Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data.

BACKGROUND: Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population. METHODS: Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications. RESULTS: A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008). CONCLUSIONS: Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

Building an Academic Transgender Medicine Center of Excellence: The 5-Year Johns Hopkins Experience.

Gender-affirming care for transgender and gender diverse (TGD) individuals is a multidisciplinary endeavor that requires organized efforts of many specialized practitioners. TGD individuals experience many health care barriers, including the scarcity of multidisciplinary teams formed to coordinate and deliver complex care in an efficient and affirming way. The Johns Hopkins Center for Transgender Health was founded in 2017 with the mission of decreasing health disparities and improving the health of the TGD community. The authors present their experience building the center around a service line model in which patients have 1 point of contact, they are tracked throughout the care process, and the multidepartmental practitioners involved in their care are aligned. This model allowed for a patient-centered experience in which all involved disciplines were seamlessly integrated and the patient could navigate easily among them. With the structure and mission in place, the next challenge was to develop an infrastructure for culturally competent care. Through competency training and adjustment of systems-based logistics, measures were put in place to prevent traumatic experiences, such as misgendering, use of culturally inappropriate vocabulary, and use of incorrect names. Partnerships among colleagues in the fields of plastic surgery, urology, gynecology, otolaryngology, anesthesia, psychiatry/mental health, internal medicine, endocrinology, fertility, nursing, social work, speech therapy, and pediatrics/adolescent care were necessary to provide the appropriate breadth of services to care for TGD patients. Since its inception, the center has seen steady and continual growth, with more than 2,800 patients in its first 5 years. By sharing their experience in creating and developing a center of excellence, the authors hope to provide a blueprint for others to expand health care quality and access for TGD individuals.

Myofascial Flap Closure Decreases Complications in Complex Surgery of the Craniocervical Junction in Ehlers-Danlos Patients.

INTRODUCTION: Patients with Ehlers-Danlos syndrome (EDS) are at elevated risk for soft tissue complications when undergoing decompression with or without fusion of the craniocervical junction. We have previously shown that muscle flap closure can decrease reoperative rates. This study investigated whether myofascial flap closure improved clinical outcomes after simple or complex surgery of the craniocervical junction in EDS patients specifically. METHODS: We performed a retrospective chart review of EDS patients who had undergone surgery for Chiari malformation at the Weill Cornell Medical Center between 2013 and 2020. Postoperative complications were recorded, including infection, wound dehiscence, seroma, hematoma, hardware removal, cerebrospinal fluid (CSF) leak, reoperation, and pseudomeningocele. Patients were stratified by type of closure and type of surgery. Fisher exact test was used for statistical comparison. RESULTS: Between 2013 and 2020, 62 EDS patients who had surgery of the cervicocranial junction were reviewed. Of these, 31 patients had complex surgery with myofascial flap closure and 22 had simple surgery with traditional closure. The mean age at the time of surgery was 21.3 years. There were no significant differences in wound complications or reoperation rates between the simple surgery and complex surgery groups. In addition, there were no significant differences in complications between complex surgery with flap closure and simple surgery with traditional closure. Our CSF cutaneous fistula rate was 0%, considerably lower than rates reported in the literature, and, in one case, a patient developed a postoperative pseudomeningocele secondary to a dural leak, but the myofascial flap closure prevented its progression. CONCLUSIONS: Patients with EDS undergoing surgery of the cervicocranial junction may benefit from myofascial flap closure. Flap closure reduced complications after complex surgery of the craniocervical junction to the level of simple surgery. Our CSF leak rate was exceptionally low and only one patient experienced pseudomeningocele. Myofascial flaps are safe to perform in the EDS cohort and prevented CSF cutaneous fistula formation.

Comparing Outcomes after Oncoplastic Breast Reduction and Breast Reduction for Benign Macromastia.

