Medical Tourism in Plastic Surgery: A Case Series of Complications.

Background: Medical tourism in plastic surgery has grown exponentially over the last decade. The rise in the number of cases is multifactorial but is mostly driven by reduced cost. While this may seem attractive to patients, it is not without risk. Even under the best circumstances, complications can arise, and patients may be put at increased risk of atypical infections due to different sterilization standards. Lack of customary follow-up and accessibility can lead to delays in diagnosing infections and cause patients to seek care locally. We present our experience in managing atypical infections resulting from cosmetic surgery tourism in a tertiary care system. Methods: We report a case series of 3 patients who underwent cosmetic procedures abroad who presented to our institutions with postoperative complications and infections. Results: Our cohort consist of 3 female patients ranging from 26 to 48 years of age who had cosmetic surgery abroad. All 3 presented with nontuberculous mycobacteria (NTM) infections. Conclusions: Cosmetic surgery tourism is luring patients with advertised all-inclusive surgery and vacation packages at reduced cost. This attracts vulnerable patients and puts them at risk of devastating long-term physical and financial sequalae. NTM infections should be considered early in this population, especially when they are not responding to other therapies. More widespread information about the consequences of traveling for medical procedures is needed to help inform and empower patients to make educated decisions when choosing where to seek care.

How I do it: robotic hiatal hernia repair with stapled conversion from Nissen to Toupet fundoplication.

The purpose of this paper is to describe a robotic surgical technique for converting a slipped Nissen fundoplication to a Toupet fundoplication. Our technique utilizes four 8 mm robotic ports placed in a horizontal pattern above the umbilicus. The robotic tools we used are a vessel sealer, bipolar forceps, and Cadière forceps. In addition, an esophagogastroduodenoscopy (EGD) is placed through the esophagus into the stomach to be used as a bougie. If a hernia is present, we dissect it from the mediastinum until the posterior confluence is identified. Next sutures from the previous Nissen fundoplication are identified and removed to mobilize the crus. All adhesions around the stomach are removed to mobilize the esophagus, ensuing 3 cm of intraabdominal esophagus is available. Using an EGD as a bougie, we used two interrupted, 0 silk suture over Teflon pledgets placed in a horizontal mattress fashion to close the hiatal defect. Using an endoscope, we identified the previous Nissen fundoplication and used a 60 mm blue load stapler to transect the wrap from the stomach. The 360° Nissen fundoplication had now been converted into a 270° Toupet fundoplication, which is confirmed with the EGD. The functionality of the wrap is confirmed if the "Stack of Coins" sign is present, and the wrap lies tight against the scope. A Nissen-to-Toupet fundoplication conversion using a robotic-assisted surgical technique may be useful in reducing reoperations and complications in patients undergoing fundoplication surgery.

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: 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 .

Complications of Medical Tourism in Aesthetic Surgery: A Systematic Review.

INTRODUCTION: As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings attract many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short- and long-term follow-up, as well as the management and cost of complications. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses on complications that presented after cosmetic surgeries performed abroad. The literature search was performed on October 18, 2022, using the databases of PubMed, Google Scholar, and Embase. RESULTS: From the 44 studies that were included, 589 patients were identified who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/hematoma, and tissue necrosis. Ninety-eight percent of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus. CONCLUSIONS: Cosmetic tourism is a global phenomenon. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that the primary procedures took place in, and the countries of origin of the patients. To aid in reducing morbidity and mortality from cosmetic tourism, regulatory bodies should educate and empower the public to aid them in making educated medical conditions when seeking care.

A Novel Method to Determine Patient Skin Type: The Skin Analyzer.

