Breast sensorisexual function: a novel patient-reported outcome measure of sexual sensory functions of the breast.

BACKGROUND: A validated measure assessing sexual sensory functions of the breast is needed to optimize sexual and other health outcomes after breast procedures. AIM: To describe the development of a patient-reported outcome measure (PROM) to assess breast sensorisexual function (BSF). METHODS: We applied the PROMIS standards (Patient Reported Outcomes Measurement Information System) for measure development and evaluation of validity. An initial conceptual model of BSF was developed with patients and experts. A literature review yielded a pool of 117 candidate items that underwent cognitive testing and iteration. Forty-eight items were administered to an ethnically diverse, national panel-based sample of sexually active women with breast cancer (n = 350) or without (n = 300). Psychometric analyses were performed. OUTCOMES: The main outcome was BSF, a measure that assesses affective (satisfaction, pleasure, importance, pain, discomfort) and functional (touch, pressure, thermoreception, nipple erection) sensorisexual domains. RESULTS: A bifactor model fit to 6 domains-excluding 2 domains with only 2 items each and 2 pain-related domains-revealed a single general factor representing BSF that may be adequately measured by the average of the items. This factor, with higher values denoting better function and with the standard deviation set to 1, was highest among women without breast cancer (mean, 0.24), intermediate among women with breast cancer but not bilateral mastectomy and reconstruction (-0.01), and lowest among those with bilateral mastectomy and reconstruction (-0.56). Between women with and without breast cancer, the BSF general factor accounted for 40%, 49%, and 100% of the difference in arousal, ability to orgasm, and sexual satisfaction, respectively. Items in each of 8 domains demonstrated unidimensionality (ie, they measured 1 underlying BSF trait) and high Cronbach's alphas for the entire sample (0.77-0.93) and the cancer group (0.71-0.95). Correlations with sexual function, health, and quality of life were positive for the BSF general factor and mostly negative for the pain domains. CLINICAL IMPLICATIONS: The BSF PROM can be used to assess the impact of breast surgery or other procedures on the sexual sensory functions of the breast in women with and without breast cancer. STRENGTHS AND LIMITATIONS: The BSF PROM was developed by using evidence-based standards, and it applies to sexually active women with and without breast cancer. Generalizability to sexually inactive women and other women warrants further study. CONCLUSION: The BSF PROM is a measure of women's breast sensorisexual function with evidence of validity among women affected and unaffected by breast cancer.

Analysis of spin in the reporting of studies of topical treatments of photoaged skin.

BACKGROUND: Spin-reporting that distorts the interpretation of results-is not unusual within scientific literature. OBJECTIVE: To appraise strategies of spin among placebo-controlled double-blind clinical trials of topical treatments for photoaged skin. METHODS: A systematic review of the literature was performed to identify placebo-controlled double-blind clinical trials of topical treatments for photoaged skin. A survey of spin strategies was developed and applied to the cohort of identified studies. RESULTS: The systematic review led to the identification of 20 studies in which various types of spin strategies, broadly classified as either inappropriate statistical analyses or inappropriate interpretation of results, were used. The most commonly used strategies included use of multiple primary outcomes (95%), inappropriate extrapolation of results from specific outcomes to global improvements (95%), focus on within-group comparisons (75%), and focus on interim analyses to give more weight to nonsignificant findings (65%). LIMITATIONS: Classification of spin strategies was subjective and might not encompass all the methods used in the published literature. CONCLUSION: Findings in this study inform efforts to reduce spin in the dermatologic literature.

Using Google to Trend Patient Interest in Botulinum Toxin and Hyaluronic Acid Fillers

Introduction: Google Search is an important tool for patients researching skin care treatments and finding dermatologists. Data from individual patient's searches are aggregated by Google and yield powerful data sets that can be used to trend population behaviors. This study investigates the correlations between the volume of Google searches and the number of procedures performed annually for both botulinum toxin type A and hyaluronic acid tissue fillers. Methods: The volume of queries performed between 2005­2016 including [botox] or [hyaluronic acid + Juvederm + Perlane + Restylane + Prevelle] were analyzed in relation to the annual number of procedures using botulinum toxin type A and hyaluronic acid based soft tissue fillers, respectively. Results: The number of procedures performed using botulinum toxin and hyaluronic acid correlated significantly with the relative search volume for related search terms in both the same year (P< .001) and year prior (P< .001). Conclusions: Our findings highlight the importance of Google search data as a resource for understanding patient motivations and behavior. Dermatologists may use this resource as a tool to better address patient concerns and forecast local demand for specific procedures.

Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes.

BACKGROUND: Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. METHODS: A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. RESULTS: Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). CONCLUSIONS: This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery.

Gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is characterized by a marked discrepancy between one's birth-assigned sex and one's gender identity and is sometimes addressed by gender-affirming surgery. As public visibility and institutional support for the transgender and gender non-conforming population continue to increase, the demand for competent multidisciplinary teams of medical professionals equipped to care for this population is expected to rise-including plastic surgeons, urologists, gynecologists, endocrinologists, and breast surgeons, among others. Genital reconstruction procedures for the male-to-female and female-to-male transgender patient present unique surgical challenges that continue to evolve from their respective origins in the 19th and 20th centuries. A historical review of surgical techniques and standards of care attendant to gender-affirming medicine is presented, with foremost emphasis placed on how techniques for genital reconstruction in particular continue to evolve and advance. In addition, the current status of transition-related health care in the United States, including research gaps and contemporary clinical challenges, is reviewed. Frey JD, Poudrier G, Thomson JE, Hazen A. A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery. J Sex Med 2017;14:991-1002.

Autologous Breast Reconstruction in Women Older Than 65 Years Versus Women Younger Than 65 Years: A Multi-Center Analysis.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson χ² and analysis of variance tests were used. Given the number of analyses, a more conservative α of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

Techniques and Applications of Lower Extremity Feminization and Masculinization.

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

Autologous fat grafting and facial reconstruction.

There is tremendous interest in autologous fat grafting for the management of soft tissue volume deficiencies, treatment of cutaneous injuries, and regeneration of missing parts. Given its relative abundance and proximity to the surface of the skin, adipose tissue seems an excellent choice for the treatment of both congenital and acquired soft tissue defects, but the mesenchymal stem cells contained within the fat may provide unexpected opportunities for tissue replacement and repair. Although adipose transfer has been successfully used for reconstructive purposes since the end of the 19th century, numerous controversies about adipose harvesting, processing, delivery, survival, and efficacy still persist today. The purpose of this article was to highlight current practices, areas of controversy, and near-term future applications of fat grafting for reconstruction of the face.

Step-based cognitive virtual surgery simulation: an innovative approach to surgical education.

BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created a complex, real-time, step-based simulation platform for plastic surgery education. These simulators combine live surgical footage, interactive 3D visualization, text labels, and voiceover as well as a high-yield, expert-approved testing mode to create a comprehensive virtual educational environment for the plastic surgery resident or physician.

Integration of surgical simulation in plastic surgery residency training.

BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created an interactive, step-based latissimus musculocutaneous flap simulator. Preliminary testing of fourteen residents (PGY1-6) demonstrates that simulator training results in significant improvement in an objective assessment of surgical knowledge (p < 0.0006, pre-training score: 81.0%, post-training score 92.7%). This study is the first in the field of plastic and reconstructive surgery to demonstrate objective improvement in surgical knowledge as a result of simulator training, suggesting the potential effectiveness of simulators for a panopoly of breast reconstruction options.

Melting the Plastic Ceiling: Where We Currently Stand on Measures to Support Women in Academic Plastic Surgery.

BACKGROUND: Previous studies have provided recommendations for increasing female leadership in academic plastic surgery. This study quantifies the extent to which these recommendations have been met in plastic surgery residency programs and identifies remaining institutional barriers to the advancement of women in academic plastic surgery. METHODS: An electronic survey was designed to quantify select recommendations for promoting female leadership in academic plastic surgery. The survey was distributed to either a female faculty member or a male program director at each academic plastic surgery program. An optional phone interview discussing current barriers to women's advancement followed the survey. RESULTS: Forty-nine of 92 survey recipients participated (52.7 percent response rate). Women constituted 25 percent of faculty, 22 percent of program directors, and 20 percent of program leaders of participating programs. Programs on average provided three of 11 resources. Programs with female leaders provided 6.20 resources versus 2.28 resources at departments with male chairs (p = 0.015). Programs with female program directors provided 5.50 resources versus 2.18 resources at programs with male program directors (p = 0.008). Of the 49 survey respondents, nine completed the interview (18.4 percent completion rate). The most frequently identified barriers to aspiring women leaders were opaque promotion criteria (cited by 77.8 percent of interviewees), motherhood bias (77.8 percent), and unequal recruitment practices (55.6 percent). CONCLUSIONS: The presence of a female chair or program director is associated with a greater quantity of resources for promoting female leaders. Remaining barriers to women seeking academic leadership positions include compensation and promotion disparities, motherhood bias, and unequal recruitment practices.

