Familiar Infections in Novel Anatomy: Patient Reports of Sexually Transmitted Infections After Gender-Affirming Penile Reconstruction.

BACKGROUND: Sexually transmitted infections (STIs) after penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations have not previously been described, despite known risk factors in the population. After T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines. METHODS: A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups. RESULTS: A total of 128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups from January to May 2020. Seven respondents (5.5%) self-reported 1 or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (P = 0.002). Sexually transmitted infections were correlated with reporting sex with cisgender men (P = 0.001), transgender men (P = 0.009), and transgender women (P = 0.012). Of health care access variables, only receiving health care at a community health center was correlated with STI history (P = 0.003). CONCLUSIONS: This exploratory survey indicates that STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of postreconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of health care provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm after gender-affirming penile reconstruction.

"Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?"

BACKGROUND: The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM: We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS: Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES: Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS: There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS: A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS: This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION: Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients.

BACKGROUND: Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM: To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS: A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES: Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS: Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS: These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS: These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION: Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

Surgical Management of Occipital Neuralgia: A Systematic Review of the Literature.

BACKGROUND: Occipital neuralgia (ON) is a primary headache disorder characterized by severe, paroxysmal, shooting or stabbing pain in the distribution of the greater occipital, lesser occipital, and/or third occipital nerves. Both medical and surgical options exist for treating headaches related to ON. The purposes of this study are to summarize the current state of surgical ON management through a systematic review of the literature and, in doing so, objectively identify future directions of investigation. METHODS: We performed a systematic review of primary literature on surgical management for ON of at least level IV evidence. Included studies were analyzed for level of evidence, therapeutic intervention, study design, sample size, follow-up duration, outcomes measured, results, and risk of bias. RESULTS: Twenty-two studies met the inclusion criteria. All 22 studies used patient-reported pain scores as an outcome metric. Other outcome metrics included complication rates (7 studies; 32%), patient satisfaction (7 studies; 32%), quality of life (7 studies; 18%), and analgesic usage (3 studies; 14%). Using the ROBINS-I tool for risk of bias in nonrandomized studies, 7 studies (32%) were found to be at critical risk of bias, whereas the remaining 15 studies (68%) were found to be at serious risk of bias. CONCLUSIONS: Greater occipital nerve decompression seems to be a useful treatment modality for medically refractory ON, but further prospective, randomized data are required.

Disparities in Postmastectomy Breast Reconstruction: A Systematic Review of the Literature and Modified Framework for Advancing Research Toward Intervention.

BACKGROUND: As the United States' population diversifies, eliminating disparities in health and healthcare has become increasingly important across all disciplines of medicine, including plastic and reconstructive surgery. This is evidenced by the growing body of literature in recent years focusing on disparities in postmastectomy breast reconstruction. No study to date has evaluated whether this research is progressing appropriately to promote tangible evidence-based interventions to reduce these disparities. METHODS: A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to identify studies focusing on disparities in postmastectomy breast reconstruction. A previously established public health framework for advancing health disparities research was used to inform analysis of the quality and progression of the included studies. This triphasic framework categorizes disparities research as follows: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities), or reducing (proposes and evaluates interventions for eliminating disparities). RESULTS: Ninety-five studies were identified between 1979 and 2016, with 61 (64.2%) published after 2010. The majority of studies (51.6%) were retrospective cohort or case-control studies (American Society of Plastic Surgery level III evidence). Fifty-eight (63.7%), 31 (34.1%), and 2 (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level, with race/ethnicity being the most common (73.7%). The most commonly measured outcome was percent of subpopulation receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system-, and research-level factors were all identified as potential targets for interventions to reduce disparities. CONCLUSIONS: Despite a recent increase in literature focusing on postmastectomy breast reconstruction disparities, the majority focuses on identifying vulnerable populations with inadequate progression to second (understanding) and third (reducing) phases. Increasing research funding, availability of language-concordant and culturally concordant educational materials, and advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and, ultimately, eliminate it.

"The GalaFLEX 'Empanada' for Direct to Implant Prepectoral Breast Reconstruction".

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Robotics in Gender Affirming Surgery: Current Applications and Future Directions.

Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.

Operative Management of Complications Following Intestinal Vaginoplasty: A Case Series and Systematic Review.

OBJECTIVE: To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications following gender-affirming intestinal vaginoplasty. METHODS: Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender-affirming intestinal vaginoplasty. RESULTS: Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%), and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15 cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to operating room rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities. CONCLUSION: Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.

Nipple-Preserving Inferior Ellipse Mastectomy: A New Technique for Gender-Affirming Top Surgery.

SUMMARY: The two most common techniques for gender affirming mastectomy are the double incision free nipple graft and peri areolar. There are however patients that are not well suited for either technique. When the nipples are high and on the pectoralis muscle yet there is marked breast tissue and skin redundancy, a double incision free nipple graft would land the incision above the pec shadow but a peri-areolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior ellipse incision allows for appropriate chest contouring leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. Retrospective review identified all consecutive patients undergoing nipple-preserving inferior ellipse mastectomy by the senior author. Indications were patients with moderate glandular tissue, skin excess and a high nipple areolar complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma which resolved with aspiration. In summary, for patients with moderate glandular tissue, excess skin in the inferior pole and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior ellipse mastectomy technique achieves excellent chest contour.

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes.

