The Legacy of Gender-Affirming Surgical Care Is Complex No abstract available

Reply to: The Legacy of Gender-Affirming Surgical Care Is Complex No abstract available

A History of the Frenchay Hospital Plastic Surgery Unit, Bristol, United Kingdom Frenchay Hospital has long since been established as the center for plastic surgery in Bristol, providing care to the city and its surrounding catchment area. From humble origins in the Second World War when the site took on the role of a large military hospital providing reconstructive surgery for the victims of war to a busy modern-day National Health Service establishment, the plastic surgery unit at Frenchay Hospital has grown and developed through in parallel with the genesis and development of the specialty. Recent centralization of care in Bristol has seen a massive reorganization of services, and with it the closure of Frenchay Hospital. Because the plastic surgery unit establishes a new home at Southmead Hospital, this review documents the foundations of reconstructive surgery in Bristol and the South West United Kingdom.

Book Review: Rhoton's Atlas of Head, Neck, and Brain: 2D and 3D Images By: Maria Peris-Celda, Francisco Martinez-Soriano, Albert L. Rhoton Jr, Published by Thieme Medical Publishers Inc, New York, NY, 2017 Hardcover, 648 pp No abstract available

Comparing the Health Burden of Living With Nasal Deformity in Actual Patients and Healthy Individuals: A Utility Outcomes Score Assessment Background Rhinoplasty is a one of the most commonly performed facial surgery aiming at restoring facial aesthetics and improving quality of life. Utility outcome scores are modern, and emerging tools are used to evaluate the burden of a health state on individuals. The study aims to evaluate the impact of living with nasal deformity among real patients and healthy individuals using utility outcome scores. Methods A cross-sectional study was conducted at Otolaryngology and Plastic Surgery clinics in a tertiary center. Healthy individuals were recruited from public facilities. A case scenario was developed to reflect an imaginary patient (Nora) with a functional and aesthetic nasal deformity and distributed to participants. Three utility outcomes scores were used: visual analog scale (VAS), time trade-off (TTO), and standard gambling (SG). Results A total of 407 adult participants were included. Most participants were female (52%). Healthy individuals comprised 71%, and actual patients comprised 29%. Mean VAS score was 0.77 (ie, participants scored Nora's health state as 77%), TTO score was 0.87 (ie, participants were willing to sacrifice 4 years to have Nora's condition corrected), and SD score was 0.91 (ie, participants were willing to take a 9% risk of death to have Nora's condition corrected). Scores differed among actual patients and healthy individuals (P < 0.0001 for VAS and TTO, P = 0.02 for SG). Conclusion Living with a nasal deformity has a significant impact on quality of life. Both patients and healthy individuals are willing to trade a significant number of years to get the condition corrected.

Aesthetic Breast Surgery Under Cold Tumescent Anesthesia: Feasibility and Safety in Outpatient Clinic Throughout the last decade, aesthetic breast surgery has enormously spread in the outpatient clinic setting where plastic surgeons perform the vast majority of procedures under local anesthesia as day-case operations. The “tumescent anesthesia” is defined as the injection of a dilute solution of local anesthetic combined with epinephrine and sodium bicarbonate into subcutaneous tissue until it becomes firm and tense, which is “tumescent.” The “cold tumescent anesthesia” (CTA) derives from Klein's solution with the introduction of a new concept, which is the low temperature (4°C) of the injected solution. This novelty adds further anesthetic and hemostatic power to the well-known benefits of tumescent anesthesia. The authors report their experience with CTA in the last 15 years in the setting of aesthetic breast surgery, describing in detail the anesthesia protocol, surgical outcomes, and patient satisfaction. A total of 1541 patients were operated on during the study period and were included in this retrospective analysis. The types of breast procedures were breast augmentation in 762 cases (49.4%), mastopexy with implants in 123 patients (8.0%), mastopexy without implants in 452 cases (29.3%), and breast reduction in 204 cases (13.3%). Patient mean age was 42.8 years (range, 18–67 years). The mean operating time was 37 ± 32 minutes for breast augmentation, 78 ± 24 minutes for mastopexy with implants, 58 ± 18 minutes for mastopexy without implants, and 95 ± 19 minutes for breast reduction. No major complications occurred, and no conversion to general anesthesia was required. The median recovery time was 150 minutes (range, 120–210 minutes), and all patients were discharged within 3 hours after surgery. Wound or implant infections occurred in 33 patients (2.1%), wound dehiscences in 21 (1.4%), and postoperative bleeding requiring return to theater in 2 cases (0.1%). Thirteen patients (0.8%) developed capsular contracture. Fifteen patients (1%) required reintervention due to implant rotation or rupture. The median visual analog scale score was 1.8 (interquartile range, 1–3) after discharge. Patient satisfaction was very high in 91.3% (n = 1407) of the cases. In experienced hands, CTA can shorten operating time with high patient satisfaction and a low complication rate. These preliminary data could be hypothesis generating for future multicenter prospective trials done to confirm the benefits of CTA in other surgical fields.

