Optimizing aesthetics in gender-affirming vaginoplasty and vulvoplasty: a narrative review and discussion based on over 600 cases of transfeminine vulvar construction.

Background and Objective: The vulva is the external portion of a gender-affirming vaginoplasty or vulvoplasty procedure-the "visible" result of surgery. The vulvar appearance can play a major role in how individuals feel about their surgical results and new genital anatomy. Therefore, optimizing the aesthetics of the vulva is an important component of surgical care. Although there is no one "ideal" vulvar appearance, aesthetics are optimal when each major sub-unit of the vulva is reconstructed to create a proportional and cohesive vulvar unit. In this article we perform a narrative review of the literature and discuss clinical approaches to improve aesthetic satisfaction such as patient education, re-defining the "ideal" vulva, aesthetic surgery tenets and technical strategies based on our collective experience of over 630 gender-affirming vulvar constructions. Methods: A narrative review of the literature was completed accessing PubMed, EMBASE, Google Scholar using search terms "Vaginoplasty OR Vulvoplasty". Articles were removed if not pertaining to gender affirmation surgery, were not in English language, were not accessible or did not discuss aesthetics in the body of the text. Key Content and Findings: A total of 1,042 articles were identified from initial search criteria. Of those, 905 were excluded as they did not involve gender affirmation as an indication. An additional 112 papers were excluded as they were not accessible, not in English, focused on non-vulvar outcomes or did not comment on vulvar aesthetics. Ultimately 25 articles were included for narrative review; 21 of these included technical descriptions of vulva and 13 had direct aesthetic discussion. The anatomy and aesthetics of the transfeminine vulva are reviewed according to the previously described principle of anatomic vulvar sub-units: the labia majora, labia minora, clitoris, urethra and the introitus. Conclusions: Ultimately, creating the optimal vulva for each individual patient will demand flexible surgical decisions based on individual anatomy and available tissues. This narrative review provides an overview of current approaches to aesthetics in gender-affirming vulvar construction and technical insights based on our institutional experience of performing over 630 gender-affirming vaginoplasty and vulvoplasty procedures.

Nasal Analysis: Considerations for Ethnic Variation.

As the United States continues to be more ethnically and racially diverse, it is important for the rhinoplasty surgeon to have an appreciation and understanding of nasal variations that exist to plan for and execute ethnically congruent results. The nasal analysis is a critical component of the patient evaluation, which has been used as a tool by surgeons to identify deviations from anatomical norms or canons. In this article, the authors describe common nasal anatomical variations that exist between ethnic groups as a guide for nasal analysis. Understanding these variations will facilitate and help define important cultural aesthetics, which can be used to plan for rhinoplasties in a diverse patient population.

Cephalic Rotation of the Nasal Tip.

The position of the nasal tip holds important aesthetic significance. Cephalic rotation of the nasal tip is a frequent motivating factor for patients seeking rhinoplasty. The position of the nasal tip is a complex interplay of the size, morphology, and position of several anatomical components of the lower one-third of the nose. Cephalic rotation can be achieved by means of six different methods. The indirect methods promote passive cephalic rotation and include cephalic trim of the lower lateral cartilages, caudal trim of the upper lateral cartilages, and caudal septal trim. Direct methods involve precise repositioning of the domes and include shortening the lateral crura, lateral domal relocation, and the tip rotation suture. Used alone or in combination, these techniques and their subtle variations represent comprehensive and effective methods to achieve cephalic rotation of the nasal tip.

Complications in Brow Lifts: A Systemic Review of Surgical and Nonsurgical Brow Rejuvenations.

BACKGROUND: Brow lift has been a part of plastic surgeons' armamentarium for over a century. Although there are multiple different techniques available, there has been a dearth of literature comparing which technique is better and has lesser complications. In this study, we performed a systemic literature review of all brow lift techniques to determine and compare complication rates of each technique. METHODS: We performed a computerized search of brow rejuvenation techniques using the MEDLINE database. Data regarding the type of brow lift procedure, number of patients, and complications were collected. RESULTS: The systematic review was performed in December of 2017. A total of 326 articles were identified initially, and 76 studies remained after final review. The review showed highest revision rate in the hairline brow lift (7.4%), highest numbness rate in the direct brow lift (5.5%), highest asymmetry rate in the temporal/lateral brow lift (1.5%), and highest alopecia rate in the endoscopic brow lift (2.8%). In addition, we found 5 studies in nonsurgical brow rejuvenation (3 botulinum toxin, 1 fat injection, 1 radiofrequency). CONCLUSION: Our study shows that each brow technique has a different complication profile, and it is important for plastic surgeons to understand the difference. Furthermore, the study demonstrated the lack of randomized prospective outcome studies and standardization of outcome measures in brow rejuvenation. We believe this information would be the key and next frontier in providing technically safe and long-lasting aesthetic outcomes for the patients.

Approach to the Post Mohs Patient.

This article discusses the often unique patient presentations and management challenges of the post Mohs resection surgical patient. This includes social, economic, and health issues. Anesthesia considerations and pre- and postoperative care are also discussed in this article.

Simplifying Lip Reconstruction: An Algorithmic Approach.

The authors provide an overview of lip reconstruction after Mohs surgery based on the senior author's practice. Lip reconstruction offers unique challenges to preserve not only lip function but also aesthetics. Lip reconstruction must take into consideration the three anatomical layers that comprise the lip and defects that involve the mucosa, the muscle, the skin or more than one layer will help determine the modality of repair. The authors offer an algorithm based on defect location, tissue involvement, and severity of defect to simplify an often complex decision-making process.

Staying Safe during Gluteal Fat Transplantation.

Gluteal augmentation with fat transplantation is increasing in demand but has been associated with a concerning number of fatality reports. Despite these reports, various surgeons have safely performed gluteal fat transplantation on a large number of patients with no reported mortality. The important aspects of safely performing gluteal fat transplantation are reviewed. Proper patient selection, favorable instrumentation, patient positioning, proper technique, and knowledge of anatomy are critical to improving the safety of this procedure. Adherence to these key principles should allow a reduction in mortality from this procedure, which would safely allow its continued offering in the setting of increasingly high demand.