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Anatomical characteristics that are incongruent with an individual’s gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care. The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population. From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation. There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. .

The Technology Combination Analysis Tool (TCAT) is a Python-based space transportation modelling package with feasibility assessment applications in active debris removal (ADR), on-orbit servicing (OOS), and constellation deployment. Developed by the EPFL Space Center (eSpace), the TCAT was first used to evaluate the system architecture of multiple ADR satellites. Now that satellite constellations for Earth observation and telecommunications, including space internets, are being deployed at an unprecedented rate, decision-makers could benefit from the rapid-prototyping capability of TCAT in spacecraft sizing and constellation design with potential applications in space traffic management where strategic options for constellation-level OOS could be explored and evaluated promptly in support of future technology planning. Another use of the TCAT is architecting logistics scenarios in the Earth-Moon system, which is the topic of this paper. The problem size is then increased drastically in terms of both spatial and temporal scales relative to the aforementioned ADR and OOS examples near Earth, which would necessitate and testify the power of prototyping even further. This paper reports the recent progress at the EPFL Space Center (eSpace) in extending the capabilities of the TCAT towards Earth-Moon scenario modelling. Its main capabilities are currently the rapid sizing of spacecraft using high-thrust propulsion for active debris removal and lunar cargo delivery missions. To implement the desired capabilities into the TCAT, a modelling approach for low-thrust Earth-Moon trajectories was adopted from the literature. Also, a third-party astrodynamics software, called FreeFlyer, was used to simulate these trajectories and integrated into the framework. Several challenges had to be overcome during the implementation, most notably the suitable adaptation of the convergence algorithm used in TCAT. Finally, to test the implementation, two example missions were modeled, namely the European Space Agencys European Student Moon Orbiter (ESMO) mission and its Small Missions for Advanced Research in Technology-1 (SMART-1) mission. Physically relevant output values, such as the required propellant mass, have been compared to the test missions and deviations between 73% and 123% have been found. Several reasons for these large deviations have been investigated, of which issues with the force model are likely among the most impactful ones. Notwithstanding these deviations, the integration of TCAT and FreeFlyer should be regarded successful given the technical challenges of suitably adapting the convergence algorithm, whose procedures and results are detailed. The limitation of the TCAT tool is currently addressed in multiple ways, such as using it for ADR/OOS scenarios where the two-body approximation is sufficient, incorporating high-fidelity force models, etc. Another feature that can be integrated into the extended TCAT is a database containing specifications of ion thrusters and other electric propulsion systems. The modelling of electric propulsion systems (EPS) is much newer and harder compared to chemical propulsion and the need of an up-to-date and scalable system is of high importance. In addition to archiving the database of ion engines, their design parametrization has been carried out. The database system, in its standalone mode, is able to perform basic CRUD (Create, Read, Update and Delete) operations on a database as well as plot the measurable quantities on a graph. Integrating this electric propulsion database into the TCAT or other platforms is being envisioned where applicable.

Background Reconstruction of the plantar surface of the foot is challenging because of its distinctive anatomy and microarchitecture. Unfortunately, no single coverage option meets the needs of all patients and defects. A comprehensive literature review is presented to better define available reconstructive options for resurfacing the plantar foot. Methods A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. The PubMed, Embase, and Scopus databases were queried for published articles. After the exclusion of duplicate records, 1624 articles were available for review. A total of 280 unique articles were included for analysis, with a total of 2684 individual reconstructions. Results Of the articles reviewed, 10 percent described a skin grafting technique, 53 percent described a locoregional flap, 32 percent described free tissue transfer, and 5 percent described multiple reconstructive methods. Isolated heel defects were the most frequently reconstructed subunit of the plantar foot (73 percent). The latissimus dorsi muscle was the most commonly used free flap, whereas the reverse sural artery flap was the most commonly used locoregional flap. Protective sensation was noted in most locoregional and free flap reconstructions, regardless of primary neurotization; however, improved two-point discrimination was noted when neurofasciocutaneous flaps were used. Complication rates varied widely, although rates of flap loss approached those of flaps performed at other anatomical sites. Conclusions Numerous methods exist for reconstructing the plantar surface. Proper flap selection should be determined by the size of the defect, the availability of donor tissue, and the surgeon's experience and comfort with the reconstructive technique.

