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.

In Search of Workforce Diversity? A Program's Successful Approach.

SUMMARY: The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.

The "Corset Repair" for Complex Hernia: A Proof-of-concept Report of an Innovative Approach.

Incisional hernias, especially those below the arcuate line, pose a unique challenge to reconstructive surgeons, as no consensus exists for repair strategy. An innovative approach is presented and illustrated. The "corset repair" involves placing an onlay mesh partially beneath released bilateral external obliques. A detailed technical review is provided to illustrate the benefits of this technique particularly in large defects and in hernia after abdominal flap harvest. Hernia recurrence and surgical site occurrence rates were reviewed and analyzed for a cohort of corset repair patients between December 2016 and January 2020. Twenty patients were included. All defects were successfully closed. Zero patients experienced hernia recurrence. Eight patients (40%) had a surgical site occurrence, of which 5 (63%) were either observed or managed non-operatively. Two of the surgical site occurrences were deep surgical site infections: 1 required surgical intervention for suspected mesh infection and the other did not. One patient (5%) developed hematoma 23 months post-operatively. The "corset repair" technique represents a modification to a classic technique for hernia repair. It is feasible and may be advantageous especially for large or challenging repairs below the arcuate line. It has promising results on early follow-up, and further research is needed to evaluate long-term efficacy.

Bicycle lanes: Are we running in circles or cycling in the right direction?

BACKGROUND: The number of urban bicyclists has grown exponentially across the United States. Bike lanes were created to promote a safe environment for both motorist and cyclists, but few studies have specifically addressed the outcomes of these interventions. The aim of this study was to analyze the effect of bike lanes on bicycle usage and safety in a major urban city. METHODS: A retrospective chart review of consecutive adult trauma patients presenting at an urban Level I trauma center due to motor vehicle versus bicycle collisions from January 1, 2007, to January 28, 2017, was performed. Cohorts were stratified into prebicycle and postbicycle lane implementation for analysis. RESULTS: Bicycle use during the study period increased almost three fold (1,672 vs. 6,060, p < 0.0001). There was also a spike in the percent of yearly bicyclists as trauma patients during the 10-year period (0.7% vs. 1.5%, p < 0.05). A total of 184 patients brought to the trauma center were identified. Significant differences between the prebike lane and postbike lane groups were identified for average Injury Severity Score (12.7 ± 1.7 vs. 8.0 ± 0.6 p = 0.0134), Glasgow Coma Scale score on arrival (12.6 ± 0.7 vs. 13.9 ± 0.2, p = 0.0171), proportion of head and face injuries (59.4% to 38.8%, p = 0.047), and patients requiring surgical intervention (100% to 55.9%, p < 0.0001). CONCLUSION: As bicycle lanes become increasing popular in US cities, it is important to review the success of this intervention on improving safety. Preliminary results from this study suggest that the implementation of urban bike lanes improved bicyclist safety. Further studies should focus on specific injury prevention programs, which could help to target areas such as helmet use and riding a bicycle while impaired to help improve overall safety. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.