Publications by authors named "Oscar J Manrique"

132 Publications

Maximizing Safety and Optimizing Outcomes of Labiaplasty: A Systematic Review and Meta-Analysis.

Plast Reconstr Surg 2022 Jul 26. Epub 2022 Jul 26.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.

Background: The considerable increase in labiaplasty, demands plastic surgeons to be acquainted with the surgical techniques, their respective complications and satisfaction rates. This is a systematic review of the available evidence on labia minoraplasty looking at surgical techniques, clinical outcomes and patient satisfaction.

Methods: A comprehensive search across PubMed, Web of Science, SCOPUS and Cochrane CENTRAL was executed through October 2020. A random-effect model meta-analysis was performed to assess the satisfaction and complications rates.

Results: Forty-six studies including 3804 patients fulfilled the inclusion criteria. The pooled satisfaction rate following labia minoraplasty was 99% (95%CI: 97%-99%). Substantial heterogeneity was present across studies (I2 = 63.09%, p < 0.001). The highest pooled incidence of dehiscence was reported for laser-assisted labiaplasty (5%, 95%CI: 2%-8%) and wedge resection (3%, 95%CI: 1%-5%). The highest pooled incidence of hematoma formation (8%, 95%CI: <1%-23%) and postoperative bleeding (2%, 95%CI: <1%-15%) was reported for W-shape resection. The highest pooled incidence of transient pain or discomfort was reported for deepithelialization (2%, 95%CI: <1%-23%) and W-shape resection (2%, 95%CI: <1%-15%). Three flap necrosis were reported, two occurred using wedge resection labia minoraplasty and one was not specified. The most common causes for revision surgery (n=169) were dehiscence and aesthetic concerns.

Conclusion: Overall, labia minoraplasty is a very safe procedure. However, serious complications requiring surgical management have been reported. In this sense, an experienced surgeon, proper knowledge of female genital anatomy, and a thorough technique selection in accordance with the patient characteristics is mandatory.
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http://dx.doi.org/10.1097/PRS.0000000000009552DOI Listing
July 2022

"Breast Resection Weight Prediction and Insurance Reimbursement in Reduction Mammoplasty: Which Scale is Reliable?"

Plast Reconstr Surg 2022 Jul 22. Epub 2022 Jul 22.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.

Background: Many insurance companies in the United States rely on the Schnur Sliding Scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. Our aim is to compare the accuracy of formulas such as Schnur, Appel, Descamps and Galveston in predicting resection weights, and to assess if it influences insurance coverage decision.

Methods: A retrospective review of bilateral reduction mammoplasty procedures from June 2017-June 2019 was performed at Mayo Clinic, Rochester. Oncoplastic reduction surgeries were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis.

Results: 154 patients (308 breasts) were reviewed. The Schnur had low correlation with actual resection weight (r2=0.381, b1=1.153, p<0.001). Appel was the most accurate (r2=0.642, b1=1.01, p<0.001), followed by Descamps (r2=0.572, b1=0.934, p<0.001) and Galveston (r2=0.672, b1=0.654, p<0.001) scales. Appel, Descamps and Galveston were more accurate for resection weights≥500g, BMI>30kg/m² and patients<50 years of age. For resection weights ≥500g, the median difference between the estimated and actual resection weight for Schnur, Appel, Descamps and Galveston were -211.4g ±272.3, -17.5g ±272.3, -9.6g ±229.5 and -99.2g ±238.5, respectively. None of the scales were accurate for resection weights <500g. Insurance reimbursement was denied in 15.56% patients, of these, 23% had resection weights<500g. The Schnur overestimated the resection weights in 28.9% of patients.

Conclusion: The Schnur scale is a poor predictor of breast resection weight. Appel is the most accurate estimator, especially in the young and obese population with larger resections.
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http://dx.doi.org/10.1097/PRS.0000000000009536DOI Listing
July 2022

Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity.

Arch Plast Surg 2022 Mar 6;49(2):227-239. Epub 2022 Apr 6.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical University, Boston, Massachusetts.

Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.
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http://dx.doi.org/10.1055/s-0042-1744412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9045509PMC
March 2022

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes.

Arch Plast Surg 2022 May 27;49(3):378-396. Epub 2022 May 27.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York.

