The Inframammary Fold (IMF): A Poorly Appreciated Landmark in Prosthetic/Alloplastic Breast Aesthetic and Reconstructive Surgery-Personal Experience.

The inframammary fold (IMF) is the most critical visual landmark that affects final aesthetic outcome of augmentation mammoplasty and even post-mastectomy alloplastic breast reconstruction. Unfortunately, structural integrity of this landmark is greatly overlooked and very often neglected. Excessive undermining of the lower breast pole with aggressive disruption/lowering and subsequent poor reconstitution of the IMF scaffold combined with imbalanced implant-tissue dynamics may result in downward implant displacement with creep bottoming and upward tilt of the nipples. The current report reviews the experience of the senior author (BA) over 30 years in breast aesthetic and reconstructive surgery with IMF reconstruction and fixation to the chest wall at the inferior border of the implant. Illustrative cases are presented. 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 .

Shortage of Plastic Surgeons in Lebanon: Impact of the 2019 Economic Crisis.

Background: Lebanon's ongoing economic crisis since 2019 has seen an unprecedented migration of professional healthcare workers. This article analyzes the adequacy of registered plastic surgeons in Lebanon in 2023. Methods: A list of registered plastic surgeons was obtained from the Lebanese Order of Physicians. Registered plastic surgeons were contacted via email or phone and were asked to fill in a survey questionnaire addressing their work status. Additionally, the number of plastic surgeon graduates, between 2018 and 2022, was obtained from Lebanese medical schools. Results: Of the 162 plastic surgeons registered with the Lebanese Order of Physicians in 2023, 158 responded to the survey (97.5%). The work settings of the active plastic surgeons fell into three categories: working in Lebanon full time, splitting work between Lebanon and abroad, and exclusively working abroad. The ratio of plastic surgeons practicing full time in Lebanon is 1.11 per 100,000 inhabitants, which is significantly below the recommended ratio of 2.01. Twenty eight percent of the plastic surgeons working in Lebanon are aged between 65 and 75 years. Meanwhile, an average of only three graduates (2018-2022) enter the workforce annually after completing training in plastic and reconstructive surgery residency. Among the various subspecialties within plastic and reconstructive surgery, aesthetic surgery was the most commonly practiced by those surveyed. Conclusions: There is a relative shortage of plastic surgeons in Lebanon that is compounded by a significant focus on aesthetic procedures. Implementation of strategies is needed to bridge this gap and meet the needs of the underserved people of Lebanon.

Single dual-trained surgeon for breast care leads to higher reconstruction rates after mastectomy.

BACKGROUND: Breast reconstruction improves the quality of life for mastectomy patients but is underutilized in the United States. This study investigated reconstruction rates for a dual-trained oncologic plastic surgeon to explore how provider-based factors influence reconstruction. METHODS: We evaluated consecutive mastectomy patients treated at the University of California, San Diego Medical Center between 2009 and 2012. We identified mastectomy patients based on Current Procedural Terminology codes and evaluated them for patient- and disease-specific variables. We evaluated reconstruction rates for the traditional team model of collaborating plastic and oncologic surgeons versus a single surgeon, dual trained in surgical breast oncology and plastic surgery. A multivariate regression analysis was then used to identify the significant predictors of reconstruction. RESULTS: Mastectomy was performed in 344 patients. The surgeon group was a significant predictor of postmastectomy reconstruction (p < 0.05). The traditional team of oncologic and plastic surgeons reconstructed 93 (63.3 %) of 147 mastectomy patients, whereas the single dual-trained surgeon reconstructed 140 (71.1 %) of 197 mastectomy patients. Race and insurance status did not influence the receipt of reconstruction in our single-surgeon model, however, patients of older age [odds ratio (OR) 0.93, confidence interval (CI) 0.89-0.98, p < 0.01], higher body mass index (OR 0.89, CI 0.82-0.97, p < 0.01), or more advanced disease (p < 0.01) were less likely to undergo reconstruction. CONCLUSIONS: A single dual-trained surgeon for breast care influences reconstruction rates. A dual-trained surgeon increases the likelihood of reconstruction and obtains rates higher than previously reported. This may reflect the comprehensive care provided by a multidisciplinary-trained professional. A single surgeon providing care in oncology and reconstruction represents a comprehensive approach to breast care and demonstrates a relationship between provider practice and breast reconstruction.

