Fat Necrosis in Single Perforator Deep Inferior Epigastric Artery and Superficial Epigastric Artery Perforator Free Flaps: A Prospective Randomized Study.

Background: The deep inferior epigastric perforator (DIEP) flap is the standard of care in autologous breast reconstruction. The superficial inferior epigastric artery perforator flap (SIEA) is an alternative reconstructive option, with the compromise of less donor-site morbidity but variable perfusion to subscarpal fat zones. Fat necrosis is a known complication from marginal perfusion variability. Volumetric analysis of fat necrosis has not been performed between the two reconstructive options, nor has the amount of flap necrosis following radiation. Our objective was to compare rates and volume of fat necrosis between single-perforator DIEP and SIEA flap techniques. Methods: A single-center, blinded, prospective cohort study of patients randomized between SIEA and DIEP breast reconstruction was conducted over 2 years (June 2011-July 2013). Inclusion criteria were women undergoing immediate reconstruction following mastectomy. Randomization protocols were strictly followed. Fat necrosis volumetric analysis was determined by an ultrasound-trained attending surgeon at 12 months postoperatively. Patient demographics and adjuvant/neoadjuvant cancer treatment were analyzed. Statistical analyses included Mann-Whitney U tests, chi square, and/or Fisher exact tests. P values of 0.05 or less were considered significant. Results: Fat necrosis was detected in 11 of 46 flaps (23.9%), with a median area of 17.9 cm2. There was no significant difference in prevalence of fat necrosis between the two flap types (P = 0.19). Postoperative radiation did not increase the prevalence (P = 0.30) or extent (P = 0.92) of fat necrosis. Conclusion: Single-perforator DIEP and SIEA flaps have comparable rates of fat necrosis. Postoperative radiation did not result in increased prevalence or extent of fat necrosis.

Factors Affecting the Choice to Forgo Nipple Grafts in Gender-Affirming Chest Surgery.

INTRODUCTION: Some patients pursuing gender-affirming mastectomy prefer to forgo autologous nipple and areolar reconstruction, instead choosing a "no nipple" option. The objective of this study is to evaluate the motives and influences contributing to this decision. METHODS: A retrospective survey-based study of patients undergoing gender-affirming mastectomy over a 4.6-year period was conducted. All patients were offered nipple and areolar reconstruction. A survey was distributed to those who elected to forgo nipple and areolar reconstruction exploring the factors influencing that choice and postoperative satisfaction. RESULTS: Five hundred thirty-six patients underwent gender-affirming mastectomy and 13% chose to forgo nipple and areolar reconstruction. The survey response rate was 72%. Most respondents identified as nonbinary (48%) or transmasculine (42%). Body image, defined in the context of this study as an improvement in body image satisfaction due to achievement of a more gender-congruent appearance, was the most highly cited and most heavily weighted decision-making factor. Concerns about nipple graft outcomes were frequently cited as important but carried less weight. There were no differences between transmasculine and nonbinary patients in terms of motivations for choosing this surgical option. Fifty-eight percent of respondents pursued or planned to pursue chest tattoos, whereas 42% preferred no further chest modifications. Patient satisfaction was high postoperatively (98%), and 82% of respondents would choose to forgo nipple and areolar reconstruction again even if surgical outcomes of free nipple grafts were improved. CONCLUSIONS: Gender-affirming mastectomy without nipple and areolar reconstruction was requested by 13% of patients presenting for gender-affirming chest surgery over the study period and had high postoperative satisfaction among patients who chose this option. This modification of gender-affirming mastectomy is a variation that surgical teams should be aware of. Many reasons to forgo nipple preservation were cited, most of which related to body image. Secondary factors were easier recovery and/or concern about outcomes of free nipple grafts. Many patients wished information about this surgical option was more widely available.

Phantom sensation in genital gender-affirming surgery: a narrative review.

