An Evaluation of Racial Diversity in Craniofacial Surgery Literature.

ABSTRACT: Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion.

OBJECTIVE: In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND: The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS: Published medical images and graphics depicting human skin were analyzed across 4 major plastic surgery journals. Up to 4 years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "White" or "non-White." Data were evaluated with pair-wise and linear regression statistics. RESULTS: Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-White skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-White before and 7.3% to 10.3% after 2010. International and multi-national authors tended to publish more non-White images. CONCLUSIONS: There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

Defining Aesthetic Preferences for the Penis: A Photogrammetric and Crowdsourcing Analysis.

BACKGROUND: Achieving an aesthetic phalloplasty result is important for patients with acquired or congenital defects of the penis, or with genital-related dysphoria. However, aside from length and girth, the aesthetic proportions of the male penis have not been defined. OBJECTIVES: This study aimed to determine proportions of the male penis through photogrammetric analysis of nude male photographs and to verify these proportions with a crowdsourcing-based survey. METHODS: Nude male photographs (n = 283) were analyzed to define aesthetic proportions of the male penis. Photographs were analyzed for the position of the penis on the torso in relation to the umbilicus and for the ratio of the dorsal and ventral glans of the penis in relation to the entire shaft length. Proportions were then further studied by crowdsourcing 1026 respondents with Amazon mechanical Turk. RESULTS: The ideal position of the penis below the umbilicus is about 55% (6/11th) of the distance from the jugular notch to the umbilicus (measured average, 53.6%; survey-weighted average, 58.9%). The dorsal glans of the penis is about 33% (1/3rd) of the length of the entire shaft (measured average, 32.1%; survey-weighted average, 37.5%). The ventral glans of the penis is about 12.5% (1/8th) of the length of the entire shaft (measured average, 12.6%; survey-weighted average, 11.7%). CONCLUSIONS: Measured proportions of the human penis follow exact fractions. Crowdsourcing data helped support photogrammetric analysis, with survey-preferred ratios within 5% of measured ratios. With further validation, these data can aid surgeons performing phalloplasty.

The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization.

OBJECTIVE: Nonsurgical and surgical options are available for transgender vocal feminization. This systematic review explores the efficacy of feminizing voice therapy and phonosurgery. METHODS: A systematic review was performed using PubMed, Cinahl Plus, Ovid SP, Web of Science, Science Direct, and Google Scholar with terms related to transgender phonosurgery and voice therapy. Included studies were outcomes-based vocal feminization interventions for transgender women. Data were collected on pre- and postintervention fundamental frequency (F0), externally measured vocal femininity, patient satisfaction, and complications. RESULTS: Two hundred twelve studies were identified and 20 met inclusion criteria. Postintervention patient satisfaction was approximately 80% to 85% for voice therapy, endoscopic shortening, and cricothyroid approximation. Complications were reported for each phonosurgery technique, most commonly decreased mean phonation time and loudness. Of the 20 studies, 17 were used for meta-analysis of F0 change. F0 increased by 31 Hz with voice therapy alone, 26 Hz with laser reduction glottoplasty, 39 Hz with cricothyroid approximation, and 72 Hz with endoscopic shortening. CONCLUSION: The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications. Most will likely benefit from voice therapy, as it is highly satisfactory, raises vocal pitch, and is noninvasive. However, endoscopic shortening is also highly satisfactory and provides the greatest absolute increase in vocal pitch. If surgery is chosen, postoperative voice therapy may additionally increase F0, stabilize the voice, and create a more female timbre. However, further studies will be necessary to provide definitive clinical recommendations.

Genital Sensibility in the Neophallus: Getting a Sense of the Current Literature and Techniques.