BACKGROUND: Oncoplastic breast reconstruction improves cosmetic outcomes when compared to standard breast conservation therapy alone. The authors studied whether tailoring a breast reduction to a cancer resection affects complication rates by comparing (1) outcomes between oncoplastic and benign macromastia patients and (2) complication rates between the cancer side and the symmetrizing side of an oncoplastic reduction. METHODS: A retrospective chart review was performed on female patients who underwent either oncoplastic or benign breast reduction over 9 years by a single surgeon. Patient demographics, intraoperative data, and postoperative outcomes were gathered from the electronic medical record. Chi-square and t tests were performed when appropriate to determine significance. RESULTS: Of the 211 patients included in the study, 62 (29.4 percent) underwent oncoplastic breast reduction and 149 (70.6 percent) underwent breast reduction for benign macromastia. Total resection weight was greater in the benign group (p = 0.00). There was a higher rate of loss of nipple sensation in the oncoplastic group (p = 0.005) but no differences in any other complication. There was a higher complication rate in the oncologic breast when compared to the symmetrizing breast within the oncoplastic cohort (p = 0.039), but no differences in the rates of individual complications. CONCLUSIONS: Although the loss of nipple sensation was increased in patients undergoing oncoplastic breast reduction, all other outcomes were not significantly different between the two groups. The authors' findings indicate that oncoplastic breast reduction can be performed with a safety profile similar to that of a standard breast reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patients and Procedures of Facial Gender Confirmation Surgery: A NSQIP Study.

ABSTRACT: Various recent developments, including legislation in 2014 banning healthcare discrimination against gender minorities, have contributed to expanding insurance coverage for gender-affirming care, which includes facial gender confirmation surgery (FGCS). Increasing evidence suggests FGCS improves quality-of-life outcomes, but literature evaluating FGCS patient demographics, surgical risk factors, procedures, and complications is limited. Therefore, the authors conducted a study of a national surgical database from 2005 to 2019 attempting to fill in these literature gaps. Statistics were used to assess temporal trends after 2014. A total of 203 FGCS cases were identified, with the earliest occurring in 2013. Case volume increased annually from 2015-2019. The average patient age was 34.0 years and racial demographics largely mirrored national estimates for the transgender/non-binary population. Obesity (20.7%) and hypertension (3.9%) were the only patient co-morbidities, although a relatively high proportion were underweight (5.4%). The majority of cases were outpatient procedures (66.5%) conducted by either plastic surgery (38.9%) or otolaryngology (61.1%). Comparing FGCSs by anatomic site, the proportion of tracheal procedures decreased between 2015-17 and 2018-19 (25.6% vs. 10.7%, P = 0.0002) whereas the proportion of brow/forehead reconstructions increased (32.6% versus 63.1%, P = 0.0005). These changes coincided with an increase in mean operative time (168.6 minutes versus 260.0, P = 0.0002). Complications were rare (3.9%), and the most common was surgical site infection (3.4%), a previously unreported outcome in the FGCS literature. Overall, FGCS patients are mostly young healthy individuals from diverse racial/ethnic backgrounds, and they have few surgical complications. The increasing volume and complexity of FGCSs may be a result of expanding insurance coverage for previously unaffordable procedures.

Home Field Advantage: Assessing the Geographic Trends of the Plastic Surgery Residency Match during the COVID-19 Pandemic.

OBJECTIVE: In previous plastic surgery residency match cycles, in-person activities at other institutions, such as away rotations, have facilitated matches outside of an applicant's home program or region. The COVID-19 pandemic, however, limited these in-person opportunities. Therefore, we hypothesized that applicants of the 2021 cycle would be more likely to match into programs with which they have existing geographic connections when compared to previous years. DESIGN: Residency websites and social media accounts were searched for resident names and educational information for those matching in 2021 and 2015 to 2020. Outcomes included proportion of applicants matching at the program affiliated with their medical school ("home program"), or matching in the same state or United States Census Map region as their medical school or undergraduate institution. Subgroup analyses were stratified by program region, incoming resident class size, and Doximity residency reputation ranking. SETTING: Columbia University (New York). PARTICIPANTS: For the 2015 to 2020 residency cycles, 963 residents were identified from 78 (95.1%) programs. For 2021, 159 incoming interns were identified from 70 (82.3%) programs. RESULTS: 2021 applicants matched into their home program at higher rates than 2015-2020 applicants (36.0% vs. 24.1%, p  = 0.019). This trend was similar regardless of program region or size. This increase was significant for programs ranked outside of the top 30 (41.5% vs. 26.4%, p = 0.032), but not for the top 30 programs (32.1% vs. 22.3%, p = 0.128). Excluding those who matched at their home program, 2015 to 2020 and 2021 applicants matched in the same state or region of their medical school or undergraduate institution at similar rates (p > 0.05 for all). CONCLUSIONS: During the COVID-19 pandemic, plastic surgery residency programs matched more applicants from affiliated medical schools than in previous years. This may result from lack of in-person opportunities for applicants at other programs. Alternative relationship-building opportunities may facilitate broader geographic connections in the 2022 cycle.

