Faculty Bibliography

BACKGROUND:Chest masculinization is aimed at aligning physical appearance of female-to-male (FtM) transgender patients to their identifying gender. Despite limited evidence, obese FtM patients have historically been denied this procedure due to concerns of complications. We reviewed chest masculinization in the high body mass index (BMI) population to analyze the outcomes. METHODS:. Primary outcomes were mastectomy-site complications. RESULTS:(SD 5.2). Preoperatively, the majority of patients had a cup size of D or larger (77.3%) and grade 3 ptosis (80.0%). Overall rate of complications was 31.5% at median follow-up of 2.1 months. Individual complications included: partial nipple graft loss 18.5%, total nipple graft loss 5.6%, seroma 3.7%, hematoma 3.7%, infection 2.9%. No complications necessitated return to the operating room. However, the majority of patients (77.8%) were completely satisfied with their aesthetic outcome. CONCLUSION/CONCLUSIONS:in this case series. A safe procedure with high satisfaction, obese FtM patients should not be excluded from the increased quality of life and dysphoria reduction chest wall masculinization offers.

BACKGROUND:Reconstructive microsurgery is an effective limb saving option for non-healing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This paper seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity. METHODS:Diabetic patients receiving lower extremity free flaps between August 2011 and January 2018 performed by a single surgeon were retrospectively identified. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined via regression analysis. RESULTS:Sixty-four patients met the criteria. Overall immediate flap success was 94% (60/64). Long term, fifty patients (78.1%) were successfully salvaged, and 14 patients (21.9%) required major amputation. Acute flap loss resulted in 4 amputations while delayed complications (hematoma; infection; recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were ESRD (OR30.7; p=0.0087), hindfoot wounds (OR4.6; p=0.020), elevated HbA1C >8.4% (OR1.4; p=0.05), and positive wound cultures (OR6.1; p=0.003). CONCLUSIONS:Multiple comorbidities and poor sugar control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible.

INTRODUCTION/BACKGROUND:The thigh has been called the reconstructive warehouse. The anterolateral thigh (ALT) and vastus lateralis (VL) flaps are popular options for free tissue transfer in lower extremity reconstruction. We sought to review the largest experience of these flaps in the chronic wound population. METHODS:We retrospectively reviewed patients who underwent lower extremity reconstruction using ALT or VL flaps by a single surgeon between 2012 and 2018. RESULTS:Fifty ALT and 34 VL flaps were identified. Comorbidities were similar between groups with the exception of body mass index (ALT, 26.8; VL, 30.1; P = 0.0121). There was also a significant difference rate of independent ambulation preoperatively (ALT, 98.0%; VL, 85.3%; P = 0.0375). An adjunct was needed for recipient site coverage in 31.5% (19/50) of ALT patients and 100% (34/34) of VL patients. Of the patients who received skin grafts, delayed placement was more frequent in the ALT (53.3%) versus VL cohort (18.2%) (P = 0.0192). Median graft take and the rate of skin graft revision were not statistically different. Flap success rates were similar: ALT, 92.0%; and VL, 94.1%. Overall complication rates were not significantly different: ALT, 26.0%; and VL, 38.2%. Infectious complications were also comparable. Subsequent debulking procedures were performed on 8.0% of ALT flaps and 11.8% VL flaps (P = 0.7092). Limb salvage rates were similar between both cohorts (ALT, 82.0%; VL, 88.2%). Ambulation rate was significantly higher for the ALT cohort at 92.0% compared with 73.5% for the VL cohort (P = 0.0216). Median follow-up was similar for both groups. CONCLUSIONS:We present the largest comparison study of ALT and VL flaps in lower extremity salvage. Complication rates, flap success, and limb salvage were similar between the 2 cohorts. Despite a high prevalence of osteomyelitis in both cohorts, there was no difference in infectious complications. Although the need for skin grafting remains an inherent disadvantage of the VL flap, a significant proportion of ALT recipients also needed an adjunct for recipient site coverage. Ambulation rate was significantly greater in the ALT group. However, flap type was no longer significant for ambulation when controlling for preoperative ambulatory status.