PURPOSE OF REVIEW: To review findings related to phantom genital sensation, emphasizing phantom sensation in the transgender and gender diverse (TGD) population. We discuss prevalence, presentation and potential implications for sensory outcomes in genital gender-affirming surgery. RECENT FINDINGS: There is a high prevalence of phantom genital sensations in the TGD population. The prevalence varies by body part, approaching 50% in the most frequently reported transgender phantom - the phantom penis. Unlike genital phantoms that occur after trauma or surgery which are often painful, transgender phantoms are typically neutral and often erogenous in experience. Phantom sensation in the TGD population can be an affirming experience and important part of sexual well being and embodiment. SUMMARY: Recent studies have begun to characterize the prevalence and presentations of phantom genital sensations in TGD people, informing our evolving understanding of the sensory experiences of the transgender and gender diverse population. Targeting integration of these centrally-mediated phantom genital sensations with the peripherally generated sensation from genital stimulation may represent one potential avenue to improve sensation and embodiment following genital gender-affirming surgical procedures. Additionally, emerging techniques in modern peripheral nerve surgery targeting phantom pain may offer potential treatment options for painful phantom sensation seen after cases of genital surgery or trauma.

Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty.

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

Making a Statement: Positions of Professional Medical Organizations Towards Gender-Affirming Care.

OBJECTIVE: Despite politically charged media coverage and legislation surrounding gender affirming care (GAC), many organizations have released position statements to provide scientifically backed clinical practice standards, combat misinformation, and inform medicolegal policies. The purpose of this study is to objectively assess the availability and the content of the official position statements of relevant medical professional organizations regarding GAC. SUMMARY BACKGROUND DATA: A list of U.S. medical professional organizations with likely involvement in GAC based on medical or surgical specialties was compiled. METHODS: For included organizations, we evaluated the availability, content, and publication year of positions on GAC through October 2023. When available, formal positions were categorized as supportive or unsupportive. RESULTS: A total of 314 professional medical organizations were screened for our study based on specialty, relevance to GAC, and issuance of patient guidelines or position statements. Inclusion criteria were met by 55 organizations. Most organizations (35, 63.6%) had formal position statements on GAC. Support for GAC was described in 97.1% (n=34). Further, 94.2% (n=33) of available statements explicitly addressed GAC in individuals less than 18 years old and were largely supportive (96.9%, n=32). CONCLUSIONS: This cross-sectional analysis demonstrates that a majority of multidisciplinary professional medical organizations with relevance to GAC have issued formal position statements on the topic. Available positions were overwhelmingly supportive of individualized access to gender-affirming therapies in adult and adolescent populations. However, silence from some organizations continues to represent a modifiable disparity in the provision of GAC.

Optimizing aesthetics in gender-affirming vaginoplasty and vulvoplasty: a narrative review and discussion based on over 600 cases of transfeminine vulvar construction.

Background and Objective: The vulva is the external portion of a gender-affirming vaginoplasty or vulvoplasty procedure-the "visible" result of surgery. The vulvar appearance can play a major role in how individuals feel about their surgical results and new genital anatomy. Therefore, optimizing the aesthetics of the vulva is an important component of surgical care. Although there is no one "ideal" vulvar appearance, aesthetics are optimal when each major sub-unit of the vulva is reconstructed to create a proportional and cohesive vulvar unit. In this article we perform a narrative review of the literature and discuss clinical approaches to improve aesthetic satisfaction such as patient education, re-defining the "ideal" vulva, aesthetic surgery tenets and technical strategies based on our collective experience of over 630 gender-affirming vulvar constructions. Methods: A narrative review of the literature was completed accessing PubMed, EMBASE, Google Scholar using search terms "Vaginoplasty OR Vulvoplasty". Articles were removed if not pertaining to gender affirmation surgery, were not in English language, were not accessible or did not discuss aesthetics in the body of the text. Key Content and Findings: A total of 1,042 articles were identified from initial search criteria. Of those, 905 were excluded as they did not involve gender affirmation as an indication. An additional 112 papers were excluded as they were not accessible, not in English, focused on non-vulvar outcomes or did not comment on vulvar aesthetics. Ultimately 25 articles were included for narrative review; 21 of these included technical descriptions of vulva and 13 had direct aesthetic discussion. The anatomy and aesthetics of the transfeminine vulva are reviewed according to the previously described principle of anatomic vulvar sub-units: the labia majora, labia minora, clitoris, urethra and the introitus. Conclusions: Ultimately, creating the optimal vulva for each individual patient will demand flexible surgical decisions based on individual anatomy and available tissues. This narrative review provides an overview of current approaches to aesthetics in gender-affirming vulvar construction and technical insights based on our institutional experience of performing over 630 gender-affirming vaginoplasty and vulvoplasty procedures.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty.

