Retrograde Umbilical Hernia Repair During Abdominoplasty: A Safe and Simple Technique.

BACKGROUND: Abdominoplasties are a very common procedure that is geared toward improving the abdominal contour and restoring quality of life. Main candidates for surgery are postpartum patients and patients after massive weight lost results in excess skin. The high incidence of umbilical hernias in the general population raises the question of whether combining its repair with cosmetic abdominoplasties is a safe and effective procedure. PURPOSE: Determine the safety of the "retrograde umbilical hernia" (RUH) technique, which utilizes a pre-peritoneal approach to the hernia, during abdominoplasty procedure and expand the literature on hernia repair during aesthetic abdominal surgery. METHODS: This is the retrospective cohort study of all patients that underwent abdominoplasty by the senior author. Eligible patients were divided into 2 groups: where one group included all patients who underwent abdominoplasty with RUH repair, and the second group underwent sole abdominoplasty. Baseline variables, surgical notes, and post-operative outcomes were obtained from the patients' medical records and analyzed for the purpose of this study. RESULTS: In total, 744 patients underwent abdominoplasties during the course of our study, 112 of which underwent concomitant umbilical hernia repair using the retrograde technique. The RUH technique was not found to result in a higher rate of complications compared to a similar population of traditional abdominoplasties. CONCLUSIONS: The retrograde umbilical hernia repair is a safe and efficient technique that can be easily implemented during abdominoplasty procedures in a heterogeneous population of patients. LEVEL OF EVIDENCE III: 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 .

Drains in Abdominoplasties: The Less the Better?

BACKGROUND: Drains are traditionally inserted during surgery for reduction of fluid accumulation in the post-operative period. The appearance of drained fluids and their quantity can be early predictors of complications. Over the years, several studies have been conducted in attempt to determine the optimal number of drains that result in low rates of fluid accumulation with minimal impairment of quality of life. PURPOSE: Determine the optimal number of suction drains in abdominoplasty procedures. METHODS: Retrospective cohort study, analyzing all abdominoplasty patients operated by a single surgeon. Patients were stratified into 3 groups based on number of drains inserted at the end of the procedure. Rate of complications was compared between the groups and a multivariate logistic regression model was computed for the development of complications. RESULTS: Seven-hundred and forty three patients were included in the analysis of this study. No drains were inserted in 355 patients (45%), whereas a single drain was inserted in 153 (20.6%) 2 drains in 255 patients (34.4%). Patients for whom a single drain was inserted intra-operatively, experienced at a statistically significant lower rate, surgical site infections (OR = 0.235), hypertrophic scars (OR = 0.326), wound dehiscence (OR = 0.272), as compared to patients with no drains. On the contrary, insertion of single drain was associated with a statistically significant higher risk for development of seroma (OR = 6.276) and the need for revision surgery (OR = 2.452). CONCLUSION: Insertion of a single drain is associated with a lower risk of SSI and wound- dehiscence, but a greater risk for seroma development that requires surgical intervention. 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.

What Role does Marital Status Play in the Outcome of Abdominoplasties? A Single-Surgeon Experience With 712 Cases.

BACKGROUND: Marital status is a commonly reported demographic variable in scientific literature. Numerous reports suggested difference in the medical outcomes of patients when stratified based on marital status. Although many reports suggested that married patient exhibit improved survival when compared to their counterparts, other reports could not replicate similar conclusions. PURPOSE: determine whether marital status plays a role in the postoperative outcomes of elective abdominoplasty patients. METHODS: The medical records of all abdominoplasty patients operated by a single surgeon over the course of 20 years were reviewed. Information regarding the preoperative state of patients, surgical procedure, and postoperative outcomes was evaluated in respect to the patients marital status. RESULTS: Seven-hundred and twelve patients were included in this study, of whom 516 (%) were married. No difference in preoperative characteristics, medical background, surgical procedure or concomitant surgeries was found. Analysis of adverse events did not demonstrate a statistically significant association with marital status. Additionally, when all unwed patients were grouped together, the results did not differ. CONCLUSION: Marital status does not play a critical role in the postoperative outcomes of patients undergoing elective abdominoplasties for cosmetic indications. LEVEL OF EVIDENCE III: 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 .