Resolution of Systemic Rheumatologic Symptoms following Breast Implant Removal.

Reports of women with breast implants who suffer a wide variety of systemic symptoms have become more and more prevalent over the past several years. This entity has become known as breast implant illness in conventional news and social media outlets but has vague and nonspecific diagnostic criteria. As a result, the phenomenon is difficult to both identify and treat. The reported patient is a 76-year-old woman who underwent breast reconstruction with a latissimus dorsi flap and textured silicone implant 20 years before the onset of symptoms, which included debilitating joint pain. She had previously maintained an active lifestyle, but symptoms progressed to a point where she was unable to perform basic tasks. A full rheumatologic and connective tissue workup was done, but other than elevated markers of inflammation, it showed no diagnosable disease entity. After a lengthy discussion with her primary care physician and plastic surgeon, she decided to undergo removal of the implant. Following explantation, her symptoms quickly improved, and within several weeks, she was able to return to her active lifestyle.

Soft Tissue Contouring at the Time of Osseointegrated Implant Reconstruction for Lower Extremity Amputation.

INTRODUCTION: Patients with lower extremity amputations using a classic socket prosthesis face many challenges related to the socket-limb interface. The adaptation of osseointegration has allowed for the attachment of a prosthesis directly to bone, eliminating this interface and providing mechanical benefits. Contrary to the socket prosthesis, the osseointegrated prosthesis requires reducing and minimizing the soft tissue envelope. Studies have shown that patients who have undergone placement of these implants have high rates of reoperation for soft tissue redundancy. The purpose of our study was to evaluate complication rates and need for revisional surgery using our technique of soft tissue closure around the prosthesis at the time of implant placement. METHODS: An institutional review board-approved, retrospective chart review was performed on all patients who underwent implantation of an osseointegrated prosthesis for lower extremity amputation with concomitant plastic surgery closure at our institution during a 2-year period from June 2017 to June 2019. Patient demographics, health status descriptors, operative data, length of admission, and rates of postoperative complications were gathered from the electronic medical record and coded into a HIPAA-compliant database. Specific outcomes tracked included minor and major infection, osteomyelitis, implant failure, hematoma, seroma, delayed wound healing, and rates of reoperation and readmission. RESULTS: There were a total of 14 patients who underwent osseointegrated implant placement with concomitant plastic surgical coverage of the prosthesis during the study period. The average patient age was 50 years (range, 26-70 years), and average body mass index was 32.2 kg/m (range, 19.7-44.8 kg/m). Average follow-up time was 28 weeks (range, 10-73 weeks). There were 2 cases of local infection resolved with a course of oral antibiotics. There were no instances of infection requiring procedural intervention or hospital admission, nor any cases of osteomyelitis. Two patients required outpatient surgery for exchange of implant abutment, one required revision of a prosthesis for hardware loosening, and one required targeted muscle reinnervation of a sciatic nerve neuroma. There were no patients who required revisional surgery for soft tissue redundancy and no cases of delayed wound healing. CONCLUSIONS: Adequate planning of incisions and soft tissue contouring is important in the care of osseointegrated patients. Plastic surgery involvement can decrease soft tissue complications and lead to improved patient outcomes.

Myofascial Flap Closure in Treatment for Patients With Craniocervical Instability and Ehlers-Danlos Syndrome.

