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Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair.A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated.Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p0.001) and time to analgesia failure ( p0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed.The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management.Therapeutic, II.

Background Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. Methods A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. Results Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4–3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p Conclusion A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

Background Achieving an aesthetic phalloplasty result is important for patients with acquired or congenital defects of the penis, or with genital-related dysphoria. However, aside from length and girth, the aesthetic proportions of the male penis have not been defined. Objectives This study aimed to determine proportions of the male penis through photogrammetric analysis of nude male photographs and to verify these proportions with a crowdsourcing-based survey. Methods Nude male photographs (n = 283) were analyzed to define aesthetic proportions of the male penis. Photographs were analyzed for the position of the penis on the torso in relation to the umbilicus and for the ratio of the dorsal and ventral glans of the penis in relation to the entire shaft length. Proportions were then further studied by crowdsourcing 1026 respondents with Amazon mechanical Turk. Results The ideal position of the penis below the umbilicus is about 55% (6/11th) of the distance from the jugular notch to the umbilicus (measured average, 53.6%; survey-weighted average, 58.9%). The dorsal glans of the penis is about 33% (1/3rd) of the length of the entire shaft (measured average, 32.1%; survey-weighted average, 37.5%). The ventral glans of the penis is about 12.5% (1/8th) of the length of the entire shaft (measured average, 12.6%; survey-weighted average, 11.7%). Conclusions Measured proportions of the human penis follow exact fractions. Crowdsourcing data helped support photogrammetric analysis, with survey-preferred ratios within 5% of measured ratios. With further validation, these data can aid surgeons performing phalloplasty.

Background Estrogen therapy and penile inversion vaginoplasty (PIV) are necessary, life-saving interventions for many transfeminine patients. Patients undergoing PIV are generally at low baseline risk for venous thromboembolism (VTE) based on Caprini Score. Estrogen therapy may increase VTE risk in surgical patients, but its cessation may be psychiatrically dysphoric for transfeminine patients. Aim This study examines whether perioperative estrogen cessation impacts VTE risk in patients undergoing PIV. Methods This was a pre-post study of patients undergoing PIV. From 2014 through 2018, all patients stopped estrogen therapy for 2 weeks before surgery and resumed 1 week postoperatively (group 1). Starting in 2019, all patients continued estrogen therapy perioperatively, with dose reductions for those whose dose was >6 mg/day (group 2). Outcomes The primary outcome was 90-day VTE rate. Results 178 patients were included in the study, with 117 in group 1 and 61 in group 2. Median Caprini Score was 4 in group 1 (interquartile range: 3–6) and 3 in group 2 (interquartile range: 3–4) (P = .011). Complications per patient were higher in group 1 (2.2 vs 0.9, P Clinical Implications Patients undergoing PIV are generally at low risk for VTE, based on 2005 Caprini Scores. This study provides preliminary evidence that perioperative estrogen therapy continuation does not appear to substantially increase VTE risk in transfeminine patients undergoing PIV with low Caprini Scores, although more investigation is needed to establish true safety. Strengths & Limitations Strengths include the pre-post design and single-surgeon experience, high proportion of patients with 90-day follow-up, and relatively large series to understand baseline VTE risk by Caprini Score in a PIV population. The main weakness of this study is its limited power to measure true differences in VTE risk based on estrogen continuation. Conclusions This study suggests that perioperative estrogen continuation may be safe for patients undergoing PIV, the overwhelming majority of whom are at low baseline VTE risk. However, clinicians should weigh the magnitude of the risks and benefits of estrogen cessation on a case-by-case basis. Nolan IT, Haley C, Morrison SD, et al. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med 2021;18:193–200.

Background Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. Methods A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. Results The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). Conclusion Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

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. .

No data exist on the prospective outcomes of facial feminization surgery. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes for gender-diverse patients.A prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria was undertaken. Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and6 months). Photogrammetric cephalometries were measured at the same time points. Self-perceived preoperative masculinity and femininity were recorded. Externally rated gender appearance (scale of 1 to 5, with 1 being most feminine) and general aesthetics (scale of 1 to 10, with 10 being very good) for 10 facial feminization surgery patients were compared with those of five cisgender controls. Univariate linear regression analyses were used to predict outcomes from facial feminization surgery.Sixty-six consecutive patients were enrolled. Patients noted that their brows, jaws, and chins were the most masculine aspects of their faces (54.5 percent, 33.3 percent, and 30.3 percent, respectively). Median facial feminization outcome score increased from 47.2 preoperatively to 80.6 at 6 months or more postoperatively (p0.0001). Mean satisfaction was excellent (3.0 at both 1-month and ≥6-month follow-up; p = 0.46). Cephalometric values were significantly more feminine after surgery. Gender appearance was feminine to very feminine (1.83 ± 0.96) and general aesthetics were good (6.09 ± 2.01) but different from those of cisgender women controls (1.25 ± 0.49 and 7.63 ± 1.82, respectively; p0.001 for each).Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months.Therapeutic, IV.

