Identification and specification of the mouse skeletal stem cell.

How are skeletal tissues derived from skeletal stem cells? Here, we map bone, cartilage, and stromal development from a population of highly pure, postnatal skeletal stem cells (mouse skeletal stem cells, mSSCs) to their downstream progenitors of bone, cartilage, and stromal tissue. We then investigated the transcriptome of the stem/progenitor cells for unique gene-expression patterns that would indicate potential regulators of mSSC lineage commitment. We demonstrate that mSSC niche factors can be potent inducers of osteogenesis, and several specific combinations of recombinant mSSC niche factors can activate mSSC genetic programs in situ, even in nonskeletal tissues, resulting in de novo formation of cartilage or bone and bone marrow stroma. Inducing mSSC formation with soluble factors and subsequently regulating the mSSC niche to specify its differentiation toward bone, cartilage, or stromal cells could represent a paradigm shift in the therapeutic regeneration of skeletal tissues.

Utilization of Virtual Consultations in Facial Plastic Surgery during the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic affected many aspects of medical practice, particularly surgical fields. The American College of Surgery initially recommended the cancellation of all elective procedures. As a result, virtual consultations (VCs; a form of telemedicine), became widely used in the field of facial plastic and reconstructive surgery. With more facial plastic and reconstructive surgeons (FPRS) conducting both in-person and virtual visits, it is imperative to understand how VCs are utilized in practice. METHODS: An electronic, anonymous survey was distributed to 1,282 electronic mail addresses in the 2018 American Academy of Facial Plastic and Reconstructive Surgery directory. The survey collected responses on various topics including demographic information and past, current, and future use of VCs. RESULTS: The survey yielded 84 responses. Most surgeons (66.7%) were 11+ years out of fellowship. There was a significant increase in the percentage of VCs scheduled after the pandemic than before (p = 0.03). FPRS most frequently responded that VCs should always be followed by an in-person visit (48.6%). A majority of FPRS (66.2%) believe that VCs have improved the delivery of health care in at least some cases. Almost all FPRS (86.5%) plan on using VCs after the pandemic. CONCLUSION: Since the pandemic, VCs are more frequently used by surgeons and are mostly utilized as an initial patient visit. A majority of FPRS believe that VCs have improved health care in at least some cases, and plan on using VCs after the pandemic.

Telemedicine trends at a comprehensive cancer center during the first wave of the COVID-19 pandemic.

INTRODUCTION: This article reports on the effects of an early outbreak during the COVID-19 pandemic on visit volume and telehealth use by various specialists at a comprehensive cancer center. MATERIALS AND METHODS: The number of on-site and telehealth visits (THV) for medical and surgical specialties were obtained from scheduling software. RESULTS: Total visits were most drastically limited in April 2020 to a low point of 3139; THV made up 28% of all visits. For head and neck surgery, THV made up 54% and 30% of visits in April and May, respectively. Other specialties, such as psychiatry and palliative care, had higher levels of THV. For most specialties, the rebound in June through September did not make up for visits lost during the outbreak, and fiscal year  (FY) 2020 had a 9% loss from FY 2019 with 5786 fewer total annual visits across all specialties. CONCLUSIONS: While telemedicine was a helpful part of this cancer center's response to the initial COVID-19 surge, it was not able to replace the in-person services offered at the same center. The main strategy of physicians at this cancer center was to defer care, with telemedicine being an auxiliary response.

The Potential Impact of COVID-19 on Aesthetic Fellowship Programs.

BACKGROUND: The COVID-19 pandemic has brought about immense change in health care. Surgical specialties in particular have had to make major adjustments because of the cancellation of nonemergent surgeries. Aesthetic surgery fellowships are uniquely affected because of the high number of elective cases and the length of the fellowship. The impact of the COVID-19 pandemic on current and upcoming aesthetic surgery fellows has not been studied. OBJECTIVE: The aim of this article was to study the potential impact of the COVID-19 pandemic on both American Society for Aesthetic Plastic Surgeons-endorsed and nonendorsed aesthetic fellowship programs. METHODS: A 23-question anonymous web-based survey was sent to aesthetic surgery fellowship directors with an active program in the United States. Surveys were collected from April 18, 2020, through May 14, 2020, with Qualtrics and then analyzed with Microsoft Excel. A 7-question follow-up survey was sent to directors, and a 23-question survey was sent to aesthetic surgery fellows. Data for these surveys were collected from June 6, 2020, through August 18, 2020. The surveys asked questions pertaining to adjustments and impact on current fellow training, as well as possible impact on fellows starting in 2020 and 2021. RESULTS: There was a 65.5% (19 of 29) response rate for the initial director survey, a 31% (9 of 29) rate for the director follow up survey, and a 28% (9 of 32) rate for the fellow-specific survey. All directors and fellows reported that the pandemic had some impact on aesthetic fellow training. A total of 5.3% of directors reported that they believe COVID-19 would have a "significant impact" on their fellows becoming well-trained aesthetic surgeons, whereas 66.7% of fellows reported that it will have a "mild impact." Predicted impact on future fellows was not as significant. CONCLUSION: Telemedicine, educational efforts, and standardization of guidelines can be increased to minimize loss of training due to COVID-19. Ongoing evaluation and shared experiences can assist fellowships in customizing programs to provide well-rounded education during the pandemic.

