Nonbinary and Transgender Male Patient Preferences for Gender-Affirming Top Surgery.

BACKGROUND: This study aimed to identify patient preferences and outcomes of chest masculinization surgery in patients identifying as nonbinary versus transgender (trans-) males. METHODS: Patients who underwent chest masculinization (2003-2022) were included. Demographics, medical comorbidities, surgical approaches, complications, secondary procedures, and BODY-Q chest module survey responses were compared between cohorts. RESULTS: Three hundred two patients were included. Thirteen percent identified as nonbinary and 87% as trans-male. The most common surgical approach in both groups was double incision with free nipple-areola graft (63% vs 71%, P = 0.33). Nonbinary patients more frequently opted for double incision without free nipple areola graft compared to trans-male patients (18% vs 2.7%, P < 0.001). Other unique surgical requests of nonbinary patients included nipple areola preservation and small breast mound preservation (5.2%) and balance between losing bulk and achieving a more androgynous appearance (5.3%). The survey response rate was 31% (93/302). Both groups reported improved quality of life postoperatively (P = 0.16). Three nonbinary patients elected not to keep their nipple-areola complexes (P = 0.005). Trans-male patients were more likely to report having a male chest as very important for their gender identity (82% vs 95%, P = 0.043). Nonbinary patients were less likely to prefer small nipples (82% vs 95%, P = 0.033) and 18% stated that they preferred no nipples (vs 2.7% trans-male patients, P < 0.001). CONCLUSIONS: Nonbinary patients have distinct surgical preferences regarding nipple-areola complexes. Chest masculinization planning can differ for this group of patients compared to their trans-male counterparts.

Breast Implant-Related Outcomes After Cardiothoracic Surgeries and Electrophysiologic Procedures.

BACKGROUND: Outcomes related to preexisting breast implants after cardiothoracic procedures are poorly characterized. This study evaluated complications after minimally invasive cardiac surgery (MICS), median sternotomy (MS), and electrophysiologic procedures (EP) in patients with preexisting breast implants. METHODS: A retrospective review of patients with prior breast implants who underwent MICS, MS, or EP from 1994 to 2019 was performed. Demographic, treatment, and outcome characteristics were recorded. χ 2 Test and analysis of variance were used to perform statistical comparisons. RESULTS: In total, 78 patients (37 MICS, 21 MS, and 20 EP) were identified. Mean breast implant age was 13.3, 11.7, and 10.2 years, respectively ( P = 0.235). Intraoperative plastic surgeon involvement was present in 26 (70.3%) MICS cases, compared with 2 (9.5%) MS and 0% EP ( P < 0.001). Intraoperative rupture occurred in 5 (13.5%) MICS cases and no MS or EP cases ( P < 0.001). Postoperative implant complications occurred in 6 (16.2%) MICS, 8 (38.1%) MS, and 5 (25.0%) EP ( P = 0.350) cases, with median time to complication of 5.9, 5.4, and 38.9 months, respectively ( P = 0.596). Revision surgery was performed in 5 (13.5%) MICS, 7 (33.3%) MS, and 5 (25.0%) EP ( P = 0.246) cases. On multivariate analysis, lack of intraoperative plastic surgeon involvement ( P = 0.034) and breast implant age ( P = 0.001) were significant predictors of postoperative complications. CONCLUSIONS: Long-term complication rates are highest among patients with breast implants undergoing MS. Plastic surgeon involvement was significantly associated with fewer postoperative complications. Our results support a multidisciplinary approach to managing breast implants during cardiothoracic procedures.

The Effect of Preoperative Gender-Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation.

BACKGROUND: Many providers require cessation of gender-affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery (MCS) due to concerns about increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender-affirming procedures. OBJECTIVES: The aim of this study was to compare adverse event rates for GAHT cessation vs GAHT continuation in patients undergoing MCS. METHODS: This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent MCS between 2016 and 2020. RESULTS: There were 236 patients who met the inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery and 64 (27.1%) continued the therapy. Mean [standard deviation] age at surgery was 25 [8] years, and mean BMI was 29.5 [6.6] kg/m.2 The median duration of testosterone therapy was 18 months (range, 0-300 months). There was no significant difference in tobacco use (P = 0.73), diabetes (P = 0.54), thrombophilia (P = 0.97), or history of thromboembolism (P = 0.39). Most patients underwent the double-incision free nipple graft technique (77.9%). There was no significant difference in surgical time (P = 0.12), intraoperative complications (P = 0.54), or postoperative complications (P = 0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications. CONCLUSIONS: There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively vs patients who stop GAHT prior to MCS.

Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative. OBJECTIVES: In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease. METHODS: This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement. RESULTS: All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up. CONCLUSIONS: In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.