INTRODUCTION: The benefits of decompression and fusion for patients with craniocervical instability are well described. However, complications such as wound breakdown and need for unplanned reoperation frequently occur. Recent studies have shown advantages of myofascial flap closure for various spinal procedures. This study investigated whether closure with myofascial flaps after surgery for craniocervical instability decreases complications with further subgroup analysis of patients with Ehlers-Danlos syndrome (EDS). METHODS: A retrospective review of patients presenting to Weill Cornell Medical Center from 2010 to 2017 for craniocervical surgery was performed. All patients who underwent craniocervical surgery, regardless of plastic surgical involvement, were included in the study. Data including patient demographics, comorbidities, EDS diagnosis, surgical history, complications, and follow-up information were collected and analyzed. RESULTS: Data from 57 patients were analyzed. Eighteen patients (31.6%) had craniocervical surgery without myofascial flap closure, whereas 39 (68.4%) had surgery with flap closure. In the nonflap group, 9 patients required unplanned reoperation (50%). In the flap group, there were 5 patients requiring unplanned reoperation (15%). For reoperation, the Fisher exact test 2-tailed P value is 0.0096. Of those 57 patients, 24 had EDS: 5 (20.8%) had no flap closure, whereas 19 (79.2%) had flap closure. In the no-flap group, 3 patients required unplanned reoperation (60%). In the flap group, 5 patients required unplanned reoperation (21%). For reoperation, the Fisher exact test 2-tailed P value is 0.1265. CONCLUSIONS: Patients undergoing surgery for craniocervical instability may benefit from myofascial flap closure even if they have EDS. Mobilizing well-vascularized tissue can decrease rates of reoperation.

Effect of MRI on breast tissue expanders and recommendations for safe use.

INTRODUCTION: Ferromagnetic port-containing breast tissue expanders are currently labeled MRI-unsafe because of the presumption that magnets should not enter the machine. However, designating these devices as MRI-unsafe can lead to unnecessary procedures or suboptimal imaging choices. This study provides an ex vivo analysis of how breast tissue expanders behave when subjected to strong magnetic fields to determine which variables might affect clinical risk. METHODS: Three different brands of tissue expanders were evaluated in three MRI environments. Translational force was determined using the deflection angle method. Torque on empty, saline-filled, and air-filled expanders was evaluated on a 0-4 scale. Magnetic field was measured using a gaussmeter. The weight required to prevent displacement of the expanders was determined for both air- and saline-filled expanders. Temperature over time was measured using an alcohol thermometer. RESULTS: Magnetic field strength, deflection angle, and torque were the greatest in 3T MRI environments and varied by device manufacturer (Sientra > Mentor > Allergan). Saline-filled expanders required 240 mL and air-filled required 360 mL volume to make the torque undetectable, and the effect of torque could be mitigated with prone positioning. A weight of 120 g was required to prevent displacement of a saline-filled tissue expander and 870 g for an empty expander. There were no appreciable changes in temperature. CONCLUSIONS: Previously described risks may be reduced by using a 1.5T MRI, device selection, filling expanders with saline, and prone positioning. MRI can be considered in patients with breast tissue expanders when appropriate peri-procedural choices have been made so that the benefits of undergoing MRI outweigh the risks.

Intravascular Papillary Endothelial Hyperplasia (Masson's Tumor) of the Hand.

A nonspecific soft tissue mass of the hand can be difficult to diagnose due to the multitude of possible etiologies. In this case, we discuss our experience in diagnosing and treating intravascular papillary endothelial hyperplasia, or Masson's tumor, of the hand. The wide range of differential diagnoses and the morphological resemblance to angiosarcoma make Masson's tumor an important clinical entity to understand. The purpose of this study is to familiarize the reader with the appropriate diagnostic and treatment modalities that allow the clinician to recognize Masson's tumor, differentiate it from similar clinical entities, and institute the appropriate management regimen.

Patterns of Intracranial Hemorrhage in Pediatric Patients with Facial Fractures.

Intracranial hemorrhage (ICH) is a potentially fatal injury accompanying fractures of the cranium and facial skeleton. When occurring at a young age, ICH can lead to developmental delay, cerebral palsy, epilepsy, and death. It is therefore important for clinicians to recognize the presence of ICH early, and understand the factors that affect its prognosis. In this study, we aim to identify diagnostic and prognostic signs for ICH in pediatric facial fracture patients by examining aspects of patient presentation, concomitant injuries, and fracture patterns. Data were collected for all radiologically diagnosed facial fractures between January 2000 and December 2012 at a level I trauma center in Newark, NJ. This was then further refined to include only patients 18 years of age or younger who had a documented ICH. Patient age, Glasgow coma scale (GCS) on presentation, fracture location, type of hemorrhage, and certain aspects of management were collected from these records. Data were then analyzed by either Pearson chi-square test or a t-test to determine significant relationships. A total of 285 pediatric patients were found to have sustained a facial fracture during this time period, 67 of which had concomitant ICH; 46 of these patients were male and 21 were female, with average ages of 14.26 and 9.52 (p < 0.01), respectively. Causes of injury included motor vehicle accidents, pedestrians struck, assault, falls, gunshot injuries, and sports-related injuries. All patients who suffered injuries as a result of violent crimes (assault and gunshot injuries) were male. Although nearly all fracture patterns were significantly associated with the presence of ICH, mandibular fractures showed a significant negative association with the presence of ICH. In addition, patients who received surgical intervention were significantly younger than those who did not (7.7 vs. 13.7, p < 0.05). The GCS was significantly lower in patients who underwent ICP (intracranial pressure) monitoring or EVD (external ventricular drain) placement, suffered intraventricular hemorrhage, experienced worsening of hemorrhage on repeat imaging, and suffered fatal injuries. Our data also showed a significant association between the need for intubation in the emergency department and fatality. Because the consequence of ICH can be life threatening, proper diagnosis and management are imperative. The purpose of this study is to describe patterns associated with ICH in pediatric facial fracture patients to promote early recognition of the injury and understanding of poor prognostic signs.

