Debra L. Friedman, MD

  • Associate Professor of Pediatrics
  • E. Bronson Ingram Chair in Pediatric Oncology
  • Department of Pediatrics
  • Vanderbilt University School of Medicine
  • Cancer Control and Prevention Program Director
  • Division of Hematology-Oncology
  • Vanderbilt-Ingram Cancer Center
  • Nashville, Tennesee

Individ uals diagnosed with silicosis should be promptly removed from any further exposure to silica and treated with bronchodilators and supple mental oxygen as required treatment 11mm kidney stone purchase arava 10 mg with mastercard. Illnesses Associated with Silicosis A variety of illnesses have been identied as being associated with the different forms of silicosis as follows medications similar to lyrica purchase generic arava online. Tuberculosis Early observers noted that silicosis and tuberculosis frequently coex isted medicine you can overdose on order 10 mg arava. The clinical introduction of radiography medicine used to stop contractions purchase 20mg arava overnight delivery, as well as the introduction of tuberculin tests and sputum staining, allowed physicians to distinguish silicosis from other respiratory diseases, including tuberculosis. Nevertheless, mycobacterial in fections continue as common complications associated with all forms of 56 silicosis. Silicotic patients are often diagnosed with atypical mycobac teria, including Mycobacterium avium intracellulare and M. The standard of care for all patients suffering from silicosis requires a thorough search for the presence of mycobacterial species, especially if there are any documented functional or clinical declines in the patientscondition. Neoplastic Disease Currently, much controversy exists with regard to the potential carci 57,58 nogenicity of inhaled silica. This more recent review did not nd any evidence for a causal association between silicosis and lung 61 cancer. This assessment included studies that were not confounded by smoking or known exposure to specic occupational carcinogens. The assessment also looked at studies that were essentially free of bias, that used appropriate reference groups, and that did not involve compensation agreements. However, studies that could have included confounding exposures to chemicals such as radon, arsenic, or polycyclic aromatic hydrocarbons were not excluded as long as there was no demonstrated association with silicosis. The same study reported that the risk for lung cancer was increased in those patients who did not have either chronic bronchitis or 62 asthma. These investigators theorized that the presence of obstructive pulmonary disease may cause silica to be deposited in the more proximal regions of the lung preferentially, thereby potentially decreasing the risk 62 of silicosis and lung cancer. With regard to the question of a causal association between silicosis and lung cancer, the main scientic uncer tainty involves whether the lung cancer rates reported in descriptive studies are confounded by smoking history, socioeconomic status differ ences, and inappropriate comparison populations. It is also possible that some exposure-response studies may have failed to identify a real relationship between silica exposure and lung cancer (if one exists). It is important to note that signicant cancer risks in subjects listed on silicosis registries in the past may have been the result of selection and diagnostic bias. Consideration of the possible relationship between silica exposure and lung cancer conferring the same increased risk to subjects without silicosis and whether it is justiable to assume that quartz and cristobalite 63 have similar health effects are all important issues. Autoimmune Disease It has been suggested that silicosis may be associated with rheumatoid 20,64-66 arthritis, scleroderma, lupus, and progressive systemic sclerosis. Some silicosis patients may have serum antinuclear antibodies, rheuma toid factor, and elevated serum concentrations of various immunoglobu 65 lins and immune complexes. In addition, renal disease without pulmo nary changes has been associated with silica exposure and may manifest as nephritic syndrome or renal failure. Specically, some workers who are involved in the production of industrial sand, as well as ceramic and granite workers, reportedly have an increased incidence of end-stage renal 67,68 disease. An increased incidence of renal disease, including nephritic syndrome and glomerulonephritis, has been reported in Bedouin tribes people who are exposed to frequent dust storms, as