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Background: Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center. Methods: This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed. Results: Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (Pâ <â 0.001), Spanish-speaking (Pâ =â 0.001), and to have obesity (Pâ =â 0.011) and HIV (Pâ =â 0.004). Patients at ZSFG took hormones for longer before surgical consultation (Pâ <â 0.001) but had shorter referral-to-surgery intervals (Pâ =â 0.024). Patients at ZSFG more frequently underwent a subglandular approach (Pâ =â 0.003) with longer operative times (Pâ <â 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (Pâ =â 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (Pâ =â 0.008). Conclusions: County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.
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PURPOSE: The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria. METHODS: The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022. RESULTS: A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting. CONCLUSIONS: The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.
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Disforia de Gênero , Identidade de Gênero , Humanos , Masculino , Feminino , Disforia de Gênero/psicologia , Inquéritos e Questionários , Adulto , Pessoa de Meia-Idade , Pessoas Transgênero/psicologiaRESUMO
BACKGROUND: In the United States, over 6 million people are affected by chronic wounds. Patients often rely on the Internet for treatment information; however, these educational materials typically exceed the average eighth-grade health literacy level. This study aimed to assess the readability and language accessibility of online patient education materials on wound care strategies. METHODS: A search was conducted on Google for articles related to wound care strategies. The first 12 unique websites from each search strategy were selected for further analysis. Readability was assessed using 11 tests, with the mean scores calculated for each. RESULTS: A total of 66 articles pertaining to wound care strategies were retrieved from 43 websites. All articles had an average reading grade level of 13.5 ± 2.5 and an average reading age of 18.7 ± 2.5 years. Websites were categorized by the following sources: academic (34.9%), reagent/biologic manufacturers (27.9%), wound care (18.6%), news media organizations (14%), and other (4.7%). Flesch Reading Ease Score, graded from 0 for most difficult to 100 for least difficult, was found to be highest for academic websites (44.2, P = .01) and lowest for news media websites (24.9, P = .01). Academic websites were available in the more languages compared to all other website categories (P < .01). CONCLUSION: Online materials related to wound care strategies often exceed the National Institute of Health recommended eighth-grade reading level. This study emphasizes the need for healthcare providers to create more accessible educational materials to address the gap in health literacy and optimize patient care.
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Compreensão , Letramento em Saúde , Internet , Educação de Pacientes como Assunto , Humanos , Educação de Pacientes como Assunto/métodos , Ferimentos e Lesões/terapia , Estados UnidosRESUMO
BACKGROUND: Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS. METHODS: Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion. RESULTS: A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship. CONCLUSIONS: A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.
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Internato e Residência , Cirurgia de Readequação Sexual , Cirurgia Plástica , Humanos , Cirurgia Plástica/educação , Técnica Delphi , Consenso , Bolsas de Estudo , Currículo , Competência ClínicaRESUMO
BACKGROUND: Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy. METHODS: A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7. RESULTS: Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point. CONCLUSIONS: There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.
