Background: The purpose of this Web-based survey was to elucidate the current perspectives of plastic surgery residency program directors on training residents to perform gender-affirming surgery. Methods: Web-based surveys were distributed to 79 plastic surgery program directors. Demographic information and perspectives on training of gender-affirming surgery in plastic surgery residency were queried. Results: Of 79 distributed surveys, there were 43 responses (54 percent). Overall, program directors reported that their trainees were prepared to address plastic surgery–related transgender concerns (67 percent), and believe plastic surgeons are the most appropriate specialty referral for each type of gender-affirming surgery (top/chest, 98 percent; facial, 95 percent; and bottom/genital, 79 percent). Ninety-three percent of program directors noted that transgender surgery is becoming more accepted and/or practiced in their referral area, with 26 percent reporting a dedicated clinic experience. There was a mixed response on the need for additional fellowship training for gender-affirming surgery. Residents are exposed to significantly more bottom (p = 0.0018), top (p = 0.0013), and facial operations (p = 0.00005) if they rotate through a “gender” clinic. Conclusions: Of the queried program directors, the majority feel their residents are well-trained in gender-affirming surgery. However, residents have more clinical exposure in facial and top (chest) gender-affirming surgery as compared to bottom (genital) surgery. Although most program directors agree that plastic surgeons are the most important referral for top, bottom, and facial operations, there is less consensus over the role of fellowship training. Most program directors reported a desire to devote additional CME time to the topic in the coming years.

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Purpose: To analyze the clinical presentation, course, and management in a large cohort of pediatric acute dacryocystitis subjects and to examine whether hospitalization and urgent surgical intervention are indeed mandatory. Methods: A retrospective analysis of all pediatric subjects diagnosed with dacryocystitis at the Children’s Hospital of Philadelphia over a 12-year period (2009–2020). Results: One-hundred sixty-nine pediatric acute dacryocystitis patients were included in this study. Management included admission in 117 cases (69%). Sixty-eight patients (40%) were treated medically with no surgical intervention, 75 cases (44%) required urgent surgical intervention, and 26 additional cases (15%) required surgery due to persistent tearing symptoms after medical management. The urgent procedures included most commonly: 1) endonasal examination and microdebridement of intranasal cysts in 26 cases (35%); 2) probing and irrigation without examination and microdebridement, with or without stent intubation, in 30 cases (40%); and 3) dacryocystorhinostomy (13 endonasal and 4 external) in 17 cases (23%). Conclusions: Management of pediatric acute dacryocystitis should be tailored individually for each case. Hospital admission and early surgical intervention are not mandatory, as 31% of cases resolved without admission, and 56% without early surgical intervention. Although a specific age cutoff is not plausible, hospital admission for younger patients is more commonly advocated. When surgical intervention is indicated, endonasal examination and microdebridement of any associated intranasal cyst and probing with possible stenting are the initial procedures of choice. Dacryocystorhinostomy is reserved for more complex obstructions. Although pediatric acute dacryocystitis is an infection with serious potential problems, when managed appropriately, complications are rare.

Background: Perineal keloids can have an overwhelming impact on patients’ lives including pain, skin breakdown, infection, and interference with intercourse. There is a paucity of literature addressing the effective treatment techniques. Cases: Three case of perineal keloid treatment, with at least 13-month follow up, are presented. All patients are African American females who were recommended a treatment plan that combined surgical wide local excision and radiation therapy. All patients had aesthetically acceptable outcomes with recurrence-free results at least 13-months post procedure. Conclusions: These three cases describe the successful treatment of perineal keloids that utilize a combination of surgical excision with targeted radiotherapy. This approach can be offered to patients with recurrent keloidal masses and the presented principles can be utilized to achieve recurrence-free results. Teaching Points: 1. Readers will understand the basics of the pathophysiology of keloid formation and their effect on patients who experience them in sensitive areas such as the mons, vulva, and/or lower abdomen. 2. Readers will be able to describe and implement the described technique for management of keloids in these potentially sensitive areas.

Purpose:The surgical management of congenital dacryocystoceles has evolved in recent decades. The aim of this study was to explore the effectiveness of endoscopic examination and powered microdebridement in the management of nasal cysts associated with congenital dacryocystoceles.Methods: In this retrospective case series, all patients with congenital dacryocystoceles who underwent surgical intervention under general anesthesia at a single institution over a 12-year period (2009-2020) were included.Results: Thirty-seven lacrimal drainage systems from 29 patients were included, 8 patients (28%) had bilateral dacryocystoceles. Twenty-two (76%) were females, and 5 (17%) patients had a history of prematurity. Mean (±SD) age at diagnosis was 15 ± 28 days, and 1.4 ± 1.7 months at surgical intervention. Mean follow-up was 7.5 months. The right side was more commonly involved (20 [69%] OD vs. 17 [59%] OS). Dacryocystitis was diagnosed at presentation in 23 lacrimal drainage systems (62%). Intraoperatively, intranasal cysts were observed in 32 lacrimal drainage systems (86%), and a powered microdebrider was used to excise each cyst. In 6 of the 21 supposed unilateral cases (29%), a contralateral cyst was identified and treated. The average birth age of patients with intranasal cysts was 39 weeks versus 36 weeks of patients without (p = 0.03). Surgical success was found in 36 of 37 sides treated (97%); one case (3%) underwent unilateral endoscopic dacryocystorhinostomy during the follow-up period due to persistent symptoms.Conclusions: Congenital dacryocystoceles are associated with intranasal cysts in most cases. Surgical intervention with microdebrider is associated with a favorable outcome. Bilateral endonasal examination is ideal in all cases.

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