A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy.

INTRODUCTION: Anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care. METHODS: The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population. RESULTS: From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation. CONCLUSION: There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. 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. .

Congenital Hypoplasia of the Extensor Tendons of the Fingers: A Case Report and Review of the Literature.

We present a rare case and unusual presentation of digital extensor tendon congenital hypoplasia. A 34-year-old woman presented to our clinic with the inability to extend her index, middle, and ring fingers since birth. Her tendons were reconstructed using transfer of flexor digitorum superficialis tendons from the middle and ring fingers to the extensor aponeurosis of the index, middle, and ring fingers. An acellular dermal substitute was applied in a novel way to reconstruct the extensor retinaculum and promote a successful functional outcome.

The Role of Endotoxin in Sterile Inflammation After Implanted Acellular Dermal Matrix: Red Breast Syndrome Explained?

BACKGROUND: Red breast syndrome (RBS) is a noninfectious erythema associated with acellular dermal matrix (ADM). The underlying cause remains unknown despite multiple suggested etiologies. No similar presentations to RBS have been reported in other anatomic regions. OBJECTIVES: The authors sought to describe and identify a common etiology for ADM-associated sterile inflammation in the breast and upper extremity. METHODS: A retrospective review of medical complaints reported to MTF Biologics (Edison, NJ) from July 1, 2017 to January 3, 2018 was performed. Inventory samples were tested for endotoxin content in endotoxin units (eu) via the Limulus Amebocyte Lysate method to determine a common etiology for sterile inflammation. RESULTS: Cases of RBS and upper extremity sterile inflammation, "red hand syndrome," are presented. Two patients developed RBS following implantation of ADM from the same donor; associated grafts in inventory had endotoxin levels of 167 eu and 320 eu per graft, respectively. Two patients developed red hand syndrome after joint arthroplasty with ADM from another donor; associated graft in inventory showed an endotoxin level of 1282 eu. Cultures were obtained and negative in 3 of the 4 cases. Since endotoxin screening of ADM donor lots began in January 2018 at MTF Biologics, no cases of sterile inflammation have been reported from screened units through December 31, 2018 (RBS rate, 39/15,529 [0.25%] vs 0/18,275 [0%], P < 0.0001). CONCLUSIONS: The sterile inflammatory response in RBS and newly reported red hand syndrome may be attributable to the presence of endotoxin in implanted ADM. Endotoxin screening has been adopted by MTF Biologics with a significant decrease in reported reactions.

STAT3 signalling pathway is implicated in keloid pathogenesis by preliminary transcriptome and open chromatin analyses.

Keloids are wounding-induced fibroproliferative human tumor-like skin scars of complex genetic makeup and poorly defined pathogenesis. To reveal dynamic epigenetic and transcriptome changes of keloid fibroblasts, we performed RNA-seq and ATAC-seq analysis on an early passage keloid fibroblast cell strain and its paired normal control fibroblasts. This keloid strain produced keloid-like scars in a plasma clot-based skin equivalent humanized keloid animal model. RNA-seq analysis reveals gene ontology terms including hepatic fibrosis, Wnt-ß-catenin, TGF-ß, regulation of epithelial-mesenchymal transition (EMT), STAT3 and adherens junction. ATAC-seq analysis suggests STAT3 signalling is the most significantly enriched gene ontology term in keloid fibroblasts, followed by Wnt signalling (Wnt5) and regulation of the EMT pathway. Immunohistochemistry confirms that STAT3 (Tyr705 phospho-STAT3) is activated and ß-catenin is up-regulated in the dermis of keloid clinical specimens and keloid skin equivalent implants from the humanized mouse model. A non-linear dose-response of cucurbitacin I, a selective JAK2/STAT3 inhibitor, in collagen type I expression of keloid-derived plasma clot-based skin equivalents implicates a likely role of STAT3 signalling in keloid pathogenesis. This work also demonstrates the utility of the recently established humanized keloid mouse model in exploring the mechanism of keloid formation.

Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis.

