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BACKGROUND: Societal awareness of transgender individuals has led to increased acceptance and demand for sex-confirming surgery. In female to male transsexuals, the most common procedure is removal of breast tissue to masculinize the chest. METHODS: Eighty-eight transgender patients underwent either a subcutaneous nipple-sparing mastectomy (NSM) with or without a periareolar mastopexy or nipple reduction, or bilateral mastectomies with free nipple grafts (MFNG) with or without nipple reduction. Surgical techniques are discussed. Demographic data, use of testosterone, specimen weights, rates of wound dehiscence, infection, hematoma, hypertrophic scars, nipple loss, and revision surgery were all assessed. RESULTS: Of the 88 patients in the study, 40 underwent NSM and 48 underwent MFNG. Patients undergoing NSM were 4.1 times more likely to have a hematoma compared with patients undergoing MFNG (P <0.05). Mastectomy weight was not correlated with the occurrence of hematoma (P >0.80). Only 1 patient who underwent NSM required revision, whereas 5 patients in the MFNG patient population underwent revision. Patients were more likely to have hypertrophic scarring with the MFNG technique (0% vs 25%, P < 0.01) There were no infections, no wound dehiscence, and no nipple loss in any patient. Eighty-three percent of the patients who responded to a satisfaction survey (57/88) were very satisfied with their result, and 100% would recommend this procedure to other transgender individuals. CONCLUSIONS: Female to male transgender mastectomy can be performed with low complication rates and high satisfaction. Nipple-sparing mastectomy were more likely to have a hematoma than patients undergoing MFNG.

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Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

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BACKGROUND: An improved method for mesh repair of ventral/incisional hernias after component separation is presented. The use of a Carter-Thomason suture passer (Cooper Surgical, http://www.coopersurgical.com) allows for safe passage of preplaced sutures on the mesh from within the abdominal cavity through the anterior rectus sheath. This "inside-out" method makes the underlay of mesh fast and easy by improving visualization and control of sharp instruments as they are passed through the abdominal cavity. Preplacement of sutures circumferentially on the mesh also improves the distribution of tension around the repair, which may ultimately reduce the risk of hernia recurrence. METHODS: The "inside-out" technique was performed on 23 patients at a single tertiary academic medical center from November 2011 to February 2014. We have followed these patients for a median of 24.5 months to assess for postoperative complications and hernia recurrence. RESULTS: We report an acceptable hernia recurrence rate (2 of 23 = 8.7%). One recurrence was observed in a patient who underwent repair of a recurrent ventral hernia and the other had significant loss of domain requiring an inlay mesh. CONCLUSIONS: The "inside-out" technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable. We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique.

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Primary spontaneous cerebral spinal fluid (CSF) rhinorrhoea is a rare disease associated with female gender, obesity and empty sella syndrome. The authors describe the case of a 59-year-old woman who presented to her primary care physician with a 2-week history of drainage of a clear fluid from her right nostril that was initially treated as allergic rhinitis. A non-contrast CT scan revealed mucosal thickening in the right sphenoid sinus and a possible defect in the adjacent skull base. The patient initially declined a CT cisternogram, which provides greater sensitivity in assessing for a CSF leak. Nasal secretions tested positive for ß-2-transferrin, which is highly sensitive and specific for CSF. After conservative interventions failed, a pedicled septal mucoperichondrial flap was used to patch the skeletal defect. At her 5-month follow-up, the patient remains asymptomatic.

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