Phalloplasty Flap Salvage Using a Superficial Circumflex Iliac Artery Perforator Propeller Flap.

Background: Partial phalloplasty flap loss presents an evolving challenge, largely due to the complex demands required for both aesthetics and function. We describe our novel experience using the superficial circumflex iliac perforator (SCIP) propeller flap for neophallus salvage when skin grafting alone provides insufficient soft tissue bulk or coverage. Methods: We retrospectively reviewed patients who underwent SCIP propeller flap reconstruction after phalloplasty partial flap loss. After suprafascial dissection, superficial circumflex iliac vessel perforator(s) were isolated toward the femoral origin. The flap was rotated 180 degrees and inset into the ventral or distal neophallus depending on the region of flap loss. If glans reconstruction was required, the flap was tubularized before inset. Division and inset were performed at a second stage, followed by subsequent glansplasty, urethral creation, and/or penile implant placement. Results: SCIP propeller flap reconstruction was performed for four patients after one to six debridements at a mean of 6.5 (range 1.0-19.2) months following the initial phalloplasty. Three patients had lost the ventral phallus due to venous insufficiency, arterial insufficiency, and excessive postoperative swelling, respectively. The fourth patient experienced near-total loss of the glans following penile implant insertion. Division and inset was performed at an average of 7.5 (range 5.0-12.0) weeks after SCIP flap. There were no complications related to SCIP flap viability. Conclusion: The SCIP propeller flap allows salvage of partial flap loss following phalloplasty by providing thin, pliable soft tissue bulk and skin coverage with minimal donor site morbidity, without the need for microsurgery, allowing progression with subsequent reconstructive stages.

Etiology and treatment of cancer-related secondary lymphedema.

Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.

Histologic Comparison of the Fascicular Area of Processed Nerve Allograft Versus Cabled Sural Nerve Autograft.

Background: The use of multiple cables of sural nerve autograft is common for peripheral nerve reconstruction when injured nerve caliber exceeds the nerve graft caliber. Although the optimal matching of neural to nonneural elements and its association with functional outcomes are unknown, it is reasonable to consider maximizing the neural tissue structure available for nerve regeneration. No prior studies have compared directly the cross-sectional fascicular area between cabled nerve autografts and size-selected nerve allografts. This study evaluated the cross-sectional fascicular area between native nerve stumps and two reconstructive nerve grafting methods: cabled sural nerve autograft (CSNA) and processed nerve allograft (PNA). Methods: CSNA from matched cadaveric specimens and PNA were used to reconstruct nerve defects in the median and ulnar nerves of six pairs of cadaveric specimens. Nerve reconstructions were done by fellowship-trained hand surgeons. The total nerve area, fascicular area, and nonfascicular area were measured histologically. Results: The CSNA grafts had significantly less fascicular area than PNA and caliber-matched native nerve. The PNA grafts had a significantly higher percent fascicular area compared with the intercalary CNSA graft. Conclusions: Fascicular area was significantly greater in PNA versus CSNA. The PNA consistently demonstrated a match in fascicular area closer to the native nerve stumps than CSNA, where CSNA had significantly smaller fascicular area compared with native nerve stumps.

Approach to Lymphedema Management.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

Immediate Lymphovenous Bypass Treated Donor Site Lymphedema during Phalloplasty for Gender Dysphoria.

Demand for gender-affirming phalloplasty continues to grow worldwide, and the extended radial forearm flap phalloplasty remains one of the most commonly performed techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting of preventative or immediate lymphovenous bypass (LVB) with axillary lymph node dissection for the treatment of breast cancer, it is possible that a subset of patients undergoing gender-affirmation surgery would benefit from immediate lymphatic reconstruction at the time of primary phalloplasty. Here, we report a case in which intraoperative indocyanine green lymphography demonstrated lymphatic obstruction within the left donor hand after flap harvest, and was treated with immediate LVB at the time of extended radial forearm phalloplasty. Two surgical teams operated simultaneously: the reconstructive urology team performed the vaginectomy, perineal urethral lengthening, scrotoplasty, and perineal reconstruction; and the microsurgery team harvested the extended radial forearm, constructed the penile urethra, shaped the phallus, and performed the immediate LVB. Lymphography showed no dermal backflow at 5 months follow-up; at 13 months, the patient demonstrated no signs or symptoms of lymphedema in the left forearm or hand. To the authors' best knowledge, this is the first report of confirmed donor site lymphedema following extended radial forearm flap harvest, which was successfully treated with immediate LVB. Careful evaluation of lymphatic vessels with indocyanine green lymphography in the forearm before and after extended flap harvest may be warranted.

Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases.

PURPOSE: Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps. METHODS: We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. RESULTS: The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention. CONCLUSIONS: Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction.

BACKGROUND: Full-thickness injuries to the hand require durable soft tissue coverage to preserve tendon gliding and hand motion. We aim to investigate the cost effectiveness of hand resurfacing comparing free fascial flap reconstruction versus bilaminate synthetic dermal matrices. METHODS: Cost effectiveness was modeled using decision tree analysis with the rollback method. Total active range of motion was modeled as the common outcome variable based on systematic literature review. Costing was performed from a payer perspective using national Medicare reimbursements. The willingness to pay threshold was determined by average worker's compensation for hand disability. Probabilistic sensitivity analysis was conducted for range of motion outcomes and the costs using 10,000 Monte Carlo simulations. RESULTS: The average cost of free fascial flap reconstruction was $14,201.24 compared with $13,674.20 for Integra, yielding an incremental cost difference of $527.04. Incremental range of motion improvement was 18.0 degrees with free fascial flaps, yielding an incremental cost effectiveness ratio of $29.30/degree of motion. Assuming willingness to pay thresholds of $557.00/degree of motion, free-fascial flaps were highly cost effective. On probabilistic sensitivity analysis, free fascial flaps were dominant in 25.5% of simulations and cost effective in 32.1% of simulations. Thus, microsurgical reconstruction was the economically sound technique in 57.5% of scenarios. CONCLUSION: Free fascial flap reconstruction of complex hand wounds was marginally more expensive than synthetic dermal matrix and yielded incrementally better outcomes. Both dermal matrix and microsurgical techniques were cost effective in the base case and in sensitivity analysis. In choosing between dermal matrix and microsurgical reconstruction of complex hand wounds, neither technique has a clear economic advantage.

An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap.

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

Radial Artery Occlusion in a Patient With Lupus, Antiphospholipid Syndrome, and Raynaud Phenomenon: A Multimodal Approach.

Radial artery occlusion (RAO) is a known complication of transradial catheterization for cardiac procedures. The transradial approach has decreased bleeding complications compared with the transfemoral approach, but risks provoking hand ischemia. We present a case of a 29-year-old peripartum woman with a history of lupus, antiphospholipid syndrome, and Raynaud phenomenon who developed RAO with hand-threatening ischemia despite therapeutic anticoagulation. Given the patient's medical history, a multimodal approach was applied including thrombectomy, arterial bypass, venous arterialization, and onobotulinum toxin A sympathectomy. The patient's ischemia improved after the procedure, and she regained normal use of the hand.

Current Concepts in Feminizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

Current Concepts in Masculinizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital masculinization. 3. Recognize key steps and anatomy during chest-wall contouring and phalloplasty reconstruction. 4. Discuss major risks and complications of chest-wall contouring and phalloplasty reconstruction. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various masculinizing gender-affirming surgical procedures.

CPG15 regulates synapse stability in the developing and adult brain.

Use-dependent selection of optimal connections is a key feature of neural circuit development and, in the mature brain, underlies functional adaptation, such as is required for learning and memory. Activity patterns guide circuit refinement through selective stabilization or elimination of specific neuronal branches and synapses. The molecular signals that mediate activity-dependent synapse and arbor stabilization and maintenance remain elusive. We report that knockout of the activity-regulated gene cpg15 in mice delays developmental maturation of axonal and dendritic arbors visualized by anterograde tracing and diolistic labeling, respectively. Electrophysiology shows that synaptic maturation is also delayed, and electron microscopy confirms that many dendritic spines initially lack functional synaptic contacts. While circuits eventually develop, in vivo imaging reveals that spine maintenance is compromised in the adult, leading to a gradual attrition in spine numbers. Loss of cpg15 also results in poor learning. cpg15 knockout mice require more trails to learn, but once they learn, memories are retained. Our findings suggest that CPG15 acts to stabilize active synapses on dendritic spines, resulting in selective spine and arbor stabilization and synaptic maturation, and that synapse stabilization mediated by CPG15 is critical for efficient learning.