Wounds Inhibit Tumor Growth In Vivo.

OBJECTIVE: The aim of this study was to determine the interaction of full thickness excisional wounds and tumors in vivo. SUMMARY OF BACKGROUND DATA: Tumors have been described as wounds that do not heal due to similarities in stromal composition. On the basis of observations of slowed tumor growth after ulceration, we hypothesized that full thickness excisional wounds would inhibit tumor progression in vivo. METHODS: To determine the interaction of tumors and wounds, we developed a tumor xenograft/allograft (human head and neck squamous cell carcinoma SAS/mouse breast carcinoma 4T1) wound mouse model. We examined tumor growth with varying temporospatial placement of tumors and wounds or ischemic flap. In addition, we developed a tumor/wound parabiosis model to understand the ability of tumors and wounds to recruit circulating progenitor cells. RESULTS: Tumor growth inhibition by full thickness excisional wounds was dose-dependent, maintained by sequential wounding, and relative to distance. This effect was recapitulated by placement of an ischemic flap directly adjacent to a xenograft tumor. Using a parabiosis model, we demonstrated that a healing wound was able to recruit significantly more circulating progenitor cells than a growing tumor. Tumor inhibition by wound was unaffected by presence of an immune response in an immunocompetent model using a mammary carcinoma. Utilizing functional proteomics, we identified 100 proteins differentially expressed in tumors and wounds. CONCLUSION: Full thickness excisional wounds have the ability to inhibit tumor growth in vivo. Further research may provide an exact mechanism for this remarkable finding and new advances in wound healing and tumor biology.

Fellow selection protocols in sleep surgery: a national survey of sleep surgery program directors.

PURPOSE: To determine the factors that sleep medicine/surgery fellowship program directors look for in applicants. METHODS: Program directors from 9 sleep medicine/surgery fellowship programs in the USA were sent an anonymous online survey. They were asked to select the five most important academic factors (of a list of 17) when evaluating potential fellowship candidates, then rank those five in order of importance. They were then asked to do the same for the most important subjective criteria (of a list of 12). RESULTS: Eight of 10 survey responses met inclusion criteria. Of the academic factors, strength of letters of recommendation, reputation of letter writer, and letters from sleep surgeons ranked highest. As for the subjective criteria, faculty assessment of the applicant on interview was ranked highest, followed by initiative and personality "fit" with the program. The reputation of an applicant's residency was ranked as more important than the reputation of their medical school. An applicant's performance in residency was assessed as more predictive of their performance in fellowship than performance during the interview process or position on the rank order list for the match. Only one program has a United States Medical Licensing Examination (USMLE) Step, and a different program has an Otolaryngology Training Examination (OTE) score cutoff. CONCLUSION: Letters of recommendation and interview are the most important factors in the selection process for hybrid sleep medicine and surgery fellowship programs, followed by research and residency program reputation. Sleep surgery-specific experience is helpful.

E-Cigarette Burns and Explosions: What are the Patterns of Oromaxillofacial Injury?

PURPOSE: With the recent increase in popularity of electronic cigarette use in the United States, its harmful effects are not only limited to smoke inhalation, but also to the possibility of e-cigarette device malfunction. The purpose of this review is to characterize oromaxillofacial trauma secondary to electronic cigarette device explosion. METHODS: For this systematic review, PubMed and Embase were searched in October 2019 using the following search terms: e-cigarette burns, e-cigarette injury, and e-cigarette explosions, which yielded 400 studies. Basic science research, animal studies, non-English studies, and reports of non-oromaxillofacial injuries were excluded. Study subject demographics, mechanism of trauma, injury type, treatment, and sequelae were recorded and analyzed. RESULTS: Of all studies, 20 studies met inclusion criteria, including 14 case reports and 6 case series, with a total of 21 study subjects. For cases that reported sex, 100% were male (20) with a mean age of 29.5 years. Most common lacerations and/or burns involved the lips (10/21), tongue (8/21), soft palate and/or hard palate (4/21), and nose (5/21). Thirteen subjects underwent surgeries including oral-maxillofacial surgery or dental implants (7/13), bone graft repair (3/13), open reduction and internal fixation for preservation of sinus outflow tracts (2/13), foreign body removal from the cervical spine (1/13), and iridectomy (1/13). Reported complications included bone loss secondary to traumatic fracture, tinnitus and hearing loss, lip paralysis secondary to persistent edema, major depressive disorder/ post-traumatic stress disorder, persistent sinusitis, photophobia, and bilateral axillary and hand contractures. CONCLUSIONS: Electronic cigarette device malfunction and explosion carries great risk for acute oromaxillofacial trauma that may be disfiguring. With the increasing popularity of electronic cigarette use, clinicians and patients should be advised regarding dangers of electronic cigarette use.

