Hydraulic fracturing (fracking) has enabled the United States to lead the world in gas and oil production over the past decade; 17.6 million Americans now live within a mile of an oil or gas well (Czolowski et al., 2017). This major expansion in fossil fuel production is possible in part due to the 2005 Energy Policy Act and its "Halli-burton Loophole," which exempts fracking activity from regulation under the Safe Drinking Water Act (SDWA). To begin quantifying the environmental and economic impacts of this loophole, this study undertakes an aggregate analysis of chemicals that would otherwise be regulated by SDWA within FracFocus, an industry-sponsored fracking disclosure database. This paper quantifies the total disclosures and total mass of these chemicals used between 2014 and 2021, examines trends in their use, and investigates which companies most use and supply them. We find that 28 SDWA-regulated chemicals are reported in FracFocus, and 62-73% of all disclosures (depending on year) report at least one SDWA-regulated chemical. Of these, 19,700 disclosures report using SDWA-regulated chemicals in masses that exceed their reportable quantities as defined under the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA). Finally, while the most common direct-supplier category is "company name not reported," Halliburton is the second-most named direct supplier of SWDA regulated chemicals. Halliburton is also the supplier most frequently associated with fracks that use SDWA regulated chemicals. These results show the necessity of a more robust and federally mandated disclosure system and suggest the importance of revisiting exemptions such as the Halliburton Loophole.

While research and regulatory attention to per-and polyfluoroalkyl substances (PFAS) has increased exponentially in recent years, data are uneven and incomplete about the scale, scope, and severity of PFAS releases and resulting contamination in the United States. This paper argues that in the absence of high quality testing data, PFAS contamination can be presumed around three types of facilities: (1) fluorinated aqueous film-forming foam (AFFF) discharge sites, (2) certain industrial facilities, and (3) sites related to PFAS-containing waste. While data are incomplete on all three types of presumptive PFAS contamination sites, we integrate available geocoded, nationwide data sets into a single map of presumptive contamination sites in the United States, identifying 57,412 sites of presumptive PFAS contamination: 49,145 industrial facilities, 4,255 wastewater treatment plants, 3,493 current or former military sites, and 519 major airports. This conceptual approach allows governments, industries, and communities to rapidly and systematically identify potential exposure sources.

Websites have become the primary means by which the US federal government communicates about its operations and presents information for public consumption. However, the alteration or removal of critical information from these sites is often entirely legal and done without the public’s awareness. Relative to paper records, websites enable governments to shape public understanding in quick, scalable, and permissible ways. During the Trump administration, website changes indicative of climate denial prompted civil society organizations to develop tools for tracking online government information sources. We in the Environmental Data & Governance Initiative (EDGI) illustrate how five data visualization techniques can be used to document and analyze changes to government websites. We examine a large sample of websites of US federal environmental agencies and show that between 2016 and 2020: 1) the use of the term “climate change” decreased by an estimated 38%; 2) access to as much as 20% of the Environmental Protection Agency’s website was removed; 3) changes were made more to Cabinet agencies’ websites and to highly visible pages. In formulating ways to visualize and assess the alteration of websites, our study lays important groundwork for both systematically tracking changes and holding officials more accountable for their web practices. Our techniques enable researchers and watchdog groups alike to operate at the scale necessary to understand the breadth of impact an administration can have on the online face of government.

The COVID-19 pandemic has coincided with a powerful upsurge in antiracist activism in the United States, linking many forms and consequences of racism to public and environmental health. This commentary develops the concept of eco-pandemic injustice to explain interrelationships between the pandemic and socioecological systems, demonstrating how COVID-19 both reveals and deepens structural inequalities that form along lines of environmental health. Using Pellow's critical environmental justice theory, we examine how the crisis has made more visible and exacerbated links between racism, poverty, and health while providing opportunities to enact change through collective embodied health movements. We describe new collaborations and the potential for meaningful opportunities at the intersections between health, antiracist, environmental, and political movements that are advocating for the types of transformational change described by critical environmental justice.

