Martinez-Jorge, Jorys

Background: Penile inversion vaginoplasty (PIV) is a common gender-affirming procedure for transgender women, but validated, transgender-specific patient-reported outcomes remain limited. This study evaluated long-term outcomes after PIV using the Post-Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM), a validated instrument assessing appearance, urologic, and gynecologic domains. Methods: We conducted a single-institution retrospective cohort with a cross-sectional, anonymous AFFIRM survey distributed in 2024. Demographics, perioperative outcomes, and complications were obtained by chart review. AFFIRM domain scores, reported on a 0–200 scale with lower scores indicating better outcomes, were analyzed descriptively. Results: Of 193 eligible patients who underwent PIV between 2017 and 2023, surveys were delivered to 186 patients, and 47.8% responded. Median age at surgery was 34.3 years (interquartile range 26.1–49.1), with a median follow-up time of 50.0 months. Most respondents reported high satisfaction with genital appearance, and 90% strongly agreed their anatomy aligned with gender identity. Clitoral sensation was reported by 93%, most commonly as pleasurable. Urologic symptoms were generally minimally bothersome; although 59% reported a misdirected urine stream, mean bother score was low (1.64 ± 1.77). Vaginal dryness and dyspareunia were reported by 43% and 44%, respectively, with 27% describing symptoms as bothersome. Major complications occurred in 13.9% and revision surgery in 34.2%, most commonly for stenosis or depth concerns (13.5%). Conclusions: AFFIRM captured meaningful, transgender-specific, long-term outcomes after PIV, complementing traditional surgical metrics and identifying opportunities to improve preoperative counseling, surgical refinement, and postoperative management of vaginal dryness and urinary symptoms.

ABSTRACT Background Abdominal‐based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well‐documented. When flap compromise occurs, operative salvage is the gold standard. However, when—and if—to place these patients on heparin infusions is unclear. The goal of this study was to investigate abdominal‐based free flap compromise and compare outcomes with and without heparin infusion. Materials and Methods This was a single‐institution, multiple‐surgeon, retrospective chart review of patients undergoing autologous, abdominal‐based free flap breast reconstruction who experienced anastomotic compromise within a 6‐year period. Treatment and outcomes data collected include flap salvage, hematoma, seroma, surgical site infection (SSI), transfusion requirement, and length of hospital stay. Results Fifty‐one flaps had evidence of compromise. A total of 31 (60.8%) patients were placed on heparin infusions after experiencing anastomotic compromise, compared to 20 who did not receive heparin infusion. Thirty‐five patients (68.6%) underwent deep inferior epigastric perforator flaps. Twenty‐six patients (51%) experienced venous congestion, 22 patients (43.1%) experienced arterial compromise, and three (5.9%) experienced both. Twenty‐eight patients (54.9%) received tissue plasminogen activator; in the heparin infusion group, 21 patients (67.7%) received tissue plasminogen activator. The total salvage rate of compromised flaps was 94.1% (48/51). There was no significant difference between heparin infusion and standard cares in length of hospital stay, length of drains in‐place, successful salvage (93.5% vs. 95%), hematoma (19.4% vs. 15%), fat necrosis, SSI, hospital readmission (19.4% vs. 15%), and return rates to the operating room (48.4% vs. 50%). However, there was a significantly higher transfusion rate in patients receiving heparin infusion (38.7% vs. 10%). Of the 25 flaps with evidence of thrombosis, 72% were placed on heparin infusions while 28% were not; there was no significant difference in salvage rate in this sub‐group. Conclusions This review of autologous breast reconstruction free flap compromise provides evidence of similar safety profiles, with similar salvage rates, when comparing salvage with and without heparin infusion; there is a higher transfusion requirement when treating with heparin infusion.

Abstract Context Transgender and gender diverse (TGD) individuals have greater access to genital surgery (GS) with improved insurance coverage and access to trained surgeons and interdisciplinary gender-affirming providers. Objective To determine perioperative medical and behavioral health outcomes in transfeminine (TF) individuals undergoing GS, with use of a specific gender-affirming hormone therapy (GAHT) algorithm based on individualized risk factor assessment. Methods In this retrospective observational cohort study, we collected preoperative and postoperative data from 183 TF individuals at a single tertiary referral center from 2017 to 2022, grouping patients by those who continued estradiol (Group 1) vs those who had temporarily discontinued estradiol for 2 to 6 weeks preoperatively (Group 2). Data included clinical and biochemical assessment, GAHT regimens, validated behavioral health measures, and postoperative complications. Main outcomes included venous thromboembolism (VTE) incidence, non-VTE postoperative complication incidence, and change in behavioral health assessments. Results The majority of individuals continued estradiol perioperatively (Group 1; 138 [75.4%]). Individuals who temporarily held estradiol preoperatively (Group 2; 45 [24.6%]) were statistically older (P < .01), had higher incidence of cardiometabolic comorbidities (P < .01), and higher Caprini scores (P < .01). Group 1 was statistically more likely to use oral estradiol (P < .01). One episode (0.05%) of VTE occurred (Group 1). There was no significant difference in postoperative complications or behavioral health measures between groups. Conclusion An individualized algorithm for preoperative hormone management for TF GS resulted in perioperative continuation of GAHT for the majority of individuals without significantly increasing the risk for postoperative surgical complications, while maintaining stable behavioral health measures perioperatively.

