Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer for the Treatment of Lymphedema-A Canadian Case Series.

Introduction: Lymphedema is a chronic and debilitating condition. This study aims to assess the efficacy and safety of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfers (VLNT) for the treatment of patients suffering from lymphedema, mainly by comparing pre- and postoperative daily compression use, limb volumes, and occurrence of cellulitis. Methods: We performed a retrospective analysis of patients who were treated by a single surgeon for lymphedema with LVA and/or VLNT between March 2018 and February 2020. Eighteen limbs met the inclusion criteria. The severity of lymphatic dysfunction was assessed by indocyanine green lymphangiography. Patients with patent vessels were offered LVA, whereas those without were offered VLNT. Pre- and postoperative circumferential limb measurements, use of compression garments, and postoperative complications were compared. Results: Nine limbs underwent LVA, 8 underwent VLNT, and one both. The minimum follow-up was 12 months. Postoperatively, all but 3 patients (83%) were able to cease daily compression. When considering excess limb volumes, the average reduction was 58%. This reduction was achieved despite compression weaning. Forty-four percent of patients (8) reported episodes of recurrent cellulitis preoperatively, while postoperatively, only 3 of those patients (17%) experienced cellulitis, which was statistically significant (P = .018). No surgical complications occurred. Conclusions: Patients with lymphedema can benefit from LVA and VLNT surgery. An important effect of surgery is decreased dependence on daily compression garments to maintain a stable and reasonable limb volume. The reduction of limb circumference after 1 year was similar to LVA and VLNT. Episodes of cellulitis were significantly lower after the intervention.

Introduction : Le lymphœdème est une affection chronique et débilitante. La présente étude vise à évaluer l'efficacité et l'innocuité de l'anastomose lymphaticoveineuse (ALV) et des transferts des ganglions lymphatiques vascularisés (TGLV) pour le traitement des patients ayant un lymphœdème, surtout en comparant l'utilisation quotidienne des vêtements compressifs, le volume des membres et l'occurrence de cellulites avant et après l'opération. Méthodologie : Les chercheurs ont procédé à une analyse rétrospective des patients chez qui le même chirurgien a procédé à une ALV ou à un TGLV à cause d'un lymphœdème entre mars 2018 et février 2020. Dix-huit membres ont respecté les critères d'inclusion. Les chercheurs ont évalué la gravité du dysfonctionnement lymphatique par lymphangiographie au vert d'indocyanine. Les patients ayant des vaisseaux perméables se sont fait offrir une ALV, et les autres, un TGLV. Les chercheurs ont comparé les mesures du périmètre des membres et l'utilisation de vêtements compressifs avant et après l'opération, de même que les complications postopératoires. Résultats : Une ALV a été effectuée sur neuf membres, des TGLV, sur huit membres, et les deux interventions, sur un membre. La période de suivi minimale était de 12 mois. Après l'opération, tous les patients, sauf trois (83%), ont pu cesser la compression quotidienne. En moyenne, le volume excessif des membres a diminué de 58%. Les chercheurs ont obtenu cette réduction malgré le sevrage de la compression. Au total, 44% des patients (huit) ont signalé des récurrences de la cellulite avant l'opération, mais après l'opération, seulement trois d'entre eux (17%) en ont souffert, ce qui est statistiquement significatif. Aucune complication chirurgicale n'a été signalée. Conclusions : Les patients ayant un lymphœdème peuvent profiter d'une ALV ou d'un TGLV. Parmi ses effets importants, l'opération réduit la dépendance au port quotidien de vêtements compressifs afin que les membres conservent un volume stable et raisonnable. La réduction du paramètre des membres au bout d'un an était semblable après l'ALV et les TGLV. Les épisodes de cellulite étaient considérablement moins fréquents après l'intervention.

Silicone Particles in Capsules Around Breast Implants: An Investigation Into Currently Available Implants in North America.

BACKGROUND: Breast implants have always been composed of a silicone elastomer envelope filled with either silicone gel or saline. Breast implant illness (BII) is a set of symptoms that has previously been linked to the leakage of silicone particles from the implants into the body. OBJECTIVES: Our research aimed to quantify the number of silicone particles present in the capsules of breast implants available in North America. METHODS: Thirty-five periprosthetic capsules were sampled and analyzed, and silicone particles were counted and measured. The capsule surface area was then measured and utilized to calculate particle density and total number of silicone particles. RESULTS: Eighty-five percent of capsules analyzed from silicone gel implants contained silicone, with an average of 62 particles per mm3 of capsular tissue. These implants had approximately 1 million silicone particles per capsule. In contrast, none of the saline implant capsules contained silicone. Capsules from macrotextured tissue expanders contained fewer and larger silicone particles. CONCLUSIONS: Silicone gel implants presented silicone particle bleeding into the periprosthetic capsule, totaling on average 1 million silicone particles per capsule. On the other hand, no silicone particle bleeding was observed from saline breast implants. These data suggest that particle bleeding comes from the inner silicone gel, and not from the smooth outer silicone shell. Previous studies have reported the presence of breast implant illness in patients with both silicone- and saline-filled implants. Therefore, our data suggest that silicone migration is not the sole cause of BII.