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.
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http://dx.doi.org/10.1055/s-0042-1748652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142245PMC
May 2022

Postmastectomy Breast Reconstruction is Safe in Patients on Chronic Anticoagulation.

Arch Plast Surg 2022 May 27;49(3):346-351. Epub 2022 May 27.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota.

 Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients.  A retrospective case-control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality.  From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m (SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%,  = 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%,  = 0.63), thromboembolism (5% vs. 0%,  = 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2],  = 0.85).  Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.
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http://dx.doi.org/10.1055/s-0042-1744405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9142228PMC
May 2022

Lymphedema prevention and immediate breast reconstruction with simultaneous gastroepiploic vascularized lymph node transfer and deep inferior epigastric perforator flap: A case report.

Microsurgery 2022 Jul 12. Epub 2022 Jul 12.

Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina.

Breast cancer-related lymphedema following axillary lymph node dissection (ALND) has been documented in 6%-55% of patients, mostly occurring within the next 3 years after radiation or surgery. We present a case of a 53-year-old patient with hormone positive, stage IB, left breast invasive ductal carcinoma treated with immediate lymphatic and microvascular breast reconstruction (MBR) using vascularized lymph node transfer (VLNT) for lymphedema prevention. A deep inferior epigastric perforator (DIEP) flap (18.3 × 11.2-cm) and simultaneous prophylactic gastroepiploic-VLNT (7 × 3-cm), orthotopically inset in the axilla, were used for reconstruction following mastectomy and radical ALND. The procedure was uneventful. The patient did not display increased postoperative arm circumferences. ICG lymphography did not show any changes at 2- and 3-years after surgery. Preventive lymphatic reconstruction with GE-VLNT and immediate MBR using the DIEP flap offers a new possibility for the primary prevention of lymphedema and simultaneous immediate autologous breast reconstruction without the risk of iatrogenic lymphedema. Further studies will be directed to unveil the external validity of these findings and the risk reduction rate of this approach.
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http://dx.doi.org/10.1002/micr.30939DOI Listing
July 2022

Preventive strategies for breast cancer-related lymphedema: Working toward optimal patient selection.

Cancer 2022 Jul 7. Epub 2022 Jul 7.

Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1002/cncr.34374DOI Listing
July 2022

Does Higher Intraoperative Fraction of Inspired Oxygen Improve Complication Rates Following Implant-Based Breast Reconstruction?

Aesthet Surg J Open Forum 2022 7;4:ojac039. Epub 2022 May 7.

Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA, USA.

Background: The surgical literature debates about whether an average intraoperative fractional inspired level of oxygen (FiO) greater than 80% confers lower postsurgical complication rates. Although some evidence demonstrates minimal or no difference in short-term mortality or surgical site infections, few studies suggest negative long-term outcomes.

Objectives: To the best of our knowledge, this is the first study examining the relationship between intraoperative FiO levels and postoperative outcomes in the setting of immediate prepectoral implant-based breast reconstruction.

Methods: The authors retrospectively reviewed the complication profiles of 309 patients who underwent prepectoral 2-stage breast reconstruction following mastectomy between 2018 and 2021 at a single institution. Two cohorts were created based on whether intraoperative FiO was greater than 80% or less than or equal to 80%. Complication rates between the cohorts were analyzed using Chi-squared test, Fisher's exact test, and multivariable logistic regressions. Variables examined included demographic information; smoking history; preexisting comorbidities; history of chemotherapy, radiation, or axillary lymph node dissection; and perioperative information.

Results: Chi-squared and multivariable regression analysis demonstrated no significant difference between cohorts in complication rates other than reoperation. Reoperation rates were significantly increased in the FiO greater than 80% cohort ( = 0.018). Multivariable logistic regression also demonstrated that the use of acellular dermal matrix was significantly associated with increased postoperative complications (odds ratio 11.985; = 0.034).

Conclusions: Complication rates did not statistically differ in patients with varying intraoperative FiO levels outside of reoperation rates. In the setting of implant-based prepectoral breast reconstruction, hyperoxygenation likely does not lead to improved postsurgical outcomes.

Level Of Evidence 3:
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http://dx.doi.org/10.1093/asjof/ojac039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9155143PMC
May 2022

Management of Facial Second-Degree Burns with Nanocellulose-Based Dressing: A Case Series and Systematic Review.

