Pretherapy 18F-fluorodeoxyglucose positron emission tomography/computed tomography robust radiomic features predict overall survival in non-small cell lung cancer.

OBJECTIVE: To extract robust radiomic features from staging positron emission tomography/computed tomography (18F- fluroodeoxyglucose PET/CT) in patients with non-small cell lung cancer from different segmentation methods and to assess their association with 2-year overall survival. METHODS: Eighty-one patients with stage I-IV non-small cell lung cancer were included. All patients underwent a pretherapy 18F-FDG PET/CT. Primary tumors were delineated using four different segmentation methods: method 1, manual; method 2: manual with peripheral 1 mm erosion; method 3: absolute threshold at standardized uptake value (SUV) 2.5; and method 4: relative threshold at 40% SUVmax. Radiomic features from each method were extracted using Image Biomarker Standardization Initiative-compliant process. The study cohort was divided into two groups (exploratory and testing) in a ratio of 1:2 (n = 25 and n = 56, respectively). Exploratory cohort was used to identify robust radiomic features, defined as having a minimum concordance correlation coefficient ≥0.75 among all the 4-segmentation methods. The resulting texture features were evaluated for association with 2-year overall survival in the testing cohort (n = 56). All patients in the testing cohort had a follow-up for 2 years from the date of staging 18F-FDG PET/CT scan or till death. Cox proportional hazard models were used to evaluate the independent prognostic factors. RESULTS: Exploratory and validation cohorts were equivalent regarding their basic characteristics (age, sex, and tumor stage). Ten radiomic features were deemed robust to the described four segmentation methods: SUV SD, SUVmax, SUVQ3, SUVpeak in 0.5 ml, total lesion glycolysis, histogram entropy log 2, histogram entropy log 10, histogram energy uniformity, gray level run length matrix-gray level non-uniformity, and gray level zone length matrix-gray level non-uniformity. At the end of 2-year follow-up, 41 patients were dead and 15 were still alive (overall survival = 26.8%; median survival = 14.7 months, 95% confidence interval: 10.2-19.2 months). Three texture features, regardless the segmentation method, were associated with 2-year overall survival: total lesion glycolysis, gray level run length matrix_gray level non-uniformity, and gray level zone length matrix_run-length non-uniformity. In the final Cox-regression model: total lesion glycolysis, and gray level zone length matrix_gray level non-uniformity were independent prognostic factors. The quartiles from the two features were combined with clinical staging in a prognostic model that allowed better risk stratification of patients for overall survival. CONCLUSION: Ten radiomic features were robust to segmentation methods and two of them (total lesion glycolysis and gray level zone length matrix_gray level non-uniformity) were independently associated with 2-year overall survival. Together with the clinical staging, these features could be utilized towards improved risk stratification of lung cancer patients.

Role of post-therapy 99mTc-MIBI single-photon emission computed tomography/computed tomography scan in predicting survival in patients with high-grade glioma.

OBJECTIVE: High-grade gliomas (HGGs) carry dismal prognosis with survival typically reported as less than a year. We explored the predictive value of qualitative and quantitative evaluations of post-treatment 99m-technetium-labelled methoxyisobutylisonitrile (99mmTc-MIBI) brain single-photon emission computed tomography-computed tomography (SPECT/CT) tumor uptake in relation to overall survival (OS) in patients with HGG. METHODS: Thirty patients with pathologically or radiologically documented high-grade glioma (HGG) were prospectively recruited for this study (24 male, 6 female; mean age 43 ± 14 years). All patients had a clinical or radiological suspicion of residual/recurrent tumor after initial therapy. 99mTc-MIBI brain SPECT/CT scanning was performed, and the scans were evaluated qualitatively on a five-point probability score (1-5, scores ≥3 considered positive for residual/recurrent tumor); and quantitively via drawing volumes of interest (VOI) on the suspected lesions and normal contralateral brain tissue. All patients were followed up for 1 year or till death. RESULTS: Positive visual MIBI results were associated with poor survival. Among 10 patients with negative MIBI scores, only two patients died (OS = 75%), while 11/20 patients reported positive on MIBI died, with a median survival of 9 months (OS = 14.5%; P = 0.03). All patients with active isocontour volume ≤1.96 cm3 were alive at the end of the study, compared to a median survival of 9 months and OS of 12% for patients with an isocontour volume of >1.97% (P = 0.003). CONCLUSION: In patients with HGG, post-therapy brain SPECT/CT with 99mTc-MIBI can provide useful prognostic information.