The transgender and nonbinary (TGNB) population is a significant minority, comprising at least 0.6% of the population. Visibility is growing rapidly, especially in younger generations. Gender affirming health care must adapt to this population's needs. Demographic data regarding TGNB health care are limited, but several disparities are clear, stemming from sociopolitical factors, such as external discrimination and insensitive and/or uninformed care. Most self-identifying TGNB patients receive some type of nonsurgical care, including hormonal and/or mental health. Gender-affirming surgery is highly prevalent as well, with at least one-quarter of TGNB people having had some combination of the procedures in this category.

The fibula free flap (FFF) remains the criterion standard for complex mandibular reconstruction. Surgeons have incorporated virtual surgical planning (VSP) into the reconstructive algorithm with the assertion that VSP increases operative efficiency and may improve clinical outcomes. To date, no large-scale studies have analyzed these claims. This study examines the literature and tests the hypothesis that VSP improves operative efficiency, clinical outcomes, and accuracy when compared with traditional techniques.A systematic review was performed to identify articles utilizing VSP and traditional techniques for FFF-based mandibular reconstruction. Two reviewers independently assessed all articles for methodological quality using a validated instrument (weighted Cohen κ for interrater reliability = 0.70). Outcomes included operative time, length of stay, complications, and accuracy. Meta-analytic comparisons were performed using data from comparative studies using a random-effects model and differences of means analysis for outcomes measured on identical scales.One hundred thirty-one articles were identified, and 25 met the inclusion criteria: 12 were VSP only, whereas 13 were comparative. There were 241 VSP patients and 214 traditional patients available for meta-analysis. Patients undergoing reconstruction with VSP had a significant reduction in operative time by 44.64 minutes (95% confidence interval [CI], -74.69 to -14.58 minutes; P0.01) and demonstrated a mean trend toward shorter hospital admission (mean difference, -1.24 days; 95% CI, -4.00 to 1.52 days; P = 0.38). There was no statistical difference between cohorts for major (odds ratio, 1.03; 95% CI, 0.46-2.31; P = 0.95) or minor complications (odds ratio, 0.97; 95% CI, 0.54-1.71; P = 0.90). Insufficient data were available for cost analysis and accuracy.Virtual surgical planning-guided mandibular reconstruction with FFF is associated with significantly decreased operative time and a mean trend toward shorter hospital admission. While multiple studies reported a high degree of accuracy, no standard measurement was available for meta-analysis.

Transgender and gender nonbinary (TGNB) individuals may seek genital gender confirming surgery (GCS) as part of their transition. Outcomes of genital GCS may include gender congruence, sexual functioning and satisfaction, urinary symptoms, aesthetic satisfaction, and overall quality of life, among others. Despite a wide number of studies on results of vaginoplasty, metoidioplasty, phalloplasty, and other genital GCS, data regarding patient reported outcomes are limited. To date, there is no patient reported outcome measure (PROM) validated within the TGNB population to assess subjective outcomes of GCS. In this review, we aim to describe existing tools being utilized to report outcomes following GCS, assessing the merits and limitations of each.

BACKGROUND Functional and aesthetic nasal operations are some of the most common plastic surgery procedures performed in the United States. The purpose of the study was to evaluate the effects of septoplasty, septorhinoplasty, and rhinoplasty procedures on postoperative olfactory function and their relationship to nasal airflow and quality of life. METHODS A systematic review and meta-analysis was performed evaluating olfactory function following nasal surgery. Preoperative and postoperative values for olfaction, nasal airflow, and quality of life/nasal symptoms were analyzed. The effect size was calculated from each study and used for meta-analysis. As studies evaluated patients at different points in the postoperative period, the latest time point reported by each study was used in the meta-analysis. The 95 percent confidence interval of the effect size was calculated for each study. Study quality was assessed using the Jadad and Methodological Index for Nonrandomized Studies instruments. All included studies were Level of Evidence II. RESULTS There were 25 included studies. Following nasal surgery, patients experienced significant improvements in olfaction (p < 0.001), nasal airflow (p < 0.001), and quality of life/nasal symptoms (p < 0.001). Patients often experienced a transient decrease in olfaction immediately after surgery, followed by improvement postoperatively. Preoperative olfactory dysfunction rates were low and postoperative dysfunction was equally low. Olfaction improvement was directly correlated with improvement in nasal airflow and quality of life. CONCLUSIONS Functional and aesthetic nasal operations appear to significantly improve olfaction, which is directly correlated with nasal airflow. Some studies report a transient worsening of these measures in the immediate postoperative period, which subsequently improved at later time points.

