Developing Practice Guidelines on Chest Masculinization: Designing Male Neo-nipple-Areolar Complex.

Nipple areola complex (NAC) reconstruction is the final stage in breast reconstruction for many women. Although general population preferences on NAC aesthetics and sensation have been studied, it is unclear if these preferences align with the preferences of women who have undergone mastectomy. Therefore, this study aimed to assess the aesthetic and sensory preferences of women who have undergone mastectomy to inform subsequent NAC reconstruction and neurotization. We conducted a cross-sectional, Facebook-based, crowdsourcing campaign to distribute a survey on NAC aesthetics (e.g., position, size, pigmentation) and sensation to women with a history of mastectomy. Analyses assessed aesthetic and sensory preferences stratified by breast shape. We received 109 responses from women with a median age of 51 years (interquartile range, 47-58 years). Most women were White (94%) and married (68%), with more than a high school education (83%) and a family income of $100,000 or more (39%). Their surgical histories included mastectomy (n = 109, 100%), autologous breast reconstruction (n = 59, 54.1%), implant-based breast reconstruction (n = 49, 45.0%), and NAC reconstruction (n = 26, 23.7%). On round breasts, respondents preferred NACs positioned in the middle of the vertical axis and laterally on the horizontal axis. On teardrop-shaped breasts, respondents preferred inferolateral NAC positioning. The most popular NAC diameter was one third the base width of the breast. Respondents preferred NAC pigmentation one shade darker than skin tone. Respondents indicated that NAC appearance, tactile sensation, and erogenous sensation were more important for sexuality and quality of life than for self-esteem, body image, or gender identity. Optimal NAC aesthetics included a NAC one third the base width of the breast, pigmented one tone darker than skin tone, and positioned in the middle of the vertical axis and laterally on the horizontal axis on round breasts or inferolaterally on teardrop-shaped breasts.

Vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) can be difficult to distinguish, given their similar clinical presentations. This study was conducted to explore the clinical value of catecholamine levels in the differential diagnosis of VVS and PPS in children. This retrospective case-control study was conducted with data from children with VVS and PPS who underwent head-up tilt tests (HUTTs) at the Children's Hospital of Hebei Province between March 2021 and March 2023. The data collected were baseline clinical characteristics, HUTT results, serum catecholamine levels in the supine and upright positions, and 24 h urinary catecholamine concentrations. These variables were compared between the VVS and PPS groups. From 328 potentially eligible cases, 54 (16.46%) cases of VVS and 24 (7.32%) cases of PPS were included in the analysis. No significant difference in age, sex, body mass index, or syncope frequency was observed between the VVS and PPS groups. The main predisposing factors for syncope were body position changes in the VSS group (83.33%) and emotional changes in the PPS group (41.67%). The episode duration was significantly shorter in the VSS group than in the PPS group (4.01 ± 1.20 vs. 24.06 ± 5.56 min, p < 0.05). The recovery time was also shorter in the VVS group than in the PPS group (1.91 ± 0.85 vs. 8.62 ± 2.55 min, p < 0.05). Relative to patients with PPS, those with VVS had significantly higher serum epinephrine (EP) levels in the upright position [199.35 (102.88, 575.00) vs. 147.40 (103.55, 227.25), p < 0.05] and lower serum epinephrine levels in the supine position [72.70 (42.92, 122.85) vs. 114.50 (66.57, 227.50), p < 0.05]. Serum EP levels have potential value in the differential diagnosis of VVS and PPS.

Endotracheal tube cuff pressure (ETCP) is an important factor to determine the development of complications associated with invasive mechanical ventilation. To avoid preventable complications arising out of immobilization, frequent changes in body positioning are necessary. Such variations in body position can affect ETCP in critically ill patients who are on mechanical ventilation. So, our study aimed to assess the effect of changes in body position on ETCP in patients who are on mechanical ventilation. This prospective observational study included 31 critically ill intubated patients. Each study subject was first placed in a neutral starting position with a 30º head elevation. Then, they were subjected to a sequential change in body position based on the 16 most used positions as part of the critical care unit's (CCUs) daily routine. Endotracheal tube cuff pressure was measured after each position change. Data were analyzed using standard statistical tests. Statistically significant difference in ETCP was observed during anteflexion of neck, hyperextension of neck, left lateral flexion of neck, right lateral flexion of neck, left lateral rotation of neck, right lateral rotation of neck, 10o recumbent position, supine position, Trendelenburg position, and right lateral 30° and 45° positions. Maximum increase in ETCP was seen during anteflexion of neck (31 ± 4.5; 22-42 cm H2O). Our study demonstrates significant deviations in ETCP from the recommended range following changes in the body position of mechanically ventilated patients, highlighting the need for the measurement of ETCP after each position change and maintenance of the same within the target range. Roy O, Dasgupta S, Chandra A, Biswas P, Choudhury A, Ghosh S, et al. Relationship of Endotracheal Tube Cuff Pressures with Changes in Body Positions of Critically Ill Patients on Mechanical Ventilation: An Observational Study. Indian J Crit Care Med 2024;28(1):36-40.