Impact of 18F-2-fluoro-2-deoxy-D-glucose PET/computerized tomography on the initial staging and changing the management intent in head and neck squamous cell carcinoma.

OBJECTIVE: To assess the role of 18F-FDG PET/CT in initial staging of head and neck squamous cell carcinoma and its impact on changing the management compared to other conventional methods. PATIENTS AND METHODS: A prospective study of 31 patients (21 male and 10 female), mean age 49.3 ± 12.1 years with histologically confirmed squamous cell carcinoma of the head and neck (nasopharynx was the commonest cancer in 15 patients (48.4%), poorly differentiated grade represented 64.5% of all tumors. Initial staging was achieved according to routine physical examination, endoscopy, CT, U/S, MRI. RESULTS: The overall change in TNM staging by 18F-FDG PET/CT in relation to conventional methods was encountered in 15/31 patients (48.4%). PET/CT changed; T staging in three patients (9.6%), upstaging in two patients and downstaging in one patient. PET/CT upstaged all 13/31 patients in N staging (41.9%). 18F-FDG PET/CT changed; M staging in 3/31 (9.6%) patients, upstaging in two and downstaging in one patient. PET/CT results caused radiotherapy modification in 21/31 patients (67.7%). PET/CT detected intra-parotid nodule in four patients, so additional radiation was added to the parotid in the treatment field. Retropharyngeal nodes were detected by PET/CT in three patients that were missed by conventional imaging. 18F-FDG PET/CT detected two patients of thyroid papillary carcinoma and one case of sigmoid neoplasm confirmed by histopathology. CONCLUSION: 18F-FDG-PET/CT is considered a valuable diagnostic test in head and neck squamous cell carcinoma at initial assessment which would change staging and radiotherapy planning and hence proper management.

Comparative effectiveness clinical trial of magnetic seizure therapy and electroconvulsive therapy in major depressive disorder.

BACKGROUND: Magnetic seizure therapy (MST) has demonstrated fewer cognitive side effects than electroconvulsive therapy (ECT) in antidepressant efficacy trials. However, there are no effectiveness trials examining antidepressant efficacy and cognitive side effects against ECT. The aims of this study were to evaluate the comparative effectiveness of MST vs ECT in major depressive disorder (MDD), and compare the cognitive side effects of MST and ECT. METHODS: In this open-label study, patients were assigned to either ECT or high-dose MST twice a week for 5 sessions based on the clinician's and the patient's decision-making. Efficacy was primarily assessed by the Hamilton Depression Rating Scale-21 (HAMD-21); cognitive side effects were assessed by time to reorientation (TRO) and cognitive battery. RESULTS: Sixty patients were enrolled. Efficacy was similar between those assigned to MST (n = 30) and ECT (n = 30). Post-treatment HAMD-21 mean scores were 12.33 after MST, 12.80 after bitemporal (BT) ECT (n = 15), and 27.93 after right unilateral (RUL) ECT (n = 15). Magnetic seizure therapy had a significantly faster TRO of 1.8 minutes (standard deviation [SD] = 0.37) compared with ECT (RUL: 18.9 minutes [SD = 8.25]; BT: 50.2 minutes [SD = 5.89]) and had fewer cognitive side effects. CONCLUSIONS: Magnetic seizure therapy was effective for the treatment of MDD in real-world clinical care, with fewer cognitive side effects than ECT. Future studies are warranted to replicate these findings.

Diagnostic performance of 18F-2-fluoro-2-deoxy-D-glucose PET/computerized tomography in identifying bone marrow infiltration in new patients with diffuse large B-cell lymphoma and Hodgkin lymphoma.

