Evaluation of Liposomal Bupivacaine at Split-Thickness Skin Graft Donor Sites Through a Randomized, Controlled Trial.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with <20% TBSA burns was conducted to evaluate the efficacy of liposomal bupivacaine at STSG donor sites. The control group received standard subcutaneous infiltration of dilute lidocaine solution at the STSG donor site, and the experimental group received dilute liposomal bupivacaine infiltration in a similar fashion. Donor site pain scores and opioid consumption in morphine equivalents (MEE) were evaluated. A total of 25 patients were enrolled in each group. There were no statistical differences in demographic variables, and TBSA was 4.0% in both groups (P = .94). There were no statistical differences in pain scores at any time point postoperatively (mean control range 3.1/10-4.9/10, experimental range 3.3/10-4.3/10, P = .12-.96). There were no statistical differences in opioid consumption at 24, 48, or 72 h postoperatively between the groups (mean control MEE range 49.3-71.1, experimental MEE range 63.6-75.8, P = .34-.85). The average length of stay was 7.7 days in both groups (P = .88). No adverse events occurred in either group. There is no statistical benefit to the use of liposomal bupivacaine for infiltration at STSG donor sites compared to standard of care with respect to pain control, opioid use, or length of stay when evaluated in a randomized, controlled fashion.

A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program.

BACKGROUND: Given the burgeoning demand for gender affirmation surgery, there are few studies examining both surgical process variables and patient outcome variables. Knowing the learning curve for surgical teams who are beginning to perform this procedure will be important for patient safety and presurgical patient counseling as more institutions open transgender surgical programs. AIM: The purpose of this study was to determine the demographics of patients pursuing penoscrotal vaginoplasty, to determine their postoperative course, and to determine a learning curve for the surgical team performing penoscrotal vaginoplasty. METHODS: We retrospectively reviewed charts of all 43 patients who underwent penoscrotal vaginoplasty from the commencement of a new male-to-female penoscrotal vaginoplasty program in March 2018 through July 2019. OUTCOMES: Primary outcomes included mean hemoglobin decrease from surgery and operative time. Mean time to neoclitoral sensation, length of hospital admission, complication rates, reoperation rates, length of narcotic use after surgery, and demographics were also evaluated. Associations between surgical team experience and outcomes were assessed with Spearman's rho and Cox regression, and curve-fitting procedures were applied to determine the relationship. RESULTS: The mean operative time from initial incision to procedure finish was 225 minutes, and the mean decrease in hemoglobin was 3.3 g/dL. The mean time to neoclitoral sensation was 0.72 months. The time until neoclitoral sensation decreased as the surgical cases performed increased (Spearman's rho, -0.577 [P < .001]), with a power function best describing the learning curve. Operative time did not change with case number (Spearman's rho, 0.062 [P = .698]) but overall time in the operating room did (Spearman's rho, 0.631 [P < .001]). Mean length of hospital admission was 2.9 days. There were no intraoperative complications. 18 patients (42%) experienced a postoperative complication. 8 of 43 patients underwent reoperation (20%). Narcotics were used a mean of 9.5 days after surgery. CLINICAL IMPLICATIONS: A learning curve can be demonstrated in penoscrotal vaginoplasty for time to neoclitoral sensation and overall time in the operating room, plateauing between 30 and 40 cases. STRENGTHS AND LIMITATIONS: Strengths include assessing a learning curve for time to neoclitoral sensation, length of hospital stay, and length of postoperative narcotic use after penoscrotal vaginoplasty, which, to our knowledge, has not been reported elsewhere. Limitations include our overall low number of patients. CONCLUSION: Despite a low number of cases, length of hospital stay was short and the postoperative complication rate was similar to that of long-standing penoscrotal vaginoplasty programs. Whynott RM, Summers K, Mickelsen R, et al. A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program. J Sex Med 2020;17:1787-1794.