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Neoplasias da Mama , Endrin/análogos & derivados , Transtornos Relacionados ao Uso de Opioides , Nervos Torácicos , Humanos , Feminino , Mastectomia/efeitos adversos , Analgésicos Opioides/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controleRESUMO
BACKGROUND: To continue education during the COVID-19 pandemic, we implemented a Virtual Education Platform (VEP) and Virtual Visiting Professorship (VVP) in March 2020 into our plastic surgery residency curriculum. This study investigated resident and guest speaker perceptions of the VEP since the start of the pandemic. METHODS: The VEP consists of weekly VVP lectures and usual conferences held over Zoom. In May 2020, residents and speakers completed surveys that assessed the perceptions of the VEP using a 5-point Likert scale and open-ended responses. In August 2021, residents also completed follow-up surveys. RESULTS: A total of 19 (100%) residents and 10 (100%) speakers responded to the 2020 surveys and 15 (88.2%) residents responded to the 2021 follow-up survey. Speakers represented nine academic institutions, one international. 74% of residents responded that they learned a lot or a great deal from the VVP. In 2021, 100% of residents agreed that virtual conferences should remain a core component in PRS residency education, even after social distancing requirements subside. The VVP lectures were mentioned as the most helpful lectures in both years. Easy accessibility without travel time was the most mentioned advantage of the VEP in both years, with significantly more residents citing this benefit in 2021 (p = 0.0076). The most reported disadvantage for residents was the lack of social interaction and community in both years, with significantly more residents in 2021 citing this as a disadvantage (p = 0.0307). Residents' attitudes also shifted such that significantly more residents liked and were satisfied with the VVP lectures from 2020 to 2021 (p = 0.04). CONCLUSION: Over a year into the COVID-19 pandemic, resident perceptions of a virtual education platform and virtual visiting professorship were very positive. The quick development, implementation, and high efficacy of these educational experiences underscore that learning is possible in alternative forms in unprecedented times.
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COVID-19 , Cirurgia Plástica , Humanos , Pandemias , COVID-19/epidemiologia , Instituições Acadêmicas , EscolaridadeRESUMO
Most patients undergo just one type of gender-affirming top surgery, but some will have a double-incision mastectomy after reduction mammaplasty. We describe a 46-year-old transgender man who requested a flatter chest after undergoing reduction mammoplasty the previous year. We also provide three considerations to guide surgical decision-making in this situation.
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BACKGROUND: Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov. METHODS: Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting. RESULTS: A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87). CONCLUSIONS: A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.
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Procedimentos de Cirurgia Plástica , Cirurgia Plástica , Humanos , Sistema de Registros , Projetos de PesquisaRESUMO
Current single-cell RNA-sequencing approaches have limitations that stem from the microfluidic devices or fluid handling steps required for sample processing. We develop a method that does not require specialized microfluidic devices, expertise or hardware. Our approach is based on particle-templated emulsification, which allows single-cell encapsulation and barcoding of cDNA in uniform droplet emulsions with only a vortexer. Particle-templated instant partition sequencing (PIP-seq) accommodates a wide range of emulsification formats, including microwell plates and large-volume conical tubes, enabling thousands of samples or millions of cells to be processed in minutes. We demonstrate that PIP-seq produces high-purity transcriptomes in mouse-human mixing studies, is compatible with multiomics measurements and can accurately characterize cell types in human breast tissue compared to a commercial microfluidic platform. Single-cell transcriptional profiling of mixed phenotype acute leukemia using PIP-seq reveals the emergence of heterogeneity within chemotherapy-resistant cell subsets that were hidden by standard immunophenotyping. PIP-seq is a simple, flexible and scalable next-generation workflow that extends single-cell sequencing to new applications.
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Sequenciamento de Nucleotídeos em Larga Escala , Microfluídica , Humanos , Animais , Camundongos , Microfluídica/métodos , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Análise de Célula Única/métodos , Genômica/métodos , Transcriptoma/genéticaRESUMO
According to cisgender respondents, the "preferred" feminine breast has a 45:55 upper-to-lower pole ratio. Preferred breast ratios have not been evaluated for transgender women undergoing breast augmentation. Therefore, this study aimed to determine the preferred breast ratio according to the transgender population and, thus, better inform surgeon planning. Methods: Patients diagnosed with gender dysphoria were sent a survey with morphed breast images of four different upper-to-lower pole ratios: 35:65, 45:55, 50:50, and 55:45. Respondents ranked the images according to aesthetic preference. Rankings were analyzed by the Condorcet method. Results: 298 survey responses were analyzed: 197 (66.1%) respondents identified as transgender women and 31 (10.4%) as transgender men. Most respondents were younger than 40 (64.8%). Eighty-one (27.2%) had undergone breast augmentation, 136 (45.6%) had not and were not considering it, and 81 (27.2%) had not but were considering it. Across all subgroups, the most preferred ratio was 45:55 (P = 0.046). Those with more masculine genders and assigned female at birth preferred the 45:55 and 50:50 ratios equally. Those in their 30's and younger preferred the 45:55 and 50:50 ratios equally. Conclusions: The 45:55 ratio, established as the most preferred morphometrics for breast augmentation by cisgender respondents, is also the most aesthetically preferred proportion among transgender patients. Interestingly, the 50:50 ratio, which projects a larger upper bust compared to the 45:55 ratio, may be equally or more appealing to younger patients and those with more masculine genders. We hope these results improve patient-physician shared decision-making and postoperative expectations.