OBJECTIVE: To compare between F-2-fluoro-2-deoxy-D-glucose PET/computerized tomography (F-FDG PET/CT) and routine iliac bone marrow biopsy (BMB) in assessment of bone marrow infiltration (BMI) in Hodgkin lymphoma and diffuse large B-cell lymphoma (DLBCL) patients at initial presentation. PATIENTS AND METHODS: A retrospective analysis of 138 patients (50 Hodgkin lymphomas, 88 DLBCLs). The study included 70 males and 68 females with median age of 43 years. All patients underwent F-FDG PET/CT and iliac crest BMB before treatment. Any focal or patchy FDG uptake in the bone marrow, superior-to hepatic uptake was interpreted as abnormal with or without corresponding CT changes. Treatment response was evaluated clinically with each cycle of chemotherapy, radiologically after three cycles and at the end of treatment. RESULTS: The overall diagnostic performance showed significant higher sensitivity of F-FDG PET/CT than that of BMB (73.9 versus 62.5%, P = 0.046), while the specificity was higher in BMB than in F-FDG PET/CT (100% in BMB versus 93.5% in F-FDG PET/CT). In Hodgkin lymphoma, sensitivity, negative predictive value (NPV) and accuracy were significantly higher in F-FDG PET/CT compared with BMB, being 87.5, 94.4 and 96% versus 50, 81 and 84% (P = 0.02, 0.03, 0.04, respectively). However, for DLBCL patients, almost comparable results were found between both tests in terms of sensitivity, NPV and accuracy (66.7, 83.9 and 81.8% versus 68.8, 84.9 and 88.6%, respectively). After PET/CT scan, 12 patients (8.6%) were upstaged to stage IV, eight of them were negative by BMB. CONCLUSION: F-FDG PET/CT seemed to be an excellent diagnostic test in assessment of BMI at initial assessment and staging of Hodgkin lymphoma and DLBCL patients.

CMOS-compatible hybrid bi-metallic TE/TM-pass polarizers based on ITO and ZrN.

Transverse-magnetic (TM) and transverse-electric (TE) pass polarizers based on a silicon-on-insulator platform are studied and analyzed. The proposed structures are CMOS-compatible based on indium tin oxide and zirconium nitride as alternative plasmonic materials. The bi-metallic combination of the plasmonic materials exhibit large coupling between one of the modes (TE or TM) in the silicon core and the surface plasmon mode, while the other mode can propagate with low losses. The numerical simulations for the TE-pass polarizer predict 32.7 dB extinction ratio (ER) and 0.13 dB insertion loss (IL) at a compact device length of 1.5 µm. Additionally, the TM-pass polarizer has 31.5 dB ER and 0.17 dB IL at a device length of 2 µm at an operating wavelength of 1.55 µm.

Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery: 20 Years of Experience.

OBJECTIVE: Bariatric surgery (BS) is currently the most effective treatment for severe obesity. However, these weight loss procedures may result in the development of gut failure (GF) with the need for total parenteral nutrition (TPN). This retrospective study is the first to address the anatomic and functional spectrum of BS-associated GF with innovative surgical modalities to restore gut function. METHODS: Over 2 decades, 1500 adults with GF were referred with history of BS in 142 (9%). Of these, 131 (92%) were evaluated and received multidisciplinary care. GF was due to catastrophic gut loss (Type-I, 42%), technical complications (Type-II, 33%), and dysfunctional syndromes (Type-III, 25%). Primary bariatric procedures were malabsorptive (5%), restrictive (19%), and combined (76%). TPN duration ranged from 2 to 252 months. RESULTS: Restorative surgery was performed in 116 (89%) patients with utilization of visceral transplantation as a rescue therapy in 23 (20%). With a total of 317 surgical procedures, 198 (62%) were autologous reconstructions; 88 (44%) foregut, 100 (51%) midgut, and 10 (5%) hindgut. An interposition alimentary conduit was used in 7 (6%) patients. Reversal of BS was indicated in 84 (72%) and intestinal lengthening was required in 10 (9%). Cumulative patient survival was 96% at 1 year, 84% at 5 years, and 72% at 15 years. Nutritional autonomy was restored in 83% of current survivors with persistence or relapse of obesity in 23%. CONCLUSIONS: GF is a rare but serious life-threatening complication after BS. Successful outcome is achievable with comprehensive management, including reconstructive surgery and visceral transplantation.

Atypical Clinical Presentation of a Newer Generation Anti-Fungal Drug-Resistant Fusarium Infection After a Modified Multi-Visceral Transplant.

