were followed for 5 years. Our primary aim was to determine whether detection of circulating tumor DNA (ctDNA) after chemoradiotherapy is associated with risk of tumor progression (growth of local, regional, or distant tumors, detected by imaging or biopsy). RESULTS: The median proportion of tumor-derived DNA in total cell-free DNA before treatment was 0.07%, indicating that ultrasensitive assays are needed for quantification and analysis of ctDNA from localized esophageal tumors. Detection of ctDNA after chemoradiotherapy was associated with tumor progression (hazard ratio, 18.7; P < .0001), formation of distant metastases (hazard ratio, 32.1; P < .0001), and shorter disease-specific survival times (hazard ratio, 23.1; P < .0001). A higher proportion of patients with tumor progression had new mutations detected in plasma samples collected after chemoradiotherapy than patients without progression (P = .03). Detection of ctDNA after chemoradiotherapy preceded radiographic evidence of tumor progression by an average of 2.8 months. Among patients who received chemoradiotherapy without surgery, combined ctDNA and metabolic imaging analysis predicted progression in 100% of patients with tumor progression, compared with 71% for only ctDNA detection and 57% for only metabolic imaging analysis (P < .001 for comparison of either technique to combined analysis). CONCLUSIONS: In an analysis of cell-free DNA in blood samples from patients who underwent chemoradiotherapy for esophageal cancer, detection of ctDNA was associated with tumor progression, metastasis, and disease-specific survival. Analysis of ctDNA might be used to identify patients at highest risk for tumor progression.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes.

BACKGROUND: While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS: Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS: A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION: For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Leaders of the Pack: A Comparison of Chairs and Chiefs to Other Surgeons in American Academic Plastic Surgery.

ABSTRACT: Chairs/chiefs of plastic surgery departments/divisions are responsible for directing activities at academic institutions and thus help determine the direction of academic plastic surgery. Other studies have characterized this group but have not shown which characteristics separate them from other surgeons in the field. To study this relationship, a cross-sectional analysis of plastic surgery faculty affiliated with United States residency training programs (n = 99) was initiated. Data were collected from public online websites. Univariate and multivariate logistic regression were used to identify factors independently associated with chairs/chief status. Sub-analyses were performed within Tiers stratified by residency program rank of chair/chief's current institution. Among 943 plastic surgeons, 98 chairs/chiefs were identified. In accordance with prior literature, most are male (89%) and fellowship-trained (62%), and they have a median H-index of 17. Compared to other surgeons, chair/chiefs have more years in practice (odds ratio [OR]: 1.026, confidence interval [CI]: 0.002-0.049, P = 0.034), higher H-index (OR: 1.103, CI: 0.048-0.147, P < 0.001), and more citations (OR: 1.000, CI: -0.000 to -0.001, P = 0.006). Chair/chiefs were also more likely to be journal editorial board members (OR: 1.728, CI: -0.033 to 1.127, P = 0.046) and national society/organization presidents (OR: 1.024, CI: 0.008-0.039, P = 0.003). No notable differences were found between department chairs versus division chiefs or across Tiers. Overall, scholarly achievement and significant years of experience distinguish chairs/chiefs in American academic plastic surgery. Criteria for achieving this leadership role may not differ between departments and divisions. Further research is needed to evaluate whether these characteristics translate into more effective leadership.

A Comparative Analysis of Fleur-de-Lis and Traditional Panniculectomy after Bariatric Surgery.

INTRODUCTION: The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP. METHODS: A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains. RESULTS: The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains. CONCLUSION: FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications. 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 .

Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze?

BACKGROUND: Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity. METHODS: Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image. RESULTS: Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05). CONCLUSIONS: This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery. 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Hitting the Books: A Nationwide Analysis of Advanced Degrees in Academic Plastic Surgery Faculty.

OBJECTIVE: Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment. METHODS: All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity. RESULTS: 949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p < 0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p<0.05). Institutional analysis revealed that employing more faculty with an AD was associated with having an integrated residency program, higher residency research ranking, and higher tier integrated residency (all p < 0.05). CONCLUSION: ADs are growing in popularity in academic plastic surgery and are temporally associated with specific advantages in terms of residency placement, research productivity, and institutional standing. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Labial Fat Grafting After Penile Inversion Vaginoplasty.

BACKGROUND: Penile inversion vaginoplasty (PIV) has become the most commonly performed genital surgery for transfeminine patients. However, patients undergoing this procedure may still require revisions to achieve a satisfactory result. OBJECTIVES: The authors report on the utilization of autologous fat grafting to the labia majora to improve results after PIV and complications that may predict the need for grafting. METHODS: A retrospective chart review was conducted of a single surgeon's patients who underwent PIV between July 2014 and December 2019. Demographic information, operative information, and postoperative outcomes were abstracted from the health records. Wilcoxon rank sum tests and chi-squared test were employed for continuous variables and categorical, respectively. RESULTS: A total of 182 transfeminine and gender-diverse patients underwent PIV, with 6 patients (3.3%) eventually undergoing labial fat grafting. The most common indication for labial fat grafting was flattened labia majora (83%). All fat grafting procedures were performed concurrently with other revisions of the vaginoplasty. There were no demographic or medical history differences detected between the fat grafting and non-fat grafting groups. Patients who underwent labial fat grafting were more likely to suffer from introital stenosis (33% vs 6%, P = 0.007) and prolonged granulation tissue greater than 6 weeks after initial vaginoplasty (83% vs 32%; P = 0.01). CONCLUSIONS: Labial fat grafting is a safe and effective method to address defects in the labia majora after PIV. Prolonged granulation tissue and introital stenosis may predict the need for labial fat grafting, possibly due to increased scarring and contracture at the surgical site.

