Perioperative Estrogen Hormonal Therapy Does Not Increase Venous Thromboembolism Risk In Facial Feminization Surgery.

BACKGROUND: Conflicting data exist regarding increased perioperative VTE risk while on feminizing hormone therapy. The effect has been poorly studied within the transgender population. Acute perioperative cessation of feminizing hormone therapy often leads to unpleasant side effects and exacerbates gender dysphoria in the perioperative period. We seek to identify the VTE incidence in patients undergoing facial feminization while continuing HRT throughout the time of surgery. METHODS: A 38-year retrospective cohort study within a two-surgeon practice (D.K.O. and J.C.D.) was designed to evaluate postoperative VTE in patients continuing hormone therapy. The primary outcome variable was identified as suffering a VTE postoperatively. RESULTS: 1,715 patients underwent facial feminization surgery within our search window. 953 patients met final inclusion criteria. 1 patient (0.10%) was diagnosed with a VTE postoperatively, comparable to reported literature rates for similar cosmetic and orthognathic procedures. The average Caprini score of all patients was 3.1±1.0 and the average case length was 491.9±111.0 minutes. Subgroup analysis of patients before and after internal practice changes identified 714 (77.7%) patients continuing full dose hormonal therapy perioperatively, 197 (20.7%) patients undergoing hormonal dose reduction to 25-50% perioperatively, and 8 patients who were either not taking hormonal therapy or stopped in the perioperative period. There was no significant difference in VTE incidence between the 3 subgroups (p > 0.99). CONCLUSIONS: Perioperative use of feminizing hormonal therapy does not increase risk for perioperative VTE in patients undergoing facial feminization surgery. Therefore, it is reasonable to continue these medications through the time of surgery.

Approach to Complex Upper Extremity Reconstruction.

The management of complex upper extremity trauma can be overwhelming in its urgency and complexity. Having a systematic approach that maintains a clear set of priorities focused on hand and upper extremity function, operative efficiency, and long-term planning for future operations allows the reconstructive extremity surgeon to effectively treat these complex injuries. This article addressed these overall clinical considerations and details the approach taken at the Buncke Clinic including replantation and revascularization as well as osseous and soft tissue reconstruction.

Microsurgical Breast Reconstruction: Maximizing Success.

Breast reconstruction is becoming increasingly recognized as a fundamental component in comprehensive breast cancer treatment. The primary goal for any reconstruction is to safely restore a natural appearing breast. When it comes to achieving the elements of size, shape, symmetry, and softness, the use of autologous tissue has many advantages. The approach to autologous breast reconstruction has changed substantially over the years as microsurgical free tissue transplants become more routine and accessible. While a variety of flap donor sites exist, careful flap selection based on surgical history and the availability of donor tissue is critical in achieving reliable results. This article reviews the clinical considerations in patient evaluation, donor site selection, and surgical approach taken at the Buncke Clinic.

Gene expression in the epileptic (EL) mouse hippocampus.

