Management of the Midface in the Transgender Patient.

Management of the midface has a central role to achieve harmony in the transgender patient requesting facial feminization surgery. The relative projection of separate areas of the craniofacial skeleton largely determines the appearance of the facial framework. In this article the authors describe the management of the midface; bony remodeling and soft tissue aspects, in the transgender patient.

Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery.

INTRODUCTION: A cornerstone of treating gender dysphoria for transgender women is gender reassignment surgery (GRS) encompassing vaginoplasty and clitoroplasty. The neoclitoris is harvested as a flap with a neurovascular pedicle from the proximal dorsal part of the glans penis. Few long-term follow-ups exist on postoperative sensation and patient-reported sexual functionality of the neoclitoris. AIM: To examine the sensitivity of the neoclitoris and its relation to orgasm and sexual function at least 1 year after GRS. METHODS: Twenty-two patients were included, with a mean follow-up of 37 months (range = 12-63) after initial surgery. Tactile and vibratory sensitivities were measured with Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A questionnaire was provided to the patients, as were interview questions about body image, orgasm, pain, and general satisfaction with the surgery. MAIN OUTCOME MEASURES: Tactile and vibratory sensitivities of the neoclitoris and questionnaire on satisfaction with orgasm, sexual function, and general satisfaction. RESULTS: The average tactile threshold for the clitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. Most participants (86%) experienced orgasm after surgery, had no or little pain, and were satisfied with the surgery. No statistical correlation was found between better or worse objective pressure and vibratory thresholds and patient answers to questions about the clitoris in the Body Image Scale for Transsexuals questionnaire. CONCLUSION: The neoclitoris derived from the glans penis in GRS provides long-term clitoral sensation that is erogenous. Overall, the vast majority of patients who undergo male-to female GRS experience orgasm and are satisfied with the surgery.

Lower Eyelid Complications in Facial Fracture Surgery.

BACKGROUND: Facial fractures may lead to sequelae due to the trauma but also as a result of surgery. Complications to lower eyelid incisions include ectropion, scleral show, entropion, canthal malposition, and lid edema. The aim of this study was to compare the occurrence of such complications depending on whether a subciliary or transconjunctival incision was used for surgical access. METHODS: All consecutive patients surgically treated for a facial fracture between June 2005 and December 2012 with a lower eyelid incision and a minimal follow-up of 6 months were included in this retrospective study. Patients were grouped according to type of lower eyelid incision (transconjunctival vs subciliary). RESULTS: Out of 128 patients, 37 (29%) had a subciliary and 91 (71%) had a transconjunctival incision. In the subciliary incision group, 3 patients (8.1%) had ectropion and 4 patients (11%) had scleral show whereas 2 patients (2.2%) had ectropion, 4 patients (4.4%) had scleral show, and 2 patients (2.2%) displayed canthal malposition in the transconjunctival incision group. The differences between the groups were not statistically significant. No patient had an entropion. CONCLUSIONS: Subciliary incisions had a higher incidence of ectropion and scleral show compared with transconjunctival incisions. Transconjunctival incisions did show a low risk of canthal malposition needing surgical correction; however, the actual numbers were low. Based on this and earlier studies, the authors routinely perform transconjunctival incisions, without a lateral canthotomy if possible, for surgery of facial fractures.

Control of Notch-ligand endocytosis by ligand-receptor interaction.