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.

Assessing Disparities in Reduction Mammaplasty: There Is Room for Improvement.

BACKGROUND: Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery. OBJECTIVES: The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores. METHODS: Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups. RESULTS: A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all P < 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (P < 0.001), BMI vs preoperative physical well-being (P < 0.001), and ethnicity vs preoperative physical well-being (P = 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (P < 0.001), median income by zip code (P < 0.001), improvement in satisfaction with breasts (P = 0.039), satisfaction with information (P = 0.007), and satisfaction with office staff (P = 0.044). CONCLUSIONS: Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling.

Social Perception of Facial Feminization Surgery Outcomes: Does Gender Identity Alter Gaze?

BACKGROUND: The evaluation of gender-affirming facial feminization surgery (FFS) outcomes can be highly subjective, which has resulted in a limited understanding of the social perception of favorable gender and aesthetic facial appearance following FFS. Eye-tracking technology has introduced an objective measure of viewer subconscious gaze. OBJECTIVES: The aim of this study was to use eye-tracking technology to measure attention and perception of surgery-naive cisgender female and feminized transgender faces, based on viewer gender identity. METHODS: Thirty-two participants (18 cisgender and 14 transgender) were enrolled and shown 5 photographs each of surgery-naive cisgender female and feminized transgender faces. Gaze was captured with a Tobii Pro X2-60 eye-tracking device (Tobii, Stockholm, Sweden) and participants rated the gender and aesthetic appearance of each face on Likert-type scales. RESULTS: Total image gaze fixation time did not differ by participant gender identity (6.00 vs 6.04 seconds, P = 0.889); however, transgender participants spent more time evaluating the forehead/brow, buccal/mandibular regions, and chin (P < 0.001). Multivariate regression analysis showed significant associations between viewer gender identity, age, race, and education, and the time spent evaluating gender salient facial features. Feminized faces were rated as more masculine with poorer aesthetic appearance than surgery-naive cisgender female faces; however, there was no significant difference in the distribution of gender appearance ratings assigned to each photograph by cisgender and transgender participants. CONCLUSIONS: These results demonstrate that gender identity influences subconscious attention and gaze on female faces. Nevertheless, differences in gaze distribution did not correspond to subjective rated gender appearance for either surgery-naive cisgender female or feminized transgender faces, further illustrating the complexity of evaluating social perception of favorable FFS outcomes.

PEMapper and PECaller provide a simplified approach to whole-genome sequencing.

The analysis of human whole-genome sequencing data presents significant computational challenges. The sheer size of datasets places an enormous burden on computational, disk array, and network resources. Here, we present an integrated computational package, PEMapper/PECaller, that was designed specifically to minimize the burden on networks and disk arrays, create output files that are minimal in size, and run in a highly computationally efficient way, with the single goal of enabling whole-genome sequencing at scale. In addition to improved computational efficiency, we implement a statistical framework that allows for a base by base error model, allowing this package to perform as well or better than the widely used Genome Analysis Toolkit (GATK) in all key measures of performance on human whole-genome sequences.

Atlantoaxial Rotatory Subluxation: A Rare Complication of Craniofacial Surgery.

INTRODUCTION: Neck pain is common in the post-operative period after craniofacial procedures. If patients present with neck pain and torticollis, it could be a manifestation of atlantoaxial rotatory subluxlation (AARS), which describes a rare condition in which there is lateral displacement of C1 relative to C2. When this occurs in the post-operative patient, it is termed Grisel syndrome. In this case series, we report on 3 patients diagnosed with Grisel syndrome after a craniofacial procedure. METHODS: A retrospective chart review of a single craniofacial surgeon at a pediatric hospital was conducted over the last 3 decades. Demographics, procedures performed, and management strategies of AARS were included for review. RESULTS: Three patients were identified who were diagnosed with Grisel syndrome after a craniofacial procedure and required inpatient cervical traction. All patients presented with torticollis within 1 week of their operation. Conservative management was ineffective, and all 3 patients were admitted for inpatient cervical traction, for an average of 13 days followed by an average of 47 days of outpatient therapy. No patients showed any signs of recurrence after removal of outpatient traction device. CONCLUSION: Grisel syndrome is a rare, but serious complication of craniofacial procedures. Physicians caring for these patients must have a high degree of suspicion if a patient with a recent craniofacial procedure presents with torticollis. Delaying the initiation of therapy has been shown to lead to higher rates of recurrence and increases the likelihood that patients will require surgical intervention.