INTRODUCTION: Phalloplasty attempts to achieve a functional and aesthetic phallus. Sensation is a key component for sexual pleasure. Sensation is also important for protection in the setting of penile implant insertion. Little data are available on genital sensibility outcomes after phalloplasty, and there are no standardized approaches for assessment of either sensibility or erogenous perception. METHODS: A literature search of PubMed, Google Scholar, and MEDLINE databases was conducted with terms related to genital sensibility after phalloplasty. Data on patient demographics, nerves used for coaptation, and measurements of genital sensibility were collected. Pooled event rates were determined for recovered glans sensibility and recovered erogenous sensation using a Freeman-Tukey arcsine transformation. RESULTS: A total of 341 articles were identified of which 26 met the inclusion criteria for final analysis. The dorsal cutaneous branch of the pudendal nerve and ilioinguinal were the most common donor nerves. The lateral and medial antebrachial cutaneous and lateral femoral cutaneous were the most common recipient nerves. Pooled event rates suggest that some recovered glans sensibility occurs in more than 70% of cismale patients and in more than 90% of transmale patients. Recovered "erogenous" sensation occurs in more than 75% of cismale patients and more than 95% of transmale patients. In cismale patients, outcomes of recovered glans sensibility and erogenous sensation may be better for upper extremity recipient nerves than lower extremity recipient nerves. CONCLUSIONS: Based on the limited data in current literature on genital sensibility after phalloplasty, it is difficult to draw evidence-based conclusions. Yet data support improved outcomes with innervation. A validated outcome measure of "erogenous sensation" and a standardized approach to measuring cutaneous sensibility are required.

Nonsurgical Management of Facial Masculinization and Feminization.

BACKGROUND: Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures. OBJECTIVES: The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization. METHODS: A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review. CONCLUSIONS: Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

Ex vivo allotransplantation engineering: Delivery of mesenchymal stem cells prolongs rejection-free allograft survival.

Current pharmacologic regimens in transplantation prevent allograft rejection through systemic recipient immunosuppression but are associated with severe morbidity and mortality. The ultimate goal of transplantation is the prevention of allograft rejection while maintaining recipient immunocompetence. We hypothesized that allografts could be engineered ex vivo (after allotransplant procurement but before transplantation) by using mesenchymal stem cell-based therapy to generate localized immunomodulation without affecting systemic recipient immunocompetence. To this end, we evaluated the therapeutic efficacy of bone marrow-derived mesenchymal stem cells in vitro and activated them toward an immunomodulatory fate by priming in inflammatory or hypoxic microenvironments. Using an established rat hindlimb model for allotransplantation, we were able to significantly prolong rejection-free allograft survival with a single perioperative ex vivo infusion of bone marrow-derived mesenchymal stem cells through the allograft vasculature, in the absence of long-term pharmacologic immunosuppression. Critically, transplanted rats rejected a second, nonengineered skin graft from the same donor species to the contralateral limb at a later date, demonstrating that recipient systemic immunocompetence remained intact. This study represents a novel approach in transplant immunology and highlights the significant therapeutic opportunity of the ex vivo period in transplant engineering.

Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender Confirming Surgery.

PURPOSE: Phalloplasty is a critical step in female-to-male (transmale) gender confirming genital surgery. We examined outcomes between transmales who underwent phalloplasty with vaginectomy and full-length urethroplasty using the anterolateral thigh pedicled flap or the radial forearm free flap. MATERIALS AND METHODS: We performed a single center, retrospective study of patients who underwent phalloplasty with vaginectomy and full-length urethroplasty using an anterolateral thigh pedicled flap or a radial forearm free flap from April 2013 to July 2016. All patients had at least 6 months of followup. Urethral and nonurethral complications were recorded. Complication rates were assessed using the OR of the anterolateral thigh pedicled flap and the radial forearm free flap groups. RESULTS: Of the 213 patients 149 and 64 underwent radial forearm free flap and anterolateral thigh pedicled flap phalloplasty, respectively. Patients with a radial forearm free flap had a significantly higher body mass index than those with an anterolateral thigh pedicled flap. The overall urethral complication rate for radial forearm free flap and anterolateral thigh pedicled flap phalloplasty was 31.5% and 32.8%, and the rate of partial or total neophallus loss was 3.4% and 7.8%, respectively. Patients in the pedicled flap cohort experienced significantly greater odds of urethral fistula (OR 2.50, p = 0.024), nonurethral complications (OR 2.38, p = 0.027) and phallus wound dehiscence (OR 5.03, p = 0.026). CONCLUSIONS: Anterolateral thigh pedicled flap phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup. Our findings can help guide surgical decision making when selecting a flap for phalloplasty.

Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes.

BACKGROUND: Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. METHODS: A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. RESULTS: Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). CONCLUSIONS: This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

The Effect of Nasoalveolar Molding on Nasal Airway Anatomy: A 9-Year Follow-up of Patients With Unilateral Cleft Lip and Palate.

OBJECTIVE: To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture. DESIGN: Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM. SETTING: Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy. MAIN OUTCOME MEASURES: Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area. RESULTS: There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients. CONCLUSIONS: NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.

Outpatient Alveolar Bone Grafting.

PURPOSE: Alveolar bone graft (ABG) has traditionally been performed with a postoperative inpatient stay secondary to donor site pain. Upon transitioning from an open iliac bone harvesting technique to an Acumed trephine, the authors observed that donor site pain was reduced eliminating an inpatient stay. This study examines the cost savings associated with outpatient ABG surgery. METHODS: A retrospective single-institution review was conducted on all patients who had an ABG performed from 2012 to 2015. Patients were categorized based upon hospital stay: inpatient, observation (23-hour), or outpatient. Cost data reported included: total direct cost, total variable direct cost, fixed direct cost, and the sum of total direct costs for both medical/surgical supplies and operating room costs. T tests were used to determine differences in various cost categories between groups of patients. RESULTS: Sixty-two procedures were performed: 7 procedures were inpatient, 16 observation, and 39 outpatient. The total direct costs averaged $4536 for inpatients, $3222 for the observation group, and $3340 for the outpatient group. Inpatient and outpatient costs were significantly different (P <0.01). Total variable direct costs (P <0.05) and fixed direct costs (P <0.01) were significantly lower in the outpatient/observation group. All costs for the observation group were significantly lower than inpatient costs, but were not significantly different than outpatient costs. There were no readmissions reported. CONCLUSIONS: Cost of an inpatient stay is significantly higher than outpatient or 23-hour observation for ABG procedures. The Acumed trephine technique allows for same-day discharge. In the face of declining reimbursement, safe and cost-efficient treatments are an appealing option.

Quantification of high-specificity cyclic diguanylate signaling.

Cyclic di-GMP (c-di-GMP) is a second messenger molecule that regulates the transition between sessile and motile lifestyles in bacteria. Bacteria often encode multiple diguanylate cyclase (DGC) and phosphodiesterase (PDE) enzymes that produce and degrade c-di-GMP, respectively. Because of multiple inputs into the c-di-GMP-signaling network, it is unclear whether this system functions via high or low specificity. High-specificity signaling is characterized by individual DGCs or PDEs that are specifically associated with downstream c-di-GMP-mediated responses. In contrast, low-specificity signaling is characterized by DGCs or PDEs that modulate a general signal pool, which, in turn, controls a global c-di-GMP-mediated response. To determine whether c-di-GMP functions via high or low specificity in Vibrio cholerae, we correlated the in vivo c-di-GMP concentration generated by seven DGCs, each expressed at eight different levels, to the c-di-GMP-mediated induction of biofilm formation and transcription. There was no correlation between total intracellular c-di-GMP levels and biofilm formation or gene expression when considering all states. However, individual DGCs showed a significant correlation between c-di-GMP production and c-di-GMP-mediated responses. Moreover, the rate of phenotypic change versus c-di-GMP concentration was significantly different between DGCs, suggesting that bacteria can optimize phenotypic output to c-di-GMP levels via expression or activation of specific DGCs. Our results conclusively demonstrate that c-di-GMP does not function via a simple, low-specificity signaling pathway in V. cholerae.

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene.

Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.

A Picture of Modern Medicine: Race and Visual Representation in Medical Literature.

