Simultaneous Zygomatic Osteotomies With Reduction Mandibuloplasty - An Approach to Mid- and Lower-Facial Feminization in the Transfeminine Patient.

BACKGROUND: Facial feminization surgery (FFS) is effective at treating gender dysphoria associated with anthropometrically masculine facial features. For many transgender women, FFS is a crucial component of the gender transition process. The purpose of this study is to report our experience with a pragmatic technique for simultaneous mid- and lower-face feminization by zygomatic osteotomy malarplasty and reduction mandibuloplasty. METHODS: The technique to perform zygomatic osteotomy malarplasty and reduction mandibuloplasty is described, utilizing harvested bone from the mandible for bone grafting the zygomatic osteotomy gap. A retrospective chart review was performed for patients who underwent simultaneous middle and lower FFS using the described technique. Independent reviewers evaluated cropped preoperative and postoperative photographs of the mid and lower face and assigned each photograph a "femininity score." RESULTS: Seventeen transgender women underwent simultaneous zygomatic osteotomy malarplasty and reduction mandibuloplasty over the study period with adequate follow-up (average 11.1 months). Transient nerve weaknesses were the primary complications noted. A statistically significant improvement in femininity score was reported in postoperative photographs, compared to preoperative photographs ( P < 0.01). CONCLUSIONS: The technique described in this study is an effective application of craniofacial approaches and techniques for feminizing the facial skeleton in transgender women by utilizing harvested mandibular bone for simultaneous malarplasty.

Are We Witnessing a Paradigm Shift?: A Systematic Review of Social Media in Residency.

As social media's applications continue to evolve, the pitfalls and dangers associated with misuse have been accentuated in the literature. Consequently, academic institutions across the nation have implemented social media policies. This study is aimed to evaluate the state of social media literature examining postgraduate trainees (residents/fellows). METHODS: A systematic search was performed identifying peer-reviewed publications presenting original research. Studies published through December 8, 2018, focusing on social media use among postgraduate trainees were considered for inclusion. RESULTS: Fifty-three studies were categorized into 4 domains: (1) resident recruitment, (2) graduate medical education, (3) professional development, and (4) academic scholarship. Thirty-four (64.15%) investigated social media's impact on professional development, of which 16 (47.05%) highlighted the detrimental potential on trainee professionalism. The remaining 18 (52.94%) focused on promoting social media training during residency, and/or enhancing social media competency to benefit professional development. Fourteen (26.42%) rationalized social media use in augmenting graduate medical education. Ten (18.87%) assessed social media's influence on resident recruitment, of which 7 (70%) depicted use as a screening instrument for program directors on resident applicants. Two (3.77%) of the studies introduced social media as a platform for academic scholarship with indicators as altmetrics. CONCLUSIONS: The well-established disadvantages of social media use by the postgraduate trainee continue to persist in the literature. However, there is recognition of social media as a valuable resource in influencing resident recruitment, graduate medical education, professional development, and academic scholarship, representing a paradigm shift-from cautiously avoidant to thoughtful capitalization on its immense potential.

Post-mastectomy radiation arteritis in a patient presenting with upper extremity claudication.

Radiation arteritis is a rare but serious complication following radiation therapy for the treatment of breast cancer. We present the case of a 53-year-old female presenting with right upper extremity claudication 4 months following radiation therapy for the treatment of right breast cancer, stage 3b invasive ductal carcinoma. She was referred to vascular surgery and initial imaging with computed tomography angiography (CTA) revealed occlusion from the origin of the subclavian to axillary artery. We discuss the implications that these vascular findings have on potential breast reconstruction options.

The Effect of Positive Postdebridement Cultures on Local Muscle Flap Reconstruction of the Lower Extremity.

BACKGROUND: Local muscle flaps are a reconstructive option for wound coverage in the distal lower extremity, particularly in high-risk patients who are poor candidates for free tissue transfer. At our institution, chronic and infected wounds are managed with serial debridement before definitive reconstruction. There is a paucity of data on optimal timing for reconstruction in this patient population. This study investigates the relationship of positive postdebridement cultures (PDC) and wound closure rates at 90 days. METHODS: A retrospective review of patients undergoing local muscle flap coverage of chronic distal lower extremity wounds between 2006 and 2012 was performed. All patients were managed with serial debridement until negative PDC were obtained. In some cases, PDC remained positive or exhibit delayed culture growth in the day(s) following closure. Data recorded include demographics, flap type/location, culture data, and wound closure at 90-day follow-up. RESULTS: Of 76 patients, 60 met inclusion criteria with minimum 90-day follow-up. Despite 100% flap survival, 17 patients (28.3%) had failure of wound closure at 90 days and 22 patients (36%) had positive PDC. Multivariate analysis identified positive PDC (odds ratio, 29.6; 95% CI, 3.6-246.4; P = 0.002) and smoking (odds ratio, 8.9; 95% CI, 1.4-57.6; P = 0.02) as independent predictors of nonclosure at 90 days. CONCLUSIONS: In this series of local muscle flap coverage of distal lower extremity wounds, positive PDC were a strong independent predictor of failure of wound closure at 90 days. This study demonstrates the importance of serial debridement to negative cultures before definitive coverage in this patient population.