Facial Plast Surg 2022 May 24. Epub 2022 May 24.

Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, United States.

Background: Previous studies have evaluated the effectiveness of bacterial nanocellulose (BNC) for the treatment of thermal injuries, but the synergic effect of platelet-rich plasma (PRP) with BNC-based dressing for burns still requires further investigation. Herein, we evaluated the effectiveness of BNC dressings in the management of facial burns using PRP.

Methods: Patients with second-degree facial burns were treated with BNC-based wound dressings after debridement. The burn's depth and epithelialization were evaluated by clinical assessment. Besides using the dressings, we injected PRP subcutaneously into the left hemifacial burns. The right hemiface was only treated with the dressings. Scar quality was assessed using the Patient and Observer Scar Assessment Scale (POSAS).

Results: Eight patients were included with superficial second-degree burns in 75% of the cases and deep second-degree burns in 25%. Overall, dressings were placed 3.25 days after the initial insult. None of the patients presented with complications after dressing placement. Dressing changes were not required, and no further surgical management was necessary. The mean time for epithelialization was 11.4 days. During subgroup analysis, we did not find a significant difference in the epithelialization time when comparing BNC-based dressings (11.8-days) to BNC-based dressings +PRP (11-days, p = 0.429). The mean POSAS score from a patient (17 versus 12.3, p=0.242) and surgeon (13.5 versus 11.3, p=0.26) standpoint were not significantly different using BNC-based dressings versus BNC-based dressings +PRP.

Conclusion: Nanocellulose-based dressings are effective to treat second-degree facial burns. It enhances re-epithelialization with optimal aesthetic outcomes with or without platelet-rich plasma.
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http://dx.doi.org/10.1055/a-1860-8504DOI Listing
May 2022

Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis.

Microsurgery 2022 May 12. Epub 2022 May 12.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA.

Background: Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate.

Methods: We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model.

Results: Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%).

Conclusions: Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.
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http://dx.doi.org/10.1002/micr.30894DOI Listing
May 2022

Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis.

Indian J Plast Surg 2022 Feb 25;55(1):18-25. Epub 2022 Feb 25.

Department of Surgery "P.Valdoni," Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.

 Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS).  A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished.  Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema. The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%-7.5%;  < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1-13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] - 18.7%, 95% CI - 29.5% to - 7.9%;  < 0.001) and by 30.3 per 100 patients treated (RD - 30.3%, 95% CI - 46.5% to - 14%;  < 0.001), respectively, versus no prophylactic lymphatic reconstruction.  Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.
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http://dx.doi.org/10.1055/s-0041-1740085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9015841PMC
February 2022

Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report.

Indian J Plast Surg 2022 Feb 28;55(1):97-101. Epub 2022 Feb 28.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.

 Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs).  Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (  = 1), supraclavicular-VLNT (  = 2), and gastroepiploic-VLNT (  = 2) were implemented. The average flap area was 69.8 cm . Patients underwent postoperative complex decompressive therapy for an average of 10.0 months.  The average mean circumference reduction rate was 24.4% (range, 10.2-37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months.  VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.
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http://dx.doi.org/10.1055/s-0041-1740520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9015821PMC
February 2022

Applications of three-dimensional surgical planning in facial feminization surgery: A systematic review.

J Plast Reconstr Aesthet Surg 2022 07 7;75(7):e1-e14. Epub 2022 Mar 7.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, NY, USA. Electronic address:

Background: Despite some reports that have shown an increase in safety, efficiency, and accuracy during feminizing craniofacial procedures utilizing three-dimensional (3D) technology, there are no reports summarizing the available evidence on this matter for facial feminization surgery (FFS). Here, we aimed to systematically review the application of 3D technology on FFS.

Methods: We conducted a comprehensive search across PubMed, SCOPUS, Ovid MEDLINE®, Web of Science, and ScienceDirect looking for studies reporting the use of 3D surgical planning in the setting of FFS following the PRISMA guidelines. We extracted data on photographic assessment, imaging, surgical application, and surgical technique and outcomes.

