November 2023
- thestitchprs
- Nov 21, 2023
- 8 min read
Welcome!
Read our pieces from this November below!
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Best, The Stitch Editorial Board
Gender Affirming Regret Guidelines
Article Review by Reid Smith, Zucker School of Medicine
Current literature estimates that there are around 9000 gender affirming surgeries (GAS) being performed annually across the US (Bustos et al, 2021). Of these, around 0.2%-3.0% of patients express some form of post-procedure regret. Although the regret rate is low, GAS regret and detransitioning has gained significant political attention. There are current recommendations for supporting patients through their gender transition, but an article published by Jedrzejewski et all offers the first guidelines for providers to assess the cause of regret/reversal request and its management.
A total of 2863 procedures for 1989 individuals during a six year period at the Oregon Health & Science University were included. Of these patients, 6 requested reversal surgery (0.3%). OHSU Transgender Health Program created a multidisciplinary, lifespan approach workgroup that was made accessible to these patients. Following surgery, these patients received close follow-up and surgical care was only offered after “multidisciplinary review of support systemes, developmental readiness, and adequate involvement of mental health providers (MHP)." They divided patient aspects of care into feasibility, stability, etiology, and expectations which were all further addressed by one or more of the multidisciplinary team inducing MHP, Surgeon, PCP/Endocrinologist, and Social Work/Care Coordinator.
The study noted that patient regret was made up of a heterogeneous group of causes. Regret was categorized into the following three buckets: true gender-related regret (e.g., a patient who desires a return to the sex assigned at birth or a different gender identity), social regret (e.g., a patient whose desire is due to societal repercussions of their transition), or medical regret (e.g., medical complications, dissatisfaction with aesthetic or functional outcome). The findings suggest that true gender-related regret can be mitigated through the involvement of an MHP and normalizing the patient’s exploration of their gender identity. Previous studies have shown that over 80% of transgender patients who detransitioned cited at least one external/social factor. As a result, it is important to involve the patient's support group and connect them with transgender community members and support groups. Medical regret, on the other hand, is an issue non-unique to GAS. The same principles used in all surgical procedures including adequate management of preoperative expectations, thorough discussion of risk/alternatives, and close follow-up in the event of complications are crucial.
In summary, GAS is becoming more accessible and is therefore increasing in frequency. Due to the complex social, political, and surgical nature of this procedure, it is important to establish a standard of care for patients who express regret or request reversal. Postoperative regret can be truly gender-related or secondary to social or medical factors. OHSU suggests using a multidisciplinary, patient-centered approach that includes frequent postoperative followup and joint decision making to most appropriately manage these patients in the perioperative period.
References
Bustos VP, Bustos SS, Mascaro A, et al. Regret after gender-affirmation surgery: a systematic review and meta-analysis of prevalence. Plast Reconstr Surg Glob Open. 2021;9:e3477.
Jedrzejewski BY, Marsiglio MC, Guerriero J, Penkin A, Connelly KJ, Berli JU; OHSU Transgender Health Program “Regret and Request for Reversal” Workgroup. Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience. Plast Reconstr Surg. 2023 Jul 1;152(1):206-214. doi: 10.1097/PRS.0000000000010243. Epub 2023 Jun 29. PMID: 36727823.
Ultrasounds to Guide Gluteal Fat Grafting: a New Florida Mandate
In the News by Parul Rai, University of Texas Medical Branch
Florida's legislature recently passed HB 1471, its first plastic surgery legislation, requiring the use of ultrasound to guide gluteal fat grafting procedures starting on July 1, 2023 (Stephens, 2023). Implementing the ultrasound ensures that fat is only injected into the subcutaneous space, and never into the muscle.
Gluteal fat grafting, popularly known as “Brazilian buttock lift” (BBL), has made headlines for its adverse effects: when fat is inadvertently injected into the gluteal muscle, it can travel to vital organs—the heart, the lungs, or the brain— often with fatal outcomes (Mofid et al, 2017). According to the American Society of Plastic Surgeons, gluteal fat grafting has one of the highest mortality rates among aesthetic procedures (Del Vecchio & Kenkel, 2022). To further enhance safety during BBLs, the new Florida law also stipulates that surgeons' first encounter with the patient cannot be on the day of the surgery; additionally, surgeons are prohibited from delegating the procedure to a nurse or assistant.
HB 1471 follows the implementation of the 90-day Emergency Rule (64B8ER22-3) introduced by the Board of Medicine and approved by the Florida Department of State on June 14, 2022. This law mandates "ultrasound guidance during cannula placement and fat injection into the subcutaneous space." Additionally, surgeons must retain the ultrasound video recording in the patient's medical records, including timestamps for both time and date.
Florida's landmark legislation, HB 1471, marks a crucial step forward in prioritizing patient safety during gluteal fat grafting procedures. By mandating ultrasound guidance to ensure accurate fat placement within the subcutaneous space, the state aims to prevent potentially fatal outcomes when fat is mistakenly injected into the gluteal muscle, leading to its migration to vital organs. The alarming mortality rates associated with gluteal fat grafting underscore the urgent need for enhanced safety measures. Furthermore, the law's provisions prohibiting surgeons from meeting patients on the day of surgery and delegating the procedure to others demonstrate commitment to responsible and competent surgical practices. With this bold step, Florida sets a precedent for other states to follow suit and prioritize patient well-being in plastic surgery.
