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Vascularized Composite Allotransplantation and Immunobiology: The Next Frontier

Jacoby, Adam; Cohen, Oriana; Gelb, Bruce E; Ceradini, Daniel J; Rodriguez, Eduardo D
PMID: 34019530
ISSN: 1529-4242
CID: 4877742

Robotic-Assisted Vaginectomy during Staged Gender-Affirming Penile Reconstruction Surgery: Technique and Outcomes

Jun, Min Suk; Shakir, Nabeel Ahmad; Blasdel, Gaines; Cohen, Oriana; Bluebond-Langner, Rachel; Levine, Jamie P; Zhao, Lee C
OBJECTIVES/OBJECTIVE:To report our novel technique and mid-term follow up for robotic-assisted laparoscopic vaginectomy (RALV), a component procedure of staged gender-affirming penile reconstructive surgery (GAPRS). METHODS:The records of patients seeking GAPRS who underwent RALV, performed by a single surgeon at our institution, between May 2016 and January 2020 were reviewed retrospectively for demographic and perioperative data. Patients were included irrespective of history of previous phalloplasty. A subset of these patients elected to have urethral lengthening during second stage phalloplasty for which an anterior vaginal mucosa flap urethroplasty was performed. Postoperative complications and outcomes and most recent follow-up were obtained. RESULTS:A total of 42 patients were reviewed, of whom 19 (45%) patients ultimately had radial forearm free flap, 15 (41%) had anterolateral thigh flap, 5 (12%) had metoidioplasty, and 1 (2.4%) had abdominal phalloplasty. A vaginal mucosa and gracilis flap was used in all of 36 (86%) patients in whom a pars fixa was created. Average operative time was 299 minutes (range 153-506). Median estimated blood loss was 200 ml (range 100-400). Median length of stay was 3 days (range 1-7). Complications within 30 days from surgery occurred in 15 patients (36%), of whom 12/15 were Clavien-Dindo grade 1 or 2, and 11/15 had complications unrelated to vaginectomy. Of the 4 patients who had vaginectomy-related complications, all resolved with conservative management. Median overall follow-up was 15.8 months. CONCLUSIONS:RALV offers a safe and efficient approach during staged gender-affirming penile reconstruction and may mitigate the subsequent risk of urethral complications.
PMID: 33493507
ISSN: 1527-9995
CID: 4767002

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

Robinson, Isabel S; Blasdel, Gaines; Cohen, Oriana; Zhao, Lee C; Bluebond-Langner, Rachel
BACKGROUND:Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM:To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS:A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES:Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS:Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS:These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS:These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION:Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.
PMID: 33663938
ISSN: 1743-6109
CID: 4875212

Review of Flap Monitoring Technology in 2020

Jacobson, Adam; Cohen, Oriana
Advances in free flap reconstruction of complex head and neck defects have allowed for improved outcomes in the management of head and neck cancer. Technical refinements have decreased flap loss rate to less than 4%. However, the potential for flap failure exists at multiple levels, ranging from flap harvest and inset to pedicle lay and postoperative patient and positioning factors. While conventional methods of free flap monitoring (reliant on physical examination) remain the most frequently used, additional adjunctive methods have been developed. Herein we describe the various modalities of both invasive and noninvasive free flap monitoring available to date. Still, further prospective studies are needed to compare the various invasive and noninvasive technologies and to propel innovations to support the early recognition of vascular compromise with the goal of even greater rates of flap salvage.
PMID: 33368128
ISSN: 1098-8793
CID: 4764782

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

Cohen, Oriana D; Abdou, Salma A; Nolan, Ian T; Saadeh, Pierre B
BACKGROUND: The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. PATIENTS AND METHODS/METHODS: Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. RESULTS:. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. CONCLUSION/CONCLUSIONS: ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.
PMID: 32643763
ISSN: 1098-8947
CID: 4580972

Use of a Split Pedicled Gracilis Muscle Flap in Robotic-Assisted Vaginectomy and Urethral Lengthening for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction

Cohen, Oriana; Stranix, John T; Zhao, Lee; Levine, Jamie; Bluebond-Langner, Rachel
BACKGROUND:We describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender affirming phalloplasty. METHODS:Vaginectomy is performed via robotic assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and vaginal cavity. It is then split longitudinally and the inferior half is passed into the vaginal cavity, where it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. RESULTS:From May 2016 to March 2018, 16 patients underwent this procedure, of average age 35.1 ± 8.8 years, BMI 31.4 ± 5.5, and ASA class 1.8 ± 0.6. The average length of operation was 423.6 ± 84.6 minutes, with an estimated blood loss of 246.9 ± 84.9 mL. Patients were generally out of bed on post-operative day 1, ambulating on post-operative day 2, and discharged home on post-operative day 3 (average day of discharge 3.4 ± 1.4 days). At mean follow-up time of 361.1 ± 175.5 days, no patients developed urinary fistula at the urethroplasty site. CONCLUSIONS:Our use of the longitudinally split gracilis muscle in first stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intra-pelvic dead space, with a single flap, in a safe, efficient, and reproducible manner.
PMID: 32195856
ISSN: 1529-4242
CID: 4353782

