Techniques and Applications of Lower Extremity Feminization and Masculinization.

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

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

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

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

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

Three-Dimensional Analysis of Donor Masks for Facial Transplantation.

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

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

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

Googling Aesthetic Plastic Surgery for Patient Insights into the Latest Trends.

BACKGROUND: Analysis of Internet search patterns is rapidly transforming the study of human behavior. Google's data, accessed through Google Trends, have proven extremely insightful in several fields of medical research. Despite its adoption in other fields of medicine, Google Trends has not yet been explored in the field of plastic surgery. METHODS: The number of cosmetic surgery procedures from 2005 through 2016 was obtained from the American Society of Plastic Surgeons annual reports. Using Google Trends, the most commonly used keywords describing each procedure were determined, and data regarding search interest over time, interest across geographic area, and Related Queries were obtained. The number of procedures performed annually was compared to relative search volume from the corresponding year and the year prior to determine correlation. RESULTS: Of the 22 procedures evaluated, the annual number of eight procedures correlated with Internet search volume in the corresponding year, and six procedures correlated with the Internet searches performed in the year prior. Florida and New York were the states with the most searches for these procedures. Related Queries suggested that several factors, such as operative techniques, notable individuals undergoing procedures, and cost, variably drove correlations for different procedures. CONCLUSIONS: Google Trends is a powerful tool that can be used to better understand patient interest in, questions about, and decisions regarding cosmetic surgery procedures. These findings warrant action by aesthetic surgeons to increase interest, address misinformation, and help patients fill the gaps of information missed by Internet searches.

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

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

The Implications of Barbed Sutures on Scar Aesthetics: A Systematic Review.

BACKGROUND: Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast operations, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regard to scarring. METHODS: A systematic review of the PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July of 2017 using the search terms "barbed suture" combined with "scar" or "wound." Studies were included if they were prospective, evaluator-blind, randomized, controlled trials; closed the dermal layer of incisions using barbed sutures; and included an evaluator-blind aesthetic assessment of scarring. RESULTS: Six prospective, randomized, controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the six controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and one study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in four of the five studies that timed incision closure. Similar complication rates were observed in all evaluated studies. CONCLUSION: Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men.

BACKGROUND: A primary goal in chest wall reconstruction ("top surgery") for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex. METHODS: The senior author's (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016. RESULTS: The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m. Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent). CONCLUSION: The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evaluating Platelet-Rich Therapy for Facial Aesthetics and Alopecia: A Critical Review of the Literature.

BACKGROUND: Despite the growing popularity of platelet-rich plasma, existing evidence supporting its efficacy remains controversial due to the lack of large-scale studies and standardized protocols for preparation and application. This article reviews its use in facial rejuvenation, fat grafting, acne scarring, and androgenic alopecia. Emphasis is placed on comparing methods of platelet-rich plasma preparation and application across studies. METHODS: A systematic review was performed for articles published between 2006 and 2015. All clinical studies and case reports that addressed platelet-rich plasma alone and/or in combination with fat grafting for facial rejuvenation, acne scarring, or androgenic alopecia were included. RESULTS: Of the 22 articles included in the analysis, seven studies used platelet-rich plasma alone for facial rejuvenation, seven in combination with fat grafting, two for treatment of acne scarring, and six for treatment of androgenic alopecia. Individual study procedures, means of evaluation, and significant results are summarized. Although the majority of studies in this review report positive results, significant variation exists in preparation protocols and in the number and frequency of clinical treatments. CONCLUSIONS: The majority of studies report positive results for all indications evaluated in this review, but the procedure is limited by the lack of a standardized method for preparation and application of platelet-rich plasma. The extent to which significant variability in platelet-rich plasma preparation and/or application methods may affect clinical outcomes is not completely clear. In the interim, we present a consolidation of platelet-rich plasma treatment techniques and outcomes currently in use to help guide physicians in their clinical practice.

The Evolving Presence of Women in Academic Plastic Surgery: A Study of the Past 40 Years.

BACKGROUND: Among surgical subspecialties, plastic surgery holds the highest percentage of women, and, the female contingent of board-certified plastic surgeons and trainees has grown steadily. However, their academic impact has been underestimated. We present the academic footprint of female plastic surgeons over the past 40 years. METHODS: A list of female plastic surgeons currently active at, and retired from, Accreditation Council for Graduate Medical Education-accredited plastic surgery residency programs was compiled. Each surgeon was searched on PubMed to gather their total number of publications, journals, and topics of research after completion of training. Date of publication and 5-year impact factor for each journal were recorded. Publications were organized into 10-year periods (1976 to 1985, 1986 to 1995, 1996 to 2005, and 2006 to 2016). RESULTS: One hundred fifty-five currently active and 80 retired academic female plastic surgeons were identified, who published 2982 articles in 479 peer-reviewed journals. The average 5-year impact factor was 4.093. The number of publications increased with each decade: 37 (1976 to 1985), 218 (1986 to 1995), 472 (1996 to 2005), and 2255 (2006 to 2016). The most commonly published areas were hand/nerve (22 percent), craniofacial (21 percent), and breast (20 percent). Over time, publications in hand/nerve research decreased (76, 60, 38, and 14 percent, respectively); craniofacial-related publications increased (8, 11, 18, and 23 percent, respectively); and publications in breast research increased (0, 8, 9, and 24 percent, respectively). The 2006 to 2016 period yielded the most even distribution of research topics. CONCLUSION: The academic contribution of female plastic surgeons has substantially increased in number and has become more evenly distributed across subspecialty topics.