Faculty Bibliography

The use of body mass index (BMI) to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested. While BMI thresholds are often meant to be protective, restricting patients from access to surgery can also cause harm. There is a rationale for the continued use of BMI, but the inherent problems with it must also be recognized, including how weight stigma impacts patients' access to gender-affirming surgery and influences clinical care. This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries, as well as analogous procedures, existing de facto BMI thresholds, and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss. BMI factors into surgical decision-making based on the existing literature, which demonstrates that high BMI is associated with increased surgical risk, including higher incidences of surgical site infections and poor wound healing, as well as the possibility of free flap complications, which are a component of certain genital procedures. This patient population is at higher risk for eating disorders, and it is prudent to find alternatives to requiring patient self-monitored weight management. The impacts of weight stigma should be considered when treating gender-affirming surgery patients, and further data and research are needed to augment shared decision-making and lead to practice change.

Restoration of upper extremity function poses a unique surgical challenge. With considerations ranging from ensuring appropriate skeletal support and musculotendinous and ligamentous anatomy, restoring adequate vascularity and innervation, and providing sufficient soft tissue coverage, upper extremity injuries present a diverse range of reconstructive problems. Recent history has been marked by an expansion of novel techniques for addressing these complex issues. Sophisticated modalities, such as targeted muscle reinnervation, free functional muscle transfer, and vascularized composite allotransplantation, have become some of the most powerful tools in the armamentarium of the reconstructive surgeon. This review article aims to define the distinguishing features of each of these modalities and reviews some of their unique advantages and limitations.

Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Subsequent authors incorporated laparoscopy and demonstrated the viability of transplanted testes based on serial postoperative exams. We sought to extend this experience with use of the da Vinci surgical robot, thereby demonstrating a novel robotic technique for the management of cryptorchidism. The procedure was performed for an 18-year-old male with a solitary left intra-abdominal testis. Following establishment of pneumoperitoneum, the robot is docked with four trocars oriented towards the left lower quadrant. Testicular dissection is carried out as shown. The gonadal and inferior epigastric vessels are isolated and mobilized; once adequate length is achieved, the former is clipped and transected, and the testicle and inferior epigastric vessels are delivered out of the body. The robot is then undocked and exchanged for the operating microscope. Arterial and venous anastomoses are completed with interrupted and running 9-0 Nylon, respectively, and satisfactory re-anastomosis is confirmed visually and with Doppler. The transplanted testicle is then fixed inferiorly and laterally within the left hemiscrotum, and all incisions are closed. We note that intraoperative testicular biopsy was not performed, for three reasons: (1) to avoid further risk to an already tenuous, solitary organ, (2) because our primary aim was to preserve testicular endocrine function, and (3) because the presence of ITGCN would neither prompt orchiectomy nor obviate the need for ongoing surveillance via periodic self-examination and ultrasonography. The patient is maintained on bed rest for two days and discharged on postoperative day seven in good condition. Over one year since autotransplantation, his now intra-scrotal testicle remains palpable and stable in size. Serum testosterone is unchanged from preoperative measurements. Robotic-assisted testicular autotransplantation is a feasible and efficacious management option for the solitary intra-abdominal testis.

BACKGROUND: From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. RESULTS: = 0.03) complications. CONCLUSION/CONCLUSIONS: DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

HYPOTHESIS/OBJECTIVE:Injuries requiring resection of tissue followed by autogenous bone transfer may be prone to infection by Staphylococcus aureus, impeding recovery and increasing medical costs. For critical sized defects, the common approach to reconstruction is a tissue transfer procedure but is subject to limitations (e.g., donor site morbidity, cost, operating time). Utilizing beta tricalcium phosphate (β-TCP) as bone grafting material augmented with silver (Ag), a custom graft may be 3D printed to overcome limitations and minimize potential infections. EXPERIMENTS/METHODS:) groups followed by electron microscopy, thermogravimetric analysis (TGA), and differential scanning calorimetry (DSC) to gather information of chemical and physical properties. Preliminary biocompatibility and bactericidal capacity of the scaffolds were tested using human osteoprogenitor (hOP) cells and methicillin-sensitive S. aureus strain, respectively. RESULTS:groups, whereas electron microscopy showed a decrease in Ca and an increase in Ag ions, decreasing Ca/P ratio with increasing surfactant concentrations. PrestoBlue assays yielded an increase in fluorescence cell counts among experimental groups with lower concentrations of Ag characterized by their characteristic trapezoidal shape whereas cytotoxicity was observed at higher concentrations. Similar observations were made with alkaline phosphatase assays. Antimicrobial evaluation showed reduced colony-forming units (CFU) among all experimental groups when compared to 100% β-TCP. β-TCP scaffolds augmented with Ag ions facilitate antibacterial effects while promoting osteoblast adhesion and proliferation.