well as individuals 69 who may have consumed water contaminated with silica. In such cases, immune complexes located in the glomerulus may be responsible for the 70 renal damage. Today, a variety of engineering controls and personal protective measures have been developed for sandblasters. Fully enclosed and ventilated blasting chambers may be utilized to minimize human expo sure to the dust generated during these operations. These chambers contain a series of baffies designed to selectively extract dust from the chamber environment. The venting system maintains a slight negative pressure within the chamber to pull the exhausted air away from the workerszone of inhalation. Personal protective equipment is recommended for sandblasters and others working in similar environments. This equipment includes cover alls, boots, and properly tted helmets supplied with ltered air. Blasting chambers and ventilation-ltration systems should be inspected and tested for integrity and functionality on a regular basis and workers should not spend extended periods of time inside a blasting chamber. A designated observer should oversee the process from a vantage point outside the chamber. Open-air sandblasting may not be as well monitored or controlled as closed sandblasting chambers. This type of sandblasting optimally should occur a safe distance away from other workers, and adequate ventilation should be provided. Workers employing open air sandblasting techniques should wear adequate respiratory protection. Federal guidelines have been established to minimize worker exposure to silica particles. In 2001, the American Conference of Industrial 3 Hygienists adopted a threshold limit value of 0. In the 1920s and 1930s, there were roughly 1000 deaths annually 75 attributed to silicosis. Despite this improvement in statistics, regulatory compliance is often difficult to monitor, and violations may occur. In addition, worksites with inadequate respiratory protection and work sites that have not established medical surveillance programs are reported 73 to be at higher risk for silicosis. Samples collected during inspections of the construction and fabricated metal product industries revealed that over one-third of samples exceeded the permissible exposure 75 limit. Consequently, it is clear that continued efforts are needed to train and supervise workers to promote worker safety with regard to silica exposure. This program focused on 77 workplace inspections where silica exposure was expected. Conclusion Silicosis has been a historically important occupational disease and continues to be a concern. Workers who may be exposed to high concentrations of free crystalline silica in unprotected settings may be at risk for developing pulmonary brosis, mycobacterial infection including tuberculosis, autoimmune disease, and lung cancer. Optimally, silica-containing materials should be replaced; work processes should be isolated and enclosed; adequate ventilation should be provided, and personal protective equipment used at all times of possible silica exposure. Silicosis is expected to be an occupational medical concern for the foreseeable future on a worldwide scale since many countries do not maintain or enforce appropriate regulations controlling silica exposure for workers. Piezoelectric properties of quartz and cristobalite airborne particulates as a cause of adverse health effects. Signalling pathways controlling the production of inammatory mediators in response to crystalline silica exposure: role of reactive oxygen/ nitrogen species. Fibrogenic activity of different forms of free silica; the action of fused silica, quartz, cristobalite, and tridymite on the livers of mice. The action of int of variable size injected at constant weight and constant surface into the lungs of rats. Policy and Position Statement: Medical surveillance of workers exposed to crystalline silica. Asbestos bers and silica particles stimulate rat alveolar macrophages to release tumor necrosis factor. Enhanced interleukin 1 production by alveolar macrophages and increase in Ia-positive lung cells in silica-exposed rats. Silica-stimulated monocytes release broblast proliferation factors identical to interleukin 1. Persistent overexpression of interleukin 1beta and tumor necrosis factor-alpha in murine silicosis. Association of tumor necrosis factor-alpha and interleukin-1 gene polymorphisms with silicosis. Morphologic characterization of alveolar macrophages from subjects with occupational exposure to inorganic particles.

