Transgender gender-affirming surgery consultation among patients seeking care in the Midwestern United States.

Gender-affirming surgery (GAS) is among the most rapidly growing and expanding subfields in plastic surgery due to increased awareness, decreased stigma, rising demand, and improved access for transgender and gender non-conforming individuals (TGNC). In order to address potential barriers and facilitators in GAS education and training, there is a need to explore the experiences of TGNC individuals. The purpose of this study was to qualitatively explore the factors that influence TGNC patient experiences in surgical consultation for GAS. Targeted recruitment was used to recruit and enroll participants who identified as TGNC and who had undergone consultation with a surgeon to discuss GAS. Semi-structured interviews were used to explore patient experiences with GAS. Recorded audio from these interviews was later transcribed verbatim. Open coding of these transcripts was then performed independently by 3 individual members of the research team using the consensual qualitative coding methods. Fifteen interviews were conducted (transmale, n = 7; transfemale, n = 4; gender non-conforming/non-binary, n = 4). Participants frequently expressed worry and frustration over insurance coverage and exorbitant out-of-pocket expense, whether actual or perceived. Logistical barriers were the most frequently cited category of barriers. The majority of participants made at least 1 reference to relying on others during the process of insurance pre-authorization. The majority of participants described their interactions with surgeons as positive, indicating that they felt comfortable during consultation and that their surgeons ensured their understanding. Our findings provide important insight into this often stressful and challenging process. Ensuring a welcoming, safe, and gender-affirming environment and experience for these individuals is essential. These findings may help to guide future education for medical students, trainees, clinic staff, and surgeons, as well as to direct changes necessary to improve the patient experience in clinics and hospitals for TGNC individuals undergoing consultation for GAS.

Review of Health Insurance Policy Inclusivity of Gender Nonconforming and Nonbinary Individuals Seeking Gender-Affirming Health Care.

Background: An increasing number of individuals who present to health care professionals identify as transgender, gender nonconforming (GNC), and gender nonbinary (NB). GNC/NB individuals experience higher rates of discrimination in health care settings compared with their binary (e.g., trans male and trans female) counterparts. Outdated language excludes the nuances of gender identity. The goal of this study was to evaluate whether current terminology found in health insurance policies may be a barrier to gender-affirming health care for GNC/NB individuals. Methods: Health insurance policies for a diverse subset of government (n=4) and private (n=6) payers were obtained in May 2020. Policies were reviewed independently by two members of the research team to determine whether each was supportive or unsupportive to GNC/NB individuals. An arbitrary scoring system was designed that allowed the reviewers to assign a specific number of points to each policy based on the aggregation of mention, coverage, and inclusivity. Results: Most policies performed poorly as indicated by a support score less than zero. It was also noted that most policies used binary, gendered language, and terminology that excludes the unique gender identities of many GNC/NB individuals. Conclusions: Most policies currently failed to provide clear, inclusive coverage to GNC/NB individuals for relevant and important aspects of their care. In their current state, these policies are a source of confusion, uncertainty, and discouragement for these individuals, which can present as a barrier to accessing quality, inclusive, gender-affirming health care.

Ultradelayed Arterial Thrombosis: Critical Flap Ischemia After Phalloplasty.

BACKGROUND AND OBJECTIVES: Delayed arterial thrombus causing loss of a cutaneous free flap at or beyond 6 months is a rare phenomenon. The purpose of this report is to describe 2 cases of arterial compromise requiring medical and surgical intervention at or beyond 6 months after radial forearm free flap (RFFF) phalloplasty and to define the phenomenon of ultradelayed arterial thrombosis. METHODS: Patient 1 is a 44-year-old transmale who presented with pulselessness, pallor, and hypersensitivity of his neophallus 10 years status post-RFFF phalloplasty using a saphenous vein interposition graft (SVIG) between the superficial femoral artery (SFA) and radial artery (RA). Patient 2 is a 35-year-old transmale who presented with similar complaints 6 months status post-RFFF phalloplasty with the same vascular connections as above. RESULTS: Patient 1 was found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator, resulting in partial loss limited to the distal three fourths of the shaft. Patient 2 was also found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator and common femoral artery CFA-RA bypass, resulting in partial loss limited to the neoglans. CONCLUSIONS: Ultradelayed arterial thrombosis is a rare phenomenon requiring urgent intervention. The exact causes of this phenomenon, whether mechanical or physiological or both, have yet to be fully elucidated but it is hypothesized that the original anastomosis may continue to serve as the critical blood supply to its flap as far as 10 years after surgery.

