Background Gender-affirming surgery (GAS) is a component of gender-affirming care. Access to GAS in Canada continues to be inconsistent owing to jurisdictional differences in GAS policies. Given the increasing politicization of transgender, non-binary, and gender-diverse (TGD) individuals and its impacts on policy, we aimed to explore the experiences of individuals involved in GAS policy development across Canada to identify facilitators and barriers to GAS policy advancement. Methods We conducted a qualitative description study with phenomenological overtones. Between May and December 2024, we interviewed 27 individuals who engaged with, were informed, or counseled on GAS-related Medicare policies. Interviews were transcribed verbatim, coded by two independent coders, and developed into themes using NVivo (Version 14.0). Themes were mapped onto Kingdon’s Multiple Streams Framework, encompassing the problem, policy, and political streams, and the policy window. Findings We generated 11 themes from our analysis. Themes were categorized under the problem stream (awareness of or interest in TGD lives and concerns, raising awareness and capturing government attention, and strategies for defining “the problem”), policy stream (feasibility, consensus, and advocate-led policy development), political stream (political will; internal political champions; pressure from TGD activists, advocates, and allies; and transphobia), and policy window (luck, timing, and magic). Participants found that GAS policies were advanced when clearly defined problems, feasible policy solutions, and political converged. Conclusion Advancing GAS Medicare policy requires clearly defined problems, feasible policy solutions, and political will. Successful policy changes hinge on skillful advocates who are prepared with actionable policy solutions that seize brief and unpredictable windows of opportunity when they arise.
Radiation-induced angiosarcoma of the breast is a rare but aggressive malignancy originating from the endothelial cells of blood or lymphatic vessels, typically arising after radiotherapy for breast cancer. Management continues to be controversial with some centres advocating aggressive surgical resection whilst others favour a more localised approach. Our centre favours aggressive surgical management with radical mastectomy including the entire radiation field where possible, and reconstruction with a pedicled latissimus dorsi and split-thickness skin graft.A retrospective cohort study was performed by including 56 radiation-induced angiosarcomas of the breast in 54 patients over a 16-year period at a single tertiary centre in the North East of England. Statistical analysis was performed using R studio.Among the 56 tumours, 51 were treated using radical mastectomy, with only 1 positive margin (1.96%), wherein the tumour had invaded through the muscle into the chest wall. No positive peripheral margins were noted. The 5-year local recurrence and disease specific survival rates were 24.1% and 60.1%, respectively. Patients who underwent mastectomy for their primary breast cancer had significantly increased risk of local recurrence (LR, p=0.037).Our results demonstrated outcomes similar to those reported by centres with similar surgical management strategies. Furthermore, improved LR and survival outcomes were achieved when compared to centres favouring more localised surgical management, thereby adding to the growing field of evidence that aggressive surgical management improves oncological outcomes in radiation-induced angiosarcoma of the breast.
The global diabetic foot pandemic has led to a rising incidence of limb-threatening disease. Advances across vascular, orthopaedic, and plastic surgery now make functional limb salvage possible for patients who might previously have faced major amputation. Emerging evidence shows that successful limb preservation in diabetes is associated with improved survival. This narrative review reflects a collaborative, multidisciplinary ‘vasculo-ortho-plastic’ perspective, offering the reconstructive plastic surgeon an updated overview of current concepts in diabetic foot management. We highlight how the integration and alignment of healthcare over a range of specialties can achieve durable, functional limb preservation while also challenging entrenched dogma in the field, and perspectives on how to make this long lasting.
Introduction Vascular thrombosis continues to be the leading cause of free-flap failure despite advances in microsurgical technique. The structural alterations underlying thrombosed human microanastomoses are poorly characterized because surgically retrieved specimens are exceptionally rare. We aimed to characterize the structural patterns of arterial wall injury associated with thrombosed microanastomoses using combined ex vivo micro-magnetic resonance imaging (micro-MRI) and histopathologic analysis. Methods Five thrombosed arterial microanastomoses from 4 patients who underwent revision of the deep inferior epigastric perforator (DIEP) or profunda artery perforator (PAP) free flaps were analyzed. Specimens were imaged directly in formalin using a preclinical 4.7-T Bruker BioSpec system with T2-weighted TurboRARE sequences, followed by histopathological analysis. Vessel wall integrity, thrombus morphology, and the associated mural abnormalities were assessed and correlated between imaging and histologic findings. Results Two arterial specimens were of sufficient size and structural preservation to permit complete micro-MRI analysis. Imaging achieved an in-plane spatial resolution of 35 µm and demonstrated occlusive intraluminal thrombi that was associated with focal mural discontinuities. Histopathologic examination revealed acute fibrinocruoric thrombosis associated with endothelial denudation, medial ischemic necrosis, intimo-medial dissection, and transmural arterial wall rupture. Micro-MRI findings spatially corresponded with histologic areas of mural disruption and thrombus attachment. All lesions were consistent with acute mechanical arterial wall injury at or adjacent to the anastomotic site. Conclusions Thrombosed human microanastomoses consistently demonstrated focal structural arterial wall injury that was associated with acute occlusive thrombosis. These findings indicate that focal mechanical arterial wall injury is a major structural contributor to free-flap thrombosis and reinforce the importance of using a meticulous atraumatic microvascular technique.