Background Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients. Objectives This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients. Methods A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction. Results We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations. Conclusions Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density. Level of Evidence: 4

Erectile ability is a common goal for transgender men seeking phalloplasty, which necessitates prosthesis placement in most phalloplasty techniques. In the absence of preexisting corpora, implant placement is associated with increased risk of poor proximal fixation, device migration, distal erosion, and neurovascular compromise, infection, and malfunction. Modifications to conventional surgical technique, such as avoidance of critical structures, proximal prosthesis anchoring, and distal cushioning with vascular or synthetic grafts, are common techniques to address anatomic challenges.

Background: The COVID-19 pandemic has resulted in unpreceded changes to medical education. Medical students interested in urology and neurosurgery have reported concerns regarding COVID-19's effects on clinical experience and the residency application process;however, the impact amongst students interested in plastic surgery is unknown. We hypothesized that students applying into plastic surgery may experience much distress as a result of the COVID-19 pandemic. Methods: An electronic survey was developed by 3 plastic surgery residents and 2 academic plastic surgeons and later refined by 4 fourth-year medical students. Questions focused on medical education curricular changes, perceived impact on medical education, and demographics. From April-May 2020 the survey was distributed to medical students who were interested in plastic surgery. Participants were identified through plastic surgery residency program personnel and social media platforms. Results: In total, 130 of the 140 respondents reported interest in plastic surgery careers. An estimated 67% were in their clinical years or completing research year(s) before residency applications. Of the respondents, 80% believed that the COVID-19 pandemic had a negative impact on their medical education. Clinical-level students compared with preclinical-level students, and students applying to residency during the 2020-2021 match cycle compared with students not applying during the 2020-2021 match cycle were significantly more likely to perceive the COVID-19 pandemic as having a negative impact on their medical education (P = 0.04 and 0.03, respectively). Conclusion: Medical students interested in plastic surgery perceive the COVID-19 pandemic as having a negative impact on their education, likely due to a reduction in clinical exposure. © 2021 Lippincott Williams and Wilkins. All rights reserved.

Background The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.Patients and Methods Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.Results A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was 2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.Conclusion ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

Background: The published literature on education about transgender health within health professions curricula was previously found to be sporadic and fragmented. Recently, more inclusive and holistic approaches have been adopted. We summarize advances in transgender health education. Methods: A 5-stage scoping review framework was followed, including a literature search for articles relevant to transgender health care interventions in 5 databases (Education Source, LGBT Source, MedEd Portal, PsycInfo, PubMed) from January 2017 to September 2019. Search results were screened to include original articles reporting outcomes of educational interventions with a transgender health component that included MD/DO students in the United States and Canada. A gray literature search identified continuing medical education (CME) courses from 12 health professional associations with significant transgender-related content. Results: Our literature search identified 966 unique publications published in the 2 years since our prior review, of which 10 met inclusion criteria. Novel educational formats included interdisciplinary interventions, post-residency training including CME courses, and online web modules, all of which were effective in improving competencies related to transgender health care. Gray literature search resulted 15 CME courses with learning objectives appropriate to the 7 professional organizations who published them. Conclusions: Current transgender health curricula include an expanding variety of educational intervention formats driven by their respective educational context, learning objectives, and placement in the health professional curriculum. Notable limitations include paucity of objective educational intervention outcomes measurements, absence of long-term follow-up data, and varied nature of intervention types. A clear best practice for transgender curricular development has not yet been identified in the literature.