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

Gender-affirming Clitoroplasty and Construction of the Clitoro-urethral Complex: An Anatomy Guided Selection of Two Techniques.

OBJECTIVE: To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty. METHODS: For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed. RESULTS: We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm. CONCLUSION: We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.

Comparing surgeries to restore upper extremity function in tetraplegia: Impact on function during the perioperative period.

CONTEXT/OBJECTIVE: To assess short-term changes in health outcomes in people with cervical-level spinal cord injury (SCI) who underwent upper extremity (UE) reconstruction via either novel nerve transfer (NT) or traditional tendon transfer (TT) surgery with individuals who did not undergo UE surgical reconstruction. DESIGN: Prospective, comparative cohort pilot study. PARTICIPANTS: 34 participants with cervical SCI met the following inclusion criteria: age 18 or older, greater than 6 months post-injury, and mid-cervical level SCI American Spinal Injury Association Impairment Scale (AIS) A, B or C. SETTING: Two tertiary academic hospitals and their affiliated veterans' hospitals. METHODS: Health outcomes were assessed using two previously validated measures, the Spinal Cord Independence Measure (SCIM) and Short-Form Health Survey (SF-36). Demographic, surgical, and survey data were collected at the initial evaluation and one month postoperatively/post-baseline. RESULTS: 34 participants with cervical SCI were recruited across three cohorts: no surgery (n = 16), NT (n = 10), and TT (n = 8). The TT group had a decline in SCIM and SF-36 scores whereas the NT and no surgery groups experienced little change in independence or health status in the immediate perioperative period. CONCLUSIONS: Surgeons and rehabilitation providers must recognize differences in the perioperative needs of people with cervical SCI who chose to have restorative UE surgery. Future work should focus on further investigation of health outcomes, change in function, and improving preoperative counseling and cross-disciplinary management.

Safety and efficacy of laquinimod for Huntington's disease (LEGATO-HD): a multicentre, randomised, double-blind, placebo-controlled, phase 2 study.