Prior Caesarean Section Delivery Increases the Risk for Seroma Development in Abdominoplasty Patients: Our Experience With 746 Patients.

BACKGROUND: Complications after body-contouring surgery is a field of great interest. Recognition of patient-related characteristics contributing to a greater risk for complication is of the utmost importance in improving the quality of care and safety profile of aesthetic procedures. Prior history of cesarean section and its impact on adverse events after abdominoplasty has yet to be investigated and defined. OBJECTIVES: Evaluate the effect of prior cesarean section on the risk for adverse events in abdominoplasty. METHODS: The medical records of 746 eligible patients were reviewed and relevant information was extracted. Stratification of patients based on prior history of CS was followed by statistical analysis of differences between the groups. Relevant regression models were implemented to further understand the data. RESULTS: Seven-hundred and forty-six patients were included in the study, of which 308 (43.1%) had history of CS delivery. the group did not differ in terms of baseline demographic and surgical details, except for greater hemoglobin level (P value= 0.007).analysis of complication rates found a statistically significant increase in the risk for seroma development in the group of patients with history of CS delivery (P value= 0.031) which correlates to a 65% increase in the risk for complications (OR= 1.65, 95% CI 1.07-2.56). CONCLUSIONS: Medical history of CS increased the risk for seroma development in the postoperative period following abdominoplasty. Several potential pathogenic mechanisms exist, and further prospective research to further characterize the association.

Should the Eigenfactor Replace the Impact Factor?: A Bibliometric Study of Plastic, Reconstructive, and Aesthetic Surgery Journals.

BACKGROUND: Despite the global acceptance of the impact factor (IF) by researchers and academic institutions as one, criticism has been voiced regarding its effectiveness in evaluating the unbiased impact of a journal. To overcome the limitations and drawbacks of the IF that were presented by the scientific community, they introduced several other citation-based bibliometric indices. METHODS: All plastic and reconstructive surgery journals were analyzed, and bibliometric indices were extracted from the relevant source. Pearson correlation coefficients were used to determine correlations between the various indices. RESULTS: All correlations in between the various bibliometric indices were found to be positively and statistically significant, ranging from moderately highly associated for the IF and Eigenfactor (r = 0.632) to very strongly associated (r = 0.962) for the IF and the Article Influence Score. CONCLUSION: In the field of plastic and reconstructive surgery, the Eigenfactor and its derivative, the Article Influence Score, could potentially serve as better indices than the IF in demonstrating the overall picture. This information is based on the inclusion of a greater number of journals in the calculation and subtraction of self-citations, without compromising their correlation with other indices.The use of Eigenfactor and other additional bibliometrics cooperatively with the IF could provide the most extensive evaluation of a journal's scientific impact.

Tranexamic Acid Irrigation in Liposuction: A Double-Blind, Half-Body, Randomized, Placebo-Controlled Trial.

BACKGROUND: Hematomas are common complications following plastic and esthetic surgeries. Large and complex hematomas might result in prolonged hospitalization, further interventions, additional expenses, and poor esthetic outcome. Tranexamic acid (TXA), an antifibrinolytic agent, has long been used to reduce blood loss. Its use in the field of plastic surgery has gained popularity recently. Several studies have presented the ability of TXA to reduce blood loss, hematomas, and ecchymoses after liposuctions. However, the proper dose and the route of administration remained controversial. OBJECTIVE: The objective of the study was to quantify the effect of a low dose of TXA in an irrigation method in reducing hematomas and ecchymoses following liposuction. METHODS: A prospective randomized controlled trial was conducted. Following liposuction, 400 mg of TXA were administered in an irrigation protocol to one side of the body in each patient, while the other side was administered with saline. The patients were photographed on 1, 2, 4, and 11 post-operative days. Ecchymosis and hematoma were measured and rated. RESULTS: No statistical difference was observed between the intervention and control groups in terms of RBC in liposuction area (p = 0.11), RBC in lipoaspirate (p = 0.79), bruising size on days 1, 2, 4, and 11 (p = 0.68, 0.21, 0.42, and 0.75), and average ecchymosis score on the same days (p = 0.34, 0.72, 0.09, and 1) CONCLUSIONS: The use of a low-dose TXA irrigation solution did not demonstrate a statistically significant difference in post-operative hematoma formations rates and subsequent ecchymosis size and scale. 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 .

