Addressing the Gray Zone in Affirmative Mastectomy: An Analysis of Fischer 2 Patients.

BACKGROUND: Surgical decision making in gender-affirming mastectomy (GAM) is based on a patient's classification using the Fischer scale. Fischer 1 patients are excellent candidates for periareolar (PA) approach and Fischer 3 patients almost exclusively undergo double incision with free nipple grafting (DIFNG). Fischer 2 patients are in a gray zone in which decision making is more challenging. In this patient population, periareolar approaches can lead to increased complication and revision rates but free grafting procedures seem excessive. We have created a treatment algorithm to address Fischer 2 patients and additionally developed a novel technique, the batwing, to provide patients with more options. METHODS: A retrospective chart review was undertaken to analyze the Fischer classification of all patients undergoing top surgery by a single surgeon at an academic institution from 2014 to 2021. The choice of surgical technique used as well as the outcomes of GAM among Fischer 2 patients was analyzed. RESULTS: Four hundred four patients underwent GAM, and 51 (11%) had Fischer 2 classification. The surgical techniques used were PA (27%), batwing (39%), nipple-sparing double incision (NSDI, 24%), and DIFNG (10%). Of those, 10% had major complications and 20% requested revision for contour irregularities. Major complication rates for PA, batwing, NSDI, and DIFNG were as follows: 2 of 14 patients (14%), 1 of 20 patients (5%), 1 of 12 patients (8%), and 1 of 5 patients (20%), respectively. The revision rate by technique was PA (36%), batwing (15%), NSDI (17%), and DIFNG (0%). CONCLUSIONS: For Fischer 2 patients, batwing and NSDI techniques avoid the need for free nipple graft while providing better exposure, improved control of nipple-areolar complex position, and decreased rate of revision as compared with the PA technique. The complication rate was not significantly different. We present an algorithm accounting for Fischer grade, unique patient characteristics, and patient desires.

Aesthetic Surgery in Plastic Surgery Academia.

BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson's chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

What is "Nonbinary" and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients.

BACKGROUND: Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES: We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS: This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS: A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS: Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population.

Migration of phthalates on culture plates - an important challenge to consider for in vitro studies.

Phthalates are endocrine disruptors of the reproductive system and suspected to influence many other organ and hormone systems. They are also semi-volatile organic compounds present in the gas phase in the environment. Their mode of action has been investigated in numerous in vitro studies. Multi-well culture plates are typically used to study phthalates in cell cultures. In a pilot study, we observed evidence of phthalate migration in 24-well culture plates. As this has not previously been described, we investigated the phenomenon in more detail. Primary human thyroid epithelial cell cultures (n = 8 cultures) were exposed to either di-ethyl phthalate (DEP), di-n-butyl phthalate (DnBP), mono-n-butyl phthalate (MnBP) or di-(2-ethylhexyl) phthalate (DEHP). Measurement of phthalate metabolites by mass spectrometry demonstrated that the short-branched DEP was able to migrate to adjacent wells when added to cell culture plates. DnBP also seemed to be able to migrate, unlike the long-branched DEHP or the monoester MnBP which did not seem to have this ability. High background levels of phthalate metabolites were also observed, which might compromise results from low dose phthalate studies. In conclusion, the migration of phthalates which is probably caused by their volatile properties might lead to false interpretation of study results.

Axillary Lymph Node Dissection Is a Risk Factor for Major Complications After Immediate Breast Reconstruction.

BACKGROUND: Complications after immediate breast reconstruction pose a significant challenge to the reconstructive surgeon. Known risk factors include smoking, obesity, age, and adjuvant oncologic therapies. Less is known about the association between axillary lymph node dissection (ALND) and the development of postoperative complications. METHODS: We conducted a retrospective study of all patients who underwent immediate breast reconstruction after mastectomy at our institution over a 10-year period. Our outcome was an occurrence of a major complication within 90 days postoperatively. For each patient, we recorded data on demographics, smoking status, pertinent medical history, reconstruction type, adjuvant chemotherapy and radiation, tumor pathology, and whether an ALND was performed. Odds ratios (OR) were calculated to estimate the risk of a complication if an ALND was performed. RESULTS: One hundred eighty-four women, with 270 surgically treated breasts, were identified as having mastectomy with immediate reconstruction between 2002 and 2012. Mean age was 49.4 years (range, 25-84 years). There were 71 mastectomies with ALND performed, with 22 complications, and 199 mastectomies without ALND, with 20 complications (31% complication rate vs 10%, respectively; OR, 3.84; P < 0.001). When adjusted for reconstruction type, smoking history, obesity, age, presence of invasive disease, chemotherapy, and radiation therapy, the OR for complications was 3.49 (P < 0.01). The most common complication was infection in both groups. CONCLUSIONS: Mastectomy with ALND is associated with a 3-fold increase in risk of major complications in women undergoing immediate breast reconstruction, even after adjustment for known risk factors and confounders. Further studies are warranted to elucidate how ALND leads to these complications and what measures can reduce their occurrence.

Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BACKGROUND: The pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. METHODS: Fifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. RESULTS: Forty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. CONCLUSIONS: Overall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.

Estrogen receptor, progesterone receptor, interleukin-6 and interleukin-8 are variable in breast cancer and benign stem/progenitor cell populations.

BACKGROUND: Estrogen receptor positive breast cancers have high recurrence rates despite tamoxifen therapy. Breast cancer stem/progenitor cells (BCSCs) initiate tumors, but expression of estrogen (ER) or progesterone receptors (PR) and response to tamoxifen is unknown. Interleukin-6 (IL-6) and interleukin-8 (IL-8) may influence tumor response to therapy but expression in BCSCs is also unknown. METHODS: BCSCs were isolated from breast cancer and benign surgical specimens based on CD49f/CD24 markers. CD44 was measured. Gene and protein expression of ER alpha, ER beta, PR, IL-6 and IL-8 were measured by proximity ligation assay and qRT-PCR. RESULTS: Gene expression was highly variable between patients. On average, BCSCs expressed 10-106 fold less ERα mRNA and 10-103 fold more ERß than tumors or benign stem/progenitor cells (SC). BCSC lin-CD49f-CD24-cells were the exception and expressed higher ERα mRNA. PR mRNA in BCSCs averaged 10-104 fold less than in tumors or benign tissue, but was similar to benign SCs. ERα and PR protein detection in BCSCs was lower than ER positive and similar to ER negative tumors. IL-8 mRNA was 10-104 higher than tumor and 102 fold higher than benign tissue. IL-6 mRNA levels were equivalent to benign and only higher than tumor in lin-CD49f-CD24-cells. IL-6 and IL-8 proteins showed overlapping levels of expressions among various tissues and cell populations. CONCLUSIONS: BCSCs and SCs demonstrate patient-specific variability of gene/protein expression. BCSC gene/protein expression may vary from that of other tumor cells, suggesting a mechanism by which hormone refractory disease may occur.

Professional burnout among US plastic surgeons: results of a national survey.

PURPOSE: Little is known about professional burnout among plastic surgeons. Our purpose is to describe its prevalence among a large national sample of plastic surgeons and identify contributing factors. METHODS: A mailed, self-administered survey was sent to 708 plastic surgeons who were randomly sampled from the American Society of Plastic Surgeons national membership (71% response rate). The dependent variable was professional burnout, measured by 3 subscales from the validated Maslach Burnout Inventory-Human Services Survey. "High" scores in either the emotional exhaustion or depersonalization subscale categories predict professional burnout. The independent variables included surgeon sociodemographic and professional characteristics. χ was used for the bivariate analyses. RESULTS: Nearly one third (29%) of surgeons scored high in subscale categories predictive of professional burnout. Factors associated with high emotional exhaustion scores included surgeon age, 40-50 years (P = 0.03); fair/poor physician health (P < 0.01); ER call (P < 0.01); >60 work hours per week (P = 0.03); primarily reconstructive practice (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). Factors associated with high depersonalization scores included fair/poor physician health (P= 0.01); ER call (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). CONCLUSIONS: Nearly one third of plastic surgeons have signs of professional burnout. Middle-aged surgeons and those in poor health are most at risk; along with those who have a reconstructive rather than cosmetic practice, long work hours, ER call responsibility, a nonacademic setting. and group as compared to solo practice. These data have important implications for future workforce shortages and health care quality.

A multicenter randomized controlled trial comparing absorbable barbed sutures versus conventional absorbable sutures for dermal closure in open surgical procedures.

