Limited Access to Facial Feminization Geographically Despite Nationwide Expansion of Other Gender-Affirming Surgeries.

Facial feminization surgery (FFS) is an integral aspect of gender-affirming surgery (GAS) for individuals seeking to align secondary sex characteristics and gender identity. Despite the importance of FFS in treating gender dysphoria, current trends and prevalence remain unknown. We sought to examine trends in GAS and FFS and investigate the payer status of facial feminization procedures in the United States. Methods: Data was extracted from the National Inpatient Sample from 2008 to 2017 by using International Classification of Diseases Ninth or Tenth diagnosis codes for gender identity disorder and procedure codes for FFS. Results: From 2008 to 2017, 3015 patients underwent GAS. The yearly number of cases increased as did the average cost of GAS, which rose from $13,657 in 2008 to $50,789 in 2017. From 2015 to 2017, when FFS data was available, 110 of 1215 (9.1%) GAS patients had FFS. Most were non-Hispanic White (66.7%) or Black (23.8%). Fifty percent of FFS cases occurred in the West, followed by the Northeast (31.8%), South (13.6%), and Midwest (4.8%) (P = 0.015). By payer the cases were, 36.4% self-pay, 31.8% Medicaid, and 27.3% private insurance (P < 0.0001). Approximately, 18% of patients undergoing male-to-female transition received FFS. Conclusions: From 2008 to 2017, GAS cases increased nationwide while the average cost of surgery rose steeply. FFS cases were primarily in the Western and Northeast United States. Despite high cost, roughly 18% of transgender women in our sample received FFS, highlighting the importance of FFS in gender transition.

Standardized Perioperative Protocol and Routine Ketorolac Use for Head and Neck Free Flap Reconstruction.

No consensus exists on ideal perioperative management or anticoagulation regimen for free flap reconstruction of the head and neck. Perceived benefits from antiplatelet therapy need to be balanced against potential complications. Ketorolac, a platelet aggregation inhibitor and a parenteral analgesic, was introduced as part of a standardized perioperative protocol at our institution. In this study, we aimed to examine the impact of implementation of this protocol as well as complications associated with the routine use of perioperative ketorolac in a diverse group of patients who underwent head and neck free flap reconstruction. Methods: A single institution retrospective review was performed, including all patients who underwent head and neck free flap reconstruction between October 2016 and November 2019. Patients were divided into two cohorts: those who received ketorolac as part of a standardized protocol, and those who did not. Results: Twenty-four consecutive patients with 24 head and neck free flaps were evaluated. Eighteen patients were in the standard protocol, and six were not. There were no microvascular thromboses, flap failures, or hematomas in either group. Intensive care unit length of stay and opiate use were significantly reduced in the standardized protocol group. Conclusions: A standardized perioperative protocol for head and neck free flap reconstruction can reduce hospital and intensive care unit length of stay. No statistically significant differences in complication rates were identified when comparing ketorolac use and perioperative regimens among patients undergoing a diverse set of microsurgical head and neck free flap reconstructions.

Which Maturation Indicator is Most Accurate in Predicting Cessation of Facial Growth? A Systematic Review of the Literature.

PURPOSE: The determination of facial growth maturity is crucial before surgical intervention in pediatric patients. To the author's knowledge, there are several indicators of skeletal maturity, but there remains a lack of consensus regarding their application when determining surgical timing. The purpose of this study was to determine the most accurate skeletal maturity indicator in predicting facial growth maturation. MATERIALS AND METHODS: A systematic review was done to determine the most predictive indicator for facial growth maturity. We hypothesized that menses' onset was the most predictive of these maturity indicators. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of MEDLINE, Cochrane, Embase, Scopus databases, and Google Scholar, was done in October 2020 to identify citations related to maturity indicators assessing craniofacial growth. The quality of evidence was determined using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. RESULTS: Of the 13,289 articles screened, 1 retrospective and 1 prospective study met inclusion criteria. No articles were identified that provided evidence for our hypothesis. Based on the 2 included studies, it was concluded that a handwrist x-ray was more predictive of facial growth cessation (compared to other skeletal maturity indicators). CONCLUSIONS: Based on the literature, handwrist radiography serves as the most predictive method in determining the facial growth maturity. The paucity of articles within this investigation highlights the need for greater research efforts to investigate the predictability of indicators to evaluate facial growth maturation. PROSPERO REGISTRATION NUMBER: CRD42020207388.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center.

PURPOSE: A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. METHODS: A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. RESULTS: Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). CONCLUSION: Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Resident Perspectives on Palliative Care at an Urban Teaching Hospital.