Nonsurgical Tissue Repositioning: Analysis of Long-Term Results and Patient Satisfaction From 100 Absorbable Suture Suspension Cases.

BACKGROUND: Absorbable suspension sutures are the only nonsurgical modality approved for tissue repositioning. OBJECTIVES: To quantitate patient perceptions of treatment at 24 months and determine the impact of age and prior surgical procedures on perceptions of efficacy, treatment longevity, and overall satisfaction. In addition, the authors sought to describe the impact of treatment with absorbable suspension sutures on the likelihood a patient will undergo future surgical procedures. METHODS: The first 100 treated patients who underwent treatment with absorbable suspension sutures, by the senior author, were critically evaluated. Subjects completed surveys 24 months following initial treatment. RESULTS: Of the initial 100 patients, complete records were available for 80 patients (age 39-86). Eighteen (22.5%) received a second treatment with absorbable suspension sutures and average time to second treatment was 23.4 months (range 13-37 months). Overall satisfaction was affected by age, 100% of patients ≤ 50 vs. 60% of patients > 50 (P = 0.026). Prior surgery appeared to be a factor in patient perception of efficacy: 82.6% of patients with no prior surgery indicated that absorbable suspension sutures were effective vs. 45.5% of patients with a prior surgical procedure (P = 0.0286). Just under one third of pretreatment surgical patients underwent surgery following treatment while 25% of surgery naïve patients went on to have surgery. Importantly, satisfaction with the initial procedure does not preclude later surgery. CONCLUSIONS: Treatment with absorbable suspension sutures is associated with high satisfaction through 24 months and does deter patients from surgery. The combination of lift and volumization results in 4-dimensional rejuvenation that includes rejuvenation of dynamic expression.

Using the BODY-Q to Evaluate Appearance and Quality of Life Following Treatment of Skin Laxity of the Outer Thigh with Microfocused Ultrasound and Calcium Hydroxylapatite.

BACKGROUND: Two procedures that have demonstrated collagen-stimulating properties and improvements in skin laxity in a variety of aesthetic indications are microfocused ultrasound with visualization (MFU-V) and injection with calcium hydroxylapatite (CaHA). OBJECTIVES: By treating skin laxity with a combination of these therapies, it was hypothesized that our patients would experience improved appearance and quality of life as measured by the BODY-Q. METHODS: A total of 60 consecutive female patients aged 30 to 60 years with body mass index less than 28 kg/m2 who expressed interest in treatment for skin laxity affecting the outer thighs completed selected scales (Body Image, Appraisal of Excess Skin, Satisfaction with Hips and Outer Thighs, and Appearance-Related Psychosocial Distress) from the BODY-Q within 1 week of treatment. At the time of treatment, MFU-V was directed to the outer thighs (150 lines at focal depths of 3.0 and 4.5 mm per outer thigh). Immediately following MFU-V, patients received treatment with CaHA injected into the subdermis (1.5 mL diluted 1:1 with 1.5 mL of 2% lidocaine solution per outer thigh). At 90 days posttreatment, these patients repeated the BODY-Q. RESULTS: At 90 days posttreatment, with 100% follow-up among the 60 consecutive female patients treated, scores from the BODY-Q scales showed statistically significant improvement (P < 0.01). CONCLUSIONS: Following treatment of skin laxity on the outer thighs with a combination of MFU-V and CaHA, our patients reported a statistically significant improvement in appearance and quality of life at 90 days posttreatment. This protocol may be applicable to other areas of the body.