BACKGROUND Fusarium spp. infections have become an emerging and lethal threat to the immunocompromised patient population, especially those with neutropenia. Recently there have been increased reports in solid organ transplant recipients. Presentation is commonly as soft tissue infections several months post-transplant. With high morbidity and mortality, efficacious antifungal therapy is essential. This remains challenging with limited data and no established clinical breakpoints defined. CASE REPORT We report on a modified multi-visceral transplant patient that developed a Fusarium infection only 7 weeks post-transplant in the native hard palate and esophagus, without any soft tissue lesions, which persisted despite aggressive combination treatment with amphotericin B lipid complex and voriconazole. CONCLUSIONS Fusarium spp. infection in solid organ transplant is a significant challenge without clear diagnostic clinical indicators of infection, or specific time of onset, in addition to possible emergence of a more aggressive drug-resistant strain.

Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndrome: Rationale for the Triple Rule-Out Concept.

BACKGROUND: The aims of the study were to evaluate the prevalence of acute coronary syndrome (ACS) among patients presenting with atypical chest pain who are evaluated for acute aortic syndrome (AAS) or pulmonary embolism (PE) with computed tomoangiography (CTA) and discuss the rationale for the use of triple rule-out (TRO) protocol for triaging these patients. METHODS: This study is a retrospective analysis of patients presenting with atypical chest pain and evaluated with thoracic (CTA), for suspicion of AAS/PE. Two physicians reviewed patient files for demographic characteristics, initial CT and final clinical diagnosis. Patients were classified according to CTA finding into AAS, PE and other diagnoses and according to final clinical diagnosis into AAS, PE, ACS and other diagnoses. RESULTS: Four hundred and sixty-seven patients were evaluated: 396 (84.8%) patients for clinical suspicion of PE and 71 (15.2%) patients for suspicion of AAS. The prevalence of ACS and AAS was low among the PE patients: 5.5% and 0.5% respectively (P = 0.0001), while the prevalence of ACS and PE was 18.3% and 5.6% among AAS patients (P = 0.14 and P = 0.34 respectively). CONCLUSION: The prevalence of ACS and AAS among patients suspected clinically of having PE is limited while the prevalence of ACS and PE among patients suspected clinically of having AAS is significant. Accordingly patients suspected for PE could be evaluated with dedicated PE CTA while those suspected for AAS should still be triaged using TRO protocol.

Comparative assessment of gastric emptying in obese patients before and after laparoscopic sleeve gastrectomy using radionuclide scintigraphy.

Radionuclide scintigraphy provides a standard physiologic evaluation of gastric emptying (GE) after laparoscopic sleeve gastrectomy (LSG). This operation can be associated with motor gastric dysfunction and abnormal GE. The aim of this study was to evaluate the short-term effect of LSG on GE quantitative indices for liquids and solids compared with preoperative results. Forty obese patients were divided into two equal groups, the liquid and solid groups. Tc-sulfur colloid GE scintigraphy was performed on all patients submitted to LSG before and after surgery (1-4 weeks for liquids and 4-6 weeks for solids). The quantitative indices included half emptying time (T1/2) and percentage gastric retention at 15, 30, and 60 min for liquids and at 30, 60, 90, and 120 min for solids. A modified technique was used to label a boiled egg in order to be tolerated by the patients. T1/2 was significantly enhanced after LSG compared with baseline (25.3±4.4 vs. 11.8±3.0 min for liquids and 74.9±7.1 vs. 28.4±8.3 min for solids, respectively, P<0.001). The percentage of gastric retention in operated patients was significantly less than that at baseline for liquids at 15, 30, and 60 min (33.9±5.6, 17.7±3.9, and 7.5±2.8% vs. 69.4±10.5, 55.6±14.95, and 26.1±4.7%, respectively, P<0.001), as well as for solids at 30, 60, 90, and 120 min (42.0±11.1, 20.8±6.1, 11.0±5.9, and 3.8±2.7% vs. 79.9±8.7, 67.4±12.2, 37.0±10.9%, and 13.8±4.4%, respectively, P<0.001). The significant acceleration of GE of liquids and solids after LSG may have contributed to weight loss in the immediate postoperative period (4-6 weeks). It remains to be determined whether the weight loss will continue beyond that period.

Bone scintigraphy in axial seronegative spondyloarthritis patients: role in detection of subclinical peripheral arthritis and disease activity.

