Gender-affirming hysterectomy in the United States: A comparative outcomes analysis and potential implications for uterine transplantation.

PURPOSE: Hysterectomy is a gynecological procedure sometimes performed as part of the gender-affirming process for transgender and gender-expansive patients assigned female at birth. Our goal was to compare surgical outcomes between patients undergoing gender-affirming hysterectomy and patients undergoing hysterectomy for benign menstrual disorders. We then explored the implications of gender-affirming hysterectomy for uterine transplantation. METHODS: We performed a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2009 through 2018. We identified patients undergoing hysterectomy in the United States based on Current Procedural Terminology code. We used the International Classification of Diseases 9 or 10 codes to identify patients with benign menstrual disorders (non-gender-affirming group) and gender dysphoria (gender-affirming group). We compared patient characteristics and surgical complications. RESULTS: Of the 40,742 patients that met inclusion criteria, 526 (1.3%) patients were individuals with gender dysphoria. Compared to patients who underwent hysterectomy for benign menstrual disorders, gender-affirming patients were younger, were healthier, had a lower prevalence of diabetes, and were more likely to undergo surgery in the outpatient setting, with shorter time to discharge. Complication rates were similar between groups. Logistic regression controlling for the American Society of Anesthesiology classification determined the difference of return to the operating room was not statistically significant (OR 1.082; 95% CI, 0.56-2.10; p = 0.816). CONCLUSION: Gender-affirming hysterectomy has a safety profile similar to hysterectomy performed for benign menstrual disorders. Researchers should further explore the possibility of uterus donation among these patients as they may be suitable candidates.

Comparative Outcomes of Malar Implants Versus Fat Transfer to Cheeks Among Transfeminine Individuals Undergoing Malar Augmentation.

BACKGROUND: Malar augmentation is a key procedure sought out by transfeminine individuals seeking to feminize their facial appearance. Different surgical techniques have been described in the literature including fat transfer to the cheeks and malar implant placement. Because of the paucity of information in the literature, there is no consensus on best practices for this procedure. The objective of our study is to determine the effectiveness and safety of malar implants as compared with fat transfer to the cheeks in transfeminine individuals. METHODS: We examined all patients with the diagnosis of gender dysphoria that were referred to the senior author seeking consultation for feminizing facial procedures between June 2017 and August 2022. Patients who underwent fat transfer to the cheeks or malar implant placement were included in our study. We reviewed the electronic medical record of each patient, and we retrieved and analyzed data regarding demographics, medical and surgical history, operative dictations, clinic notes, and postoperative follow-up. Univariate analysis was used to assess for differences in postoperative complications between these 2 groups. RESULTS: We identified 231 patients underwent feminizing facial gender affirming surgery, with 152 patients receiving malar augmentation through malar implants or fat grafting. One hundred twenty-nine patients (84.9%) underwent malar implant placement and 23 (15.1%) underwent fat grafting to the cheeks. The mean follow-up time was 3.6 ± 2.7 months. Patient satisfaction was greater in the malar implant group (126/129, 97.7%) compared with the fat transfer group (20/23, 87%, P < 0.045). Two patients who received implants (1.8%) experienced postoperative complications. No patient undergoing fat transfer experiences similar adverse outcomes. Nevertheless, the difference was not statistically significant (P = 1.00). CONCLUSIONS: Our findings support the contention that malar implants are a safe alternative for malar augmentation among transfeminine individuals. While autologous fat transfer to the cheek is an indispensable option in patients requiring minor malar enhancement, malar implants offer a more permanent option with a better aesthetic outcome in patients requiring major malar enhancement. To minimize postoperative complications, surgeons should emphasize patient compliance with postoperative directions.

Graft Survival and Acute Rejection in Cross-Sex Solid Organ Transplants: A Systematic Review and Meta-Analysis to Inform Vascularized Composite Allotransplantation Practice.