BACKGROUND: Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location. OBJECTIVE: To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach. DESIGN: We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries. SETTING: This study was conducted at the Mayo Clinic in Rochester, Minnesota. PATIENTS: Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified. MAIN OUTCOME MEASURES: The primary outcome measures were the R0 resection rate and surgical outcomes. RESULTS: An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence. LIMITATIONS: Small cohort with heterogeneous tumors and a short follow-up duration. CONCLUSION: A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract. MEJORANDO LAS TASAS DE RESECCIÓN R0 CON UN ABORDAJE DE DOS ETAPAS PRIMERO POSTERIOR PARA LA RESECCIÓN EN BLOQUE DE CÁNCERES ANORRECTALES PRIMARIOS Y RECURRENTES LOCALMENTE AVANZADOS QUE AFECTAN LA PARED LATERAL PÉLVICA PROFUNDA ANTECEDENTES: Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación. OBJETIVO: Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje. DISEÑO: Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente. AJUSTE: Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU. PACIENTES: Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior. PRINCIPALES MEDIDAS DE RESULTADO: Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos. RESULTADOS: Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local. LIMITACIONES: Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento. CONCLUSIÓN: Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción—Dr. Aurian Garcia Gonzalez)

Background:The coronavirus disease 2019 (COVID-19) pandemic provoked rapid changes in clinical practice to accommodate mandated restrictions within healthcare delivery. This study reviewed patient-reported experiences and clinical outcomes after implementation of a same-day discharge protocol after mastectomy with immediate alloplastic breast reconstruction compared with our historical overnight stay protocol.Methods:This is a retrospective single-institution study of consecutive patients who underwent mastectomy and immediate alloplastic reconstruction between July 2019 and November 2020. A postoperative survey was completed by patients to evaluate satisfaction with perioperative communications, recovery, and their overall experience.Results:A total of 302 patients (100% women) underwent mastectomy and immediate alloplastic reconstruction (174 pre-COVID-19, 128 during COVID-19). During COVID-19, 71% of patients were scheduled for a same-day discharge, among which 89% were successfully discharged the same day. Compared with pre-COVID-19, there were no differences in type of surgery, operative times, pain scores, 30-day readmission, or unplanned visits (allP> 0.05) during the COVID-19 pandemic. Compared with pre-COVID-19, patients during the pandemic reported comparable satisfaction with their care experience and postoperative recovery (56% survey response rate). Patient satisfaction was also similar between those discharged the same day (n = 81) versus the next day (n = 47) during COVID-19.Conclusions:Same-day discharge is feasible, safe, and can provide similar patient-reported satisfaction and outcomes compared with traditional overnight stay. These data highlight the ability to deliver adaptable, high-quality breast cancer care, within the constraints of a global pandemic.

Abstract The complex three-dimensional (3D) anatomy in facial allotransplantation creates a unique challenge for surgical reconstruction. Evolution of virtual surgical planning (VSP) through computer-aided design and computer-aided manufacturing has advanced reconstructive outcomes for many craniomaxillofacial indications. Surgeons use VSP, 3D models, and surgical guides to analyze and to trial surgical approaches even prior to entering the operating room. This workflow allows the surgeon to plan osteotomies and to anticipate challenges, which improves surgical precision and accuracy, optimizes outcomes, and should reduce operating room time. We present the development, evolution, and utilization of VSP and 3D-printed guides in facial allotransplantation at our institution, from guide conception to first clinical case.