Measuring skin color for medical research in an objective and nonbiased manner usually requires expensive equipment such as spectrophotometry and requires the subject to be present in person. We present a novel method to measure skin color from photographs using the Skin Analyzer application as a more effective, accessible, and efficient alternative. A desktop application, the Skin Analyzer, was developed to convert skin samples collected from digital images to the L*a*b color space and uses those values to calculate an individual typology angle that correlates to a Fitzpatrick skin type. To assess accuracy in variable lighting, six known colors representing the six Fitzpatrick skin types were printed and photographed in 15 separate locations within the hospital. To account for user variability in sample selection, interrater reliability was calculated with data generated by 13 untrained users testing the app on six subjects. The accuracy of measuring known values, which is the classification accuracy, was calculated to be 80%. Krippendorff alpha test was used to evaluate interrater reliability. The obtained alpha of 0.84 indicates a high interrater reliability. The high accuracy and reliability make the Skin Analyzer a suitable method of objectively determining Fitzpatrick skin type from images. The app may be used to investigate the effects of skin tone in various areas of interest, especially in retrospective studies where skin colorimeters cannot be used.

Reducing drain use with paraspinal muscle flaps for spinal closures: A retrospective cohort study.

BACKGROUND: Paraspinal muscle (PSM) flaps can be mobilized with superficial undermining and lateral release from the thoracolumbar fascia and/or deep undermining and medial release from the transverse processes and ribs. The objective of the study was to compare the effect of the PSM flap technique on drain use, retention, and complication rates. METHODS: A retrospective chart review was performed for patients who underwent spinal coverage with PSM flaps at a single institution from April 2020 to June 2021. Patient demographics, preoperative comorbidities, surgical technique, drain usage, and postoperative complications were analyzed to compare the effects of different PSM flap surgical techniques on postoperative drain use and complications. RESULTS: Sixty patients were included. Both superficial and deep releases were performed in half (47%) of the cases, while the remainder was split between superficial (25%) and deep (28%) releases. Drains were used less frequently for the deep release (35%) than the superficial (93%) or both releases (96%, p < 0.01). The deep release had shorter mean drain retention time (5.8 days) than the superficial (30.3 days) or both releases (24.8 days, p < 0.01). There were no significant differences between the techniques in terms of complications. For the deep release, the use of drains was not associated with a reduction in complications (odds ratio 0.91 [0.84 - 0.98], p = 0.97). CONCLUSIONS: In a selected patient population, a "deep release only" PSM flap technique may allow for drainless spinal closure without an increased risk of seroma or other complications.

Readability of Online Materials in Spanish and English for Breast Reduction Insurance Coverage.

INTRODUCTION: Breast reduction surgery aims to alleviate physical discomfort and improve the quality of life for individuals with macromastia. Insurance coverage plays a crucial role in making this surgery accessible, but navigating the complex approval process can be challenging. Online resources have become a primary information source, but limited research exists on the adequacy of online materials, particularly for Spanish-speaking patients. This study evaluates the readability, actionability, and understandability of online educational materials on breast reduction insurance coverage for Spanish- and English-speaking patients. METHODS: We conducted an online search using the phrase "breast reduction insurance" and selected the first eight institutional or organizational websites that provided information on breast reduction insurance in both English and Spanish. We evaluated online materials using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL). These tools were used to assess factors such as understandability and actionability, cultural sensitivity, and readability of the materials. RESULTS: Both English and Spanish materials scored high in understandability and actionability, with similar average scores between the languages. Cultural sensitivity scores indicated acceptable materials. However, Spanish materials had a higher reading grade level and more hard words compared to English materials. CONCLUSION: There is a need for accessible and understandable online resources on breast reduction insurance coverage, particularly for Spanish-speaking patients. While the assessed websites generally provided comprehensible information, improvements can be made to enhance visual aids and simplify language. These improvements can better educate patients, improve outcomes, and reduce healthcare costs. LEVEL OF EVIDENCE V: 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 .

High epigenetic potential protects songbirds against pathogenic Salmonella enterica infection.

