Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study.

BACKGROUND: It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS: This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS: Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION: Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.

The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis.

BACKGROUND: The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures. METHODS: Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05. RESULTS: When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic. CONCLUSION: Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.

Lessons learned from the first 15 years of penile transplantation and updates to the Baltimore Criteria.

Since 2006, five penis transplants have been performed worldwide. Mixed outcomes have been reported, and two of the five penile transplants have required explantation. However, the long-term outcomes have been encouraging when compliance is implemented, whether standard induction and triple therapy maintenance, or single therapy maintenance. Follow-up monitoring of transplant recipients has enabled a synthesis of technical considerations for surgical success and has shown stable leukocyte counts and renal function after a donor bone-marrow-based immunomodulatory regimen followed by tacrolimus monotherapy as long as 3 years post-transplant, as well as continuous nerve regeneration of penile allografts 3 years post-transplant. Areas of uncertainty include the ethics of donor-recipient colour mismatch, surveillance for sexually transmitted infections and how to optimize patient compliance. Questions also remain with respect to the long-term immunological sequelae of penile tissue, functional outcomes, psychosocial implications and patient selection. Patient counselling should be modified to mention the possibility of long-term improvement in nerve regeneration and sufficient renal function with single-therapy maintenance, and to build a longitudinal dialogue and partnership between the patient and the multidisciplinary care team regarding the risks of sexually transmitted infection instead of surveillance.

Policies and Price Tags: The Public's Perception of Face Transplantation and Its Funding.

Study Design: Survey study. Objective: Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson's opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries. Methods: Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn's test. Results: The majority of respondents were supportive of FVCA in 10 out of 11 statements (P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma (P > 0.01). Conclusions: This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents' acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure's accessibility to a wider range of individuals.

Penile Transplantation: Lessons Learned and Technical Considerations.

PURPOSE: Penile vascularized composite allotransplantation is a powerful tool for penile reconstruction. Traditional methods of reconstruction utilizing free tissue and prostheses have well-known complications, can require reoperation and cannot truly emulate the natural form or function of the penis. While vascularized composite allotransplantation may alleviate these difficulties, penile transplantation carries its own ethical, surgical and medical complications. To date, the procedure has only been attempted 5 times. Broader use of this procedure requires unique surgical considerations. We present the first comprehensive, detailed review of this procedure in order to present lessons learned from both our own and the global experience. MATERIALS AND METHODS: A review of published reports of penile transplant methods and outcomes was conducted to compile lessons learned from these cases. RESULTS: Five penile transplant cases have been reported in literature, 4 with published methodology and outcomes data. All 4 detailed unique surgical approaches and postoperative immunosuppressive regimens. Three of these cases resulted in successful sensory and functional outcomes. CONCLUSIONS: Though all 4 analyzed cases employed unique anastomotic and immunosuppressive approaches, 3 resulted in successful recovery of penile urinary and sexual function. Still, specific approaches used by different teams circumvented otherwise common complications, and these differences should guide future research and penile transplant cases.

Infections after mastectomy and tissue expander placement: A multivariate regression analysis.

BACKGROUND: While breast surgery is considered a clean case, tissue expander-based breast reconstruction (TE-BR) has infection rates quoted up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections. Through multivariate regression, we sought to analyze risk factors that contribute to infections following TE placement. METHODS: A retrospective study reviewed all patients undergoing mastectomy with immediate or delayed TE placement over a 22-month period. Infections were defined as clinically documented cellulitis or infection, return to the operating room (RTOR) for suspected infection, or positive operative or seroma cultures. RESULTS: A total of 311 patients underwent mastectomy and TE placement to 490 breasts. 13.5% of breasts developed an infection prior to second stage reconstruction. Multivariate logistic regression indicated that patients who developed infections were older (52.8 vs. 47.6 years, OR 1.04, p = 0.02), had higher rates of full-thickness necrosis (24.6% vs. 3.6%, OR 6.64, p<0.01), had higher rates of seromas requiring drainage (33.3% vs. 11.5%, OR 2.79, p<0.01), and had longer periods of drain therapy (24.9 vs. 21.0 days, OR 1.04, p = 0.04). Logistic regression established that longer discharge antibiotic length was not protective against the development of infection. CONCLUSION: Patients were more likely to develop an infection as the length of surgical drain retention increased, patient age increased, or if they developed seromas and full-thickness necrosis. Longer post-operative antibiotics were not protective against the development of infection in this sample. Prospective studies are needed to assess how antibiotic lengths can affect the morbidity of patients undergoing TE-BR.