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Background: Social media platforms have changed the way medical information is disseminated. Transgender patients may utilize social media to learn about gender-affirming surgery (GAS). Although videos on social media are readily accessible, their content is not verified or peer-reviewed. Therefore, this study aimed to evaluate the quality and reliability of YouTube and TikTok videos related to GAS. Methods: YouTube and TikTok were queried for gender-affirming top surgery, metoidioplasty, phalloplasty, breast augmentation, and vaginoplasty. Quality of video content was analyzed by the DISCERN scale. Quality scores were compared among the type of GAS, account user, and content category. Results: There were 275 YouTube videos and 55 TikTok videos. Most videos focused on masculinizing top surgery (P < 0.001). Overall, videos on masculinizing GAS had higher quality and reliability than videos on feminizing GAS (P < 0.001). Chest surgery videos were of higher quality than those on genital surgery (P ≤ 0.001). Videos on masculinizing top surgery had the highest quality, whereas vaginoplasty had the lowest quality and reliability (P < 0.001). Videos produced by health care professionals and academic institutions had the greatest quality and reliability, respectively (P < 0.0001), whereas videos produced by patients were the least reliable (P < 0.0001). Conclusions: Videos on GAS ranged from poor to good quality and reliability. Health care professionals, especially plastic surgeons, should create high-quality videos on social media to educate transgender patients. There should also be greater efforts in disseminating existing high-quality videos on social media. Resources posted on social media platforms can reach a wide audience through accessible means.
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PURPOSE: Plastic surgeons are often consulted to manage postoperative groin lymphatic leaks that may lead to serious sequelae if not promptly treated. Because there are no standardized guidelines for best treatment practices, this systematic review and meta-analysis evaluates the outcomes of multiple management modalities to ultimately guide decision making for surgeons. METHODS: Literature surrounding lymphatic leaks in the groin was reviewed from PubMED, MEDLINE, EMBASE, and the Cochrane Library from January 1, 2000, to December 1, 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The inciting procedure, postoperative lymphatic complication, used management, and days to resolution were recorded. Pairwise comparisons using the Wilcoxon rank sum test with Bonferroni continuity correction were used to determine which treatment modalities differed significantly and accounted for multiple hypothesis testing. RESULTS: A total of 1468 total studies were initially found, which narrowed to 267 unique articles after duplicates were removed. Twelve articles ultimately met the inclusion criteria and were included in the data analysis. There were 264 groin complications, of which 217 were initially treated with conservative management, 81 with a minimally invasive procedure, and 125 with surgery. More than 95% of all cases had an inciting procedure of a vascular nature.For vascular surgery-induced lymphatic leak treated by minimally invasive and surgical techniques, a significantly higher number of cases resolved compared with those treated conservatively (100% and 96.7% compared with 29.5%, respectively, P < 0.05). However, there were no significant differences in the proportion that resolved between the minimally invasive and surgical cases ( P = 0.11). Vascular cases that were only managed with surgery had significantly shorter days to resolution compared with cases that first attempted conservative management ( P < 0.001). CONCLUSIONS: Both minimally invasive and surgical options have increased odds of resolution and lower failure rates compared with conservative management alone. The odds of resolution were higher when treated with more invasive procedures compared with conservative-only management, but the mean days to resolution was longer. This meta-analysis depicts successful resolution with procedural management and supports an initial trial of minimally invasive techniques.