Temporomandibular Joint Dislocation following Pterygomasseteric Myotomy and Coronoidectomy in the Management of Postradiation Trismus [Case Report]

Cohen, Oriana; Levine, Jamie; Jacobson, Adam S
Trismus is a known complication following treatment of oral and oropharyngeal cancers, with radiation therapy reported as a known risk factor for its development. The prevention of trismus after radiation therapy is hard to achieve, with no clear benefit of early prophylactic rehabilitation. Pterygomasseteric myotomy and coronoidectomy are well described procedures in the management of extra-articular trismus. Herein, we present 2 cases of temporomandibular joint dislocation as a cautionary tale of the potential risk for temporomandibular joint dislocation and need for closed reduction and maxillomandibular fixation.
PMID: 32766081
ISSN: 2169-7574
CID: 4651562

Robotic Excision of Vaginal Remnant/Urethral Diverticulum for Relief of Urinary Symptoms Following Phalloplasty in Transgender Men

Cohen, Oriana D; Dy, Geolani W; Nolan, Ian T; Maffucci, Fenizia; Bluebond-Langner, Rachel; Zhao, Lee C
OBJECTIVE:To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report post-operative outcomes. MATERIALS AND METHODS/METHODS:Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26 - 50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20 - 39) post-op following their primary vaginectomy and radial forearm free flap (n=3) or anterolateral thigh (n=1) phalloplasty. All had multiple urological complications after primary phalloplasty, most commonly urinary retention (n=4), urethral stricture (n=3), fistula (n=3), dribbling (n=2), and obstruction (n=2). Indication for revision was obstruction and retention (n=3) and/or dribbling (n=2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. RESULTS:At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. CONCLUSION/CONCLUSIONS:Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.
PMID: 31790784
ISSN: 1527-9995
CID: 4218082

Knowledge and Skills Acquisition by Plastic Surgery Residents Through Digital Simulation Training: A Prospective Randomized Blinded Trial

Kantar, Rami S; Alfonso, Allyson R; Ramly, Elie P; Cohen, Oriana; Rifkin, William J; Maliha, Samantha G; Diaz-Siso, J Rodrigo; Eisemann, Bradley S; Saadeh, Pierre B; Flores, Roberto L
INTRODUCTION/BACKGROUND:Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. We evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial. METHODS:Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip (UCL) repair. The following parameters were evaluated before (pre-intervention) and after (post-intervention) randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional (3D) stone model, and surgical performance using a hands-on/high-fidelity 3D haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intra-class correlation coefficients (ICC) were calculated. Wilcoxon signed-rank and Mann-Whitney U tests were used. RESULTS:Interrater reliability was strong for pre-intervention and post-intervention grading of markings (ICC=0.97; p<0.001 and ICC=0.96; p<0.001) and surgical (ICC=0.83; p=0.002 and ICC=0.81; p=0.004) performance. Post-intervention surgical knowledge (40.3±4.4 vs. 33.5±3.7; p=0.03), procedural confidence (24.0±7.0 vs. 14.7±2.3; p=0.03), markings performance (8.0±2.5 vs. 2.9±3.1; p=0.03), and surgical performance (12.3±2.5 vs. 8.2±2.3; p=0.04) significantly improved in the digital simulation group compared to pre-intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7±2.5 vs. 14.4±4.4; p<0.001). CONCLUSIONS:We present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, as well as surgical performance.
PMID: 31609286
ISSN: 1529-4242
CID: 4140222

A Cost and Efficiency Analysis of the WALANT Technique for the Management of Trigger Finger in a Procedure Room of a Major City Hospital

Maliha, Samantha G; Cohen, Oriana; Jacoby, Adam; Sharma, Sheel
The "Wide Awake Local Anesthesia No Tourniquet" (WALANT) technique is gaining popularity in hand surgery owing to its benefits of reduced cost, shorter hospital stay, improved safety, and the ability to perform active intraoperative examinations. The aim of this study is to analyze the cost savings and efficiency of performing A1 pulley release for treatment of trigger finger using the WALANT technique in a major city hospital procedure room (PR) as compared with the standard tourniquet, operating room (OR) approach.
PMID: 31942301
ISSN: 2169-7574
CID: 4264462