The effect of contralateral prophylactic mastectomy on breast-related charges: A 5-year analysis.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine charges following unilateral mastectomy (UM) and bilateral mastectomy (BM) for patients with unilateral breast cancer (UBC). We hypothesized that BM may be associated with fewer charges over time. METHODS: A retrospective review was conducted of patients with UBC treated between 2006 and 2010 with UM and BM in a large healthcare system. Institutional billing data were investigated for 5 years postoperatively to calculate the immediate and subsequent charges of all inpatient and outpatient breast-related care associated with the initial diagnosis for a subset of patients identified using propensity score matching method. RESULTS: A subset of matched patients (n = 320) undergoing UM (n = 160) or BM (n = 160) were included in this analysis. At 1 year, there was a trend toward lower total charges following UM as compared with BM (median, $125 230 vs $138 467; P = .6075). However, during years 2 to 5, total charges were significantly higher following UM vs BM ($22 128 vs $13 478; P = .0116). CONCLUSIONS: While initially higher, overall charges for BM are lower than UM between 2 and 5 years out from surgery. Further study is necessary to determine if this trend is sustained over the long term. These data can inform patient decision making regarding mastectomy for their breast cancer.

Assessing Patient Satisfaction Among Transgender Individuals Seeking Medical Services.

BACKGROUND: Gender dysphoria is estimated to occur in up to 0.4% of the US population. Gender-confirming surgery (GCS) has been shown to improve the quality of life of transgender patients. However, a dearth of standardized and reliable measures specific to transgender individuals exists to objectively gauge sensitivity and competency among providers caring for these patients. METHODS: A comprehensive literature search of PubMed, MEDLINE, ISI Web of Science, and Cochrane databases using search terms related to provider competency and sensitivity during consultation for GCS was conducted for studies published through December 2017. Data were gathered from the publications that met inclusion criteria. RESULTS: The total number of articles focusing on transgender persons was 14 of more than 75,000 patient satisfaction-oriented published articles (<0.001%). Only 8 (57%) of the 14 represented original research. After applying the inclusion criteria, only 2 were found to discuss measures of patient satisfaction specific to transgender individuals. Of these 2, none evaluated patient satisfaction specific to the time of surgical consultation. CONCLUSIONS: With increasing awareness and decreasing stigma surrounding transgender issues, it is likely that more transgender individuals will begin to seek GCS. There is a need for patient-reported experience measures specific to transgender individuals in order to appropriately gauge the interactions they experience with their surgeons. However, current instruments are neither standardized nor reliable for transgender patients to gauge provider sensitivity and competency.

Delayed versus Delayed-Immediate Autologous Breast Reconstruction: A Blinded Evaluation of Aesthetic Outcomes.

BACKGROUND: The technique of delayed-immediate breast reconstruction includes immediate insertion of a tissue expander, post-mastectomy radiation, followed by reconstruction. The aesthetic benefits of delayed-immediate reconstruction compared to delayed reconstruction are postulated but remain unproven. The purpose of this study was to compare aesthetic outcomes in patients following delayed and delayed-immediate autologous breast reconstruction. METHODS: A retrospective analysis was performed of all patients who underwent delayed or delayed-immediate autologous breast reconstruction by the senior author from 2005 to 2011. Postoperative photographs were used to evaluate aesthetic outcomes: skin quality, scar formation, superior pole contour, inferior pole contour, and overall aesthetic outcome. Ten non-biased reviewers assessed outcomes using a 5-point Likert scale. Fisher's Exact and Wilcoxon-Mann-Whitney tests were used for comparative analysis. RESULTS: Patient age and body mass index were similar between delayed (n=20) and delayed-immediate (n=20) cohorts (P>0.05). Skin and scar quality was rated significantly higher in the delayed-immediate cohort (3.74 vs. 3.05, P<0.001 and 3.41 vs. 2.79, P<0.001; respectively). Assessment of contour-related parameters, superior pole and inferior pole, found significantly improved outcomes in the delayed-immediate cohort (3.67 vs. 2.96, P<0.001 and 3.84 vs. 3.06, P<0.001; respectively). Delayed-immediate breast reconstruction had a significantly higher overall score compared to delayed breast reconstructions (3.84 vs. 2.94, P<0.001). Smoking and the time interval from radiation to reconstruction were found to affect aesthetic outcomes (P<0.05). CONCLUSIONS: Preservation of native mastectomy skin may allow for improved skin/scar quality, breast contour, and overall aesthetic outcomes following a delayed-immediate reconstructive algorithm as compared to delayed breast reconstruction.

The impact of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study.