In Notch signaling, cell-bound ligands activate Notch receptors on juxtaposed cells, but the relationship between ligand endocytosis, ubiquitylation and ligand-receptor interaction remains poorly understood. To study the specific role of ligand-receptor interaction, we identified a missense mutant of the Notch ligand Jagged1 (Nodder, Ndr) that failed to interact with Notch receptors, but retained a cellular distribution that was similar to wild-type Jagged1 (Jagged1(WT)) in the absence of active Notch signaling. Both Jagged1(WT) and Jagged1(Ndr) interacted with the E3 ubiquitin ligase Mind bomb, but only Jagged1(WT) showed enhanced ubiquitylation after co-culture with cells expressing Notch receptor. Cells expressing Jagged1(WT), but not Jagged1(Ndr), trans-endocytosed the Notch extracellular domain (NECD) into the ligand-expressing cell, and NECD colocalized with Jagged1(WT) in early endosomes, multivesicular bodies and lysosomes, suggesting that NECD is routed through the endocytic degradation pathway. When coexpressed in the same cell, Jagged1(Ndr) did not exert a dominant-negative effect over Jagged1(WT) in terms of receptor activation. Finally, in Jag1(Ndr/Ndr) mice, the ligand was largely accumulated at the cell surface, indicating that engagement of the Notch receptor is important for ligand internalization in vivo. In conclusion, the interaction-dead Jagged1(Ndr) ligand provides new insights into the specific role of receptor-ligand interaction in the intracellular trafficking of Notch ligands.

Implant Attributes or Patient Characteristics? Factors Affecting Outcome after Breast Augmentation in Transgender Women.

Implant-based breast augmentation is a valuable tool for treatment of gender dysphoria in transgender women. The aim was to assess whether implant attributes, plane selection, and patient characteristics had an impact on the surgical outcome, and to compare these parameters between transgender and cisgender breast augmentations. Methods: A cohort of transgender women who underwent breast augmentation at our department during 2009-2018 were retrospectively studied. The cohort was also compared with a cohort of 12,884 mainly cisgender women registered in the Swedish breast implant registry (BRIMP) during 2014-2019. Results: A total of 143 transgender individuals were included, with a median follow-up of 5.7 years. Complications occurred in 20 patients (14.0%), four patients (2.8%) underwent acute reoperation, and 20 patients (14.0%) had secondary corrections. No differences were seen in complication rates when comparing prepectoral with subpectoral placement (15.1% versus 12.9%; P = 0.81); size, less than 400 mL versus greater than or equal to 400 mL (14.7% versus 13.3%; P = 0.81), or the shape of the implants, round versus anatomic (10.7% versus 22.2%; P = 0.10). In comparison with the cohort from BRIMP, the transgender cohort had more round implants (72.0% versus 60.7%; P < 0.01), larger implants (44.1% had volumes of 400-599 mL, compared with 25.4%; P < 0.0001), and more prepectoral placement (51.0% versus 7.3%; P < 0.0001). The risk of reoperation less than 30 days was 1.2% in BRIMP and 2.8% in the transgender cohort (P = 0.08). Conclusions: In transgender women, implants are often larger, round, and placed prepectoral' compared with cisgender women. Despite these differences, complication rates were equivalent. Implant attributes, surgical techniques, and patient characteristics were not independently associated with the rate of complications.

Erythrocytes Induce Vascular Dysfunction in COVID-19.

Current knowledge regarding mechanisms underlying cardiovascular complications in patients with COVID-19 is limited and urgently needed. We shed light on a previously unrecognized mechanism and unravel a key role of red blood cells, driving vascular dysfunction in patients with COVID-19 infection. We establish the presence of profound and persistent endothelial dysfunction in vivo in patients with COVID-19. Mechanistically, we show that targeting reactive oxygen species or arginase 1 improves vascular dysfunction mediated by red blood cells. These translational observations hold promise that restoring the redox balance in red blood cells might alleviate the clinical complications of COVID-19-associated vascular dysfunction.

Heparan sulfation-dependent fibroblast growth factor signaling maintains embryonic stem cells primed for differentiation in a heterogeneous state.