The Montréal Classification of urethral lengthening for phalloplasty in transmasculine patients-surgical techniques and urethral complications.

Introduction: Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes. Materials and methods: All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student's T-test, Chi-squared test, Fisher's exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction. Results: Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively. Conclusions: We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results.

Printing in Time for Cranio-Maxillo-Facial Trauma Surgery: Key Parameters to Factor in.

Study Design: retrospective cohort study. Objective: 3D printing is used extensively in cranio-maxillo-facial (CMF) surgery, but difficulties remain for surgeons to implement it in an acute trauma setting because critical information is often omitted from reports. Therefore, we developed an in-house printing pipeline for a variety of cranio-maxillo-facial fractures and characterized each step required to print a model in time for surgery. Methods: All consecutive patients requiring in-house 3D printed models in a level 1 trauma center for acute trauma surgery between March and November 2019 were identified and analyzed. Results: Sixteen patients requiring the printing of 25 in-house models were identified. Virtual Surgical Planning time ranged from 0h 08min to 4h 41min (mean = 1h 46min). The overall printing phase per model (pre-processing, printing, and post-processing) ranged from 2h 54min to 27h 24min (mean = 9h 19min). The overall success rate of prints was 84%. Filament cost was between $0.20 and $5.00 per model (mean = $1.56). Conclusions: This study demonstrates that in-house 3D printing can be done reliably in a relatively short period of time, therefore allowing 3D printing usage for acute facial fracture treatment. When compared to outsourcing, in-house printing shortens the process by avoiding shipping delays and by having a better control over the printing process. For time-critical prints, other time-consuming steps need to be considered, such as virtual planning, pre-processing of 3D files, post-processing of prints, and print failure rate.

How Big Is Too Big? Exploring the Relationship between Breast Implant Volume and Postoperative Complication Rates in Primary Breast Augmentations.

There is no consensus regarding implant size as an independent risk factor for complications in primary breast augmentation. Choosing appropriate implant volume is an integral part of the preoperative planning process. The current study aims to assess the relationship between implant size and the development of complications following augmentation mammaplasty. Methods: A retrospective chart review of patients undergoing primary breast augmentation at the Westmount Institute of Plastic Surgery between January 2000 and December 2021 was conducted. Demographics, implant characteristics, surgical technique, postoperative complications, and follow-up times were recorded. Univariate logistic regression was used to identify independent predictors, which were then included in multivariate logistic regressions of implant volume and implant volume/body mass index (BMI) ratio regarding complications. Results: A total of 1017 patients (2034 breasts) were included in this study. The average implant volume used was 321.4 ± 57.5 cm3 (range: 110-605). Increased volume and volume/BMI ratio were associated with a significant increase in risk of implant rupture (odds ratio = 1.012, P < 0.001 and 1.282, P < 0.001 respectively). Rates of asymmetry were significantly associated with increases in implant volume and volume/BMI ratio (odds ratio = 1.005, P = 0.004 and 1.151, P < 0.001, respectively). No single implant volume or volume/BMI ratio above which risks of complications significantly increase was identified. Conclusions: Implant rupture and postoperative asymmetries are positively correlated with bigger implant volumes. Implant size could likely be a useful independent predictor of certain complications, especially in patients with high implant to BMI ratios.

Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction.

Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.

Introduction: Les transferts de tissus libres sont devenus une clé de voûte du sauvetage du membre inférieur, permettant une reconstruction sûre et fiable après un traumatisme, l'extirpation d'une tumeur et des blessures complexes. La gestion périopératoire optimale (PO) de ces volets reste controversée. Cette étude vise à évaluer l'état actuel des pratiques parmi les chirurgiens canadiens pratiquant la microchirurgie. Méthodes: Soixante-quatre spécialistes canadiens de microchirurgie ont été approchés et il leur a été demandé de répondre à un questionnaire en ligne sur leur gestion PO des lambeaux fascio-cutanés libres utilisés pour la reconstruction du membre inférieur. Les tendances concernant des échéances et des durées du protocole de jambe pendante, l'utilisation de coupleurs veineux, les vêtements compressifs, la thromboprophylaxie et la satisfaction des chirurgiens envers leur protocole ont été évaluées. Résultats: Vingt-huit chirurgiens ont répondu. Cinquante-sept pour cent (57 %) n'avaient pas de protocole de mobilisation précis. Le protocole de jambe pendante sans appui a été instauré aux jours postopératoires 5 ou 6 (44 %). La durée la plus courante du protocole était de 5 à 6 jours (43 %). La préoccupation d'une accumulation prolongée de sang veineux était la principale raison pour retarder l'exercice de jambe pendante (71 %). Douze (12) chirurgiens (43 %) ont mis en place de manière régulière des vêtements compressifs: 20 % d'entre eux ont commencé avant de laisser pendre le membre, 46 % en même temps et 33 % après avoir laissé pendre le membre. Des coupleurs veineux ont été utilisés en routine par 24 chirurgiens (85,7 %). Les tendances en matière de gestion ont été influencées par la formation antérieure dans 53,6 % des cas (contre la médecine fondée sur des données probantes: 7,1 %). Même si 89,3 % des chirurgiens étaient satisfaits de leur approche, 92,8 % d'entre eux envisageraient de modifier leur pratique si des données probantes de plus haut niveau étaient disponibles. Conclusions: La majorité des spécialistes canadiens de la microchirurgie instaurent précocement la mise en décharge hors du lit du membre inférieur et utilisent des coupleurs veineux. Cependant, l'utilisation de vêtements compressifs est limitée. Les tendances en matière de gestion reposent largement sur l'expérience personnelle. Presque tous les chirurgiens envisageraient de modifier leur pratique si des données probantes de plus haut niveau étaient disponibles.