Necrotizing metachronous facial ulcerations after "stem cell face lift".

INTRODUCTION: A 63-year-old woman underwent face and neck lift with autologous fat transfer-called by her physician a "stem cell face lift." METHODS: Fatty aspirate from her abdominal wall was enriched by hyaluronic acid, triiodothyronine, thyroxine, insulin, dimethylaminoethanol, estriol, dexamethasone, indomethacin, and fibroblast growth factor before injection into the face. RESULTS: At approximately 4-weeks postoperative, the patient developed facial swellings, erythema, necrotizing ulcers, and an orocutaneous fistula. New lesions continued occurring up to 16 weeks after surgery. After multiple surgical debridements and an oral course of rifampin, a decisive reduction in inflammation and healing was observed. Differential diagnosis included (1) mistaken transfer of allogeneic fat (ruled out), (2) toxic impurities in transferred material, (3) microbial contaminant(s) from multiple use liposuction cannula or tissue markers, and (4) endogenous anaerobic orofacial infection (history of previous radiation for tonsillar cancer and dental implants). CONCLUSIONS: The most probable etiology was mycobacterial infection. This is based on a single colony of mycobacterium isolated, histologic finding revealing granulomatous inflammation, and the favorable response to rifampin. The patient underwent subsequent autologous fat transfers, which successfully reduced some disfigurement and scarring.

A comparison of cell-enriched fat transfer to conventional fat grafting after aesthetic procedures using a patient satisfaction survey.

INTRODUCTION: The role of regenerative cells in adult human fat is still unfolding. At present, limited clinical studies comparing patient satisfaction with cell-enriched fat transfer (CEFT) to conventional autologous fat transfer (AFT) for aesthetic indications have been performed. Herein, we present our data obtained from patient satisfaction questionnaires. METHODS: Patients undergoing fat grafting received AFT or CEFT. Study participants were surveyed for overall satisfaction, symmetry, deformity, scarring, and pigmentation. Hospital charts were reviewed for complications, and patient survey responses between the groups were compared. RESULTS: Between January 2009 and September 2011, 36 patients had 6-months follow-up and were mailed surveys. Of these, 17 (12 CEFT and 5 AFT) returned completed Patient Satisfaction Rating surveys. At a median follow-up time of 10.7 months, the overall mean satisfaction rate was 5.2 of 6 (5.3 vs 5.0 for CEFT and AFT, respectively, P = 0.42). There were no significant differences about deformity (5.1 vs 4.7, P = 0.50), symmetry (4.5 vs 5.0, P = 0.48), or scarring (5.3 vs 4.5, P = 0.23). However, pigmentation was improved in the CEFT vs the AFT groups (P < 0.001). No patients in the AFT group noted skin pigmentation improvement, whereas 7 of 12 receiving CEFT noted improvement in skin pigmentation. CONCLUSIONS: Cell-enriched fat transfer to the face and body of aesthetic patients produces high satisfaction rates. Our preliminary data demonstrates similar satisfaction with regard to symmetry, scarring, and deformity in patients treated with CEFT versus AFT, without any complications. Unexpectedly, a clinical and statistical improvement in pigmentation was seen for patients treated with CEFT over AFT. Further studies need to be done to better understand this phenomenon.

Treatment of linear scleroderma "En coup de Sabre" with single-stage autologous fat grafting: A case report and review of the literature.

BACKGROUND: Linear scleroderma "en coups de sabre" is a disease that causes scar-like lesions in the forehead and the scalp, and atrophy of the underlying structures. The result is an acute facial asymmetry that can be distressing to affected young adults. Several surgical treatments are available such as free tissue transfer and synthetic fillers. AIMS: In this report, we present a rare case of linear scleroderma "en coups de sabre," which was successfully managed with single-stage autologous fat grafting. PATIENTS/METHODS: The patient was a 17-year-old male who presented with a soft-tissue defect in the left forehead region. Treatment consisted of transferring autologous fat into the defect in a retrograde fashion, as described by Coleman, and overcorrecting the defect to account for fat resorption. RESULTS: At 6 mo postoperatively, the patient had maintained a satisfactory correction of his left forehead and scalp regions with minimal resorption of fat. CONCLUSION: Autologous fat grafting provides a safe and easy approach for the treatment of linear scleroderma "en coups de sabre". With minimal manipulation of the aspirated fat, combined with overcorrection of the defect, long-term clinically satisfactory results can be obtained.

