Faculty Bibliography

BACKGROUND:Penile inversion vaginoplasty (PIV) is the most common procedure for genital reconstruction in transwomen. While PIV usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. Here, we describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. METHODS:Between 2017 and 2018, 41 female-to-male patients were identified who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6cm wide by 8cm long peritoneal flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. RESULTS:The 41 patients had an average age of 34 +/- 14 years. Average length of procedure was 262 +/- 35 minutes and the average length of stay was 5 days. Average length of follow up was 114 +/- 79 days and at most recent follow up, vaginal depth and width were measured to be 14.2 +/- 0.7 cm and 3.6+/- 0.2 cm respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. CONCLUSION/CONCLUSIONS:Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex with acceptable anticipated complications.

In conjunction with social transition, hormones, and counseling, gender-affirming surgery (GAS) is a key component in the treatment gender dysphoria. Gender affirming surgeries can be divided into genital surgery (phalloplasty, metoidioplasty, oophorectomy, vaginoplasty, and orchiectomy) and non-genital surgeries. The non-genital surgeries for transmasculine individuals include chest masculinization and body contouring. For transfeminine individuals, they include breast augmentation, and facial feminization. Chest masculinization eliminates the need for binding and improves overall confidence and quality of life. Choice of technique depends on body habitus and patient preference. For transfeminine individuals, some breast growth can be achieved with the use of estrogen over the course of 1-2 years, but many still require breast augmentation for breasts that are proportionate to their frame. Facial surgery for transfeminine patients is highly effective in changing classic masculine anatomic features to feminine norms. The most common of these procedures include forehead contouring, rhinoplasty, lip lift, mandible angle reduction, genioplasty and chondrolaryngoplasty. These non-genital surgeries are critical to treating gender dysphoria in transgender and gender non-binary individuals. Further research with standardized and validated assessments of patient reported outcomes is needed to fully understand long term effects on quality of life and gender dysphoria.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

BACKGROUND: The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. METHODS:-tests for continuous variables. Multivariate regression was performed to control for confounders. RESULTS: = 0.14) for local flaps of the lower extremity. CONCLUSIONS: Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.

OBJECTIVE/UNASSIGNED:Informed decision-making relies on available information, including online resources. We evaluated the content and readability of websites published by American Cleft Palate-Craniofacial Association (ACPA)-approved cleft lip and/or palate (CLP) teams in the United States. DESIGN/UNASSIGNED:Team websites were reviewed, and teams with no accessible website or <30 sentences of content were excluded. Website content was scored by presence/absence of 20 variables derived from ACPA approval standards. Readability was evaluated with 8 scales. Readability was then compared to American Medical Association (AMA) recommendations. The relationship between website content and readability was assessed. MAIN OUTCOME MEASURE(S)/UNASSIGNED:Content and readability of team websites. RESULTS/UNASSIGNED:From 167 reviewed teams, 47 (28.1%) had nonfunctional links, 17 (10.2%) had no accessible website, and 39 (23.4%) had <30 sentences. The average content score for all 111 team websites included was 14.5 (2.6) of 20. The combined average reading level across all scales (10.7 [1.9]) exceeded the AMA-recommended sixth-grade reading level; this finding held true for each individual website. Children's Hospital-affiliated teams (n = 86) had a significantly higher content score (14.8 vs 13.5; P = .03) and better readability as evidenced by lower reading grade level (10.5 vs 11.4; P = .04). On linear regression, a higher content score significantly predicted better readability (β = -0.226; P < .001). CONCLUSIONS/UNASSIGNED:Websites published by ACPA-approved CLP teams vary in accessibility and content and exceed the recommended reading level. These findings could inform future efforts to improve patient-oriented resources.

Facial transplant (FT) is a viable option for patients with severe craniomaxillofacial deformities. Transplant imaging requires coordination between radiologists and surgeons and an understanding of the merits and limitations of imaging modalities. Digital subtraction angiography and CT angiography are critical to mapping vascular anatomy, while volume-rendered CT allows evaluation of osseous defects and landmarks used for surgical cutting guides. This article highlights the components of successful FT imaging at two institutions and in two index cases. A deliberate stepwise approach to performance and interpretation of preoperative FT imaging, which consists of the modalities and protocols described here, is essential to seamless integration of the multidisciplinary FT team. ^©RSNA, 2019 See discussion on this article by Lincoln .