Facial Gender-Affirming Surgery: Frontal Bossing Surgical Techniques, Outcomes and Safety.

BACKGROUND: Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250-261, 2011). This article describes the author's three main surgical techniques used in forehead feminization and reports on the results. METHODS: The type of surgery performed is based on the patient's anatomy. Type one FGAS consists of burring the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes burring and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing. RESULTS: We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout's methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome. CONCLUSIONS: FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incidence of Testicular Cancer in Transfeminine Patients following Vaginoplasty with Orchidectomy.

Background: Little is known about the prevalence of testicular cancer in the transfeminine population. Only six cases have been reported in the literature. This case series reports six additional cases of various testicular cancers found in transfeminine patients who underwent vaginoplasty with orchidectomy in our institution. Methods: In our institution, all specimens are routinely sent to pathology following vaginoplasty with orchidectomy. This permitted the identification of all positive cases of testicular cancer. A chart review was conducted to retrieve patient demographics, duration of hormonotherapy, type of neoplasm, the context of its discovery, and cancer follow-up. Results: A total of 2555 patients underwent vaginoplasty with orchidectomy between January 2016 and January 2021. All specimens were sent to pathology for analysis. A total of six (0.23% of patients) specimens revealed malignant lesions. Conclusions: Increased societal awareness toward the transgender population encourages recourse to gender-affirming procedures. Little is known about the incidence of testicular cancer in the transfeminine population. In total, 0.23% of patients in our cohort presented with positive pathology findings indicative of testicular cancer. All cancers were found to be only locally invasive, and all patients were successfully treated. We therefore encourage routine pathology examination for all specimens following vaginoplasty with orchidectomy.

In-house 3D Model Printing for Acute Cranio-maxillo-facial Trauma Surgery: Process, Time, and Costs.

Three-dimensional (3D) printing is used extensively in cranio-maxillo-facial (CMF) surgery, but its usage is limited in the setting of acute trauma specifically, as delays in outsourcing are too great. Therefore, we developed an in-house printing solution. The purpose of this study was to describe this process for surgeons treating acute CMF trauma. This series describes the printing process, time required, and printing material costs involved for in-house printing applied to a variety of acute CMF trauma cases involving the upper, middle, and lower thirds of the face and skull. All consecutive patients requiring in-house 3D printed models in a level 1 trauma center for acute trauma surgery in mid-2019 were identified and analyzed. Nine patients requiring the printing of 12 in-house models were identified. The overall printing time per model ranged from 2 hours, 36 minutes to 26 hours, 54 minutes (mean = 7h 55 min). Filament cost was between $0.20 and $2.65 per model (mean = $0.95). This study demonstrates that in-house 3D printing can be done in a relatively short period of time, therefore allowing 3D printing usage for various acute facial fracture treatments. The rapid improvements in the usability of 3D software and printing technology will likely contribute to further adoption of these technologies by CMF-trauma surgeons.

Intraoperative Surgical Navigation Reduces the Surgical Time Required to Treat Acute Major Facial Fractures.

BACKGROUND: Assessing bone reduction and implant placement in facial fractures is time-consuming because of limited visibility. An intraoperative navigation system allows real-time confirmation of bone positioning and implant placement on the patient's computed tomographic scan. This circumvents the visibility problem and therefore appears to shorten the surgery time. The goal of this study was therefore to determine whether intraoperative navigation reduces the surgical time required to treat patients with acute major facial fractures. METHODS: In this retrospective quasi-experimental study, 50 patients with major facial fractures were identified and randomly assigned to treatment groups. Twenty-two were treated without the use of a navigation system, and 28 were treated using navigation. The Facial frActure Severity Score (FASS) was devised to better assess and control for complexity of cases and control for possible selection bias. RESULTS: The FASS was directly linked to surgery time, whether or not navigation was used. An analysis of covariance demonstrated that the surgical time required to treat major facial fractures, taking into account the FASS, was reduced by 36.1 percent (124.8 minutes) when navigation was used. CONCLUSIONS: This study compared the surgical time required to treat patients with major facial fractures, with and without a navigation system. The use of a navigation system reduced the surgical time by 36.1 percent. This is a significant improvement in reducing the length of craniomaxillofacial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.