Faculty Bibliography

GENERAL PURPOSE/UNASSIGNED:To present the 2021 update of the Wound Bed Preparation paradigm. TARGET AUDIENCE/BACKGROUND:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES/UNASSIGNED:After participating in this educational activity, the participant will: 1. Apply wound assessment strategies. 2. Identify patient concerns about wound care. 3. Select management options for healable, nonhealable, and maintenance wounds.

INTRODUCTION/BACKGROUND:Indications for prophylactic antibiotic therapy in nonoperative, closed fractures of the orbit and zygoma remain controversial and are based on anecdotal data. The purpose of this study was to report the incidence of infectious sequelae among patients who presented to our institution with stated fractures and who were not administered prophylactic antibiotic therapy. The authors hypothesized that an increase in infectious complications would not be seen in these patients. METHODS:The authors conducted a prospective single site study from October 2015 to December 2019. Patients with closed, nonoperative fractures involving the orbit and/or zygoma were included. These patients did not receive prophylactic antibiotic therapy for their fracture patterns, and infectious complications including orbital cellulitis, meningitis, and bacterial sinusitis were noted if present during follow-up. RESULTS:Of 301 patients with closed, nonoperative orbital and/or zygomatic fractures, 268 were included in the study and 33 were excluded because of administration of antibiotics. The average age was 60 years, and the most common mechanism of injury was a traumatic fall. Fracture types included 100 orbital wall, 133 orbital floor, 15 orbital rim, 23 orbital roof, 48 zygoma, and 44 zygomaticomaxillary compound fractures. Infectious sequelae were not identified in any patient. CONCLUSIONS:Of the 268 patients included in the study, no infectious complications were identified during the follow-up period. This outcome further supports that the use of prophylactic antibiotics is not indicated for closed, nonoperative fractures involving the orbital and/or zygoma. Prospective randomized control studies would be useful to support this outcome and better guide clinical antibiotic prescribing practices.

BACKGROUND:To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. METHODS:A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. RESULTS:Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. CONCLUSIONS:Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

SUMMARY/CONCLUSIONS:Radiation-induced changes in skin and soft tissue result in significant cosmetic and functional impairment with subsequent decrease in quality of life. Fat grafting has emerged as a therapy for radiation-induced soft-tissue injury, and this narrative review aims to evaluate the current clinical evidence regarding its efficacy. A review was conducted to examine the current clinical evidence of fat grafting as a therapy for radiation-induced injury to the skin and soft tissue and to outline the clinical outcomes that can be used to more consistently quantify chronic radiation-induced injury in future clinical studies. The current clinical evidence regarding the efficacy of fat grafting to treat radiation-induced injury of the skin and soft tissue suggests that fat grafting increases skin softness and pliability, induces volume restoration, improves hair growth in areas of alopecia, reduces pain, and improves cosmetic and functional outcomes. However, literature in this field is far from robust and mired by the retrospective nature of the studies, lack of adequate controls, and inherent limitations of small case series and cohorts. A series of actions have been identified to strengthen future clinical data, including the need for physical examination using a validated scale, appropriate imaging, skin biomechanics and microcirculation testing, and histologic analysis. In conclusion, radiation-induced soft-tissue injury is a significant health burden that can lead to severe functional and aesthetic sequelae. Although still in a preliminary research phase, there is promising clinical evidence demonstrating the benefits of fat grafting to treat chronic changes after radiation therapy. Future clinical studies will require larger cohorts, adequate controls, and consistent use of objective measurements.

Glands in the skin are essential for various physiological functions involving exocrine secretion. Like other tissues and organs, they possess the ability to repair injury and self-renew during homeostasis. Progenitor cells in glands are mostly unipotent but include some multipotent stem cells that function when extensive remodelling or regeneration is required. In this review, using two glandular models in skin, mouse sweat gland and mammary gland, we discuss lineage restriction that develops during glandular morphogenesis, as well as the mechanisms regulating cell fate and plasticity during wound repair and regeneration. Understanding the intrinsic and extrinsic factors that control the behaviours of glandular stem cell and maintain glandular functions will provide insight into future prospects for glandular regeneration.

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.

Background/UNASSIGNED:A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods/UNASSIGNED:This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results/UNASSIGNED:The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions/UNASSIGNED:In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Background/Purpose: Newborns with cleft lip and/or palate (CLP) exceed 100 000 per year in low- and middle-income countries (LMICs). Patients, if left untreated, are at high risk of morbidity, due to functional deficits, malnutrition, aspiration, and infections. Limited resources in LMICs create barriers for establishing Interdisciplinary Cleft Care programs. Surgical missions driven by nonprofit organizations have been able to partially address this need, but their ability to promote long-term sustainable cleft care has come to a question. Simulation-based training has emerged as an essential tool for enhancing medical education and training. Global Smile Foundation, a nonprofit organization, is a leader in the establishment of Interdisciplinary Cleft Care programs, with its volunteers being involved in cleft care for over 3 decades. We were able to demonstrate the efficacy of our first Simulation-Based Comprehensive Cleft Care Workshop (SBCCW), in the Middle East-North Africa (MENA) region, and its wide acceptance by our recipients. In the current study, we want to prove the effectiveness and successfulness of our second SBCCW, in Latin America. Methods/Description: Our second SBCCW took place in Lima, Peru, in October 2019. Hands-on simulations of CLP repair using highfidelity CLP simulators were also provided to our participants. Participants were asked to complete a satisfaction survey at the end. Attendees were also asked about the obstacles facing cleft care in their countries and the possible interventions to overcome these obstacles. Short-term (at the end of the SBCCW) and medium-term (6 months later) follow ups were conducted by our team collecting data about improvements in the participants' competence, performance, outcomes, clinical care, and whether the SBCCW has changed their practice. Procedural confidence for pre- and postsimulation was evaluated using the psychometrically validated tool for measuring selfconfidence during surgical learning. Descriptive statistics were used for the collected data. Data analyses were performed using the Statistical Package for the Social Sciences. XXResult(s): Ninety-eight of the 198 participants from 29 different countries filled the satisfaction survey at the end of the workshop. The 2 most common barriers to cleft care in LMICs identified by our participants are the absence of financial support and the absence of multidisciplinary teams. Respondents claimed an improvement in their procedural confidence after the simulation sessions. Respondents had consistent short-term and medium-term impressions about the SBCCW positively impacting their competence, performance, outcomes, clinical care, and even changing their practice. XXConclusion(s): This study provides evidence that implementation of a SBCCW leads to a significantly improved procedural confidence, as well as a sustained positive impact on the clinical practice of the participants, reinforcing its role as a cleft care capacity-building tool