Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery.

BACKGROUND: Literature focused on cancer screening and management is lacking in the transgender population. AIM: To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients. METHODS: We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories. RESULTS: Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated. CONCLUSION: When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.

Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature. METHODS: This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes. RESULTS: One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature. CONCLUSIONS: The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.

A national multi-institutional analysis of predictors of surgical site complications and unplanned reoperation after paramedian forehead flap reconstruction.

Background: Although postoperative complications of paramedian forehead flap (PMFF) are generally low, surgical site complications and unplanned reoperation can still occur. Recent literature suggests infection to be the most common complication following PMFF reconstruction. This study sought to determine the patient and preoperative factors associated with surgical site complications and unplanned reoperations at a national level. Methods: Patients who underwent PMFF reconstruction from the ACS-NSQIP 2007 - 2019 database were analyzed to determine composite surgical site morbidity and unplanned return to the operating room. Patient and operative factors were also analyzed to assess independent risk factors for surgical site morbidity and unplanned reoperation in the first 30 postoperative days. Results: A total of 1,592 PMFF were analyzed between 2007 and 2019. Of these, 2.7% (43/1592) developed a composite surgical site complication in the first 30 postoperative days. Risk factors for composite surgical site complication included >10% weight loss in the previous 6 months (p<0.05), disseminated cancer (p<0.01), class 4 wounds (dirty/infected) (p<0.01), and operative time greater than 123 min (p<0.01). Based on the univariate analysis, low preoperative albumin and hematocrit were also associated with increased odds of composite surgical site complication. 2.5% (40/1592) of patients underwent unplanned reoperation. Higher ASA class (p<0.05) and class 4 wounds (p<0.05) were associated with unplanned return to the operating room. Conclusion: Significant weight loss, disseminated cancer, prolonged operation time, low preoperative albumin, and hematocrit are associated with higher PMFF composite surgical site complications. Higher ASA and class 4 wound status are associated with an increased risk of unplanned reoperation.

Critical Importance of the First Postoperative Days After Head and Neck Free Flap Reconstruction: An Analysis of Timing of Reoperation Using the National Surgical Quality Improvement Program Database.

BACKGROUND: Head and neck free flaps remain associated with considerable rates of take-back and prolonged hospital length of stay. However, there have been no studies on a national level benchmarking the timeline and predictors of head and neck free flap take-back. METHODS: Patients undergoing head and neck free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 database were analyzed to determine the rates of take-back. Timing and rates of unplanned head and neck free flap take-backs were stratified by tissue type and postoperative day (POD) over the first month. Weibull survival models were used to compare rates of take-backs among time intervals. Multivariable logistic regression was used to identify the independent predictors of take-back. RESULTS: Three thousand nine hundred six head and neck free flaps were analyzed. The mean daily proportion of patients experiencing take-back during PODs 0 to 1 was 0.95%; this dropped significantly to a mean daily proportion of 0.54% during POD 2 (P < 0.01). In addition, there were significant drops in take-back when comparing POD 2 (0.54%) to POD 3 (0.26%) and also when comparing POD 4 (0.20%) with PODs 5 to 30 (0.032% per day) (P < 0.05). The soft tissue and osseous flap populations demonstrated a similar trend in unplanned take-back. CONCLUSION: This is the first national study to specifically analyze the timing of take-back in the head and neck reconstruction population. These data highlight the importance of flap monitoring during the first 5 PODs, with ERAS pathway optimization aiming for discharge by the end of the first postoperative week.

Nationally Validated Scoring System to Predict Unplanned Reoperation and Readmission after Breast Reduction.

