Pubic Aneurysmal Bone Cyst Following Penile Inversion Vaginoplasty: A Case Report.

Background: Aneurysmal bone cysts (ABCs) are aggressive, expansile, and locally destructive vascular lesions. The exact etiology of ABCs is currently unknown and hypothesized to be related to vascular malformations or disruption of osseous vascularity. To date, there have been no reports describing the development of pubic ABCs following penile inversion vaginoplasty (PIV). Methods: This report describes the development of a pubic ABC in a transgender patient who had previously undergone PIV, possibly indicating a very rare complication of this gender-affirming operation. Results: A 37-year-old transgender female was initially referred to the orthopedic oncology clinic for evaluation of a 12-month history of left hip and groin pain. She had undergone gender-affirming PIV about 19 months prior to presentation. Magnetic resonance imaging (MRI) with contrast revealed a low T1 signal intensity and heterogenous T2 hyperintensity 7.5 × 4.9 × 4.3-cm destructive mass in the left superior pubic ramus extending across the pubic symphysis into the right superior pubic ramus. A needle core bone biopsy demonstrated a variably cellular spindle and round lesion with islands of osteoid formation and focal necrosis. The cells were negative for CD34, S100, and desmin. There was no evidence suggesting osteosarcoma, and final review favored the diagnosis of an ABC. Given the highly destructive nature of the mass, it was resected, and the resulting wound was reconstructed with a biologic dermal mesh. Conclusions: Although it is impossible to distinguish coincidence from causation in this case, the patient's recency of PIV and development of a rare ABC in a nearby bone warrants the speculation and discussion provided in this report.

Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review.

INTRODUCTION: Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population. METHODS: A systematic review of several databases was conducted. After compiling the articles, we extracted study characteristics. From the data set, weighted proportions were generated and analyzed. RESULTS: A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the United States, 514 in European nations, 97 in Asian nations, which included only Thailand, and 19 in South American nations, which included only Brazil. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% while the prevalence of transmasculine regret was 0.8%. CONCLUSIONS: Both transfeminine and transmasculine patients had significantly lower rates of regret in the United States when compared with the rest of the world. Our study largely excluded facial gender-affirming surgeries as most of its articles did not fall into our inclusion search criteria. To our knowledge, this is the most recent review performed on the topic of regret among gender-affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.

Outcomes Using Two Unique Methods of Immediate Implant-Based Breast Reconstruction After Nipple-Sparing Mastectomy in Ptotic Patients.

OBJECTIVE: After nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction, patients with significant ptosis are at increased risk for nipple-areolar complex (NAC) necrosis. Attempts to salvage the nipple using inferior dermal pedicles have yielded unsatisfactory results. This study aims to evaluate complications using 2 unique methods of breast reconstruction using either a Wise incision with dermal infolding or batwing incision after NSM. MATERIALS AND METHODS: A retrospective chart review was conducted on all patients who underwent NSM and immediate implant reconstruction using the methods described by a single surgeon between 2016 and 2022. Outcomes were assessed by comparing average complications rates. RESULT: Seventy-three reconstructions were performed after NSM in patients with ptosis. Sixteen reconstructions used a prior technique, Wise pattern with inferior dermal flap. Thirty reconstructions used the Wise incision with dermal infolding, while 27 other reconstructions used a batwing incision. For the Wise with inferior dermal flap technique, NAC necrosis occurred in 43.8%. In the cases in which the newer techniques were used, NAC necrosis occurred in 11.1% in the batwing group and 10% in the dermal infolding group. Other complications measured were within acceptable percentiles between both groups. Aesthetic outcomes were acceptable for most of the cases involving NAC necrosis. CONCLUSIONS: A batwing pattern incision or a Wise pattern with a broad, infolded dermal pedicle is a more effective method of immediate reconstruction after NSM in patients with ptosis according to these findings. Nipple-areolar complex necrosis continues to be a major complication that is important to discuss with patients. However, these methods offer patients with ptosis the benefit of preserving a native NAC while allowing for simultaneous skin reduction during an immediate reconstruction.

The Use of Hemostatic Agents to Decrease Bleeding Complications in Breast Cancer Surgery.

INTRODUCTION: Following breast cancer surgery, patients often require adjuvant radiation and chemotherapy for locoregional and systemic disease control. These procedures may result in postoperative complications, which may delay adjuvant therapy. To potentially decrease these complications, hemostatic agents may be used. This study evaluated the rate of postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in oncologic breast surgery with and without hemostatic agents. METHODS: After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent oncoplastic breast surgery, mastectomy with or without expander/implant-based reconstruction, and subsequent reconstruction with expander to implant exchange were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL®, Ethicon, USA) or combination powder (CP, HEMOBLAST™ Bellows, biom'up, France), length of follow-up, time to JP drain removal, and post-operative complications (seroma, hematoma, or operating room (OR) takeback). This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP. RESULTS: The use of a hemostatic agent resulted in fewer bleeding complications and significantly decreased time until JP drain removal. Although not significant, subgroup analysis demonstrated that this was more pronounced in the CP group. JP drain duration was decreased among all procedures for CP compared to FS. CONCLUSIONS: The use of hemostatic agents in oncologic breast surgery may result in decreased postoperative complications and significantly reduce time to JP drain removal.