Some patients with obstructive sleep apnea syndrome remove the CPAP device during sleep, although they start CPAP at bedtime. We hypothesized that body position changes and oxygen desaturations may be associated with patient removal of the CPAP device. We consecutively enrolled 36 poor CPAP adherers and 25 good CPAP adherers. Body positions and oxygen desaturations were evaluated when these subjects used CPAP during sleep for 2 nights, permitting the removal of the CPAP device during the recording. Twelve poor CPAP adherers exhibited subject removal of the CPAP device within 4 h from the start of body position recording. The frequency of body position changes was significantly higher within 15 min before the CPAP removal than during other periods when CPAP was used. At the same time, oxygen desaturations were significantly more frequent within 15 min before CPAP removal than during other periods when CPAP was used. In addition, the majority (66.7%) of the CPAP removal events were followed by a change from a supine position to a non-supine position within 5 min. The number of body position changes during the first 4-h recording was significantly higher in the poor CPAP adherers who had removed their CPAP device compared with the poor CPAP adherers who had not removed their device. However, the number of body position changes or oxygen desaturation index under CPAP during the first 4-h recording was not significantly different between the poor CPAP adherers and good CPAP adherers. Our findings are the first to indicate associations among CPAP removal, body position changes, and oxygen desaturations during sleep in poor CPAP adherers. However, our findings also indicated that most good CPAP adherers make frequent body position changes without removal of CPAP device, suggesting that patients can adapt to the discomfort of CPAP therapy at the time of body position changes.

Nipple-areolar complex (NAC) reconstruction can be broadly categorized into surgical reconstruction, tattooing, or both. NAC tattooing has shown continued advances recently, resulting in increased discussion of tattoo-only methods within the literature. This study aims to quantify recent trends in choice of NAC reconstruction and explore driving factors. Patients who underwent postmastectomy breast and NAC reconstruction between January 2007 and December 2021 at a single academic institution were reviewed and grouped based on method of NAC reconstruction: (1) surgical-only, (2) tattoo-only, and (3) both surgical and tattoo. Trends were assessed in each group using Poisson regression. The study included 138 patients; 17.4% (n = 24) were in the surgical-only group, 16.7% (n = 23) tattoo-only, and 65.9% (n = 91) both surgical and tattoo. Over the 15-year period, patients receiving tattoo-only NAC reconstruction significantly increased (β = 0.173, P < 0.0001), while those receiving both surgical and tattoo significantly decreased (β = -0.064, P = 0.007). There were no significant changes in surgical-only (β = 0.013, P = 0.563) or total (any type) NAC reconstruction (β = -0.013, P = 0.503). Rates of breast reconstruction significantly increased (β = 0.062, P < 0.0001). Variables such as autologous versus implant-based, unilateral versus bilateral, revision number, and radiation were stable over time and were not significantly associated with NAC reconstruction method. There is a significant trend toward tattoo-only and away from surgical-only reconstruction over the past 15 years, highlighting the importance of access to tattoo-based NAC reconstruction as part of comprehensive breast reconstruction care. The less invasive nature of tattooing and increase in tattoo quality are possible reasons for the increase in popularity.

Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM. Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire. Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM. We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer. 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 .

After massive weight loss, male breasts in particular are one of the most disturbing body regions and can be a difficult area to treat often requiring nipple-areola repositioning. The need for bilateral repositioning of the nipple-areola complex is also increasing in other surgical fields such as in female-to-male transsexual patients with large breasts and in patients with severe forms of gynecomastia. Proper configuration and localization of the nipple-areola complex requires both meticulous planning and a thorough understanding of the male anatomy and is essential in determining final aesthetic outcome. Currently available guidelines create areolas that are too large, place the nipple-areola complex too high and too far medially, and/or require complex abstract mathematical calculations. Relying on the recently appreciated aesthetic value of the golden number Phi (phi) we propose an easy and reliable method to determine the horizontal and vertical coordinates of the male nipples. With only 2 easily measurable distances, umbilicus-anterior axillary fold apex and umbilicus-suprasternal notch, the internipple distance and the position of the horizontal nipple plane relative to the suprasternal notch can be calculated. The internipple distance can be determined with 95% accuracy and the distance from the suprasternal notch can be determined in 80% of cases within a range of 3.33 +/- 1.25 cm.