The neuropathology of hippocampal seizure foci in human temporal lobe epilepsy (TLE) and several animal models of epilepsy reveal extensive neuronal loss along with astrocyte and microglial activation. Studies of these models have advanced hypotheses that propose both pathological changes are essential for seizure generation. However, some seizure foci in human TLE show an extreme loss of neurons in all hippocampal fields, giving weight to hypotheses that favor neuroglia as major players. The epileptic (EL) mouse is a seizure model in which there is no observable neuron loss but associated proliferation of microglia and astrocytes and provides a good model to study the role of activated neuroglia in the presence of an apparently normal population of neurons. While many studies have been carried out on the EL mouse, there is a paucity of studies on the molecular changes in the EL mouse hippocampus, which may provide insight on the role of neuroglia in epileptogenesis. In this paper we have applied high throughput gene expression analysis to identify the molecular changes in the hippocampus that may explain the pathological processes. We have observed several classes of genes whose expression levels are changed. It is hypothesized that the upregulation of heat shock proteins (HSP70, HSP72, FOSL2 (HSP40), and their molecular chaperones BAG3 and DNAJB5 along with the down regulated gene MALAT1 may contribute to the neuroprotection observed. The increased expression of BDNF along with immediate early gene expression (FosB, JunB, ERG4, NR4A1, NR4A2, FBXO3) and the down regulation of GABRD, DBP and MALAT1 it is hypothesized may contribute to the hyperexcitability of the hippocampal neurons in this model. Activated astrocytes and microglia may also contribute to excitability pathomechanisms. Activated astrocytes in the ELS mouse are deficient in glutamine synthetase and thus reduce the clearance of extracellular glutamate. Activated microglia which may be associated with C1Q and MHC class I molecules we propose may mediate a process of selective removal of defective GABAergic synapses through a process akin to trogocytosis that may reduce neuronal inhibition and favor hyperexcitability.

Abdominal Flap-based Breast Reconstruction versus Abdominoplasty: The Impact of Surgical Procedure on Scar Location.

BACKGROUND: Autologous breast reconstruction has been demonstrated to be associated with superior patient-reported outcomes, and hence is regarded as the gold standard reconstructive modality. A common drawback of this procedure, however, is related to a high abdominal scar. Recently, hybrid breast reconstruction (ie, the combination of autologous and implant-based reconstruction) was presented as an approach that would combine the benefits of both reconstructive modalities. In this study, we sought to assess abdominal aesthetic outcomes associated with this approach. METHODS: Thirty-two blinded reviewers evaluated standardized pre- and postoperative abdominal images of patients following autologous reconstruction with free abdominal flap (Group 1; N = 10), hybrid reconstruction (Group 2; N = 5), and abdominoplasty (Group 3; N = 10). Aesthetic abdominal appearance, including overall result, scar position, skin redundancy, and lateral abdominal contour, was rated on a 5-point Likert scale and a comparative analysis was performed. RESULTS: Hybrid reconstruction was associated with significantly lower abdominal scars compared with Group 1 (P = 0.01), nearing results of patients in Group 3 (P = 0.39). Significantly higher aesthetic ratings were ascribed to Groups 2 and 3 when compared with Group 1 (P < 0.001) with regard to scar positioning (P < 0.001), skin redundancy (P < 0.001), and lateral abdominal contour (P < 0.001). No significant difference in aesthetic ratings was noted between Groups 2 and 3. CONCLUSIONS: When applied to the appropriate patient population, hybrid breast reconstruction is a powerful method to achieve reconstructive goals while optimizing abdominal aesthetics. A significantly lower scar position was noted and higher abdominal aesthetic ratings were given following abdominoplasty and hybrid reconstruction compared with conventional abdominal flap-based reconstruction.

Comparison of Patient Symptomatology before and after Labiaplasty.

BACKGROUND: Labiaplasty has grown in popularity, but it remains controversial. Few studies have quantified the change in specific symptomatology from before to after labiaplasty to establish its effectiveness in improving quality of life. METHODS: In a prospective study, 62 patients undergoing labiaplasty completed written surveys privately in an examination room preoperatively and postoperatively about the presence of 11 physical and appearance-related symptoms. RESULTS: Mean patient age was 33.5 years (range, 17 to 61 years). Two patients were of minority age. All patients presented with at least one symptom, averaging 6.5 (range, one to 11). Most (82.2 percent) had a trim labiaplasty, and the rest (17.7 percent) had a wedge. After labiaplasty, 93.5 percent of patients were symptom-free, with the average dropping to 0.23 of 11 symptoms. Symptom-prevalence changes from preoperatively to postoperatively included self-consciousness, dropping from 93 percent to 6.5 percent; tugging (from 66.1 percent to 0 percent); feeling less attractive (from 66.1 percent to 0 percent); negative impact on self-esteem (from 64.5 percent to 1.6 percent); negative impact on intimacy (from 62.5 percent to 0 percent); twisting (from 58.1 percent to 3.2 percent); being uncomfortable (from 56.5 percent to 4.8 percent); clothing restriction (from 54.8 percent to 3.2 percent); visible outline (from 46.8 percent to 1.6 percent); pain (from 43.5 percent to 1.6 percent); and exposure in swimsuits (from 38.7 percent to 1.6 percent). No major complications occurred. Two patients felt their labia were still too long and revision was offered. Average follow-up was 13.3 months (range, 6 to 24 months). CONCLUSIONS: Patients with elongated labia have a high incidence of functional and appearance-related symptoms. Labiaplasty is a safe procedure that yields significant improvement in quality of life. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, IV.