War-related ocular injuries in Damascus during the Syrian Crisis.

BACKGROUND: . Ocular injuries constitute a major cause of visual morbidity, and they have a significant socioeconomic impact worldwide. We aimed to document the types and causes of Syrian War related ocular injuries in Damascus, Syria. METHODS: . Medical records were retrospectively reviewed to evaluate all patients in Al-Mouwasat University Hospital and Damascus Hospital, whose ocular injuries were caused by war-related activities during the period extending between January of 2016 and December 2017. RESULTS: . 150 eye injuries in 127 patients were reviewed, in which 46 (31%) were bilateral and 87 (58%) were open globe injuries. The leading cause of the observed ocular injuries was improvised explosive devices (IED) [37 eyes (41%)]. The majority of patients presented with an initial best corrected visual acuity (BCVA) of "light perception" (LP) to "hand movement" (HM) [51 eyes (34%)]. Information on the final BCVA was available for 69 injured eyes only, and it was "no light perception" (NLP) in 20 eyes (29%). CONCLUSION: . Explosive weaponry is the main culprit in most war-related ocular injuries in Syria. The high incidence of open globe injuries caused many of the cases to be severe in nature. Education on the precautionary measures that protect the eyes such as the use of combat eye protection during wartimes ought to be enforced, so that future ocular injuries can be prevented.

Iatrogenic sciatic nerve injury during liposuction and fat tissue grafting: a preventable surgical complication with devastating patient outcomes.

BACKGROUND: Liposuction and autologous fat transplantation represent widely used techniques in plastic surgery to correct or enhance contour irregularities in the face and body. While these techniques are assumed to be safe, liposuction and fat grafting impose a hidden risk for serious preventable surgical complications and adverse patient outcomes. We hereby report two cases of iatrogenic sciatic nerve injury and provide recommendations on how to prevent this serious surgical complication. CASE PRESENTATION: We present two cases of sciatic nerve injury - one related to liposuction and the other related to gluteal lipo-augmentation. The first case is a 20-year-old female who presented to our institution with right leg weakness one week after undergoing scar revision and fat grafting in the left peri-oral region to correct peri-oral cicatricial banding and tissue atrophy. Fat was harvested from the medial thigh using a 3-mm cannula with low-pressure manual suction, utilizing minimal tumescent solution. Nerve conduction velocity and electromyography testing suggested a right-sided sciatic nerve lesion as a result of direct trauma. The patient was observed for a period of 4 months during which time she underwent physical therapy. At four months post-operatively, she had recovered completely. The second case is that of a 39-year-old female who presented to our institution with left-sided weakness of foot eversion and dorsiflexion five days after she had undergone liposuction of the thighs, flanks, and abdomen in addition to gluteal lipo-augmentation at an outside facility. The patient had undergone super wet liposuction in the areas of the abdomen, flanks and thighs. 200 mL of collected fat was then transplanted into each buttock at multiple levels. Post-operative computed tomography and electroneurography revealed acute left sided sciatic injury consistent with direct trauma to or compression of the sciatic nerve. The patient underwent an extensive regimen of physical therapy. Three months post-operatively, the patient had regained some motor function, but was lost to follow-up thereafter. CONCLUSION: The sciatic nerve is relatively superficial and vulnerable to injury in the upper thigh and lower buttock regions. Therefore, extreme care should be taken when working in these areas to avoid direct or indirect injury to the sciatic nerve by compression or traction.

Composite tissue engineering on polycaprolactone nanofiber scaffolds.