BACKGROUND: Out of nearly 90 hand and 50 face transplant recipients, only 5 have received a cross-sex vascularized composite allotransplantation (CS-VCA) to date. CS-VCA has the potential to expand the donor pool and has been shown to be anatomically feasible and ethically acceptable in previous cadaveric and survey studies. However, there is a lack of immunologic data. This study aims to evaluate the immunologic feasibility of CS-VCA through analysis of the solid organ transplant (SOT) literature, given the paucity of CS-VCA data. We hypothesize the rates of acute rejection (AR) and graft survival (GS) in CS vs. same-sex (SS)-SOT to be similar. METHODS: A systematic review and meta-analysis of the PubMed, EMBASE, and Cochrane databases were performed in accordance with PRISMA guidelines. Studies comparing GS or AR episodes in CS- and SS- adult kidney (KT) and liver transplant (LT) populations were included. Odds ratios were calculated for overall GS and AR for all SS and CS transplant combinations (male-to-female (MTF), female-to-male (FTM) and overall). RESULTS: A total of 693 articles were initially identified and 25 studies were included in the meta-analysis. No significant difference in GS was noted between SS-KT vs. CS-KT (OR 1.04 [1.00, 1.07]; P=0.07), SS-KT vs. MTF-KT (OR 0.97 [0.90, 1.04]; P=0.41) and SS-LT vs. MTF-LT (OR 0.95 [0.91, 1.00]; P=0.05). No significant difference in AR was noted between SS-KT vs. MTF-KT (OR 0.99 [0.96, 1.02]; P=0.57), SS-LT vs. CS-LT (OR 0.78 [0.53, 1.16]; P=0.22) and SS-LT vs. FTM-LT (OR 1.03 [0.95, 1.12]; P=0.47). For the remaining pairings, GS was significantly increased and AR was significantly decreased in the SS transplants. CONCLUSIONS: Published data suggest immunologic feasibility of CS-KT and CS-LT, with the potential for generalization to the VCA population. In theory, CS-VCA could expand the potential donor pool, leading to decreased wait times for recipients.

Characterizing Cleft Rhinoplasty Across Skeletal Maturity: A Systematic Review of Terminology and Surgical Techniques.

OBJECTIVE: The purpose of this study is to assess cleft rhinoplasty terminology across phases of growth.Design/Setting: A systematic review was performed on cleft rhinoplasty publications over 20 years.Interventions: Studies were categorized by age at surgical intervention: infant (<1 year); immature (1 to 14 years); mature (>15 years).Main Outcome Measures: Collected data included terminology used and surgical techniques. RESULTS: The 288 studies included demonstrated a wide range of terminology. In the infant group, 51/54 studies used the term "primary." In the immature group, 7/18 studies used the term "primary," 3/18 used "secondary." In the mature group, 2/33 studies used the term "primary," 16/33 used "secondary," 2/33 used "definitive," 5/33 used terms such as "mature," "adult," and "late," and 8/33 did not use terminology.Surgical technique assessment demonstrated: cleft rhinoplasty at infancy used nostril rim or no nasal incision, immature rhinoplasty used closed and open rhinoplasty incisions; and mature rhinoplasty used a majority of open rhinoplasty. Infant and immature cleft rhinoplasty incorporated septal harvest or spur removal in <10% of cases, whereas these procedures were common in mature rhinoplasty. No studies in infants or immature patients used osteotomies or septal grafts, common techniques in mature rhinoplasty. CONCLUSIONS: Current terminology for cleft rhinoplasty is varied and inconsistently applied across stages of facial development. However, cleft rhinoplasty performed at infancy, childhood, and facial maturity are surgically distinct procedures. The authors recommend the terminology "infant," "immature," and "mature" cleft rhinoplasty to accurately describe this procedure within the context of skeletal growth.

Perioperative Medication Management in Elective Plastic Surgery Procedures.

BACKGROUND: Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes. METHODS: A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English. RESULTS: A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together. CONCLUSIONS: The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

Systematic Review and Meta-analysis of Facial Anthropometric Variations Among Cisgender Females of Different Ethnicities: Implications for Feminizing Facial Gender Affirming Surgery.