Results: This review included 10 studies comprising 1473 transgender female patients and 50 cadaveric cranial specimens. Four studies employed virtual surgical planning (VSP) and the concomitant use of prefabricated cutting guides. One study reported the implementation of 3D VSP using a female skull as a reference. One study used computer-aided design cutting guides and custom plates for FFS. Standardized incorporation of 3D printed models allowed for preoperative planning in three studies. Three studies reported VSP using 3D reconstruction of CT images, but without the use of 3D printing. Three studies used 3D photography with specialized camera technology to enrich clinical documentation and provide a comprehensive facial analysis of soft tissue. Accuracy ranged from 85.7% to 97%. Morbidity ranged from 0% to 12.5%.

Conclusion: Based on this data, we believe 3D VSP has promising outcomes in terms of accuracy and low morbidity, encouraging its implementation in FFS. However, further prospective double-arm cohort studies are required.
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http://dx.doi.org/10.1016/j.bjps.2022.02.073DOI Listing
July 2022

Imaging biomarkers for diagnosis and treatment response in patients with lymphedema.

Biomark Med 2022 03 18;16(4):303-316. Epub 2022 Feb 18.

Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA.

Lymphedema is defined as a dysfunction of the lymphatic system producing an accumulation of lymphatic fluid in the surrounding tissue, as well as edema and fibrosis. A total of 250 million people worldwide are affected by this condition. Greater than 99% of these cases are related to a secondary cause. As there is a lack of curative therapy, the goal involves early diagnosis, in order to prevent the progression of the disease. Additionally, early diagnosis can aid in decreasing the demand for more complex surgical procedures. Currently, there is an impressive breadth of diagnostic tests available for these patients. We aimed to review the available literature in relation to the utilization of imaging biomarkers for the early diagnosis and treatment response in lymphedema.
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http://dx.doi.org/10.2217/bmm-2021-0487DOI Listing
March 2022

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction.

Plast Reconstr Surg 2022 Apr;149(4):801-809

From the Divisions of Plastic and Reconstructive Surgery and Department of Surgery, Mayo Clinic.

Background: Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction.

Methods: A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors.

Results: Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not.

Conclusions: Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000008895DOI Listing
April 2022

Reply: Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence.

Plast Reconstr Surg Glob Open 2021 Nov 11;9(11):e3954. Epub 2021 Nov 11.

Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

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http://dx.doi.org/10.1097/GOX.0000000000003954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8751773PMC
November 2021

The use of free colon flap transfer for management of xerostomia in a patient.

Microsurgery 2022 Feb 23;42(2):199-200. Epub 2021 Dec 23.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1002/micr.30852DOI Listing
February 2022

Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review.

J Reconstr Microsurg 2022 Jul 14;38(6):481-490. Epub 2021 Dec 14.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York.

Background:  Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes.

Methods:  This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted.

Results:  A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy.

Conclusion:  AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.
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http://dx.doi.org/10.1055/s-0041-1740121DOI Listing
July 2022

The keystone flap: A multi-centric experience in elderly patients treatment.

J Plast Reconstr Aesthet Surg 2022 Jan 20;75(1):226-239. Epub 2021 Sep 20.

Sapienza University of Rome, Policlinico Umberto I, Department of Surgery "P. Valdoni", Unit of Plastic and Reconstructive Surgery, Roma, Italy.

Soft tissue reconstruction in elderly patients must be rapid and reliable. The keystone island flap (KF) offers an effective solution, with low complication rates and quick recovery. This multi-centric study aims to show authors' experience with KFs in treating soft tissue defects of trunk and limbs. Patients with soft tissue defects suitable for KF reconstruction were recruited from March 2019 to December 2019. Active inflammation and previous surgeries in the same region were considered exclusion criteria. Complications that occurred during follow-up were recorded, and their incidence pattern was assessed with the Fisher test. Seventy-two patients with mean age of 76.2 years old were selected. They presented lesions in torso (46; 63.9%) or in upper (4; 5.6%) or lower (22; 30.6%) limb regions. Fifteen (20.8%) wounds were non-oncologic lesions, and the others were oncologic lesions, mostly non-melanoma skin cancers. KF type I was carried out in 42 (58.3%) cases, KF type II-A in 13 (18%) cases, double opposed type III KF in 16 (22.2%) patients, and 1 (1.4%) case required partial flap's undermining (IV KF). Mean post-operative recovery period was 4.3 days (range, 1-9 days). Post-surgical complications occurred in 15 (20.8%) cases, 7 (9.7%) of them were considered major complications. No statistically significant difference in complications' incidence, nor among different surgical sites nor among KF types, was registered. Reconstructive surgeons have to adapt their work to elderly patients. The KF allows rapid operative times, low morbidity rates, and short post-operative recovery time, thus appearing as a feasible solution.
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http://dx.doi.org/10.1016/j.bjps.2021.08.043DOI Listing
January 2022

Building a gender-affirming surgery service: The fundamentals.