Visualizing treatment options for breast reconstructive surgery.

We propose that high-fidelity animations enhanced with real-time 3d interactivity, that demonstrate various breast reconstruction procedures will assist in a patient's decision-making process. These computer based modules will in no way replace a consultation with the physician; instead they will be added to the armamentarium of patient education.

Three-Dimensional Analysis of Donor Masks for Facial Transplantation.

BACKGROUND: Face transplant teams have an ethical responsibility to restore the donor's likeness after allograft procurement. This has been achieved with masks constructed from facial impressions and three-dimensional printing. The authors compare the accuracy of conventional impression and three-dimensional printing technology. METHODS: For three subjects, a three-dimensionally-printed mask was created using advanced three-dimensional imaging and PolyJet technology. Three silicone masks were made using an impression technique; a mold requiring direct contact with each subject's face was reinforced by plaster bands and filled with silicone. Digital models of the face and both masks of each subject were acquired with Vectra H1 Imaging or Artec scanners. Each digital mask model was overlaid onto its corresponding digital face model using a seven-landmark coregistration; part comparison was performed. The absolute deviation between each digital mask and digital face model was compared with the Mann-Whitney U test. RESULTS: The absolute deviation (in millimeters) of each digitally printed mask model relative to the digital face model was significantly smaller than that of the digital silicone mask model (subject 1, 0.61 versus 1.29, p < 0.001; subject 2, 2.59 versus 2.87, p < 0.001; subject 3, 1.77 versus 4.20, p < 0.001). Mean cost and production times were $720 and 40.2 hours for three-dimensionally printed masks, and $735 and 11 hours for silicone masks. CONCLUSIONS: Surface analysis shows that three-dimensionally-printed masks offer greater surface accuracy than silicone masks. Greater donor resemblance without additional risk to the allograft may make three-dimensionally-printed masks the superior choice for face transplant teams. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Platelet rich plasma for photodamaged skin: A pilot study.

INTRODUCTION: Despite increasing popularity of platelet-rich plasma (PRP) in treating aging facial skin, the quality of evidence supporting its use is poor due to the lack of consistent methods of its preparation and application. OBJECTIVE: This study was conducted to assess treatment efficacy and patient satisfaction with a single PRP treatment prepared with a simplified preparation and application technique. METHODS: Four millilitre of PRP were injected into 6 standardized points on each side of the face. Outcomes were assessed by independent physician evaluation of pretreatment and posttreatment photographs using the Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale (GAIS). In addition, patient-reported outcomes were evaluated using the FACE-Q. RESULTS: Thirty-one participants ranging from 27 to 71 years of age (median, 38; IQR 32-58) were recruited for this study. Posttreatment WSRS scores improved in only 1 patient; the GAIS scores of 14 patients indicated aesthetic improvement. Analysis of FACE-Q scores revealed statistically significant increases in participant satisfaction with overall facial appearance and cheeks. The most frequently reported adverse effects were tenderness (23.4%; 7 of 31), facial tightness (20.0%; 6 of 31), and swelling (20.0%; 6 of 31). CONCLUSIONS: A simple method of PRP preparation offers modest benefit in treating the effects of skin aging and photodamage. Future research studies should alter our methods using a stepwise approach to optimize the treatment of aging facial skin with PRP.

Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study.

BACKGROUND: Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is an important gender-affirming procedure sought by many transmasculine and nonbinary individuals. Current literature is focused primarily on details of surgical technique and complication rates, with limited data available on how top surgery affects subjective quality-of-life measures. METHODS: An anonymous online survey was distributed to 81 of the senior author's former top-surgery patients. The survey response rate was 72 percent (58 respondents). Responses were analyzed to investigate quality of life, sexual confidence, mental health, satisfaction with top surgery, and patient attitudes toward top surgery's role in gender affirmation. RESULTS: Following top surgery, measures of quality of life and sexual confidence improved significantly (p < 0.001). In addition, 86 percent reported improvement in gender dysphoria-related mental health conditions. All but one respondent reported that top surgery had an overall positive impact on their life. CONCLUSIONS: Top surgery had major positive effects on all mental health and quality-of-life metrics. The authors' findings contribute to a much-needed body of evidence that top surgery markedly improves the daily lives and functioning of transgender and nonbinary individuals who choose to undergo it.

Current status of simulation training in plastic surgery residency programs: A review.

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors' opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.