Tissue engineering has largely focused on single tissue-type reconstruction (such as bone); however, the basic unit of healing in any clinically relevant scenario is a compound tissue type (such as bone, periosteum, and skin). Nanofibers are submicron fibrils that mimic the extracellular matrix, promoting cellular adhesion, proliferation, and migration. Stem cell manipulation on nanofiber scaffolds holds significant promise for future tissue engineering. This work represents our initial efforts to create the building blocks for composite tissue reflecting the basic unit of healing. Polycaprolactone (PCL) nanofibers were electrospun using standard techniques. Human foreskin fibroblasts, murine keratinocytes, and periosteal cells (4-mm punch biopsy) harvested from children undergoing palate repair were grown in appropriate media on PCL nanofibers. Human fat-derived mesenchymal stem cells were osteoinduced on PCL nanofibers. Cell growth was assessed with fluorescent viability staining; cocultured cells were differentiated using antibodies to fibroblast- and keratinocyte-specific surface markers. Osteoinduction was assessed with Alizarin red S. PCL nanofiber scaffolds supported robust growth of fibroblasts, keratinocytes, and periosteal cells. Cocultured periosteal cells (with fibroblasts) and keratinocytes showed improved longevity of the keratinocytes, though growth of these cell types was randomly distributed throughout the scaffold. Robust osteoinduction was noted on PCL nanofibers. Composite tissue engineering using PCL nanofiber scaffolds is possible, though the major obstacles to the trilaminar construct are maintaining an appropriate interface between the tissue types and neovascularization of the composite structure.

Facial Nerve Axonal Analysis and Anatomical Localization in Donor Nerve: Optimizing Axonal Load for Cross-Facial Nerve Grafting in Facial Reanimation.

BACKGROUND: Donor nerve axonal count over 900 in two-stage reconstructions using cross-facial nerve grafts is possibly associated with improved outcomes in facial reanimation. Facial nerve axonal analysis was performed to determine the ideal location for optimizing axonal load. Correlation of axonal number, branch diameter, and age was also assessed. METHODS: Twenty-eight fresh unpreserved cadaveric hemifaces were dissected exposing the extracranial facial nerve branches. Axonal counts at 2-cm intervals from the pes anserinus along branches inserting into the zygomaticus major muscle were taken, noting position relative to the zygomatic arch, posterior ramus border, lateral border of the zygomaticus muscle, and anterior parotid gland border. Nerves were fixed, sectioned, and stained with SMI-31 antineurofilament stain for digital axonal analysis. RESULTS: All specimens had one or more intraparotid zygomatic branches with over 900 axons, and 96 percent had an extraparotid branch with over 900 axons. The likelihood that a zygomatic branch would have over 900 axons at its last intraparotid point (mean, 6 mm posterior to the parotid border) was 92 percent (range, 67 to 100 percent) in contrast to 61 percent (range, 25 to 100 percent) when sampled at the first extraparotid point (mean, 14 mm anterior to the parotid border). Nerve cross-sectional area was positively correlated to its axonal count (R° = 78 percent; p < 0.0001), with nerve diameter over 0.6 mm predicting over 900 axons. Age did not correlate with axonal counts. CONCLUSIONS: Branches with adequate axonal load were found in all specimens. The likelihood of adequate branch selection improved from 61 percent to 92 percent with short retrograde intraparotid dissection. Nerve diameter correlated with axonal load.

The Deep Temporal Nerve Transfer: An Anatomical Feasibility Study and Implications for Upper Facial Reanimation.

BACKGROUND: Facial paralysis has a profound impact on the brow, and currently static procedures are the mainstay of treatment. The deep temporal branches of the trigeminal nerve, given their proximity to the brow, may serve as possible donor nerves for both potential innervation of a free muscle transfer in patients with prolonged facial palsy or nerve transfers in acute or subacute palsy. As such, the authors present the detailed surgical anatomy of the deep temporal nerve, assessing feasibility for both functional muscle and nerve transfers, including a proposed surgical technique. METHODS: Thirty cadaver hemifaces were dissected to establish deep temporal nerve anatomy and perform axonal analysis. RESULTS: Two (53 percent) or three (47 percent) divisions of the deep temporal nerve were noted, with the most consistent division being the middle division (30 of 30 specimens). This division was consistently found approximately 4.1 cm (range, 3.7 to 4.5 cm) anterior to the tragus at the level of the zygomatic arch. For each 1 cm cranial to the arch, the nerve courses approximately 1 mm posteriorly. The number of axons in the proposed temporal branch is 1469 as it emerges from behind the zygomatic arch, 889 at 1 cm, 682 at 2 cm, 534 at 3 cm, 355 at 4 cm, 377 at 5 cm, and 256 at 6 cm. CONCLUSION: Given its anatomical consistency, and expendability, the middle division of the deep temporal nerve is a viable donor nerve for dynamic upper facial reanimation with either nerve transfer or functional muscle transfer, depending on the length of facial palsy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Role of oxidative stress in the increased activation of signal transducers and activators of transcription-3 in the fatty livers of obese Zucker rats.

