Bostwick Autoderm and Implant Technique: Improved Outcomes for Obese Patients in Immediate Breast Reconstruction.

BACKGROUND: The Bostwick autoderm technique uses the patient's own deepithelialized mastectomy flap for lower pole coverage of an implant, similar to the use of acellular dermal matrix. The skin is closed over the autoderm flap in a Wise pattern. Unlike acellular dermal matrix, autoderm is perfused tissue that offers immediate protection for the implant. Because of this extra protective vascularized layer, implants can often be salvaged in cases of wound breakdown. METHODS: A retrospective review of 370 patients and 592 immediate implant reconstructed breasts was performed. RESULTS: Four hundred twenty-two (71 percent) were reconstructed with autoderm, 93 (16 percent) with total muscle coverage, and 77 (13 percent) with acellular dermal matrix. Higher body mass index patients were overrepresented in the autoderm group. Ninety-one of the reconstructions in the autoderm group (21.3 percent) were performed on patients with a body mass index greater than 35 kg/m2 compared to four (4.3 percent) in the total muscle coverage group and two (2.6 percent) in the acellular dermal matrix group. Despite this higher proportion of obese patients, the complication rate in the autoderm group was similar to that of the acellular dermal matrix group. The implant loss rate for all reconstructions was 3.4 percent. There were 17 losses (4 percent) in the autoderm group, zero in the total muscle coverage group, and 20 (3.4 percent) in the acellular dermal matrix group. There were 15 patients and 28 breasts that had prepectoral reconstruction. CONCLUSION: The autoderm flap is a safe, reliable, and resource-conscientious technique for immediate, implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs.

BACKGROUND: With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown. OBJECTIVE: We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training. METHODS: PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed. RESULTS: In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001). CONCLUSIONS: A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

Educational Exposure to Transgender Patient Care in Plastic Surgery Training.

BACKGROUND: Gender dysphoria is estimated to occur in up to 0.9 percent of the U.S. POPULATION: With increasing awareness and decreasing stigma surrounding transgender issues, it is predicted that more patients will begin to seek medical and surgical transition. This study aims to determine the current state of transgender-related education in U.S. plastic surgery residency programs and to evaluate trainee perceptions regarding the importance of such training. METHODS: Plastic surgery trainees from a representative sample of 21 U.S. training programs were asked to complete a cross-sectional eight-question survey between November of 2015 and January of 2016. Respondents were queried regarding demographics, transgender curricular exposure (didactic versus clinical), and perceived importance of training opportunities in transgender patient care. RESULTS: A total of 322 residents or fellows responded to the survey (80 percent response rate) from four U.S. Census regions. Sixty-four percent of respondents had education on or direct exposure to transgender patient care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to chest and genital surgery. Overall, the majority of respondents believed that training in gender-confirming surgery is important, and 72 percent endorsed the necessity for gender-confirming surgery fellowship training opportunities. CONCLUSIONS: A significant number of plastic surgery trainees are exposed to transgender patient care, although exposure type is variable. The majority of trainees endorsed the importance of residency and fellowship training in gender-confirming surgery. To better serve the transgender population, formal fellowship training in gender-confirming surgery should be offered.

Signaling by SHH rescues facial defects following blockade in the brain.

BACKGROUND: The Frontonasal Ectodermal Zone (FEZ) is a signaling center in the face that expresses Sonic hedgehog (Shh) and regulates patterned growth of the upper jaw. Blocking SHH in the forebrain blocks Shh expression in the FEZ and creates malformations resembling holoprosencephaly (HPE), while inhibition of BMP signaling in the mesenchyme blocks FEZ formation and causes similar dysmorphology. Thus, the brain could regulate FEZ formation by SHH or BMP signaling, and if so, activating one of these pathways in the face might alleviate the effects of repression of SHH in the brain. RESULTS: We blocked SHH signaling in the brain while adding SHH or BMP between the neural and facial ectoderm of the frontonasal process. When applied early, SHH restored Shh expression in the FEZ and significantly improved shape outcomes, which contrasts with our previous experiments that showed later SHH treatments have no effect. BMP-soaked beads introduced early and late caused apoptosis that exacerbated malformations. Finally, removal of Smoothened from neural crest cells did not inhibit Shh expression in the FEZ. CONCLUSIONS: Collectively, this work suggests that a direct, time-sensitive SHH signal from the brain is required for the later induction of Shh in the FEZ. We propose a testable model of FEZ activation and discuss signaling mediators that may regulate these interactions.

Quantitative analyses link modulation of sonic hedgehog signaling to continuous variation in facial growth and shape.

Variation is an intrinsic feature of biological systems, yet developmental biology does not frequently address population-level phenomena. Sonic hedgehog (SHH) signaling activity in the vertebrate forebrain and face is thought to contribute to continuous variation in the morphology of the upper jaw, but despite its potential explanatory power, this idea has never been quantitatively assessed. Here, we test this hypothesis with an experimental design that is explicitly focused on the generation and measurement of variation in multivariate shape, tissue growth, cellular behavior and gene expression. We show that the majority of upper jaw shape variation can be explained by progressive changes in the spatial organization and mitotic activity of midfacial growth zones controlled by SHH signaling. In addition, nonlinearity between our treatment doses and phenotypic outcomes suggests that threshold effects in SHH signaling may play a role in variability in midfacial malformations such as holoprosencephaly (HPE). Together, these results provide novel insight into the generation of facial morphology, and demonstrate the value of quantifying variation for our understanding of development and disease.

KLRG1 binds cadherins and preferentially associates with SHIP-1.

The killer cell lectin-like receptor G1 (KLRG1) is a unique inhibitory receptor expressed on a phenotypically mature subset of resting NK cells as well as subsets of T cells in naive mice. In vivo, pathogenic immune system activation induces dramatic changes in the expression patterns of KLRG1 among the different cell subsets. In order to enhance our understanding of KLRG1 signaling properties and to clarify the functions of KLRG1 on these cells, we identified the broadly expressed N-cadherin molecule as a ligand for KLRG1. We further demonstrate that a second member of this superfamily of adhesion molecules, E-cadherin, binds to KLRG1. Additionally, we show that upon phosphorylation of the immunoreceptor tyrosine-based inhibitory motif (ITIM) tyrosine, KLRG1 recruits both SHIP-1 and SHP-2 but not SHP-1. We also delineate the key KLRG1 ITIM amino acid residues required for optimal association with these phosphatases. Finally, we demonstrate that KLRG1 engagement can inhibit sub-optimal TCR signaling. Taken together, our results indicate that KLRG1 may differentially regulate NK cell and T cell functions through the association with different ligands as well as the recruitment of distinct phosphatases.