Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multi-database literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, four of which were comparative in nature and included both closures by PS and SS. Of these four, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in two of the four (50%) studies (p=0.014, p<0.001) and radiation in three of the four (75%) studies (p<0.001, p<0.01, p<0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

Background Gender-affirming mastectomy is a common surgery for the treatment of gender incongruence and gender dysphoria and improves quality of life. Hematoma rates for gender-affirming double incision mastectomies are between 2.8% and 8.1%. This study aims to investigate the utility of a blood pressure challenge, whereby the patient's blood pressure is medically increased intraoperatively to reveal bleeding vessels that can be addressed with additional hemostasis before skin closure, to reduce postoperative hematoma. Methods A retrospective chart review of patients who underwent gender-affirming double incision mastectomies over a 6-year period by a single surgeon was conducted. Surgeries were separated into a blood pressure challenge experimental group and a non–blood pressure challenge control group. Demographics, surgical characteristics, and postoperative complications were compared between the 2 cohorts using Pearson χ 2 , Fisher exact, t tests, univariate logistic regression, and multivariable logistical regression. Significance was established at P < 0.05. Results A total of 92 patients (184 breasts) were included with 32 patients (64 breasts) in the control group and 60 (120 breasts) in the blood pressure challenge group. In the control group, there were 5 hematomas (7.81%) compared with 1 (0.83%) in the blood pressure challenge group ( P = 0.02). On univariate logistical regression analysis, blood pressure challenge was the only variable significantly associated with hematoma (odds ratio, 0.1; 95% confidence interval, 0.01–0.63; P = 0.04). On multivariable logistical regression, after controlling for age, body mass index, smoking status, and mass of excised breast tissue, patients who underwent blood pressure challenge demonstrated lower hematoma rates (odds ratio, 0.08; 95% CI, 0.004–0.59; P = 0.04). Conclusions Using an intraoperative blood pressure challenge was associated with reduced hematoma rates. Guidelines for blood pressure challenge goals should be established to standardize care and reduce complications in gender-affirming mastectomies.

Tears of the gluteus medius and minimus are an important cause of recalcitrant greater trochanteric pain syndrome. Although endoscopic and open abductor repairs have demonstrated promising outcomes, the success of these techniques is dependent on the size of the tear and the quality of the tissue. In patients presenting with abductor insufficiency and evidence of previous repair failure, large retracted tears, muscle atrophy and/or fatty infiltration, reconstruction/augmentation techniques should be considered. In the present study, we present a retrospective cohort study assessing patient outcomes following open gluteus maximus transfer for irreparable or severely retracted gluteus medius tears. Patients were included in the present study if they underwent open gluteus maximus transfer to address hip abductor tears that a senior surgeon deemed irreparable or at high risk for failure following isolated repair secondary to the following tear characteristics: large tears with >2 cm of retraction, the presence of extensive fatty infiltration (Goutallier Grade 3 or greater) and/or patients requiring revision abductor repair due to primary repair failure with associated pain and a Trendelenburg gait. Patients undergoing a concomitant, or those with a previous history of hip arthroplasty, were excluded from the study. All participants were prospectively enrolled in the study, and both pre- and post-operative patient-reported outcomes were collected at 6 months and 1 year including the modified Hip Harris Score, Visual Analog Score, Hip Outcomes Score of Activities Daily Living, Hip Outcomes Score for Sports-Related Activities and Overall Satisfaction with Hip. Pre-operative scores were compared with post-operative assessments using Student's t-test with a significance level of P < 0.05. Twenty-one patients and 22 hips were included. The average age was 69 (SD ±9.2) and 17 (81%) were females. The average body mass index was 30.0 (±6.2). The outcome scores at both 6 months and 1 year demonstrated significant improvements compared with pre-operative functional assessment. This article reports the utility of gluteus medius/minimus repair augmentation or reconstruction via gluteus maximus transfer demonstrating improvement in patient-reported outcomes at short-term follow-up.

Online crowdfunding allows transgender patients to fundraise for their surgeries or hormonal therapy. In this study, we updated the geographic trends in fundraising for gender-affirming surgery and sought to establish the factors influencing the amount raised per campaign. Campaigns were identified from GoFundMe. In total, 1010 crowdfunding campaigns were identified. The West had the highest proportion of campaigns (n=242, 34.6%). Controlling for each variable, we found that campaigns that raised the greatest amount of funds were associated with longer descriptions (p<0.0001, r=0.34), higher number of social media shares (p<0.0001, r=0.39), higher goal amount (p=0.041, r=0.19), and number of donors (p<0.0001, r=0.44).

Many transgender and gender diverse people want to have children, but cross-sex hormone treatments limit fertility and complete gender affirming genital surgeries preclude it (Auer et al., 2018; Ch...