BACKGROUND: Laquinimod modulates CNS inflammatory pathways thought to be involved in the pathology of Huntington's disease. Studies with laquinimod in transgenic rodent models of Huntington's disease suggested improvements in motor function, reduction of brain volume loss, and prolonged survival. We aimed to evaluate the safety and efficacy of laquinimod in improving motor function and reducing caudate volume loss in patients with Huntington's disease. METHODS: LEGATO-HD was a multicentre, double-blind, placebo-controlled, phase 2 study done at 48 sites across ten countries (Canada, Czech Republic, Germany, Italy, Netherlands, Portugal, Russia, Spain, UK, and USA). Patients aged 21-55 years with a cytosine-adenosine-guanine (CAG) repeat length of between 36 and 49 who had symptomatic Huntington's disease with a Unified Huntington's Disease Rating Scale-Total Motor Score (UHDRS-TMS) of higher than 5 and a Total Functional Capacity score of 8 or higher were randomly assigned (1:1:1:1) by centralised interactive response technology to laquinimod 0·5 mg, 1·0 mg, or 1·5 mg, or to matching placebo, administered orally once daily over 52 weeks; people involved in the randomisation had no other role in the study. Participants, investigators, and study personnel were masked to treatment assignment. The 1·5 mg group was discontinued before recruitment was finished because of cardiovascular safety concerns in multiple sclerosis studies. The primary endpoint was change from baseline in the UHDRS-TMS and the secondary endpoint was percent change in caudate volume, both comparing the 1·0 mg group with the placebo group at week 52. Primary and secondary endpoints were assessed in the full analysis set (ie, all randomised patients who received at least one dose of study drug and had at least one post-baseline UHDRS-TMS assessment). Safety measures included adverse event frequency and severity, and clinical and laboratory examinations, and were assessed in the safety analysis set (ie, all randomised patients who received at least one dose of study drug). This trial is registered with ClinicalTrials.gov, NCT02215616, and EudraCT, 2014-000418-75, and is now complete. FINDINGS: Between Oct 28, 2014, and June 19, 2018, 352 adults with Huntington's disease (179 [51%] men and 173 [49%] women; mean age 43·9 [SD 7·6] years and 340 [97%] White) were randomly assigned: 107 to laquinimod 0·5 mg, 107 to laquinimod 1·0 mg, 30 to laquinimod 1·5 mg, and 108 to matching placebo. Least squares mean change from baseline in UHDRS-TMS at week 52 was 1·98 (SE 0·83) in the laquinimod 1·0 mg group and 1·2 (0·82) in the placebo group (least squares mean difference 0·78 [95% CI -1·42 to 2·98], p=0·4853). Least squares mean change in caudate volume was 3·10% (SE 0·38) in the 1·0 mg group and 4·86% (0·38) in the placebo group (least squares mean difference -1·76% [95% CI -2·67 to -0·85]; p=0·0002). Laquinimod was well tolerated and there were no new safety findings. Serious adverse events were reported by eight (7%) patients on placebo, seven (7%) on laquinimod 0·5 mg, five (5%) on laquinimod 1·0 mg, and one (3%) on laquinimod 1·5 mg. There was one death, which occurred in the placebo group and was unrelated to treatment. The most frequent adverse events in all laquinimod dosed groups (0·5 mg, 1·0 mg, and 1·5 mg) were headache (38 [16%]), diarrhoea (24 [10%]), fall (18 [7%]), nasopharyngitis (20 [8%]), influenza (15 [6%]), vomiting (13 [5%]), arthralgia (11 [5%]), irritability (ten [4%]), fatigue (eight [3%]), and insomnia (eight [3%]). INTERPRETATION: Laquinimod did not show a significant effect on motor symptoms assessed by the UHDRS-TMS, but significantly reduced caudate volume loss compared with placebo at week 52. Huntington's disease has a chronic and slowly progressive course, and this study does not address whether a longer duration of laquinimod treatment could have produced detectable and meaningful changes in the clinical assessments. FUNDING: Teva Pharmaceutical Industries.

Use of Supinator Motor Branches in Targeted Muscle Reinnervation of the Superficial Radial Nerve.

Symptomatic neuromas of the superficial radial nerve (SRN) can cause debilitating pain. Traditional surgical management options have demonstrated inconsistent outcomes prompting a search for alternatives. Recent reports have emerged on the use of targeted muscle reinnervation (TMR) for neuromas of the SRN using donors that are well established in hand surgery, such as the brachioradialis (BR) or extensor capri radialis longus or brevis. Use of the brachioradialis or extensor capri radialis longus motor targets can require surgery at or above the level of the antecubital fossa, and denervation of these muscle groups may be undesirable in cases of complex upper extremity injury where these donors may be needed for tendon or nerve transfer. The supinator is an expendable and often overlooked donor nerve that has not been assessed as a target for TMR of the SRN. In this case series, three patients with SRN neuromas whose conservative management failed and who did not have an SRN lesion amenable to reconstruction were managed with TMR to the nerves to supinator. At latest follow-up (9-22 months), no patients had deficits in supination or evident donor site morbidity. Two patients reported complete resolution of their SRN neuroma pain, and one patient reported partial improvement. This case series reports early results of TMR of the SRN using nerves to supinator in cases of SRN neuromas not amenable to reconstruction, demonstrating technical feasibility, improvements in neuroma pain, and no discernible donor morbidity.