BACKGROUND: Feminizing Facial Gender-Affirming Surgery (FFGAS) is gaining popularity among the diverse population of patients impacted by gender incongruence. However, most studies examining facial femininity are based on Caucasians. Thus, it is unclear if ethnic differences exist in anthropometric measures relevant to FFGAS procedures. This study aims to analyze ethnic anthropometric variations in the cisgender female face to identify differences that are potentially relevant to FFGAS. METHODS: A systematic review and meta-analysis of the PubMed, EMBASE, and Cochrane databases was performed following PRISMA guidelines on June 25, 2021. Original studies reporting facial anthropometry in cisgender women were included. Anthropometric measures of interest included mandibular and zygomatic width, facial and forehead height, and nasolabial angle. A meta-analysis was performed using a linear mixed-effects model for each anthropometric measure. RESULTS: A total of 1246 abstracts were screened, yielding 21 articles that met the inclusion criteria. Facial anthropometric data of 4792 cisgender females of 16 different ethnicities were analyzed. This meta-analysis demonstrated that compared with Caucasian cisgender women, Japanese, Chinese, and Korean cisgender women had a wider mandible (Japanese +20.13 mm [SE 4.43, P <0.001, P value adjusted for multiple comparisons (p-adj)=0.002], Chinese +16.22 mm [SE 4.39, P =0.002, p-adj=0.013]; and Korean +14.46 mm [SE 3.97, P =0.002, p-adj=0.014]). Further, when compared with Caucasian cisgender women, Chinese cisgender women demonstrated a larger zygomatic width, African American cisgender women tended to have smaller nasolabial angles, and Indian and Japanese cisgender women tended to have a smaller and larger facial height, respectively. However, following P value adjustment for multiple comparisons, these differences were not found to be statistically significant. CONCLUSIONS: We found that mandibular width tends to be greater for Japanese and Chinese cisgender women relative to Caucasian cisgender women. This data may be useful in counseling patients during preoperative evaluations ahead of mandibular reduction. No other anthropometric features were found to be significantly different among the ethnic groups studied. This portends that current approaches to FFGAS, which emphasize patient-specific needs and maintenance of a harmonious appearance, may require minimal or no adjustment to account for ethnic facial anthropometric differences.

The presence of 3D printing in orthopedics: A clinical and material review.

The field of additive manufacturing, 3D printing (3DP), has experienced an exponential growth over the past four decades, in part due to increased accessibility. Developments including computer-aided design and manufacturing, incorporation of more versatile materials, and improved printing techniques/equipment have stimulated growth of 3DP technologies within various industries, but most specifically the medical field. Alternatives to metals including ceramics and polymers have been garnering popularity due to their resorbable properties and physiologic similarity to extracellular matrix. 3DP has the capacity to utilize an assortment of materials and printing techniques for a multitude of indications, each with their own associated benefits. Within the field of medicine, advances in medical imaging have facilitated the integration of 3DP. In particular, the field of orthopedics has been one of the earliest medical specialties to implement 3DP. Current indications include education for patients, providers, and trainees, in addition to surgical planning. Moreover, further possibilities within orthopedic surgery continue to be explored, including the development of patient-specific implants. This review aims to highlight the use of current 3DP technology and materials by the orthopedic community, and includes comments on current trends and future direction(s) within the field.

"Septoplasty" Performed at Primary Cleft Rhinoplasty: A Systematic Review of Techniques and Call for Accurate Terminology.

OBJECTIVE: Primary cleft nasal repair can include septal reconstruction. We hypothesize that primary cleft septoplasty and adult septoplasty have fundamental differences that render these procedures as distinct surgical entities. DESIGN: Systematic review of the PubMed, Cochrane, and Embase databases performed on pediatric cleft and general adult septoplasty techniques through December 2021. (PROSPERO ID CRD42022295763). MAIN OUTCOME MEASURES: Collected data included information on septal dissection, septal detachment, and management of the bony and cartilaginous septum. RESULTS: Twenty-eight pediatric cleft septoplasty and 229 adult septoplasty studies were included. Dissection in primary cleft septoplasty was limited to the anterocaudal septum, while secondary cleft septoplasty and adult septoplasty techniques entailed wide exposures of the cartilaginous septum with or without exposure of the perpendicular plate of the ethmoid. In primary cleft septoplasty, detachment of the septum was mostly limited to the nasal spine and anterior base of the cartilaginous septum, while secondary cleft septoplasty and adult septoplasty included detachment from the vomer, and ethmoid. In the few reports of cartilage excision during primary cleft septoplasty, removal was limited to the anterior inferior border of the septum, while secondary cleft septoplasty and adult septoplasty included excision of the cartilaginous and bony septum. CONCLUSION: Primary cleft septoplasty is distinct from septoplasty performed on facially mature patients. More specifically, septal dissection and detachment are limited to the anterior caudal area during primary lip repair, with rare removal of cartilage or bone. Given these differences, the authors suggest the term "septal reset" to describe septoplasty performed during primary cleft nasal repair.

An in vivo preclinical study assessing biocompatibility of Pd-based bulk metallic glass.