Background Several online resources such as Google Trends (GT) enable plastic surgeons to track search volume trends for cosmetic procedures. Understanding these data may allow surgeons to better anticipate patients’ interests and meet their needs. Objectives The authors sought to evaluate the correlation between GT search volumes and annual surgery volumes. Methods Search terms were generated using the “related queries” feature of GT. Data were obtained for the terms breast augmentation, buttock augmentation, buttock implants, buttock lift, calf augmentation, liposuction, lower body lift, thighplasty, abdominoplasty, and brachioplasty from January 2004 to November 2017. Annual volumes for respective procedures were obtained from statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Correlations were evaluated applying univariate linear regression of GT data to both ASPS and ASAPS data. Results Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: “butt implants surgery” (ASPS: R2 = 0.366, P = 0.049; ASAPS: R2 = 0.380, P = 0.019); “liposuction” (ASPS: R2 = 0.690, P = 0.002; ASAPS: R2 = 0.578, P = 0.002); and “liposuction surgery” (ASPS: R2 = 0.672, P = 0.002; ASAPS: R2 = 0.476, P = 0.006). Several search terms demonstrated no significant relationships, negative correlations, or were significant with only one database. Conclusions This study characterizes GT as a convenient and informative data set for plastic surgeons to analyze patient interest in cosmetic body-sculpting procedures. GT represents a useful instrument for tailoring marketing strategies and addressing the needs of our patient population.

Objective Nonsurgical and surgical options are available for transgender vocal feminization. This systematic review explores the efficacy of feminizing voice therapy and phonosurgery. Methods A systematic review was performed using PubMed, Cinahl Plus, Ovid SP, Web of Science, Science Direct, and Google Scholar with terms related to transgender phonosurgery and voice therapy. Included studies were outcomes-based vocal feminization interventions for transgender women. Data were collected on pre- and postintervention fundamental frequency (F0), externally measured vocal femininity, patient satisfaction, and complications. Results Two hundred twelve studies were identified and 20 met inclusion criteria. Postintervention patient satisfaction was approximately 80% to 85% for voice therapy, endoscopic shortening, and cricothyroid approximation. Complications were reported for each phonosurgery technique, most commonly decreased mean phonation time and loudness. Of the 20 studies, 17 were used for meta-analysis of F0 change. F0 increased by 31 Hz with voice therapy alone, 26 Hz with laser reduction glottoplasty, 39 Hz with cricothyroid approximation, and 72 Hz with endoscopic shortening. Conclusion The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications. Most will likely benefit from voice therapy, as it is highly satisfactory, raises vocal pitch, and is noninvasive. However, endoscopic shortening is also highly satisfactory and provides the greatest absolute increase in vocal pitch. If surgery is chosen, postoperative voice therapy may additionally increase F0, stabilize the voice, and create a more female timbre. However, further studies will be necessary to provide definitive clinical recommendations.

Background A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care. Methods We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017. Results Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients. Conclusion Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

BACKGROUND Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty. METHODS A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed. RESULTS A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent). CONCLUSIONS Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Objective To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report postoperative outcomes. Materials and Methods Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26-50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20-39) post-op following their primary vaginectomy and radial forearm free flap (n = 3) or anterolateral thigh (n = 1) phalloplasty. All had multiple urologic complications after primary phalloplasty, most commonly urinary retention (n = 4), urethral stricture (n = 3), fistula (n = 3), dribbling (n = 2), and obstruction (n = 2). Indication for revision was obstruction and retention (n =3 ) and/or dribbling (n = 2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal, or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. Results At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. Conclusion Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

The transgender and nonbinary (TGNB) population is a significant minority, comprising at least 0.6% of the population. Visibility is growing rapidly, especially in younger generations. Gender affirming health care must adapt to this population's needs. Demographic data regarding TGNB health care are limited, but several disparities are clear, stemming from sociopolitical factors, such as external discrimination and insensitive and/or uninformed care. Most self-identifying TGNB patients receive some type of nonsurgical care, including hormonal and/or mental health. Gender-affirming surgery is highly prevalent as well, with at least one-quarter of TGNB people having had some combination of the procedures in this category.

Background Google Trends (GT) provides cost-free, customizable analyses of search traffic for specified terms entered into Google’s search engine. GT may inform plastic surgery marketing decisions and resource allocation. Objectives The aim of this study was to determine GT’s utility in tracking and predicting public interest in nonsurgical cosmetic procedures and to examine trends over time of public interest in nonsurgical procedures. Methods GT search volume for terms in 6 ASPS and ASAPS nonsurgical procedure categories (Botox injections, chemical peel, laser hair removal, laser skin resurfacing, microdermabrasion and soft tissue fillers [subcategories: collagen, fat, and hyaluronic acid]) were compared with ASPS and ASAPS case volumes for available dates between January 2004 and March 2019 with the use of univariate linear regression, taking P < 0.01 as the cutoff for significance. Results Total search volume varied by search term within the United States and internationally. Significant positive correlations were demonstrated for 17 GT terms in all 6 ASPS and ASAPS categories: “Botox®,” “collagen injections,” “collagen lip injections” with both databases; and “chemical skin peel,” “skin peel,” “acne scar treatment,” “CO2 laser treatment,” “dermabrasion,” “collagen injections,” “collagen lip injections,” “fat transfer,” “hyaluronic acid fillers,” “hyaluronic acid injection,” “hyaluronic acid injections,” “Juvederm®,” and “fat transfer” with just 1 database. Many search terms were not significant, emphasizing the need for careful selection of search terms. Conclusions Our analysis further elaborates on recent characterization of GT as a powerful and intuitive data set for plastic surgeons, with the potential to accurately gauge global and national interest in topics and procedures related to nonsurgical cosmetic procedures.