An immunologically active, adipose-derived extracellular matrix biomaterial for soft tissue reconstruction: concept to clinical trial.

Soft tissue reconstruction remains an intractable clinical challenge as current surgical options and synthetic implants may produce inadequate outcomes. Soft tissue deficits may be surgically reconstructed using autologous adipose tissue, but these procedures can lead to donor site morbidity, require multiple procedures, and have highly variable outcomes. To address this clinical need, we developed an "off-the-shelf" adipose extracellular matrix (ECM) biomaterial from allograft human tissue (Acellular Adipose Tissue, AAT). We applied physical and chemical processing methods to remove lipids and create an injectable matrix that mimicked the properties of lipoaspirate. Biological activity was assessed using cell migration and adipogenesis assays. Characterization of regenerative immune properties in a murine muscle injury model revealed that allograft and xenograft AAT induced pro-regenerative CD4+ T cells and macrophages with xenograft AAT additionally attracting eosinophils secreting interleukin 4 (Il4). In immunocompromised mice, AAT injections retained similar volumes as human fat grafts but lacked cysts and calcifications seen in the fat grafts. The combination of AAT with human adipose-derived stem cells (ASCs) resulted in lower implant volumes. However, tissue remodeling and adipogenesis increased significantly in combination with ASCs. Larger injected volumes of porcine-derived AAT demonstrated biocompatibility and greater retention when applied allogeneicly in Yorkshire cross pigs. AAT was implanted in healthy volunteers in abdominal tissue that was later removed by elective procedures. AAT implants were well tolerated in all human subjects. Implants removed between 1 and 18 weeks demonstrated increasing cellular infiltration and immune populations, suggesting continued tissue remodeling and the potential for long-term tissue replacement.

Special Considerations for Secondary Surgery After Upper Extremity Transplantation.

BACKGROUND: Upper extremity (UE) transplantation is a complex undertaking that may require emergent or elective secondary surgery (SS) days to years following transplant. Various patient and transplantation may help determine what SS is needed. In this study, we characterize the SS needed by our UE transplant patients. METHODS: We retrospectively reviewed 6 patients who underwent hand and UE transplantation by one of the authors. Transplantation and SS details were obtained from medical records. Hand and arm function was quantified both subjectively (patient-reports) and objectively (Disabilities of the Arm, Shoulder, and Hand Score; Carroll test; Action Research Arm Tests; Box and Block test). RESULTS: Six patients underwent transplantation for a total of 10 transplanted limbs. Five transplants were performed below and 5 above the elbow. Mean time post-transplantation at last follow-up was 5 years (range: 1-9 years). In all, 66.7% of the patients required SS: total 7 surgeries comprising 13 procedures. The most common procedures were to improve hand function-nerve decompressions and tendon transfer, both in above-elbow transplant. Both patients showed a mean improvement of 15 points on Carroll scores. One above-elbow transplant had a brachioplasty for excess skin and another had a hematoma evacuation immediately after transplantation. Procedures in the below-elbow transplants included multiple incision and drainages for a septic wrist and an open reduction and internal fixation for a forearm fracture. CONCLUSION: Patients receiving UE transplantation often require one or more secondary procedures which may vary with level of transplantation. Secondary surgery should be an important aspect of pretransplant planning and cost-effectiveness determinations. LEVEL OF EVIDENCE: Level IV.

Personality, Success, and Beyond: The Layperson's Perception of Patients With Facial Transplantation.