BACKGROUND: Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities. OBJECTIVES: We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy. METHODS: One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05. RESULTS: Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01). CONCLUSIONS: Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.

Keloid-derived, plasma/fibrin-based skin equivalents generate de novo dermal and epidermal pathology of keloid fibrosis in a mouse model.

Keloids are wounding-induced tumor-like human scars. Unclear etiology and lack of animal models to reveal disease mechanisms and invent therapies deepen the grievous health and psychosocial state of vulnerable individuals. Epitomizing the injury-repair environment which triggers and fosters keloid formation and essential dermal/epidermal interactions in disease development, the novel animal model was established by implanting porous polyethylene ring-supported plasma/fibrin-based epidermal-dermal skin constructs on the dorsum of athymic NU/J mice. The implants were stable to 18 weeks, contained abundant human cells, and remodeled to yield scar architecture characteristic of keloid fibrosis compared with normal implants and clinical specimens: (1) macroscopic convex or nodular scar morphology; (2) morphogenesis and accumulation of large collagen bundles from collagen-null initial constructs; (3) epidermal hyperplasia, aberrant epidermal-dermal patency, and features of EMT; (4) increased vasculature, macrophage influx, and aggregation; and (5) temporal-spatial increased collagen-inducing PAI-1 and its interactive partner uPAR expression. Development of such pathology in the NU/J host suggests that T-cell participation is less important at this stage than at keloid initiation. These accessible implants also healed secondary excisional wounds, enabling clinically relevant contemporaneous wounding and treatment strategies, and evaluation. The model provides a robust platform for studying keloid formation and testing knowledge-based therapies.

Abdominal Bulge After Retroperitoneal Dissection: The Definitive Management Using Bone Anchored Mesh.

BACKGROUND: Abdominal bulge after retroperitoneal dissection occurs at a rate of 1% to 56%. Injury to the T11 and T12 nerves is thought to result in abdominal musculature denervation, laxity, and symptomatic abdominal bulge. This complication has become more prevalent because the retroperitoneal approach for spinal surgery has become the preferred approach in specific lumbar and thoracic cases. Current repair techniques fail to address the etiology of abdominal wall laxity, and outcomes are poorly reported. Recurrence rates in lateral abdominal bulge repair are reported between 0% and 100%, and the complication rate is nearly 25%. We present a method of bone anchored fixation of mesh for abdominal wall reinforcement after the imbrication of the atrophied musculature, resulting in the definitive treatment of abdominal bulge after retroperitoneal dissection. METHODS: A retrospective review of 4 consecutive patients who underwent bony fixation of mesh using Mitek suture anchors (De Puy, Raynham, MA) for abdominal bulge after retroperitoneal dissection between February 2013 and September 2014 was performed. The preoperative, intraoperative, and postoperative records of 4 patients were reviewed and compared. RESULTS: There were no reported early recurrences and no perioperative morbidity or mortality related to the operation. Average follow-up was 12.8 months (range, 6-26 months); operative time, 157 minutes; postoperative length of stay, 3.5 days; and estimated blood loss was 50 mL. CONCLUSIONS: Reinforcement of the myofascial repair using bone anchored fixation of mesh represents a novel approach for the treatment of abdominal bulge after retroperitoneal dissection. Results demonstrate safety and no early recurrence.

Lateral Intercostal Artery Perforator Flap in Breast Reconstruction: A Simplified Pedicle Permits an Expanded Role.