Introduction: In the United States, 1.4-1.65 million people identify as transgender, many of whom will seek genital gender-affirming surgery (GAS). The number of surgeons, geographic proximity thereof, and exclusionary insurance policies has limited patient access to genital GAS. Aim: To assess the accessibility of both feminizing and masculinizing genital GAS (vaginoplasty, metoidioplasty, and phalloplasty) by identifying the location of GAS surgeons, health insurance, or payment forms accepted. Methods: Between February and April 2018, genital GAS surgeons were identified via Google search. Surgeons' offices were contacted by telephone or e-mail. Main Outcome Measure: We queried the type of genital GAS performed, the health insurance or payment forms accepted, and the type of medical practice (academic, private, or group managed-care practice). Results: We identified 96 surgeons across 64 individual medical centers offering genital GAS. The survey response rate was 83.3%. Only 61 of 80 (76.3%) surgeons across 38 of 53 (72%) locations confirmed offering genital GAS. Only 20 (40%) U.S. states had at least one genital GAS provider. 30 of 38 (79%) locations reported accepting any form of insurance. Only 24 of 38 (63%) locations (14 academic; 10 private/group) accepted Medicaid (P = .016); 18 of 38 (47%) locations (13 academic; 5 private/group) accepted Medicare (P = .001). Clinical Translation: Reconciliation of the public policies regarding insurance coverage for GAS with the actual practices of the providers is necessary for improving access to GAS for transgender individuals. Strengths & Limitations: We purposefully used a methodology mirroring how a patient would find GAS surgeons, which also accounts for key limitations: only surgeons whose services were featured on the internet were identified. We could not verify the services or insurance-related information surgeons reported. Conclusion: This study suggests that access to genital GAS is significantly limited by the number of providers and the uneven geographic distribution across the United States, in which only 20 of 50 U.S. states have at least one genital GAS surgeon. Feldman AT, Chen A, Poudrier G, et al. How Accessible Is Genital Gender Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers. Sex Med 2020;8:664-672. Copyright (c) 2020, International Society for Sexual Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Immediately after President Trump’s inauguration, US federal science agencies began deleting information about climate change from their websites, triggering alarm among scientists, environmental activists, and journalists about the administration’s attempt to suppress information about climate change and promulgate climate denialism. The Environmental Data & Governance Initiative (EDGI) was founded in late 2016 to build a multidisciplinary collaboration of scholars and volunteers who could monitor the Trump administration’s dismantling of environmental regulations and science deemed harmful to its industrial and ideological interests. One of EDGI’s main initiatives has been training activists and volunteers to monitor federal agency websites to identify how the climate-denialist ideology is affecting public debate and science policy. In this paper, we explain how EDGI’s web-monitoring protocols are being incorporated into college curricula and how, in this way, EDGI’s work aligns with STS work on “critical making” and “making and doing.” EDGI’s work shows how STS scholars can establish new modes of engagement with the state that demand a more transparent and trustworthy relationship with the public, creating spaces where the public can define and demand responsible knowledge practices and participate in the process of creating STS inspired forms of careful, collective, and public knowledge construction.

