Outcomes in Facial Feminization Surgery: A Systematic Review.

Objective: Review literature on facial feminization surgery (FFS) for the transgender population and identify whether heterogeneity in reported outcomes and outcome measures exists across studies, as measured by a lack of consensus, and number of outcomes and outcome measures used. Evidence Review: A search of MEDLINE and EMBASE (database inception to January 20, 2021) was performed to retrieve FFS studies. Primary outcomes included number of reported outcomes and outcome measures; secondary outcomes included clinimetric properties of outcome measures and study characteristics. Findings: In total, 15 articles were included. Sixty-nine outcomes and 12 outcome measures were identified. Of those outcome measures, zero were found to be valid, reliable, and responsive in patients who had undergone FFS. A variety of FFS interventions were studied, with the three most common interventions being: rhinoplasty (n = 7, 46.7%), mandibuloplasty (n = 7, 46.7%), and chondrolaryngoplasty (n = 6, 40%). Conclusion and Relevance: Heterogeneity was evident in reported outcomes and outcome measures in FFS literature and there is currently no outcome measure commonly used for this patient population.

Concurrent Prophylactic Mastectomy, Immediate Reconstruction, and Salpingo-Oophorectomy in High-Risk Patients: A Case Series.

PURPOSE: There are limited data on coordinated breast and gynecological risk-reduction surgery for high-risk patients in Canada. Therefore, this study aims to evaluate the patient demographics, surgical details, and outcomes of prophylactic mastectomy (PM) with immediate reconstruction and bilateral salpingo-oophorectomy (BSO) in high-risk patients. METHODS: We conducted a retrospective chart review at an academic center of patients who concurrently underwent PM with immediate reconstruction and laparoscopic BSO over a 7-year period (March 2010-February 2017) were identified. RESULTS: A total of 16 patients underwent PM with immediate reconstruction and concurrent BSO. The mean age at the time of surgery was 46.2 ± 6.6 years. Thirteen (81%) patients were carriers of the BRCA1 or BRCA2 mutation. Two patients had prophylactic surgical therapy for BRCA1 mutation and 14 (87.5%) patients had prior oncological treatment. The most common type of procedures performed were skin-sparing, nipple-sparing mastectomy (56.2%) and reconstruction with acellular dermal matrix and implants (43.8%). All patients underwent laparoscopic BSO. The average combined case time was 282.5 ± 81.3 minutes with an average postoperative hospital stay of 1.3 ± 0.5 days. Six (37.5%) patients presented with 30-day postoperative complications, with higher rates in the alloplastic group. There were no gynecological complications. CONCLUSIONS: In conclusion, our results demonstrate that a combined multidisciplinary surgical approach did not increase length of stay or 30-day complication rates. Furthermore, concurrent risk-reducing strategies are an effective option for patients at high risk of breast or ovarian cancer.

OBJECTIFS: Les données sur la coordination des opérations mammaire et gynécologique de réduction des risques sont limitées chez les patientes à haut risque au Canada. La présente étude vise donc à évaluer la démographie des patientes, les détails de l'opération et les résultats cliniques d'une mastectomie prophylactique (MP) suivie d'une reconstruction immédiate et d'une salpingoovariectomie bilatérale (SOB) chez des patientes à haut risque. MÉTHODOLOGIE: Dans un centre universitaire, les chercheurs ont réalisé une analyse rétrospective des dossiers des patientes qui ont subi une MP coordonnée avec une reconstruction immédiate et une SOB par laparoscopie, et ce, sur une période de sept ans (de mars 2010 à février 2017). RÉSULTATS: Au total, 16 patientes, d'un âge moyen de 46,2 ± 6,6 ans au moment de l'opération, ont subi une MP coordonnée avec une reconstruction immédiate et une SOB. Treize d'entre elles (81 %) étaient porteuses de la mutation du gène BRCA1 ou BRCA2. Deux patientes ont subi un traitement chirurgical prophylactique à cause de la mutation du gène BRCA1 et 14 patientes (87,5 %) avaient subi un traitement oncologique auparavant. Les interventions les plus pratiquées étaient une mastectomie avec conservation de la peau et des mamelons (56,2 %) et une reconstruction par implants avec matrice dermique acellulaire (43,8 %). Toutes les patientes ont subi une SOB par laparoscopie. Les cas combinés ont duré 282,5 ± 81,3 minutes en moyenne et ont été associés à une hospitalisation postopératoire moyenne de 1,3 ± 0,5 jour. Six patientes (37,5 %) ont souffert de complications dans les 30 jours suivant l'opération, et le taux était plus élevé dans le groupe alloplastique. Aucune complication gynécologique n'a été observée. CONCLUSIONS: Les résultats démontrent qu'une approche chirurgicale multidisciplinaire combinée n'ont accru ni la durée de l'hospitalisation ni le taux de complications au bout de 30 jours. De plus, les stratégies coordonnées de réduction du risque constituent une option efficace pour les patientes à haut risque de cancer du sein ou des ovaires.

Body mass index impacts infection rates in immediate autogenous breast reconstruction.

