Faculty Bibliography

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/Purpose: For the past 25 years computer-based simulation of cleft lip repair has been an elusive goal. To date, interactive 3D models have allowed students to make preoperative incision markings. Animation generated blend shapes allow premodeled surgical animations to be played back in 3D video game format. Neither of these efforts allow the student to actually perform his/her own lip repair. This article presents what we believe to be the first cleft lip simulator to allow the student to prospectively do complete cleft lip/ nose corrections. Historical procedures and proposed new ones can be performed. A deeper level of understanding can be obtained using this cognitive experiential approach without injuring a real patient. Methods/Description: A 3D solid model of a complete unilateral cleft lip/nose has been prepared based on a laser scan of an actual patient. Procedures are performed using a surgical toolkit consisting of (1) skin hooks, (2) skin/mucosa scalpel, (3) skin and periosteal undermine tool, (4) deep cut tool for cutting through muscle, fat, and cartilage, and (5) a suture tool. First order biologically accurate physics are provided by modeling the solids as a half million tetrahedra. Projective dynamics are used to implement biphasic tissue behavior in which at low strain Hooke's law elasticity is provided, but as strain exceeds 14% the tissue becomes much stiffer to model the commonly observed the flap won't reach phenomenon. Collision is modeled between the teeth and bone of the maxilla and the undersurface of the lip using a Schur complement approach. Near real-time performance is provided on a laptop computer in 3D video game format. A history files may be recorded of the sequence of actions performed by the surgeon.
Result(s): A demonstration of the model and the surgical toolset will be performed in real time. A full cleft lip/nose repair using the simulator will be demonstrated using its history feature.
Conclusion(s): A first order biophysically accurate simulator of cleft lip and nose repair has been developed. It permits the student to cognitively explore different methods of repair and store his/her surgical sequence. This simulator has application in experiential education, proficiency testing, and the design of new surgical procedures

OBJECTIVE/UNASSIGNED:This study evaluates skeletal and dental outcomes of LeFort I advancement surgery in patients with cleft lip and palate (CLP) with varying degrees of maxillary skeletal hypoplasia. DESIGN/UNASSIGNED:Retrospective study. METHOD/UNASSIGNED:: ≤-10 mm. PARTICIPANTS/UNASSIGNED:Fifty-one patients with nonsyndromic CLP with hypoplastic maxilla who met inclusion criteria. INTERVENTION/UNASSIGNED:LeFort I advancement. MAIN OUTCOME MEASURE/UNASSIGNED:Skeletal and dental stability post-LeFort I surgery at a 1-year follow-up. RESULTS/UNASSIGNED:At T2, LeFort I surgery produced an average correction of maxillary hypoplasia by 6.4 ± 0.6, 8.1 ± 0.4, and 10.7 ± 0.8 mm in the mild, moderate, and severe groups, respectively. There was a mean relapse of 1 to 1.5 mm observed in all groups. At T3, no statistically significant differences were observed between the surgical groups and controls at angle Sella, Nasion, A point (SNA), A point, Nasion, B point (ANB), and overjet outcome measures. CONCLUSIONS/UNASSIGNED:LeFort I advancement produces a stable correction in mild, moderate, and severe skeletal maxillary hypoplasia. Overcorrection is recommended in all patients with CLP to compensate for the expected postsurgical skeletal relapse.

Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.

General and local anesthetics are generally well tolerated in the healthy population. Complications may arise affecting the surgical and anesthetic course. We present a case of severe bradycardia and hypotension, along with ST depressions which developed following general anesthesia and local injection of lidocaine with epinephrine to the nose in a healthy male during routine otolaryngological surgery. Symptoms improved with atropine, epinephrine and chest compressions. Subsequent electrocardiogram and Troponin were abnormal, and normalized within days. Reviewing the literature, several possible etiologies arise. These include the Trigeminocardiac Reflex, Takotsubo cardiomyopathy and others. These are discussed and the condition's immediate management recommended.

BACKGROUND:Occipital neuralgia (ON) is a primary headache disorder characterized by severe, paroxysmal, shooting or stabbing pain in the distribution of the greater occipital, lesser occipital, and/or third occipital nerves. Both medical and surgical options exist for treating headaches related to ON. The purposes of this study are to summarize the current state of surgical ON management through a systematic review of the literature and, in doing so, objectively identify future directions of investigation. METHODS:We performed a systematic review of primary literature on surgical management for ON of at least level IV evidence. Included studies were analyzed for level of evidence, therapeutic intervention, study design, sample size, follow-up duration, outcomes measured, results, and risk of bias. RESULTS:Twenty-two studies met the inclusion criteria. All 22 studies used patient-reported pain scores as an outcome metric. Other outcome metrics included complication rates (7 studies; 32%), patient satisfaction (7 studies; 32%), quality of life (7 studies; 18%), and analgesic usage (3 studies; 14%). Using the ROBINS-I tool for risk of bias in nonrandomized studies, 7 studies (32%) were found to be at critical risk of bias, whereas the remaining 15 studies (68%) were found to be at serious risk of bias. CONCLUSIONS:Greater occipital nerve decompression seems to be a useful treatment modality for medically refractory ON, but further prospective, randomized data are required.