BACKGROUND: The lateral intercostal artery perforator (LICAP) flap is a versatile second-tier option in breast reconstruction. The flap is rotated from redundant lateral chest fold on an easily dissected skin bridge pedicle without microsurgery in an outpatient setting. This series illustrates safety and effectiveness of the LICAP flap for prosthesis coverage when a muscle flap is not available or desired. In some cases, it even provides adequate soft tissue to reconstruct the breast mound without an implant. METHODS: Lateral intercostal artery perforator flaps performed for breast reconstruction at an ambulatory surgery center were reviewed. RESULTS: A total of 39 flaps were performed on an outpatient basis for a variety of breast reconstruction indications. One immediate reconstruction with bilateral LICAP flaps was performed after mastectomy. All remaining flaps were for delayed breast reconstruction. Mean operative time for each flap was 65 minutes, and concomitant procedures were performed in 25 of 27 patients. Follow-up was 5 to 96 months. There was 1 major complication (2.5%) and 5 minor (12.8%) complications. CONCLUSIONS: This series demonstrates unique advantages of the LICAP flap for a variety of breast reconstruction problems, including outpatient setting, no muscle sacrifice, flap reliability, and low donor site morbidity. These results confirm previous reports in post bariatric augmentation that the LICAP flap reliably supplies a large skin/adipose flap from the redundant tissue of the lateral chest fold with minimal morbidity even after radiation. The LICAP flap warrants closer consideration in breast reconstruction.

Hand Rejuvenation: A Comprehensive Review of Fat Grafting.

Dermal atrophy, bulging reticular veins, and prominent bones and tendons are characteristic of the aging hand. Demand for cosmetic procedures to restore a youthful appearance to the dorsum of the hand has risen in recent years. A review of the literature reveals that of the many options for hand restoration, autologous fat grafting stands out as the most promising choice compared with many available alternative options such as microdermabrasion, peeling agents, and dermal fillers. This article details the surgical technique and relevant anatomy necessary for successful hand rejuvenation. Future advancements may rely on further study into adipose-derived stem cells.

Cadaveric Meniscus Arthroplasty for Post-Traumatic Arthritis: A Case Report.

We present a novel treatment for post-traumatic arthritis of the hand and fingers using joint resurfacing with cadaveric meniscus. A 20-year-old man presented to the clinic with chronic pain and stiffness after an intra-articular fifth metacarpal fracture. Meniscus allograft, which has been used successfully in treatments for thumb carpometacarpal and radiocarpal degenerative osteoarthritis, was used to reconstruct the joint surface with complete resolution of stiffness and pain.

Lateral Epicondylitis: Treatment Preferences from the Potential Patient Perspective.

Background: Knowing the questions and concerns that patients have regarding treatment options for lateral epicondylitis may allow for shared-decision making and potentially superior patient outcomes and satisfaction. In the present study, we aimed to further delineate patient preferences with treatment of lateral epicondylitis. Methods: An online, survey-based, descriptive study was conducted through Amazon Mechanical Turk. Survey participants were presented with a clinical scenario regarding lateral epicondylitis and asked four questions regarding treatment preferences for nonoperative treatment, whether they would consider platelet-rich plasma (PRP) injection, and whether they would consider surgical intervention for recalcitrant symptoms. A Likert scale was used for responses. McNemar chi-square test was used for paired nominal data for statistical analysis. Results: A total of 238 survey responses were included. A majority (63%) of respondents elected to proceed with formal physical therapy. When given additional information regarding corticosteroid injections, 50.8% of respondents reported preferring physical therapy. There were no differences between groups for questions 1 and 2 (P = 0.90). Of the respondents, 75.2% were "likely" or "extremely likely" to consider PRP injection. When asked about surgical intervention, 74.8% of respondents were "likely" or "extremely likely" to proceed with continued symptoms. Conclusions: It is important to include patient preferences in treatment discussions of lateral epicondylitis. Survey respondents preferred formal physical therapy for initial treatment. A surprising majority of respondents were likely to consider a PRP injection. With prolonged symptoms, respondents were interested in discussions of surgical intervention and thus, it should continue to be offered to patients with recalcitrant symptoms.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction Between Palmaris Longus Autograft and Knee Medial Collateral Ligament Allograft.