BACKGROUND: Barbed sutures were developed to reduce operative time and improve security of wound closure. OBJECTIVE: The authors compare absorbable barbed sutures (V-Loc, Covidien, Mansfield, Massachusetts) with conventional (smooth) absorbable sutures for soft tissue approximation. METHOD: A prospective multicenter randomized study comparing barbed sutures with smooth sutures was undertaken between August 13, 2009, and January 31, 2010, in 241 patients undergoing abdominoplasty, mastopexy, and reduction mammaplasty. Each patient received barbed sutures on 1 side of the body, with deep dermal sutures eliminated or reduced. Smooth sutures with deep dermal and subcuticular closure were used on the other side as a control. The primary endpoint was dermal closure time. Safety was assessed through adverse event reporting through a 12-week follow-up. RESULTS: A total of 229 patients were ultimately treated (115 with slow-absorbing polymer and 114 with rapid-absorbing polymer). Mean dermal closure time was significantly quicker with the barbed suture compared with the smooth suture (12.0 vs 19.2 minutes; P<.001), primarily due to the need for fewer deep dermal sutures. The rapid-absorbing barbed suture showed a complication profile equivalent to the smooth suture, while the slow-absorbing barbed suture had a higher incidence of minor suture extrusion. CONCLUSIONS: Barbed sutures enabled faster dermal closure quicker than smooth sutures, with a comparable complication profile. LEVEL OF EVIDENCE: 1.

Alemtuzumab-induced thyroid disease: A Danish cohort study.

OBJECTIVES: Alemtuzumab, a monoclonal antibody against the cluster of differentiation 52 (CD52) molecule, is used in the treatment of multiple sclerosis (MS). A side effect of the treatment is development of secondary autoimmune thyroid disease. The aim of this study was to evaluate the rate, type and course of thyroid disease in Danish patients with multiple sclerosis (MS) treated with alemtuzumab. METHODS: We conducted a retrospective cohort study of patients treated with a first series of alemtuzumab for MS in the Capital and Zealand regions of Denmark (population: 2.6 million) between 2014 and 2018 (n = 60 RESULTS: The duration of follow-up was median 81 months (range 54-105). Thyroid disease occurred in 47 % of the patients with the following distribution: Graves' disease (GD), thyrotropin (TSH) receptor antibody (TRAb) positive hyper- or hypothyroidism 35 %; multinodular goitre 5 %; silent thyroiditis, gestational transient thyrotoxicosis or unclassified hyperthyroidism 7 %. Of patients with GD, 14 % had an additional silent or postpartum thyroiditis before onset or after remission of GD. Unusual courses of GD occurred in 67 %, most commonly fluctuation from hypo- to hyperthyroidism or vice versa, mainly treated with antithyroid drug alone or thyroxine substitution regime but switched to concomitant block and replace treatment in 25 % and/or subsequent total thyroidectomy in less than 25 %. CONCLUSION: Data from the largest Danish MS center supports previous observations of unusual, long-lasting and unpredictable courses of alemtuzumab-induced GD. Thus, follow-up of these patients may require long lasting and more frequent biochemical measurements compared to other patients with GD. Also, concomitant block and replace treatment or definitive treatment, such as thyroidectomy, should be considered in a subgroup of patients.

Fresh surgical specimens yield breast stem/progenitor cells and reveal their oncogenic abnormalities.

BACKGROUND: The process by which breast cancer stem cells arise is unknown. It may be that the benign stem cells in breast tissue are transformed into malignant stem cells through the acquisition of genetic abnormalities. In this study, we collected and compared benign and malignant breast stem/progenitor cells to determine whether specific genetic abnormalities occur in breast cancer stem/progenitor cells within the human body. METHODS: Fresh surgical specimens from benign and malignant breast tissues were obtained directly from the operating room and examined. Cells variably expressing stem cell-associated surface markers CD49f and CD24 were collected by fluorescence-activated cell sorting. The frequencies of these cells in benign and malignant breast tissues were ascertained. Oncogenetic mutation analyses were performed and expression of stem cell-associated genes was measured. RESULTS: The frequencies of stem/progenitor cells were similar between benign and malignant tissues. Stem cell-associated gene expression also was similar between benign and malignant stem cells. Genetic mutations in the PIK/AKT pathway were found in 73% of the tumors' stem cells, specifically within two subpopulations. No mutations were found in stem/progenitor cell subpopulations from benign breast tissue. CONCLUSIONS: The results of this study suggest that, following malignant transformation, breast cancer stem/progenitor cells retain their stem cell functions and relative frequencies. In addition, they develop malignant capabilities by acquiring mutations in genes critical for maintaining normal cellular metabolism and proliferation.