Importance: Patient-reported outcomes data are needed to determine the efficacy of cosmetic procedures. Objective: To describe the development and psychometric evaluation of 8 appearance scales and 2 adverse effect checklists for use in minimally invasive cosmetic procedures. Design, Setting, and Participants: We performed a psychometric study to select the most clinically sensitive items for inclusion in item-reduced scales and to examine reliability and validity with patients. Recruitment of the sample for this study took place from June 6, 2010, through July 28, 2014. Data analysis was performed from December 11, 2014, to December 22, 2015. Pretreatment and posttreatment patients 18 years and older who were consulting for any type of facial aesthetic treatment were studied. Patients were from plastic surgery and dermatology outpatient clinics in the United States and Canada (field-test sample) and a clinical trial of a minimally invasive lip treatment in the United Kingdom and France (clinical trial sample). Main Outcomes and Measures: The FACE-Q scales that measure appearance of the skin, lips, and facial rhytids (ie, overall, forehead, glabella, lateral periorbital area, lips, and marionette lines), with scores ranging from 0 (lowest) to 100 (highest), and the FACE-Q adverse effects checklists for problems after skin and lip treatment. Results: Of 783 patients recruited, 503 field-test patients (response rate, 90%) and 280 clinical trial participants were studied. The mean (SD) age of the patients was 47.4 (14.0) years in the field-test sample and 47.7 (12.3) years in the clinical trial sample. Most of the patients were female (429 [85.3%] in the field-test sample and 274 [97.9%] in the clinical trial sample). Rasch Measurement Theory analyses led to the refinement of 8 appearance scales with 66 total items. All FACE-Q scale items had ordered thresholds and acceptable item fit. Reliability, measured with the Personal Separation Index (range, 0.88-0.95) and Cronbach alpha (range, 0.93-0.98), was high. Lower scores for appearance scales that measured the skin (r = -0.48, P < .001), lips (r = -0.21, P = .001), and lip rhytids (r = -0.32, P < .001) correlated with the reporting of more skin- and lip-related adverse effects. Higher scores for the 8 appearance scales correlated (range, 0.70-0.28; P < .001) with higher scores on the core 10-item FACE-Q satisfaction with facial appearance scale. In the pretreatment group, older age was significantly correlated with lower scores on 5 of the 6 rhytids scales (exception was forehead rhytids) (range, -0.28 to -0.65; P = .03 to <.001). Pretreatment patients reported significantly lower scores on 7 of the 8 appearance scales compared with posttreatment patients (exception was skin) (P < .001 to .005 on independent sample t tests). Conclusions and Relevance: The FACE-Q appearance scales and adverse effects checklists can be used in clinical practice, research, and quality improvement to incorporate cosmetic patients' perspective in outcome assessments.

BACKGROUND:Detecting clinically meaningful change from the patients' perspective is critical to evaluating a successful cosmetic procedure. FACE-Q is a patient-reported outcome instrument for use in patients undergoing cosmetic procedures. OBJECTIVE:We sought to determine the impact of laser resurfacing and injectable treatment (neurotoxin or fillers) on patient perceived improvement in facial appearance. METHODS AND MATERIALS/METHODS:Patients were asked to complete FACE-Q scales (Satisfaction with Facial Appearance, Satisfaction with Facial Skin, and Appraisal of Facial Lines) at their pre-procedure consultation and/or at post-procedural follow-up. Item means (range 1-4) and Rasch transformed scores (range 0-100) were compared pre to post-procedure using two sample t-tests. Higher FACE-Q scores indicated greater satisfaction. RESULTS:Overall, patients experienced a statistically significant improvement in all three scales pre- to post-procedure (P <0.05). Sub-group analysis showed statistically significant improvement in Satisfaction with Facial Appearance and Satisfaction with Facial Skin for both the laser resurfacing group and injectables group with moderate effect sizes. Improvement on Appraisal of Facial Lines trended toward improvement but did not reach statistical significance. CONCLUSION/CONCLUSIONS:Our results support the ability to directly measure and quantify meaningful improvement in appearance among facial cosmetic dermatology patients using FACE-Q scales. Reporting this data is important, as this is the first step towards evidence-based cosmetic procedures in dermatology.

BACKGROUND: Face lifting is one of the most common operative procedures for facial aging and perhaps the procedure most synonymous with plastic surgery in the minds of the lay public, but no verifiable documentation of patient satisfaction exists in the literature. This study is the first to examine face-lift outcomes and patient satisfaction using a validated questionnaire. METHODS: One hundred five patients undergoing a face lift performed by the senior author (C.H.T.) using a high, extended-superficial musculoaponeurotic system with submental platysma approximation technique were asked to complete anonymously the FACE-Q by e-mail. FACE-Q scores were assessed for each domain (range, 0 to 100), with higher scores indicating greater satisfaction with appearance or superior quality of life. RESULTS: Fifty-three patients completed the FACE-Q (50.5 percent response rate). Patients demonstrated high satisfaction with facial appearance (mean +/- SD, 80.7 +/- 22.3), and quality of life, including social confidence (90.4 +/- 16.6), psychological well-being (92.8 +/- 14.3), and early life impact (92.2 +/- 16.4). Patients also reported extremely high satisfaction with their decision to undergo face lifting (90.5 +/- 15.9). On average, patients felt they appeared 6.9 years younger than their actual age. Patients were most satisfied with the appearance of their nasolabial folds (86.2 +/- 18.5), cheeks (86.1 +/- 25.4), and lower face/jawline (86.0 +/- 20.6), compared with their necks (78.1 +/- 25.6) and area under the chin (67.9 +/- 32.3). CONCLUSION: Patients who responded in this study were extremely satisfied with their decision to undergo face lifting and the outcomes and quality of life following the procedure.

OBJECTIVE:To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). METHODS:A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, preoperative angiographic imaging and interventions performed were analyzed. RESULTS:A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). CONCLUSION/CONCLUSIONS:In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete preoperative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

OBJECTIVE:To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. METHODS:Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients' demographics, access history, HeRO patency, and number of reinterventions were analyzed. RESULTS:Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. CONCLUSIONS:In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.