Faculty Bibliography

Facial feminization surgery (FFS) is a critical gender-affirming intervention utilized to alleviate gender dysphoria. This study investigates the role of Instagram in shaping public perceptions and disseminating information about FFS. The authors analyzed the most recent 500 Instagram posts using the hashtag "#facialfeminizationsurgery" through a nonbiased data scraping platform between June 1, 2023 and October 13, 2023. Posts were categorized, for example, by tone, author, hospital, practice location, and whether it was a patient or physician-reported outcome. Of the posts, 85% connoted a positive tone. Health care providers and organizations posted 65.4% of content. Geographic breakdown showed that of posts written in English, 55% of health care providers were from the United States. The top 3 most frequently cited locations outside of the United States were India (25.2%), England (19.1%), and South Korea (16.0%). Common themes among posts were perception of FFS and whether it be deemed cosmetic or reconstructive, ethical considerations, and insurance/funding. 36% of posts were advertisements, and 20% were educational, which emphasized the role of social media in disseminating information. This study emphasizes the dynamic nature of social media and its large impact on FFS with regard to disseminating accurate information, navigating the patient-physician relationship, and posting ethical content. The demographics of the users and posts show growing global interest in FFS, a largely positive tone from users, and a large presence of health care workers. Lastly, Instagram is an educational tool for FFS and spreads awareness of insurance and issues faced by patients through first-hand perspectives.

Preclinical testing of tissue engineering modalities are commonly performed in a healthy wound bed. These conditions do not represent clinically relevant compromised oral wound environments due to radiation treatments seen clinically. This study aimed to characterize the bone regeneration outcomes in critical-sized mandibular defects using particulate grafting in an irradiated preclinical model of compromised wound healing. Sixteen New Zealand white rabbits were divided into two groups (n = 8/group), namely (i) irradiated (experimental) and (ii) non-irradiated (control). The rabbits in the experimental group received a total of 36 Gy radiation, followed by surgical intervention to create critical-sized (10 mm), full-thickness mandibular defects. The control group was subjected to the same surgical intervention. All defects were filled with bovine bone grafting material (Bio-Oss, Geistlich, Princeton, NJ, USA) and allowed to heal for 8 weeks. At the study endpoint, rabbits were euthanized, and their mandibles were harvested for micro-computed tomographic, histological, and histomorphometric processing and analysis. Qualitative histological analysis revealed increased levels of bone formation and bridging in the control group relative to the experimental group. This was accompanied by increased levels of soft tissue presence in the experimental group. Volumetric reconstruction showed a significantly higher degree of bone in the control group (27.59% ± 2.71), relative to the experimental group (22.02% ± 2.71) (p = 0.001). The irradiated rabbit model exhibited decreased bone regeneration capacity relative to the healthy subjects, highlighting its suitability as a robust compromised wound healing environment for further preclinical testing involving growth factors or customized, high-fidelity 3D printed tissue engineering scaffolds.

INTRODUCTION/BACKGROUND:The aging neck is a prevalent aesthetic concern, with over 160,000 neck procedures performed in 2020. It is characterized by increased soft tissue laxity and displacement of cervical structures. While nonsurgical interventions like cryoablation and laser resurfacing show promise, their variable responses highlight the necessity for surgical solutions. Traditional neck lifts address superficial structures but often neglect the subplatysmal plane. Recently, deep plane neck lifts have gained attention for addressing deeper anatomical structures. This paper systematically reviews the literature on subplatysmal modifications in cervicoplasty, aiming to clarify the risks and benefits of these evolving surgical techniques. METHODS:On February 20, 2024, a systematic review adhering to Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 guidelines was performed. MEDLINE, PubMed, Cochrane, and Scopus databases were searched for terms related to neck rejuvenation. Independent reviewers screened titles, abstracts, and full texts, including all relevant studies. Data extracted included patient numbers, procedures, outcomes, and complications. RESULTS:From an initial 771 articles, 57 studies encompassing 8648 patients met inclusion criteria. The most commonly altered anatomical structures during "deep plane" neck lift (DPNL) were the submandibular gland (69.9%), digastric muscles (58.6%), and subplatysmal fat (48.6%). Postoperative complications were reported in 59.6% of studies, with nerve palsy (0.2%-12%) and hematoma (0.2%-4%) being most common. Aesthetic outcomes were less frequently reported (56% of studies); patient satisfaction ranged from 81.6% to 98.6%, while objective measures were reported in only 12% of studies. CONCLUSIONS:Recent surveys indicate a growing concern over excess laxity under the chin, with patients increasingly seeking neck rejuvenation. Our review found that DPNL techniques vary widely, with the submandibular gland and digastric muscles being the most frequently altered structures. Despite a general lack of standardized outcome measures, patient satisfaction was high. However, DPNL showed a higher rate of postoperative nerve palsy compared to traditional neck lift. Overall, while DPNL demonstrates potential aesthetic benefits, the increased risk necessitates thorough patient counseling and further studies for standardization and comparison.