Characteristics of Cervical Spine Injury in Pediatric Patients With Facial Fractures.

OVERVIEW: Cervical spine injury may present with pediatric patients having sustained fractures of the craniofacial skeleton. Management considerations of the cervical spine often take priority to the fractures of the facial skeleton. The goal of this study was to examine this subset of patients with a focus on initial presentation and need for intervention. METHODS: A retrospective review from 2000 to 2012 of all facial fractures in patients ≤ 18 years at a level 1 trauma center was performed. Patient demographics, location of fractures, and the presence of a cervical spine injury were collected. RESULTS: During this time period, 285 patients met inclusion criteria. Ten patients were found to have a cervical spine injury. Fractures of the zygoma and orbit were significantly associated with a cervical spine injury. Patients with a cervical spine injury had a Glasgow Coma Scale of 11.2 compared with 13.8 in those without (P < 0.05). C1 was injured in 4 patients, C2 in 2 patients, and C3 to C7 in 4 patients. A surgical airway was required in 1 patient, and 6 were intubated in the trauma bay. Fractures of the mandible were significantly associated with injury to C2. Le Fort fractures and palate fractures approached significance with injury to C1. Only 1 patient had neurologic impairment at presentation, manifested as upper extremity parasthesias, and underwent decompression and fusion in the operating room. Those patients admitted (90%) were all admitted for reasons other than management of the cervical spine injury. The majority of patients (70%) were treated with collar immobilization. One patient expired. No patients had a neurologic deficit at the time of discharge. CONCLUSIONS: In this study only 1 cervical spine injury necessitated intervention, with an eventual full recovery. Cervical spine injuries presenting with fractures of the facial skeleton appear to be relatively benign in this series; however, care must be taken to identify all such injuries to avoid exacerbation during maneuvers commonly used for facial fracture treatment. Special caution should be used when examining patients with a depressed Glasgow Coma Scale or in those with upper midface fractures.

Fat Grafting and Adipose-Derived Regenerative Cells in Burn Wound Healing and Scarring: A Systematic Review of the Literature.

BACKGROUND: There is an abundance of literature supporting the efficacy of fat grafting in aesthetic and reconstructive cases. There has been a recent emphasis on the regenerative capacity of adipose-derived stem cells and their utility in the improvement of wound healing and scarring provided by their cytokine and growth factor profiles. Despite the wealth of evidence supporting their efficacy, little attention has been paid to their utility in burn treatment. The authors' purpose was to provide an analysis of the literature regarding the use of fat grafting and regenerative cells in the treatment of burn wounds to guide surgeons and scientists on their clinical use. METHODS: A systematic review of the literature was performed by a thorough search of 12 terms using the PubMed, Medline, and Cochrane databases. Two hundred forty-one articles were subject to evaluation by predetermined inclusion and exclusion criteria. RESULTS: Six murine and 12 human studies were selected, including case-control studies, case series, and case reports. They describe histologic and clinical effects of fat grafting and regenerative cell therapy, including improvements in burn scar size and texture, enhanced angiogenesis, decreased inflammation, alleviation of pain, and return of function. CONCLUSIONS: There is a dearth of randomized controlled trials and quantitative analysis supporting the efficacy of fat grafting and adipose regenerative cells in burns. However, the subjective improvements in scars are encouraging. The authors hope that this review will be a foundation for future studies and will highlight the breadth of knowledge yet to be explored by this therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.