BACKGROUND: Negative-pressure wound therapy with instillation is a novel wound therapy that combines negative pressure with instillation of a topical solution. METHODS: This retrospective, historical, cohort-control study examined the impact of negative-pressure wound therapy with and without instillation. RESULTS: One hundred forty-two patients (negative-pressure wound therapy, n = 74; therapy with instillation, 6-minute dwell time, n = 34; and therapy with instillation, 20-minute dwell time, n = 34) were included in the analysis. Number of operative visits was significantly lower for the 6- and 20-minute dwell time groups (2.4 ± 0.9 and 2.6 ± 0.9, respectively) compared with the no-instillation group (3.0 ± 0.9) (p ≤ 0.05). Hospital stay was significantly shorter for the 20-minute dwell time group (11.4 ± 5.1 days) compared with the no-instillation group (14.92 ± 9.23 days) (p ≤ 0.05). Time to final surgical procedure was significantly shorter for the 6- and 20-minute dwell time groups (7.8 ± 5.2 and 7.5 ± 3.1 days, respectively) compared with the no-instillation group (9.23 ± 5.2 days) (p ≤ 0.05). Percentage of wounds closed before discharge and culture improvement for Gram-positive bacteria was significantly higher for the 6-minute dwell time group (94 and 90 percent, respectively) compared with the no-instillation group (62 and 63 percent, respectively) (p ≤ 0.05). CONCLUSION: The authors' results suggest that negative-pressure wound therapy with instillation (6- or 20-minute dwell time) is more beneficial than standard negative-pressure wound therapy for the adjunctive treatment of acutely and chronically infected wounds that require hospital admission. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Mesenteric ischemia secondary to toxic epidermal necrolysis: case report and review of the literature.

A 28-year-old otherwise healthy man was admitted to the burn center for treatment of toxic epidermal necrolysis (TEN) involving 90% of the TBSA and oropharynx. On hospital day 8, his cutaneous lesions were healing well, but he developed respiratory distress, fever, and abdominal distension. Computerized tomography demonstrated distended bowel, pneumatosis intestinalis, and portal venous gas. He underwent emergent celiotomy. Patchy areas of nonperforated necrosis along the jejunum and ileum were present. No mechanical or embolic source of ischemia could be identified. A 120-cm segment of ischemic small bowel was resected and the abdomen was closed temporarily. On planned "second look" the following day, no further disease was encountered and intestinal continuity was restored. Tube feeds were then initiated and the patient's recovery was uneventful thereafter. Although traditionally considered a skin disorder, TEN may be more accurately described as a disorder affecting the junction of an epithelium and its supporting tissue. It is most prominently manifested at the epidermal-dermal junction, but epithelial-submucosal junctions are also affected. The ocular, respiratory, genitourinary, and gastrointestinal manifestations of TEN are variable and incompletely understood. This disease is rooted in immunological dysfunction and the small bowel is rich in immunologically active tissue; Peyer patches and lymph nodes abound. Clinicians should be vigilant for gastrointestinal tract involvement, which is potentially treatable with resection of the ischemic bowel. The authors suspect that, given the critical condition of many TEN patients, bowel symptoms may be incorrectly attributed to global hypoperfusion and sepsis.

Longevity mutation in SCH9 prevents recombination errors and premature genomic instability in a Werner/Bloom model system.

Werner and Bloom syndromes are human diseases characterized by premature age-related defects including elevated cancer incidence. Using a novel Saccharomyces cerevisiae model system for aging and cancer, we show that cells lacking the RecQ helicase SGS1 (WRN and BLM homologue) undergo premature age-related changes, including reduced life span under stress and calorie restriction (CR), G1 arrest defects, dedifferentiation, elevated recombination errors, and age-dependent increase in DNA mutations. Lack of SGS1 results in a 110-fold increase in gross chromosomal rearrangement frequency during aging of nondividing cells compared with that generated during the initial population expansion. This underscores the central role of aging in genomic instability. The deletion of SCH9 (homologous to AKT and S6K), but not CR, protects against the age-dependent defects in sgs1Delta by inhibiting error-prone recombination and preventing DNA damage and dedifferentiation. The conserved function of Akt/S6k homologues in lifespan regulation raises the possibility that modulation of the IGF-I-Akt-56K pathway can protect against premature aging syndromes in mammals.