[Autoimmune/inflammatory syndrome induced by aduvants].

For decades, breast implants have been available for breast reconstructions and breast augmentations to improve the patients' health-related quality of life. Silicone implants (SI) have been used since the middle of the last century for breast reconstruction, for example after breast cancer, for birth defects, gender confirmation procedures, or for breast augmentation. Every year, several hundred SI are performed in Iceland for these purposes, but no central register is maintained. It can be estimated that at least 1000 - 3000 women have SI in Iceland and that around 300 Icelandic patients get SI every year. This informal review article discusses the so-called ASIA syndrome, the immunological effects of silicone and the possible relationship of SI to autoimmune diseases, symptoms, and diagnosis. In the methodology, this paper does not rely on the strict conditions of systematic reviews, but the authors relied only on peer-reviewed sources through PubMed, UpToDate and Scopus. The keywords used are silicon, silicon implant, silicon particles, immune response, autoimmunity, autoinflammation, Autoimmune/inflammatory syndrome induced by aduvants, ASIA, ASIA syndrome, breast implant illness. The paper reviews known facts about the disease, its characteristics, and statistical aspects.

Implant Attributes or Patient Characteristics? Factors Affecting Outcome after Breast Augmentation in Transgender Women.

Implant-based breast augmentation is a valuable tool for treatment of gender dysphoria in transgender women. The aim was to assess whether implant attributes, plane selection, and patient characteristics had an impact on the surgical outcome, and to compare these parameters between transgender and cisgender breast augmentations. Methods: A cohort of transgender women who underwent breast augmentation at our department during 2009-2018 were retrospectively studied. The cohort was also compared with a cohort of 12,884 mainly cisgender women registered in the Swedish breast implant registry (BRIMP) during 2014-2019. Results: A total of 143 transgender individuals were included, with a median follow-up of 5.7 years. Complications occurred in 20 patients (14.0%), four patients (2.8%) underwent acute reoperation, and 20 patients (14.0%) had secondary corrections. No differences were seen in complication rates when comparing prepectoral with subpectoral placement (15.1% versus 12.9%; P = 0.81); size, less than 400 mL versus greater than or equal to 400 mL (14.7% versus 13.3%; P = 0.81), or the shape of the implants, round versus anatomic (10.7% versus 22.2%; P = 0.10). In comparison with the cohort from BRIMP, the transgender cohort had more round implants (72.0% versus 60.7%; P < 0.01), larger implants (44.1% had volumes of 400-599 mL, compared with 25.4%; P < 0.0001), and more prepectoral placement (51.0% versus 7.3%; P < 0.0001). The risk of reoperation less than 30 days was 1.2% in BRIMP and 2.8% in the transgender cohort (P = 0.08). Conclusions: In transgender women, implants are often larger, round, and placed prepectoral' compared with cisgender women. Despite these differences, complication rates were equivalent. Implant attributes, surgical techniques, and patient characteristics were not independently associated with the rate of complications.

Improved Surgical Outcome with Double Incision and Free Nipple Graft in Gender Confirmation Mastectomy.

BACKGROUND: Mastectomy and chest-wall contouring is the most common gender confirmation surgery. With increasing prevalence of transgender individuals, there is a demand for better surgical outcomes and aesthetic results. Our aim was to evaluate surgical techniques used and assess modifications in gender confirmation mastectomies at Karolinska University hospital in Stockholm, Sweden. METHODS: A retrospective cohort study was performed on 464 patients undergoing gender confirmation mastectomies in our department between 2009 and 2018. Patient demographics, psychiatric comorbidity, surgical method, and outcome were analyzed. Follow-up was at least one year. RESULTS: The most frequently used surgical technique for gender confirmation mastectomies was double incision with free nipple graft (243 patients, 52.4%), followed by periareolar incision (113 patients, 24.4%) and semicircular incision (67 patients, 14.4%). The double incision technique and periareolar technique were associated with 18.9% and 28.3% complications, 3.3% and 12.4% acute reoperations, 28.4% and 65.5% secondary revisions, respectively. The double incision technique increased from being used in 17.8% of all mastectomies during 2009-2013 to 62.9% during 2014-2018, while periareolar incision decreased from 43.0% to 18.5%. CONCLUSIONS: The current study describes a successful transition of surgical technique from periareolar incision to double incision with free nipple graft in gender confirmation mastectomy, leading to significant improvements in the overall outcome with fewer complications, less acute reoperations and less secondary corrections. Hence, we consider the double incision with free nipple graft technique to be the favored technique in the vast majority of cases in female-to-male chest wall contouring.