Current Trends in the Use of Social Media by Plastic Surgeons.

BACKGROUND: As social media continue to be widely used, understanding the current trend in social media use by plastic surgeons will help determine how the specialty can better harness its power and respect its risks. In this study, the authors performed a survey study of trainees, candidates, and members of the American Society of Plastic Surgeons to determine current use and consensus on social media in plastic surgery. METHODS: An electronic survey was sent to plastic surgery trainees, candidates, and members of the American Society of Plastic Surgeons using SurveyMonkey. Demographic data, social media use patterns, and views on social media use were collected. RESULTS: When compared with salaried surgeons, private practitioners used social media for the promotion of their practice, such as patient acquisition (74.3 percent versus 28.3 percent) and branding (61 percent versus 21.7 percent). The majority of nonusers felt social media was too time consuming and susceptible to breach of patient privacy. The majority of social media users agreed that acceptable use included before-and-after photographs, video testimonials, and patient reviews. Both social media users and nonusers alike agreed that plastic surgery residents should receive training on social media. CONCLUSIONS: This study showed that a majority of plastic surgeons use social media to brand their practice, attract patients, and educate the public. Without engaging in this valuable tool, plastic surgeons' voices will be lost in the conversation. To use social media to their greatest potential, this specialty needs to begin formal training in the proper and ethical use of social media.

The Role of Pornography, Physical Symptoms, and Appearance in Labiaplasty Interest.

BACKGROUND: With the American College of Obstetricians and Gynecologists reaffirming its 2007 opposition to labiaplasty in 2019, the procedure continues to be controversial. Particular emphasis on pornography as a major influencer on women seeking labiaplasty contributes to its controversy and distracts from other motivations. Few articles have established pornography's influence relative to functional and appearance-related symptoms. OBJECTIVES: The objective of this study was to investigate the relative influence of pornography on women's decision to seek labiaplasty relative to other factors compared with a control cohort. METHODS: In this prospective study, 124 consecutive patients consulting about labiaplasty and a control cohort of 50 women were questioned about 11 labia-related symptoms and the possible influence of pornography. RESULTS: The mean age was 34.2 and 38.9 years in the labiaplasty and control cohorts, respectively. Women in the labiaplasty cohort had on average 2.8 of the 6 queried physical symptoms and 3.2 of the 5 queried appearance-related symptoms compared with control patients who reported an average of 0.3 of the 6 queried physical symptoms and 0.2 of the 5 queried appearance-related symptoms (P < 0.001). Less than one-half (47% of the labiaplasty and 42% of the control cohort) never viewed pornography. Pornography was not an influential factor to seek labiaplasty in 42% of the labiaplasty cohort and 54% of the control cohort. A minority (11% in the labiaplasty cohort and 4% in the control cohort) said that pornography influenced them to seek labiaplasty. There were no statistically significant differences between these 2 groups. CONCLUSION: Pornography influences some women to seek labiaplasty, but relative to other motivating factors its role is minor.

Breast Reconstruction with Free Abdominal Flaps Is Associated with Persistent Lower Extremity Venous Stasis.

