Nationwide Resident Access to Elective Rotations: A Survey Study.

OBJECTIVE: This study seeks to assess the status of elective rotations offered in plastic and reconstructive surgery residency programs throughout the country while also qualifying resident and alumni experiences and identifying barriers to offering electives. DESIGN: Two prospective surveys were created for (1) program leadership and (2) residents, fellows, and alumni's who have graduated in the last 5 years. SETTING: This is a multi-institutional survey study. PARTICIPANTS: Of 81 plastic and reconstructive surgery programs, 45 programs, and 102 residents, fellows and/or recent graduates responded to survey 2. RESULTS: Fifty-six percent of respondents stated that their institution offered electives, 62% of which permitted residents to participate in regional, national, and international rotations primarily in the fifth and sixth years of training. Types of elective rotations completed included aesthetic, craniofacial, sex, hand, and microsurgery. Fifty-three percent responding programs denied barriers to offering elective rotations. When programs noted barriers, the most common were cost to resident/department (28%), institutional Graduate Medical Education policy (22%), and lack of service coverage at the home institution (22%). There was no difference between departments versus divisions offering electives (56.3% vs 57.1%, P = 0.95). Programs that did not offer electives spent an average of 14.6 months on general surgery compared with 9.4 months for programs that did offer electives ( P = 0.06). For programs that did not currently offer elective rotations, 71% indicated a desire to do so. CONCLUSION: The primary goal of plastic surgery training programs is to produce plastic surgeons of the highest caliber with regard to safety and competence. Although several regulatory bodies ensure that programs adhere to a similar standard, not all programs have opportunities for residents to experience the breadth of our multifaceted specialty. Elective rotations constitute an excellent supplement to a well-rounded training where gaps may exist.

Gender-Affirming Health Insurance Reform in the United States.

INTRODUCTION: In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. METHODS: Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. RESULTS: Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. CONCLUSIONS: After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Surgical management of early and late ureteral complications after renal transplantation: techniques and outcomes.

BACKGROUND: In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to a matched control population. METHODS: We performed a retrospective analysis of our database between 1997 and 2012. We divided the cases into early (<60 d) and late repairs. Kaplan-Meier and Cox proportional hazards models were used to compare graft survival between the intervention cohort and controls generated from the Scientific Registry of Transplant Recipients data set. RESULTS: Of 2671 kidney transplantations, 51 patients were identified as to having undergone 53 ureteral revision procedures; 43.4% of cases were performed within 60 d of the transplant and were all associated with urinary leaks, and 49% demonstrated ureteral stenosis. Reflux allograft pyelonephritis and ureterolithiasis were each the indication for intervention in 3.8%; 15.1% of the lesions were located at the anastomotic site, 37.7% in the distal segment, 7.5% in the middle segment, 5.7% proximal ureter, and 15.1% had a long segmental stenosis. In 18.9%, the location was not specified. Techniques used included ureterocystostomy (30.2%), ureteroureterostomy (34%), ureteropyelostomy (30.1%), pyeloileostomy (1.9%), and ureteroileostomy (3.8%). No difference in overall graft survival (HR 1.24 95% CI 0.33-4.64, p = 0.7) was detected when compared to the matched control group. CONCLUSION: Using a variety of techniques designed to re-establish effective urinary flow, we have been able to salvage a high percentage of these allografts. When performed by an experienced team, a ureteric complication does not significantly impact graft survival or function as compared to a matched control group.

Midfacial volumetric and upper lip soft tissue changes after Le Fort I advancement of the cleft maxilla.

PURPOSE: To analyze, using 3-dimensional photogrammetric data, midfacial soft tissue and volumetric changes in the cleft maxilla after 1- or 2-piece Le Fort I (LF1) advancement. MATERIALS AND METHODS: This was a retrospective study of patients with cleft and maxillary hypoplasia who underwent LF1 advancement. The primary predictor variable was the type of advancement (1 piece vs 2 pieces). Outcome measurements were changes in soft tissue linear measurements (subnasale [Sn], labium superius [LS], and stomion [SO]) and midfacial volume after maxillary advancement. RESULTS: Eleven patients (7 male, 4 female) underwent LF1 advancements (4 underwent 2-piece advancement). The mean maxillary advancement was 6.2 ± 1.7 mm. Soft tissue changes at the Sn, LS, and SO were 5.2 ± 2.0, 5.8 ± 2.5, and 5.2 ± 1.8 mm, respectively. The average volume change was 12.2 ± 5.7 cm(3). The mean ratios of soft tissue change to the amount of maxillary advancement (millimeters per millimeter) at the Sn, LS, and SO were 0.89 ± 0.49, 0.97 ± 0.44, and 0.89 ± 0.34, respectively. Volume increased by 2.1 ± 1.3 cm(3)/mm. Patients undergoing 1-piece advancement had greater mean advancement and greater soft tissue changes at the LS and SO (P < .03). After controlling for the amount of advancement, 1-piece LF1 osteotomy showed significantly greater improvements at the LS and SO (P < .04). CONCLUSIONS: Midface advancement at the LF1 level in patients with cleft consistently expands upper lip soft tissue and midfacial volume. Greater changes at the LS and SO were seen with 1-piece than with 2-piece osteotomy.