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Virilha , Vasos Linfáticos , Virilha/cirurgia , Humanos , Vasos Linfáticos/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Resultado do Tratamento , Procedimentos Cirúrgicos VascularesRESUMO
INTRODUCTION: This study describes perceived knowledge gaps of third-year medical students after participating in a virtual surgical didactic rotation (EMLR) and shortened in-person surgery rotation during the COVID-19 Pandemic. METHODS: Open-ended and Likert questions were administered at the end of the virtual rotation and inperson-surgical rotation to medical students. Three blinded coders identified themes by semantic analysis. RESULTS: 82 students (51% of all MS3s) participated in the EMLR. Semantic analysis revealed gaps in perioperative management (Post-EMLR:18.4%, Post-Inpatient:26.5%), anatomy (Post-EMLR:8.2%, PostInpatient:26.5%). and surgical skills (Post-EMLR: 43.0%, Post-Inpatient: 44.1%). Students also described gaps related to OR etiquette (Post-EMLR: 12.2%, Post-Inpatient: 8.8%) and team dynamics/the hidden curriculum (Post- Inpatient:26.6%). There was a significant improvement in perceived confidence to perform inpatient tasks after completing the inpatient clinical experience (p ≤ 0.01). CONCLUSION: Virtual interactive didactics for cognitive skills development cannot replace a full clinical surgical experience for third-year medical students. Future curricula should address perceived gaps.
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Educação a Distância , Cirurgia Geral , Estudantes de Medicina , COVID-19/epidemiologia , Currículo , Educação de Graduação em Medicina/métodos , Educação de Graduação em Medicina/organização & administração , Cirurgia Geral/educação , Humanos , Conhecimento , Pandemias , Estudantes de Medicina/psicologiaRESUMO
BACKGROUND: The incidence of breast cancer in transmale patients and their continued risk after gender-affirming mastectomy (GAM) has not been well established. Plastic surgeons who offer GAM are often one of the few medical professionals sought out by this population, placing them in a unique position to not only deliver surgical care but also improve access to preventative cancer care. METHODS: We reviewed the senior author's experience with GAMs over the past 5 years for any incidence of breast cancer noted after or at time of surgery. We subsequently performed a thorough review of the literature for cases of breast cancer in transmen, to provide a comprehensive overview of screening, therapy, and postoperative surveillance practices. RESULTS: We identified 2 cases of breast cancer (ages 49 and 54 years) found on routine examination of pathology specimens after GAM at our institution. Both patients had been taking hormone therapy for the past 1 year. Pathology specimen revealed low-grade estrogen receptor-/progesterone receptor-positive ductal carcinoma in situ in 1 patient, and estrogen receptor-/progesterone receptor-positive invasive ductal carcinoma in the other. Both patients were referred to oncology for appropriate treatment, and both elected to continue their exogenous hormone therapy for personal reasons.Review of the literature demonstrated 36 other cases of documented breast cancer in transmen. Sixty-seven percent (24) were found after GAM, and of those, 50% were incidentally found on pathology specimen. At least 50% were found to be either estrogen-, progesterone-, or androgen receptor-positive cancers. At least 17% of cases documented continued use of masculinizing hormone therapy after cancer diagnosis. CONCLUSIONS: Most documented cases of breast cancer in transmen were diagnosed after gender-affirming surgery, which would suggest residual breast tissue does pose some risk for breast cancer. In addition, those diagnosed with cancer may elect to continue exogenous testosterone therapy despite potential added risks with hormone-receptor positivity. These cases highlight the need for agreement in current screening practices, surgical recommendations, and continuation of masculinizing hormone therapy.Plastic surgeons have the unique opportunity to educate these patients on appropriate breast cancer-related surveillance both before and after chest surgery.