Gender-affirming surgery, which for many transgender men includes bilateral mastectomy, or "top surgery," is a medically necessary intervention for those who seek it, and is associated with higher overall subjective quality of life and lower rates of gender dysphoria, substance abuse, human immunodeficiency virus, and suicide.1–3 Publically funded coverage for both general and transition-related healthcare for transgender patients has shown to be cost-effective, likely due to decreased rates of the aforementioned comorbidities.2 However, despite recent policy changes at federal, state, and city levels that have improved insurance coverage for transition-related care, coverage is not mandated, and many transgender patients still face difficulties accessing care.4 This survey examined barriers to transition-related care via a survey of insured transgender men and nonbinary individuals who underwent masculinizing top surgery. This retrospective study enrolled 58 transgender men and nonbinary individuals assigned female at birth who had previously undergone top surgery at New York Univerity Langone Health. The survey distribution period was November of 2016 to April of 2017. The survey recorded (1) demographics, including extent of insurance coverage, (2) concerns that hindered the decision to have top surgery, and (3) considerations when choosing a surgeon. Of the 58 participants who completed the survey, 56 were privately insured at the time of surgery. Of these 56, insurance coverage for top surgery was either full (66 percent), partial (27 percent), none (4 percent), or "other" (4 percent) (Table 1). Among this insured cohort, the most-reported considerations and access barriers when considering top surgery were financial. They included lack of money and/or insurance (53 percent), difficulty with insurance (47 percent), and difficulty finding a surgeon who accepted insurance (44 percent) (Table 2). The top consideration when choosing a surgeon was also financial: whether the surgeon accepted the subject's insurance (80 percent). Table 1. - Demographics and Extent of Coverage* Characteristic Proportion of Participants, % (no.) (n = 56)† Mean age at time of top surgery, years (SD) 33 (9.4) Mean age at which first considered surgery, years (SD) 25 (11.2) Mean individual delay in time between point at which first considered surgery and undergoing surgery, years (SD) 7 (5.9) Gender identity‡ Male 43 (24) Female 0 (0) Trans male/trans man 68 (38) Genderqueer/gender nonconforming 25 (14) Other (please state)§ 5 (3) Estimated time since surgery <1 year 58 (33) 1-2 years 23 (13) 3-4 years 2 (1) 4-6 years 7 (4) >6 years 11 (6) Insurange coverage of top surgery Full 66 (37) Partial 27 (15) None (with health insurance) 4 (2) Other 4 (2) *Summary demographic information including gender identity and extent of insurance coverage for top surgery are reported for the 56 subjects who had insurance.†Unless otherwise specified‡Selections were not mutually exclusive§Participant wrote in gender identity Table 2. - Concerns That Hindered Decision to Have Top Surgery* Measure Overall Proportion of Participants, % (no.) (n = 55) By Insurance Coverage Full (n = 37) Partial (n = 15) None or "Other" (n = 3) p Financial concerns when considering top surgery Financial barriers (e.g., lack of money/insurance) 53 (29) 43 (16) 67 (10) 67 (2) 0.370 Difficulty obtaining coverage from insurance 47 (26) 41 (15) 53 (8) 100 (3) 0.138 Difficulty finding a surgeon who performed top surgery and took my insurance 44 (24) 41 (15) 53 (8) 33 (1) 0.726 Practical concerns (e.g., taking enough time off work for recovery, and so on) 33 (18) 24 (9) 40 (6) 100 (3) 0.030 Surgical concerns when considering top surgery Fear of surgical complications 31 (17) 