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The use of loading doses of warfarin is not postoperatively) are at lower risk of recurrence moroccanoil treatment buy arava 20 mg low price. Consider lower doses for patients who are elderly treatment vaginal yeast infection generic 10mg arava otc, debilitated treatment venous stasis order 10mg arava otc, have liver disease or heart failure xerogenic medications purchase arava with mastercard, or In general, patients with a first episode of venous thrombosis who are on medications which are known to increase should receive 3 months of anticoagulation. Therefore, the duration of therapy combined analysis of 7 studies reveals that 19 of 1283 must be determined individually, considering risks for patients (1. Since the list of medications that interact with warfarin is lengthy, advise Assessing risk after discontinuing warfarin. Giving them a written list of potential testing one month after completion of warfarin therapy. An interactions (such as a package insert or patient education elevated D-dimer suggests ongoing increased risk, sheet) may be helpful. Discuss the risk of recurrence 15% rate of recurrence among those with an abnormal D with the patient and decide on a plan together. Resumption of warfarin among those with abnormal D-dimers reduced the recurrence rate to 2. Table 13 pregnancy, because of compression effects on the left iliac addresses duration of anticoagulation (minimum of 3 months vein. Antithrombin, protein C, embryopathy with warfarin and the higher risk of fetal and protein S deficiencies do not appear strongly associated, intracranial hemorrhage at the time of delivery with warfarin. This prophylactic dosing should be stopped 24 hours prior to anticipated delivery. Use of unfractionated heparin near delivery Screen women who have a history of recurrent early is helpful as it can be stopped closer to the time of delivery, pregnancy loss (more than 3) or any late pregnancy loss for thus minimizing the duration of time without antiphospholipid antibodies. Warfarin does not cross into compression ultrasound is the test of choice as it has similar breast milk in active form, and may be used during nursing. Serum testing with D-dimer level as an adjunct is not as reliable for Anticoagulation facilitation. Institutional services and patients with low pretest clinical likelihood compared to non home monitoring can improve anticoagulation pregnant patients. A dedicated evaluated a higher threshold based on trimester and found anticoagulation management service (eg, that this modification could be reliable; however, standard. These patients may poorly-adherent free-floating thrombus (though the only benefit from catheter-directed pharmacomechanical prospective study does not support this indication), and for thrombolysis, which includes various techniques of safely patients with malignancy at risk of hemorrhage if eliminating the occlusive clot and restoring lumen patency anticoagulated. Treatment should be delivered within 2 for elderly patients with isolated long bone fractures, weeks of symptom onset, and typically requires 2-3 days of comatose patients with severe head injury, patients with inpatient therapy. Because this field is rapidly evolving, multiple long bone and pelvic fractures, and spinal cord discuss prospective candidates for this therapy with vascular patients with para or quadriplegia, because case studies surgery or interventional radiology. The defined removal guidelines do not yet exist, so consultation significant risk of systemic bleeding with systemic on a case-by-case basis is required. Retrievable filters vary thrombolysis must be balanced against the relatively in their recommended windows for percutaneous extraction, uncertain benefit. The most common reason for failing to retrieve a filter is loss of the patient to medical In cases of hemodynamic instability, consider systemic follow-up. In clinical series, retrieval rates have been thrombolysis in the absence of a high risk of bleeding, using reported as low as 20%. Patients with such placements situation are best managed in the inpatient setting. Secondary Prevention and Prophylaxis Long-term secondary prevention after discontinuing anticoagulation. The benefit is primarily in adult patients risk patient population or in younger patients is unknown. The protective effect is specific to statins as compared to non-statin lipid lowering medications. When results from these two trials were combined, can also help reduce symptoms of post-thrombotic low-dose aspirin resulted in a 32% reduction in recurrent syndrome. It can cause significant Patients with cancer, thrombophilia, symptomatic morbidity in the form of pain, swelling, skin breakdown and atherosclerosis, and bleeding during initial anticoagulation ulcerations. Therefore, the benefit of highest with iliocaval thrombosis, and diminishes with more low-dose aspirin is unclear for these patient populations. At present, data are insufficient to recommend