Telemedicine in International Cleft Care: A Systematic Review.

BACKGROUND: Cleft lip and cleft palate (CLP) are among the world's most common congenital malformation and has a higher prevalence in developing nations due to environmental and genetic factors. Global efforts have been developed in order to prevent and treat the malformation. Telemedicine has been implemented in various humanitarian global missions with success and is currently the primary means of care due to COVID-19. OBJECTIVE: To assess the benefits and barriers of telehealth in the care of patients with CLP through a global approach. METHODS: Systematic review of the PubMed and Cochrane Review databases with relevant terms related to telemedicine in cleft lip and palate surgery. RESULTS: Eight articles fit the inclusion criteria and suggested benefits with the use of telemedicine in regard to education, preoperative, and postoperative care as well as increased access to underserved populations. Barriers included connectivity and accessibility concerns. CONCLUSION: Telehealth is a beneficial way to evaluate patients with CLP in developing countries with proper care and follow-up to reduce complications and to improve health outcomes.

Coordinating Tissue Regeneration Through Transforming Growth Factor-ß Activated Kinase 1 Inactivation and Reactivation.

Aberrant wound healing presents as inappropriate or insufficient tissue formation. Using a model of musculoskeletal injury, we demonstrate that loss of transforming growth factor-ß activated kinase 1 (TAK1) signaling reduces inappropriate tissue formation (heterotopic ossification) through reduced cellular differentiation. Upon identifying increased proliferation with loss of TAK1 signaling, we considered a regenerative approach to address insufficient tissue production through coordinated inactivation of TAK1 to promote cellular proliferation, followed by reactivation to elicit differentiation and extracellular matrix production. Although the current regenerative medicine paradigm is centered on the effects of drug treatment ("drug on"), the impact of drug withdrawal ("drug off") implicit in these regimens is unknown. Because current TAK1 inhibitors are unable to phenocopy genetic Tak1 loss, we introduce the dual-inducible COmbinational Sequential Inversion ENgineering (COSIEN) mouse model. The COSIEN mouse model, which allows us to study the response to targeted drug treatment ("drug on") and subsequent withdrawal ("drug off") through genetic modification, was used here to inactivate and reactivate Tak1 with the purpose of augmenting tissue regeneration in a calvarial defect model. Our study reveals the importance of both the "drug on" (Cre-mediated inactivation) and "drug off" (Flp-mediated reactivation) states during regenerative therapy using a mouse model with broad utility to study targeted therapies for disease. Stem Cells 2019;37:766-778.

Global trends of hand and wrist trauma: a systematic analysis of fracture and digit amputation using the Global Burden of Disease 2017 Study.

BACKGROUND: As global rates of mortality decrease, rates of non-fatal injury have increased, particularly in low Socio-demographic Index (SDI) nations. We hypothesised this global pattern of non-fatal injury would be demonstrated in regard to bony hand and wrist trauma over the 27-year study period. METHODS: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 was used to estimate prevalence, age-standardised incidence and years lived with disability for hand trauma in 195 countries from 1990 to 2017. Individual injuries included hand and wrist fractures, thumb amputations and non-thumb digit amputations. RESULTS: The global incidence of hand trauma has only modestly decreased since 1990. In 2017, the age-standardised incidence of hand and wrist fractures was 179 per 100 000 (95% uncertainty interval (UI) 146 to 217), whereas the less common injuries of thumb and non-thumb digit amputation were 24 (95% UI 17 to 34) and 56 (95% UI 43 to 74) per 100 000, respectively. Rates of injury vary greatly by region, and improvements have not been equally distributed. The highest burden of hand trauma is currently reported in high SDI countries. However, low-middle and middle SDI countries have increasing rates of hand trauma by as much at 25%. CONCLUSIONS: Certain regions are noted to have high rates of hand trauma over the study period. Low-middle and middle SDI countries, however, have demonstrated increasing rates of fracture and amputation over the last 27 years. This trend is concerning as access to quality and subspecialised surgical hand care is often limiting in these resource-limited regions.