Immediate Single-Stage Cranioplasty Following Calvarial Resection for Benign and Malignant Skull Neoplasms Using Customized Craniofacial Implants.

UNLABELLED: Craniectomy defects following resection of calvarial lesions are most often reconstructed using on-table manufacturing. With the advent of computer-aided design/manufacturing and customized craniofacial implants (CCIs), there seems to be more suited alternatives. In this study, the authors report their institutional experience and outcome using immediate, single-stage, CCI-based reconstruction for benign and malignant skull neoplasm defects. METHODS: A retrospective review of a prospectively maintained database of all implant cranioplasties performed between 2011 and 2014, by a single craniofacial surgeon at a tertiary academic medical institution was performed. Preoperative and postoperative computed tomography scans with 3D reconstruction were performed for the purpose of assessing adequate resection and reconstructive outcomes. Primary endpoints included length of surgery, predicted defect versus postoperative implant surface area, contour irregularities, and complications. RESULTS: Of the 108 patients with cranioplasty identified, 7 patients were found to undergo immediate CCI-based reconstruction for calvarial neoplasms; 4 patients (4/7, 57%) presented with malignant pathology. All defects were >5  cm2. As compared with their original size, all implants were modified intraoperatively between 0.2% and 40.8%, with a mean of 13.8%. With follow-up ranging between 1 and 16 months, there were no implant-related complications identified. The immediate and long-term aesthetic results, as well as patient satisfaction, were ideal. CONCLUSION: With this preliminary experience, the authors have successfully demonstrated that immediate customized implant reconstructive techniques, by way of intraoperative modification, are both safe and feasible for benign and malignant skull neoplasms. The authors believe that with wider acceptance of this multidisciplinary approach and increased surgeon familiarity, this technique will soon become the reconstructive standard of care.

Reconstruction of periorbital soft tissue defects.

Because of the complex anatomy and fine mechanics of the periorbital soft tissues, the reconstruction of this region can be particularly daunting. Through a structured assessment of the defect, based on subunit analysis and thorough understanding of the surgical layers, we believe to allow the reconstructive surgeon to develop an algorithmic approach to these complex problems. The sequela of a suboptimal reconstruction do not only result in an inferior aesthetic result, but also have the potential for long-term functional problems such as epiphora, dry eye, ptosis, eyelid retraction, and thus requiring secondary surgery. There is no better time to aim for a perfect reconstruction than at the time of the initial surgery. In this chapter, we hope to encourage the reader to strengthen and recapitulate these analytical skills and present the most commonly used and studied techniques to help achieve a reproducible functional and aesthetically appealing result.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty.

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

Current concepts and systematic review of vascularized composite allotransplantation of the abdominal wall.

INTRODUCTION: Abdominal wall vascularized composite allotransplantation (AW-VCA) is a rarely utilized technique for large composite abdominal wall defects. The goal of this article is to systematically review the literature and current concepts of AW-VCA, outline the challenges ahead, and provide an outlook for the future. METHODS: Systematic review of the literature was performed using MEDLINE, EMBASE, and PubMed to identify relevant articles discussing results of AW-VCA. Cadaver and animal studies were excluded from the systematic review, but selectively included in the discussion. RESULTS: The resultant five papers report their results on AW-VCA(Transplantation, 85, 2008, 1607; Am J Transplant, 7, 2007, 1304; Transplant Proc, 41, 2009, 521; Transplant Proc, 36, 2004, 1561; Lancet, 361, 2003, 2173). These papers represent the result of two study groups in which a total of 18 AW-VCA were performed in 17 patients. Two different operative approaches were used. Overall flap/graft survival was 88%. No mortality related to the transplant was reported. One cadaver study and two animal models were identified and separately presented (Transplant Proc, 43, 2011, 1701; Transplantation, 90, 2010, 1590; Journal of Surgical Research, 162, 2010, 314). CONCLUSION: Literature review reports AW-VCA is technically feasible with low morbidity and mortality. Functional outcomes are not reported and minimally considered. With advancements in vascularized composite allotransplantation research and decreasing toxicity of immunosuppression therapies and immunomodulatory regimens, AW-VCA can be applied in circumstances beyond conjunction with visceral transplantation.

Optimizing Innervation in Radial Forearm Phalloplasty: Consider the Posterior Antebrachial Cutaneous Nerve.