How Does Oncoplastic Surgery Compare with Standard Partial Mastectomy? A Systematic Review of Patient-Reported Outcomes.

BACKGROUND: Many breast-conserving surgical options exist for patients with breast cancer. Surgical choices can have lasting effects on a patient's life, so patient satisfaction is important to assess. Patient-reported outcome measures provide important tools when evaluating surgical modalities. This systematic review aimed to evaluate how patients describe breast-conserving surgical choices in standard partial mastectomy and oncoplastic surgery options. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was performed in PubMed for studies discussing standard partial mastectomy or oncoplastic surgery and measurement of preoperative and postoperative patient-reported outcomes using the BREAST-Q or other validated patient-reported outcome measures. Oncoplastic surgery was categorized as volume displacement or volume replacement. Articles in languages other than English, not involving partial mastectomy or oncoplastic surgery, or not measuring patient-reported outcomes were excluded. Weighted proportions were generated and analyzed with a Welch t test. RESULTS: Of 390 articles, 43 met inclusion criteria, and 8784 patients were included in a pooled database. Although standard partial mastectomy scored well, oncoplastic surgery performed significantly better than partial mastectomy in all postoperative BREAST-Q categories: satisfaction with breasts (74.3 versus 65.7), psychosocial well-being (81.3 versus 78.0), sexual well-being (61.6 versus 54.9), and satisfaction with outcome (85.4 versus 62.2). Level 2 volume displacement surgery had the most favorable scores. CONCLUSIONS: Breast-conserving surgical choices that include a variety of oncoplastic surgery and partial mastectomy methods all score well in patient-reported outcome measures, with oncoplastic surgery significantly preferred over partial mastectomy. Oncoplastic surgery should be considered in all cases, and the appropriate breast-conserving surgical choice should depend on the patient's tumor presentation and anatomy.

The Use of Hemostatic Agents to Decrease Bleeding Complications in General Plastic Surgery Procedures.

Within plastic surgery, hematomas and seromas are frequently reported complications that can negatively impact wound healing and result in significant morbidity in patients. As a result, there has been considerable interest in hemostatic agents to complement traditional methods of hemostasis. The purpose of this study was to evaluate postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in general plastic surgery procedures with and without hemostatic agents. METHODS: After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent bilateral breast reduction, panniculectomy, or abdominoplasty were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL, Ethicon, USA) or combination powder (CP, HEMOBLAST Bellows, Biom'up, France), length of follow-up, time to JP drain removal, postoperative complications, and specimen weight. This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP. RESULTS: The use of a hemostatic agent resulted in reduced time duration for JP drain use and overall fewer recorded complications in the hemostatic agent groups. Although not significant, the hemostatic agent group (FS and CP) experienced fewer hematomas and seromas compared with the nonhemostatic agent group. JP drain duration was significantly less among breast reduction (3.46 versus 6.92 days, P < 0.01) for CP when compared with FS. CONCLUSION: The use of hemostatic agents in general plastic surgery procedures may result in decreased postoperative complications and significantly reduce time to JP drain removal.

The prevalence of asymptomatic carriers of COVID-19 as determined by routine preoperative testing.

BACKGROUND: The coronavirus disease SARS-CoV-2 (COVID-19) has swiftly spread throughout the globe, greatly influencing all aspects of life. As in previous pandemics, concerns for limited resources and a sustainable medical workforce have been on the forefront of infrastructure modifications. Consequently, surgical specialties have needed to consider each surgical case for necessity and safety during the COVID-19 outbreak. At our institution, availability of SARS-CoV-2 assay has allowed preoperative testing of asymptomatic surgical patients. AIM/OBJECTIVE: To better define the prevalence of asymptomatic carriers in a surgical population and to better understand the impact of testing on our personal protective equipment (PPE) supply. METHODS: We began routine, preoperative testing for all asymptomatic patients coming to our academic medical centre on 30 March 2020. Scheduled surgeries were deemed urgent by the surgeon with a review for appropriateness by a novel surgical committee. A retrospective patient chart review was performed. Emergency surgeries were excluded. Asymptomatic patients with positive test results had their surgeries rescheduled at the discretion of the surgeon and patient. Patients who tested negative underwent surgery with staff using standard PPE. RESULTS: Eighty-four asymptomatic surgical patients were tested preoperatively with three (3.6%) testing positive for SARS-CoV-2. Preoperative testing saved 498 N95 respirators over this time period. DISCUSSION: This is the first report of routine COVID-19 preoperative testing in an asymptomatic surgical population. Within this population, there is a 3.6% rate of asymptomatic SARS-CoV-2 carriers. Through this practice, personnel exposure can be minimised and access to PPE can be preserved.