Embryonic stem (ES) cells continuously decide whether to maintain pluripotency or differentiate. While exogenous leukemia inhibitory factor and BMP4 perpetuate a pluripotent state, less is known about the factors initiating differentiation. We show that heparan sulfate (HS) proteoglycans are critical coreceptors for signals inducing ES cell differentiation. Genetic targeting of NDST1 and NDST2, two enzymes required for N-sulfation of proteoglycans, blocked differentiation. This phenotype was rescued by HS presented in trans or by soluble heparin. NaClO(3) (-), which reduces sulfation of proteoglycans, potently blocked differentiation of wild-type cells. Mechanistically, N-sulfation was identified to be critical for functional autocrine fibroblast growth factor 4 (FGF4) signaling. Microarray analysis identified the pluripotency maintaining transcription factors Nanog, KLF2/4/8, Tbx3, and Tcf3 to be negatively regulated, whereas markers of differentiation such as Gbx2, Dnmt3b, FGF5, and Brachyury were induced by sulfation-dependent FGF receptor (FGFR) signaling. We show that several of these genes are heterogeneously expressed in ES cells, and that targeting of heparan sulfation or FGFR-signaling facilitated a homogenous Nanog/KLF4/Tbx3 positive ES cell state. This finding suggests that the recently discovered heterogeneous state of ES cells is regulated by HS-dependent FGFR signaling. Similarly, culturing blastocysts with NaClO(3) (-) eliminated GATA6-positive primitive endoderm progenitors generating a homogenous Nanog-positive inner cell mass. Functionally, reduction of sulfation robustly improved de novo ES cell derivation efficiency. We conclude that N-sulfated HS is required for FGF4 signaling to maintain ES cells primed for differentiation in a heterogeneous state. Inhibiting this pathway facilitates a more naïve ground state.

Improved Surgical Outcome with Double Incision and Free Nipple Graft in Gender Confirmation Mastectomy.

BACKGROUND: Mastectomy and chest-wall contouring is the most common gender confirmation surgery. With increasing prevalence of transgender individuals, there is a demand for better surgical outcomes and aesthetic results. Our aim was to evaluate surgical techniques used and assess modifications in gender confirmation mastectomies at Karolinska University hospital in Stockholm, Sweden. METHODS: A retrospective cohort study was performed on 464 patients undergoing gender confirmation mastectomies in our department between 2009 and 2018. Patient demographics, psychiatric comorbidity, surgical method, and outcome were analyzed. Follow-up was at least one year. RESULTS: The most frequently used surgical technique for gender confirmation mastectomies was double incision with free nipple graft (243 patients, 52.4%), followed by periareolar incision (113 patients, 24.4%) and semicircular incision (67 patients, 14.4%). The double incision technique and periareolar technique were associated with 18.9% and 28.3% complications, 3.3% and 12.4% acute reoperations, 28.4% and 65.5% secondary revisions, respectively. The double incision technique increased from being used in 17.8% of all mastectomies during 2009-2013 to 62.9% during 2014-2018, while periareolar incision decreased from 43.0% to 18.5%. CONCLUSIONS: The current study describes a successful transition of surgical technique from periareolar incision to double incision with free nipple graft in gender confirmation mastectomy, leading to significant improvements in the overall outcome with fewer complications, less acute reoperations and less secondary corrections. Hence, we consider the double incision with free nipple graft technique to be the favored technique in the vast majority of cases in female-to-male chest wall contouring.

Sp1 mediate hypoxia induced ephrinB2 expression via a hypoxia-inducible factor independent mechanism.

Environmental factors are instrumental in maintaining a healthy vasculature. Oxygen tension is higher in arteries than in veins and thus has the potential to be an instructive signal in arterial/venous specification. EphrinB2 is specifically expressed in arteries and required during embryonic vessel formation. In this study, we show that expression of ephrinB2 is oxygen dependent. Mutagenesis of hypoxia-responsive elements and transactivation experiments determined this regulation to be achieved in a hypoxia-inducible factor independent manner. MAZ and Sp1 are known to regulate transcription together and have been shown to bind to the same sites within promoters. Chromatin immunoprecipitation confirmed that binding of Sp1 to the ephrinB2 promoter was favored compared to MAZ under hypoxic relative to normoxic conditions. Furthermore, siRNA mediated knockdown of Sp1 attenuated this hypoxic response. These results indicate that hypoxia drives arterial differentiation by increasing ephrinB2 expression in endothelial cells through Sp1 activation.