Transgender and gender non-binary (TGNB) individuals are a growing demographic with unique healthcare needs. Amid changes in public and private insurance coverage of gender confirming surgeries (GCS), utilization of these procedures is increasing. Meanwhile, systemic barriers continue to limit access to gender confirming care and perpetuate health disparities among TGNB individuals. Studies on the prevalence of TGNB identities and utilization of GCS are limited by a lack of gender identity data in population-based surveys and electronic medical records. However, data collection on gender identity is improving, and will be essential for characterizing the healthcare practices and needs of TGNB individuals.

Medical decisions made by celebrities have a profound influence on medical decisions made by the general population. Google Trends (GT) is a free, online resource with virtually no barriers to use that allows for tracking of global search volumes as a proxy for determining public interest. In this study, we utilize GT to characterize the significant and measurable effects that the May 2013 announcement of Angelina Jolie's BRCA-influenced prophylactic mastectomy, May 2015 announcement of Kylie Jenner’s lip augmentation, April 2017 announcement of Caitlyn Jenner’s gender affirming surgery and February 2014 media attention given to Kim Kardashian’s rumored buttock augmentation had on corresponding surgical procedure volumes. GT databases of search volumes were collected for terms related to prophylactic mastectomy, lip augmentation, gender affirming surgery and buttock augmentation categories from January 2004 to March 2019 using the “related queries” feature. Mean search volumes prior to respective announcements were compared to that of the period starting 6 months after. Additionally, the percent change from the month preceding respective celebrity announcements was compared to the month of the announcement for each search term. For mastectomy, all terms demonstrated peak interest during May 2013. Following Jolie’s announcement, interest in “mastectomy” rose 1328%, “prophylactic mastectomy” rose 324%, “BRCA1” rose 316%, “BRCA2” rose 138% and “BRCA gene” rose 354%. Long-term interest was higher after May 2013 than beforehand for all terms except “prophylactic mastectomy” (each, p

INTRODUCTION AND OBJECTIVES:Penile inversion vaginoplasty (PIV) is the most common technique for primary feminizing genital reconstruction in transwomen, which requires regular lifelong dilation to...

Background The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures. Objectives The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis. Methods The “related queries” feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Results Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: “eyelid plastic surgery” (ASPS R2 = 0.336, P = 0.048; ASAPS R2 = 0.661, P = 0.001); “facelift” (ASPS R2 = 0.767, P ≤ 0.001; ASAPS R2 = 0.767, P = 0.001); “lip injections” (ASPS R2 = 0.539, P = 0.007; ASAPS R2 = 0.461, P = 0.044); and “rhinoplasty surgery” (ASPS R2 = 0.797, P ≤ 0.001; ASAPS R2 = 0.441, P = 0.01). Several search terms demonstrated no significant relationships or were significant with only one database. Conclusions GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

BACKGROUND Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is an important gender-affirming procedure sought by many transmasculine and nonbinary individuals. Current literature is focused primarily on details of surgical technique and complication rates, with limited data available on how top surgery affects subjective quality-of-life measures. METHODS An anonymous online survey was distributed to 81 of the senior author's former top-surgery patients. The survey response rate was 72 percent (58 respondents). Responses were analyzed to investigate quality of life, sexual confidence, mental health, satisfaction with top surgery, and patient attitudes toward top surgery's role in gender affirmation. RESULTS Following top surgery, measures of quality of life and sexual confidence improved significantly (p < 0.001). In addition, 86 percent reported improvement in gender dysphoria-related mental health conditions. All but one respondent reported that top surgery had an overall positive impact on their life. CONCLUSIONS Top surgery had major positive effects on all mental health and quality-of-life metrics. The authors' findings contribute to a much-needed body of evidence that top surgery markedly improves the daily lives and functioning of transgender and nonbinary individuals who choose to undergo it.

A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care.We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017.Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients.Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.