SUMMARY: One goal of an ideal phallic reconstruction is achieving tactile and erogenous sensation. Traditionally, the most common flap used in phalloplasty has been the radial forearm flap, where the medial and lateral antebrachial cutaneous nerves are coapted to meet this goal. The purpose of this article is to draw attention to the lesser-known posterior antebrachial cutaneous nerve (PABC) as an alternative or additional nerve for coaptation that innervates a majority of the shaft, where sensation is most desired. The presence, anatomical location, and territory of innervation of the antebrachial cutaneous nerves were assessed in a series of 12 consecutive in vivo radial forearm phalloplasties. A literature review was conducted to establish which nerves have traditionally been used for sensory reinnervation of the phallus. The PABC was the first nerve encountered on the radial border of the flap lying on the fascia in the interval between the brachioradialis and extensor carpi radials longus. The posterior and lateral antebrachial cutaneous nerves innervated the phallic shaft, whereas the anterior branch of the medial antebrachial cutaneous nerve innervated the phallic urethra. There were no articles in our review that used PABC for nerve coaptation in radial forearm phalloplasty. The skin innervated by the PABC represents a significant portion of the phallic shaft when using the standard template for radial forearm phalloplasty. Despite this, its use is not described in the literature. The authors introduce the PABC as an alternative or additional nerve for coaptation in radial forearm phalloplasty.

Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience.

BACKGROUND: Lasting regret after gender-affirming surgery (GAS) is a difficult multifaceted clinical scenario with profound effects on individual well-being as well as being a politically charged topic. Currently, there are no professional guidelines or standards of care to help providers and patients navigate this entity. This article summarizes the authors' Transgender Health Program's cohesive multidisciplinary lifespan approach to mitigate, evaluate, and treat any form of temporary or permanent regret after GAS. METHODS: A multidisciplinary (primary care, pediatric endocrinology, psychology, social work, plastic surgery, urology, gynecology, and bioethics) workgroup including cisgender, transgender, and gender-diverse professionals met for a duration of 14 months. The incidence of individuals who underwent GAS at the authors' program between 2016 and 2021 and subsequently expressed desire to reverse their gender transition was reported. RESULTS: Among 1989 individuals who underwent GAS, six (0.3%) either requested reversal surgery or transitioned back to their sex assigned at birth. A multidisciplinary assessment and care pathway for patients who request reversal surgery is presented in the article. CONCLUSIONS: A care environment that welcomes and normalizes authentic expression of gender identity, affirms surgical goals without judgment, and destigmatizes the role of mental health in the surgical process are foundational to mitigating the occurrence of any form of regret. The authors hope this can provide a framework to distinguish normal postoperative distress from temporary forms of grief and regret and regret attributable to societal repercussions, surgical outcomes, or gender identity.

Nerve morbidity at the radial forearm donor site following gender-affirming phalloplasty.

INTRODUCTION: In the radial forearm phalloplasty multiple nerves are harvested to provide phallic sensation, resulting in iatrogenic nerve injuries. Despite this, nerve morbidity following this procedure has been minimally assessed. The purpose of this study was to assess donor site nerve morbidity following radial forearm phalloplasty. METHODS: Patients who underwent gender-affirming phalloplasty at our institution between 2016-2020 using the radial forearm were included. Pain characteristics were assessed with a modified Mackinnon Pain questionnaire consisting of 33 items, including visual analog scales (VAS) for reporting of pain and impact on aspects of quality of life (QoL), as well as 20 descriptive pain adjectives and a 21-item questionnaire to capture overall pain experience. RESULTS: A total of 37 patients were included. 31 had minimal-mild pain (VAS scores 0-3), and 6 patients had moderate-severe pain (VAS scores 4-10). The mild pain group reported a mean 2.74 (0-7) pain descriptors and reported minimal impact on QoL metrics. The moderate-severe pain group reported mean 6.33 (2-15) pain descriptors and reported significant impacts on QoL metrics. Significant differences were observed with decreased QoL (p = 0.018), increased sadness (p = 0.009), increased frustration (p = 0.030), increased anger (p = 0.0496), and decreased hopefulness (p = 0.0496) in the moderate-severe pain group along with interference of pain with sleep (p = 0.002). CONCLUSIONS: In a cross-sectional analysis of 37 patients who underwent gender-affirming radial forearm phalloplasty, the majority (31) experienced a minimal degree of donor site nerve pain. Six patients suffered from more significant nerve pain that was associated with a decreased QoL. Treatment and prevention of this nerve pain represent important areas for future exploration.

Neurosensory Re-education following Gender-affirming Phalloplasty: A Novel Treatment Protocol.