Context: Medroxyprogesterone acetate (MPA) is a widely used progestin in feminizing hormone therapy. However, the side effects and hormonal changes elicited by this drug have never been investigated in the transgender population. Objective: We evaluated the incidence of self-reported effects among transwomen using MPA and this drug's impact on hormonal and metabolic parameters. Design, Setting, and Participants: We retrospectively collected data from 290 follow-up visits (FUVs) of transwomen treated at Rhode Island Hospital from January 2011 to July 2018 (mean duration of therapy 3.4 +/- 1.7 years). FUVs followed regimens of estradiol (E) and spironolactone, with MPA (n = 102) or without MPA (n = 188). Main Outcome Measures: We assessed the incidence of self-reported effects after MPA treatment. We also compared blood levels of E, testosterone, and various laboratory parameters between MPA and non-MPA groups. Results: Mean weighted E level was 211 +/- 57 pg/mL after MPA treatment and 210 +/- 31 pg/mL otherwise; this difference was nonsignificant [t(274) = 0.143, P = 0.886]. Mean weighted testosterone level was 79 +/- 18 ng/dL after MPA treatment and 215 +/- 29 ng/dL otherwise; testosterone levels were significantly lower in the MPA group [t(122) = 32.4, P < 0.001]. There were minimal changes in other laboratory parameters. Of 39 patients receiving MPA, 26 reported improved breast development and 11 reported decreased facial hair. Five patients experienced mood swings on MPA. Conclusions: In our cohort of transwomen, we found minimal side effects, unchanged E levels, and a decline in testosterone associated with MPA, outcomes consistent with feminization. Prospective studies are needed to confirm our findings.

Background:. Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%–30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. Methods:. Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. Results:. Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. Conclusions:. This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

BACKGROUND:Maxillomandibular fixation (MMF) is an important tool in the treatment of facial fractures and bone-anchored arch bar systems have emerged as treatment options. This study illustrates our experience with the Synthes MatrixWAVE MMF system and the novel application in closed treatment of patients with multiple concurrent mandibular fractures.METHODS:We enrolled eight patients with concurrent mandibular fractures and treated them with the MatrixWAVE MMF system. The malleable arch bars were fitted and then secured using 6-8 mm screws. The arch bar was and either stretched or compressed to ensure optimal positioning. 24-gauge interdental fixation wiring was placed using the fish loop technique on either side of the fracture to achieve stabilization of the mandible fractures.RESULTS:All eight patients were retained in MMF until stable occlusion was achieved with clinical evidence of healing, approximately 4-6 weeks. Post-operative Panorex scans did not reveal any evidence of damage to tooth roots. None of the screws became overly embedded in the mucosa secondary to overgrowth; the arch bars were successfully removed in an outpatient setting without local anesthesia.CONCLUSIONS:The Synthes MatrixWAVE MMF system has unique features such as prominent screw anchor heads and horizontal malleability unique from other bone anchored arch bars. These features allow for completely closed treatment of patients with multiple concurrent mandible fractures.

BACKGROUND:Gender affirmation surgery is an important treatment for patient with gender dysphoria. It consists of a series of complex procedures, and well-informed patients have been shown to have better outcomes. However, there are no published data regarding the readability of currently available online patient recourses for gender affirmation surgery. This study aims at identifying the most popular online resources and evaluating the readability of these documents in the context of average literacy within the United States.METHODS:An online search with the terms "gender affirmation surgery," "gender reassignment surgery," "top surgery," and "bottom surgery" was performed. Location, cookies, and user account information was disabled before each search to avoid bias in the results. Readability assessment was performed using the 10 commonly used readability scales.RESULTS:The overall mean readability level was 13.4. The mean reading level was 14 (range, 7.6-17.0) for the search term "gender affirmation surgery," 14.2 (range, 11.9-16.7) for the search term "gender reassignment surgery," 13 (range, 8.9-17.5) for the search term "top surgery," and 12.6 (range, 7.1-15.0) for the search term "bottom surgery." There was no statistically significant difference between the search terms.CONCLUSIONS:Our findings demonstrate that the articles most commonly seen by patients who perform an Internet search for information on gender reassignment surgery are more difficult than the recommended readability level.