Surgical Adjuncts to Rhinoplasty: An Algorithmic Approach.

BACKGROUND: Nasal aesthetics can be significantly affected by the interdependence of the surrounding bone and soft tissues of the face. These include the maxilla, septum, frontal bone, mandible, and the soft tissues and cartilage surrounding the nose. Therefore, it is pertinent to analyze and address these critical relationships of the nose in order to achieve a successful rhinoplasty. This work seeks to describe the battery of adjunct procedures available to supplement a rhinoplasty. Furthermore, each preoperative finding or indication for the adjunct is described in an algorithmic fashion. METHODS: A literature search using PubMed, Google Scholar, and a university library database was performed to locate papers describing adjunctive procedures to rhinoplasty. Indications and preoperative analysis were extracted from each paper. If the indication or finding was unclear, supplementary literature describing rhinoplasty and adjunctive analysis were sought in order to supplement our findings. RESULTS: Sixteen papers in total described adjunctive procedures for rhinoplasty. Each work highlighted a procedure or set of procedures on a surrounding facial feature including the forehead, brow, cheeks, lips, and chin, and neck. In total, 13 adjunct procedures for rhinoplasty are described with their respective indications. Additional literature and techniques were researched to clarify indicated procedures. CONCLUSION: The ability to correctly understand the critical relationships of the nose can help the surgeon correctly recognize the indication for a rhinoplasty adjunct procedure, leading to better aesthetic balance and surgical outcomes. LEVEL OF EVIDENCE II: 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 .

Characterizing the Circulating Cell Populations in Traumatic Heterotopic Ossification.

Heterotopic ossification (HO) occurs secondary to trauma, causing pain and functional limitations. Identification of the cells that contribute to HO is critical to the development of therapies. Given that innate immune cells and mesenchymal stem cells are known contributors to HO, we sought to define the contribution of these populations to HO and to identify what, if any, contribution circulating populations have to HO. A shared circulation was obtained using a parabiosis model, established between an enhanced green fluorescent protein-positive/luciferase+ donor and a same-strain nonreporter recipient mouse. The nonreporter mouse received Achilles tendon transection and dorsal burn injury to induce HO formation. Bioluminescence imaging and immunostaining were performed to define the circulatory contribution of immune and mesenchymal cell populations. Histologic analysis showed circulating cells present throughout each stage of the developing HO anlagen. Circulating cells were present at the injury site during the inflammatory phase and proliferative period, with diminished contribution in mature HO. Immunostaining demonstrated that most early circulatory cells were from the innate immune system; only a small population of mesenchymal cells were present in the HO. We demonstrate the time course of the participation of circulatory cells in trauma-induced HO and identify populations of circulating cells present in different stages of HO. These findings further elucidate the relative contribution of local and systemic cell populations to HO.

Scleraxis-Lineage Cells Contribute to Ectopic Bone Formation in Muscle and Tendon.

The pathologic development of heterotopic ossification (HO) is well described in patients with extensive trauma or with hyperactivating mutations of the bone morphogenetic protein (BMP) receptor ACVR1. However, identification of progenitor cells contributing to this process remains elusive. Here we show that connective tissue cells contribute to a substantial amount of HO anlagen caused by trauma using postnatal, tamoxifen-inducible, scleraxis-lineage restricted reporter mice (Scx-creERT2/tdTomatofl/fl ). When the scleraxis-lineage is restricted specifically to adults prior to injury marked cells contribute to each stage of the developing HO anlagen and coexpress markers of endochondral ossification (Osterix, SOX9). Furthermore, these adult preinjury restricted cells coexpressed mesenchymal stem cell markers including PDGFRα, Sca1, and S100A4 in HO. When constitutively active ACVR1 (caACVR1) was expressed in scx-cre cells in the absence of injury (Scx-cre/caACVR1fl/fl ), tendons and joints formed HO. Postnatal lineage-restricted, tamoxifen-inducible caACVR1 expression (Scx-creERT2/caACVR1fl/fl ) was sufficient to form HO after directed cardiotoxin-induced muscle injury. These findings suggest that cells expressing scleraxis within muscle or tendon contribute to HO in the setting of both trauma or hyperactive BMP receptor (e.g., caACVR1) activity. Stem Cells 2017;35:705-710.

Combined reflectance and Raman spectroscopy to assess degree of in vivo angiogenesis after tissue injury.