Background: There has been an increasing need to address end of life (EOL) care and palliative care in an era when measures to extend life for terminal illnesses are often initiated without consideration of quality of life. Addressing the barriers for resident physicians to initiate EOL conversations with patients is an important step towards eliminating the disconnect between patient wishes and provider goals. Objective: To assess resident physician perspectives on initiating palliative care conversations with terminally ill patients at an urban teaching hospital. Methods: This paper solicited the experiences of pediatric, general surgery, and internal medicine residents through an anonymous survey to assess exposure to palliative care during training, comfort with providing palliative care, and barriers to implementing effective palliative care. Results: 45% of residents reported exposure to palliative care prior to medical training. Ninety-three percent of these residents reported being formally introduced to palliative care during medical training through formal lecture, although the majority reported also being exposed through either small group discussions or informal teaching sessions. Time constraints and lack of knowledge on how to initiate and continue conversations surrounding EOL care were the greatest barriers to effectively caring for patients with terminal illnesses. Residents concurred that either attending physicians or hospital-designated palliative care providers should initiate palliative care discussions, with care managed by an interdisciplinary palliative care team; this consensus demonstrates a potential assumption that another provider will initiate EOL discussions. Conclusions: This study evaluated the current state of physician training in EOL care and provided support for the use of experience-based training as an important adjunct to traditional didactic lectures in physician education.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

A Single Center Review of Pediatric Nasal Bone Fractures - An Analysis of Concomitant Injuries, Management, and Outcomes.

Background: Pediatric nasal bone fractures presenting as isolated fractures or with concomitant facial injuries are rare and not well documented. Analysis of treatment at an urban, level-one trauma center provides insight into their management. Methods: Data were collected for pediatric nasal bone fractures diagnosed between January 2000 and December 2014. Patients were divided into groups based on presence or absence of isolated nasal bone fractures. Groups were compared using Chi-squared analysis, and a Bonferroni correction was used for a more conservative alpha (a = .004). Results: Assault was the most common etiology presenting in 46 of 122 pediatric nasal bone fractures. There was no significant difference in surgical versus non-surgical management of isolated and non-isolated nasal bone fractures (P = 0.98). Treatment for both was predominantly watchful waiting in 91% to 95% of the cases followed by closed reduction in 3.2% to 3.3%. In the patients with isolated fractures, 11.5% sustained intracranial hemorrhage, compared to 35.6% of multifracture cases (P = .002); 15.0% of isolated fractures sustained a traumatic brain injury, compared to 55.9% of multifracture cases (P = .000003). No significant difference in fatality existed between groups (P = 0.53). Conclusions: Multi-facial fracture cases were more likely to present with traumatic brain injuries and be admitted to the intensive care unit than isolated nasal bone fractures. Rates of surgical and non-surgical management were not significantly different between the 2 groups. Watchful waiting of pediatric nasal bone fractures was the management approach selected 92% to 95% of the time regardless of the presence or absence of concomitant facial fractures.

A Three-Step Technique for Optimal Nipple Position in Transgender Chest Masculinization.

BACKGROUND: The ideal position of the nipple-areola complex (NAC) in the transgender population can be a challenge to determine. OBJECTIVES: The authors sought to determine the best location and aesthetics of the female to male NAC. METHODS: Patients who underwent female to male mastectomy with free nipple grafting were included. NAC position is confirmed utilizing a vertical coordinate at the level of the 4th rib near the border of the pectoralis muscle and a horizontal coordinate determined by dividing each unilateral chest into vertical thirds from midline to anterior axillary line laterally. The NAC position is confirmed at the junction of the middle and lateral third. Symmetry is ensured bilaterally by creating a triangle and transposing it side to side; the base lies from sternal notch to inframammary fold in the midline and the apex is adjusted to the NAC. A 24-question survey utilizing a 5-point Likert scale was distributed postoperatively to assess the patient's thoughts about their chest, nipples, scar, and overall experience with the gender affirmation process. RESULTS: Thirty-one patients were included in this study. Eighteen patients responded to the postmastectomy survey, all of whom were highly satisfied with the aesthetic result postoperatively. All patients felt comfortable with their exposed chest. Nipple location was particularly highly received with 100% satisfaction rate (mean Likert score, 4.72). Nipple size and shape received a mean Likert score of 4.17 and 3.89, respectively. CONCLUSIONS: The triple confirmation technique is an easy, reproducible method to guide the surgeon in relocation of the NAC.

Human-derived Acellular Dermal Matrix Grafts for Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.