years after the initial thrombosis. Of the 82 patients with no combined oral contraceptive or hormone replacement prophylaxis, four (4. Data are conflicting on whether can transiently reduce the levels of antithrombin, protein C, smoking status represents an independent risk factor for and protein S. Heparin treatment can reduce Related Treatment Issue: antithrombin activity and antigen levels and interfere with Superficial Venous Thrombosis. Warfarin treatment can increase antithrombin levels and will Treatment of superficial thrombophlebitis depends on the reduce protein C and S levels as they are vitamin K extent and location of thrombus burden. Thrombosis risk also appears to be increased for burden (thrombus measuring at least 5 cm in length and prolonged travel by car, train, or bus. Venous thromboembolism is a serious Evidence is insufficient to recommend routine use of condition caused by a blood clot forming in the deep veins. Patients may be hospitalized while determining the risk factors against both the risks and benefits of amount of blood thinner they need. The initial prospective literature searches for this project were performed on Medline in 1996, 1997, 2002, and 2008. Call your doctor if you have any the current update is based on a supplemental literature abnormal bleeding while on blood thinners. Seek reviewed the overlapping literature search results published emergency care if you develop sudden chest pain or in the American College of Chest Physician evidence-based shortness of breath. Major key words were: pulmonary embolism and deep venous thrombosis Related National Guidelines thrombophlebitis (includes venous thromboembolism, thromboembolism, venous thrombosis), guidelines, this guideline is consistent with the following national controlled trials, meta-analyses. Additional search terms for guidelines: diagnosis were: primary risk factors (hereditary American College of Chest Physicians, Antithrombotic predisposition for clotting, estrogen [women], tobacco, etc. The search was supplemented with very recent clinical trials known to expert members of the panel. The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges Acknowledgements and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant the following individuals are acknowledged for their relationships with commercial companies whose products or contributions to previous versions of this guideline. Disclosure of a relationship is not intended to suggest bias in the information presented, but is 1998: Lee A. Hematology Am Soc Hematol Educ Medicine, Family Medicine, General Medicine, Nuclear Program. Medicine, Pulmonary & Critical Care Medicine, Radiology, Surgery, and Vascular Surgery. Development of idraparinux and testing for prevention of recurrent venous thromboembolism. Diagnosing thrombosis and venous thromboembolism: A large, acute pulmonary embolism. Management of deep vein thrombosis and Cleveland Clinic Center for Continuing Education, 2010. Med Clin N Am Diagnosis and treatment of deep venous thrombosis and 95:1203-1222, 2011. Multidetector computed tomography for assessing clinical probability of pulmonary embolism. Prediction of pulmonary of the Guidelines from Scientific Societies and Working embolism in the emergency department: the revised Geneva Groups. Fixed dose subcutaneous low Thoracic Society/Society of Thoracic Radiology clinical molecular weight heparins versus adjusted dose practice guideline: Evaluation of suspected pulmonary unfractionated heparin for venous thromboembolism. American Journal of respiratory and Cochrane Database of Systematic Reviews Issue 4:2002. Clinical Decision Rules for ultrasonographic imaging in outpatients with suspected Excluding Pulmonary Embolism: A Meta-analysis.

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Regular injections (daily permatex rust treatment safe arava 20 mg, every-other-day or bi weekly) simply become a part of your day-to-day existence chapter 9 medications that affect coagulation discount arava 20 mg otc, just like brushing your teeth or walking your dog medications parkinsons disease arava 20mg low price. When you perform your rst successful injection symptoms of anxiety discount arava online, you will realize how simple and painless it actually is. Syringe, Needle Gauge, and Withdrawing Syringes come in lots of sizes, so to keep the math of your tes tosterone dosage simple, we recommend your physician to provide you with 1 mL syringes. The barrel portion of the syringe will have units of measure from 3 mL in the form of tick marks along the side (see the picture on next page). You then replace the 18 gauge needle attached to the syringe with a thinner (smaller) 26-28 gauge injection needle (while the solution is still in the barrel) prior to injecting yourself. For an incredibly informative website on safe and proper injection techniques, along with the correct use of syringes and needles, visit Vitality Medical166. This is another reason to focus on losing excess body fat: Being