The benefits and disappointments following clitoral reconstruction after female genital cutting: A qualitative interview study from Sweden.

Female genital cutting or mutilation refers to the cutting of girls' external genitalia. Due to migration from contexts where female genital cutting is common, it is estimated that around 38 000 cut women and girls live in Sweden. Clitoral reconstruction, a relatively new form of surgical healthcare offered to women with female genital cutting, was established in Sweden in 2014. This surgery aims at restoring clitoral function and anatomy, but there is yet a dearth of evidence demonstrating the effects of the surgery. The aim of this study was to explore how women undergoing clitoral reconstruction in Sweden between 2016 and 2019 experienced the surgical process and its aftereffects from a physical, sexual and psychosocial perspective. Eighteen women who had undergone clitoral reconstruction at a university hospital in Sweden agreed to participate in the study. The women were interviewed using semi-structured interviews, which were recorded, transcribed and analysed using thematic analysis. The results, based on self-categorization and labelling theory, demonstrated both benefits and disappointments following the surgery. Several women reported positive outcomes in terms of sexual, psychosocial and aesthetic terms. They experienced reduced genital pain, improvements in their sex lives, and a sense of feeling more empowered and at ease in their bodies. Yet, some women reported aesthetic, functional and process-related disappointment related to clitoral reconstruction. Nonetheless, the women expressed gratitude for the possibility of undergoing the surgery. In conclusion, the women reported that they experienced physical, sexual and psychosocial benefits of the surgery.

Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty.

INTRODUCTION: After free or pedicled flap phalloplasty, many transgender men need penile prosthesis implantation to successfully engage in penetrative sexual intercourse. Postoperative complications occur frequently. There is a choice between inflatable and malleable penile prostheses. Until recently, no prostheses were designed specifically for this population. AIM: The aim of this study was to describe our preliminary experience with, and surgical outcomes of, implantation of the ZSI 100 FtM Malleable Penile Implant after phalloplasty in transgender men. METHODS: A retrospective chart study was conducted on surgical characteristics and postoperative complications after implantation of the ZSI Malleable Penile Implant in transgender men in 3 European centers for genital transgender surgery in Amsterdam, Stockholm, and Reykjavik. MAIN OUTCOME MEASURE: The main outcomes measures were surgical outcome, complications, and reason of implant failure. RESULTS: 25 patients were retrospectively identified, with a mean age of 36 ± 9 years at implantation. The mean time between prosthesis implantation and phalloplasty was 3.6 ± 2.5 years. 10 patients previously underwent free radial forearm flap phalloplasty, 6 patients had anterolateral thigh flap phalloplasty, 2 patients had superficial circumflex iliac artery perforator phalloplasty, 1 patient had groin flap phalloplasty, and 6 patients underwent combination flap phalloplasty. With a mean follow-up of 6.3 months, prosthesis explantation because of complications was performed in 8 patients (32%), because of infection (n = 3), protrusion (n = 4), or pubic pain (n = 1). In an additional 3 patients, the prosthesis was explanted due to difficulty living with the malleable prosthesis. Of those with the prosthesis in place, 13 of 14 patients (93%) were able to engage in penetrative sexual intercourse. CLINICAL IMPLICATIONS: The current article provides advantages and disadvantages of this medical device. STRENGTH & LIMITATIONS: This is the first study on the ZSI Malleable Penile Implant prostheses in this patient group. It also provides information on the use of malleable prostheses; whereas current literature predominantly focusses on inflatable devices. Limitations comprise the small patient population, short follow-up time, and retrospective nature of the study. CONCLUSION: Complication rates of the ZSI Malleable Penile Implant prosthesis seem high at the start of the learning curve. Although designed specifically for the transgender community, not all transgender patients will be eligible for this type of prosthesis. Patients need to be well counseled on specific (dis)advantages of the prosthesis. Pigot GLS, Sigurjónsson H, Ronkes B, et al. Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty. J Sex Med 2020;17:152-158.

'I want what every other woman has': reasons for wanting clitoral reconstructive surgery after female genital cutting - a qualitative study from Sweden.