Notch signaling regulates platelet-derived growth factor receptor-beta expression in vascular smooth muscle cells.

Notch signaling is critically important for proper architecture of the vascular system, and mutations in NOTCH3 are associated with CADASIL, a stroke and dementia syndrome with vascular smooth muscle cell (VSMC) dysfunction. In this report, we link Notch signaling to platelet-derived growth factor (PDGF) signaling, a key determinant of VSMC biology, and show that PDGF receptor (PDGFR)-beta is a novel immediate Notch target gene. PDGFR-beta expression was upregulated by Notch ligand induction or by activated forms of the Notch receptor. Moreover, upregulation of PDGFR-beta expression in response to Notch activation critically required the Notch signal integrator CSL. In primary VSMCs, PDGFR-beta expression was robustly upregulated by Notch signaling, leading to an augmented intracellular response to PDGF stimulation. In newborn Notch3-deficient mice, PDGFR-beta expression was strongly reduced in the VSMCs that later develop an aberrant morphology. In keeping with this, PDGFR-beta upregulation in response to Notch activation was reduced also in Notch3-deficient embryonic stem cells. Finally, in VSMCs from a CADASIL patient carrying a NOTCH3 missense mutation, upregulation of PDGFR-beta mRNA and protein in response to ligand-induced Notch activation was significantly reduced. In sum, these data reveal a hierarchy for 2 important signaling systems, Notch and PDGF, in the vasculature and provide insights into how dysregulated Notch signaling perturbs VSMC differentiation and function.

Late-onset posttraumatic skin and soft-tissue infections caused by rapid-growing mycobacteria in tsunami survivors.

BACKGROUND: In the tsunami catastrophe in Thailand in 2004, several thousand Swedish tourists were injured, with contaminated crush trauma of the legs being the main cause of injury among the survivors. METHODS: Patient and laboratory data for those who received hospital care in Stockholm and Gothenburg and contracted late-onset infections due to rapid-growing mycobacteria were reviewed retrospectively. Also, concomitant infections were recorded. RESULTS: Fifteen patients with late-onset skin and soft-tissue infections due to rapid-growing mycobacteria are described here. Mycobacterium abscessus was isolated in 7 cases, Mycobacterium fortuitum was isolated in 6 cases, and Mycobacterium peregrinum and Mycobacterium mageritense were isolated in 1 case each. The infections appeared after a delay of 20-105 days (median, 60 days) after the trauma, targeting undamaged skin located near primary sutured wounds or skin grafts. Antimycobacterial drugs were given to 9 (60%) of the patients. The course of infection was protracted, but all infections due to rapid-growing mycobacteria healed within 12 months. Concomitant subcutaneous infections due to other microorganisms, such as Burkholderia pseudomallei or Cladophialophora bantiana, appeared early or late after the trauma. CONCLUSIONS: Repeated cultures of abscess and wound specimens for Mycobacterium species may be needed to find the etiologic agents causing contaminated skin and soft-tissue infections, such as those that developed after traumas that occurred during the tsunami. These cultures are especially necessary when symptoms appear late and when conventional bacterial culture results are negative. A biopsy is recommended for the best yield and for complementary histopathological examination.

Assessment of NORE1A as a putative tumor suppressor in human neuroblastoma.