BACKGROUND: Treating diabetic foot ulcers (DFUs) requires thorough understanding of available surgical tools. OBJECTIVE: This meta-analysis compares human-derived acellular dermal matrices (H-ADMs) with standard of care (SOC) to evaluate the number of healed ulcers at 12 and 16 weeks and number of days to complete healing. As a secondary outcome, the efficacy of 3 H-ADM subtypes are studied. METHODS: Two researchers searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials for relevant titles from inception through July 2018. Inclusion criteria indicated articles be randomized controlled trials investigating the effects on neuropathic, nonischemic DFUs. RESULTS: Data from 312 DFUs in total were included in the meta-analysis. The results show H-ADMs are more effective in healing patients within a 12-week (3.14; range, 2.04-4.83) and 16-week period (2.35; range, 1.25-4.43) in comparison with SOC. Further, the mean time to complete healing was shorter in the H-ADM group (-2.31 days; range, -2.67 to -1.95 days) in comparison with SOC. Within the subgroups, 2 H-ADMs were associated with a higher likelihood of complete healing within 12 weeks when compared with SOC. The third H-ADM had a point estimate, which suggested superiority over SOC. CONCLUSIONS: This study shows H-ADMs are associated with a higher likelihood of complete healing and fewer days to complete healing within a 12-week and 16-week periods when compared with SOC. Also, the commercial products performed similarly.

Pediatric facial injuries: Hitting close to home.

PURPOSE: The aims of this study were as follows: To determine the national incidence of facial fractures among infants, toddlers, and children; to evaluate the types of facial fractures; and to analyze common products/activities associated with the fractures. MATERIALS AND METHODS: A retrospective review was conducted to explore patterns of facial fractures among infants (<1 year), toddlers (1-3 years), and children (3-5 years), using the National Electronic Injury Surveillance System (NEISS) from the Consumer Product Safety Commission (CPSC). The database was searched for emergency department (ED) visits involving facial fractures sustained by children 1 month through 5 years of age from 2004 through 2016 and analyzed for patient demographics, primary diagnosis and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences. RESULTS: A total of 1507 ED visits for facial fractures among infants, toddlers, and children were obtained and extrapolated to an estimated total of 39,388 ED visits, averaging 3030 annually. The majority of these ED visits were for facial fractures that occurred at home. Most facial fractures sustained at the age period of 1 month-5 years old were nasal fractures. Facial fractures in infants were caused most commonly by floors or flooring materials, likely due to falls, while household items/furniture-related injuries were the most common cause of facial fractures in both toddlers and children. Facial fractures from playground equipment and riding toys were more common in children than in the other age groups. CONCLUSION: The reported trends in the incidence by age group and types of fracture can assist physicians by serving as supplement for clinical history and examination when encountering this challenging patient population. Our findings highlight preventative opportunities, particularly in baby care items and beds for reducing facial fractures in infants. Similarly, preventative opportunities are highlighted in household items and furniture for lowering the incidence of facial fractures in toddlers and children. Our study also suggests ensuring safe handling of playground equipment and riding toys for the prevention of facial fractures in children.

The NF-κB pathway mediates lysophosphatidic acid (LPA)-induced VEGF signaling and cell invasion in epithelial ovarian cancer (EOC).

OBJECTIVES: Our previous report has implicated the involvement of VEGF-VEGFR-2 h signaling in LPA-induced EOC invasion. However, the mechanism by which LPA regulates VEGF and VEGFR-2 expression remains to be elucidated. In the present study, we systematically examined the signal transduction pathways activated by LPA and further evaluated whether LPA's effect on VEGF-VEGFR-2 signaling and EOC invasion was mediated by the activation of NF-κB pathway. METHODS: Using a signal transduction PathwayFinder PCR array, we examined the expression change of 86 key genes representing 18 signal transduction pathways in DOV13 and SKOV3 cells upon LPA (20 µM) treatment. We also used quantitative PCR, Western blotting and ELISA to evaluate the effect of NF-κB pathway inhibition on VEGF(121), VEGF(165) and VEGFR-2 mRNA and protein expression/secretion with or without the presence of LPA (20 µM) in SKOV3. Cell invasion under various treatment conditions was assessed by Matrigel invasion assay and MMP-2 secretion was detected by gelatin zymography. RESULTS: Our results showed that in both DOV13 and SKOV3, several of the NF-κB pathway components, such as TNF, are consistently activated by LPA stimulation. In addition, treatment with an NF-κB pathway activation inhibitor, at 10 µM, significantly decreased LPA-induced VEGF(121), VEGF(165) and VEGFR-2 mRNA expression and VEGF secretion, as well as LPA-induced SKOV3 invasion (p<0.05). When combined with an EGFR inhibitor, NF-κB pathway inhibition exhibited a significantly stronger effect than used alone (p<0.05) on reducing LPA-induced VEGF secretion and cell invasion. Additionally, NF-κB inhibition also decreased LPA-induced MMP-2 secretion and MMP-1 expression (p<0.05). CONCLUSIONS: These results suggest that the NF-κB pathway plays an important role in LPA-induced VEGF signaling and EOC invasion and targeting this pathway may reveal potential therapeutic options for metastatic EOC.