BACKGROUND: Reduction mammoplasty continues to be a commonly sought procedure with complication rates ranging from 4.3 to 8.2%. In the current study, we sought to identify the clinical and preoperative risk factors for unplanned reoperation and readmission within the first postoperative month on a national scale. METHODS: Patients who underwent reduction mammoplasty from the ACS-NSQIP 2012-2019 database were analyzed to determine rates of reoperation and readmission within 30 days of the initial breast surgery. The cohort was divided into 60 and 40% random testing and validation samples. A multivariable logistic regression analysis was then performed to isolate independent factors of unplanned readmission and reoperation using the testing sample (n = 22,743). The predictors were weighted according to beta coefficients to develop an integer-based clinical risk score predictive of complications. This system was then validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 15,162). RESULTS: A total of 37,905 reduction mammoplasties were analyzed. 1.3% of patients had an unplanned readmission. Independent risk factors for unplanned readmission included age older than the median of 44 years (p < 0.01), inpatient procedure (p < 0.01), smoking (p < 0.01), hypertension (p = 0.01), COPD (p < 0.05), BMI ≥ 35 (p < 0.01), and operation time greater than the median of 142 minutes ( p < 0.01). The factors were integrated into a scoring system, ranging from 0 to 36, and an ROC analysis revealed an area under the curve of 0.66. 1.9% of patients underwent unplanned reoperation. Independent risk factors for unplanned reoperation in this population included age older than the median of 44 years (p < 0.01), inpatient status (p < 0.01), and a history of bleeding disorders (p < 0.05). The factors were integrated into a scoring system, ranging from 0 to 25, and the ROC analysis revealed an area under the curve of 0.61. CONCLUSIONS: We present a validated scoring system to better inform patients about their risk for unplanned reoperation and readmission following reduction mammoplasty. This system will enable surgeons to optimize patient selection and interventions in order to decrease morbidity and unnecessary health-care expenditure. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Incisional Negative Pressure Wound Therapy Is Protective Against Postoperative Cardiothoracic Wound Infection.

BACKGROUND: Sternal wound infections are a rare but life-threatening complication of cardiothoracic surgery. Prior literature has supported the use of negative pressure wound therapy to decrease sternal wound infections and promote healing. This study sought to determine whether closed incision negative pressure therapy reduced wound infection and improved outcomes in cardiothoracic surgery. METHODS: A retrospective cohort study was performed including all adult patients who underwent nontraumatic cardiothoracic surgery at a single institution between 2016 and 2018 (n = 1199). Patient characteristics, clinical variables, and surgical outcomes were compared between those who did and did not receive incisional negative pressure wound therapy intraoperatively. Multivariable logistic regression analysis determined factors predictive or protective of the development of complications. RESULTS: Incisional negative pressure wound therapy was used in 58.9% of patients. Patients who received this therapy were older with statistically higher rates of hyperlipidemia, statin, and antihypertensive use. The use of negative pressure wound therapy was found to significantly reduce rates of both wound infection (3.0% vs 6.3%, P = 0.01) and readmission for wound infection (0.7% vs 2.6%, P = 0.01). After controlling for confounding variables, negative pressure wound therapy was found to be a protective factor of surgical wound infection (odds ratio, 0.497; 95% confidence interval, 0.262-0.945). CONCLUSIONS: In the largest population studied to date, this study supported the expanded use of negative pressure therapy on sternal wound incisions to decrease infection rates.

Optimizing Abdominoplasty Surgical Site Morbidity Profiling Through an Effective and Nationally Validated Risk Scoring System.