Inhibitory dendrite dynamics as a general feature of the adult cortical microcircuit.

The mammalian neocortex is functionally subdivided into architectonically distinct regions that process various types of information based on their source of afferent input. Yet, the modularity of neocortical organization in terms of cell type and intrinsic circuitry allows afferent drive to continuously reassign cortical map space. New aspects of cortical map plasticity include dynamic turnover of dendritic spines on pyramidal neurons and remodeling of interneuron dendritic arbors. While spine remodeling occurs in multiple cortical regions, it is not yet known whether interneuron dendrite remodeling is common across primary sensory and higher-level cortices. It is also unknown whether, like pyramidal dendrites, inhibitory dendrites respect functional domain boundaries. Given the importance of the inhibitory circuitry to adult cortical plasticity and the reorganization of cortical maps, we sought to address these questions by using two-photon microscopy to monitor interneuron dendritic arbors of thy1-GFP-S transgenic mice expressing GFP in neurons sparsely distributed across the superficial layers of the neocortex. We find that interneuron dendritic branch tip remodeling is a general feature of the adult cortical microcircuit, and that remodeling rates are similar across primary sensory regions of different modalities, but may differ in magnitude between primary sensory versus higher cortical areas. We also show that branch tip remodeling occurs in bursts and respects functional domain boundaries.

Structural basis for the role of inhibition in facilitating adult brain plasticity.

Although inhibition has been implicated in mediating plasticity in the adult brain, the underlying mechanism remains unclear. Here we present a structural mechanism for the role of inhibition in experience-dependent plasticity. Using chronic in vivo two-photon microscopy in the mouse neocortex, we show that experience drives structural remodeling of superficial layer 2/3 interneurons in an input- and circuit-specific manner, with up to 16% of branch tips undergoing remodeling. Visual deprivation initially induces dendritic branch retractions, and this is accompanied by a loss of inhibitory inputs onto neighboring pyramidal cells. The resulting decrease in inhibitory tone, also achievable pharmacologically using the antidepressant fluoxetine, provides a permissive environment for further structural adaptation, including addition of new synapse-bearing branch tips. Our findings suggest that therapeutic approaches that reduce inhibition, when combined with an instructive stimulus, could facilitate restructuring of mature circuits impaired by damage or disease, improving function and perhaps enhancing cognitive abilities.

cpg15 and cpg15-2 constitute a family of activity-regulated ligands expressed differentially in the nervous system to promote neurite growth and neuronal survival.

Many ligands that affect nervous system development are members of gene families that function together to coordinate the assembly of complex neural circuits. cpg15/neuritin encodes an extracellular ligand that promotes neurite growth, neuronal survival, and synaptic maturation. Here we identify cpg15-2 as the only paralogue of cpg15 in the mouse and human genome. Both genes are expressed predominantly in the nervous system, where their expression is regulated by activity. cpg15-2 expression increases by more than twofold in response to kainate-induced seizures and nearly fourfold in the visual cortex in response to 24 hours of light exposure following dark adaptation. cpg15 and cpg15-2 diverge in their spatial and temporal expression profiles. cpg15-2 mRNA is most abundant in the retina and the olfactory bulb, as opposed to the cerebral cortex and the hippocampus for cpg15. In the retina, they differ in their cell-type specificity. cpg15 is expressed in retinal ganglion cells, whereas cpg15-2 is predominantly in bipolar cells. Developmentally, onset of cpg15-2 expression is delayed compared with cpg15 expression. CPG15-2 is glycosylphosphatidylinositol (GPI) anchored to the cell membrane and, like CPG15, can be released in a soluble-secreted form, but with lower efficiency. CPG15 and CPG15-2 were found to form homodimers and heterodimers with each other. In hippocampal explants and dissociated cultures, CPG15 and CPG15-2 promote neurite growth and neuronal survival with similar efficacy. Our findings suggest that CPG15 and CPG15-2 perform similar cellular functions but may play distinct roles in vivo through their cell-type- and tissue-specific transcriptional regulation.