BACKGROUND: The bulk metallic glass (BMG), Pd79Ag3.5P6Si9.5Ge2, has a high fracture toughness and has been found to accommodate post-yield stress, unlike most other BMG. Moreover, due to its greater noble gas composition it has a intrinsic corrosion resistance, ideal for dental and orthopedic implants. OBJECTIVE: This present study aimed to evaluate the in vivo application of Pd79Ag3.5P6Si9.5Ge2 in a large translational sheep model to assess its efficacy to be utilized as an endosteal device. METHODS: Twelve implants in the form of cylindrical rods (3 mm in diameter) were produced through rapid quenching. Each sheep (n = 12) received one osteotomy in the mandibular region using rotary instrumentation, which was filled with Pd79Ag3.5P6Si9.5Ge2. After 6- and 24-weeks the animals were euthanized, and samples collected en bloc to conduct histomorphometric analysis. The degree of osseointegration were assessed through bone-to-implant contact (BIC). RESULTS: All samples revealed favorable BIC along with with fibrous connective tissue layers at both 6- and 24-weeks. Bone along with interfacial remodeling was observed in proximity with the metallic glass surface at 6 weeks with higher degrees of bone organization being observed at the later healing time, 24 weeks. CONCLUSIONS: The synthesized BMG, given its unique combination of toughness and strength, revealed potential to serve as an alternative to commonly used Ti alloys.

Secondary Surgery in Facial Feminization: Reasons and Recommendations.

BACKGROUND: As facial feminization surgery (FFS) continues to grow in access and popularity, the need for secondary FFS can be expected to increase. The purpose of this study was to identify reasons for FFS reoperation and offer recommendations to minimize secondary surgery. METHODS: A retrospective cohort study of patients who underwent FFS from October 2017 to 2021 was performed. Patients who underwent nonstaged secondary surgery were identified and sorted in 2 non-mutually exclusive surgical cohorts: additional surgery, defined as unplanned additional feminization surgery on previously unoperated facial units, and revision surgery, defined as redo surgery on previously operated facial units. Reasons for secondary surgery were examined in the context of the senior author's experience. RESULTS: Of 161 patients who underwent FFS, 41 (25.5%) underwent secondary surgery consisting of additional surgery (n = 32) and/or revision surgery (n = 30). There were no significant differences in clinical or demographic data between the secondary surgery and total FFS cohorts. Among additional surgery patients, facial units that had been previously operated on were as follows: nose (46.3%), trachea (31.7%), forehead/brow (22.0%), chin (12.2%), lips (9.8%), and cheeks (7.3%). Among revision patients, facial units revised were as follows: nose (36.6%), forehead/brow (26.8%), cheeks (17.1%), chin (17.1%), lips (12.5%), and trachea (2.4%). The main indication for revision for all facial units was undercorrection to feminine ideals. CONCLUSIONS: One-quarter of patients who underwent FFS had prior FFS and/or sought revision. Keeping in mind that the dominant indication for revision was undercorrection, FFS surgeons can minimize the need for secondary surgery in the future.

Patient-centred outcomes and dental implant placement in computer-aided free flap mandibular reconstruction: a systematic review and meta-analysis.

Computerised surgical planning (CSP) and computer-aided design and manufacturing (CAD/CAM) have been demonstrated to increase surgical accuracy and reduce operative time in free flap mandibular reconstruction, but evidence is lacking as to their impact on patient-centred outcomes. Implant-supported dental prostheses, however, have been associated with improved quality of life outcomes following free flap mandibular reconstruction. We aim to review reported patient-centred outcomes in mandibular reconstruction with CSP and CAD/CAM and determine whether use of these technologies is associated with higher rates of dental implant placement following free flap mandibular reconstruction. On December 20, 2020, a systematic review and meta-analysis were conducted according to PRISMA guidelines for studies reporting quality of life, functional outcomes, and rates of dental implant placement in computer-aided free flap mandibular reconstruction. A random-effects meta-analysis was performed to compare dental implant placement rates between surgeries using CSP and those using conventional freehand techniques. A total of 767 articles were screened. Nine articles reporting patient-centred outcomes and 16 articles reporting dental implant outcomes were reviewed. Of those reporting dental implant outcomes, five articles, representing a total of 302 cases, were included in the meta-analysis. Use of CSP was associated with a significant increase in the likelihood of dental implant placement, with an odds ratio of 2.70 (95% CI 1.52 to 4.79, p = 0.0007). Standardised reporting methods and controlled studies are needed to further investigate the impact of CSP and CAD/CAM technologies on functional outcomes and patient-reported quality of life in free flap mandibular reconstruction. Use of CSP and CAD/CAM technologies is associated with higher rates of dental implant placement in patients undergoing free flap mandibular reconstruction when compared to conventional freehand techniques.

Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes.

Purpose: Gender-affirming surgery (GAS) has become an important component of the treatment of gender dysphoria. Although the frequency of these procedures is on the rise, a complete safety profile has yet to be established. The goal of our study is to analyze the trends and outcomes of these surgical procedures. Methods: All patients with a primary diagnosis of gender dysphoria undergoing GAS were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between the years 2009 and 2018. Patient demographics and 30-day postoperative outcomes were recorded. We performed a multivariate logistic regression for postoperative complications, controlling for several confounding variables. Results: We identified 2956 patients, of which 1767 (59.78%) were transgender men and 1189 (40.22%) were transgender women. The number of patients undergoing GAS per year increased from 7 in 2010 to 1069 in 2018, a 152-fold increase. For patients undergoing top surgery, Black race (odds ratio [OR] = 2.255, 95% confidence interval [CI] 1.189-4.277, p = 0.013) and diabetes (OR = 4.156, 95% CI 1.571-10.999, p = 0.004) were independent predictors of 30-day postoperative complications. For patients undergoing bottom surgery, total operative time in minutes (OR = 1.005, 95% CI 1.003-1.007, p = 0.001) was an independent predictor of 30-day postoperative complications. Conclusion: The demand for GAS has increased exponentially since 2014. While postoperative complication rates are acceptable, Black race was shown to be an independent predictor of postoperative morbidity in patients undergoing top surgery, a finding that calls for further investigation of racial disparities among transgender patients.

Quantification of Facial Allograft Edema During Acute Rejection: A Software-Based 3-Dimensional Analysis.

BACKGROUND: Acute rejection (AR) is a common complication in facial transplant (FT) patients associated with allograft edema and erythema. Our study aims to demonstrate the feasibility of using software-based 3-dimensional (3D) facial analysis to quantify edema as it resolves during/after AR treatment in an FT patient. METHODS: Our patient is a 23-year-old man who underwent a face and bilateral hand allotransplant in August 2020. The Vectra H1 (Canfield, Fairfield, NJ) portable scanner was used to capture 3D facial images at 8 time points between postoperative day (POD) 392 and 539. The images were analyzed with the Vectra Software using a rejection-free image (POD 539) as a control. RESULTS: Edema increased in the periorbital, lower third, and submandibular regions before AR treatment (POD 392-415). At POD 448, total facial edema was reduced to near baseline values in response to plasmapheresis and thymoglobulin (+156.94 to +28.2 mL). The fastest and most notable response to treatment was seen in the periorbital region, while some edema remained in the submandibular (+19.79 mL) and right lower third (+8.65 mL) regions. On POD 465, after the initial improvement, the edema increased but was resolved with steroid use. Facial edema did not correlate with the histopathological evaluation in our patient. CONCLUSIONS: We demonstrated the feasibility of analyzing 3D facial images to quantify edema during/after AR treatment in an FT patient. Our analysis detected edema changes consistent with AR followed by an improvement after treatment. This technology shows promise for noninvasive monitoring of FT patients.

Recipient Selection Criteria for Facial Transplantation: A Systematic Review.

BACKGROUND: Recipient selection is an important determinant of surgical outcomes in facial transplantation (FT). Appropriately, each FT program develops their own guidelines for recipient selection criteria. Currently, there is no resource to simultaneously assess and identify similarities and differences between these guidelines. Such information could be useful in distinguishing areas of FT that are well understood from those that could benefit from further exploration. METHODS: We performed a systematic review of the scientific literature from inception to June 18, 2021, using Pubmed, Embase, Cochrane Library, and Scopus to identify articles pertaining to recipient selection criteria. Clinical trials were identified through the Clinicaltrials.gov registry. United States and international program websites were reviewed for patient-facing information. RESULTS: Our systematic review yielded 90 suitable articles, 8 clinical trials, and 7 program websites containing the recipient selection criteria of 24 different FT programs. The most reported on recipient criteria were age, positive human immunodeficiency viral status (HIV+), positive hepatitis C viral status, psychosocial stability, and medical compliance. Other criteria were rarely addressed, such as blindness and recipient immune status. CONCLUSIONS: Guidelines among different face transplant programs are changing over time. We found consensus on certain recipient selection criteria, but the majority remain program or surgeon dependent, emphasizing that FT is still an evolving procedure. Although most programs reported on their recipient selection criteria, the rationale was often missing. Further discussion about recipient selection criteria and the reasoning behind employing or changing them will help advance the field.