Imaging plays an important role in evaluating peripheral nerves. In the preoperative setting, imaging helps overcome pitfalls of electrodiagnostic testing and provides key anatomical information to guide surgical management. In the postoperative setting, imaging also offers key information for treating physicians, although it comes with several challenges due to postsurgical changes and alteration of normal anatomy. This article reviews our approach to peripheral nerve imaging, including how we use imaging in the pre- and postoperative setting for several common indications.

BACKGROUND:There has been increasing emphasis on patient-reported satisfaction as a measure of surgical outcomes. While previous research has investigated factors influencing patient satisfaction following breast reconstruction, there are few studies on how patient satisfaction is impacted by revision procedures. The purpose of this study was to investigate whether elective revisions following breast reconstruction are significantly associated with changes in patient-reported outcomes and quality of life. METHODS:A retrospective review was conducted of patients who underwent immediate autologous or alloplastic breast reconstruction at a single institution from 2015-2021. Patients were included if they had completed BREAST-Q pre-operatively, post-initial reconstruction, and post-revision procedures. Patients were excluded if they received adjuvant radiation or if they had previously undergone breast reconstruction procedures. The primary outcome measures were BREAST-Q domains. Demographic, clinical, and surgical variables were also analyzed. RESULTS:Of the 123 patients included for analysis, 61 underwent autologous breast reconstruction and 62 underwent alloplastic reconstruction. Mean age was 49.31 ± 11.58 years and BMI was 29.55 ± 5.63 kg/m2. 48 patients underwent no revision procedures and 75 patients underwent at least one revision. Between these two groups, there were no differences in age, BMI, complication rates, socioeconomic status, or pre-operative BREAST-Q scores. Patients reported significantly higher satisfaction with outcome after their first revision compared to after initial reconstruction alone (p=0.04). Autologous reconstruction patients who had at least one revision had significantly higher Satisfaction with Outcome (p=0.02) and Satisfaction with Surgeon (p=0.05) in the 2-year follow-up period compared to patients who had no revisions. CONCLUSION/CONCLUSIONS:Revision procedures following autologous breast reconstruction are associated with higher patient satisfaction with outcome. Further research should explore specific factors influencing patient decision-making regarding whether to undergo revisions.

INTRODUCTION/BACKGROUND:With increased access to gender affirming care, the rate of vaginoplasties in the US has risen rapidly. Although some retrospective studies report high rates of lower urinary tract symptoms (LUTS) after gender affirming vaginoplasty, the type and severity of symptoms has not been well-described. The purpose of this study was to prospectively characterize postoperative changes in lower urinary tract function after robotic peritoneal flap vaginoplasty as measured by the American Urological Association Symptom Index questionnaire (AUASI), Urogenital Distress Inventory 6 (UDI6), and additional measures. METHODS:This was a prospective observational study of patients undergoing gender affirming robotic peritoneal flap vaginoplasty enrolled between August 2020 to September 2021. LUTS were evaluated pre- and postoperatively (1, 3, 6, and 12-month) via the AUASI, UDI6, uroflowmetry, and post void residual (PVR) measurements. Averages and 95% confidence intervals over time were estimated and compared through univariate mixed-effect linear regression models. RESULTS:A total of 43 patients were enrolled. The average patient age was 31.1 ± 9.1 years. Overall AUASI Score declined over time (p = 0.002; -0.42,-0.09), though the decrease was less than the clinically minimum importance difference (MID) of 3 points. Preoperative AUASI was 8.1 ± 5.2, 1 month: 8.1 (95% CI: -1.9,1.8); 3 months: 5.2 (-5.0,-1.2); 6 months: 5.7 (-4.6,-0.62); 12 months: 5.2 (-4.9,-0.81). Similarly, UDI6 score declined over time (p = 0.002; -1.12,-0.26), though the decrease was less than MID of 16.7 points. UDI6 score preoperatively was 16.3 ± 1.8; 1 month post op: 16.5 (-5.2,5.0); 3 months: 16.2 (-5.6,5.1); 6 months: 11.6 (-10,1.0), and at 12 months: 8.1 (-13,-2.3). Overall uroflowmetric outcomes measured at postoperative visits including post void residual volume, maximum flow velocity, and average flow velocity did not show any difference at any postoperative time point when compared with preoperative measurements. CONCLUSIONS:In this study both the AUASI and UDI6 declined over time from initial preoperative evaluation to the 12 month follow up period, although the changes in AUASI and UDI6 score did not reach MID. Additionally, urodynamic measurements remained unchanged postoperatively. This data suggests that robotic peritoneal flap vaginoplasty has no effect on lower urinary tract function.

