Assessing Patient-Reported Outcomes After Female Cosmetic Genital Surgery.

PURPOSE: Patient-reported outcomes after female cosmetic genital surgery (FCGS) have been well documented; however, methods vary widely between studies and are often very detailed, time-consuming, and difficult to reproduce. The purpose of this study was to assess patient-reported outcomes after FCGS using a novel method and survey as well as to present the results of a pilot study aimed at validating this survey. METHODS: A retrospective chart review identified patients who underwent FCGS. Demographic, clinical, operative, and outcome characteristics were recorded. A novel survey, including 14 items administered by telephone interview, was developed and extrapolated from the BREAST-Q for augmentation mammaplasty, to assess patient-reported outcomes after FCGS with regard to satisfaction with outcome and physical, psychosocial, and sexual well-being. RESULTS: The survey response rate was 50.6% (39 patients). Over a mean time after surgery of 56 months, 14 complications occurred in 11 patients (28.2%), and 10 complications required revision surgery. Postoperative asymmetry and dehiscence were the most common complications. Despite the higher complication and revision surgery rates, 97.4% agreed that the surgery was a good experience and were satisfied with the results after surgery. In addition, patient-reported outcomes after FCGS showed significant improvement in physical well-being, psychosocial well-being, and sexual well-being (P < 0.001). CONCLUSIONS: This novel survey can be used to assess patient-reported outcomes after FCGS in an efficient approach. Despite the potential complications and need for revision surgery, the vast majority of patients who undergo FCGS feel that it is a good experience, are satisfied with the results after surgery, and show significant improvement in physical, psychosocial, and sexual well-being after surgery.

Outcomes, Techniques, and Risk Factors for Dehiscence in Central Wedge Labiaplasty.

PURPOSE: Outcomes after female cosmetic genital surgery (FCGS) performed by plastic surgeons working in a group practice setting have not been well documented. This article aimed to assess outcomes and to describe FCGS techniques used in a large group private plastic surgery practice. METHODS: A retrospective chart review identified patients who underwent FCGS from 2009 to 2018. Demographic, clinical, and operative information was reviewed and recorded. Outcomes were assessed by evaluating postoperative complications and the need for revision surgery. RESULTS: Seventy-seven women between the ages of 14 and 53 years underwent FCGS performed by 1 of 6 surgeons. Forty-five patients underwent central wedge excision for labia minora hypertrophy, whereas 32 patients underwent extended central wedge excision for labia minora and clitoral hood hypertrophy. Four patients underwent liposuction of the mons pubis as an additional procedure. Over a mean follow-up of 37.4 months, postoperative asymmetry/redundancy occurred in 12 patients, requiring revision in 10. Wound dehiscence occurred in 12 patients, requiring revision in 9. There was one hematoma postoperatively requiring evacuation, one case of dyspareunia, and one case of decreased sensation. A single-layer wound closure (P = 0.050) and mons liposuction (P = 0.011) were risk factors for wound dehiscence. CONCLUSIONS: Central wedge excision and extended central wedge excision labiaplasty were the techniques used in a large group plastic surgery practice. Postoperative asymmetry and dehiscence were the most common complications, and the revision surgery rate was high. A single-layer wound closure and additional mons liposuction were risk factors for dehiscence after central wedge labiaplasty.

Patient draping and endotracheal tube positioning during facelift surgery.

A comprehensive approach to facial rejuvenation often requires facelift surgery combined with ancillary facial procedures. This may require prolonged operating time under general anesthesia or conscious sedation. When general anesthesia is used, secure endotracheal tube fixation and ready access to the face is essential. We describe an anesthetic technique that assures secure tube placement, rapid intubation, and ready access to the entire face. A fiber-reinforced tube is placed orotracheally, wired to the mandibular dentition, and brought over the head in the fashion similar to a nasotracheal tube. The reinforced nature of the tube prevents kinking and allows rapid repositioning inferiorly to allow access to the upper face. In over 400 rhytidectomies, this technique has allowed rapid intubation and surgical preparation. There have been no airway-related problems or other related complications. This is a safe, effective, and rapid means of securing orotracheal intubation during facial esthetic surgery allowing ready access to the face.

Assessment of donor-site morbidity using balance and gait tests after bilateral fibula osteoseptocutaneous free flap transfer.