BACKGROUND: Previous work has demonstrated the occurrence of lower extremity venous stasis in the early postoperative period after breast reconstruction with free abdominal flaps. The authors investigated whether venous stasis persisted through the day of discharge, thus potentially exposing patients to an elevated risk of venous thromboembolism following discharge. METHODS: Patients who underwent breast reconstruction with free abdominal flaps were enrolled prospectively and underwent duplex ultrasound of the common femoral vein at the following time points: preoperatively, postoperative day 1, and day of discharge. Parameters of interest included common femoral vein diameter, area, and maximum flow velocity. RESULTS: Thirty patients with a mean age of 50.3 years (range, 29 to 70 years) underwent breast reconstruction with 52 free abdominal flaps. A significant increase in common femoral vein diameter (19.1 percent; p < 0.01) and area (46.8 percent; p < 0.01) correlated with a significant reduction in maximum flow velocity (-10.9 percent; p = 0.03) between baseline and postoperative day 1. These changes persisted through the day of discharge [common femoral vein diameter, 17.8 percent (p < 0.01); area, 46 percent (p < 0.01); and maximum flow velocity, -11.3 percent (p = 0.01)]. Venous parameters were not influenced by unilateral versus bilateral flap harvest (p = 0.48). CONCLUSIONS: Postoperative lower extremity venous stasis following autologous breast reconstruction with free abdominal flaps seems to persist through the day of discharge. This finding may explain why patients remain at risk for venous thromboembolism after discharge. Although the authors' findings are at odds with current venous thromboembolism prophylaxis recommendations, additional studies are indicated to examine whether these findings translate into venous thromboembolism events. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

An Analysis of Differences in the Number of Children for Female and Male Plastic Surgeons.

BACKGROUND: Historically, the structure of surgical programs discourages women interested in both surgery and motherhood from pursuing a surgical career, and women plastic surgeons have been more likely than men to have no children or to have fewer, later in life. Female plastic surgery trainees now constitute over one-third of residents, and pregnancy rates can be expected to rise, but with women now a majority in medical schools, the specialty's maternity policies may be deterring interested women from entering the specialty. A survey study was conducted to measure reproductive outcomes and to identify current disparities between women and men plastic surgeons. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates, allowing comparisons of men's and women's responses. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Compared with male respondents, women were more likely than men to have no biological children (45.1 percent versus 23.1 percent). They were nearly twice as likely to delay having children because of the demands of training (72.6 percent versus 39.2 percent) and to experience infertility (26.3 percent versus 12.5 percent). Among the childless plastic surgeons, women were 11 times more likely to say they did not want children compared with men (20.1 percent versus 1.8 percent). CONCLUSIONS: Poor institutional maternity support results in a persistent, wide gap in reproductive outcomes between female and male plastic surgeons. Establishing a universal, comprehensive parental support policy is essential to closing that gap.

The Impact of Device Innovation on Clinical Outcomes in Expander-based Breast Reconstruction.

Staged expander-based breast reconstruction represents the most common reconstructive modality in the United States. The introduction of a novel tissue expander with an integrated drain (Sientra AlloX2) holds promise to further improve clinical outcomes. METHODS: Patients who underwent immediate expander-based pre-pectoral breast reconstruction were identified. Two cohorts were created, that is, patients who underwent placement of a conventional tissue expander [133MX (Allergan)] (Group 1) versus AlloX2 (Sientra) (Group 2). The study endpoint was successful completion of expansion with the objective being to investigate differences in outcome following expander placement. RESULTS: Fifty-eight patients underwent 99 breast reconstructions [Group 1: N = 24 (40 breasts) versus Group 2: N = 34 (59 breast)]. No differences were noted for age (P = 0.586), BMI (P = 0.109), history of radiation (P = 0.377), adjuvant radiotherapy (P = 1.00), and overall complication rate (P = 0.141). A significantly longer time to drain removal was noted in Group 1 (P < 0.001). All patients with postoperative infection in Group 1 required surgical treatment versus successful washout of the peri-prosthetic space via the AlloX2 drain port in 3 of 5 patients in Group 2 (P = 0.196). Furthermore, both cases of seroma in Group 1 required image-guided drainage versus in-office drainage via the AlloX2 drain port in 1 patient in Group 2 (P =0.333). CONCLUSION: The unique feature of the AlloX2 provides surgeons easy access to the peri-prosthetic space without altering any of the other characteristics of a tissue expander. This resulted in a reduced time to drain removal and facilitated management of postoperative seroma and infection.

Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction.

Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR. METHODS: One hundred seventy-eight patients who underwent APR between May 2000 and July 2017 were retrospectively analyzed. Sarcopenia was identified on preoperative computed tomography scans using the Hounsfield Unit Average Calculation. Two cohorts were compared (group 1: primary perineal closure; group 2: flap-based perineal reconstruction). Multivariable analysis evaluated predictors of complications. RESULTS: Sarcopenia was an independent risk factor for postoperative surgical site infection in patients undergoing APR (odds ratio [OR] = 2.9, P = 0.04). The risk for sarcopenic patients who underwent flap-based perineal reconstruction was even higher (OR = 8.9, P < 0.01). Male sex was also found to be a risk factor for infection (OR = 3.5, P < 0.01). Perineal flap-based reconstruction was a risk factor for delayed wound healing (OR = 3.2, P < 0.01). CONCLUSIONS: Sarcopenia was an independent risk factor for infection in patients undergoing APR. This risk was even greater in patients undergoing flap-based perineal reconstruction. Sarcopenia can be identified on preoperative imaging and inform surgeons on risk stratification and surgical plan.

Determining the impact of sarcopenia on postoperative complications after ventral hernia repair.

BACKGROUND: Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR. METHODS: A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6 HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications. RESULTS: Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR] = 5.3; p = 0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications (OR = 5.7; p = 0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [p = 0.04]) and renal failure (19% vs. 2.7% [p = 0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia. CONCLUSIONS: Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates.

Gender Differences in the Professional and Personal Lives of Plastic Surgeons.

BACKGROUND: Although the number of women becoming plastic surgeons has increased during the past six decades, in comparison with the current gender parity in medical schools, plastic surgery still attracts disproportionately more men. Previous studies have shown disparities in the professional and personal lives of female and male plastic surgeons. A survey study was conducted to identify current challenges women and men encounter in the pursuit of a plastic surgical career to guide remedial strategies. METHODS: An anonymous electronic survey was distributed to American Society of Plastic Surgeons members and candidates for comparison between sexes. Differences were tested by the Fisher's exact and chi-square tests. RESULTS: Women were more likely than men to have experienced sexism or bias. Women were less likely to be married; be satisfied with work-life balance; or feel recognized for ideas, authorship, promotions, or raises. Women felt that their sex was a disadvantage in career advancement, with one exception: unlike men, women felt many patients chose them because of their sex. Despite these challenges, over 80 percent of all plastic surgeons were satisfied with their choice of career. CONCLUSIONS: Traditions and gender bias create disparities in the personal and professional lives of female and male plastic surgeons. Our specialty must make concrete changes to promote all plastic surgeons, both women and men, to thrive personally and professionally.

Reduced incidence of feeding tube dislodgement and missed feeds in burn patients with nasal bridle securement.