References
Del Vecchio D, Kenkel JM. Practice advisory on gluteal fat grafting. Aesthetic surgery journal. 2022 Sep 1;42(9):1019-29.
Mofid MM, Teitelbaum S, Suissa D, Ramirez-Montañana A, Astarita DC, Mendieta C, Singer R. Report on mortality from gluteal fat grafting: recommendations from the ASERF task force. Aesthetic Surgery Journal. 2017 Jul 1;37(7):796-806.
Stephens K. Florida Passes Ultrasound Mandate to Improve Brazilian Butt Lift Safety. AXIS Imaging News. 2023 Jul 28.
Use of Radiation with Breast Conserving Surgery in Older Patients
Article Review by Olivia Waldron, Pennsylvania State University
Breast cancer in older women is rising, yet published clinical trials often exclude older women (Morgan et al, 2020). To address this discrepancy, the PRIME II Trial evaluated women 65 years old with early (no nodal involvement) hormone receptor-positive tumors undergoing breast-conserving treatment. They found that though irradiation leads to fewer patients developing local recurrence (4.1% without radiation; 1.3% with radiation), guidelines support the omission of radiation regardless of the perceived benefits.
The PRIME II randomized trial evaluated the 10-year outcomes of women undergoing whole breast radiation with breast-conserving surgery. Annual clinical visits and mammography evaluated local breast cancer recurrence. The incidence of local recurrence in women without radiation therapy was 9.5% (95% CI, 6.8 to 12.3) versus 0.9% (95% CI, 0.1 to 1.7). The cumulative incidence of distant recurrence was 1.6% without radiation versus 3.0% with radiation. The disease-free survival was 68.9% without radiation and 76.3% with radiation. There is clearly a perceived benefit of radiotherapy, however, the difference between local recurrence was modest (8.6%), and in line with established guidelines.
Though benefits do exist with radiation post-breast-conserving therapy, they may not neccessarily outweigh the costs (i.e. complications like cardiac toxicity or secondary cancers). There continues to be a pressing need for more literature in regards to early breast cancers, and especially regarding older breast cancer patients. If we want to be able to offer every patient a personalized treatment plan that works best for them, more studies are needed in these populations.
Reference
Kunkler IH, Williams LJ, Jack WJL, Cameron DA, Dixon JM. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N Engl J Med. 2023 Feb 16;388(7):585-594.. PMID: 36791159.
Morgan JL, George J, Holmes G, Martin C, Reed MW, Ward S, Walters SJ, Cheung KL, Audisio RA, Wyld L. Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study. Journal of British Surgery. 2020 Oct;107(11):1468-79.
Buccal Fat Removal and Social Media: Should We Intervene?
Opinion by Sarah Moffitt, USF Morsani College of Medicine
You may have seen the words "buccal fat removal" trending on your social media in the past year. This procedure, which removes the buccal fat pad, translates into a sharper definition of the face and accentuated cheekbones, which is generally desirable. Many celebrities and so-called "influencers" are rumored to have underwent this procedure, creating a trend that has fascinated the general public and increased popularity in buccal fat removal. However, though its results are quick and definite, this procedure is not reversible-- once removed, the buccal fat is not coming back. And though this may create a younger appearance in the present moment, the natural aging process-- which includes a decline in collagen strength and volume to the face and skin-- may turn that "tightened" look into a “gaunt” one. What is interesting is not that there is a new plastic surgery trend, which is likely occur until the end of time, it’s the discussion that it's brought forth for providers.
Social media has undoubtedly done wonderful things for the world of plastic surgery. People can now share their experiences and express how a procedure has contributed to greater self-esteem, confidence, and joy, which is ultimately the best outcome for any elective surgery. The “taboo” that used to surround having “work done” is slowly fading away, allowing for more conversations about the positive aspects of cosmetic plastic surgery.
But social media has also received backlash for contributing to too much emphasis on physical appearance and the drive to obtain the beauty standards set by celebrities and influencers worshipped on these platforms. Social media has become the avenue for trends to come and go, which can encourage individuals to consider how their appearance matches up to the latest “new look."
So, in this modern age of rapid turnover of trending styles and looks, how do plastic surgeons responsibly care for their patients? With great power comes great responsibility. Plastic surgery, which really took hold in the wake of World War 1 to reconstruct injuries, has the power to restore function and structure to damaged tissues all over the body, and it has the power to boost an individual’s self esteem about their appearance. When trends come along that may be controversial regarding risks and results, should plastic surgeons always say yes? Should we blame the influencers and celebrities if someone feels regret for a procedure? Should plastic surgeons be at fault if they do remove someone’s buccal fat? These are complex questions. However, I am of the opinion that everyone has a right to make decisions to feel comfortable and happy in their own skin, and I think it’s wonderful that plastic surgery can assist with that. I think there is a delicate balance with these life altering decisions-- surgeons should inform patients of all possible consequences of their choice (especially if the procedure is likely not reversible)-- but personal freedom should be at the forefront of these conversations.
The field of plastic surgery and the TikTok trends are both ever evolving, and this dilemma will too. The principle of caring for the patient’s best interest could not be more important than it is right now.
Reference
Surek CC, Kochuba AL, Said SA, Cho KH, Swanson M, Duraes E, McBride J, Drake RL, Zins JE. External approach to buccal fat excision in facelift: anatomy and technique. Aesthetic surgery journal. 2021 May 1;41(5):527-34.
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