OBJECTIVE: 1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS: Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS: Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION: ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Gender-Affirming Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations.

BACKGROUND: The number of transgender adolescents seeking gender-affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender-affirming surgery for individuals under the age of legal majority and propose directions for future research. METHODS: A scoping review of recent literature was performed to assess evidence on gender-affirming surgery in individuals under the age of legal majority. Articles were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion. RESULTS: Twelve articles were identified that met inclusion criteria. Ten of these articles discussed ethical challenges in adolescent GAS, seven discussed legal challenges, and five discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the effects of puberty blockade on natal tissue. CONCLUSIONS: Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?

BACKGROUND: Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone before top surgery. This is the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS: This retrospective review included patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, before May of 2019, all patients were required to discontinue testosterone before surgery; all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographic characteristics and postoperative outcomes compared among groups. RESULTS: A total of 490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients; 104 patients never received testosterone therapy. Demographic characteristics were similar among groups and there was no difference in rates of hematoma (2.9% versus 2.8% versus 2.9%, respectively; P = 0.99), seroma (1.1% versus 0% versus 1%, respectively; P = 0.31), venous thromboembolism (0% versus 0.5% versus 0%, respectively; P = 0.99), or overall complications (6.9% versus 4.3% versus 5.8%, respectively; P = 0.54). CONCLUSIONS: Our results demonstrate no difference in postoperative complication rates among groups. Whereas further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Performance of cervical cytology and HPV testing for primary cervical cancer screening in Latin America: an analysis within the ESTAMPA study.

Background: Cervical cytology remains widely used as the initial tool in cervical cancer screening worldwide. WHO guidelines recommend replacing cytology with primary HPV testing to reach cervical cancer elimination goals. We assessed the performance of cytology and high-risk HPV testing to detect cervical precancer, cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN3+) among women aged 30-64 years participating in the ESTAMPA study. Methods: Women were screened with cytology and HPV across ESTAMPA study centres in Latin America. Screen-positives were referred to colposcopy with biopsy collection and treatment as needed. Those with no evident precancer were recalled at 18-months for a second HPV test to complete disease ascertainment. Performance indicators for cytology and HPV to detect CIN3+ were estimated. Findings: 30,606 participants with available cytology and HPV results were included in the analysis. A total of 440 histologically confirmed CIN3s and 30 cancers were diagnosed. Cytology sensitivity for CIN3+ was 48.5% (95% CI: 44.0-53.0), whereas HPV testing had a sensitivity of 98.1% (95% CI: 96.3-96.7). Specificity was 96.5% (95% CI: 96.3-96.7) using cytology and 88.7% (95% CI: 88.3-89.0) with HPV. Performance estimates varied substantially by study centre for cytology (ranging from 32.1% to 87.5% for sensitivity and from 89.2% to 99.5% for specificity) while for HPV results were more consistent across sites (96.7%-100% and 83.6-90.8%, respectively). Interpretation: The limited and highly variable sensitivity of cytology strongly supports transition to the more robust and reproducible HPV-based cervical screening to ensure progress towards global cervical cancer elimination targets in Latin America. Funding: IARC/WHO, UNDP, HRP/WHO, NCI and local funders.

The Management of Intra-abdominal Complications Following Peritoneal Flap Vaginoplasty.

OBJECTIVE: To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS: Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS: Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSION: Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare. In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.

Recommendations for Communication in Gender-Affirming Surgical Care.

SUMMARY: The surgical treatment of gender incongruence with gender-affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women and those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to mistakes during patient care. Based on the lessons learned from these experiences, the authors provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns.

Background: Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques. Methods: Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups. Results: In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique. Conclusions: Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.

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.

Feasibility and Perception of Cross-sex Face Transplantation to Expand the Donor Pool.

BACKGROUND: A major challenge in face transplantation (FT) is the limited donor allograft pool. This study aimed to investigate the feasibility of cross-sex FT (CSFT) for donor pool expansion by: (1) comparing craniomaxillofacial metrics following CSFT versus same-sex FT (SSFT); and (2) evaluating the public and medical professionals' perception of CSFT. METHODS: Seven cadaveric FTs were performed, resulting in both CSFT and SSFT. Precision of bony and soft tissue inset was evaluated by comparing pre- versus post-operative cephalometric and anthropometric measurements. Fidelity of the FT compared to the virtual plan was assessed by imaging overlay techniques. Surveys were administered to medical professionals, medical students, and general population to evaluate opinions regarding CSFT. RESULTS: Five CSFTs and 2 SSFTs were performed. Comparison of recipients versus post-transplant outcomes showed that only the bigonial and medial intercanthal distances were statistically different between CSFT and SSFT (P = 0.012 and P = 0.010, respectively). Of the 213 survey participants, more were willing to donate for and undergo SSFT, compared with CSFT (donate: 59.6% versus 53.0%, P = 0.001; receive: 79.5% versus 52.3%, P < 0.001). If supported by research, willingness to receive a CSFT significantly increased to 65.6% (P < 0.001). On non-blinded and blinded assessments, 62.9% and 79% of responses rated the CSFT superior or equal to SSFT, respectively. CONCLUSIONS: Our study demonstrates similar anthropometric and cephalometric outcomes for CSFT and SSFT. Participants were more reticent to undergo CSFT, with increased willingness if supported by research. CSFT may represent a viable option for expansion of the donor pool in future patients prepared to undergo transplantation.