BACKGROUND: While the goal of facial vascularized composite allotransplantation (FVCA) is to provide patients with improved physical and social function, no study has evaluated layperson perception of social acceptance and perceived career success of patients with FVCA. The purpose of this study was to determine how FVCA changes social acceptance and perceived career success of patients with facial disfiguration. METHODS: Eight hundred fifteen laypersons were surveyed through Mechanical Turk to evaluate their perceptions of patients with FVCA. Respondents were shown facial photographs of patients pre-FVCA, post-FVCA, and matched controls and evaluated these photos on 26 items of perceived social acceptance and career success. Responses were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS: Both male and female post-FVCA photos were perceived as significantly more socially accepted and professionally successful than their pre-FVCA photos in at least 21 out of 26 items (P < 0.001 for all), but the posttransplant patients scored lower than their control in at least 25 out of 26 items (P < 0.001 for all). Additionally, there were discrepancies in findings based on patient gender. CONCLUSIONS: This study suggests that while FVCA has a significantly positive impact on social acceptance and perceived professional success, it does not fully reinstate these qualities. Furthermore, varying surgical outcomes and/or cognitive biases (such as gender) may impact perceptions of the individual by the public. Our findings suggest a need to standardize practices to better predict and improve outcomes and encourage surgeons to consider patient factors such as gender when planning these procedures.

Vascularized composite allotransplantation of the penis: current status and future perspectives.

Given the multifunctional role of the penis in daily life, penile loss can be a physically and emotionally devastating injury. Options to restore penile loss have traditionally relied on autogenous free flap, local flaps, and skin grafts. These techniques provide satisfactory outcomes but carry high rates of urologic and prosthesis-related complications. Vascularized composite allotransplantation may offer a novel solution for these patients through reconstruction with true penile tissue. Still, penile transplants pose ethical, logistical, and psychosocial challenges. These obstacles are made more complex by the limited cases detailed in published literature. A review of the literature was conducted to assay current practices for penile reconstruction. Most modern complex penile reconstructions utilize autogenous pedicled or free tissue flaps, which may be harvested from a variety of donor sites. A total of five penile transplants have been described in the literature. Of these, four report satisfactory outcomes. The advent of genital allotransplantation has recently broadened the landscape of treatment for penile loss. Reconstruction using true penile tissue through vascularized penile allotransplantation has the possibility to engender increased penile function, sensation, and overall quality of life.

Correction: The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis.

[This corrects the article DOI: 10.7759/cureus.18675.].

The Effects of Depression and Anti-Depressants on Quality of Life After Breast Reconstruction: A Post-Hoc Analysis.

Background A personal history of depression prior to breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores. Methodology We conducted a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to November 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, six weeks following tissue expander (TE) insertion for patients undergoing staged reconstruction, and six and 12 months following the final reconstruction. Medical records were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between groups and within groups. Groups compared were the depression (n = 50) and no depression (n = 250) patients, along with anti-depressant (n = 36) and no anti-depressant (n = 14) use in the depression group. Results Within-group Sexual Well-being scores at the six-week post-TE follow-up for patients in the depression group (median = 37, interquartile range [IQR] = 25-47) were significantly lower (p < 0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60). There were no statistically significant differences in BREAST-Q scores in other domains. When compared to patients diagnosed with depression who were not taking anti-depressants, anti-depressant medication use did not result in statistically significant higher BREAST-Q scores, although Satisfaction With Breasts six months post-operatively, Psychosocial Well-being at six weeks post-TE, Sexual Well-being at six weeks post-TE and six months post-operatively were clinically higher in patients taking anti-depressants for depression. Conclusions Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the six-week TE group with or without anti-depressant medication. Patients with a pre-cancer diagnosis of depression considering TEs may benefit from additional counseling prior to breast reconstruction or electing a different method of breast reconstruction. Anti-depressant medications may provide clinically higher BREAST-Q scores in patients with a pre-cancer diagnosis of depression. Adding an anti-depressant medication to a patient's treatment plan may provide additional benefits. Larger samples are required to properly determine the impact of anti-depressant medications on BREAST-Q scores in patients with a pre-cancer diagnosis of depression.

An Analysis of Gender Bias in Plastic Surgery Resident Assessment.