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men.

BACKGROUND: The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique. OBJECTIVES: To present and discuss the Transgender Standard of Care and our personal experience. METHODS: Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed. RESULTS: Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis. CONCLUSIONS: A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.

Myiasis in Neglected Cutaneous Squamous Cell Carcinoma of the Head and Neck: Review of Management and Current Protocol Recommendations.

OBJECTIVE: To propose a first-aid management protocol for myiasis in neglected cutaneous squamous cell carcinoma (SCC) in the ED based on a recent literature review. DATA SOURCES: PubMed. STUDY SELECTION: Inclusion criteria were all series and case reports of primary/secondary cutaneous SCC with myiasis of the head and neck, including orbital SCC cases, published after 2005. DATA EXTRACTION: A total of 14 articles including 15 patients were included. DATA SYNTHESIS: Demographics, socioeconomic situation, site of the lesion, larvae species with bacterial suprainfection, and first-aid treatment options were discussed. Two representative cases are described. CONCLUSIONS: Large, ulcerated, necrotic, myiasis-burdened SCC lesions in the head and neck area present a challenge for treatment, and to date, no consensus regarding first-aid management exists. The authors' proposed four-pillar first-aid management scheme may be a valid option to rapidly improve wound condition through disinfection, pain relief, and malodor and discharge eradication as a bridge to surgery.

[PLASTIC SURGERY - RESTORING CONTOUR, FUNCTION AND HAPPINESS].

INTRODUCTION: Plastic surgery history denotes two forefathers: Sushruta Samhita, who dates back to the 6th century BC with the Sanskrit surgical handbook, composed mainly by him, and Sir Harold Delf Gillies who is considered the father of modern plastic surgery due to his pioneer work during World War I.

[A MULTIFACETED APPROACH FOR TRAUMATIC AURICULAR AVULSION WITH VENOUS CONGESTION].

INTRODUCTION: Choice of operative technique is often a major factor in the success of replantation of traumatic avulsions of the auricle. While microsurgery is considered to produce the best aesthetic results, this approach may not be an option due to vascular damage. We present the case of a 66-year-old Caucasian male with a subtotal traumatic left auricle avulsion. Microsurgical repair was not attempted as vessels amenable to anastomosis could not be found. Instead, the auricle was replanted in a non-microsurgical manner as a composite graft using Monocryl sutures. As a preventative measure for clot formation heparin was injected intradermally throughout the anterior auricular surface and helix. Twenty-four hours postoperatively, as signs of venous congestion were noted, a multimodal therapy was initiated combining mechanical, chemical and biological therapies. Medicinal leech therapy (hirudotherapy) was used to enhance venous drainage and prevent clot formation. Hirudotherapy is an effective and safe treatment modality for venous outflow obstruction in avulsed auricle injuries. However, one must consider the possible complications of leech therapy and the need for close monitoring. An examination conducted two months following the initial injury revealed optimal patient outcomes with excellent aesthetic results and full auricular sensation. Good vascular outflow is integral to the successful salvage of replanted tissues. Venous stasis must be identified and addressed early for good patient outcomes. The current report highlights the importance of a multifaceted approach in cases of traumatic auricular avulsions followed by venous congestion.