Background: Medial ulnar collateral ligament (mUCL) injury can cause significant pain and alter throwing mechanics. Common autograft options for mUCL reconstruction (UCLR) include the palmaris longus (PL) and hamstring tendons. Allograft use may reduce donor site morbidity and decrease function related to PL autografts. Purpose: To compare varus stability and load to failure between a novel allograft for UCLR-knee medial collateral ligament (kMCL)-and a PL autograft in human donor elbow specimens. Study Design: Controlled laboratory study. Methods: A total of 24 fresh-frozen human elbows were dissected to expose the mUCL. Medial elbow stability was tested with the mUCL intact (native), deficient, and reconstructed utilizing the humeral single-docking technique with either a (1) kMCL allograft (n = 12) or (2) a PL autograft (n = 12). A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion tracking cameras. The elbow was cycled through a full range of motion 5 times. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion, and failure modes were recorded. Results: The mUCL-deficient elbows demonstrated significantly greater valgus rotation compared with the intact and reconstructed elbows at every flexion angle tested (10°-120°) (P <.001). Both kMCL- and PL-reconstructed elbows exhibited significantly higher mean valgus rotation compared with the intact state between 10° and 40° of flexion (P < .01). There were no significant differences in valgus rotation at any flexion angle between the kMCL and PL graft groups. When loaded to failure, elbows reconstructed with both kMCL and PL grafts failed at similar torque values (18.6 ± 4 and 18.1 ± 3.4 N·m, respectively; P = .765). Conclusion: Fresh-frozen and aseptically processed kMCL allografts demonstrated similar kinematic and failure properties to PL tendon autografts in UCL-reconstructed elbows, although neither graft fully restored kinematics between 10° and 40°. Clinical Relevance: Prepared kMCL ligament allografts may provide a viable graft material when reconstructing elbow ligaments while avoiding the potential complications related to PL autografts- including donor site morbidity.

Reconstruction of Ollier disease in a severely involved hand.

Ollier disease is a nonhereditary disorder characterized by multiple enchondromata, with a random asymmetrical distribution. We report an unusual case of massive ulcerating multiple enchondromata of the left hand of an 11-year-old male patient. A methodical approach to treating such a massive tumor burden and steps in reconstructing the hand are described. This case report demonstrates a radical expression of this disease; however, no malignancy was identified despite the aggressive and chronic nature of the disease. Unlike previously reported cases with less severe involvement, this patient did not undergo amputation, and this approach demonstrates a strategy for limb salvage not previously described. In particular, despite bony defects of 6 cm, no autograph was necessary for the reconstruction of the hand.

Carpal Tunnel Syndrome: As Seen from the Perspective of the Patient.

Carpal tunnel syndrome (CTS) is the most common nerve compression syndrome in the upper extremity and is one of the most common problems treated by hand surgeons. Despite its ubiquity-or perhaps because of it-there is a lack of unanimity regarding how best to treat CTS and what the options for treatment are. This study aimed to explore what patients find important when deciding on treatment of CTS in an effort to improve the physician-patient shared decision-making process. Methods: An online crowdsourcing platform was used to recruit participants for this study. Study participants were first led through a clinical scenario in which the symptoms of CTS were explained. They were then asked a series of questions regarding what was important to them when deciding upon treatment. A Likert scale was used for responses. Results: In total, 268 participant responses were included in the study. A majority of patients responded that all surveyed factors were either very important or important when considering treatment. The risk of surgery was most important, whereas postoperative pain was least important. The risk of surgery was significantly more important to patients than postoperative pain and time out of work. The cost of surgery was significantly more important to patients than postoperative pain. Conclusions: Given the lack of consensus regarding an algorithm for the treatment of CTS, the patient's preference is increasingly important when formulating a treatment plan. The results of this study may better help physicians frame the discussion of treatment options for CTS with their patients.

Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial.

The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release. Methods: Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates. Results: POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups. Conclusions: Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique.

Endoscopic Retrograde Approach for Trigger Finger Release: A Cadaver Study.

Trigger finger is one of the most common causes of disability and pain in the hand. Current surgical techniques for trigger finger release fall short in that they are performed blindly with trauma to, or require incision of, the palmar fascia, which can be a source of significant and long-lasting morbidity. Retrograde endoscopic release of the A1 pulley was performed through a single incision at the proximal digital crease in cadaveric specimens. The fingers were then dissected to assess for completeness of release and inspected for injury to nearby structures. Complete release of the A1 pulley was noted in 16 of 16 fingers. No significant injuries to the A2 pulley and flexor tendon were found, and no injuries to the digital nerves or vasculature occurred. The described technique, as demonstrated in cadaveric specimens, is a feasible alternative approach in the treatment of trigger finger. The technique allows complete visualization of A1 pulley release through a single palmar fascia sparing incision.