27 (10) 33 (5) 67 (2) 0.361 The potential for nipple sensation loss 25 (14) 27 (10) 27 (4) 0 0.391 Fear of painful recovery 16 (9) 14 (5) 27 (4) 33 (1) 0.310 Dissatisfaction with the potential for scarring 15 (8) 14 (5) 20 (3) 0 0.800 Fear of regretting the surgery 11 (6) 5 (2) 20 (3) 33 (1) 0.101 Dissatisfaction with the surgical options presented (e.g., not satisfied with available surgical options) 5 (3) 0 20 (3) 33 (1) 0.009 Miscellaneous concerns when considering top surgery Unsupportive/disapproving friends/family members 24 (13) 19 (7) 27 (4) 67 (2) 0.195 Difficulty obtaining the necessary letters of approval from a mental health professional 9 (5) 8 (3) 7 (1) 33 (1) 0.355 Difficulty obtaining enough information about the surgery to make an informed decision 5 (3) 5 (2) 7 (1) 0 >0.999 Considerations when choosing a surgeon Surgeon's acceptance of insurance 80 (44) 86 (32) 73 (11) 33 (1) 0.066 Difficulty finding a surgeon that was liked and trusted 33 (18) 32 (12) 33 (5) 33 (1) >0.999 Difficulty finding a medical provider/surgeon who was knowledgeable about transgender health issues 22 (12) 19 (7) 33 (5) 33 (1) 0.392 Travel distance to surgeon 22 (12) 24 (9) 20 (3) 0 0.016 My decision was not hindered by any of the above factors 13 (7) 16 (6) 7 (1) 0 0.527 *Financial and nonfinancial concerns that negatively affected the decision to undergo top surgery are reported in terms of overall prevalence, and as comparative prevalence between groups of subjects with differing levels of coverage for top surgery from their health insurance plans, with p values reported from analysis of variance comparisons. Selections were not mutually exclusive. Notably, all of the most important concerns in our survey were reported equally by those whose insurance offered complete, partial, or no coverage for their top surgery, highlighting the complexity of costs related to gender-affirming surgery (Table 2). Our survey did not ascertain what additional factors contributed to prohibitive cost in cases of "complete" insurance coverage. Several possibilities exist, including ancillary costs (such as anesthesia and facility fees), additional procedures (such as nipple tattooing or scar revision), the cost of follow-up care, costs associated with complications of surgery, the need to take off time from work, and surgeons' selective acceptance of insurance. Further investigation into which noninsurance-related costs are most prohibitive and how to best address them is surely warranted. The financial concerns reported by this survey are likely underrepresentative of those faced by transgender patients generally. All 56 subjects in this analysis had insurance, while 19 percent of the transgender population are uninsured.5 In addition, these data were collected in a large metropolitan area and do not necessarily reflect financial concerns in other regions of the country, where nondiscrimination protections, health insurance coverage regulation, and provider availability may be less accommodating to transgender persons. Clearly, in addition to further expanding insurance coverage for gender-affirming surgery, noninsurance-related efforts are needed in order to ensure equitable access to this medically necessary and life-changing intervention. DISCLOSURE The authors have no relevant financial disclosures in relation to the content of this article. Ian T. Nolan, B.M.Grace Poudrier, B.A.Catherine C. Motosko, M.D.Tiffany E. Cook, B.G.S.Whitney Saia, F.N.P.-C.Hansjörg Wyss Department of Plastic SurgeryNew York University School of MedicineNew York, N.Y. M. David Gothard, M.S.Biostats, Inc.Canton, Ohio Alexes Hazen, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University School of MedicineNew York, N.Y.Biostats, Inc.Canton, Ohio