[OUR EXPERIENCE IN MASTECTOMY FOR TRANSGENDERS FEMALE TO MALE - A 90 CASES COHORT STUDY].

AIMS: We present our experience in mastectomies for masculine chest contouring, including discussion of techniques, complications and decision-making processes. BACKGROUND: Creating a masculine chest is an important component in the process of gender reassignment, in female to male transgenders. This surgery may be performed using various techniques and the main complication is acute hematoma requiring surgical revision. METHODS: The study population included all the patients operated on during 2013-2018. Data was collected from the medical files and clinical photos. RESULTS: A total of 180 mastectomies were performed on 90 patients, 67 of which were performed in the past 5 years; average age was 22.4 years; average tissue weight was 467 grams per breast and operation length was 2.5 hours; 13 (14%) were operated on with the periareolar approach, 3 (3.3%) using a Nipple Areolar Complex (NAC) on scar approach, 37 (41.1%) using a dermal NAC flap approach and 37 (41.1%) using a free NAC graft (41.1%). Complications included two hypertrophic scars, five hematomas requiring revision surgery, three wound dehiscence and two cases of nipple necrosis. CONCLUSIONS: We will present a series of 90 cases of female to male transgenders operated on by the senior author over the past two decades. DISCUSSION: The choice of technique changed over the years as did the operation length. The two main approaches are dermal NAC flap and a free NAC graft. Future studies will compare these techniques. There is a need for a clinical classification for choosing the tailored type of operation according to the characteristics of the breast.

[DELAYED PERSISTENT BREAST IMPLANT INFECTION WITH MYCOBACTERIUM FORTUITUM].

INTRODUCTION: Non-Tuberculous Mycobacteria (NTM) are opportunistic environmental pathogens that can produce a wide range of diseases, including infection of the skin and soft tissues. Mycobacterium fortuitum is a predominant causative agent of postsurgical wound infection, especially in breast surgery. Peri-prosthetic infection due to Mycobacterium fortuitum are uncommon, but increasingly reported. This report summarizes the case of a young healthy female who underwent bilateral breast mastopexy with insertion of silicone implants. Shortly after the procedure she presented with clinical signs of wound infection that failed to heal completely in spite of repeated drainage and empiric antibiotic therapy. Additional microbiological investigation allowed for a diagnosis of Mycobacterium fortuitum. A prolonged course of anti-mycobacterial therapy, combined with removal of the implants initiated eradication of the infection and enabled re-implantation of the prosthesis. This case report underscores the importance of awareness to this type of pathogen especially in cases of exudative infection with sterile cultures. Timely identification can lead to prompt therapy of patients preventing further complications, costs and remaining aesthetic damage.

Effect of testosterone replacement therapy on scar quality in gender-affirming mastectomies.

BACKGROUND: The term transgenders refer to people who sense discordance between their gender identity and the sex assigned to them at birth. Some transgenders receive hormonal therapy, which may lead to specific skin conditions. The purpose of the present study was to determine whether a causal relationship exists between hormonal therapy (specifically testosterone therapy) and unsatisfying surgical scarring, including hypertrophic and keloid scars. In addition, this study may serve as a basis for future studies, which may test means that aim to reduce such undesired effects. METHODS: In this retrospective, observational cohort study, data were collected regarding 170 patients who underwent mastectomy as a gender-affirming surgery by the senior author between 2003 and 2021. The medical records were analysed to obtain personal, medical (including the duration of testosterone treatment) and surgical information from the patients' medical files. A blinded evaluator assessed the surgical scars by reviewing the postoperative clinical pictures of the patients. The scars were rated using the validated Stony Brook Scar Evaluation Scale (SBSES). The use of pictures to assess surgical scars is described in the validation study of the SBSES and is, therefore, accepted. RESULTS: In total, 63 patients were included in the testosterone group and 63 were included in the non-testosterone treated group. The averages of the SBSES score were 2.74 and 2.66, respectively. The difference between the two averages was not statistically significant. CONCLUSION: In our retrospective cohort study, we did not find the effect of testosterone therapy on post-operative surgical scars to be significant. EVIDENCE BASED MEDICINE (EBM) LEVEL: 3.