Are We Teaching Evidence-Based and Inclusive Practices in Gender-Affirming Care? Perspectives From Plastic Surgery In-Service Examinations.

Background Resident physicians take annual in-service examinations (ISEs) as part of continuing medical education, which set educational priorities, allow for formative feedback, and guide preparation for final board examinations. Gender-affirming care is provided in many specialties but has been an underrepresented area in medical education. Plastic surgeons provide a large portion of gender-affirming surgical care. Educational gaps in standardized ISEs may contribute to ongoing health care disparities for transgender and gender diverse people. Objective To evaluate the quality of content pertaining to gender-affirming surgery (GAS) on plastic surgery ISEs. Methods Plastic surgery ISEs from years 2012 to 2020 were accessed online through the American Council of Academic Plastic Surgeons website in June 2022. All 5 gender diverse authors analyzed examinations for the presence of GAS questions; identified questions were analyzed for quantity, organization based on content category, affirming language, and accuracy against current guidelines. Results Of 1959 ISE questions available for review, 11 GAS questions were identified for a total frequency of 0.56%. Most GAS questions (6 of 11, 55%) were miscategorized. Inappropriate language, including misgendering of patients, occurred in 7 of 11 (64%) questions. No questions discussed GAS beyond chest or genital surgery, or common variations of these procedures. Transgender identities were represented as only binary, with no mention of nonbinary or gender-fluid individuals. Conclusions Our study illustrates that there are significant gaps in educational content pertaining to gender-affirming care on plastic surgery ISEs.

Pain Medication Prescribing Patterns in Augmentation Mammoplasty.

Background: The rate of opioid prescribing after low-risk surgical procedures has increased over the past decade, and surgeons are responsible for prescribing approximately one-third of all opioid medications. There is additional supporting evidence that patients only consume about half of the opioids prescribed to them after outpatient plastic surgery. Currently, there is no literature to provide surgeons with reference ranges for how much opioid medication will adequately provide analgesia for patients after undergoing bilateral breast augmentation (BBA) surgery. Objective: To quantify the amount of opioid medication required to adequately control pain for patients after undergoing BBA and use these data to provide recommendations on opioid prescribing practices. Methods: Cross-sectional prospective data were obtained through a take-home medication and pain tracking questionnaire for 56 patients after they underwent either subpectoral or subglandular BBA. Patients documented their pain scores on a 0 to 10 analogue scale and documented the type and amount of pain medication they took for a 7-day period. Results: Our study demonstrated that patients in the subglandular BBA group required an average of either 25 ± 1.2 Tylenol #3 or 19.3 ± 2.3 Tramacet tablets, and the subpectoral group required 27.7 ± 1.7 Tylenol #3 or 25.6 ± 0.9 Tramacet tablets over a 7-day period. There was no statistically significant difference between the 2 surgical groups. Conclusion: We propose a reference range of medication required on average for patients undergoing BBA to obtain adequate pain control in the initial postoperative period that falls within the most recent Canadian guidelines for safe opioid prescribing practices.