BACKGROUND: Angiogenesis, the formation of blood vessels, is a critical aspect of wound healing. Disorders of wound healing are often characterized by lack of angiogenesis, a condition frequently observed in aging and diabetic patients. Current techniques for assessing blood at injury sites are limited to contrast-imaging, including angiography. However, these techniques do not directly observe oxygenation of blood and are not amenable to serial evaluation. A multimodal noninvasive reflectance and Raman spectrometer have been proposed to help clinicians as a point-of-care tool to interrogate local angiogenesis and tissue architecture, respectively. The spectrometer system is a rapid, noninvasive, and label-free technology well-suited for the clinical environment. MATERIALS AND METHODS: To demonstrate feasibility, the spectrometer system was used to interrogate angiogenesis serially over 9 wk as a result of heterotopic ossification (HO) development in a validated murine model. End-stage HO was confirmed by micro-computed tomography. RESULTS: Our preliminary results suggest that reflectance spectroscopy can be used to delineate vessel formation and that pathologic wounds may be characterized by unique spectra. In our model, HO formed at sites 1-3, whereas sites 4 and 5 did not have radiographic evidence of HO. CONCLUSIONS: A point-of-care system like that demonstrated here shows potential as a noninvasive tool to assess local angiogenesis and tissue architecture that may allow for timely intervention in a clinical setting.

Wnts produced by Osterix-expressing osteolineage cells regulate their proliferation and differentiation.

Wnt signaling is a critical regulator of bone development, but the identity and role of the Wnt-producing cells are still unclear. We addressed these questions through in situ hybridization, lineage tracing, and genetic experiments. First, we surveyed the expression of all 19 Wnt genes and Wnt target gene Axin2 in the neonatal mouse bone by in situ hybridization, and demonstrated--to our knowledge for the first time--that Osterix-expressing cells coexpress Wnt and Axin2. To track the behavior and cell fate of Axin2-expressing osteolineage cells, we performed lineage tracing and showed that they sustain bone formation over the long term. Finally, to examine the role of Wnts produced by Osterix-expressing cells, we inhibited Wnt secretion in vivo, and observed inappropriate differentiation, impaired proliferation, and diminished Wnt signaling response. Therefore, Osterix-expressing cells produce their own Wnts that in turn induce Wnt signaling response, thereby regulating their proliferation and differentiation.

A Comparison of Dermal Autograft and Acellular Dermal Matrix in Tissue Expander Breast Reconstruction: Long-term Aesthetic Outcomes and Capsular Contracture.

BACKGROUND: The use of acellular dermal matrix (ADM) in tissue expander breast reconstruction has been touted to reduce capsular contracture rates and improve aesthetic outcomes. Autogenous dermal grafts have shown to be a safer and more cost-effective alternative to ADM. The purpose of this study was to compare the capsular contracture rates and long-term aesthetic outcomes of tissue expander breast reconstruction using dermal autografts with ADM-assisted reconstruction. METHODS: Patients undergoing tissue expander breast reconstruction with either ADM or dermal autografts were enrolled. Autografts were harvested from the lower abdomen. The capsular contracture rate was assessed via physical examination using the Baker scale. Standardized patient photographs were scored for aesthetic appearance on a 7-point Likert scale by blinded female observers. The ADM and autograft groups were compared using Student t test. Significance was defined as P < 0.05. RESULTS: Forty-eight patients were enrolled (76 breasts). The average follow-up time for the ADM group was 9.6 months and 9.9 months for the dermal autograft group. Twenty-seven patients received ADM, and 21 patients received dermal autograft. Capsular contracture scores were identical between the 2 groups (mean Baker grade = 1.15, P = 0.55). The average long-term aesthetic outcome score for dermal autograft-assisted breast reconstruction was 3.85, compared to 3.79 for ADM-assisted reconstruction. This difference was not statistically significant (P = 0.87). CONCLUSIONS: In addition to an improved safety profile and lower cost, dermal autograft-assisted tissue expander breast reconstruction affords equivalent aesthetic results and capsular contracture rates, when compared to ADM.

Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q.

Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2 %. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.

Outcome analysis of expander/implant versus microsurgical abdominal flap breast reconstruction: a critical study of 254 cases.

BACKGROUND: Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option. METHODS: Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications. RESULTS: MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.8 ± 1.32 days for MAFBR and 2.1 ± 0.9 days for EIBR. Complication occurred in 21.3 % of MAFBR versus 37.4 % for EIBR patients. Follow-up duration was 24.7 ± 17.2 months for EIBR and 30.1 ± 18.5 months for MAFBR. On multivariate analysis, EIBR and a body mass index of ≥30 kg/m(2) were the only significant predictors of major complication. CONCLUSIONS: For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.