Treatment Strategies of Complications of Breast Implants Associated With Ventriculoperitoneal Shunts: A Case Report and Review of the Literature.

ABSTRACT: Breast augmentation is among the most commonly performed cosmetic procedures in the United States. As these patients age or develop comorbidities, surgeons across many other disciplines will inevitably encounter these patients in their own practices. Consequently, surgeons must be aware of the potential interactions between breast implants and devices commonly used in their fields. This case, the second of its kind encountered by our own department, describes a woman who suffered one such interaction: migration and coiling of a ventriculoperitoneal shunt around her breast implant. A systematic review was conducted to characterize breast-related ventriculoperitoneal shunt complications reported in the literature and generate an algorithm for management of the most commonly reported scenarios. Recognition of potential complications will aid surgeons in appropriate operative planning and prevention of these adverse events.

Prognostic value of sentinel lymph node biopsy according to Breslow thickness for cutaneous melanoma.

BACKGROUND: Sentinel lymph node (SLN) biopsy is widely performed for melanoma with certain histologic parameters and offers important prognostic and staging information. Breslow thickness (BT) by itself also provides meaningful prognostic information. OBJECTIVE: To evaluate whether SLN status provides prognostic information independent from that which is already provided by BT. METHODS: We conducted a retrospective cohort study of 896 patients who underwent SLN biopsy for primary cutaneous melanoma. Stratified analysis of the impact of SLN status within BT groups (0.01-1 mm, 1.01-2.00 mm, 2.01-4.00 mm, and >4.00 mm) was performed. In addition, a Cox proportional hazard model was fit to evaluate the interaction between BT unadjusted and then adjusted for SLN status to determine whether predictive ability is improved. RESULTS: Having a negative SLN did not confer a statistically significant survival advantage for any BT subgroup (P = .54, .075, .17, and .95 for subgroups 0.01-1 mm, 1.01-2.00 mm, 2.01-4.00 mm, and >4.00 mm, respectively). In multivariate analysis, SLN status did not demonstrate independent prognostic ability over that of BT alone (P = .067). LIMITATIONS: Retrospective study, single institution. CONCLUSION: Our data suggest that SLN status does not offer better prognostic information for patients than BT alone.

Traumatic Facial Myopericytoma: A Differential to Consider.

Myopericytoma is a slow-growing, benign soft tissue neoplasm that arises from perivascular smooth muscle cells. This tumor is a rare entity itself, but it is only scarcely mentioned in the literature occurring secondary to trauma. The authors report a 21-year-old male patient who presented with a pulsatile mass in the medial canthal area where he had experienced previous trauma from a car accident 1-year prior. The mass was excised and histopathology revealed myopericytoma. This clinical report adds to the limited body of evidence supporting trauma as an etiology for this rare tumor.

The Role of Injectables in Aesthetic Surgery: Financial Implications.

Background: The plastic surgeon competes with both core and noncore physicians and surgeons for traditional cosmetic procedures. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) joined efforts to form a Cosmetic Medicine Task Force to further analyze this trend. Objectives: Our objective is to document and quantify the patient capture and total collections generated in a single surgeon's practice exclusive from Botulinum Toxin A and filler injections over a 10-year period. We subsequently identified the effect and importance that fillers and Botulinum Toxin A have on an active cosmetic practice. Methods: A retrospective chart review of all male and female patients who received Botulinum Toxin A or soft tissue filler injections (noninvasive aesthetic treatment) in a single surgeons practice from January 2004 to December 2013 was undertaken. Only those patients new to the practice and who were exclusively seeking out Botulinum Toxin A or fillers were included in the study. Chart review then identified which of these selected patients ultimately underwent invasive aesthetic surgery during this 10-year period. Noninvasive and invasive aesthetic surgery total collections were calculated using billing records. Results: From January 2004 to December 2013, 375 patients entered the senior surgeon's practice specifically requesting and receiving noninvasive aesthetic treatments. Of these 375 patients, 59 patients (15.7%) subsequently underwent an aesthetic surgery procedure at an average of 19 months following initial noninvasive aesthetic treatment. Of these 375 patients, 369 were female and 6 were male. The most common initial invasive aesthetic procedure performed after injectable treatment included 22 facelifts (18.5%), 21 upper eyelid blepharoplasties (17.6%), and 15 endoscopic brow lifts (12.6%). Total collections from noninvasive aesthetic sessions and invasive surgery combined represented US$762,470 over this 10-year span. This represented US$524,771 and US$396,166 in total collections for injectables and surgery respectively. Conclusions: Noninvasive aesthetic surgery is a critical part of a plastic surgery practice. A measurable and significant number of patients who sought out a single plastic surgeon exclusively for noninvasive treatment ultimately underwent traditional invasive cosmetic surgical procedures.

Botulinum Toxin and Muscle Atrophy: A Wanted or Unwanted Effect.

