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Background At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. Aim To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. Methods We use expert opinion to provide a “first of its kind” framework for training surgeons to care for transgender and gender nonconforming individuals. Outcomes We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. Results This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. Clinical Implications The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. Strengths and Limitations This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. Conclusion We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures.

In 2010, the World Professional Association for Transgender Health (WPATH) released a statement declaring the Association's opposition to surgery or sterilization as requirements to change legal ge...

Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal.

With advances in psychological, medical, and surgical treatment of transgendered individuals, a multidisciplinary approach has been postulated to improve overall patient care. Because no single discipline can meet all the needs of this patient population, a close working relationship between the surgeon, behavioral scientist, and medical physician responsible for hormonal therapy is important in providing the highest level of patient care. Moreover, the surgeon must assume an active role in understanding the patient's diagnosis and medical and hormonal therapies.

Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Hereditary gingival fibromatosis (HGF) is a rare condition characterized by progressive enlargement of the gingiva. Most cases follow autosomal dominant genetics, with a reported incidence of 1 in 750,000. In addition to cosmetic concerns, the compromised oral cavity may cause difficulty with eating, speech, hygiene, and oral competence. In addition, social consequences can be dramatic, forcing patients to lead isolated, reclusive lives. Traditional therapy uses serial gingival resections ("quadrantectomies") with primary closure. However, this method is associated with frequent recurrence and additional resections. We report on a family of 12 siblings, 8 of whom, including monozygotic twins, are affected with HGF. We describe corrective surgery for 3 siblings, as well as their long-term follow-up.Three sisters suffered from severe maxillary and mandibular gingival hyperplasia. All complained similarly of weight loss, difficulty with articulation, and social isolation. Physical examination revealed massive overgrowth of both maxillary and mandibular gingiva, as well as multiple ectopic teeth. Following diagnostic biopsy, all 3 patients underwent staged resections. The first stage involved resection of the maxillary component, followed by a planned second-stage resection of the mandibular component. All resections included gingivectomies, odontectomies, and alveolar ridge ostectomies. The oral cavity was allowed to heal by secondary intention.All 3 patients were female, and ages ranged from 34-48 years (mean: 43). Follow-up on the 3 patients ranged from 3-18 months (mean: 11 months). There has been no evidence of recurrence to date. The gingiva remucosalized uneventfully within several weeks, and all patients are tolerating solid food. All patients report dramatically improved speech, oral hygiene, and self-confidence.In an effort to address the high recurrence rate, we describe our aggressive surgical approach, including resection of the hypertrophied gingiva and alveolar processes. Two-staged gingival resection, as opposed to the more traditional 4-stage quadrantectomy approach, has resulted in no recurrence to date, suggesting an improved outcome over the traditional techniques.

Background. Acute vascular thrombosis is a dreaded complication in solid organ transplantation. Pediatric liver transplantation is associated with a high incidence of hepatic artery thrombosis. Graft salvage is dependent upon early recognition and correction of the thrombosis. Current methods of surveillance for vascular thrombosis lack early detection. Methods. Four consecutive pediatric liver transplantations were performed using the implantable Doppler probe to monitor the patency of the hepatic artery and the portal vein during the early postoperative period. Results. The implantable Doppler probes provided reliable monitoring of vascular patency. Early detection of hepatic artery thrombosis, with subsequent correction and graft salvage, was achieved with the use of the implantable Doppler probe. Conclusions. The implantable Doppler probe provides real-time surveillance of vascular patency for up to 7 days in the postoperative period. Signal quality and character was easily assessed by physician and nursing staff and reliably reflected intravascular flow.

Importance In 2014, the US Department of Health and Human Services decided that its 1981 exclusion of transsexual surgical treatments from Medicare coverage was based on outdated, incomplete, and biased science and did not reflect current evidence or standards of care, and the exclusion was therefore lifted. As a direct result of this decision, surgeons nationwide are seeing an increase in consultations for surgical therapy to help transgender and gender-nonconforming individuals. Although some clinicians may have the technical training for such surgical procedures, in many cases, they may not have a full understanding of the complex and comprehensive care required to provide optimal health care for transgender individuals. Observations Gender confirmation surgery is a developing field in the United States and other areas of the world. The World Professional Association for Transgender Health started a global education initiative intended to provide surgeons and other health care professionals with the necessary background knowledge to understand and treat this patient population. This article provides an overview of best practices as set forth in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health, including mental health, endocrinology, and surgery for trans women and trans men. Conclusions and Relevance Experts in each aspect of transgender health have summarized the content of the global education initiative in this article. It provides valuable information to surgeons of all disciplines and other health care professionals to help guide the treatment and management of transgender individuals.

