Faculty Bibliography

OBJECTIVE:To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS:Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS:Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION/CONCLUSIONS:AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.

Recent years have seen the emergence of endoscopic-ultrasound-guided liver biopsy (EUS-LB) as an effective alternative to traditional (percutaneous or transjugular) liver biopsy techniques. Comparative studies have demonstrated that both endoscopic and non-endoscopic approaches are similar in terms of diagnostic adequacy, accuracy, and adverse events; however, EUS-LB offers the advantage of reduced recovery time. Additionally, EUS-LB enables the sampling of both lobes of the liver as well as the advantage of portal pressure measurements. However, EUS-LB may be argued to have a high cost, although this procedure can be cost-effective if bundled with other endoscopic procedures. Approaches utilizing EUS-guided liver therapy, such as the administration of chemotherapeutic agents and EUS elastography, are in development, and their optimal integration into clinical care is likely to emerge in the coming years. In the present review, we evaluate the available literature on EUS-LB indications, contraindications, variations in needle biopsy techniques, comparative outcomes, advantages and disadvantages, and future trends and perspectives.

Background: Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty. Methods: A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction. Results: A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort. Conclusions: Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.

Background: Early surgical exposure and research fellowships can influence medical students' specialty choice, increase academic productivity, and impact residency match. However, to our knowledge, there is no published guidance on the programmatic evaluation and quality enhancement necessary for the sustainability of formal plastic surgery summer research programs for first year medical students. We present seven years (2013-2020) of institutional experience in an effort to inform program development at other institutions. Methods: From 2013 to 2016, a sole basic science research arm existed. In 2017, a clinical research arm was introduced, with several supplemental activities, including surgical skills curriculum. A formalized selection process was instituted in 2014. Participant feedback was analyzed annually. Long-term outcomes included continued research commitment, productivity, and residency match. Results: The applicant pool reached 96 applicants in 2019, with 85% from outside institutions. Acceptance rate reached 7% in 2020. With adherence to a scoring rubric for applicant evaluation, good to excellent interrater reliability was achieved (intraclass correlation coefficient = 0.75). Long-term outcomes showed that on average per year, 28% of participants continued involvement in departmental research and 29% returned for dedicated research. Upon finishing medical school, participants had a mean of 7 ± 4 peer-reviewed publications. In total, 62% of participants matched into a surgical residency program, with 54% in integrated plastic surgery. Conclusions: A research program designed for first year medical students interested in plastic surgery can achieve academic goals. Students are provided with mentorship, networking opportunities, and tools for self-guided learning and career development.

The US FDA in response to concerns that patients undergoing breast implant surgery were not adequately informed about the risks of receiving an implanted medical device mandated a patient decision checklist (PDC) in October 2021. Breast implant manufactures communicated with plastic surgeons in 2022 regarding the use of the PDC as a condition for the sale of breast implants. Plastic surgeons voiced concerns over the accuracy of content in the PDC and its confusing statements about risk of adverse events associated with breast surgery. In April 2022, the Aesthetic Society developed a survey that was sent to its members regarding their experiences with the PDC. This was a 5-question survey and one additional place for comments. The purpose for this survey was to develop data on the six-month experience of plastic surgeons using the PDC. A total of 206 Aesthetic Society members (9%) participated in the survey (1849 total active members in the United States). Patients deserve appropriate information prior to breast implant surgery to make an informed decision after reviewing the potential risks and benefits. The authors believe that there is still more work to be done on an ideal PDC will make it fair and balanced and that it scientifically describes risk incidence in a way that patients understand and can be updated.

INTRODUCTION/BACKGROUND:Non-tuberculous mycobacterial (NTM) infection commonly manifests as subacute or chronic cervicofacial lymphadenitis in immunocompetent children. The optimal management of this pathology remains controversial. OBJECTIVES/OBJECTIVE:This international consensus guideline aims to understand the practice patterns for NTM cervicofacial lymphadenitis and to address the primary diagnostic and management challenges. METHODS:A modified three-iterative Delphi method was used to establish expert recommendations on the diagnostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. SETTING/METHODS:Multinational, multi-institutional, tertiary pediatric hospitals. RESULTS:Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. CONCLUSION/CONCLUSIONS:The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.

BACKGROUND:Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia. METHODS:A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. RESULTS:A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors. CONCLUSION/CONCLUSIONS:The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Background: Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals. Methods: A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected. Results: A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "˜"˜ideal"™"™ for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others. Conclusions: Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

BACKGROUND:Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone prior to top surgery. This represents the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS:Retrospective review identified patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, prior to May 2019, all patients were required to discontinue testosterone prior to surgery, while all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographics and postoperative outcomes compared between groups. RESULTS:490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients, while 104 patients never received testosterone therapy. Demographics were similar between groups, and there was no difference in rates of hematoma (2.9% vs. 2.8% vs 2.9% respectively, p=0.99), seroma (1.1% vs. 0% vs 1%, p=0.31), venous thromboembolism (0% vs. 0.5% vs 0%, p=0.99), or overall complications (6.9% vs. 4.3% vs 5.8%, p=0.54). CONCLUSIONS:Our results demonstrate no difference in postoperative complication rates between groups. While further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.