BACKGROUND: Abdominoplasty complication rates are among the highest for cosmetic surgery. We sought to create a validated scoring system to predict the likelihood of wound complications after abdominoplasty using a national multi-institutional database. METHODS: Patients who underwent abdominoplasty in the American College of Surgeons National Surgical Quality Improvement Program 2007-2019 database were analyzed for surgical site complications, a composite outcome of wound disruption, and surgical site infections. The cohort was randomly divided into a 60% testing and a 40% validation sample. Multivariable logistic regression analysis was performed to identify independent predictors of complications using the testing sample (n = 11,294). The predictors were weighted according to ß coefficients to develop an integer-based clinical risk score. This system was validated using receiver operating characteristic analysis of the validation sample (n = 7528). RESULTS: A total of 18,822 abdominoplasty procedures were identified. The proportion of patients who developed a composite surgical site complication was 6.8%. Independent risk factors for composite surgical site complication included inpatient procedure (P < 0.01), smoking (P < 0.01), American Society of Anesthesiologists class ≥3 (P < 0.01), and body mass index ≥25.0 and ≤18.0 kg/m2 (P < 0.01). African American race was a protective factor against surgical site complications (P < 0.01). The factors were integrated into a scoring system, ranging from -5 to 42, and the receiver operating characteristic analysis revealed an area under the curve of 0.71. CONCLUSIONS: We present a validated scoring system for postoperative 30-day surgical site morbidity after abdominoplasty. This system will enable surgeons to optimize patient selection to decrease morbidity and unnecessary healthcare expenditure.

Use of Needle Localization in the Surgical Management of Non-seroma, Mass-forming BIA-ALCL.

Outcomes related to the treatment of breast implant-associated anaplastic large cell lymphoma, a rare extranodal T-cell lymphoma associated with textured breast implants, are largely dependent on the successful resection to negative margins via en bloc capsulectomy and resection of any associated masses. To date, the use of needle localization, a common technique used in breast surgery, to assist in the complete removal of breast implant-associated anaplastic large cell lymphoma has not been described. We present the case report of a 66-year-old woman, with a previous medical history of left-sided invasive ductal carcinoma, who presented 7 years after textured breast implant placement with a left-sided mass without peri-implant seroma. Biopsy demonstrated breast implant-associated anaplastic large cell lymphoma and the associated breast mass extended beyond the capsule borders. The present report describes the novel use of needle localization in this patient to facilitate the complete removal of the malignancy-associated mass with maximal preservation of the overlying soft tissue envelope.

Safe perioperative tamoxifen use in autologous breast free flap reconstruction: systematic review and meta-analysis.

BACKGROUND: Perioperative tamoxifen remains a valuable therapeutic modality for breast cancer patients. Studies in the existing literature have suggested a potential increased risk of thrombotic complications in autologous breast free flap reconstruction patients exposed to tamoxifen perioperatively. However, several recent publications have questioned the validity of these associations. Therefore, we aim to perform a systematic appraisal of the existing literature to determine if perioperative tamoxifen exposure increases the risk of flap complications in autologous breast-free flap reconstruction patients. METHODS: A systematic literature search was performed using: PubMed, EMBASE, Cochrane Central, Web of Science, EBSCOHost, ClinicalTrials.gov, and TRIP databases from their inception up to April 2021. Articles analyzing the impact of perioperative tamoxifen in autologous breast free flap patients were included. The outcomes assessed were total flap loss, overall flap complications, thrombotic flap complications, which was defined as the sum of arterial and venous flap thrombi, and systemic venous thromboembolism (VTE). Pooled estimates and relative risk were calculated using a random effects model. RESULTS: 9294 Articles were screened and 7 were selected for analysis, which included 3669 flaps in 2759 patients. Compared to patients who did not receive tamoxifen perioperatively, those who received tamoxifen did not have an increased risk of thrombotic flap complications (pooled RR 1.06; 95% CI 0.61-1.84), total flap loss (pooled RR 2.17; 95% CI 0.79-5.95), overall flap complications (pooled RR 1.04; 95% CI 0.76-1.41), or systemic VTE (pooled RR 1.93; 95% CI 0.72-5.13). The heterogeneity of the studies was not significant for any of the outcomes. CONCLUSIONS: The purpose of this study was to update the current understanding of the impact of perioperative tamoxifen on autologous breast free flap reconstruction outcomes. The existing literature supports that the perioperative continuation of tamoxifen in breast free flap patients is not associated with an increased risk of thrombotic flap complications, total flap loss, overall flap complications, or systemic VTE.