Social science-environmental health (SS-EH) research takes many structural forms and contributes to a wide variety of topical areas. In this article we discuss the general nature of SS-EH contributions and offer a new typology of SS-EH practice that situates this type of research in a larger transdisciplinary sensibility: (1) environmental health science influenced by social science; (2) social science studies of environmental health; and (3) social science-environmental health collaborations. We describe examples from our own and others' work and we discuss the central role that research centers, training programs, and conferences play in furthering SS-EH research. We argue that the third form of SS-EH research, SS-EH collaborations, offers the greatest potential for improving public and environmental health, though such collaborations come with important challenges and demand constant reflexivity on the part of researchers.

Access to gender-affirming surgery remains unattainable for many transgender patients, despite recent sociopolitical advances aimed at improving access to this medically necessary standard of care.1,2 While many transgender men and gender nonbinary patients assigned female at birth choose to forgo genital reconstruction, or "bottom surgery," those who do face considerable barriers to doing so. This study examines barriers to bottom surgery (phalloplasty and metoidioplasty) for 104 transgender men and nonbinary patients assigned female at birth who had not had this surgery (Table 1). Table 1. - Demographics (N = 104)* Parameter Subjects, % (n) Mean age (SD), years 28.8 (8.35) Gender identity Transmale 33.7 (35) Male and transmale 31.7 (33) Gender queer and nonconforming 16.3 (17) "Other" or multiple gender identities 18.3 (19) Previous gender-affirming surgery Top/chest surgery 58.7 (61) Hysterectomy† 3.8 (4) Currently on hormone therapy 82.7 (86) Duration of hormone therapy <1 year 20.9 (18) 1–5 years 70.9 (61) >5 years 8.1 (7) *Mean age, gender identity, history of previous gender-affirming surgery, and history of hormone therapy are reported. Gender identities were reported as nonexclusive categories, allowing each subject to identify with multiple options.†Four subjects offered this information as an "other" write-in option. A central finding in our study was the degree to which financial constraints and inadequate insurance coverage remain prevalent barriers for those patients who desire bottom surgery. The single most common barrier affecting patients' decision to pursue or forgo bottom surgery was "financial barriers" (43.3 percent, n = 45). "Difficulty with my insurance" (26.9 percent, n = 28) and "difficulty finding a surgeon who takes my insurance" (13.5 percent, n = 14) were also important (Table 2). These findings may reflect transgender patients' increased likelihood of unemployment and lack of health insurance as compared with the general (cisgender) population, inadequate coverage for gender-affirming care by commercial health insurance companies, and a relative dearth of surgeons who both perform genital gender-affirming surgery and accept reimbursement for those procedures from Medicaid and Medicare, which transgender patients are more likely to utilize.1–3 Table 2. - Barriers to Obtaining Bottom Surgery* Barrier Total Reporting Barrier, % (n), N = 103 Prevalence by Age Range, % (n) p <21 Years, N = 18 21–30 Years, N = 46 31–40 Years, N = 31 41+ Years, N = 8 Financial barriers 43.3 (45) 61.1 (11) 47.8 (22) 32.3 (10) 12.5 (1) 0.009† No barriers reported 35.6 (37) 16.7 (3) 28.3 (13) 51.6 (16) 62.5 (5) 0.002† Difficulty finding a surgeon who performs bottom surgery 28.8 (30) 44.4 (8) 30.4 (14) 16.1 (5) 37.5 (3) 0.162 Difficulty finding a surgeon I trust 27.9 (29) 50.0 (8) 26.1 (12) 22.6 (7) 12.5 (1) 0.034† Difficulty with my insurance 26.9 (28) 27.8 (5) 28.3 (13) 25.8 (8) 25.0 (2) 0.078 Difficulty finding a surgeon who is knowledgeable about trans health issues 25.0 (26) 27.8 (5) 26.1 (12) 25.8 (8) 12.5 (1) 0.593 Difficulty finding a surgeon who takes my insurance 14.4 (15) 22.2 (4) 15.2 (7) 9.7 (3) 12.5 (1) 0.325 Travel distance to surgeon 11.5 (12) 16.7 (3) 13.0 (6) 9.7 (3) 0 0.277 Difficulty obtaining letters of approval from a mental health provider 2.9 (3) 11.1 (2) 2.2 (1) 0 0 0.078 *Prevalence of barriers to obtaining bottom surgery are reported, including financial, practical, and surgeon-related concerns. Prevalence of barriers by age, in bins of 10 years, are also reported, as well as the overall significance of age on prevalence for each barrier.†Statistically significant. Younger patients were especially likely to be deterred by financial barriers, by difficulty finding a surgeon knowledgeable about transgender health issues, and to face barriers in general (Table 2). This may reflect overall lower financial security among younger patients, or less comfort and/or access to the medical system generally. Financial barriers in gender-affirming surgery are not unique to bottom surgery and are not limited to insurance. We previously demonstrated that a cohort of 58 transgender men and nonbinary patients reported significant financial and insurance-related barriers to accessing chest ("top") surgery, despite having insurance coverage, suggesting an important role of ancillary medical costs not covered by medical insurance.4 Our study highlights a clear role for surgeons and residency programs in promoting increased access to bottom surgery. Surgeon-related barriers, such as "difficulty finding a surgeon who performs bottom surgery," "difficulty finding a surgeon I trust," and "difficulty finding a surgeon who is knowledgeable about trans health issues" were each reported by 25 percent to 30 percent of our cohort (Table 2). In order to meet the needs of a growing transgender patient population, more surgeons must complete specialized training in genital gender-affirming surgery, including training in cultural competency and the unique health issues faced by transgender patients. This will likely involve development of surgical training programs specific to gender-affirming surgery and increased emphasis on transgender health curriculum within graduate and undergraduate medical programs. We must continue advocating for improved access to gender-affirming care, financially and otherwise. Doing so is not only morally sound but also likely a cost-effective public health intervention.5 Failure to do so perpetuates existing financial inequalities and health disparities experienced by transgender patients, and falls short of our duty as medical professionals to provide quality care to all patients, regardless of gender identity. ACKNOWLEDGMENT The authors thank David Gothard, M.S., for his contribution to statistical analysis. DISCLOSURE The authors have no financial interest to declare in relation to the content of this work. Ian T. Nolan, B.M.David A. Daar, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University School of MedicineNew York, N.Y. Grace Poudrier, B.A.Department of Sociology and AnthropologyNortheastern UniversityBoston, Mass. Catherine C. Motosko, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University School of Medicine Tiffany E. Cook, B.G.S.New York University School of Medicine Alexes Hazen, M.D.Hansjörg Wyss Department of Plastic SurgeryNew York University School of MedicineNew York, N.Y.