AIM: To detect subclinical peripheral arthritis and disease activity in axial seronegative spondyloarthritis (SpA) patients using bone scintigraphy. METHODS: Seronegative SpA patients with an established diagnosis and no clinically evident arthritis at the time of the study were included. After excluding symptomatic cases, 20 patients were recruited; 18 with ankylosing spondylitis (AS) and another two with psoriatic arthritis (PsA). Conventional bone scintigraphy was performed to detect the distribution of increased uptake, blood vascular pool (vascularity) and activity. RESULTS: The peripheral joints in all the patients were asymptomatic with no signs of arthritis on clinical examination. Disease activity was higher in those with hypervascularity and activity (75%) detected by scintigraphy. Scintigraphic activity of the sacroiliac joints was found in 10 patients (50%) with a mean sacroiliac joint index of 2.4 ± 0.6. Subclinical involvement of the hips, knees, shoulders, ankles, small joints of the hands, ankles and sternoclavicular joints, as well as the small joints of the feet were detected with descending frequencies (25%, 25%, 20%, 20%, 15%, 10% and 10%, respectively). Dorsal spine increased uptake was found in 35% and hypervascularity of the skull in two cases. Avascular necrosis of the hip was present in one case with hypovascularity. CONCLUSION: The spectrum of joint involvement in seronegative SpAs should not be limited to sacroiliitis. Bone scintigraphy provides a cost-effective method for detecting the extent of involvement in this group of autoimmune systemic diseases (axial SpA) without clinical evidence of peripheral arthritis.

Significance of popliteal lymph nodes visualization during radionuclide lymphoscintigraphy for lower limb lymphedema.

PURPOSE: To examine the frequency and significance of visualization of popliteal nodes during lymphoscintigraphy for the investigation of lower extremity swelling. MATERIALS AND METHODS: Technetium-99m-labeled nanocolloid was injected subcutaneously in the first web spaces of both feet of 90 patients (24 males, 66 females; age range, 4-70 years) who had clinical evidence of lower limb lymphedema and were referred for routine lymphoscintigraphy; imaging was performed 5, and 90 minutes after injection without any vigorous exercise between the injection and imaging. RESULTS: According to the scan findings, patients were divided into two groups; group I included 63 patients without popliteal nodes visualization on scanning, and group II included 27 patients with positive popliteal nodes uptake. None of patients with primary lymphedema (N = 22) due to agenesis or hypoplasia showed popliteal node uptake, whereas, patients with secondary lymphedema (N = 68) had either severe (N = 23) or partial (N = 45) lymphatic obstruction. A high positive association of popliteal node uptake with the severity of lymphatic obstruction was noted. Popliteal nodes were visualized in 26 of 57 patients with dermal back flow (46%), and in only 1 of 33 patients without dermal back flow (3%). There was a strong association between skin rerouting and popliteal node visualization (P < 0.01). Skin changes were detected in 24 patients (38%) with positive popliteal node uptake. CONCLUSION: Popliteal lymph nodes uptake during lymphoscintigraphy for clinical lymphedema of the lower limb indicates lymph rerouting through the deep system and raises a diagnosis of higher severity and longer duration of lymphatic dysfunction.

Influence of early (F+0) intravenous furosemide injection on the split renal function using 99mTc-DTPA renography.

In busy nuclear medicine departments, the F+0 protocol for diuretic renography is routinely used to shorten the acquisition time. The aim of this study was to evaluate the influence of the F+0 protocol on the split renal function (SRF) during a dynamic renal scan using technetium-99m diethylene triamine pentaacetic acid (Tc-DTPA) compared with that using the standard technetium-99m dimercaptosuccinic acid (Tc-DMSA). A total of 102 patients referred for a dynamic renal scan for varied etiologies were divided into two groups: the F+0 group, comprising 53 patients who were injected with furosemide just before Tc-DTPA injection, and the F+10 group, comprising 49 patients who were injected with the diuretic at the 10th minute after radiotracer injection. All patients were also subjected to a static cortical Tc-DMSA scan with geometric quantification of SRF. A highly significant statistical difference (P<0.001) was obtained on comparing the mean value of the difference in SRF calculated using DTPA and DMSA between the F+0 and F+10 groups, being 5.0±2.6 and 1.5±0.6%, respectively. All 49 patients in the F+10 group had a difference in split function of 5% or less, whereas 17/53 patients representing 32.1% of the F+0 group had a difference in SRF of greater than 5%. Early (F+0) furosemide injection before administration of Tc-DTPA has a significant influence on the estimation of SRF of the diseased kidney (either obstructed or functionally impaired) when compared with furosemide injection after standard Tc-DMSA administration. Care should be taken during interpretation of the scan findings when accurate split function is required.

