Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty.

SUMMARY: As volume and understanding of genital gender affirming surgery (gGAS) has grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and non-binary individuals. Given the diverse spectrum of individuals seeking phalloplasty, we emphasize the importance of patient driven decision-making, beginning with the initial consultation. Phalloplasty surgery is not a one-size-fits-all surgery, but instead should be viewed from an individually-customized approach. This article discusses the technical details for vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty (SOP). The technique involves degloving the clitoral shaft, with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris, and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and re-suspends the labia minora anteriorly, improving final aesthetics and striving to meet patient genital goals.

Venous Tributaries of the Lip: Implications for Lip Filler Injection.

BACKGROUND: Demand for lip filler injection continues to increase. Despite the current literature's acknowledgement of the role both venous and arterial vasculature play in minor and major side effects, research addressing the venous vasculature of the lower one-third of the face is scarce. METHODS: A photographic analysis of the venous vasculature of 26 participants was performed using a vein transilluminator to display the venous flow around the perioral region. The data were analyzed for commonalities among participants and then compared with common lip filler injection techniques and locations. RESULTS: Venous tributaries were identified in all patients, with slight variation in pattern, superior to the upper vermilion border between the nasolabial fold and philtral column on each side of the mouth. Venous tributaries were noted approximately 1 to 1.5 cm lateral to the oral commissures extending inferiorly to the chin and along the labiomental crease. Four areas of venous pooling were deemed significant: a small area approximately 2 mm superior to the Cupid's bow, along the middle tubercle of the upper lip, along the wet-dry line of the lower lip; and centrally along the vermilion border between the lower lip tubercles. CONCLUSIONS: Perioral venous mapping provides a guide for injectors performing lip enhancement procedures in identifying areas at risk for injury because of venous pooling. Avoiding these anatomically vulnerable regions can minimize the potential for inflammation and ecchymosis associated with intravenous injection and prevent dissatisfactory aesthetic results because of lumps, excessive bruising, swelling, or asymmetry.

Upper extremity mass with lipomatous axillary involvement and multiple level encasement of the brachial plexus.

A 40-year-old female presented for surgical consultation of an upper extremity soft tissue mass. Initial ultrasound report recorded a 5.5 cm mass, consistent with a subcutaneous lipoma. Intra-operative visualization revealed an intramuscular lipoma emerging from brachialis muscle. Post-excision MRI was ordered for continued axillary fullness which revealed lipomatous extension into axilla and posterior arm with multiple level encasement of the brachial plexus. Lipomas with brachial plexus involvement are rare and can present with a range of symptoms and distortion of local anatomy. Surgical debulking is challenging requiring microsurgical expertise for adequate removal and to minimize long-term neurological deficits.

Analysis of Nipple-Areola Complex Localization Using Male Cadavers: Considerations for Gender-Affirming Surgery.

BACKGROUND: Masculinizing chest reconstruction is the most common gender-affirming surgery in transgender males. Despite the current literature's acknowledgment of the vital role that proper placement of the nipple-areola complex (NAC) plays in a masculine chest contour, there is still much debate regarding the best anatomical landmarks to achieve the desired result. OBJECTIVES: The primary aim of this study is to determine which landmarks for NAC placement can be applied across diverse body types and aid surgeons in creating a masculine chest. METHODS: Twenty-five formaldehyde-embalmed male cadavers were analyzed by conducting various measurements of the NAC, nipple, and surrounding bony and muscular landmarks to identify the most consistent landmarks for proper NAC placement. Linear regression analyses were run to determine how the distance between nipple to respective landmarks varied based on antemortem body mass index (BMI), height, weight, and age. RESULTS: The measurements for the inferior and lateral borders of the pectoralis major muscle (PMM) displayed the least amount of variance of all the anatomical landmarks studied. Additionally, there was no significant change in these pectoral measurements with varying BMI, height, weight, or age, indicating that these measurements are reliable landmarks for NAC placement across various body types. The average NAC placement in relation to the inferior and lateral borders of PMM was around 2.5 and 2.0 cm, respectively. CONCLUSIONS: Our cadaveric analysis indicates that aesthetically pleasing masculine chest results can be produced consistently across varying body types when adhering to a simple pectoral approach in NAC placement.

The Critical Shoulder Angle as a Diagnostic Measure for Osteoarthritis and Rotator Cuff Pathology.

The purpose of this study was to correlate critical shoulder angle (CSA), a measurement that takes into account both glenoid tilt and the acromial index (AI), with shoulder pathologies as presented in an earlier study by Moor et al. (2013). Based on Moor et al.'s predicted normal CSA range of 30-35°, we hypothesized that a greater-than-normal CSA would be correlated to or associated with rotator cuff pathology, while a smaller-than-normal CSA would be associated with osteoarthritis (OA). Following Moore et al., we utilized Grashey radiographic imaging because it provides the clearest view of the entire glenoid fossa and acromion. We analyzed 323 anterior-posterior (AP) radiographs to identify and measure the CSA, classifying each patient into one of five groups [none reported (n=94), mild OA (n=156), moderate OA (n=36), severe OA (n=37), and rotator cuff pathology (n=40)]. Our results were statistically significant, supporting the association of smaller CSAs with OA and larger CSAs with rotator cuff pathology. CSA measurements could provide a new means for identifying shoulder pathology and thereby reduce the need for costly and timely imaging techniques. CSA values could also provide useful information to utilize preventatively with interventions such as physical therapy to alter the CSA and reduce the prevalence of OA and shoulder arthroplasties. This study builds on the findings of Moore et al. in creating a correlation between CSA and shoulder pathology.