Background: Many insurance companies in the United States rely on the Schnur sliding scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. The authors compared the accuracy of formulas such as the Schnur, Appel, Descamps, and Galveston scales in predicting resection weights, and assessed whether they influence insurance coverage decision. Methods: A retrospective review of bilateral reduction mammaplasty procedures from June of 2017 to June of 2019 was performed at the Mayo Clinic, Rochester. Oncoplastic reduction operations were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis. Results: One hundred fifty-four patients (308 breasts) were reviewed. The Schnur scale had low correlation with actual resection weight (r 2 = 0.381; b1 = 1.153; p < 0.001). The Appel scale was the most accurate (r 2 = 0.642; b1 = 1.01; p < 0.001), followed by the Descamps (r 2 = 0.572, b1 = 0.934, p < 0.001) and Galveston (r 2 = 0.672; b1 = 0.654; p < 0.001) scales. The Appel, Descamps, and Galveston scales were more accurate for resection weights of 500 g or greater, body mass index greater than 30 kg/m², and patients younger than 50 years. For resection weights of 500 g or greater, the median difference between the estimated and actual resection weight for the Schnur, Appel, Descamps, and Galveston scales was −211.4 ± 272.3, −17.5 ± 272.3, −9.6 ± 229.5, and −99.2 ± 238.5 g, respectively. No scale was accurate for resection weights less than 500 g. Insurance reimbursement was denied in 15.56 percent of patients; of these, 23 percent had resection weights less than 500 g. The Schnur scale overestimated the resection weights in 28.9 percent of patients. Conclusions: The Schnur scale is a poor predictor of breast resection weight. The Appel scale is the most accurate estimator, especially in the young and obese population with larger resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Abstract Background Postmastectomy breast reconstruction (PMR) increases patient satisfaction, quality of life, and psychosocial well-being. There is scarce data regarding the safety of PMR in chronic anticoagulated patients. Perioperative complications can reduce patient satisfaction; therefore, it is important to elucidate the safety of PMR in these patients. Methods A retrospective case–control study of patients who underwent PMR with implants and were on chronic anticoagulation was performed at our institution. Inclusion criteria were women ≥ 18 years old. Exclusion criteria included autologous reconstructions, lumpectomy, and oncoplastic procedures. Two controls for every one patient on anticoagulation were matched by age, body mass index, radiotherapy, smoking history, type of reconstruction, time of reconstruction, and laterality. Results From 2009 to 2020, 37 breasts (20 patients) underwent PMR with implant-based reconstruction and were on chronic anticoagulation. A total of 74 breasts (40 patients) who had similar demographic characteristics to the cases were defined as the control group. Mean age for the case group was 53.6 years (standard deviation [SD] = 16.1), mean body mass index was 28.6 kg/m2 (SD = 5.1), and 2.7% of breasts had radiotherapy before reconstruction and 5.4% after reconstruction. Nine patients were on long-term warfarin, six on apixaban, three on rivaroxaban, one on low-molecular-weight heparin, and one on dabigatran. The indications for anticoagulation were prior thromboembolic events in 50%. Anticoagulated patients had a higher risk of capsular contracture (10.8% vs. 0%, p = 0.005). There were no differences regarding incidence of hematoma (2.7% vs. 1.4%, p = 0.63), thromboembolism (5% vs. 0%, p = 0.16), reconstructive-related complications, or length of hospitalization (1.6 days [SD = 24.2] vs. 1.4 days [SD = 24.2], p = 0.85). Conclusion Postmastectomy implant-based breast reconstruction can be safely performed in patients on chronic anticoagulation with appropriate perioperative management of anticoagulation. This information can be useful for preoperative counseling on these patients.

Background: Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction. Methods: A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors. Results: Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not. Conclusions: Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: Panniculectomy is a commonly performed body contouring procedure to address skin laxity and its related complications. This study aimed to assess clinical outcomes of abdominal panniculectomy and identify predictors of complications at a tertiary academic healthcare center. Methods: A retrospective review of patients who underwent panniculectomy between January 2010 and January 2020 at our institution was performed. Exclusion criteria were a history of prior panniculectomy or abdominoplasty. Patient characteristics and clinical outcomes were collected. Univariate and multivariable analyses were performed to assess the risk factors of complications. Results: The mean age in the included 238 patients was 51.7 ± 12.7 years, and the mean body mass index (BMI) at the time of panniculectomy was 33 ± 7.5 kg/m 2 . Median resection weight was 2.7 kg (range: 0.15–14.6) and median length of hospital stay was 2 days (range: 0–24). Mean follow-up time was 50 ± 37 months. The rate of major complications was 22.3%. Revision surgery was performed in 3.4% of the cases. Multivariable analyses demonstrated that increase in BMI ( P = 0.007) and active smoking ( P = 0.026) were significantly associated with increased odds of major complication, and increase in BMI ( P = 0.0004), history of venous thromboembolism ( P = 0.034) and having a concomitant ventral hernia repair ( P = 0.0044) were significantly associated with having a length of hospital stay of 3 days or more. Conclusions: Panniculectomy is generally safe to perform, with major postoperative complication rate of 22.3% in our series. Increase in BMI and active smoking were significantly associated with having a major complication. Higher BMI, concomitant hernia repair, and a history of venous thromboembolism were associated with length of hospital stay of 3 days or more.