Breast reconstruction using DIEP flap: The free flap alone be enough? Quality of life and satisfaction analysis after complementary surgeries

Normal subjects have a larger diffusing capacity normalized per liter alveolar volume (DL/VA) in the supine than in the sitting position. Body position changes total lung diffusing capacity (DL), DL/VA, membrane conductance (Dm), and effective pulmonary capillary blood volume (Qc) as a function of alveolar volume (VA). These functions were studied in 37 healthy volunteers. DL/VA vs. VA yields a linear relationship in sitting as well as in supine position. Both have a negative slope but usually do not run parallel. In normal subjects up to 50 yr old DL/VA and DL increased significantly when subjects moved from a sitting to a supine posture at volumes between 50 and 100% of total lung capacity (TLC). In subjects greater than 50 yr old the responses of DL/VA and DL to change in body position were not significant at TLC. Functional residual capacity (FRC) decreases and DL/VA increases in all normal subjects when they change position from sitting to supine. When DL/VA increases more than predicted from the DL/VA vs. VA relationship in a sitting position, we may infer an increase in effective Qc in the supine position. In 56% of the volunteers, supine DL was smaller than sitting DL despite a higher DL/VA at FRC in the supine position because of the relatively larger decrease in FRC. When the positional response at TLC is studied, an estimation obtained accidentally at a volume lower than TLC may influence results. Above 80% of TLC, Dm decreased significantly from sitting to supine. Below this lung volume the decrease was not significant. The relationship between Qc and VA was best described by a second-order polynomial characterized by a maximum Qc at a VA greater than 60% of TLC. Qc was significantly higher in the supine position than in the sitting position, but the difference became smaller with increasing age. In observing the sitting and supine positions, we saw a decrease in maximum Qc normalized per square meter of body surface area with age.

The nipple-areolar complex (NAC) is important from an aesthetic and functional standpoint for both sexes; however, methodology for NAC placement in men is less established. The objectives of this research are to determine normal measurements for NAC in the male Mexican population, its association with body mass index (BMI), and age, as well as presenting a reliable linear regression model for preoperative planning and placement. This study was carried out on the male population of the State of Mexico. NAC anthropometry was performed on 385 adult males. Descriptive statistics were used to determine measures of central tendency and dispersion. Spearman correlation test was performed in order to evaluate the linear association between age and BMI with anthropometry, and a linear regression model was generated for the measured variables. Finally, the predicted and measured values were compared. BMI is strongly correlated with NAC anthropometry, an association that is independent from age. NAC diameter was also independent from BMI and age, 2.25cm being the average. We provide the anthropometric values obtained, and a linear regression equationwhich might be used in preoperative planning to determine optimal NAC placement. This method covers a wide range of BMI and age values. 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 .

A novel approach to identify false positives due to body position changes during ST-segment monitoring

Introduction Chest masculinization is currently the most commonly performed gender-affirming surgery. It is often preceded by testosterone replacement therapy, whose duration is not agreed upon before surgery. Our study evaluates the postoperative satisfaction of transgender men who have undergone chest masculinization surgery according to their preoperative hormonal treatment duration. Material and methods We conducted a single-center prospective study conducted from 2021 to 2022. All transgender men older than 18 years who had chest masculinization surgery were included. Demographic data, medical history, operative data, and duration of preoperative hormone therapy were collected. Participants completed the BREAST-Q© and BODY-Q© questionnaires pre- and postoperatively. Results Forty-six patients were included, with a median age of 21 years (18–45 years). The median preoperative testosterone duration was 596 days (186–4479 days). A significant improvement was found in BREAST-Q© (psychosocial, sexual and physical well-being; satisfaction with chest) and BODY-Q© (satisfaction with chest and nipples) parameters (p < 0.01). There was no significant correlation between preoperative hormone therapy time and chest satisfaction of BREAST-Q© (ρ = 0.069; R2 = 0.002; p = 0.647) and BODY-Q© (ρ = –0.114; R2 = 0.007; p = 0.450). Conclusion All patients in our study were exposed to exogenous testosterone for at least six months. Our study suggests that satisfaction remains unchanged with a longer duration of usage, indicating that an extended period of hormone impregnation may not be necessary before performing chest masculinization surgery in transgender men. Furthermore, the findings confirm a significantly high post-operative satisfaction rate among participants, emphasizing the positive impact of this type of surgery.