BACKGROUND: Fatty livers have chronic oxidative stress, which could activate several transcription factors. We hypothesized that fatty livers of obese rats have increased activation of signal transducers and activators of transcription-1 and transcription-3 (Stat-1 and Stat-3) and that tocopherol treatment will decrease Stat activation. METHODS: Obese (Ob) and lean (Ln) Zucker rats with or without tocopherol treatment were used. Western blots of liver nuclear and cytoplasmic extracts to assess phosphorylated and total Stat-3 and tyrosine kinases Jak-2 and Tyk-2, immunohistochemistry to assess distribution of phosphoStat-3, and gel shift assays to assess Stat and nuclear factor kappa B binding were performed. Interleukin-6 serum levels and hepatic transcripts were determined by immunoassay and reverse polymerase chain reaction with Southern blotting, respectively. RESULTS: Livers of Ob animals had increased nuclear phosphoStat-3, decreased cytoplasmic Stat-3, and increased Stat-3 binding. Serum interleukin-6 was not measurable in either Ob or Ln animals and hepatic transcript levels were not significantly different. Tocopherol administration decreased nuclear phosphoStat-3, increased cytoplasmic Stat-3, and decreased Stat-3 binding activity. CONCLUSIONS: Chronic oxidative stress in fatty livers is associated with increased Stat-3 activation and decreased cytosolic Stat-3. Tocopherol treatment decreases Stat-3 activation and increases cytosolic Stat-3. Tocopherol-induced changes in Stat-3 may play a role in its beneficial effects in hepatic ischemia in fatty livers.

Competency versus performance in plastic surgery: navigating through new technologies and medical devices.

The purpose of this article is to examine how plastic surgeons learn to use novel technology in their practices. In addition, a critical evaluation of current teaching methods as they relate to surgeon competence in these new technologies is discussed.

Evaluating the safety and efficacy of BMI-based preoperative administration of low-molecular-weight heparin in morbidly obese patients undergoing Roux-en-Y gastric bypass surgery.

BACKGROUND: One of the most concerning and potentially fatal complications of gastric bypass surgery is pulmonary embolism (PE) with published rates exceeding 1%. Although this procedure has been proven effective in reducing the morbidity and mortality of obesity and associated health care costs, it is elective and risk must be minimized. No dosing guidelines exist for pharmacologic prophylaxis in obese patients who are already at increased risk for these events. Although the current ASMBS and Chest guidelines recommend preoperative pharmacologic prophylaxis against thromboembolic events, no standard dosing protocols exist for the obese population. We propose a protocol including immediate pre followed by twice daily postoperative BMI-based dosing of low-molecular-weight heparin (LMWH), along pneumatic compression devices, and early ambulation. METHODS: We retrospectively reviewed the charts of 170 patients who underwent Roux-en-Y gastric bypass surgery between March 2004 and December 2007. The incidence of deep venous thrombosis (DVT) and PE and bleeding complications associated with a BMI-based preoperative dosing protocol of LMWH was determined. RESULTS: All patients received LMWH preoperatively within 1 h of the incision, with doses varying between 30 and 60 mg given subcutaneously. Eleven patients received 30 mg, 145 patients received 40 mg, 9 patients received 50 mg, and 5 patients received 60 mg. None of the patients suffered from clinically significant DVT or PE during the hospital stay or in follow up (>2 years). Five patients (2.9%) were treated with discontinuation of lovenox and blood transfusion for postoperative bleeding. One of those patients returned to the operating room for exploration. CONCLUSIONS: We propose that immediate BMI-based preoperative dosing of LMWH along with postoperative prophylaxis is both safe and effective and should be standard for all patients undergoing Roux-en-Y gastric bypass surgery.

Anatomical relationship of Roos' type 3 band and the T1 nerve root.

