ADMs and synthetic meshes improve implant-based breast reconstruction aesthetics, but at what cost?

Acellular dermal matrices (ADMs) have shown promise for use in reconstructive breast surgery as they improve aesthetic outcomes and decrease capsular contracture rates. However, concerns about their use remain because of the higher cost and complication profile. We report a single institution's implant-based-reconstruction (IBR) experience between 2007 and 2021, including cases performed by 51 plastic surgeons. For each stage of IBR, data on age, comorbidities, type of mesh used, and acute complications were collected. Of 1379 patients who underwent subpectoral IBR, 937 received an ADM or synthetic mesh as part of their reconstruction. 256 patients out of 264 treated with prepectoral IBR received an ADM or mesh. Infection and wound dehiscence rates were highest for patients who underwent prepectoral IBR with ADM. Both subpectoral and prepectoral IBR with ADM were associated with higher rates of infection and wound complications compared to without ADM or mesh, but only the difference among the subpectoral cohort reached statistical significance. Prepectoral IBR with ADM or mesh had the lowest rates of capsular contracture and aesthetic reoperations. Although the use of Vicryl® mesh in subpectoral IBR was associated with a higher risk of capsular contracture and skin flap necrosis compared to reconstruction with ADMs (10.53% versus 3.29%; p < 0.05), Vicryl® was associated with fewer aesthetic revisions. Our study demonstrated that prepectoral IBR with ADM or mesh resulted in the fewest aesthetic reoperations and the lowest rates of capsular contracture. Infection and wound dehiscence rates were notably higher for patients who had reconstruction with ADM.

The molecular consequences of androgen activity in the human breast.

Estrogen and progesterone have been extensively studied in the mammary gland, but the molecular effects of androgen remain largely unexplored. Transgender men are recorded as female at birth but identify as male and may undergo gender-affirming androgen therapy to align their physical characteristics and gender identity. Here we perform single-cell-resolution transcriptome, chromatin, and spatial profiling of breast tissues from transgender men following androgen therapy. We find canonical androgen receptor gene targets are upregulated in cells expressing the androgen receptor and that paracrine signaling likely drives sex-relevant androgenic effects in other cell types. We also observe involution of the epithelium and a spatial reconfiguration of immune, fibroblast, and vascular cells, and identify a gene regulatory network associated with androgen-induced fat loss. This work elucidates the molecular consequences of androgen activity in the human breast at single-cell resolution.

Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes.

Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow. Methods: We retrospectively reviewed consecutive patients who underwent gender-affirming free-flap phalloplasty at our single institution from June 2017 through June 2021. The DIEA/V was used as recipient vessels, with the DIEA/V pedicle externalized via a passageway made through the external inguinal ring. Results: Thirty-eight consecutive free flaps (26 radial forearm free-flap phalloplasties, 10 anterolateral thigh phalloplasties, and two radial forearm free-flap urethroplasties) were performed. Mean age was 37.3 years; mean BMI was 25.7. Mean follow-up was 17.9 months. All flaps were anastomosed to the DIEA/V, without use of vein grafts. Most flaps (89.5%) had at least two veins anastomosed. To augment outflow, a saphenous vein branch was used in one of 38 (2.6%) cases and other superficial veins were used in two of 38 (5.3%) cases. One of 38 (2.6%) cases (early in our experience) resulted in total flap loss. Conclusions: Advantages of the DIEA/V as free-flap phalloplasty recipient vessels include a short, direct pathway for vessels, excellent donor-recipient vessel size match that allows end-to-end anastomoses, and elimination of risks associated with arterialized interposed veins. When venous outflow appears compromised, we recommend a low threshold to use additional local or saphenous veins, though this is rarely needed given the DIEV's reliability.

The Coronavirus (COVID-19) Effect on Public Sentiments Regarding Elective Plastic Surgery in the United States.