Micro-face-lift: A novel biplanar, composite, less-invasive procedure.

Background: Facial rejuvenation procedures have been in existence for over a century. Since its first introduction, it improved anatomical understanding and clinical implications and gave rise to numerous techniques and re-ideations of the original face-lift. The increase in popularity of face-lift procedures attracts patients of various ages and with different medical comorbidities. In this paper, we describe the less-invasive facelift procedure, termed the "Micro-Face-lift," with minimal complications, a short recovery period, and few contraindications. Materials and Methods: The authors retrospectively analyzed the medical files of 51 patients who underwent the "Micro-Face-lift" procedure between 2014 and 2019 by three independent surgeons. Results: Fifty-one patients met the inclusion criteria for the procedure. Forty-nine patients were women (96.1%) and the remainder were men (3.9%). The mean age at the time of the procedure was 60.8 years (range 45-87). Complications were encountered in five patients (9.8%): two hypertrophic scars (3.8%), one hematoma (2%), one surgical wound infection (2%), and one edema (2%), persistent for more than 2 weeks postoperatively. All complications resolved within 6 weeks of postoperatively. Thirty-five patients (68.6%) underwent additional procedures to maximize the aesthetic outcome. Thirty patients (58.8%) underwent submental liposuction and five patients (9.8%) underwent mid-face lipo-filling. The average satisfaction score on the self-reported "Likert" scale was 4.27 (range 1-5). All patients were followed for a minimum period of 18 months. Conclusions: The "Micro-Face-lift" is a less-invasive procedure that can be performed under local anesthesia and sedation in the outpatient setting. Complication rates and mortality are low, contraindications are rare, and the recovery period is short. In our experience, patient satisfaction is high with the Micro-Face-lift procedure, and the learning curve for the experienced practitioner is short.

The articulated dual-supply pedicle for reduction mammoplasty.

Breast reduction surgery achieves symptomatic relief and improved quality of life for patients with excessive breast enlargement. Reduction mammoplasty has evolved over the last century with the introduction of multiple new pedicles and skin excision patterns utilizing the ample blood supply of the breasts. The superior pedicle is a relatively safe technique in small resections, while the superomedial pedicle, supplied by the internal mammary perforators, serves as a proper alternative in broader resections. We aim to introduce the dual-supply pedicle technique, taking advantage of the two efficient workhorse pedicles-the superior and superomedial. A retrospective study of 48 bilateral reduction mammoplasty patients operated over a 2-year period between 2017 and 2019 by a single surgeon (Y.W). Patient characteristics and postoperative outcome data were collected and evaluated. The novel surgical technique showed compatibility with different types of patients and breasts, forming excellent aesthetic outcomes. Complication rates were comparable or lower than previously published series. Major complications requiring revision surgery were encountered in 2 patients (2.08%) and minor complications in 11 patients (11.5%); 4 moderate surgical wound dehiscence, 6 minor surgical wound dehiscence and 1 fat necrosis. The Dual-Supply Pedicle Reduction Mammoplasty is a safe, reproducible technique, with a short learning curve, excellent aesthetical results, and an acceptable complication rate. Level of Evidence is Level III.

Age-related Outcomes of Chest Masculinization Surgery: A Single-surgeon Retrospective Cohort Study.