Introduction: Vascularized composite allotransplantation provides a reconstructive option for patients with otherwise irreparable defects. Despite significant advances in the field, successful multi-vascularized composite allotransplantation has yet to be reported. We herein describe our experience with the first successful combined face and bilateral hand transplant, focusing on the sequence and timing of allograft procurement.
Method(s): The recipient was a 22-year-old male who presented for multi-vascularized composite allotransplantation evaluation after sustaining a motor vehicle accident resulting in 80% total body surface area burns, including his full face and bilateral upper extremities. Following multidisciplinary team evaluation and institutional review board approval, he was deemed an appropriate candidate for combined face and bilateral hand transplant. In defining his expectations for the transplant, the recipient wished to prioritize recovery of hand function above all else.
Result(s): Combined face and bilateral hand transplant was performed over 23 h and 3 min in two adjacent operating rooms. Given the recipient's right-hand dominance, we opted for procurement and transplantation of the right upper extremity first, followed by the left upper extremity, with the facial allograft procured last. The vascular pedicles in the donor left upper extremity allograft were only divided once vascular inflow and outflow was re-established in the right upper extremity. Similarly, the external carotid arteries were clamped and divided after the left upper extremity was reperfused. To minimize ischemia, no tourniquet was used in the donor room, while tourniquet use was limited to <2 h in the recipient room. Total ischemia times were 2 h and 30 min for the right upper extremity; 2 h and 46 min for the left upper extremity; and 2 h and 52 min for the face. Optimization of arterial inflow and venous outflow was ensured with preservation of the muscular perforators and reconstruction of both the deep and superficial venous systems. At 10 months post-transplant, the recipient is demonstrating continuous improvement in functional outcomes.
Conclusion(s): In this report, we describe our approach for procuring three allografts in the first successful face and bilateral hand transplant. In addition to meticulous preparation, this case highlights the importance of understanding and prioritizing the recipient's goals for the transplant

Introduction: Acute rejection is exceptionally common in the first year after vascularized composite allotransplantation. Recipients with burns are at increased risk of developing donor-specific antibodies due to sensitization. Lymphocyte depleting induction with rabbit antithymocyte globulin is commonly utilized. We hypothesized that combination B- and T-cell depletion induction therapy is more efficacious in preventing acute rejection in the early post-transplant period.
Method(s): Our induction protocol calls for intraoperative administration of methylprednisolone (1000 mg) and rabbit antithymocyte globulin beginning intraoperatively (1.5 mg/ kg, cumulative dose 6 mg/kg over the first postoperative week) and rituximab (1000 mg administered on postoperative day 1) for thorough T and mature B-cell depletion. Standard infection prophylaxis is utilized. Donor-specific antibodies are monitored postoperatively with Luminex single-antigen microbeads (mean fluorescence intensity >= 1000 considered clinically significant).
Result(s): Our latest recipient was a 22-year-old male with 80% total body surface area burns. The donor was an ABOidentical, 47-year-old brain dead male. Human leukocyte antigen (HLA) mismatch was 0, 1, 0 (A, B, DR), and 2 HLA-DPB1. Donor-recipient complement-dependent cytotoxicity and flow cytometric T- and B-cell crossmatch were all negative. Abrupt rise in donor-specific antibodies on postoperative days 7 and 8 was treated with two rounds of plasmapheresis and intravenous immunoglobulin. Persistent wound colonization (Acinetobacter baumannii) was treated with meropenem, polymyxin, and tigecycline. The recipient experienced a single episode of acute rejection 9 months post-transplant, successfully treated with pulse doses of methylprednisolone (500 mg intravenous, daily) over 3 days. We suspect this may have been triggered by inflammation induced by revision surgery of all three vascularized composite allotransplantation components in the preceding month
Conclusion(s): We present our third consecutive vascularized composite allotransplantation recipient utilizing this novel immune strategy. In the context of the most extensive vascularized composite allotransplantation performed to date, acute rejection was prevented until 9 months post-transplant in this highly sensitized patient. Two previous recipients remained rejection-free for greater than 1 year post-transplant and have experienced only one rejection episode each to date. Acute rejection in vascularized composite allotransplantation may be better prevented by including rituximab in the induction immunosuppression strategy, and the risk of metabolic or severe infectious complications appears to be manageable