The reconstruction of the nipple–areola complex (NAC) following breast reconstruction significantly improves the cosmetic result and enables the visual transformation of the newly created breast mound into the breast as an organ (Shestak, Revision of nipple areola reconstruction. In: Reoperative plastic surgery of the breast. Lippincott Williams & Wilkins, 2006). The NAC is generally performed as a second-stage procedure under local anaesthesia in a sterile operating theatre, often in combination with other minor revisions like lipomodelling or scar corrections. Accurate planning and mark-up is mandatory for bilateral symmetry of the NAC. In terms of timing, nipple reconstruction optimally has to allow the gravitational settling of the reconstructed breast mound (Shestak, Revision of nipple areola reconstruction. In: Reoperative plastic surgery of the breast. Lippincott Williams & Wilkins, 2006). The most popular techniques for nipple reconstruction combine local random skin flaps, sometimes composite flaps, with costochondral cartilage with tattooing procedure. These techniques are able to offer high level patient satisfaction. Problems mostly associated with nipple reconstruction include asymmetric bilateral nipple position, loss of nipple projection and partial or total nipple necrosis (Shestak, Revision of nipple areola reconstruction. In: Reoperative plastic surgery of the breast. Lippincott Williams & Wilkins, 2006).

Breast mound and nipple creation are the goals of the reconstructive process. Unlike in normal body mass index (BMI) women, breast reconstruction in the obese is associated with increased risk of perioperative complications. Our aim was to determine if reconstruction technique and the incidence of perioperative complications affect the achievement of reconstruction completion in the obese female. Consecutive obese women (BMI ≥30) who underwent mastectomy and implant or autologous reconstruction were evaluated for the completion of breast reconstruction. Two hundred twenty-five women with 352 reconstructions were included. Seventy-four women underwent 111 autologous reconstructions and 151 women underwent 241 implant-based reconstructions. Chemotherapy, radiation, and delayed reconstruction timing was more common in the autologous patients. Major perioperative complications (requiring hospital readmission or unplanned surgery) occurred more frequently in the implant group (p ≤ 0.0001). Breast mounds were completed in >98% of autologous cases compared with 76% of implant cases (p ≤ 0.001). Nipple areolar complex (NAC) creation was completed in 57% of autologous patients and 33% of implant patients (p = 0.0009). The rate of successfully completing the breast mound and the NAC was higher in the autologous patient group (Mound odds ratio or OR 3.32, 95% confidence interval or CI 1.36-5.28 and NAC OR 2.7, 95% CI 1.50-4.69). Occurrence of a major complication in the implant group decreased the rate of reconstruction completion. Obese women who undergo autologous breast reconstruction are more likely to achieve breast reconstruction completion when compared with obese women who undergo implant-based breast reconstruction.

Respiratory mechanics and the role of sex hormones in pregnancy are not well elucidated. We examined longitudinal and positional changes in lung mechanics in pregnancy and investigated the role of sex hormones. A longitudinal study enrolled 135 women with obesity in early pregnancy. Fifty-nine percent of women identified as White; median body mass index at enrollment was 34.4kg/m2. Women with respiratory disease were excluded. We obtained measurements of airway resistance and respiratory system reactance in various positions using impedance oscillometry and sex hormones in early and late pregnancy. With pregnancy progression, there was a significant increase in resonant frequency (Fres) (p = 0.012), integrated area of low frequency reactance (AX) (p = 0.0012) and R5-R20Hz (p = 0.038) in the seated position,and a significant increase in R5Hz (p = 0.000), Fres (p = 0.001), AX (p < 0.001 = 0.000), and R5-R20Hz (p = 0.014) in the supine position. Compared to the seated position, the supine position was associated with a significant increase in R5Hz, R20Hz, X5Hz, Fres, and AX in early (p-values < 0.026) and late pregnancy (p-values ≤ 0.001). Changes in progesterone levels between early and late pregnancy predicted the change in R5, Fres, and AX (p-values ≤ 0.043). Resistive and elastic loads increase with pregnancy progression and a change in body position from seated to supine increases resistive and elastic loads in both early and late pregnancies. The increase in airway resistance is primarily related to an increase in peripheral rather than central airways resistance. There was an association between the change in progesterone levels and airway resistance.