BACKGROUND: There has been a recent focus on the impact of race on health equity, which has revealed unsettling results. Multiple studies have shown that the underrepresentation of minorities in medical education such as course slides, pre-clinical lecture material, case studies, and textbooks impedes racial equity in the practice of medicine. AIM OF STUDY: In this study, we aimed to survey the landscape of published imaging in modern medicine to understand the degree of racial diversity represented in current biomedical literature. METHODS: We performed a photogrammetric analysis of medical images from the New England Journal of Medicine representing various medical fields and geographic regions to examine implicit biases with regards to human skin color. RESULTS: Overall, 18% of images depicted non-white skin tone but there was considerable heterogeneity in the percentage of non-white medical images published from different geographic regions and specialties (ranging from 0% to 67%). CONCLUSIONS: Unfortunately, these results suggest that there is an underlying implicit racial bias in published images from medical literature with an underrepresentation of minorities compared to the general population, which could also contribute to inequities in health care. It is critical that health care providers, educators, and trainees promote cultural competency and work to understand the multifaceted influence of race and culture on the daily experience of patients in the modern healthcare system. We hope this study will encourage authors to critically evaluate their medical images for implicit bias so that documented photography in scientific literature may better reflect the populations we serve.

Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study.

BACKGROUND: No data exist on the prospective outcomes of facial feminization surgery. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes for gender-diverse patients. METHODS: A prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria was undertaken. Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and >6 months). Photogrammetric cephalometries were measured at the same time points. Self-perceived preoperative masculinity and femininity were recorded. Externally rated gender appearance (scale of 1 to 5, with 1 being most feminine) and general aesthetics (scale of 1 to 10, with 10 being very good) for 10 facial feminization surgery patients were compared with those of five cisgender controls. Univariate linear regression analyses were used to predict outcomes from facial feminization surgery. RESULTS: Sixty-six consecutive patients were enrolled. Patients noted that their brows, jaws, and chins were the most masculine aspects of their faces (54.5 percent, 33.3 percent, and 30.3 percent, respectively). Median facial feminization outcome score increased from 47.2 preoperatively to 80.6 at 6 months or more postoperatively (p < 0.0001). Mean satisfaction was excellent (3.0 at both 1-month and ≥6-month follow-up; p = 0.46). Cephalometric values were significantly more feminine after surgery. Gender appearance was feminine to very feminine (1.83 ± 0.96) and general aesthetics were good (6.09 ± 2.01) but different from those of cisgender women controls (1.25 ± 0.49 and 7.63 ± 1.82, respectively; p < 0.001 for each). CONCLUSION: Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.

INTRODUCTION: Gender-affirmation surgery is essential in the management of gender dysphoria. For male-to-female transgender women (transwomen), feminization of the chest is a component in this process. There is minimal literature describing effective and safe techniques for breast augmentation in transwomen. Here we describe our operative techniques and considerations. METHODS: A retrospective review of a single surgeon experience was performed for transwomen who underwent primary breast augmentation between October 1, 2014, and February 1, 2017. Surgical outcomes and complications were analyzed. RESULTS: Thirty-four patients with an average age of 34.4 years were included in this series (range 19-59 years). Surgical approach was through an inframammary incision with a submuscular pocket and either silicone smooth round (24%) or textured anatomic implants (76%). Six patients experienced postoperative complications (17.6%). Two patients underwent reoperation for implant extrusion (5.9%). Higher BMI and longer preoperative hormonal therapy duration were significantly associated with complications (p = 0.008; p = 0.039, respectively). Feedback from the respondents was overall positive. Most of patients (92.7%) reported being happier and feeling more satisfied with their chest than before their operation. All respondents (100%) reported improvement in their gender dysphoria and would undergo the operation again. Patient dissatisfaction was significantly associated with longer time on preoperative hormones (p = 0.008) and had a trend toward association with higher implant volume (p = 0.083). CONCLUSIONS: Breast augmentation in transwomen is safe and typically leads to high patient satisfaction with improvement of gender dysphoria. Larger, longer term studies are needed to appropriately delineate complication risks and contributing factors.