A Novel Periareolar Approach to Chest Wall Reconstruction Using a Nipple-Areola Complex Transposition Flap C wall reconstruction for transgender men and gender nonbinary patients seeks to improve contour and nipple-areola complex position.1–3 The male nipple-areola complex is described as small, ovoid, and laterally positioned along the pectoralis major.1,2 Patients with small breasts, minimal ptosis, and good skin quality are suitable candidates for periareolar techniques; however, traditional approaches fail to reposition the nipple-areola complex to a more masculine-appearing position.4,5 We describe a novel periareolar technique using a lateral nipple transposition flap based on a superomedial neurovascular pedicle, which permits versatile mobility of a vascular and neurotized nipple-areola complex. An eccentric ellipse is marked around the nipple-areola complex with the nipple located in the medial pole and the ellipse extending inferolaterally to encompass the ideal nipple-areola position. Incisions are made to the level of the dermis around the native areola using a cookie cutter as well as around the previously marked ellipse. The skin intervening the two markings is de-epithelialized. Inferiorly, the dermis is incised and dissected to the chest wall. The breast gland is then dissected inferiorly and laterally off of the chest wall. A superomedial pedicle is marked and the dermis is incised were very close to the proposed 1-2-3 rule.4 This rule is effective, even in a population of smaller stature. There are also some points that surgeons should know before using the 1-2-3 rule. Distance in the anatomical studies, including that by Lee et al.4 and our own, was measured with a microcaliper, which resulted in a “displacement” and was not a “distance” that curved along costal cartilage (Fig. 1).4 This could be confusing for the surgeon intraoperatively, and a wrong method of measurement could lead to inferior precision for locating internal mammary vessels. Moreover, the studies were conducted using formalin-embalmed cadavers and not fresh cadavers.4 There is a potential that the tissue has shrunken and the distance could minimally deviate.5 Therefore, the proposed 5-mm deviation4 from the 1-2-3 rule should be kept in mind during dissection near the theoretical point. In conclusion, we confirm that the 1-2-3 rule is useful and could be generalized to a population of patients of smaller stature. DOI: 10.1097/PRS.0000000000005925

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors' opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.

Background: Despite the growing popularity of platelet-rich plasma, existing evidence supporting its efficacy remains controversial due to the lack of large-scale studies and standardized protocols for preparation and application. This article reviews its use in facial rejuvenation, fat grafting, acne scarring, and androgenic alopecia. Emphasis is placed on comparing methods of platelet-rich plasma preparation and application across studies. Methods: A systematic review was performed for articles published between 2006 and 2015. All clinical studies and case reports that addressed platelet-rich plasma alone and/or in combination with fat grafting for facial rejuvenation, acne scarring, or androgenic alopecia were included. Results: Of the 22 articles included in the analysis, seven studies used platelet-rich plasma alone for facial rejuvenation, seven in combination with fat grafting, two for treatment of acne scarring, and six for treatment of androgenic alopecia. Individual study procedures, means of evaluation, and significant results are summarized. Although the majority of studies in this review report positive results, significant variation exists in preparation protocols and in the number and frequency of clinical treatments. Conclusions: The majority of studies report positive results for all indications evaluated in this review, but the procedure is limited by the lack of a standardized method for preparation and application of platelet-rich plasma. The extent to which significant variability in platelet-rich plasma preparation and/or application methods may affect clinical outcomes is not completely clear. In the interim, we present a consolidation of platelet-rich plasma treatment techniques and outcomes currently in use to help guide physicians in their clinical practice.