While the facial rejuvenating effect of botulinum toxin type A is well known and widespread, its use in body and facial contouring is less common. We first describe its use for deliberate muscle volume reduction, and then document instances of unanticipated and undesirable muscle atrophy. Finally, we investigate the potential long-term adverse effects of botulinum toxin-induced muscle atrophy. Although the use of botulinum toxin type A in the cosmetic patient has been extensively studied, there are several questions yet to be addressed. Does prolonged botulinum toxin treatment increase its duration of action? What is the mechanism of muscle atrophy and what is the cause of its reversibility once treatment has stopped? We proceed to examine how prolonged chemodenervation with botulinum toxin can increase its duration of effect and potentially contribute to muscle atrophy. Instances of inadvertent botulinum toxin-induced atrophy are also described. These include the "hourglass deformity" secondary to botulinum toxin type A treatment for migraine headaches, and a patient with atrophy of multiple facial muscles from injections for hemifacial spasm. Numerous reports demonstrate that muscle atrophy after botulinum toxin type A treatment occurs and is both reversible and temporary, with current literature supporting the notion that repeated chemodenervation with botulinum toxin likely responsible for both therapeutic and incidental temporary muscle atrophy. Furthermore, duration of response may be increased with subsequent treatments, thus minimizing frequency of reinjection. Practitioners should be aware of the temporary and reversible effect of botulinum toxin-induced muscle atrophy and be prepared to reassure patients on this matter.

Reconstruction options following breast conservation therapy.

Women who have had breast conservation therapy for malignancy are candidates for various surgical techniques for immediate or delayed breast reconstruction. These include local tissue rearrangement, therapeutic reduction mammaplasty, and various flap reconstruction procedures. Each technique has advantages and disadvantages, and individual patient factors, particularly breast size and resection defect size, should drive the choice among procedures. Immediate reconstruction (at the time of breast conservation surgery) is preferred over delayed reconstruction, for multiple reasons. Patients tend to be satisfied with the cosmetic outcome of these procedures, but thorough patient counseling and preop-immediate or erative planning is critical to a good result.

Adipofascial Flap in the Recipient Incision Site for Coverage of Vascular Pedicle in Free Tissue Transfer.

The recipient incision adipofascial flap offers a simple approach to address a tight skin closure over a vascular pedicle. This technique is not just fast and easy to perform but also adds little to no morbidity, removing a potential source of flap failure.

Weight loss is higher among patients who undergo body contouring procedures after bariatric surgery.

BACKGROUND: As the number of patients who have undergone bariatric surgery increases, it is expected that more patients will present for body contouring procedures after weight loss. It has been reported that abdominoplasty can improve mobility, reduce skin fold complications, and improve psychosocial functioning. No previous studies have evaluated weight loss in patients who pursue plastic surgery after bariatric surgery. OBJECTIVES: The aim of this study is to evaluate weight loss outcomes in patients who choose to undergo body contouring procedures after bariatric surgery. SETTING: Academic center, United States. METHODS: Patients who underwent body contouring procedures after bariatric surgery between 2002 and 2014 were included. A comparison was made to a matched cohort based on age, gender, type of bariatric procedure, preoperative body mass index (BMI), and length of follow-up. RESULTS: In total, 186 patients had documentation of a body contouring procedure after bariatric surgery. There were 158 (84.9%) female participants in the body countering group. Mean age was 48.5±12.7 years and mean BMI was 49.8±10.4 kg/m2. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 157 (84.4%), 17 (9.1%), and 11 (5.9%) patients, respectively. After a matched follow-up period of 61 months, total weight loss was 43.0±22.6 kg in the body contouring group versus 33.5±21.7 kg in the control group (P<.001), percentage of total weight loss was 30.8±11.4% versus 24.0±13.2% (P<.001), percentage excess weight loss was 66.4±25% versus 52.5±30.5% (P<.001), and BMI dropped by 15.7±7.8 kg/m2 versus 12.1±7.3 kg/m2 (P<.001) in the body contouring group compared with the bariatric surgery-only group, respectively. Multivariate analysis indicated that body contouring after bariatric surgery is significantly associated with increase and durable weight loss (odds ratio 3.59, 95% confidence interval 2.04-5.14, P< .001). CONCLUSION: Patients who underwent body contouring procedures after bariatric surgery had significantly better long-term weight loss than a matched cohort of patients. This finding likely has many contributing factors, and the association between long-term weight loss and body contouring procedures after bariatric surgery requires more detailed study.

Long-Term Outcomes of Total Knee Arthroplasty following Soft-Tissue Defect Reconstruction with Muscle and Fasciocutaneous Flaps.

BACKGROUND: Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. METHODS: A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive débridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. RESULTS: Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). CONCLUSIONS: Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.