Sensory nerve transfers are performed as part of phalloplasty surgery. Despite this, sensory re-education to rehabilitate these nerve transfers has not been employed. Additionally, little attention has been paid to the role of the central nervous system in experienced sensation following phalloplasty. The purpose of this article is to report on the development of a targeted rehabilitation protocol to integrate and optimize peripheral and central contributions to sensation following phalloplasty. Methods: This neurosensory re-education protocol was constructed over four phases by a multi-disciplinary team (phalloplasty/peripheral nerve surgeon, reconstructive urologist, pelvic floor physiotherapists, nerve therapist, sex therapist, sexual medicine physician) and individuals with lived phalloplasty experience. The final protocol was approved by all team members and is supported here by qualitative narratives from people with lived phalloplasty experience. Results: The protocol is built to follow each stage of phalloplasty surgery. In each stage, exercises are grouped into three core themes: visualization, tactile stimulation, and sexual/erogenous stimulation. Visualization exercises progress from static to dynamic. Tactile exercises start at simple touch and progress toward targeted sensory stimulation. Sexual stimulation focuses on developing erogenous sensation in the phallus that is separate from erogenous sensation in the natal clitoral tissue. By recommendation of individuals with phalloplasty, the protocol is now integrated into our center's phalloplasty care pathway for all individuals undergoing phalloplasty surgery. Conclusion: We introduce a novel protocol targeting peripheral and central contributions to sensation to provide a tool to help optimize experienced sensation for transmasculine individuals undergoing phalloplasty.

Shaft-only Phalloplasty: Technical Modifications to Optimize Aesthetics.

Shaft-only phalloplasty (SOP) has been described as an alternative option for phalloplasty. Although traditional phalloplasty represents the most complete form of genital gender-affirming surgery, this variation also carries the greatest surgical risk. Patients may opt for a lower risk SOP for reasons including gender identity, gender expression, sexual function, desire for future childbearing, or minimal gender dysphoria associated with sedentary urination. Further, some patients may, due to associated co-morbidities, not be a candidate for neourethral reconstruction. Forgoing urethral reconstruction also means forgoing the presence of a distal urethral meatus and thereby compromising on one of the basic tenets of phalloplasty surgery-the aesthetic appearance. In an SOP, the flap is usually a simple tube with a purse-string suture placed at the distal end. Another concern can be the insufficient bulk of the phallus due to the absence of the volume added by the inner tube. The purpose of this article is to review our technical modifications that allow for creation of a phallic meatus as well as increasing phallic girth when needed. The most frequently described technique to create a neo-urethra is the tube-within-tube concept. We expanded on this and apply it as a short segment for distal meatal creation in an SOP. Improved aesthetics are achieved by creating the appearance of a phallic meatus and when desired, utilizing a lateral de-epithelialized strip to increase phallic bulk and girth. We hope these technical refinements can assist the surgeon in better meeting the goal of creating an aesthetically pleasing phallus.

Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging.

SUMMARY: The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

An Option for Shaft-Only Gender-Affirming Phalloplasty: Vaginal Preservation and Vulvoscrotoplasty. A Technical Description.

SUMMARY: Genital masculinizing gender-affirming surgery is a growing field. Because of a spectrum of gender identity, gender expression, sexual expression, patient desires, and patient tolerance for complications, options for surgery vary accordingly. Shaft-only phalloplasty avoids urethral lengthening, but may still be accompanied by hysterectomy, vaginectomy, scrotoplasty, clitoroplasty (burying of the clitoris), glansplasty, and placement of erectile devices and testicular implants. Patients who desire retention of vaginal canal patency are candidates for vaginal preservation vulvoscrotoplasty; however, there is a paucity of literature describing the procedure and its outcomes. In this article, the authors review the technique used by the senior author at Oregon Health and Science University and report surgical outcomes for four patients. Future studies regarding patient-recorded outcome measures, aesthetics, sexual function, urologic function, patient satisfaction, and conversion to other options will help surgeons better understand patients pursuing gender-affirming surgery through shaft-only phalloplasty.

Outcomes of Transperineal Gender-Affirming Vaginectomy and Colpocleisis.

OBJECTIVES: There are multiple approaches to vaginectomy for the purpose of masculinizing gender-affirming genital surgery including mucosal fulguration and excision. The outcomes of the approaches are not well described. We aim to describe the surgical outcomes of gender-affirming vaginectomy and colpocleisis by complete mucosal excision. METHODS: We performed a case series study of 40 transmasculine patients who underwent gender-affirming vaginectomy and colpocleisis. Vaginectomy was performed by complete excision of the vaginal mucosa via a transperineal approach. We recorded perioperative outcomes and operative time. We performed a multivariate analysis to assess patient factors on operative outcomes. RESULTS: Forty vaginectomies were performed between September 2016 and April 2019, 27 (67.5%) in phalloplasty patients and 13 (32.5%) in metoidioplasty patients. Perioperative complications included 2 blood transfusions, 1 pelvic hematoma, and 1 Clostridium cifficile colitis. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased significantly with later surgery year. CONCLUSIONS: This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.