[Hyperpigmentation reveals Addison's disease in a pregnant woman].

A 31-year-old woman was admitted to the local department of endocrinology for control of known anti-TPO positive hypothyroidism during pregnancy. The clinician noticed a remarkable hyperpigmentation. Primary adrenal insufficiency was diagnosed and treatment with cortico- and mineralosteroids commenced. Diagnosis of primary adrenal insufficiency during pregnancy is challenging as many symptoms overlap with normal symptoms of pregnancy. The usual diagnostic criteria cannot be used due to the altered hormone concentrations during pregnancy.

Surgeon Gender-Related Differences in Operative Coding in Plastic Surgery.

BACKGROUND: Numerous studies in the medical and surgical literature have discussed the income gap between male and female physicians, but none has adequately accounted for the disparity. METHODS: This study was performed to determine whether gender-related billing and coding differences may be related to the income gap. A 10 percent minimum difference was set a priori as statistically significant. A cohort of 1036 candidates' 9-month case lists for the American Board of Plastic Surgery over a 5-year span (2014 to 2018) was evaluated for relationships between surgeon gender and work relative value units, coding information, major and minor cases performed, and work setting. Data were deidentified by the American Board of Plastic Surgery before evaluation. The authors hypothesized that work relative value units, average codes per case, major cases, and minor cases would be at least 10 percent higher for male than for female physicians. RESULTS: Significant differences were found between male and female surgeons in work relative value units billed, work relative value units billed per case, and the numbers of major cases performed. The average total work relative value units for male surgeons was 19.34 percent higher than for female surgeons [3253.2 (95 percent CI, 3090.5 to 3425.8) versus 2624.1 (95 percent CI, 2435.2 to 2829.6)]. Male surgeons performed 14.28 percent more major cases than female surgeons [77.6 percent (95 percent CI, 72.7 to 82.7 percent) versus 90.5 percent (95 percent CI, 86.3 to 94.9 percent); p = 0.0002]. CONCLUSIONS: The authors' findings support the hypothesis that billing and coding practices can, in part, account for income differences between male and female plastic surgeons. Potential explanations include practices focusing on larger and more complex operative cases and differences in coding practices.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening.

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Full-thickness skin grafting with marginal deepithelialization of the defect for reconstruction of helical rim keloids.

Excising a keloid from the helical rim generally results in a narrow defect with exposed cartilage. Skin grafting is a surgical method with a lowest recurrence rate for keloid treatment. Full-thickness skin grafting may produce an excellent cosmetic outcome, but is generally considered too unreliable over a poorly vascularized defect with exposed cartilage. Adding a new healthy bed with rich vascularity on the periphery will increase the probability of the entire graft surviving via the bridging phenomenon. We report full-thickness skin grafting using a marginal deepithelialization technique for treatment of helical rim keloids. After keloid excision, the surrounding normal skin was deepithelialized 2 to 3 mm wide over the defect border, followed by full-thickness skin grafting. All grafts survived completely. None of the keloids recurred, and they all showed an excellent aesthetic result during the follow-up period from 9 months to 6 years.

Silicone granuloma mimicking Breast Implant Associated Large Cell Lymphoma (BIA-ALCL): a case report.

We describe the case of a 75-year-old woman with textured silicone implants who was referred to our institution with concern for implant rupture and Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). After explantation and pathologic evaluation, she was diagnosed with silicone granuloma and adenitis, though her presentation mimicked BIA-ALCL.

Academics in the Pandemic: Early Impact of COVID-19 on Plastic Surgery Training Programs.