The putative tumor suppressor NORE1A (RASSF5) is a member of the Ras association domain family and is commonly inactivated in human cancer. The closely related gene family member and functional collaborator RASSF1A is a bona fide tumor suppressor and is frequently involved in neuroblastoma. In the present study, we sought to investigate the role of NORE1A in human neuroblastoma. A panel of tumors (36 neuroblastomas and 4 ganglioneuromas) and neuroblastoma cell lines was assessed for NORE1A gene expression by Taqman quantitative RT-PCR. Promoter methylation was quantitatively determined by methylation sensitive pyrosequencing. The antitumourigenic role was functionally investigated in Nore1a transfected SK-N-BE (2) cells by fluorescent inhibition of caspase activity and BrdU incorporation assays. Neuroblastoma cells showed very low or absent NORE1A mRNA expression, which could not be reversed by trichostatin A or 5-aza-cytidine treatments. Neuroblastoma tumors showed suppressed NORE1A gene expression that was particularly pronounced in cases without MYCN amplification or 1p loss. Methylation of the NORE1A promoter was not observed in primary tumors and only one out of seven neuroblastoma cell lines displayed weak partial methylation. Transient expression of Nore1a resulted in enhanced apoptosis and delayed cell cycle progression. In conclusion NORE1A appears to be strongly suppressed in neuroblastic tumors and reconstitution of its expression diminishes the tumorigenic phenotype. Promotor methylation is not a common mechanism responsible for NORE1A transcriptional suppression in this tumor type.

Lentiviral rescue of vascular endothelial growth factor receptor-2 expression in flk1-/- embryonic stem cells shows early priming of endothelial precursors.

The vascular endothelial growth factor (VEGF) family and its receptors are important for vascular development and maintenance of blood vessels, as well as for angiogenesis, the formation of new vessels. Loss of VEGF receptor-2 (VEGFR-2; designated Flk-1 in mouse) results in arrest of vascular and hematopoietic development in vivo. We used lentiviral transduction to reconstitute VEGFR-2 expression in flk1-/- embryonic stem (ES) cells. VEGF-induced vasculogenesis and sprouting angiogenesis were rescued in transduced ES cultures differentiating in vitro as EBs. Although the transgene was expressed in the pluripotent stem cells and lacked linage restriction during differentiation, the extent of endothelial recruitment was similar to that in wild-type EBs. Reconstitution of VEGFR-2 in flk1-/- ES cells allowed only precommitted precursors to differentiate into functional endothelial cells able to organize into vascular structures. Chimeric EB cultures composed of wild-type ES cells mixed with flk1-/- ES cells or reconstituted VEGFR-2-expressing ES cells were created. In the chimeric cultures, flk1-/- endothelial precursors were excluded from wild-type vessel structures, whereas reconstituted VEGFR-2-expressing precursors became integrated together with wild-type endothelial cells to form chimeric vessels. We conclude that maturation of endothelial precursors, as well as organization into vascular structures, requires expression of VEGFR-2. Disclosure of potential conflicts of interest is found at the end of this article.

Functional arterial and venous fate is determined by graded VEGF signaling and notch status during embryonic stem cell differentiation.

OBJECTIVE: The aim of this work was to develop a mouse embryonic stem (ES) cell system addressing the early specification of the developing vasculature into functional arteries and veins. METHODS AND RESULTS: ES cells were differentiated 4 days on collagen-type IV coated dishes to obtain Flk1+ endothelial precursors. Sub-culture of these precursors for additional 4 days robustly generated, in a VEGF dose-dependent manner, mature endothelial cells. Arterial marker genes were specifically expressed in cultures differentiated with high VEGF concentration whereas the venous marker gene COUP-TFII was upregulated in endothelial cells induced through low and intermediate VEGF concentrations. This VEGF-dependent arterialization could be blocked by inhibition of Notch resulting in an arterial to venous fate switch. Functional and morphological studies, ie, measurement of sprout length, pericyte recruitment, and interleukin-I-induced leukocyte adhesion, further confirmed their arterial and venous identity. CONCLUSIONS: We conclude that endothelial cells with distinct molecular, morphological, and functional characteristics of arteries and veins can be derived through in vitro differentiation of ES cells in a VEGF dose-dependent and Notch-regulated manner.

The Ras effectors NORE1A and RASSF1A are frequently inactivated in pheochromocytoma and abdominal paraganglioma.