BACKGROUND: Maxillomandibular fixation (MMF) with stainless steel Erich arch bars or intermaxillary screws has traditionally been the cornerstone of the treatment of mandibular fractures. Nonetheless, several well-documented disadvantages persist including intraoperative wire-stick injuries, poor oral hygiene maintenance, and increased operative time. 1, 2 Hybrid systems using bone supported arch bars have therefore been proposed as an alternative to address these issues. 3, 4 The newest addition is the Matrix Wave MMF system that features wave-shaped bone supported arch bars with locking screws. This study illustrates our experience with this novel system in the treatment of mandibular fractures. METHODS: Two patients with mandibular fractures were treated with the new Matrix Wave MMF system. The first patient presented with a parasymphyseal fracture on the right side and an angle fracture on the left. The second patient had a nondisplaced right mandibular body fracture and a left ramus and coronoid process fracture. The arch bars were contoured, fitted and secured using 6 mm screws. The malleable arch bar was either stretched or compressed to ensure optimal positioning. 24-gauge interdental fixation wiring was placed using the fish loop technique and transverse 24-gauge wires were fashioned on either side of the fracture to achieve compression and relative fixation about this point. RESULTS: Patients were retained in MMF until there was stable occlusion and clinical evidence of healing. Oral hygiene was unproblematic and there were no intraoperative wire-stick injuries with insertion of the system. Post-operative Panorex scans did not reveal any evidence of damage to tooth roots. None of the screws became embedded in the mucosa secondary to overgrowth; the arch bars were successfully removed in an outpatient setting without local anesthesia. CONCLUSIONS: The malleability of the bone supported arch bar allows for optimal screw placement and robust compression. Moreover, the self-drilling, locking screws sit above the plate to provide additional anchor points for bridge wires to better approximate fracture segments. In our experience, this novel hybrid system minimizes the drawbacks associated with traditional MMF techniques and offers a viable alternative for closed fixation of mandibular fractures. DISCLOSURE:Nothing to disclose. REFERENCES: 1. Coletti, D. P., Salama, A., Caccamese, J. F., Jr. Application of intermaxillary fixation screws in maxillofacial trauma. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 2007;65:1746–1750. 2. Farber, S. J., Snyder-Warwick, A. K., Skolnick, G. B., Woo, A. S., Patel, K. B. Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources. Annals of plastic surgery 2015. 3. Chao, A. H., Hulsen, J. Bone-supported arch bars are associated with comparable outcomes to Erich arch bars in the treatment of mandibular fractures with intermaxillary fixation. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 2015;73:306–313. 4. Kendrick, D. E., Park, C. M., Fa, J. M., Barber, J. S., Indresano, A. T. Stryker SMARTLock Hybrid Maxillomandibular Fixation System: Clinical Application, Complications, and Radiographic Findings. Plastic and reconstructive surgery 2016;137:142e-150e.

In this article, we outline the important role the surgeon plays in the management of chronic wounds. Debridement and washout are required for grossly infected wounds and necrotizing soft tissue infections. Cutaneous cancers such as squamous cell carcinomas may contribute to chronic wounds and vice versa; if diagnosed, these should be treated with wide local excision. Arterial, venous, and even lymphatic flows can be restored in select cases to enhance delivery of nutrients and removal of metabolic waste and promote wound healing. In cases where vital structures, such as bones, joints, tendons, and nerves, are exposed, vascularized tissue transfers are often required. These tissue transfers can be local or remote, the latter of which necessitates anastomoses of arteries and veins. Pressure sores are managed by relieving pressure, treating acute trauma or infection, and using rotation fasciocutaneous flaps. Lastly, the surgeon must always consider the possibility of osteomyelitis and retained foreign body as etiology for chronic wounds.

Background: Treacher Collins and Nager syndromes may present with mandibular hypoplasia that causes posterior collapse of the tongue base and a decreased oropharyngeal airway. Mandibular distraction and orthognathic advancement are effective treatments to correct the airway, but failure may occur despite achieving class I occlusion. For this select population, the authors propose a novel procedure of genioplasty distraction and hyoid advancement to optimize epiglottal positioning. Methods: Patients diagnosed with Treacher Collins (n = 5) or Nager syndrome (n = 3) with obstructive sleep apnea or tracheostomy dependency (n = 8) underwent genioplasty distraction and hyoid advancement. Airway outcome was assessed by preoperative and 1-year follow-up comparison of (1) laryngobronchoscopy, (2) sleep studies, and (3) tracheostomy dependency. For genioplasty outcome, three groups were used: group I (distraction genioplasty, syndromic) (n = 8), group II (acute genioplasty, syndromic) (n = 7), and group III (acute genioplasty, nonsyndromic) (n = 10). Lateral cephalogram measurements were used in the preoperative, postoperative, and follow-up periods to assess horizontal and vertical advancement and relapse. Results: Epiglottal position was optimized by the procedure in all patients based on direct endoscopic assessment. All five patients with obstructive sleep apnea had resolution of symptoms, and two of three patients achieved removal of their tracheostomy. Mean advancement for groups I, II, and III was 25, 14, and 8 mm, respectively. Follow-up horizontal advancement for groups I, II, and III were 18, 4, and 6 mm, respectively. Cephalometric measurements showed a horizontal relapse for groups I, II, and III of 10, 62, and 11 percent, respectively. Conclusions: Data suggest that genioplasty distraction allows for a greater advancement and decreased relapse rate than acute procedures alone; and genioplasty distraction with hyoid advancement is a useful technique for resolution of obstructive sleep apnea or to achieve tracheostomy removal in those syndromic patients who have already undergone mandibular advancement into a class I occlusion.