Female genital cutting (FGC) involves the removal of women's external genitalia for non-therapeutic reasons. An estimated 38,000 women living in Sweden have undergone some form of the procedure. These women often belong to marginalised minorities of immigrant women from countries where FGC is widespread. Clitoral reconstructive surgery following FGC has recently been introduced in Sweden. This study investigates women's perceptions of FGC and clitoral reconstructive surgery with a particular focus on: (1) reasons for requesting reconstructive surgery, and (2) FGC-affected women's expectations of the surgery. Seventeen women referred for clitoral reconstructive surgery at the Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, participated in the study. Findings revealed five factors motivating women's request for clitoral reconstruction (CR): (1) symbolic restitution - undoing the harm of FGC; (2) repairing the visible stigma of FGC; (3) improving sex and intimacy through physical, aesthetic and symbolic recovery; (4) eliminating physical pain; (5) and CR as a personal project offering hope. These factors were highly interconnected, suggesting that the reasons for seeking surgery were often multiple and complex.

Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery.

PURPOSE OF THE REVIEW: The aim of this review is to give an overview of the recent evidence on clitoral reconstruction and other relevant reconstructive plastic surgery measures after female genital mutilation/cutting (FGM/C). RECENT FINDINGS: Recent publications present refinements and modifications of the surgical technique of clitoral reconstruction along with reconstruction of the labia majora and clitoral hood. Novel approaches with reposition of the clitoral nerve, anchoring of the labia majora, fat grafting, and full thickness mucosa grafts have been introduced. The current evidence on outcomes of clitoral reconstruction shows potential benefits. However, there is a risk of postoperative complications and a negative outcome. Experts in the field advocate for a multidisciplinary approach including psychosexual counseling and health education with or without subsequent clitoral reconstructive surgery. SUMMARY: The evolution of reconstructive treatment for women with FGM/C is expanding, however at a slow rate. The scarcity of evidence on clitoral reconstruction halters availability of clinical guidelines and consensus regarding best practice. Clitoral reconstruction should be provided by multidisciplinary referral centers in a research setting with long-term follow-up on outcomes of postoperative morbidity and possible benefits.

Quality of life improves early after gender reassignment surgery in transgender women.

BACKGROUND: Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS). METHODS: We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. RESULTS: On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined. CONCLUSIONS: To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group. Level of evidence: Level III, therapeutic study.

Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery.

INTRODUCTION: A cornerstone of treating gender dysphoria for transgender women is gender reassignment surgery (GRS) encompassing vaginoplasty and clitoroplasty. The neoclitoris is harvested as a flap with a neurovascular pedicle from the proximal dorsal part of the glans penis. Few long-term follow-ups exist on postoperative sensation and patient-reported sexual functionality of the neoclitoris. AIM: To examine the sensitivity of the neoclitoris and its relation to orgasm and sexual function at least 1 year after GRS. METHODS: Twenty-two patients were included, with a mean follow-up of 37 months (range = 12-63) after initial surgery. Tactile and vibratory sensitivities were measured with Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A questionnaire was provided to the patients, as were interview questions about body image, orgasm, pain, and general satisfaction with the surgery. MAIN OUTCOME MEASURES: Tactile and vibratory sensitivities of the neoclitoris and questionnaire on satisfaction with orgasm, sexual function, and general satisfaction. RESULTS: The average tactile threshold for the clitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. Most participants (86%) experienced orgasm after surgery, had no or little pain, and were satisfied with the surgery. No statistical correlation was found between better or worse objective pressure and vibratory thresholds and patient answers to questions about the clitoris in the Body Image Scale for Transsexuals questionnaire. CONCLUSION: The neoclitoris derived from the glans penis in GRS provides long-term clitoral sensation that is erogenous. Overall, the vast majority of patients who undergo male-to female GRS experience orgasm and are satisfied with the surgery.

Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery.

BACKGROUND: Gender reassignment surgery due to transsexualism (International Classification of Diseases, Tenth Revision: F64.0) is a procedure becoming increasingly common worldwide as a result of a significant increase in diagnostic incidence. Several methods have been described for this complex surgery, but no internationally agreed upon gold standard exists, in particular with regard to which methods allow for creating a sufficient neovaginal depth. METHODS: We use a 2-stage technique using solely penile skin for creating a neovaginal cavity and present the long-term outcome in terms of measured neovaginal depth. Eighty patients were included. Patients' neovaginal depth was measured in a standardized fashion 6 months or more after initial surgery. Results were compared with published data on female anatomy. RESULTS: The average neovaginal depth achieved was 10.2 cm. Having had a postoperative complication and noncompliance to neovaginal dilatation were both negatively correlated with neovaginal depth, whereas higher body mass index was not. Most patients received a neovaginal depth sufficient for penetrative intercourse and within the range for biological women. CONCLUSIONS: Using solely penile skin for the vaginal lining is a satisfactory surgical method to achieve adequate vaginal depth, provided that the postoperative dilatation regimen is followed. This holds true regardless of age or body mass index.