Surgery 2022 02 28;171(2):498-503. Epub 2021 Sep 28.

Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC. Electronic address:

Background: As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success.

Methods: In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service.

Results: A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services.

Conclusion: Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.
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http://dx.doi.org/10.1016/j.surg.2021.08.043DOI Listing
February 2022

The Goldilocks Procedure with and without Implant-Based Immediate Breast Reconstruction in Obese Patients: The Mayo Clinic Experience.

Plast Reconstr Surg 2021 10;148(4):703-716

From the Divisions of Plastic and Reconstructive Surgery and Departments of Surgery, Mayo Clinic Rochester, Jacksonville, and Scottsdale; and Mayo Clinic Alix School of Medicine.

Background: Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only.

Methods: A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed.

Results: One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups.

Conclusions: The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000008362DOI Listing
October 2021

Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes.

J Reconstr Microsurg 2022 Jul 17;38(6):429-440. Epub 2021 Sep 17.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York.

Background:  Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival.

Methods:  A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020.

Results:  Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections ( = 8) and injury to the urinary system ( = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively.

Conclusion:  UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.
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http://dx.doi.org/10.1055/s-0041-1735261DOI Listing
July 2022

The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis.

J Reconstr Microsurg 2022 Jun 28;38(5):378-389. Epub 2021 Aug 28.

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York.

Background:  Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction.

Methods:  A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap.

Results:  A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1-8%). No significant heterogeneity was present across studies (Q statistic 22.12,  = 0.14;  = 27.68%,  = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm, respectively. The area of the skin paddles was 117 cm.

Conclusion:  The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.
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http://dx.doi.org/10.1055/s-0041-1733978DOI Listing
June 2022

High-Definition Lipoplasty in Male Patients: A Systematic Review of Surgical Techniques and Outcomes.

Aesthet Surg J 2022 01;42(1):68-85

Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA.

Background: Lipoplasty has undergone a series of refinements since its inception. It is now possible to apply superficial suction to enhance the outline of a muscle in order to improve the results of aesthetic lipoplasty.

Objectives: The aim of this study was to summarize the available evidence on the techniques and surgical outcomes of high-definition lipoplasty (HDL) in male patients.

Methods: A systematic search across PubMed MEDLINE, Web of Science, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and SCOPUS was performed in accordance with the PRISMA guidelines. Data regarding the surgical techniques, outcomes, and complications were extracted.

Results: Thirteen studies comprising 1280 patients fulfilled the inclusion criteria. The age of patients ranged from 18 to 71 years. The average BMI was 26.5 kg/m2. The follow-up ranged from 2 weeks to 10 years. The liposculpting concepts reported were abdominal etching, high-definition, muscular sculpture, and dynamic definition. Four studies used conventional liposuction, 3 used VASER-assisted HDL, and 6 studies used power-assisted liposculpting. Eight studies reported the use of fat grafting. All studies reported the use of postoperative garments and a well-established wound treatment protocol. Overall satisfaction ranged from 84% to 100%. The most common complications reported were fluid collection, hyperpigmentation, contour irregularities, anemia, and port dehiscence.

Conclusions: A wide variety of techniques are available to perform HDL with a variable degree of definition. Careful patient selection is critical for successful results because HDL is not suitable for every patient. Finally, proper training and adequate knowledge of abdominal anatomy is necessary to avoid complications.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjab300DOI Listing
January 2022

A4 Pulley Reconstruction Using the Superficialis Oblique Flap and the Transverse Double Loop Techniques: A Biomechanical Evaluation Using a Chicken Model.

Ann Plast Surg 2021 12;87(6):650-656

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.

Background: The pulley system plays an important role in flexion mechanism. Reconstruction after trauma can be challenging. Numerous techniques have been described with several drawbacks. Herein, we describe the superficialis flap oblique technique for A4 pulley reconstruction using an animal model.