Gabapentin has analgesic efficacy for neuropathic pain and is increasingly used in burn care. This study investigated the effect of a neuropathic pain control protocol, as well as early gabapentin initiation (

Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Objective In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. Background The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. Methods Published medical images and graphics depicting human skin were analyzed across four major plastic surgery journals. Up to four years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "white" or "non-white". Data were evaluated with pair-wise and linear regression statistics. Results Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-white skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-white prior to and 7.3%-10.3% after 2010. International and multi-national authors tended to publish more non-white images. Conclusions There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

Residency education has adapted to current social distancing recommendations by relying heavily on videoconferences. There is concern however, that this new paradigm may lead to over-saturation or burnout.A 12-question survey investigating resident experiences with educational videoconferences was distributed to University of Washington plastic surgery residents. A modified Maslach Burnout Inventory was used to assess resident burnout from virtual conferences. Conference attendance and reasons for missing conferences were compared using paired two-tailed t-tests.A total of 24 residents were given the survey with 100% response rate. There was a significant decrease in the total number of weekly attended videoconferences (p0.01) and in the number of attended educational videoconferences (p0.01) over time. Reasons for absences included clinical duties (92% of respondents) followed by symptoms of burnout, including forgetfulness (67%) and feeling fatigued by videoconferencing lectures (54%), and to a lesser extent the belief that the lecture was not educational (25%). 79% of residents reported at least occasionally feeling emotionally drained from videoconferencing and 88% reported at least occasionally feeling burned out due to the number of videoconferencing activities. Despite declining attendance and burnout, 96% believe that videoconferences should continue after the end of quarantine but in a limited quantity.Videoconferences have become a valued means of resident education. The data suggests however that attendance has waned, largely due to what can be perceived as burnout. Residents remain interested in continuing educational videoconferences, although prioritizing quality over quantity will remain essential to prevent emotional fatigue and burnout.

Background There has been a recent focus on the impact of race on health equity, which has revealed unsettling results. Multiple studies have shown that the underrepresentation of minorities in medical education such as course slides, pre-clinical lecture material, case studies, and textbooks impedes racial equity in the practice of medicine. Aim of study In this study, we aimed to survey the landscape of published imaging in modern medicine to understand the degree of racial diversity represented in current biomedical literature. Methods We performed a photogrammetric analysis of medical images from the New England Journal of Medicine representing various medical fields and geographic regions to examine implicit biases with regards to human skin color. Results Overall, 18% of images depicted non-white skin tone but there was considerable heterogeneity in the percentage of non-white medical images published from different geographic regions and specialties (ranging from 0% to 67%). Conclusions Unfortunately, these results suggest that there is an underlying implicit racial bias in published images from medical literature with an underrepresentation of minorities compared to the general population, which could also contribute to inequities in health care. It is critical that health care providers, educators, and trainees promote cultural competency and work to understand the multifaceted influence of race and culture on the daily experience of patients in the modern healthcare system. We hope this study will encourage authors to critically evaluate their medical images for implicit bias so that documented photography in scientific literature may better reflect the populations we serve.

Background:. Over the past decade, there has been a worldwide increase in plastic and reconstructive surgery research as well as increased interest in global collaboration. However, little is known about who is contributing to this global expansion or the trends of individual countries. The aim of our study was to analyze the output of Plastic and Reconstructive Surgery (PRS) over a decade to elucidate trends in the plastic surgery field. Methods:. The country of origin for all first authors of articles published by PRS from 2010 to 2019 were determined and date extracted using PubMed2XL. The change in frequency of publications over the decade by country, continental contributions, as well as state-level analysis within the United States were analyzed. Results:. From 2010 to 2019, there were a total number of 8680 publications with an increase in total articles from 747 to 1049 per year. 54 countries contributed over the decade, with the United States producing the most followed by Italy, China, Canada, and the UK. The top producing states were Texas, New York, California, Massachusetts, and Pennsylvania. Conclusions:. The last decade (2010–2019) saw a large international increase in research, not only with the total number of publications, but also in the diversity of originating country. Our work shows a shift away from a US-focused journal to incorporate more work from our international colleagues, as research is conducted in centers across the globe.

Background: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. Methods: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1–3 versus 4–6). Additionally, the authors’ geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. Results: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). Conclusions: Roughly 60%–70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.