Background: A primary goal in chest wall reconstruction (“top surgery”) for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex. Methods: The senior author’s (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016. Results: The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m 2 . Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent). Conclusion: The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: Among surgical subspecialties, plastic surgery holds the highest percentage of women, and, the female contingent of board-certified plastic surgeons and trainees has grown steadily. However, their academic impact has been underestimated. We present the academic footprint of female plastic surgeons over the past 40 years. Methods: A list of female plastic surgeons currently active at, and retired from, Accreditation Council for Graduate Medical Education–accredited plastic surgery residency programs was compiled. Each surgeon was searched on PubMed to gather their total number of publications, journals, and topics of research after completion of training. Date of publication and 5-year impact factor for each journal were recorded. Publications were organized into 10-year periods (1976 to 1985, 1986 to 1995, 1996 to 2005, and 2006 to 2016). Results: One hundred fifty-five currently active and 80 retired academic female plastic surgeons were identified, who published 2982 articles in 479 peer-reviewed journals. The average 5-year impact factor was 4.093. The number of publications increased with each decade: 37 (1976 to 1985), 218 (1986 to 1995), 472 (1996 to 2005), and 2255 (2006 to 2016). The most commonly published areas were hand/nerve (22 percent), craniofacial (21 percent), and breast (20 percent). Over time, publications in hand/nerve research decreased (76, 60, 38, and 14 percent, respectively); craniofacial-related publications increased (8, 11, 18, and 23 percent, respectively); and publications in breast research increased (0, 8, 9, and 24 percent, respectively). The 2006 to 2016 period yielded the most even distribution of research topics. Conclusion: The academic contribution of female plastic surgeons has substantially increased in number and has become more evenly distributed across subspecialty topics.

Background Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. Methods A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. Results Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). Conclusions This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

INTRODUCTION:Despite increasing popularity of platelet-rich plasma (PRP) in treating aging facial skin, the quality of evidence supporting its use is poor due to the lack of consistent methods of its preparation and application.OBJECTIVE:This study was conducted to assess treatment efficacy and patient satisfaction with a single PRP treatment prepared with a simplified preparation and application technique.METHODS:Four millilitre of PRP were injected into 6 standardized points on each side of the face. Outcomes were assessed by independent physician evaluation of pretreatment and posttreatment photographs using the Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale (GAIS). In addition, patient-reported outcomes were evaluated using the FACE-Q.RESULTS:Thirty-one participants ranging from 27 to 71 years of age (median, 38; IQR 32-58) were recruited for this study. Posttreatment WSRS scores improved in only 1 patient; the GAIS scores of 14 patients indicated aesthetic improvement. Analysis of FACE-Q scores revealed statistically significant increases in participant satisfaction with overall facial appearance and cheeks. The most frequently reported adverse effects were tenderness (23.4%; 7 of 31), facial tightness (20.0%; 6 of 31), and swelling (20.0%; 6 of 31).CONCLUSIONS:A simple method of PRP preparation offers modest benefit in treating the effects of skin aging and photodamage. Future research studies should alter our methods using a stepwise approach to optimize the treatment of aging facial skin with PRP.

Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery (alternatively, gender reassignment surgery, sexual reassignment surgery, or gender-affirming surgery). This review presents a robust overview of genital reconstruction in the female-to-male transgender patient-an operation that, historically, was seldom performed and has remained less surgically feasible than its counterpart (male-to-female genital reconstruction). However, as the visibility and public awareness of the trans community continues to increase, the demand for plastic surgeons equipped to perform these reconstructions is rising. The "ideal" neophallus is aesthetic, maintains tactile and erogenous sensibility, permits sexual function and standing urination, and possesses minimal donor-site and operative morbidity. This article reviews current techniques for surgical construction, including metoidioplasty and phalloplasty, with both pedicled and free flaps. Emphasis is placed on the variety of techniques available for constructing a functional neophallus and neourethra. Preparative procedures (such as vaginectomy, hysterectomy, and oophorectomy) and adjunctive reconstructive procedures (including scrotoplasty and genital prosthesis insertion) are also discussed.