Methods: Forty-two fresh legs of 21 eight-week-old chickens were used to evaluate the maximum flexion angle (MFA) and force at maximum flexion (FMF) in intact and sectioned A4 pulley equivalents of the third digit after reconstruction with the transverse double loop (TDL) technique and the superficialis oblique flap (SOF) technique. Biomechanical measurements were obtained in an exclusively designed instrument. Descriptive statistics were reported, and mean differences between the reconstructive techniques were analyzed.

Results: Intact and severed A4 pulley equivalent average MFA were 96.50° ± 1.70° and 115.60° ± 1.50°, respectively. Average FMF were 8.16 ± 0.23 psi with the intact pulley and 6.92 ± 0.20 psi with the sectioned pulley (P < 0.001). After reconstruction with TDL and SOF techniques, the legs reached an average MFA at the distal interphalangeal joint of 98.13° ± 1.20° and 96.90° ± 1.30°, respectively. Mean MFA difference was 1.23° (P = 0.03). Force at maximum flexion was 8.12 psi and 8.10 psi for the TDL and SOF techniques (P = 0.6), respectively.

Conclusions: The authors believe that SOF technique for A4 pulley reconstruction can be used as first option when available, taking into account its theoretical advantages and its proven biomechanical characteristics. Long-term functional results should be assessed to translate these results into the clinical setting.
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http://dx.doi.org/10.1097/SAP.0000000000002796DOI Listing
December 2021

Systematic review of fertility preservation options in transgender patients: a guide for plastic surgeons.

Ann Transl Med 2021 Apr;9(7):613

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Transgender patients often desire to have biological children. However, their reproductive potential is often negatively impacted by gender affirming surgery (GAS) such as gender confirmation surgery (bottom surgery) and medical hormone therapy. Therefore, counselling patients on fertility preservation options before initiating gender-affirming treatments is prudent to avoid reducing their reproductive potential. A systematic review of English, Spanish, Chinese, French and Turkish languages from 2000 to December 23rd, 2019, using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Fifteen articles that report outcomes of fertility preservation options in transgenders were included. Eight articles described options for transgender women, six reported options for transgender men and one included both transgender women and transgender men. Semen cryopreservation and oocyte cryopreservation are the most common and available methods for fertility preservation in transgenders. Physician awareness of fertility preservation options in transgender patients is crucial to ensure informed discussions regarding reproductive options in the early phase of transition.
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http://dx.doi.org/10.21037/atm-20-4523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105795PMC
April 2021

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes.

Ann Transl Med 2021 Apr;9(7):612

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.
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http://dx.doi.org/10.21037/atm-20-4522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105810PMC
April 2021

Breast augmentation in the transgender patient: narrative review of current techniques and complications.

Ann Transl Med 2021 Apr;9(7):611

Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.

Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.
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http://dx.doi.org/10.21037/atm-20-5087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105870PMC
April 2021

Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature.

Ann Transl Med 2021 Apr;9(7):608

Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Phalloplasty is the main treatment for gender dysphoria disorder. It is difficult to ascertain if staging of phalloplasty influences the rate of complications. We aim to describe and compare the rates of complication between single versus two-stage phalloplasty for transgender female-to-male patients. PubMed, Ovid Medline, EMBASE and SCOPUS databases were queried for studies reporting complications of female-to-male transgender patients who underwent phalloplasty. The keywords "phalloplasty", "female to male", "outcome", "complication" and synonyms in different combinations were used for the search. Only studies that could identify whether phallic shaft creation was performed in a single or two-stage procedure were included. From a total of 336 articles, 20 met the inclusion criteria. Sixteen studies reported complications associated with a single-stage phalloplasty and seven studies identified complications after a two-stage procedure. The most common complications found for both groups of staging were fistula, stricture and total/partial flap necrosis. Patients who underwent two-stage phalloplasty had higher complication rates (partial or total flap necrosis and fistulas), compared with the single-stage procedure (P<0.05). In conclusion, this systematic review identified the impact of staging in the rate of complications related to phalloplasty for transgender female-to-male patients; a two-stage phalloplasty has a higher rate of complications.
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http://dx.doi.org/10.21037/atm-20-3514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105811PMC
April 2021

Editorial on gender affirming surgery.

Ann Transl Med 2021 Apr;9(7):599

Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.21037/atm-21-905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8105843PMC
April 2021
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