[Outcome of myocardial revascularisation in Iceland]. / Árangur kransaedahjáveituadgerda á Íslandi 2002-2006.

INTRODUCTION: In Iceland over 3500 coronary artery bypass operations have been performed, both On-Pump, using cardiopulmonary bypass and Off-Pump, surgery on a beating heart. The aim was to study their outcome. MATERIAL AND METHODS: This was a retrospective study on 720 consecutive patients who underwent surgical revascularisation at Landspítali-The National University Hospital of Iceland between 2002-2006; 513 On-Pump and 207 Off-Pump patients. Complications and operative mortality (<30 days) were compared between the groups and predictors of survival identified using multivariate analysis. RESULTS: The number of males was significantly higher in the On-Pump group, but other risk factors of coronary artery disease, including age and high body mass index, were comparable, as were the number of distal anastomoses and EuroSCORE. The Off-Pump procedure took 25 minutes longer on average and chest tube output was significantly increased, but the amount of transfusions administered was similar. The rate of minor complications was higher in the On-Pump group. Of the major complications, stroke rates were similar in both groups (2%) but the rate of reoperation for bleeding was higher in the On-Pump group. Mean length of hospital stay was one day longer for On-Pump patients but operative mortality was similar for both groups (4% vs. 3%, p=0.68) as was 5 year survival (92% in both groups). In multivariate analysis both EuroSCORE and age predicted outcome of operative mortality and long term survival but type of surgery (On-Pump vs. Off-Pump) was not a predictive variant. CONCLUSIONS: Outcome of myocardial revascularisation in Iceland is good as regards operative mortality and long term survival. This applies to both conventional On-Pump and Off-Pump procedures.

Lower mortality following coronary arterial revascularization in patients taking statins.

OBJECTIVES: Numerous studies have suggested that statins have beneficial non-lipid-lowering effects, including reduction of systemic inflammatory response following surgery. We wanted to evaluate the effect of preoperative statin treatment on complications and operative mortality after coronary arterial revascularization. DESIGN: We performed a retrospective study of 720 consecutive patients who underwent on-pump coronary artery bypass grafting (CABG) (n = 513) or off-pump (OPCAB) (n = 207) in Iceland from 2002-2006. Patients taking statins preoperatively (n = 529) were compared with those not taking statins (n = 191). Predictors of complications and operative mortality were evaluated by univariate and multivariate analysis. RESULTS: Cardiovascular risk profiles were similar. However, hypertension was more common in the statin group but EuroSCORE was slightly lower. Operative mortality was significantly lower in patients taking statins (1.7% vs. 5.8%, p < 0.001). There were no significant differences in the incidence of major complications. Multivariate analysis showed that preoperative statin treatment was an independent predictor of lower operative mortality (OR = 0.33, p = 0.043), even after adjusting for EuroSCORE, acute operations, advanced age, or other medications. CONCLUSIONS: In this non- randomized study, patients taking statins had lower operative mortality than the controls after adjusting for multiple confounders. The reason for this might be linked to pleiotropic effects of statins.

Cardiac myxoma in Iceland: a case series with an estimation of population incidence.

Cardiac myxoma (CM) is the most common primary benign tumor of the heart, but the true age-standardized incidence rate (ASR) has remained unknown. We therefore used nationwide registries in Iceland to study CM and establish its incidence rate. This was a retrospective study involving all patients diagnosed with CM in Iceland between 1986 and 2010. Cases were identified through three different registries, and hospital charts and histology results reviewed. An ASR was estimated based on a world standard population (w). Nine cases of CM (six women) were identified with a mean age of 62.8 years (range: 37-85), giving an ASR of 0.11 (95% CI: 0.05-0.22) per 100,000. The mean tumor size was 4.4 cm (range: 1.5-8.0) with all the tumors located in the left atrium. Dyspnea (n = 6) and ischemic stroke (n = 2) were the most common symptoms. All patients underwent complete resection of the tumor and there were no postoperative deaths or CM-related deaths at follow-up (mean 85 months). The ASR of CM in Iceland was 0.11 per 100,000. To our knowledge, this is the first study to determine the incidence of CM in an entire population. In Iceland, the presenting symptoms and mode of detection of CM are similar to those in other series.

[Impact of obesity on surgical outcomes following coronary artery bypass graft surgery]. / Tengsl offitu við árangur kransæðahjáveituaðgerða.