PURPOSE: Risk of postoperative infection following breast cancer reconstruction warrants consideration of both classic and procedure-specific risk factors. We performed a retrospective chart review of patients with breast cancer over a 10-year period that underwent reconstructive surgery to identify factors that increase risk of postoperative infection. METHODS: Rates of postoperative infection were assessed in primary (immediate or delayed, alloplastic or autogenous) and secondary reconstructive procedures. Patient characteristics, surgical details, and cancer features were analyzed using two-sample t test and Fisher's exact test for continuous and categorical data, respectively. RESULTS: 456 procedures were performed on 264 patients with 29 cases of postoperative infection (6%). Infection was more likely to occur in earlier reconstructive procedures (p < 0.03). Overall, primary reconstructive procedures were associated with a higher infection rate (p = 0.005). Other associated risk factors included: autogenous reconstruction (p < 0.018), length of admission (p < 0.001) and immediate reconstruction (p = 0.01). Subgroup analysis revealed increased risk of infection with immediate autogenous reconstruction (p < 0.03). Furthermore, patients with greater body mass index (BMI) receiving immediate autogenous reconstruction had a greater risk of infection (p < 0.003). Factors unrelated to risk of infection included history of irradiation, smoking, cancer stage, tumor type and tumor size. CONCLUSIONS: Our findings suggest that risk of infection is higher in immediate autogenous reconstructions particularly when patients are overweight (BMI > 30). Our data do not support a relationship between infection and irradiation, features of cancer, or repeated reconstructive procedures. Prospective studies may be required to further validate these findings.

What are the acute cardiovascular effects of subcutaneous and topical epinephrine for hemostasis during burn surgery?

Although subcutaneous and topical epinephrine are widely used for hemostasis during burn surgery, the acute systemic cardiovascular effects of the epinephrine are neither well documented nor completely understood. The purpose of this work was to prospectively study the acute cardiovascular responses to epinephrine (epi) administered subcutaneously and topically during burn surgery. Consecutive patients who received subcutaneous and topical epi during burn surgery were monitored prior to the administration of epi, at 2-minute intervals during subcutaneous epi infiltration, and then after epi infiltration (during which time, topical epi was applied). This period of monitoring lasted up to 20 minutes and was referred to as an epinephrine event (EE). A total of 100 EEs from 38 operations in 24 patients (mean +/- SD: age 43 +/- 16 years, mean % TBSA burn 23 +/- 17%) were studied. The mean dose of subcutaneous epi was 30 +/- 30 microg/kg. Although all patients received topical epi, it was impossible to document the topical dose. There was no significant increase in heart rate from baseline, and no arrhythmias occurred. Mean arterial pressure (MAP) did acutely increase significantly by 17.0 +/- 14.1% from baseline (P =.009) and increased more than 10% from baseline in 64/100 EEs. However, the increase in MAP was independent of the dose of epi (r =.053). The increase in MAP was not clinically significant, did not require intervention, and did not appear to be related to the type of wound that received epi (donor site vs burn wound), or the depth of anesthesia, analgesia, or sedation. On the basis of these findings, the use of subcutaneous and topical epi appears to be safe and produces minimal acute cardiovascular effects.

How well does the Parkland formula estimate actual fluid resuscitation volumes?

We had anecdotally observed that fluid resuscitation volumes often exceed those estimated by the Parkland Formula in adults with isolated cutaneous burns. The purpose of this study was to compare estimated and actual fluid resuscitation volumes using the Parkland Formula. We performed a retrospective study of fluid resuscitation in patients with burns > or = 15% TBSA. Patients with inhalation injury, high voltage electrical injury, delayed resuscitation, or associated trauma were excluded. We studied 31 patients (mean age 51 +/- 20 years, mean TBSA burn 27 +/- 10%). The 24 hour resuscitation volume of 13 354 +/- 7386 ml (6.7 +/- 2.8 ml/kg/%TBSA) was significantly greater than predicted (P = 0.001) and exceeded estimated volume in 84% of the patients. The mean urine output in the first 24 hrs was 1.2 +/- 0.6 ml/kg/hr. After the first 8 hours of resuscitation, the infusion rate decreased by 34% in 16 patients (DCR group), while in 15 patients the rate increased by 47% (INCR group). Both the DCR and INCR groups received significantly more fluid than predicted, (5.6 +/- 2.1 ml/kg/%TBSA and 7.7 +/- 3.1 ml/kg/%TBSA respectively). The INCR patients had significantly larger full thickness burns (14 +/- 11% vs 3 +/- 6%, P < 0.001). Our findings reveal that despite its effectiveness, the Parkland Formula underestimated the volume requirements in most adults with isolated cutaneous burns, and especially in those with large full thickness burns.

The effect of silicone gel sheets on perfusion of hypertrophic burn scars.

The mechanism of action of topical silicone gel sheets on hypertrophic scars is not well understood and their effect on the blood flow within hypertrophic scars has not been investigated. The purpose of this study was to examine whether application of silicone gel sheets produced any acute effects on blood flow in hypertrophic burn scars. Perfusion of hypertrophic scars and adjacent normal skin was measured using a laser Doppler with and without application of silicone gel sheets. Continuous measurements were made for 5 minutes before gel application, for 30 minutes during gel application and for 5 minutes following gel removal. Surface temperature of the scar was continuously monitored. An occupational therapist, blinded to the perfusion level, rated each scar using the Vancouver Scar Scale. Eighteen scars and adjacent control sites in sixteen adult burn patients (11 male, 5 female; mean age: 42 +/- 14 years) were evaluated. The mean scar age was 5.4 +/- 3.7 months. The mean Vancouver Scar Scale was 5.5 +/- 2.4. Hypertrophic scars demonstrated higher perfusion measurements at baseline compared to control areas (58.5 +/- 19.3 flux units vs 25.0 +/- 8.4 flux units; P < 0.001). Application of silicone sheeting gel did not significantly alter perfusion in either the hypertrophic scar or normal tissue from the baseline measurements. However, application of silicone gel sheeting did significantly increase the mean baseline surface temperature of the hypertrophic scar from 29 +/- 0.8 degrees C to 30.7 +/- 0.6 degrees C (P < 0.001). The mechanism of action of silicone gel sheeting probably does not involve an acute alteration in blood flow within the scar. However, surface temperature of the scar increased significantly following gel application, raising the possibility that temperature alteration is involved in the mechanism of action.