INTRODUCTION: Feeding tubes in burn patients are at high risk for becoming dislodged as traditional tape securement does not adhere well to sloughed skin, resulting in nutrition delivery disruption and placing patients at increased risk for iatrogenic injury upon reinsertion. METHODS: Seventy-four patients admitted to our regional burn center requiring nasoenteric nutritional support were prospectively followed. Fourty-one patients received a nasal bridle while thirty-three received traditional tape and elastic dressings. Primary outcomes centered on measuring clinical efficacy of the nasal bridle system. RESULTS: Conventional tape-secured feeding tubes were dislodged more frequently (0.9±0.2 times per 10 feeding days vs. 0.2±0.1 times per 10 feeding days; p=0.005). Nasal bridle secured tubes showed significantly longer functional life on Kaplan Meier analysis (hazard ratio 0.35; p=0.01). Fewer abdominal x-ray studies were performed to confirm tube placement in nasal bridle patients (1.48±0.13 for nasal bridle vs. 2.21±0.21 for conventional tape-secured; p=0.003). Overall, patients with bridle securement had fewer hours of missed enteric feeds (2.51±0.95hours vs. 6.72±2.07hours; p=0.05). Importantly, utilization of a nasal bridle decreased overall estimated costs for enteric feeding management ($1,379.72±120.70 vs. $1,107.66±63.95; p=0.05). CONCLUSIONS: Utilization of a nasal bridle system provides a reliable method for securement of nasoenteric feeding tubes with clinical benefits in the burn patient population.

Opinions on Authorship: A Survey of Plastic Surgery Residents and Fellows.

BACKGROUND: Scientific publications are the cornerstone of scholarly activities. The importance of appropriately assigned authorship cannot be overstated. Hence, we felt it prudent to examine the perception of plastic surgery trainees regarding authorship. We hypothesized that plastic surgery trainees would not be in compliance with International Committee of Medical Journal Editors guidelines when determining what constitutes an authorship justifying contribution. METHODS: An online survey describing 4 distinct scenarios was distributed to plastic surgery trainees at 2 academic institutions using the Qualtrics research software (Provo, UT). Additional parameters queried included level of training and number of publications. Linear regression models were used to test correlation between responses and level of training and number of publications. RESULTS: Thirty-three of 48 trainees responded (response rate, 68.8%). All respondents had previously authored publications, with the majority (54.5%) having at least 10 publications. Although none of the scenarios presented justified authorship based on international guidelines, 33.3% of respondents believed that authorship was warranted in at least 3 of the 4 presented scenarios. Linear regression comparing for demographic variables to number of perceived authorship scenarios found a mild-moderate positive correlation with level of training (R = 0.34, P = 0.05) and number of publications (R = 0.32, P = 0.07). CONCLUSIONS: Plastic surgery trainees do not seem to be familiar with guidelines regarding authorship justifying contributions. It is important to raise awareness regarding criteria that warrant authorship and to educate our residents and fellows in matters of appropriate scholarly conduct because nothing short of the credibility of our scientific endeavors is otherwise in question.

Social Media and the Plastic Surgery Patient.

BACKGROUND: Many plastic surgeons use social media as a marketing tool to attract and retain patients, but information about how patients use social media and their preferred types of plastic surgery posts have been lacking. METHODS: To investigate patients' preferred social media networks and the type of posts they wished to see, a cross-sectional study was conducted in a single aesthetic practice of two plastic surgeons by surveying 100 consecutive patients. RESULTS: The age of the patients averaged 44.4 years (range, 17 to 78 years). Facebook had the greatest patient use and engagement, with YouTube second in use, and Instagram second in number of engaged users. Over half used Pinterest, but with little daily engagement. Only one-fourth used Snapchat, but the percentage of users who were highly engaged was second only to Facebook. The least popular network was Twitter, with the fewest patient users and least engagement. Social media played a minor role compared with the practice's Web site in both influencing patients to choose the practice and providing information on the day of the appointment. Patients most wanted to see posts on a plastic surgeon's social media platform related to practice information, before-and-after photographs, and contests. Articles about plastic surgery held the least interest. Among five types of Web site content, patients expressed most interest in before-and-after photographs. CONCLUSIONS: This study is the first to articulate the plastic surgery patient perspective regarding social media. The findings aim to help plastic surgeons maximize their influence on their target audience.