Contexte: La fréquence de prescription des opioïdes après des procédures chirurgicales à faible risque a augmenté au cours de la dernière décennie et les chirurgiens sont responsables de la prescription d'environ un tiers de tous les médicaments opioïdes. Des données probantes supplémentaires indiquent que les patients ne consomment qu'environ la moitié des opioïdes qui leur ont été prescrits après une chirurgie plastique en chirurgie de jour. Aucune publication ne procure, à ce jour, des plages de référence aux chirurgiens pour leur indiquer combien d'opioïdes fournira aux patients une analgésie adéquate après avoir subi une chirurgie bilatérale d'augmentation mammaire. Objectif: Quantifier les médicaments opioïdes requis pour contrôler efficacement la douleur chez les patients ayant subi une chirurgie bilatérale d'augmentation mammaire et utiliser ces données pour fournir des recommandations sur les pratiques de prescription des opioïdes. Méthodes: Des données prospectives transversales ont été obtenues au moyen d'un questionnaire à remplir à domicile de suivi des médicaments et de la douleur auprès de 56 patientes venant de subir une chirurgie d'augmentation mammaire sous-pectorale ou sous-glandulaire. Les patientes ont documenté leurs scores de douleur sur une échelle analogique de 0 à 10, ainsi que le type et la quantité de médicament antidouleurs pris pendant une période de 7 jours. Résultats: Notre étude a démontré que les patientes du groupe augmentation mammaire sous glandulaire a nécessité une moyenne de 25 ± 1,2 comprimés de Tylénol #3 ou 19,3 ± 2,3 comprimés de Tramacet; les patientes du groupe sous-pectoral ont nécessité 27,7 ± 1,7 comprimés de Tylénol #3 ou 25,6 ± 0,9 comprimés de Tramacet comprimés sur une période de sept jours. Il n'y a pas eu de différence statistiquement significative entre les deux groupes chirurgicaux. Conclusion: Nous proposons une plage de référence pour les médicaments nécessaires en moyenne pour les patientes subissant une chirurgie d'augmentation mammaire pour contrôler correctement la douleur au cours de la période postopératoire initiale; cette plage de référence correspond aux plus récentes lignes directrices canadiennes sur les pratiques de prescription sécuritaire des opioïdes.

Primary Regenerative Peripheral Nerve Interfaces Using Devascularized Vastus Lateralis Muscle in Sensate Anterolateral Thigh Flap Donor Sites.

Sensate flaps are increasingly used in diverse areas of plastic surgery. Concurrently, modern techniques in neuroma prevention have emerged, such as regenerative peripheral nerve interface (RPNI). Despite increasing use of sensate flaps, the combined use of donor-site neuroma prevention techniques has yet to be described. We report on the use of primary donor-site RPNI at the time of sensate anterolateral thigh (ALT) reconstructions. In ALT flaps, the vastus lateralis muscle can be segmentally devascularized from perforator dissection. These segments of devascularized vastus lateralis muscle can easily be used and repurposed as the free muscle grafts needed for RPNI, providing a physiologic target for the regenerating neurons. Donor-site neuroma has not been shown to be a significant issue at standard ALT flap donor sites. Sensate ALT flaps involve harvest of the lateral femoral cutaneous nerve and/or additional femoral sensory branches at a more proximal location close to the level of the anterior superior iliac spine, where injury to the lateral femoral cutaneous nerve may be associated with pain. In this series, eight patients underwent senate ALT flaps with the use of primary RPNI at the sensate ALT donor site. At a mean follow-up of 16.3 months (range 5-25 months), there was minimal to no nerve pain and no clinical evidence of donor-site neuroma. As sensate flap reconstructions are increasingly performed in plastic surgery and data on neuroma prevention techniques continue to grow, we propose consideration of their combined use.

Donor and Recipient Nerve Axon Counts in Gender-affirming Radial Forearm Phalloplasty: Informing Choice of Nerve Coaptations.