OBJECTIVE/UNASSIGNED:Assess the weight and contribution of each of the parameters of the Asher-McDade Scale to overall subjective assessment of nasolabial aesthetics following cleft lip repair. DESIGN/UNASSIGNED:Retrospective cohort evaluation. SETTING/UNASSIGNED:Cleft and craniofacial center. PARTICIPANTS/UNASSIGNED:Forty-one patients who underwent unilateral cleft lip repair. INTERVENTIONS/UNASSIGNED:Unilateral cleft lip repair. MAIN OUTCOME MEASURES/UNASSIGNED:Nasolabial rating using the Asher-McDade scale and overall subjective assessment of nasolabial aesthetics using a rank score following unilateral cleft lip repair. RESULTS/UNASSIGNED:= .69; P < .001). CONCLUSION/UNASSIGNED:The parameters evaluated in the Asher-McDade scale have different weights and contribute differently to overall subjective assessment of nasolabial aesthetic outcomes following cleft lip repair. Adjusting for their weights results in a modified score that demonstrates superior correlation with overall subjective assessment of nasolabial aesthetic outcomes.

This study evaluated the effect of alumina-blasted/acid-etched (AB/AE) or microabrasive blasting (C3-Microblasted) surface treatment on the osseointegration of commercially-pure Ti (grade II) and Ti-6Al-4V alloy (grade V) implants compared to as-machined surfaces. Surface characterization was performed by scanning electron microscopy and optical interferometry (IFM) to determine roughness parameters (Sa and Sq, n = 3 per group). One-hundred forty-four implants were placed in the radii of 12 beagle dogs, for histological (n = 72, bone-to-implant contact - BIC and bone-area-fraction occupancy -BAFO) and torque to interface failure test at 3 and 6 weeks (n = 72). SEM and IFM revealed a significant increase in surface texture for AB/AE and C3-Microblasted surfaces compared to machined surface, regardless of titanium substrate. Torque-to-interface failure test showed significant increase in values from as-machined to AB/AE and to C3-Microblasted. Considering time in vivo, alloy grade, and surface treatment, the C3-microblasted presented higher mean BIC values relative to AB/AE and machined surfaces for both alloy types. BAFO levels were significantly higher for both textured surfaces groups relative to the machined group at 3 weeks, but differences were not significant between the three surfaces for each alloy type at 6 weeks. Surface treatment resulted in roughness that improved osseointegration in Grade II and V titanium substrates.

This study's objective was to mechanically characterize and validate the synthesis method of a polycrystalline composite comprised of 80% alumina reinforced with 20% translucent zirconia (zirconia-toughened alumina, ZTA) and compare to an experimental translucent zirconia. Experimental ZTA (ZTA ZPEX 80/20) and translucent Y-TZP (ZPEX) green-state disc-shaped specimens were obtained via uniaxial/isostatic ceramic powder pressing technique. The discs were sintered using a predefined protocol after both sides of the discs were polished. The specimens were subjected to nanoindentation testing to acquire their elastic modulus (E) and hardness (H) before and after a simulated low temperature degradation (LTD) challenge. Subsequently, the fabricated discs had their 3D surface topographical (Sa/Sq) parameters assessed via interferometry before and after exposure to a simulated LTD aging protocol. The specimens were evaluated using X-ray diffraction (XRD) to assess the tetragonal-monoclinic phase transformation and via scanning electron microscopy (SEM) to evaluate the homogeneity of the surfaces and distribution of the grains. The apparent density was measured using Archimedes"™ principle. All of the data were statistically evaluated through repeated measures ANOVA following post-hoc comparisons using the Tukey test (p < 0.05). The XRD patterns indicated a higher increase in the monoclinic peak for ZPEX compared to ZTA ZPEX 80/20 aged. LTD aging did not have an effect on the surface roughness (Sa/Sq) for both groups (p > 0.05). A significant decrease in the E values after the aging protocol was observed for both groups (p < 0.01). While ZTA ZPEX 80/20 did not show statistically significant differences in the hardness values after the aging protocol (p = 0.36), ZPEX demonstrated a significant decrease in the H values (p = 0.03). For ZTA ZPEX 80/20, simulated LTD aging did not affect the tested properties, except for the E values. Although artificial aging did not affect the surface roughness of ZPEX, the E and H values significantly decreased after aging.