Many transmasculine individuals face chest dysphoria, an emotional distress associated with breast development. The definitive management for reduction of existing breast tissue and alleviation of chest dysphoria comes in the form of chest masculinization surgery. Over the years, a substantial increase in the number of youth seeking gender-affirming chest masculinization surgery was observed globally. The study was hypothesized to answer the question as to whether the age limit of chest masculinization surgery should be lowered to include adolescents. Methods: A retrospective cohort study was conducted, based on the experience of a single surgeon over a period of 20 years. Results: Two-hundred eight patients were included in this cohort. Patients were divided into two equal groups based on their age. No statistically significant differences between the groups were observed in terms of resected breast tissue (P = 0.62 and 0.30, for the right and left breast, accordingly), auxiliary liposuction (P = 0.30), liposuction volume (P = 0.20), procedure (P = 0.15), postoperative drains (P = 0.79), and surgery duration (P = 0.72). Statistically significant differences were found in the 18 years or younger group, with lower rates of complication (P < 0.001), lower rates of revision surgery (P = 0.025), and higher satisfaction rankings (P < 0.001). Apart from age, no other factors were found to potentially explain the different rates of complications between the age groups. Conclusion: Patients aged 18 or younger opting for chest masculinization surgery experience fewer complications and revision procedures while having higher satisfaction rates with the surgical outcome.

Implications of testosterone therapy on wound healing and operative outcomes of gender-affirming chest masculinization surgery.

The increased awareness of the transgender population and their medical needs has given rise to a wide array of gender-affirming surgeries and hormonal therapies. To better understand the implication of testosterone therapy on female-to-male gender-affirming mastectomies, we conducted a retrospective cohort study based on the medical histories of 170 transgender males operated on by a single surgeon over 18 years. One hundred and one (59.4%) patients received hormonal therapy. The average age of patients in the testosterone treatment group was 20.6 ± 5.3 (range 14-49) years. The median weight of resected breast tissue was 318 g (IQR 221-515) and 311.5 g (IQR 223-480) in patients treated with testosterone, compared to 380 g (IQR 225-735) and 370 g (IQR 240-700) in patients without testosterone treatment (for the right and left breast, respectively). Supplementary liposuction was performed in 35 patients, of whom 23 (64%) were treated with testosterone. Fifty-four patients (31.7%) experienced surgical complications, and 55.6% of complications were recorded in the group treated with testosterone. Forty-nine patients (28.8%) recorded their satisfaction using the Likert satisfaction scale; the average satisfaction was 4.86 ± 0.35 in the non-testosterone group and 4.63 ± 0.69 in the testosterone group. Opposing previous cohorts, we did not find a statistically significant association between testosterone and increased surgical complications in gender-affirming mastectomies. Possible explanations include our practice of avoiding testosterone therapy several weeks before the operation and vigorous hemostasis methods.

Gender affirming surgery in non-binary patients: The importance of patient-centered care.

BACKGROUND: Gender-affirming mastectomies are a growing necessity for transgender and gender-diverse patients. The preoperative evaluation and surgical outcome must be tailored to the individual, taking into consideration previous medical history, medications, hormonal therapy, patient anatomy, and expectations. Although non-binary patients constitute a significant portion of patients referring for gender-affirming mastectomies, current literature rarely acknowledges them as a separate patient category from trans-masculine patients. METHODS: Retrospective cohort, demonstrating the single-surgeon experience with gender-affirming mastectomies over the course of 2 decades. RESULTS: A total of 208 patients were included in this cohort, patients identifying as "non-binary" in gender accounted for 30.8% of the cohort. Non-binary patients were found to be younger (P value<0.001) at the time of surgery, at the time of HRT initiation (P value<0.001), at the first feeling of gender dysphoria, coming out to society, and use of non-female pronouns (P value = 0.04,<0.001 and<0.001, accordingly). In the non-binary patient group, a shorter period of time passed from the first feeling of gender dysphoria to initiation of HRT and surgery (P value<0.001 and<0.001, accordingly). However, the average time from HRT initiation to surgery and from the first use of non-female pronouns to HRT initiation or surgery did not statistically differ (P value= 0.34, 0.06, and 0.08, accordingly). CONCLUSION: Non-binary patients demonstrate a significantly different timeline from trans-masculine patients in terms of gender development. In order to accommodate their needs, caregivers must take the information into consideration and develop appropriate guidelines and courses of action.