A key component of success of a nerve transfer is the innervation density, which is directly affected by the donor nerve axonal density and donor-to-recipient (D:R) axon ratio. Optimal D:R axon ratio for a nerve transfer is quoted at 0.7:1 or greater. In phalloplasty surgery, there are currently minimal data available to help inform selection of donor and recipient nerves, including unavailability of axon counts. Methods: Five transmasculine people who underwent gender-affirming radial forearm phalloplasty had nerve specimens processed with histomorphometric evaluation to determine axon counts and approximate donor-to-recipient axon ratios. Results: Mean axon counts for recipient nerves were 6957 ± 1098 [the lateral antebrachial (LABC)], 1866 ± 590 [medial antebrachial (MABC)], and 1712 ± 121 [posterior antebrachial cutaneous (PABC)]. Mean axon counts for donor nerves were 2301 ± 551 [ilioinguinal (IL)] and 5140 ± 218 [dorsal nerve of the clitoris (DNC)]. D:R axon ratios using mean axon counts were DNC:LABC 0.739 (0.61-1.03), DNC:MABC 2.754 (1.83-5.91), DNC:PABC 3.002 (2.71-3.53), IL:LABC 0.331 (0.24-0.46), IL:MABC 1.233 (0.86-1.17), and IL:PABC 1.344 (0.85-1.82). Conclusions: The DNC is the more powerful donor nerve with greater than two times the axon count of the IL. The IL nerve may be under-powered to re-innervate the LABC based on an axon ratio consistently less than 0.7:1. All other mean D:R are more than 0.7:1. DNC axon counts may be excessive for re-innervation of the MABC or PABC alone with D:R of more than 2.5:1, potentially increasing risk of neuroma formation at the coaptation site.

Process intensification for lentiviral vector manufacturing using tangential flow depth filtration.

For gene therapies to become more accessible and affordable treatment options, process intensification is one possible strategy to increase the number of doses generated per batch of viral vector. Process intensification for lentiviral vector manufacturing can be achieved by enabling perfusion in the production bioreactor when applied in tandem with a stable producer cell line, allowing for significant expansion of cells and production of lentiviral vectors without the need for transfer plasmids. Tangential flow depth filtration was used to achieve an intensified lentiviral vector production by enabling perfusion to expand cell density and allow for continuous separation of lentiviral vectors from producer cells. Hollow-fiber depth filters made of polypropylene with 2- to 4-µm channels demonstrated high filter capacity, extended functional life, and efficient separation of lentiviral vectors from producer cells and debris when used for this intensified process. We anticipate that process intensification with tangential flow depth filtration at 200-L scale from a suspension culture can produce on the order of magnitude of 10,000 doses per batch of lentiviral vectors required for CAR T or TCR cell and gene therapy that would require approximately 2 × 109 transducing units per dose.

Comprehensive Reconstructive Care for Patients of All Gender Identities After Cancer of the Breast.

ABSTRACT: Breast cancer can affect anyone; therefore, it affects people of all gender identities. Reconstructive options after breast cancer must then address the needs of all people. Our institution is unique in its provision of both high-level comprehensive breast and gender affirmation care. In our practice, patients have expressed gender diverse identities during their breast cancer reconstructive journey. In these cases, goals have deviated from traditional breast restoration, gravitating toward gender-affirming mastectomy, or results often seen with "top surgery." We present a framework for the administration of breast cancer care and discussions of reconstruction from a lens of gender inclusivity. Breast cancer is a diagnosis that has been gendered, resulting in the erasure and exclusion of reconstructive needs for people affected by breast cancer that are not cisgender women. This is illustrated through the case of a nonbinary individual seen in breast cancer clinic for multifocal ductal carcinoma in situ. Our standard review of options of "going flat," implant-based reconstruction, and autologous reconstruction led to initial confusion given their early exploration of gender identity co-occurring with a new diagnosis of breast cancer. These scenarios can be challenging when viewed solely from the perspective of a breast reconstructive surgeon or a gender-affirming surgeon alone. Both perspectives are often needed. Our gender-affirming and breast reconstructive teams have discussed methods to identify patients who require more robust discussion of gender identity and reconstructive options in the setting of breast cancer, such as chest masculinization. By adding gender-affirming surgeons to the list of providers available to counsel breast cancer patients, we may be able to better provide early education on all reconstructive options and appropriately address the needs of transgender and gender diverse people affected by breast cancer.