BACKGROUND: Previous studies have shown men and women attending physicians rate or provide operating room (OR) autonomy differently to men and women residents, with men attendings providing higher ratings and more OR autonomy to men residents. Particularly with the advent of competency-based training in plastic surgery, differential advancement of trainees influenced by gender bias could have detrimental effects on resident advancement and time to graduation. OBJECTIVE: We determined if plastic surgery residents are assessed differently according to gender. METHODS: Three institutions' Operative Entrustability Assessment (OEA) data were abstracted from inception through November 2018 from MileMarker, a web-based program that stores trainee operative skill assessments of CPT-coded procedures. Ratings are based on a 5-point scale. Linear regression with postgraduate year adjustment was applied to all completed OEAs to compare men and women attendings' assessments of men and women residents. RESULTS: We included 8377 OEAs completed on 64 unique residents (25% women) by 51 unique attendings (29% women): men attendings completed 83% (n = 6972; 5859 assessments of men residents; 1113 of women residents) and women attendings completed 17% (n = 1405; 1025 assessments of men residents; 380 of women residents). Adjusted analysis showed men attendings rated women residents lower than men residents (P < .001); scores by women attendings demonstrated no significant difference (P = .067). CONCLUSIONS: Our dataset including 4.5 years of data from 3 training programs showed men attendings scored women plastic surgery residents lower than their men counterparts.

Decision aid for women with newly diagnosed breast cancer seeking breast reconstruction surgery: A prospective, randomized, controlled, single-blinded, pilot study.

BACKGROUND: Women undergoing immediate breast reconstruction for breast cancer often experience anxiety when faced with reconstruction and the type of reconstruction to choose. The purpose of this study is to analyze the impact of a decision aid on decisional conflict in women with newly diagnosed breast cancer seeking breast reconstruction. METHODS: Newly diagnosed breast cancer patients seeking breast reconstruction at a single center were prospectively randomized into two groups. Comparisons were made between two groups using the decisional conflict scale (DCS): women who reviewed the standard educational materials prior to initial consultation (control) and women who reviewed standard materials prior to initial consultation and then reviewed a decision aid brochure at initial consultation and two-week post-consultation (intervention). Pre-to-post-consultation DCS scores were compared within and between the control groups and intervention groups to assess which group had lower DCS scores. RESULTS: A total of 20 patients, mean age 53±9 years were included. Median differences between pre-to-post-consultation DCS total scores in the control and intervention groups lowered from 32 to 22 and 28 to 16, respectively. Significant differences in subscores were control group: uncertainty: 54-21 (p = 0.030), and intervention group: uncertainty: 46-29 (p = 0.036) and values clarity: 29-25(p = 0.042). Pre-to-post-consultation differences between DCS scores and subscores did not demonstrate any statistical significance. CONCLUSION: Decision aids did not significantly reduce pre-operative DCS total scores compared to current educational materials. More educational materials may not always be helpful for patients.

Differences in operative self-assessment between male and female plastic surgery residents: A survey of 8,149 cases.

BACKGROUND: Previous studies show female residents tend to underrate and male residents to overrate their own performance. We sought to determine if plastic surgery resident trainee self-evaluations differ by resident sex. METHODS: We extracted Operative Entrustability Assessment (OEA) data for plastic surgery programs from MileMarker™, a program capable of storing assessment data for CPT-coded procedures. Complete OEAs contain a trainee self-assessment and attending surgeon assessment. We used simple statistics and linear regression to assess differences, stratifying by trainee sex and post-graduate year (PGY). RESULTS: We analyzed 8149 OEAs from 3 training programs representing 64 residents (25% female) and 51 attendings. Compared to attending assessments, both male and female residents significantly underrated their performance during PGY1. However, during PGY2-6 male residents' self-evaluations were significantly higher and female residents' self-evaluations significantly lower than their attending evaluations. CONCLUSIONS: Results demonstrated female plastic surgery residents underestimated and male residents overestimated their performance. Further studies are needed to determine reasons for these differences.

Latissimus Dorsi Myocutaneous Flap Procedure in a Swine Model.

