Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned.

BACKGROUND: Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program. METHODS: Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process. RESULTS: Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient's experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation. CONCLUSIONS: This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report.

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC-VLN) flap was used in the management of a 33-year-old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow-up, the IC-VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC-VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow-up are required to analyze the efficacy and long-term results of this flap.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia.

BACKGROUND: Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7 years. METHODS: From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle. RESULTS: The average amount of tumescent solution infiltrated while performing TLA was 740 mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation). CONCLUSIONS: TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied. 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 .

Vascularized appendicular lymph node transfer for treatment of extremity lymphedema: A case report.

Vascularized lymph node transfer has demonstrated promising results for the treatment of extremity lymphedema. In an attempt to find the ideal donor site, several vascularized lymph nodes have been described. Each has a common goal of decreasing morbidity and avoiding iatrogenic lymphedema while obtaining good clinical results. Herein, we present the preliminary clinical outcomes of an intra-abdominal lymph node flap option based on the appendicular artery and vein used for the treatment of extremity lymphedema. A 62 year-old woman with moderate lower extremity lymphedema, on chronic antibiotics because of recurrent infections and unsatisfactory outcomes after conservative treatment underwent a vascularized appendicular lymph node (VALN) transfer. At a follow-up of 6 months, the reduction rate of the limb circumference was 17.4%, 15.1%, 12.0% and 9% above the knee, below the knee, above the ankle and foot respectively. In addition, no further episodes of infection or other complications were reported after VALN transfer. Postoperative lymphoscintigraphy demonstrated that the VALN flap was able to improve the lymphatic drainage of the affected limb. According to our findings, the use of VALN transfer minimizes donor-site morbidity, avoids iatrogenic lymphedema and may provide a strong clearance of infection because of the strong immunologic properties of the appendiceal lymphatic tissue in selected patients. Despite these promising results, further research with larger number of patients and longer follow- up is needed.

Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema.

BACKGROUND: Vascularized lymph node (VLN) transfer for lymphedema treatment has shown promising results. Optimal donor and recipient sites remain a matter of debate. We describe the technique and outcomes of a laparoscopically harvested extended gastroepiploic VLN flap with two levels of inset. PATIENTS AND METHODS: Between 2014 and 2015, four-patients with upper limb breast cancer-related lymphedema and three-patients with lower limb pelvic cancer-related lymphedema who underwent VLN transfers were included. After harvest, the gastroepiploic VLN flap was divided into two halves that were separately inset at the level of elbow and wrist (upper limb) or knee and ankle (lower limb). The mean patient age was 53.1 years (range, 42-65 years). RESULTS: The average flap size after division was 6.3 cm in length (range, 5-7 cm) and 3.4 cm in width (range, 3-4 cm). The mean pedicle length was 3.2 cm (range, 2.5-4 cm). All flaps survived completely. No donor or recepient site complication was noted. At a mean follow-up of 9.7 months (range, 8-11 months), the mean circumference reduction rate was 43.7 ± 2.5% along the entire limb (P < 0.05). No episode of infection was noted postoperatively. CONCLUSIONS: Double gastroepiploic VLN transfers to middle and distal limb are a safe approach with very promising results. This technique may be used to improve clinical outcomes by enhancing the lymphatic drainage of the entire affected limb in a uniform fashion. In addition, the laparoscopic harvest can provide decreased donor site morbidity with a faster recovery.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions.

BACKGROUND AND OBJECTIVE: Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions. METHODS: Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method. RESULTS: Our results confirm the efficacy and safety of this treatment for facial vascular lesions. CONCLUSIONS: Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.