BACKGROUND: The SARS-CoV-2 coronavirus (COVID-19) has challenged the US's healthcare systems to adapt and innovate on multiple fronts. As the course of the COVID-19 pandemic changes, we explore the US public sentiments on resuming previously postponed elective plastic surgery procedures. METHODS: A prospective national survey of one thousand US adults was conducted to study public perception of elective plastic surgery procedures during the COVID-19 pandemic. Binomial logarithmic multivariable regression modeling was employed to study the response data. RESULTS: Nine hundred seventy-three participants were included in study. The majority (86.6%) believed elective plastic surgery should continue during the COVID-19 pandemic. Most (79.6%) would not delay obtaining plastic surgery more than 6 months. Participants expressed concerns of contracting COVID-19 at elective surgery centers (67.5%) or at hospitals (68.5%). Participants who reside in the Midwest (odds ratio [OR] 2.3, P < 0.05) and participants between the ages of 41 and 60 years old (OR 2.8, P < 0.03) were more likely to resume elective plastic surgery. Participants who had undergone a COVID-19 test (OR 0.13, P < 0.04), contracted the COVID-19 infection (OR 0.26, P < 0.03), or were older than 60 years (OR 0.41, P < 0.02) were less likely to resume elective plastic surgery. CONCLUSION: The majority of the US adult participants (1) agree with resuming elective plastic surgery services, (2) but harbor some concerns of contracting COVID-19 during their procedures, and (3) agree with the majority of safety protocols taken to prevent the spread of COVID-19.

Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

BACKGROUND: The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. OBJECTIVES: This study investigates insurance requirements for referral letters and their negative impact on care. MATERIALS AND METHODS: We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. RESULTS: Nearly all reviewed U.S. health insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. DISCUSSION AND CONCLUSION: Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.

The Ideal Male Nipple-Areola Complex: A Critical Review of the Literature and Discussion of Surgical Techniques for Female-to-Male Gender-Confirming Surgery.

INTRODUCTION: Top surgery (mastectomy and masculinization of the chest) is a key gender affirming operation for many female-to-male transgender patients. Positioning of the nipple-areola complex (NAC) is a crucial part of this procedure. To date, there are no standards as to where to place the new NAC based on the patient's anatomy, to achieve the most aesthetically pleasing result. OBJECTIVE: The objectives of this study were to review the literature and analyze the anatomical averages for NAC shape, width, and height as well as vertical and horizontal placement and to compile the recommendations and proposed equations of NAC placement based on chest wall measurements, chest wall landmarks, and body habitus. METHODS: A systematic review of the literature was conducted in the spring of 2018. Eleven articles met the inclusion criteria, with objective measurements of, and guidelines for, positioning the male NAC in men that had not been preselected for being aesthetically perfect. RESULTS: The average diameter for a round NAC was 25.9 mm (SD, 2.5 mm), and the width and height of the oval-shaped NAC were found to be 25.3 mm (SD, 2.6 mm) and 20.1 mm (SD, 0.75 mm), respectively. The average sternal notch to nipple distance was found to be 19.3 cm (SD, 1.7 cm). The average internipple distance was 22.3 cm (SD, 1.6 cm). CONCLUSIONS: The data are inconclusive about the effects of anatomical measurements on NAC vertical and horizontal position, but areola diameter is reasonably consistent. There are a wide variety of guidelines and algorithms offered for determining these measurements.

Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer.

BACKGROUND: When replantation of an avulsed/amputated thumb is not feasible, toe-to-hand transfer may be considered as a reconstructive option in appropriately chosen patients. Although selection criteria are purposefully restrictive, immediate one-stage transfer, as opposed to a delayed procedure, provides many advantages. Primary reconstruction reduces hospitalization and operative and recovery time. It also may expedite return of function and allow patients to return to work sooner. The ability of the patient to undergo extensive microvascular reconstruction at the time of injury, the psychological preparation required, and the need to understand potential risks are important factors to consider. METHODS: In the past 5 years, six patients suffering thumb amputation underwent immediate great toe-to-hand transfer. The overall results of these thumb reconstructions were evaluated retrospectively with regard to function, outcome, length of stay, complications (e.g., infection, contracture, reexploration), and time to return to work/normal activity. The authors calculated objective and subjective scores with which to quantify patient satisfaction and clinical success. RESULTS: All of the authors' patients were laborers who suffered work-related avulsion-amputations. No complications were reported during initial hospitalization, lasting an average of 12 days. Donor-site morbidity was minimal. CONCLUSIONS: The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating thumb avulsion-amputations.