NORE1A (RASSF5) and RASSF1A are newly described Ras effectors with tumour suppressor functions. Both molecules are frequently inactivated in various cancers. In this study, we aimed to explore the potential involvement of NORE1A and RASSF1A in pheochromocytoma and abdominal paraganglioma tumorigenesis. A panel of 54 primary tumours was analysed for NORE1A and RASSF1A mRNA expression by TaqMan quantitative RT-PCR. Furthermore, NORE1A and RASSF1A promoter methylation was assessed by combined bisulphite restriction endonuclease assay and methylation-sensitive Pyrosequencing respectively. The anti-tumorigenic role of NORE1A was functionally investigated in Nore1A-transfected PC12 rat pheochromocytoma cells by fluorescent inhibition of caspase activity and soft agar assays. Significantly suppressed NORE1A and RASSF1A mRNA levels were detected in primary tumours compared with normal adrenal medulla (P<0.001). Methylation of the NORE1A promoter was not observed in primary tumours. On the other hand, 9% (5/54) of the primary tumours examined showed RASSF1A promoter methylation greater than 20% as detected by Pyrosequencing. Methylation of the RASSF1A promoter was significantly associated with malignant behaviour (P<0.05). Transient expression of Nore1a resulted in enhanced apoptosis and impaired colony formation in soft agar. Our study provides evidence that NORE1A and RASSF1A are frequently suppressed in pheochromocytoma and abdominal paraganglioma. Silencing of NORE1A contributes to the transformed phenotype in these tumours.

Midface Osteotomies for Feminization of the Facial Skeleton.

Facial feminization surgery is a term to describe the surgical alteration of a masculine facial appearance to a more feminine appearance, which is most commonly performed for male-to-female transsexual individuals. To alter the midfacial relations, segmentalized osteotomies were performed in selected patients expanding on the established techniques for facial feminization surgery. All patients underwent a preoperative 3D computerized tomography scan and 3D photography before and after the surgery. The inclusion of the midface in surgery was determined based on the relative projection and angle of the zygomatic body compared with the supraorbital region (the supraorbital region was reduced in all patients). Patients were prospectively followed up by 3D surface photography and 3D computerized tomography scans. Rotation and advancement of the zygomatic region was found to be an effective way to further feminize the midfacial appearance in selected male-to-female transsexual patients. No major surgical complications occurred. Although somewhat technically challenging, we suggest that midface surgery should be considered for feminizing purposes in order for the patient to achieve a long-term favorable result compared with other alternative methods.

Long-term sensory disturbances after orbitozygomatic fractures.

BACKGROUND: Orbitozygomatic fractures often lead to infraorbital nerve (ION) injury, and affected sensibility is a common long-term complaint within this patient group. We present a long-term follow-up study where the validated von Frey filament system was used for testing ION sensibility. Furthermore, we examined the incidence of persistent nerve injury and whether more complex fractures led to more pronounced ION sensibility disturbances. METHODS: Patients treated for facial fractures involving the orbitozygomatic complex were included and the follow-up time was 3 years or more. Depending on the location and severity of the fractures, the patients were divided into 4 groups. The patients answered a questionnaire before ION sensibility testing with von Frey filaments. RESULTS: Eighty-one patients were examined: 65 males (80%) and 16 females (20%). Examinations were conducted between 3.0 and 7.6 years (mean 4.9 years) after injury. Sixteen patients (20%) had affected and 6 patients (7.4%) had severely affected ION sensibility according to von Frey testing. No statistically significant differences were found in terms of questionnaire score between the groups. There was also no statistically significant correlation between questionnaire results and log von Frey values. Although the effect of groups could not be statistically verified using the log von Frey values, a larger proportion of patients with complex fractures had higher log von Frey values than the other groups. CONCLUSIONS: Patients with complex fractures report more permanent sensory disturbance of the ION after surgery than those with isolated orbitozygomatic fractures, although this could not be verified statistically with von Frey filament testing at several locations. Hence, a validated method for testing facial sensibility such as von Frey filaments, although sensitive, is inadequate to determine all aspects of sensory malfunction after orbitozygomatic fractures. This suggests that the patient's experience of long-term sensation after trauma may not be correlated with objective measures.