OBJECTIVES/OBJECTIVE:To examine the feasibility of outpatient alveolar bone grafting (ABG) using Exparel (bupivacaine liposome injectable suspension) for donor site analgesia. DESIGN/METHODS:Retrospective, observational study. SETTING/METHODS:Single institution, 39-month retrospective review. PATIENTS/PARTICIPANTS/METHODS:In total, 21 patients with cleft alveolus were included in this study. INTERVENTION/METHODS:In autologous outpatient ABG procedures using a mixed open harvest and Acumed trephine method to retrieve corticocancellous bone from the iliac crest, Exparel was injected in the donor site fascia. MAIN OUTCOME MEASUREMENTS/METHODS:Postoperative data including length of stay, post anesthesia care unit narcotics delivered, and maximum pain scores were recorded. Successful outcomes were assessed by exploring 30-day complications, 30-day emergency department visits, 30-day readmissions, and ambulation at follow-up. RESULTS:The average hospital length of stay was 360.8 min. Four patients required overnight stay secondary to pain. The average doses of pain medications administered postoperatively were 198.4 mg acetaminophen, 9.3 mg ketorolac, 3.0 µg fentanyl, and 1.5 mg oxycodone. No patient reported 30-day complications secondary to donor site pain, 30-day emergency department visits, or 30-day readmissions, and there was only one case of wound dehiscence. All patients exhibited proper ambulation at follow-up and healed well from ABG. CONCLUSIONS:The use of Exparel for donor site analgesia in outpatient ABG procedures using corticocancellous grafts can result in adequate pain management and ambulation without an increased risk of complications and readmissions.

OBJECTIVE:The objective of this study was to determine the outcomes of robotic peritoneal flap vaginoplasty. BACKGROUND:There is a lack of long-term outcomes data for gender-affirming vaginoplasty to inform patient decision-making. METHODS:A retrospective cohort of 500 consecutive patients undergoing robotic peritoneal flap vaginoplasty from 2017-2023 were reviewed. Complications requiring procedural intervention, self-reported vaginal dimensions, and orgasm were recorded at each follow up visit and analyzed as outcomes. RESULTS:487 (97%) of patients were followed to 3 months, and 425 (85%) to 1 year or greater. Twenty patients (4%) had a complication requiring procedural intervention, and 61(12%) had elective revision surgery. Median self-reported vaginal depth and width at 1 year was 14.5 cm (14.5-14.5) and 3.8 cm (3.8-3.8 cm). There were 12 patients (4%) no longer dilating using standard dilators at this pre-scheduled 1-year appointment, and at last follow-up ≥1 year, 8% were no longer dilating. Thirty-six (8%) of patients were considered anorgasmic at last follow up. Difficulty with orgasm prior to surgery was associated with lower rates of achieving orgasm after surgery and less consistent vaginal depth at 1 year, however 80% of these patients were able to orgasm after surgery. CONCLUSIONS:Clinician-observed and patient-reported outcomes for robotic gender-affirming peritoneal flap vaginoplasty were superior to those reported in the literature for penile inversion vaginoplasty. Patients who do not achieve orgasm prior to surgery are less likely to achieve orgasm and maintain vaginal depth afterwards, however the majority of these patients have improved sexual health after surgery.

Hair follicle neogenesis (HFN) occurs following large skin excisions in mice, serving as a rare regenerative model in mammalian wound healing. Wound healing typically results in fibrosis in mice and humans. We previously showed small skin excisions in mice result in scarring devoid of HFN, displaying features of non-regenerative healing, and Hedgehog (Hh) activation in the dermis of such wounds can induce HFN. In this study, we sought to verify the role of dermal Wnt/β-catenin signaling in HFN, as this pathway is essential for HF development, but is also paradoxically well-characterized in fibrosis of adult wounds. By deletion of β-catenin in large wound myofibroblasts, we show Wnt/β-catenin signaling is required for endogenous mechanisms of HFN. Through utilizing a combined mouse model that simultaneously induces deletion of β-catenin and constitutive activation of Smoothened (Smo) in myofibroblasts, we also found β-catenin is required for Hh-driven DP formation. Transcriptome analysis confirms Wnt/β-catenin and Hh pathways are activated in dermal papilla (DP) cells. Our results indicate that Wnt-active fibrotic status may also create a permissive state for the regenerative function of Hh, suggesting that activation of both Wnt and Hh pathways in skin wound fibroblasts must be ensured in future strategies to promote HFN.