The no-vertical scar technique for oncoplastic breast reconstruction.

INTRODUCTION: Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri­areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction. METHODS: Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation. RESULTS: Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required. CONCLUSION: The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Assessing Whether Medical Students Consistently Ask Patients About Sexual Orientation and Gender Identity as a Function of Year in Training.

Purpose: The Institute of Medicine has suggested that teaching health care providers to inquire about and document the sexual orientation and gender identity (SOGI) of their patients will provide more accurate epidemiological data and allow for more patient-centered care, thus improving sexual and gender minority health. The purpose of this study was to determine whether medical students are asking about SOGI and to identify reasons why students were opting not to ask. Methods: In July 2020, an online survey was made available to second-, third-, and fourth-year medical students at a Midwestern medical school. Respondents were asked whether they consistently inquired about the SOGI of their patients, and the reasons they do not ask. The number of students asking about SOGI and reasons for not asking were analyzed using chi-square analyses as a function of year in training. Results: Of 1089 eligible participants, 364 completed the survey (33.4%). The number of students asking about sexual orientation significantly decreased with every year of training (92.8%, 82.2%, and 52.7%). The number of students asking about gender identity significantly decreased after the second year of training (69.9%, 40.6%, and 26.4%). Reasons that significantly increased across training included believing SOGI is irrelevant to encounters, limiting inquiries to patients with sexual health complaints only, and negative influence from their attendings. Conclusion: As medical students progressed into the clinical years of their training, they were less likely to ask their patients about SOGI and more likely to cite negative influence from their attendings and question the relevance of obtaining SOGI.

They "Don't Know How to Deal with People Like Me": Assessing Health Care Experiences of Gender Minorities in Indiana.

Purpose: Within the LGBTQ+ community, the transgender and nonbinary (TGNB) population experience a disproportionate amount of discrimination when seeking health care. Such disparities may arise from lack of proper medical training and resources for providers or biases. In this study, we examine the health care experiences of TGNB individuals living in Southern Indiana. Methods: We analyzed responses from TGNB respondents to an LGBTQ+ health care needs assessment survey in Southern Indiana. Respondents were asked about demographic data, their self-assessed health status, quality of health care received, whether they have a provider with whom they feel comfortable sharing their gender identity with, and if they have to commute to see their provider. Finally, respondents were asked an open-ended question about their health care experiences while living in Southern Indiana. Responses were coded and several themes emerged and were analyzed. Results: Eighty-five TGNB individuals completed our survey. Less than half of respondents indicated that they had an LGBTQ+-welcoming provider (44.7%). Individuals with an LGBTQ+-welcoming provider were more likely to report their self-assessed health as excellent/good (p=0.02) and quality of health as excellent/very good (p=0.03) compared to individuals without an LGBTQ+-welcoming provider. Five themes emerged from the write-in responses (n=64): discrimination (34.4%), invalidation (32.8%), distrust (28.1%), logistic concerns (35.9%), and positive experiences (35.9%). Conclusion: The TGNB community living in Southern Indiana reports numerous barriers related to provider attitudes when obtaining health care. Additional training is needed to address provider biases and improve LGBTQ+ community health disparities.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction.

Radial forearm free flap phalloplasty (RFFFP) is the most common surgery performed for genital reconstruction of female-to-male transgender patients. However, up to 19% require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFFFP was first reported in 1996 and has subsequently been reported by 1 high-volume center in Belgium. METHODS: Here, we present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation. RESULTS: In both cases, the creation of a distal AVF salvaged the neophallus. Importantly, the patient that had been transferred out of the operating room before reintervention suffered partial flap necrosis compared with no flap loss in the patient who had an AVF created during initial surgery. One AVF was ligated 18 days postoperative, whereas the other was never formally closed. CONCLUSIONS: These cases demonstrate that AVF can be reliably used for RFFFP salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss. Finally, in contrast with the prior explanation of this technique, timing of AVF ligation may be less critical than previously described. Microsurgeons are reminded that this technique may save complicated flaps in the uncommon case of microcirculatory flap obstruction.

Serotonin signaling suppresses the nutrition-responsive induction of an alternate male morph in horn polyphenic beetles.

Environment-responsive development contributes significantly to the phenotypic variation visible to selection and as such possesses the potential to shape evolutionary trajectories. However, evaluation of the contributions of developmental plasticity to evolutionary diversification necessitates an understanding of the developmental mechanisms underpinning plastic trait expression. We investigated the role of serotonin signaling in the regulation and evolution of horn polyphenism in the beetle genus Onthophagus. Specifically, we assessed the role of serotonin in development by determining whether manipulating serotonin biosynthesis during the larval stage alters body size, developmental rate, and the formation of relative adult trait size in traits characterized by minimal (genitalia), moderate (elytra), and pronounced (horns) nutrition-responsive development in O. taurus. Second, we assessed serotonin's role in evolution by replicating a subset of our approaches across four species reflecting ancestral as well as derived conditions. Lastly, we employed immunohistochemical approaches to begin assessing whether serotonin may be acting via the endocrine or nervous system. Our results show that pharmacological manipulation of serotonin signaling affects overall size, developmental rate, and the body size threshold separating alternate male morphs. Threshold body sizes were affected across species, regardless of the severity of horn polyphenism, and independent of the precise morphological location of horns. However, histological assessments suggest it is unlikely serotonin functions as a neurotransmitter and instead may rely on other mechanisms that remain to be identified. We discuss the most important implications of our results for our understanding of the evolution of and through plasticity in horned beetles and beyond.