Animals encounter many novel and unpredictable challenges when moving into new areas, including pathogen exposure. Because effective immune defenses against such threats can be costly, plastic immune responses could be particularly advantageous, as such defenses can be engaged only when context warrants activation. DNA methylation is a key regulator of plasticity via its effects on gene expression. In vertebrates, DNA methylation occurs exclusively at CpG dinucleotides and, typically, high DNA methylation decreases gene expression, particularly when it occurs in promoters. The CpG content of gene regulatory regions may therefore represent one form of epigenetic potential (EP), a genomic means to enable gene expression and hence adaptive phenotypic plasticity. Non-native populations of house sparrows (Passer domesticus) - one of the world's most cosmopolitan species - have high EP in the promoter of a key microbial surveillance gene, Toll-like receptor 4 (TLR4), compared with native populations. We previously hypothesized that high EP may enable sparrows to balance the costs and benefits of inflammatory immune responses well, a trait critical to success in novel environments. In the present study, we found support for this hypothesis: house sparrows with high EP in the TLR4 promoter were better able to resist a pathogenic Salmonella enterica infection than sparrows with low EP. These results support the idea that high EP contributes to invasion and perhaps adaptation in novel environments, but the mechanistic details whereby these organismal effects arise remain obscure.

A Case Report of a Rare Hernia: Incarcerated Falciform Ligament Hernia.

Falciform ligament hernias are a rare type of internal hernia that occurs through an abnormal opening in the falciform ligament of the liver. This is the case of a 38-year-old female who presented with a symptomatic enlarging ventral bulge near her umbilicus and was treated with a robotic-assisted laparoscopic falciform hernia repair with mesh. The nonspecific clinical manifestation of a falciform ligament hernia and the low sensitivity of computerized tomography (CT) for these hernias make them hard to diagnose preoperatively. Falciform ligament hernias are mostly attributed to congenital defects, but recently an iatrogenic etiology has also been proposed, given the prior history of laparoscopic surgeries in more recent cases. In our case report, we demonstrate that a robotic-assisted laparoscopic approach is a safe and effective means of correcting this hernia, with an outline of the current literature.

Seamguard Buttressing of the Staple Line During Laparoscopic Sleeve Gastrectomy Appears to Decrease the Incidence of Postoperative Bleeding, Leaks, and Reoperations. A Systematic Review and Meta-Analysis of Non-Randomized Comparative Studies.

Leaks and bleeding are major acute postoperative complications following laparoscopic sleeve gastrectomy (LSG). Various staple line reinforcement (SLR) methods have been invented such as oversewing/suturing (OS/S), omentopexy/gastropexy (OP/GP), gluing, and buttressing. However, many surgeons do not use any type of reinforcement. On the other hand, surgeons who use a reinforcement method are often confused of what kind of reinforcement they should use. No robust and high-quality data supports the use of one reinforcement over the other or even supports the use of reinforcement over no-reinforcement. Therefore, SLR is a controversial topic that is worth our focus. The aim of this study is to compare the outcomes of LSG with versus without Seamguard buttressing of the staple line during LSG.

Gastropleural Fistula Presenting as a Complication of Gastric Sleeve Surgery: A Case Report.

A rare complication of sleeve gastrectomy surgery is gastropleural fistulas (GPF), where a fistula develops between the stomach and the pleural cavity. This complication can be debilitating and present with many nonspecific symptoms making it hard to diagnose. This is a case report of a 45-year-old female who underwent robotic-assisted gastric sleeve revision after developing a GPF as a complication of her gastric sleeve six years later. This led to the development of a recurrent subdiaphragmatic abscess in the left upper quadrant. Before presenting to us, she underwent multiple hospitalizations and received numerous endoscopic stent treatments. However, the abscess continued to recur. Given her recurrent abscess, she consented to gastric sleeve revision. GPFs are amongst the rarest complications, with only 76 reported cases. Since this complication can cause shock, early diagnosis and treatment are necessary to improve patient outcomes and reduce morbidity.

Breast Paraffinoma: A Case Report of 20-Year-Old Mineral Oil Injection in a Male Patient.

Background: Mineral oil injection represents a dated practice of rapid and inexpensive breast augmentation. After a latency period, surrounding tissue becomes inflamed and fibrotic. Breast paraffinoma is well-documented in women; however, only 3 cases of such masses in male patients exist in the literature. Methods: We present a case of paraffinoma in a 63-year-old man from Puerto Rico who, desiring breasts, serially injected mineral oil into each breast daily for 13 years. Conservative management was initially attempted due to cardiac comorbidities and insurance authorization issues. The patient ultimately developed erosive wounds and therefore underwent excision of the bilateral breast masses as an en bloc specimen weighing 2.17 kg. Results: Pathology indicated sclerosing lipogranulomatosis (paraffinoma). The quality of the wounds remaining warranted negative pressure wound therapy with serial debridement. The patient went on to successful reconstruction with a reverse abdominoplasty preserving periumbilical and intercostal perforators. Conclusions: Plastic surgeons must educate patients against using exogenous injected materials for augmentation of the breasts, penis, or buttocks. Although uncommon in the US, certain populations like body builders and foreign immigrants are at higher risk for current or prior injection practices. Reverse abdominoplasty is a viable reconstructive modality for the large resulting defect.