Growth hormone and epidermal growth factor upregulate specific sodium-dependent glutamine uptake systems in human intestinal C2BBe1 cells.

Glutamine (Gln) is one of the major oxidative fuels of the enterocyte and enters from the lumen via Na(+)-dependent transport mechanisms. When given parenterally, growth hormone (GH) + epidermal growth factor (EGF) increase apical Gln uptake after massive enterectomy in rabbits. Although both receptors are basolateral, GH and EGF are present in luminal contents. We hypothesized that short-term luminal growth factor exposure to enterocytes increases apical Gln uptake by selective upregulation of systems A, B(0,+), or ASC+B(0). A monolayer of C2(BBe)1 cells was exposed for 10 or 60 min to GH (500 microg/L), EGF (100 microg/L), both, or neither. Initial uptake of [(3)H]Gln (50 micromol/L) was measured in the presence of Na(+) or choline. The contributions of systems A, B(0,+), and ASC+B(0) were determined by competitive inhibition with arginine and/or alpha-(methylamino)butyric acid. Gln uptake was linear for up to 8 min. Na(+)-independent transport was negligible. Under control conditions the relative contributions of systems A, B(0,+), and ASC+B(0) were 0, 19 +/- 6, and 80 +/- 4%, respectively. GH alone had no effect on Gln transport. After 10 min of EGF exposure, Na(+)-dependent Gln uptake increased by 50% (P < 0.001) with no change in individual transport systems. Combined EGF and GH for 60 min increased Gln transport by system B(0,+) nearly 250% (P < 0.001) and system A from undetectable levels to 16% of total transport (P < 0.01). Thus, short-term luminal exposure to EGF+GH increases Na(+)-dependent Gln transport mainly by upregulating system B(0+).

ATB0/ASCT2 expression in residual rabbit bowel is decreased after massive enterectomy and is restored by growth hormone treatment.

Two weeks after 70% enterectomy, glutamine (Gln) transport is downregulated in rabbit residual bowel due to a decrease in system B(0) activity. Providing epidermal growth factor (EGF) and growth hormone (GH) restores Gln transport by increasing systems A and B(0,+) activities. We hypothesized that changes in Na(+)-dependent broad-spectrum neutral amino acid transporter (ATB(0)/ASCT2) protein and mRNA expression correlate with system B(0) activity. New Zealand White rabbits underwent 70% jejunoileal resection or no resection. Resected rabbits immediately received parenteral EGF, GH, both, or neither agent for 2 wk. Tissues harvested from jejunum, ileum, and colon were subjected to Western and Northern blot analyses for ATB(0)/ASCT2 protein and mRNA. In all tissues, ATB(0)/ASCT2 mRNA was reduced by approximately 50% in resected rabbits compared with nonresected controls. Similar reductions in protein amount occurred in the ileum and cecum. None of the growth factor treatments restored ATB(0)/ASCT2 protein, but GH treatment increased ATB(0)/ASCT2 mRNA abundance 250% in the residual ileum. Because changes in the ATB(0)/ASCT2 protein amount paralleled those in the system B(0) activity in this model, it is likely that this is the protein responsible for this transport system. The increase in mRNA abundance in rabbits treated with GH for 2 wk may be a harbinger of subsequent increases in transporter protein and activity. Unlike reported upregulation of transporters in human colon after small bowel resection, ATB(0)/ASCT2 protein and mRNA expression in rabbit colon are decreased, suggesting different regulatory pathways.