A comprehensive literature review of patient-reported outcome measures (PROMs) among common breast reconstruction options: What types of breast reconstruction score well?

PURPOSE: Breast cancer continues to be the most prevalent cancer affecting women. Many reconstructive options exist after oncologic resection. Breast reconstruction can have a lasting impact on many areas of the patient's life, and therefore, a high consideration for patient satisfaction is crucial. Patient-reported outcome measures (PROMs) provide an important tool in the evaluation of different surgical methodologies. The aim of this comprehensive systematic review is to look at various surgical modalities in breast reconstruction as they relate to patient satisfaction. METHODS: A PubMed PRISMA search was performed. Criteria for inclusion included nipple-sparing or skin-sparing mastectomy with autologous or implant-based reconstruction, level 2 volume displacement or volume replacement oncoplastic surgery, and measurement of patient-reported outcomes using the BREAST-Q or other validated PROMs. From the data set, weighted proportions were generated and analyzed using the Kruskal-Wallis rank sum test and a post hoc Dunn's test. RESULTS: After obtaining 254 full text copies, 43 articles met inclusion criteria and were included. Analysis of BREAST-Q data showed oncoplastic breast surgery was significantly preferred over mastectomy regardless of the type of reconstruction. Nipple-sparing was significantly preferred over skin-sparing mastectomy, autologous reconstruction was significantly preferred over implant-based reconstruction, and prepectoral implant placement was preferred over subpectoral implant placement. Validated PROMs other than BREAST-Q showed similar trends in all but type of mastectomy. CONCLUSIONS: In this comprehensive systematic review, oncoplastic surgery showed the most favorable PROMs when compared to other reconstructive modalities. Autologous was preferred over implant-based reconstruction, and prepectoral was preferred over subpectoral implant placement.

Race-based disparities in presentation and outcomes in infrainguinal bypass patients.

BACKGROUND: Racial disparities in healthcare are well documented, however their effects on surgical outcomes remain controversial. While studies have examined outcomes along the white-black dichotomy, Asian populations remain frequently unstudied. We use the VQI to examine disparities among white, black and Asian patients undergoing infrainguinal bypass. METHODS: The VQI database was queried for black, white and Asian patients undergoing infrainguinal surgery between 2012 and 2017. Preoperative characteristics, disease severity, and perioperative characteristics were compared between the racial groups. Primary outcomes included overall mortality, time to death, long term loss of primary patency, and patency at discharge. Analyses were done using a 1:3:3 matched sample of Asian to whites to black patients. RESULTS: Among the patients included, 139 (0.56%) were Asian, 4222 (16.9%) were black and 20,582 (82.5%) were white, of which 129 Asian patients were matched to 387 black and 387 white patients. Asian patients had more advanced disease as demonstrated by higher rates of tissue loss/acute ischemia (P<0.0001) and the highest percentage of below knee popliteal target sites (P=0.0011). There were no differences in mortality (P=0.6808) or long-term loss of primary patency (P=0.4500). However, black patients had higher rates of amputation (OR=1.68, P=0.0224) and reoperation (OR=2.22, P=0.0015). CONCLUSIONS: Asian patients presented with more advanced disease requiring more distal bypass targets. Despite these disparities in presentation, overall long-term primary patency and mortality showed no significant difference.

Reproducibility and staging of 3D human retinal organoids across multiple pluripotent stem cell lines.

Numerous protocols have been described for producing neural retina from human pluripotent stem cells (hPSCs), many of which are based on the culture of 3D organoids. Although nearly all such methods yield at least partial segments of retinal structure with a mature appearance, variabilities exist within and between organoids that can change over a protracted time course of differentiation. Adding to this complexity are potential differences in the composition and configuration of retinal organoids when viewed across multiple differentiations and hPSC lines. In an effort to understand better the current capabilities and limitations of these cultures, we generated retinal organoids from 16 hPSC lines and monitored their appearance and structural organization over time by light microscopy, immunocytochemistry, metabolic imaging and electron microscopy. We also employed optical coherence tomography and 3D imaging techniques to assess and compare whole or broad regions of organoids to avoid selection bias. Results from this study led to the development of a practical staging system to reduce inconsistencies in retinal organoid cultures and increase rigor when utilizing them in developmental studies, disease modeling and transplantation.