INTRODUCTION: Obesity has been related to increased postoperative morbidity and mortality following open-heart surgery. However, recent studies have shown no association or even a more favourable outcome in obese patients. This relationship was investigated in a well-defined cohort of patients that underwent myocardial revascularisation in Iceland. MATERIAL AND METHODS: A retrospective study including all patients that underwent isolated myocardial revascularisation in Iceland from 2002 to 2006. Altogether 720 patients were divided into two groups, an obese group, with BMI >30 kg/m2 (n=207, 29%), and a non-obese group with BMI ≤30 kg/m2 (n=513, 71%). Patient demographics, complications, operative mortality and long term survival of both groups were compared. RESULTS: Demographics were comparable between the groups. Obese patients were 2.4 years younger, more likely to use statins (83,3% vs. 71,2%, had a significantly lower EuroSCORE (4.3 vs. 5.0) but a slightly longer operation time. Pleural fluid was less often drained in obese patients (8.2 vs. 15.0%) but rates for other complications were similar in both groups, as was operative mortality ≤30 days (2.0% vs. 3.7%), 1 and 5 year survival. In a multivariate analysis obesity was not an independent risk factor for minor or major complications, operative mortality or long term survival. CONCLUSION: The rate of complications and operative mortality after myocardial revascularisation is not significantly higher in obese patients and the same applies to long term survival. This is true even after correcting for confounding factors in a multivariate analysis.

[Reoperation for bleeding following open heart surgery in Iceland]. / Enduradgerdir vegna blaedinga eftir opnar hjartaskurdadgerdir á Islandi.

INTRODUCTION: Postoperative bleeding is a common and potentially fatal complication following open heart surgery, studies reporting a reoperation rate for bleeding in the range of 2-6%. Surgical outcome after such reoperations has not been previously studied in Iceland. MATERIAL AND METHODS: In this retrospective study were included all adults that underwent open heart surgery in Iceland during a 6 year period, between January 1, 2000 and December 31, 2005. RESULTS: There were 103 reoperations (mean age 68 years, 76% males), but throughout the same 6 year period a total of 1295 open heart procedures were performed, the reoperation-rate being 8%. One third of all patients were on aspirin and 8% on clopidogrel less than 5 days before surgery. The bleeding in the primary operation averaged 1523 ml (range 300-4780) and 3942 ml for the first 24 hours postoperatively. Half of the patients were reoperated on within 2 h and 97% within 24 hours. The patients received on average 16.5 units of packed cells, 15.6 units of plasma and 2.3 sets of thrombocytes. The most common postoperative complication was atrial fibrillation (58.3%), pleural effusion that needed chest tube drainage (24.3%), myocardial infarction (23.3%) and sternal wound infection (11.7%). Median length of stay was 14 days (range 6-85), including 2 days (range 1-38) in ICU. Operative mortality was 15.5% and 1 year crude survival 79.6%. CONCLUSION: Reoperation-rate for bleeding was 8%, which is higher compared to other studies. Bleeding is a serious complication following open heart surgery with high morbidity and significant mortality.

[Apical ballooning syndrome, case series]. / Broddthensluheilkenni--sjúkratilfelli og yfirlit.

Apical ballooning syndrome is a cardiac syndrome typically characterized by transient focal dyskinesia or akinesia of the mid and apical regions of the left ventricle and hyperkinesia of the basal region. The symptoms and signs of the patient mimic myocardial infarction, with chest pain, electrocardiographic changes and elevation of cardiac enzymes but without significant coronary artery disease. The syndrome is frequently preceded by physical or emotional stress. We describe three cases of apical ballooning syndrome diagnosed during 10 days in December 2007 at Landspítali University Hospital Reykjavík.

[Congenital diaphragmatic hernia diagnosed in adulthood--a case report and review of the literature]. / Fyrirferd í brjóstholi--ekki er allt sem sýnist!

Congenital diaphragmatic hernia (CDH) is a rare anomaly (1 of 2-4000 live births) where abdominal organs can enter the thoracic cavity. It is usually diagnosed shortly after birth, often associated with pulmonary hypoplasia and pulmonary hypertension causing life threatening condition. In approximately one out of four patients CDH is diagnosed later in life, usually within several weeks or months from birth. CDH diagnosed in adulthood is very uncommon. Here we describe a 45 year old previously healthy woman that was diagnosed with a large tumor in her right hemithorax, after having symptoms of chronic cough and chest pain for several months. At thoracotomy the tumor was found to be omentum covered with a hernial sac that had penetrated the chest through a small diaphragmatic hernia. Six months postoperatively she was doing well with no respiratory or abdominal symptoms.