Predicting success after gastric bypass: the role of psychosocial and behavioral factors.

BACKGROUND: Success after bariatric surgery requires behavioral modification. This study analyzes outcomes after Roux-en-Y gastric bypass surgery performed by a single surgeon between 1994 and 2002, and correlates preoperative factors with long-term outcome. METHODS: A bariatric database has been maintained since 1994. Beginning in April 1997, patients completed preoperative and annual postoperative questionnaires that collected an array of psychosocial information. We hypothesized that certain attributes are predictive of success after surgery. RESULTS: Of the 243 patients in our database, 181 enrolled after 1997. A total of 149 were seen for follow-up at 1 year. Life Experiences Survey (LES) scores and sexual satisfaction improved significantly. Perceived obesity-related health problems, motivation unrelated to social distress about obesity, a Sense of Coherence (SOC) score >110, and an LES score <-1 each independently predicted better weight loss (P<.05). A history of sexual abuse correlated with poorer weight loss (P<.05). Patients with more confidants, multiple previous dieting attempts, and greater anticipated postoperative diet-related stress tended toward better weight loss, but these data did not reach significance. CONCLUSIONS: Intrinsic motivational factors appear to predict greater weight loss after surgery. Ongoing follow-up will help determine the utility of preoperative evaluations and the role of preoperative intervention in those with poor predictive factors.

Use of the CBDI to detect malingering when malingerers do their "homework".

Previous research has demonstrated the ability of the Cognitive Behavioral Driver's Inventory (CBDI) to detect neuropsychological malingering [Arch. Clin. Neuropsychol. 12 (5) (1997) 491.], however, the present study tests if the CBDI can discern malingerers when they are "coached" on how brain-damaged patients actually perform on neuropsychological tests. Ninety-eight college student participants were given financial incentive to fake brain damage on the CBDI. Fifty-three of these subjects were "coached" and 45 were not. The coached and uncoached subjects performed indistinguishably on the CBDI. Both types of malingerers were discernable from real brain-damaged patients (99.2% accuracy area under the sensitivity-specificity curve). Further, CBDI profiles of five actual plaintiffs judged to be malingering were compared to CBDI profiles of experimental subjects. In each case, the malingering plaintiff's CBDI profile was indistinguishable from that of malingering experimental subjects and was clearly discernable from that of actual brain-damaged patients.

Growth hormone and epidermal growth factor together enhance amino acid transport systems B0,+ and A in remnant small intestine after massive enterectomy.

BACKGROUND: Sodium-dependent brush-border nutrient transport is decreased 2 weeks after massive enterectomy. This down-regulation is ameliorated by a 1-week infusion of parenteral growth hormone (GH) and epidermal growth factor (EGF) started 1 week after resection. We hypothesize that glutamine (GLN) transport will be enhanced by earlier and longer growth factor infusion, with differential effects on the Na(+)-dependent GLN transport systems A, B(0,+), and B(0)/ASCT2. MATERIALS AND METHODS: New Zealand White rabbits underwent 70% small bowel resection then immediately received parenteral EGF, GH, both EGF and GH, or neither for 2 weeks. Na(+)-dependent 3H-GLN uptake by jejunal and ileal brush-border membrane vesicles was measured and the contribution of systems A, B(0,+), and B(0) was then determined by competitive inhibition. Data were analyzed using one-way analysis of variance. RESULTS: In nonresected animals, the relative contribution of the systems was similar in jejunum (A 9%, B(0,+) 20%, and B(0) 71%) and ileum (A 13%, B(0,+) 27%, and B(0) 60%). Na(+)-dependent GLN uptake was reduced by one half in resected untreated controls, primarily because of decreased B(0) activity. EGF or GH alone did not affect Na(+)-dependent GLN transport, but, as a combination, there was increased uptake in the residual ileum and jejunum by 144% and 150%, respectively, over resected controls (P < 0.05). This was twice that achieved by delayed and shorter-duration combination treatment. This augmentation was a result of a 6.1-8.2-fold increase in system A as well as a 3.8-3.9-fold enhancement of system B(0,+) activity in remnant ileum and jejunum (P < 0.01). CONCLUSIONS: Parenteral EGF and GH, given in combination for 2 weeks immediately after massive enterectomy, synergistically enhance GLN uptake by systems A and B(0,+).

