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SUMMARY The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

INTRODUCTION AND OBJECTIVE:Penile amputation is a traumatic injury that can be an intimidating problem for surgeons. Successful replantation requires multi-disciplinary care, including a urologist ...

Summary:. Shaft-only phalloplasty (SOP) has been described as an alternative option for phalloplasty. Although traditional phalloplasty represents the most complete form of genital gender-affirming surgery, this variation also carries the greatest surgical risk. Patients may opt for a lower risk SOP for reasons including gender identity, gender expression, sexual function, desire for future childbearing, or minimal gender dysphoria associated with sedentary urination. Further, some patients may, due to associated co-morbidities, not be a candidate for neourethral reconstruction. Forgoing urethral reconstruction also means forgoing the presence of a distal urethral meatus and thereby compromising on one of the basic tenets of phalloplasty surgery—the aesthetic appearance. In an SOP, the flap is usually a simple tube with a purse-string suture placed at the distal end. Another concern can be the insufficient bulk of the phallus due to the absence of the volume added by the inner tube. The purpose of this article is to review our technical modifications that allow for creation of a phallic meatus as well as increasing phallic girth when needed. The most frequently described technique to create a neo-urethra is the tube-within-tube concept. We expanded on this and apply it as a short segment for distal meatal creation in an SOP. Improved aesthetics are achieved by creating the appearance of a phallic meatus and when desired, utilizing a lateral de-epithelialized strip to increase phallic bulk and girth. We hope these technical refinements can assist the surgeon in better meeting the goal of creating an aesthetically pleasing phallus.

Background Gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. Aim Our objective is to describe the factors influencing patient choice or surgeon recommendation of vulvoplasty and to assess the patient’s satisfaction with this choice. Methods Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. Outcomes We report demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. Results In total, 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty. 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index than those seeking vaginoplasty. The majority (63%) of the patients seeking vulvoplasty chose this surgery despite no contra-indications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision for vulvoplasty. Clinical Translation Vulvoplasty creates the external appearance of female genitalia without creation of a neovaginal canal; it is associated with high satisfaction and low decision regret. Conclusions This is the first study of factors impacting a patient’s choice of or a surgeon’s recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also is the first reported series of patients undergoing vulvoplasty only. Limitations of this study include its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how we offer vulvoplasty. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Phalloplasty is an exceptionally complicated reconstructive procedure that attempts to create a structure that is penis-like. As patient goals vary widely, it is helpful to think about phalloplasty as a modular set of procedures that can be combined, mixed and matched to meet the needs of each individual patient while also taking into account their anatomy. Each module—but particularly the shaft and penile urethra—can be performed using a variety of techniques. To date, there is no consensus among surgeons regarding the optimum staging of the reconstructive steps. Our primary goal is to outline the most frequently performed and reported options in phallic reconstruction and outline the various considerations that go into choosing a given sequence of procedures for the specific patient. The secondary goal of this article is to describe the complications common to each of those modules and how they interact when combined.

INTRODUCTION AND OBJECTIVES:For transgender women undergoing gender-affirming vaginoplasty, the creation of the vaginal canal causes disruption of the pelvic floor; furthermore, patients must perfo...

Background A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

BACKGROUND:Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES:We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS:This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS:A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS:Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population. LEVEL OF EVIDENCE: 4

Coccidioidomycosis osteomyelitis is a rare entity considered even more rare when identified in the immunocompetent patient. In non-endemic areas, the diagnosis of a fungus-causing osteomyelitis is often delayed or overlooked. This results in delayed or inappropriate treatment. We present the case of a 35-year-old immunocompetent male immigrant from India who was ultimately diagnosed as having Coccidioidomycosis immitis osteomyelitis of his ring finger metacarpal. His initial surgery included drainage and bacterial cultures only. When he failed to improve, he presented for a second opinion. The patient's origin and travel history coupled with the appearance of rapid bone destruction on plain radiographs prompted a second operation for tissue biopsy and culture for bacteria, fungus, and mycobacteria cultures. This case highlights the importance of a thorough clinical history in deriving an appropriate differential diagnosis prior to surgical intervention.

In this paper, the authors present two case reports with patients who presented at different institutions for traumatic aneurysmal dilation of temporal vessels. The first case is a 18-year-old male who presented to plastic surgery following attempted excision by an outside provider after a fist fight. The second case is a 22-year-old male who presented to plastic surgery while inpatient after gunshot wound to the face. The differences in the cases are highlighted by the different approaches to the management of the lesions with direct incision and embolization respectively.

Our aim was to identify the predictive factors for permanent pacemaker (PM) implantation in patients undergoing isolated aortic valve replacement (AVR). A total of 3534 patients received an AVR between January 1990 and December 2003 in our institution. Permanent PM implantation was performed in 234 (6.6%) patients, over median time of three days (range one to 24 days). This patient population was compared to a random sample of 191 patients undergoing AVR without permanent PM implantation. The overall mean age was 63.5 years (±14.2) and 261 patients (62%) were male. Univariate and multivariate logistic regression analysis of pre- and perioperative data were performed. Overall the 30 days mortality was 4.2% (10/234) in patients with PM and 1% (2/191) in the control group (P=0.046). Patients with PMs were older (P