lean makes your injections far easier! Where To Inject the Needle, and How to Inject Yourself Safely It is safest to inject testosterone into the following muscle areas: deltoids, gluteus, or upper/outside quadriceps. Crisler are successfully using subcutaneous injection protocols with hundreds of patients. This means that one would have to try this form of therapy out for himself to see how his body responds. In jecting testosterone subcutaneously into men with higher body fat levels *might* lead to greater estradiol (E2) conversion, and the resulting side efects that come with greater levels of estrogen. Although we were reluctant to support this delivery system back then, subcutaneous injections are now a well-recognized delivery system backed by solid research data173. We both acknowledge 172 Intra-adipose sex steroid metabolism and body fat distribution in idiopathic human obesity. Patient satisfaction with testosterone replacement therapies: the reasons behind the choices. The most hygienic way to dispose of your used syringes is by purchasing a Sharps Container Biohazard Needle Disposal container (or check174 container), or check with your local waste management company as they sometimes have suggestions. Minimizing Scar Tissue Formation with Foam Rolling and Myofascial Release A foam roller175 and/or a Beastie Ball176 are essential home tools to break up scar tissue that forms at injection sites. Again, using foam rollers and the Beastie Ball will also help as a personal form of therapy. Again, your primary goal is to achieve balance (dened as feeling good without side efects) between your levels of testosterone (both free and total) and estrogen (E2). Often times, an inability to alleviate side efects forces men to prematurely end their treatment altogether. As we stress throughout this book (and will continue to do so), it is crucial that you keep detailed records of your blood panels in order to best understand your test results as they change over time. Es trogen is actually composed of three difer ent forms183, including one that plays a huge role in how men feel: estradiol (E2). It has profound implications for general health and has the potential to cause some very unpleasant symptoms if its levels are unbalanced. As testosterone levels decrease and estradiol levels increase, the ratio of free testosterone to estradiol reaches a critical point where high estrogenic side efects are more noticeable184: Sexual dysfunction (poor erectile strength), lack of libido/ arousal, poor sleep and reduced insulin sensitivity are just some of them. Unfortunately, a man can have side efects when sufering from both low and high levels of estrogen. Believe it or not, the single biggest determinant of whether estra diol (E2) is out of balance or not is erectile strength. When a man is unable to maintain a strong erection, this is normally the sign of excess E2 (estrogen) production. There is nothing more psychologically damaging to a man than be ing unable to perform sexually when the op portunity arises. Some men genetically overproduce aromatase (the enzyme necessary for the conversion of testosterone to estrogen), leading to increased estrogen production and its potentially negative side efects. There is a narrow therapeutic estrogen (E2) range in which a patient feels good when balancing estrogen and testosterone, while initiating and adhering to lifelong optimization at the same time. In our opinion, there is no cookie-cutter range of values within which men should attempt to keep their E2 levels. Doing so will help establish a legitimate baseline between testosterone and estrogen. Therefore, they should be aware that the normal E2 test overestimates estradiol in men. Furthermore, if you recall, earlier in the book we mentioned that one of the main reasons Dr. There are numerous medications men take to prevent thinning hair from receding entirely. If your hair is that important to you, we recommend you try a topical application to directly afect the hair at its root. You can read much more about the causes of hair loss and available topical treatments on the Excel Male forums192. There are exciting new developments in regard to hair transplants, such as Hair Cloning(which is likely to be available soon). As more and more men continue to re port these side efects to health and regulato ry agencies worldwide, medical and scientic communities are only beginning to realize the scope of the problem. For those men who were prone to incidences of acne in their teen years, testosterone can cause are-ups on their backs and shoulders later on. Fasting via the lifestyle protocols found in our book the Metabolic Blowtorch Diet: How to Optimize Intermittent Fasting 193. There is also a genetic component to acne and some men may do well by consulting a dermatologist for severe issues. Studies have found that high pro lactin levels in men (>30 ng/dL), a condition known as hyperprolactinemia, are linked to low sexual desire, erectile dysfunction and galactorrhea.