Case report: an unusual combined retrograde and antegrade transpedal subintimal recanalization of the infrainguinal arteries.

Retrograde or combined retrograde and antegrade recanalization should be considered when antegrade recanalization has failed in selected patients with critical limb ischemia (CLI). Retrograde recanalization is typically attempted through a patent segment of the popliteal artery or an infrapopliteal artery. The challenge arises, however, when there are no patent popliteal or infrapopliteal arteries suitable for retrograde access.

Controlling difficult pelvic bleeding with argon beam coagulator during laparoscopic ultra low anterior resection.

In recent years, the standard of care for lower rectal tumors has developed to include a total mesorectal excision, which provides optimal long-term results. There has been debate with regard to the best approach for lower rectal tumors, conventional open versus less invasive procedures. As the trend toward less invasive surgical procedures progresses, similar complications, which are seen in open cases, are being encountered, such as the notorious presacral fascia bleed. These are small vessels, which are difficult to locate and control. Surgical literature suggests different methods during laparoscopic procedures. These include: placing lap pads and holding pressure, placing saline bag, placing tacks, using bone wax, and electrocautry at different settings. We present a case of a 57-year-old male, positive for lymph node disease, who underwent laparoscopic ultra low anterior resection with total mesorectal excision and protective loop ileostomy.

Life saving surgery for ruptured pseudo aneurysm of external iliac artery: case report / Cirurgia para salvamento de vida após ruptura de pseudoaneurisma da artéria ilíaca: relato de caso

The incidence of pseudo aneurysm after total hip arthroplasty is extremely rare. The most common mechanism of vascular injury is due to direct trauma during the operative procedure, and the most reported cases are acute in presentation. We reported an unusual case of ruptured pseudo aneurysm and control of life-threatening intra-operative hemorrhage of the external iliac artery in a male patient, 68 years old, with displaced total hip arthroplasty (THA), planned for removal, occurring 2 years after the last hip surgery, in Armed Forces hospital, Southern region, Saudi Arabia. This case highlights the importance of prompt recognition of life-threatening intra-operative hemorrhage to save the patient's life and the limb.

A incidência de pseudoaneurisma após a artroplastia total de quadril é extremamente rara. O mecanismo mais comum de lesão vascular deve-se ao trauma direto durante o procedimento cirúrgico, e os casos mais relatados são de apresentação aguda. Relatamos um caso incomum de ruptura de pseudoaneurisma e controle de hemorragia intraoperatória com risco de morte da artéria ilíaca externa em um paciente do sexo masculino, de 68 anos, com artroplastia total do quadril deslocada, planejada para remoção, ocorrendo 2 anos depois da última cirurgia de quadril, no Hospital das Forças Armadas, região sul da Arábia Saudita. Este caso destaca a importância do pronto reconhecimento da hemorragia intraoperatória com risco de morte para salvar a vida e o membro do paciente.

Single-incision laparoscopic cholecystectomy (SILC): a refined technique.

BACKGROUND: Reports of decreasing the number of incisions in laparoscopic procedures began appearing in the 1990s. A recent spark in pursuing such an approach has been accelerated by natural-orifice transluminal endoscopic surgery. METHOD: Several modifications in performing single-incision laparoscopic cholecystectomy (SILC) were introduced until it was possible to develop a simple and safe technique. RESULTS: SILC was completed in 61 of 71 operated patients. Fifty-five patients had SILC without cholangiography (average operative time, 49 minutes). Thirteen patients had SILC with cholangiography, 11 with negative results (average operative time, 67 minutes). Three patients needed additional trocars (bi-incision access surgery [BIAS]). None were converted to open procedures. Of the 69 patients with SILC or BIAS, 66 had same-day discharge, and 3 were discharged the following day. CONCLUSION: SILC or BIAS is effective for gallbladder removal, with comparable lengths of stay, operative times, and safety as the traditional method, with better cosmetic results.