BACKGROUND: As surgical research expands in both breadth and scope, translational models become increasingly important. The accessibility, reproducibility, and clinical applicability of translational models is of vital importance to ensure adequate and accurate research. Though different flap models have been described, the literature lacks an in-depth, technical description of an easy large-animal preclinical model. We here describe the procedure for elevation of a latissimus dorsi flap in a swine. This flap contains muscle and skin that can be isolated on a vascular pedicle, transferred as a free flap, perfused, or innervated/denervated as dictated by the needs of the experiment. METHODS: Five different latissimus dorsi flaps were elevated in miniature swine. Careful attention was paid to anatomical landmarks and optimal placement of incision, dissection, and retraction. Temporary ischemia with vascular clamping was performed along with serial digital and infrared imaging both intra- and postoperatively. In three of the flaps with induced ischemia, the animal was observed for a 30-day follow up with daily photodocumentation and intermittent biopsy. RESULTS: A reproducible latissimus flap model was designed with optimized conditions. In the animals in which flaps were followed postoperatively, complete healing was seen within 30 days without evidence of procedure-related ischemia or loss of motor function. CONCLUSION: We have identified and described a pre-clinical large animal flap model that can be easily reproduced for translational studies of multiple scientific areas including flap-based repair, ischemia, ischemia reperfusion, and operative technique. This provides an important model for ready replication in preclinical studies of many varieties.

Postoperative Complications of Panniculectomy and Abdominoplasty: A Retrospective Review.

BACKGROUND: Recent studies of panniculectomy outcomes have reported variable complication rates ranging from 8.65% to 56%. Meanwhile, reported abdominoplasty complication rates are considerably lower (~4%). This discrepancy may be attributable to inaccurate inclusion of abdominoplasty patients in panniculectomy cohorts. We performed the current study to better characterize panniculectomy complication rates at a large tertiary care center. METHODS: We performed a retrospective review of patients who underwent abdominoplasty or panniculectomy at the Johns Hopkins Hospitals between 2010 and 2017. Patients were identified by Common Procedural Terminology codes (15847/17999, 15830) confirmed via the operative note. We examined postoperative complication rates including surgical site infection, seroma formation, wound dehiscence, readmission/reoperation, and postoperative length of stay (LOS). We used parametric and nonparametric methods to determine differences between abdominoplasty and panniculectomy outcomes, as well as logistic regression analysis to evaluate factors associated with patient outcomes following panniculectomy. RESULTS: Of the 306 patients included, 103 underwent abdominoplasty while 203 underwent panniculectomy. Initial complication rates following abdominoplasty and panniculectomy were 1.94% and 12.8%, respectively (P = 0.002). Thirty-day complication rates were 9.7% for abdominoplasty and 21.2% for panniculectomy (P = 0.012). The median LOS was 1 day (interquartile range, 0-1 day) for abdominoplasty and 2 days (interquartile range, 1-4 days) for panniculectomy (P = 0.002). No statistically significant differences in complication rates at 6 months and 1 year were observed. CONCLUSIONS: Panniculectomy offers many functional benefits including improved hygiene and enhanced mobility. However, this study demonstrates that panniculectomy patients may have significantly higher complication rates initially and 30 days postoperatively and longer LOS than individuals undergoing abdominoplasty.

Integrated Plastic Surgery Match: Trends in Research Productivity of Successful Candidates.

BACKGROUND: Plastic surgery continues to be one of the most competitive specialties in the residency match. Research productivity is a key component of the selection process. Nevertheless, potential applicants have a poor understanding of the strength of their research credentials in comparison to other applicants. METHODS: The authors identified successful applicants from the 2012 to 2017 integrated plastic surgery residency application cycles. The authors performed a bibliometric analysis of these residents using Scopus, PubMed, and Google Scholar to identify published articles at the time of application. The authors then calculated the h-index of each applicant at the time of application. RESULTS: The authors included 829 integrated residents. The median h-index was 0 (interquartile range, 0 to 3) and the median number of publications was 2 (interquartile range, 0 to 5) for all applicants. The proportion of applicants with at least one publication at the point of application increased significantly over time (60 percent in 2012 versus 76 percent in 2017; p = 0.0072). In addition, the number of publications per applicant increased over time (one in 2012 versus two in 2017; p = 0.0005), as did h-index (0 in 2012 versus 1 in 2017; p = 0.0015). Strikingly, the number and percentage of review articles among applicants increased significantly over this time frame (9 percent versus 14 percent; p = 0.0299). CONCLUSIONS: The increasing level of academic productivity among applicants may reflect the increasing competitiveness of the integrated plastic surgery residency application process. As the pressure to compete for a training position increases, students may seek faster-to-publish articles to gain an edge.