Prevalence and cost of imaging in inpatient falls: the rising cost of falling.

OBJECTIVE: To quantify the type, prevalence, and cost of imaging following inpatient falls, identify factors associated with post-fall imaging, and determine correlates of positive versus negative imaging. DESIGN: Single-center retrospective cohort study of inpatient falls. Data were collected from the hospital's adverse event reporting system, DrQuality. Age, sex, date, time, and location of fall, clinical service, Morse Fall Scale/fall protocol, admitting diagnosis, and fall-related imaging studies were reviewed. Cost included professional and facilities fees for each study. SETTING: Four hundred and fifteen bed urban academic hospital over 3 years (2008-2010). PATIENTS: All adult inpatient falls during the study period were included. Falls experienced by patients aged <18 years, outpatient and emergency patients, visitors to the hospital, and staff were excluded. MEASUREMENTS AND MAIN RESULTS: Five hundred and thirty inpatient falls occurred during the study period, average patient age 60.7 years (range 20-98). More than half of falls were men (55%) and patients considered at risk of falls (56%). Falls were evenly distributed across morning (33%), evening (34%), and night (33%) shifts. Of 530 falls, 178 (34%) patients were imaged with 262 studies. Twenty percent of patients imaged had at least one positive imaging study attributed to the fall and 82% of studies were negative. Total cost of imaging was $160,897, 63% ($100,700) from head computed tomography (CT). CONCLUSION: Inpatient falls affect patients of both sexes, all ages, occur at any time of day and lead to expensive imaging, mainly from head CTs. Further study should be targeted toward clarifying the indications for head CT after inpatient falls and validating risk models for positive and negative imaging, in order to decrease unnecessary imaging and thereby limit unnecessary cost and radiation exposure.

Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.

BACKGROUND: Skin flap necrosis is the most common complication following prosthesis-based breast reconstruction. Many studies have reported on the efficacy of laser-assisted indocyanine green angiography (SPY Elite System) in detecting flap necrosis. A cost-effectiveness analysis of laser-assisted indocyanine green angiography is lacking. METHODS: The authors performed a retrospective review of all consecutive immediate postmastectomy prosthesis-based reconstructions at the Brigham and Women's Hospital over a 7-year 10-month period. The rate of mastectomy skin flap necrosis and related implant loss was determined for the entire cohort and for the subgroups of patients at increased risk for developing this complication: smokers, obese patients, and patients with large breasts. Cost of treating implant loss and skin flap necrosis was calculated based on the average treatment courses and costs at the authors' institution. The cost of the SPY was obtained from LifeCell Corp. RESULTS: From January of 2004 through October of 2011, 79 of 710 prosthesis-based breast reconstructions (11.1 percent) developed mastectomy skin flap necrosis requiring excision and reclosure. Performing laser-assisted indocyanine green angiography on the entire cohort would result in an additional cost of $1537.30 per case of flap necrosis prevented. If laser-assisted indocyanine green angiography was performed on only these high-risk subgroups, the cost savings per case of flap necrosis prevented is $2098.80 for smokers, $5162.30 for patients with a body mass index greater than 30, and $1892.70 for patients with mastectomy weight greater than 800 g. CONCLUSION: Laser-assisted indocyanine green angiography is not cost-effective as a preventative measure for flap necrosis if used indiscriminately on all patients undergoing prosthesis-based breast reconstructions, but it is cost-effective for high-risk patients, such as smokers, obese patients, and patients with large breasts.

Prophylactic antipropagation stitch in total knee arthroplasty performed via medial parapatellar approach: a simple and cost-effective technique for reducing quadriceps injury.

This article describes a novel, simple, and effective technique for limiting extensor mechanism damage during total knee arthroplasty (TKA) performed via the medial parapatellar (MPP) approach. Immediately on making the quadriceps tendon split in the MPP approach, a figure-of-eight stitch is placed at the apex of the split. The prophylactic stitch technique has been used by one surgeon in 1000 consecutive TKAs over the past 5 years. This technique has eliminated proximal extension of the quadriceps tendon split into the muscle belly and may help to decrease postoperative pain, increase postoperative quadriceps strength, and improve patient satisfaction and outcomes.