Use of Acellular Dermal Matrix to Prevent Recurrence of Radioulnar Heterotopic Ossification.

Radioulnar heterotopic ossification is a rare occurrence found in approximately 2% of all forearm injuries. Treatment is complicated by relatively high recurrence rates. Strategies to decrease recurrence have included the range of motion exercises and the interposition of inert or autogenous barriers. We report on the interposition of human acellular dermal matrix (ADM) for the treatment of distal radioulnar synostosis. We report a novel technique for the treatment of distal radioulnar heterotopic ossification. After resection, ADM in a cigar-shaped construct is interposed between the radius and ulna. Patients are followed clinically and radiographically. Two female patients were treated. Both patients had significant improvement in the range of motion in supination and pronation of the affected wrist postoperatively with an average follow-up of 36 months. There were no postoperative complications. Neither patient had recurrent disease. We describe the successful treatment of 2 patients with distal radioulnar heterotopic ossification with the use of human ADM. The ADM provides a barrier between the radius and ulna to prevent the recurrent formation of heterotopic ossification. ADM usage results in no donor site morbidity and is theoretically more resistant to infection when compared with nonbiologic barriers such as silicone and Integra. This technique is a simple, safe, and effective way to treat and prevent the recurrence of radioulnar heterotopic ossification.

Use of Acellular Dermal Matrix Following Fasciectomy for the Treatment of Dupuytren's Disease.

BACKGROUND: Recurrence rates following surgical intervention for Dupuytren's disease (DD) remains high. In this study, we investigate the use of acellular dermal matrix (ADM) to reduce recurrence and improve long-term clinical outcome. METHODS: We examined 132 patients undergoing open fasciectomy for DD from 2007 to 2017. The experimental group had a sheet of ADM (FlexHD) sutured into the surgical bed controls were not closed with ADM. Patient characteristics, range of motion, and complications were examined. RESULTS: Twenty-eight (21.2%) patients were treated with acellular dermal matrix, whereas 104 (78.8%) patients were not. The median age was 67.0 years (range 34-91 years). with no differences between group regarding age, comorbidities, and laterality. The mean preoperative interphalangeal joint flexion contracture in the ADM group of 66.5 ± 29.9 degrees was corrected to 9.7 ± 12.4 degrees, whereas the mean metacarpophalangeal joint preoperative flexion contracture of 51.4 ± 23.9 degrees was corrected to 7.8 ± 14.1 degrees at postoperative examination (P < 0.05). The median follow-up was 18.7 months, during which the recurrence of contracture was observed in 1 of 28 patients in the group receiving ADM compared with 9 of 104 in the control group (P = 0.37). There were no differences in the incidence of minor wound complications observed. CONCLUSION: The adjunct placement of acellular dermal matrix into the wound bed following fasciectomy for DD may be an important surgical strategy to reduce recurrence rates as well as augment coverage of exposed vital structures in cases of severe flexion contracture.

Surgical Repair of an Avulsed Distal Flexor Carpi Radialis Tendon in a Boxer: A Case Report.

CASE: A 25-year-old professional boxer presented with a right distal flexor carpi radialis (FCR) tendon avulsion after sustaining an injury while boxing. The avulsion was identified and confirmed with magnetic resonance imaging, and the tendon was successfully reinserted into the trapezium. The patient returned to professional boxing 10 months later without complication. CONCLUSIONS: Distal FCR tendon avulsions are rare. Occasionally, this tendon can avulse after an application of excessive force. For some patients, unrepaired distal FCR tendon avulsions may prevent competitive performance. In this case, the tendon was reattached to the trapezium to aid wrist motion and stability, which are essential for professional boxing.