Growth hormone and epidermal growth factor together enhance amino acid transport systems B(0,+) and A in remnant small intestine after massive enterectomy.

BACKGROUND: Sodium-dependent brush border nutrient transport is decreased 2 weeks after massive enterectomy. This downregulation is ameliorated by a 1-week infusion of parenteral growth hormone (GH) and epidermal growth factor (EGF) started 1 week after resection. We hypothesized that glutamine (GLN) transport would be enhanced by earlier and longer growth factor infusion, with differential effects on the Na(+)-dependent GLN transport systems A, B(0,+), and B0/ASCT2. MATERIALS AND METHODS: New Zealand White rabbits underwent 70% small bowel resection then immediately received parenteral EGF, GH, both, or neither for 2 weeks. Na(+)-dependent 3H-GLN uptake by jejunal and ileal brush-border membrane vesicles was measured and the contribution of systems A, B(0,+), and B0 then determined by competitive inhibition. Data were analyzed using one-way analysis of variance. RESULTS: In nonresected animals, the relative contribution of the systems was similar in jejunum (A, 9%, B(0,+), 20%; and B0, 71%) and ileum (A, 13%; B(0,+), 27%; and B0, 60%). Na(+)-dependent GLN uptake was reduced by half in resected, untreated controls, primarily because of decreased B(0) activity. EGF or GH alone did not affect Na(+)-dependent GLN transport, but as a combination, increased uptake in the residual ileum and jejunum by 144% and 150%, respectively, over resected controls (P<0.05). This was twice that achieved by delayed and shorter-duration combination treatment. This augmentation was due to a 6.1- to 8.2-fold increase in system A as well as a 3.8- to 3.9-fold enhancement of system B(0,+) activity in remnant ileum and jejunum (P<0.01). CONCLUSIONS: Parenteral EGF and GH, given in combination for 2 weeks immediately after massive enterectomy, synergistically enhance GLN uptake by systems A and B(0,+).

Methods used to study intestinal nutrient transport: past and present.

BACKGROUND: Vitally important to the future of surgical care is the study of nutrition and nutrient uptake. Advances in this field of research have become increasingly dependent upon the disciplines of immunology, histology, and molecular biology. The fusion of these sciences has deepened our insight into the relationship between molecular structure and physiologic function. The ability to apply new technologies to this endeavor will enable the surgeon-investigator to further widen our understanding of nutrient transport. MATERIALS AND METHODS: Medline and current literature review. RESULTS AND CONCLUSIONS: We summarize many of the methods used to measure the uptake of nutrients by the intestinal epithelium, providing a historical perspective.

Growth factor regulation of enterocyte nutrient transport during intestinal adaptation.

BACKGROUND: Intestinal adaptation occurs in response to injury or alteration in nutrient availability. It is both morphologic and physiologic in nature and can be mediated by growth factors and nutrients. Pathologic conditions such as short-bowel syndrome and inflammatory bowel disease lead to derangements in nutrient absorption that may exceed the body's regenerative and adaptive capacity. Failure to fully adapt often results in long-term dependence on parenteral nutrition, leading to decreased quality of life and excessive medical expenses. The therapeutic use of appropriate growth factors may increase the adaptive capabilities of the gut. DATA SOURCE: Medline and current literature review. CONCLUSIONS: The major known nutrient transporters present in the gut and the mechanisms by which growth factors alter transport activity during intestinal adaptation are summarized. Growth factors have the potential to improve nutrient absorption in some bowel diseases.