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Consultation is readily accomplished when a surgeon practices as part of an interdisciplinary health care team symptoms of mono buy arava 10mg with mastercard. In the absence of this 20 medications that cause memory loss 10 mg arava sale, a surgeon must be condent that the referring mental health professional(s) symptoms 3 dpo order 10 mg arava overnight delivery, and if applicable the physician who prescribes hormones medications you cant donate blood order arava 10mg without a prescription, is/are competent in the assessment and treatment of gender dysphoria, because the surgeon is relying heavily on his/her/their expertise. Once a surgeon is satised that the criteria for specic surgeries have been met (as outlined below), surgical treatment should be considered and a preoperative surgical consultation should take place. During this consultation, the procedure and postoperative course should be extensively discussed with the patient. These discussions are the core of the informed consent process, which is both an ethical and legal requirement for any surgical procedure. Ensuring that patients have a realistic expectation of outcomes is important in achieving a result that will alleviate their gender dysphoria. All of this information should be provided to patients in writing, in a language in which they are uent, and in graphic illustrations. The elements of informed consent should always be discussed face-to-face prior to the surgical intervention. Questions can then be answered and written informed consent can be provided by the patient. Because these surgeries are irreversibile, care should be taken to ensure that patients have sufficient time to absorb information fully before they are asked to provide informed consent. Surgeons should provide immediate aftercare and consultation with other physicians serving the patient in the future. Patients should work with their surgeon to develop an adequate aftercare plan for the surgery. Overview of Surgical Procedures for the Treatment of Patients with Gender Dysphoria For the Male-to-Female (MtF) Patient, Surgical Procedures May Include the Following: $. Nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipolling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipolling), hair reconstruction, and various aesthetic procedures. For the Female-to-Male (FtM) Patient, Surgical Procedures May Include the Following: $. Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipolling, pectoral implants, and various aesthetic procedures. Aesthetic or cosmetic surgery is mostly regarded as not medically necessary and therefore is typically paid for entirely by the patient. Unfortunately, in the eld of plastic and reconstructive surgery (both in general and specically for gender-related surgeries), there is no clear distinction between what is purely reconstructive and what is purely cosmetic. Most plastic surgery procedures actually are a mixture of both reconstructive and cosmetic components. While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures. Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Based on the available evidence and expert clinical consensus, different recommendations are made for different surgeries. The number and sequence of surgical procedures may vary from patient to patient, according to their clinical needs. Criteria for Breast/Chest Surgery (One Referral) Criteria for mastectomy and creation of a male chest in FtM patients: $. If signicant medical or mental health concerns are present, they must be reasonably well controlled. Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum $" months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results. Criteria for Genital Surgery (Two Referrals) the criteria for genital surgery are specic to the type of surgery being requested. Criteria for hysterectomy and salpingo-oophorectomy in FtM patients and for orchiectomy in MtF patients: $. If signicant medical or mental health concerns are present, they must be well controlled. The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention. These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria. Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients: $. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualied mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, "##&). The duration of $" months allows for a range of different life experiences and events that may occur throughout the year. During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. In some situations, if needed, health professionals may request verication that this criterion has been fullled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable. Surgery for People with Psychotic Conditions and Other Serious Mental Illnesses When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing. It is preferable that this mental health professional be familiar with the patient. No surgery should be performed while a patient is actively psychotic (De Cuypere & Vercruysse, "##%). Competency of Surgeons Performing Breast/Chest or Genital Surgery Physicianswhoperformsurgicaltreatmentsforgenderdsyphoriashouldbeurologists,gynecologists, plastic surgeons, or general surgeons, and board-certied as such by the relevant national World Professional Association for Transgender Health &! Surgeons should have specialized competence in genital reconstructive techniques as indicated by documented supervised training with a more experienced surgeon. Even experienced surgeons must be willing to have their surgical skills reviewed by their peers. An official audit of surgical outcomes and publication of these results would be greatly reassuring to both referring health professionals and patients. Surgeons should regularly attend professional meetings where new techniques are presented. The internet is often effectively used by patients to share information on their experience with surgeons and their teams. Ideally, surgeons should be knowledgeable about more than one surgical technique for genital reconstruction so that they, in consultation with patients, can choose the ideal technique for each individual. Alternatively, if a surgeon is skilled in a single technique and this procedure is either not suitable for or desired by a patient, the surgeon should inform the patient about other procedures and offer referral to another appropriately skilled surgeon. Breast/Chest Surgery Techniques and Complications Although breast/chest appearance is an important secondary sex characteristic, breast presence or size is not involved in the legal denitions of sex and gender and is not necessary for reproduction. The performance of breast/chest operations for treatment of gender dysphoria should be considered with the same care as beginning hormone therapy, as both produce relatively irreversible changes to the body. It is usually performed through implantation of breast prostheses and occasionally with the lipolling technique. Infections and capsular brosis are rare complications of augmentation mammoplasty in MtF patients (Kanhai, Hage, Karim, & Mulder, $%%%).

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