TEVAR Stent to the False Lumen of a Chronic Type B Aortic Dissection With Aneurysmal Dilatation, When no Other Options Are Left.

We report a case of a 72 years-old male referred to us with a 2-year history of an enlarging aortic aneurysm secondary to a chronic Type B aortic dissection and a complete occlusion of the true lumen in the thoracic and abdominal aorta except at the level of visceral arteries origins. Several attempts to recanalize the true lumen was not successful. Because of the patient's high risk for an open repair and the normal size of his thoracic aorta proximal to the celiac artery, we deployed the TEVAR stent to the false lumen to prevent aneurysmal enlargement and rupture. The operation was successful, and the patient recovered without complications and with complete exclusion of the aneurysm on two years follow up.

Epigenetic potential affects immune gene expression in house sparrows.

Epigenetic mechanisms may play a central role in mediating phenotypic plasticity, especially during range expansions, when populations face a suite of novel environmental conditions. Individuals may differ in their epigenetic potential (EP; their capacity for epigenetic modifications of gene expression), which may affect their ability to colonize new areas. One form of EP, the number of CpG sites, is higher in introduced house sparrows (Passer domesticus) than in native birds in the promoter region of a microbial surveillance gene, Toll-like Receptor 4 (TLR4), which may allow invading birds to fine-tune their immune responses to unfamiliar parasites. Here, we compared TLR4 gene expression from whole blood, liver and spleen in house sparrows with different EP, first challenging some birds with lipopolysaccharide (LPS), to increase gene expression by simulating a natural infection. We expected that high EP would predict high inducibility and reversibility of TLR4 expression in the blood of birds treated with LPS, but we did not make directional predictions regarding organs, as we could not repeatedly sample these tissues. We found that EP was predictive of TLR4 expression in all tissues. Birds with high EP expressed more TLR4 in the blood than individuals with low EP, regardless of treatment with LPS. Only females with high EP exhibited reversibility in gene expression. Further, the effect of EP varied between sexes and among tissues. Together, these data support EP as one regulator of TLR4 expression.

Epigenetic Potential in Native and Introduced Populations of House Sparrows (Passer domesticus).

Epigenetic potential, defined as the capacity for epigenetically-mediated phenotypic plasticity, may play an important role during range expansions. During range expansions, populations may encounter relatively novel challenges while experiencing lower genetic diversity. Phenotypic plasticity via epigenetic potential might be selectively advantageous at the time of initial introduction or during spread into new areas, enabling introduced organisms to cope rapidly with novel challenges. Here, we asked whether one form of epigenetic potential (i.e., the abundance of CpG sites) in three microbial surveillance genes: Toll-like receptors (TLRs) 1B (TLR1B), 2A (TLR2A), and 4 (TLR4) varied between native and introduced house sparrows (Passer domesticus). Using an opportunistic approach based on samples collected from sparrow populations around the world, we found that introduced birds had more CpG sites in TLR2A and TLR4, but not TLR1B, than native ones. Introduced birds also lost more CpG sites in TLR1B, gained more CpG sites in TLR2A, and lost fewer CpG sites in TLR4 compared to native birds. These results were not driven by differences in genetic diversity or population genetic structure, and many CpG sites fell within predicted transcription factor binding sites (TFBS), with losses and gains of CpG sites altering predicted TFBS. Although we lacked statistical power to conduct the most rigorous possible analyses, these results suggest that epigenetic potential may play a role in house sparrow range expansions, but additional work will be critical to elucidating how epigenetic potential affects gene expression and hence phenotypic plasticity at the individual, population, and species levels.