BACKGROUND: The most common clinical presentation of thoracic outlet syndrome stems from compression of the lower trunk of the brachial plexus or ulnar nerve. A plethora of anatomical variations have been implicated in the cause of thoracic outlet syndrome. Roos' identification and classification of scalene muscle and fibrous bands have added an additional dimension to understanding its cause and subsequent treatment. Understanding the anatomy and relationship of this band with the lower trunk of the brachial plexus is of paramount importance. METHODS: As part of the authors' long-term study of the type 3 band in relation to the brachial plexus, 70 embalmed cadavers were dissected to yield 100 first thoracic ribs. Fibrous bands, when present, were studied in relation to the brachial plexus. RESULTS: A fibrous band consistent with Roos' type 3 was identified and found to occur in 35 percent of first ribs and 41 percent of cadavers. The mean size was 3.45 × 0.27 cm. Origins and insertions are described. Contrary to Roos' own description, however, the authors observed that Roos' type 3 band was anterior to the T1 nerve root, creating a tunnel through which the T1 nerve root must pass before joining the C8 nerve root. CONCLUSIONS: The authors believe that the type 3 band, when present, can create a tunnel that compresses the T1 nerve root against the first rib, potentially predisposing susceptible individuals to thoracic outlet syndrome. Clinical studies are needed to determine whether correlations between type 3 bands and thoracic outlet syndrome exist.

Clinical evaluation comparing the efficacy of aquacel ag hydrofiber dressing versus petrolatum gauze with antibiotic ointment in partial-thickness burns in a pediatric burn center.

We conducted this Institutional Review Board-approved retrospective study to compare Aquacel Ag Hydrofiber dressing (Aquacel Ag) to a standard dressing for the treatment of partial thickness burns in children. We used the St. Christopher's Hospital burn center registry to identify 20 pediatric patients who had sustained partial thickness burns over a 10-month period. Ten of these patients had been treated with Aquacel Ag Hydrofiber dressing and 10 were treated with conventional Xeroflo gauze with Bacitracin Zinc ointment, the institutional standard of care for nonoperative partial-thickness burn wounds. Inclusion criteria included anyone with partial-thickness burns below the age of 18 years and in excellent baseline health. Exclusion criteria included inhalation injury, presence of full-thickness burns necessitating surgical debridement, cellulitic, or infected wounds, and percentage total body surface area involvement greater than 40%. Outcomes measured for the Aquacel Ag versus the Xeroflo gauze with Bacitracin Zinc ointment group included hospital length of stay (2.4 vs. 9.6 days), total number of in-house dressing changes (2.7 vs. 17.1), pain on a 10-point scale associated with dressing changes (6.4 vs. 8.2), total number of intravenous narcotic administrations (2.3 vs. 14.4), nursing time adjusted for percentage total body surface area (1.9 vs. 3.5 min), time to wound reepithelialization (10.3 vs. 16.3 days), and patient primary caregiver satisfaction score using a 4-point scale--with four delineating maximum satisfaction (3.8 vs. 1.8). Aquacel Ag proved to be a safe and effective means of treating partial thickness burns with a significant reduction in nursing time and patient pain involved with dressing changes.

Salvage of a thumb replant using a bilobed dorsal metacarpal artery island flap: case report and literature review.

Amputations and degloving injuries of the hand are highly disabling, especially when they affect the thumb. Dorsal metacarpal artery (DMCA)-based flaps have been well-documented in the literature for use in extensive degloving injuries of both dorsal and palmar aspects of the thumb surface. Modifications on these flaps, such as the bilobed island flap, offer additional advantages when larger surface areas or more distal defects of the thumb are present. We present a review of the literature on the DMCA flap and describe its use to salvage a partial survival of a thumb amputation through the metacarpophalangeal joint.

Single port access adrenalectomy.

OBJECTIVE: To report the first single port access (SPA) adrenalectomy to minimize patient discomfort through a less invasive procedure. METHODS/RESULTS: We performed the first SPA in a 63-year-old, otherwise healthy Caucasian female who had a 4.5-cm left adrenal mass that was incidentally discovered on computed tomography scan of the abdomen and pelvis. Through a 2-cm single longitudinal supraumbilical incision extended down to the abdominal fascia, three 5-mm ports were placed through separate facial entry points, to make a triangular port arrangement. The adrenal vein was identified and ligated using hemoclips. The remainder of the dissection was done using hemocoagulation. The adrenal gland was extracted via an EndoCatch bag device by removing one 5-mm port and upsizing to a 12-mm port. CONCLUSION: We report on the first SPA adrenalectomy. Although this technology is still in its infancy, the use of a single port for surgery provides a means to provide a potentially better patient outcome with a less invasive procedure.