Implications of Demographics and Socioeconomic Factors in Breast Cancer Reconstruction Background Not all women undergo breast reconstruction despite its vital role in the recovery process. Previous studies have reported that women who are ethnically diverse and of lower socioeconomic status are less likely to undergo breast reconstruction, but the reasons remain unclear. The purpose of this study is to evaluate the demographic characteristics of our patient population and their primary reason for not undergoing breast reconstruction. Methods An institutional review board-approved, single-institution study was designed to evaluate all female breast cancer patients of all stages who underwent mastectomy but did not undergo breast reconstruction from 2008 to 2014. Patients were contacted via telephone and asked to participate in a validated, prompted survey. Data regarding their demographic information and primary reason for not undergoing breast reconstruction were collected. Results Inclusion criteria were met by 181 patients, of which 61% participated in the survey. Overall, the most common reason for not undergoing breast reconstruction (26%) was unwillingness to undergo further procedures. However, the most common reason for patients that identified as Hispanic, Spanish-speaking, high school graduates, or having an annual income less than US $25,000 (P < 0.05) was insufficient information received. Conclusions This study demonstrates that ethnicity and socioeconomic factors play a key role in determining why patients forego breast reconstruction. Ethnicity, language, education, income, and employment status are associated with patients not receiving appropriate education regarding their reconstructive options. Breast surgeons with a diverse patient population should ensure that these patients are adequately educated regarding their options, and if perhaps, more of these patients would decide to partake in the reconstruction process.

Direct-To-Implant and 2-Stage Breast Reconstruction After Nipple Sparing Mastectomy: Results of a Retrospective Comparison Breast reconstruction after nipple sparing mastectomy (NSM) plays, nowadays, a fundamental role in breast cancer management. There is no consensus on the best implant-based reconstruction technique, considering 2 stages (expander-prosthesis) or direct-to-implant (DTI). A retrospective review of consecutive adult female patients who underwent NSM with breast reconstruction over a 3-year period (January 2013 to December 2015) was performed. Patients were divided into 2 groups according to the type of reconstruction: expander/prosthesis (group A) and DTI (group B). Anamnestic data were collected. Number and type of procedures, complications and esthetic satisfaction were registered and compared. Fifty-six patients were included in group A (34.6%) and 106 in group B (65.4%). Complications associated with the 2 types of breast reconstruction were not different (P = 0.2). Patients in group A received a higher number of total surgical procedures (considering revisions, lipostructures and contralateral symmetrizations) than those in group B (2.5 ± 0.69 and 1.88 ± 1.02, P = 0.0001). Satisfaction with breast reconstruction resulted higher in group A (7.5 ± 2.6 and 6 ± 1.9, P = 0.0004). At the multivariate analysis, chemotherapy and radiotherapy were not correlated with complications, regardless of the group (odds ratio, 0.91 and 2.74, respectively). Radiotherapy and chemotherapy did not even influence the esthetic result, regardless of the group (P = 0.816 and P = 0.521, respectively). Prosthetic breast reconstructions, both in a single and in 2 stages, are welcomed by patients and have relatively low and almost equivalent complication rates, independent of other factors such as chemotherapy, radiotherapy, lymphadenectomy, smoking and age. In our experience, 2-stage breast reconstruction, although requiring more operations, is associated with a higher esthetic satisfaction. Patients who perform a DTI breast reconstruction after NSM should be informed of the high probability of surgical revision.

Surgical Outcomes of Implant-based Breast Reconstruction Using TiLoop Bra Mesh Combined With Pectoralis Major Disconnection Objective This study aimed to compare breast symmetry and patient satisfaction with breast appearance between implant-based breast reconstruction using TiLoop Bra mesh combined with pectoralis major disconnection (IMR) and conventional implant reconstruction (IR), and to analyze differences in complications. Methods This retrospective study included 59 patients administered IMR or IR in 2016 to 2018. Three-dimensional scanning was performed to objectively evaluate breast symmetry. The BREAST-Q scale was used to survey satisfaction with breast appearance, social psychosocial health, physical health, and sexual well-being. Results There were no significant differences in age, TNM stage, and chemotherapy between the 2 groups (all P > 0.05). In 3-dimensional scanning data, patients who underwent IMR had better bilateral breast symmetry compared with those administered IR (all P < 0.001). Based on the BREAST-Q survey, the satisfaction rate was significantly higher for IMR compared with IR (P = 0.0368), whereas psychosocial health, physical health, and sexual well-being showed no significant differences between the 2 groups (all P > 0.05). The IMR model showed no obvious advantages in common complications, including hematoma, incision site infection, skin flap necrosis, and prosthesis exposure and rupture compared with IR; loss of skin and nipple sensations was evident in both groups. The IMR model was associated with reduced incidence of fibrous capsule contracture compared with IR (0% vs 18.75%, P = 0.0267). The incidence rates of pectoralis major disconnection syndrome after IMR and IR were 18.50% and 0%, respectively (P = 0.0161). Conclusions Patients administered IMR have better breast symmetry and greater satisfaction with breast appearance compared with those treated by IR; however, IMR has unique complications, including pectoralis major disconnection syndrome.

Breast Reduction Following Hormonal Therapy in a Transgender Female Patient In male-to-female gender transition, individuals request a number of interventions, including hormonal therapy, to promote feminizing characteristics. Estrogen-based medication is prescribed to increase breast development, decrease facial hair, promote feminine adipose tissue deposition, and soften skin. Surgical breast augmentation to supplement unsatisfying breast growth after hormonal therapy is a common and well-studied course of management for such transgender patients. In a departure from convention, the authors present a case of symptomatic macromastia requiring surgical breast reduction in a transgender woman following 24 years of hormonal therapy and illicit silicone injections in multiple areas of her body, including the breasts.