Frontal Sinus Fractures: Evidence and Clinical Reflections.

Background: Despite significant advances in the management of frontal sinus fractures, there is still a paucity of large-cohort data, and a comprehensive synthesis of the current literature is warranted. The purpose of this study was to present an evidence-based overview of frontal sinus fracture management and outcomes. Methods: A comprehensive literature search of PubMed and MEDLINE was conducted for studies published between 1992 and 2020 investigating frontal sinus fractures. Data on fracture type, intervention, and outcome measurements were reported. Results: In total, 456 articles were identified, of which 53 met our criteria and were included in our analysis. No statistically significant difference in mechanism of injury, fracture pattern, form of management, or total complication rate was identified. We found a statistically significant increase in complication rates in patients with nasofrontal outflow tract injury compared with those without. Conclusions: Frontal sinus fracture management is a challenging clinical situation, with no widely accepted algorithm to guide appropriate management. Thorough clinical assessment of the fracture pattern and associated injuries can facilitate clinical decision-making.

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery.

Purpose: Given the increasing frequency with which gender affirming surgery (GAS) is performed, understanding risk factors for poor outcomes is imperative. Recent investigations highlight inferior health outcomes experienced by Black transgender and gender expansive (TGE) individuals. Herein, we evaluate the relationship between race and postoperative outcomes in TGE patients undergoing GAS, utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: We conducted a retrospective review of ACS NSQIP from 2010 to 2018. Patients with a primary diagnosis of gender dysphoria undergoing GAS were identified and grouped by race. Patient characteristics and 30-day postoperative outcomes were recorded. Univariate analysis was used to compare patient characteristics and postoperative outcomes across groups. Multivariate logistic regression was used to determine independent predictors of complications. Results: We included 2308 patients (1780 White, 419 Black, 109 Asian). Gender, body mass index, smoking status, and type of surgery performed differed significantly between groups (p < 0.001). Univariate analysis revealed significant differences in 30-day readmission and organ space surgical site infection (SSI) across groups (p = 0.03). Multivariate logistic regression, adjusted for confounders, revealed that Black patients had higher odds of reoperation (odds ratio [OR] 1.82, p = 0.047), 30-day readmission (OR 2.46, p = 0.003), and organ space SSI (OR 4.65, p = 0.024) than White patients. Conclusion: We found that race was an independent predictor of important short-term postoperative outcomes in GAS. Inclusive clinical research, effective engagement with the TGE community, and surgery-specific enhanced recovery after surgery protocols may help address disparities, but we must acknowledge race as a social determinant of health.

Trends, Gaps, and Collaboration in Facial Transplantation: A Bibliometric Study.

Facial transplantation (FT) has advanced extensively over the past two decades, with over 40 transplants performed to date. Over this time, the FT literature has evolved as well, from early discussions on ethics and feasibility of FT to functional outcomes reports more recently. We aimed to evaluate the entire body of FT literature to identify trends in publications over time in addition to current existing gaps in the field. Methods: We conducted a comprehensive bibliometric analysis of the published FT literature from 1994, the first year FT was mentioned in the literature, through July 2020. Co-authorship and keyword information were analyzed using VOSviewer. Articles were manually categorized based on keywords and their aim to provide insight on trends. Results: A total of 2182 articles were identified. Analysis identified the top 50 publishing authors in the field and demonstrated co-authorship linkage between 84.8% of the top 1000 authors. Clinical surgical techniques, protocols, and experiments were the most frequently published category. Within clinical outcomes, immunologic outcomes were most frequent, while psychosocial were the lowest. Gaps were identified in long-term outcomes reporting and patient-reported outcomes, with physician-reported outcomes heavily outweighing patient-reported outcomes. Conclusions: As the field continues to evolve, rigorous tracking of publication patterns over time will encourage development of a more robust evidence base, identify gaps in the published literature, and highlight opportunities to enhance collaboration in the field. This data will provide surgeons and research institutions with information to further improve this life-changing procedure.

Double-Barrel Versus Single-Barrel Fibula Flaps for Mandibular Reconstruction: Safety and Outcomes.

OBJECTIVES/HYPOTHESIS: Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively. RESULTS: Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019). CONCLUSION: Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1576-1581, 2022.