Summary Background Breast MRIs have become increasingly common in breast cancer work-up. Previously obtained breast MRIs may facilitate oncoplastic surgery by delineating the blood supply to the nipple-areola complex (NAC). The aim of this study was to identify and classify the in vivo blood supply to the NAC using breast MRI exams. Methods Breast MRIs obtained over a one-year period were retrospectively reviewed. Patients with negative MRI findings (BI-RADS category 1) were included; patients with diagnoses of breast cancer or previous breast surgery were excluded. Twenty-six patients were evaluated. Dominant blood supply was determined by maximum filling at 70 s post-contrast. Blood supply to the NAC was classified into five anatomic zones: medial (type I), lateral (type II), central (type III), inferior (type IV) and superior (type V). Results Patient age ranged from 33 to 70 years. Fifty-two breasts were evaluated and 80 source vessels were identified (37 right, 43 left). Twenty-eight breasts had type I only blood supply, 22 breasts had multi-zone blood supply (type I + II, n = 20; type I + III n = 2), one breast had type II only blood supply, and a single breast had type III only blood supply. Anatomic symmetry was observed in 96% of patients. Conclusion This study utilized MRI to evaluate in vivo vascular anatomy of the NAC, classify NAC perfusion ("NACsomes"), and assess vascular symmetry between breasts. Superomedial source vessels supplying the NAC were predominant. Preoperatively defining NAC blood supply may aid planning for oncoplastic procedures.

In July of 2011, the American Society of Plastic Surgeons Executive Committee approved the Venous Thromboembolism Task Force Report. The report includes a summary of the scientific literature relevant to venous thromboembolism and plastic surgery along with five evidence-based recommendations. The recommendations are divided into two sections: risk stratification and prevention. The risk stratification recommendations are based on the 2005 Caprini Risk Assessment Module, which has been validated in the scientific literature as an effective tool for risk-stratifying plastic and reconstructive surgery patients based on individual risk factors for 60-day venous thromboembolism. The three prophylaxis recommendations are dependent on an individual patient's 2005 Caprini Risk Assessment Module score.

Rarely, patients with blood disorders may seek to undergo plastic surgery. Although plastic surgeons are not expected to diagnose or manage blood disorders, they should be able to recognize which patients are suitable for surgery and which should be referred to a hematologist before a procedure. This practice advisory provides an overview of the perioperative steps that should be completed to ensure appropriate care for patients with blood disorders.

Objective: We present a case of femoral artery thrombosis and acute limb ischemia in an infant following attempted femoral venipuncture. Microsurgical reconstruction of the lesion and a review of the literature are described. Methods: Insertion of intravascular catheters is a commonly performed procedure in neonatal and pediatric intensive care units. However, significant iatrogenic injuries to the peripheral vascular system can occur. Management ranges from anticoagulation and thrombolytics to surgical intervention. In this case, surgical therapy involved thrombectomy and microsurgical reconstruction of the femoral artery. Results: Vascular inflow was reestablished and the limb was salvaged. Conclusions: We believe that microsurgical techniques are an important component for successful vascular reconstruction after iatrogenic artery thrombosis in an infant. Microvascular techniques allow for a controlled operating field with magnification, thereby assisting in the accuracy of vessel repair.

Free omental tissue transfer is a versatile reconstructive option for trunk, head and neck, and extremity reconstruction. Its utility is due to the length and caliber of the vascular pedicle and the malleability and surface area of the flap. We report our experience with omental free flap coverage of complex upper-extremity defects. A retrospective analysis of eight omental free-tissue transfers in seven patients with complex upper-extremity defects between 1999 and 2008 was performed. Indications, operative technique, and outcome were evaluated. Patient age ranged from 12 to 59 years with five male and two female patients. Indications included tissue defects due to crush-degloving injuries, pitbull mauling, or necrotizing soft tissue infection. All patients had prior operations including: revascularization, debridement, tendon repair, skin grafts, and/or fixation of associated fractures. One patient sustained severe bilateral crush-degloving injuries requiring free omental hemiflap coverage of both hands. The mean defect size was 291 cm2 with all patients achieving complete wound coverage. No flap loss or major complications were noted. Laparoscopic-assisted omental free flap harvest was performed in conjunction with the general surgery team in three cases. Mean follow-up was 2 years. The omental free flap is a valuable, often overlooked reconstructive option. The long vascular pedicle and large amount of pliable, well-vascularized tissue allow the flap to be aggressively contoured to meet the needs of complex three-dimensional defects. In addition, laparoscopic-assisted harvest may aid with flap dissection and may result in reduced donor-site morbidity.

Mucormycosis (zygomycosis) is a rare, aggressive, invasive fungal infection that usually afflicts immunosuppressed patients. Indolent presentations are rare, especially in the setting of immune suppression.Case report and review of the pertinent English-language literature.A 64-year-old male patient with diabetes mellitus and rheumatoid arthritis, treated chronically with infliximab, presented with toothache, headache, and right facial numbness. Therapy with intravenous glucocorticoids and antibiotics resulted in transitory improvement before his referral to a tertiary-care center, where imaging studies and biopsy revealed rhinocerebral mucormycosis. Four weeks after initial presentation, a radical right maxillectomy, followed by long-term therapy with amphotericin B lipid complex, resulted in clinical improvement. Five reconstructive procedures were required to obliterate the facial defect and restore contour. Although biopsies during the reconstructive procedures revealed persistent fungal colonization, there was no clinical recurrence during nearly five years of followup.Indolent rhinocerebral mucormycosis is rare and is seldom survived by immunosuppressed patients. Multimodal therapy with surgical debridement and antifungal chemotherapy is required for an optimal outcome. Discontinuance of immunosuppressive therapy, if possible, is a cornerstone of management.