The COVID-19 global pandemic has impacted plastic surgery training in the United States, requiring unprecedented measures to prepare for potential surges in critically ill patients. This study investigates how plastic surgery programs responded to this crisis, as well as how successful these changes were, through a survey of program directors and of residents at academic training programs in the United States. METHODS: Two separate anonymous online surveys were conducted via REDCap between April 16 and June 4, 2020. The first survey was distributed to program directors, and the second was distributed to plastic surgery residents. Resident responses were then subdivided for an analysis between geographic regions. RESULTS: Of the 59 program director responses (43.7%), the majority of programs implemented a platoon approach for resident coverage. A minority did the same for attending coverage. In total, 92% transitioned to virtual didactics only. Plastic surgery residents covered alternative services at 25% of responding institutions, and an additional 68% had a plan in place for responding to personnel shortages. Overall, residents were satisfied with their program's response in a variety of categories. When subdivided based on geographic region, respondents in the Northeast and Northwest were less satisfied with resident wellness, personal and loved ones' safety, and program communication. CONCLUSIONS: With the possibility of a "second wave," successful methods of academic programs adapting to the pandemic should be communicated to reduce the future impact. Increased frequency of communications between program directors and residents can improve mental health and wellness of the resident population.

Differences in Chest Measurements between the Cis-female and Trans-female Chest Exposed to Estrogen and Its Implications for Breast Augmentation.

BACKGROUND: Gender confirming primary breast augmentation is becoming more common. The purpose of this study was to compare the demographic and anatomical differences in cis-female and trans-female populations. METHODS: This was a retrospective analysis of trans-female patients and cis-female patients undergoing primary breast augmentation at a single institution. Analysis included patient demographics and preoperative chest measurements including sternal notch to nipple distance (SSN), breast width (BW), nipple to inframammary fold distance (N-IMF), and nipple to midline distance (N-M). Continuous variables were compared using independent t tests, and discrete variables were compared using Pearson's χ2 tests. RESULTS: Eighty-two trans-female and 188 cis-female patients undergoing primary breast augmentation were included. Trans-female patients were older (40.37 versus 34.07), more likely to have psychological comorbidities (50% versus 12.23%), and had a higher body mass index, 27.46 kg/m2 versus 22.88 kg/m2 (P = 1.91E-07), than cis-female patients. Cis-female patients most commonly had an ectomorph body habitus (52% versus 26%), whereas trans-female patients most commonly had an endomorph body habitus (40% versus 7%). Pseudoptosis or ptosis was more commonly seen in cis-female patients (P = 0.0056). There were significant differences in preoperative breast measurements including sternal notch to nipple distance, BW, and N-M between groups, but not in N-IMF. The ratio of BW/N-IMF was statistically significant (P = 2.65E-07 on right), indicating that the similarity in N-IMF distance did not adjust for the difference in BW. CONCLUSIONS: The trans-female and cis-female populations seeking primary breast augmentation have significant demographic and anatomical differences. This has implications for surgical decision-making and planning to optimize outcomes for trans-female patients.

Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact.

BACKGROUND: Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. METHODS: This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. RESULTS: A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. CONCLUSIONS: We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

Revascularization of rat fasciocutaneous flap using CROSSEAL with VEGF protein or plasmid DNA expressing VEGF.

BACKGROUND: Fasciocutaneous tissue transfer is a common reconstructive procedure. Revascularization of flap tissue is an important component of tissue healing. Gene therapy offers an avenue through which the period of pedicle vascular dependency can be reduced. MATERIALS AND METHODS: Rat fasciocutaneous flaps were elevated and a two-hour ischemic time induced. Polycation complex (jet PEI) and human fibrin sealant CROSSEAL was applied between flap and underlying abdominal tissues. Group 1 (six rats) was the control; Group 2 (seven rats) had vascular endothelial growth factor (VEGF) protein applied; Group 3 (seven rats) had plasmid DNA expressing VEGF applied. Vascular pedicles were ligated on postoperative day 5, percentage flap survival evaluated on day 7. RESULTS: All flaps survived initial ischemia. Mean +/- SD percentage area of the flap that survived was 28.1 +/- 12.4 (Group 1), 71.6 +/- 16.2 (Group 2), and 77.5 +/- 12.7 (Group 3) (P < 0.001, Group 1-3, 2-3). No differences were observed between Groups 2 and 3. CONCLUSIONS: Locally administered VEGF protein or plasmid DNA expressing VEGF enhanced survival of fasciocutaneous flaps.