The donor-site morbidity from harvesting unilateral free fibular osteoseptocutaneous flaps has been previously evaluated and is considered minimal. The purpose of this study was to investigate functional deficits after bilateral fibular osteoseptocutaneous flap harvest. Between 1990 and 2004, 7 consecutive patients undergoing mandible reconstruction utilizing bilateral autogenous free fibular osteoseptocutaneous flaps were included in the study. They were evaluated for the following subjective symptoms on the donor leg: pain, paresthesia, walking ability, restriction in activity, gait alteration, and aesthetic result. In addition, balance test and gait analysis were used to quantitatively assess functional outcomes. The results of this objective assessment were compared with those of 8 age-matched control subjects. Most patients had few subjective symptoms. The most common complaints were pain after prolonged walking (14%), slight difficulty in squatting (28%), and minimal paresthesia on 1 of the donor legs (14%). There were no significant differences in reaction time and movement velocity on either the balance test or gait analysis between the study and control groups (P > 0.05). However, there were significant differences with regard to right backward directional control, maximum stability with eye closing, sway referenced support, and ankle strategy (P < 0.05). Long-term follow-up revealed minimal donor-site morbidity after bilateral fibular osteoseptocutaneous free flap harvests. The functional deficits could only be found under the most unfavorable sensory feedback conditions.

Topical vascular endothelial growth factor reverses delayed wound healing secondary to angiogenesis inhibitor administration.

The prevention of new blood vessel growth is an increasingly attractive strategy to limit tumor growth. However, it remains unclear whether anti-angiogenesis approaches will impair wound healing, a process thought to be angiogenesis dependent. Results of previous studies differ as to whether angiogenesis inhibitors delay wound healing. We evaluated whether endostatin at tumor-inhibiting doses delayed excisional wound closure. C57/BL6J mice were treated with endostatin or phosphate-buffered solution 3 days prior to the creation of two full-thickness wounds on the dorsum. Endostatin was administered daily until wound closure was complete. A third group received endostatin, but also had daily topical vascular endothelial growth factor applied locally to the wound. Wound area was measured daily and the wounds were analyzed for granulation tissue formation, epithelial gap, and wound vascularity. Endostatin-treated mice showed a significant delay in wound healing. Granulation tissue formation and wound vascularity were significantly decreased, but reepithelialization was not effected. Topical vascular endothelial growth factor application to wounds in endostatin-treated mice resulted in increased granulation tissue formation, increased wound vascularity, and wound closure approaching that of control mice. This study shows that the angiogenesis inhibitor endostatin delays wound healing and that topical vascular endothelial growth factor is effective in counteracting this effect.

Stem cells and distraction osteogenesis: endothelial progenitor cells home to the ischemic generate in activation and consolidation.

BACKGROUND: Ischemia is a limiting factor during distraction osteogenesis. The authors sought to determine the extent of ischemia in the distraction zone and whether endothelial progenitor cells home to the distraction zone and participate in local vasculogenesis. METHODS: Laser Doppler imaging was used to assess the extent of blood flow in the distraction zone in gradually distracted, immediately distracted, and osteotomized rat mandibles during activation and consolidation. Animals (n = 50; 25 rats with unilateral gradual distraction and contralateral osteotomy as an internal control, and 25 rats with unilateral immediate distraction) were examined on postoperative days 4, 6, and 8 of activation, and after 1 and 2 weeks of consolidation. Endothelial progenitor cells isolated from human peripheral blood were labeled with fluorescent DiI dye, and 0.5 x 10 cells were injected intra-arterially under direct vision into each carotid artery at the start of activation in nude rats (n = 18) that then underwent the distraction protocol outlined above. RESULTS: Doppler flow analysis demonstrated relative ischemia during the activation period in the distraction osteogenesis group and increased blood flow in the osteotomized control group as compared with flow in a normal hemimandible [normal, 1 (standardized); distraction osteogenesis, 0.58 +/- 0.05; control, 2.58 +/- 0.21; p < 0.05 for both results]. We observed a significantly increased endothelial progenitor cell population at the generate site versus controls at midactivation and at 1 and 2 weeks of consolidation [25 +/- 1.9 versus 1 +/- 0.3 DiI-positive cells per high-power field (p < 0.05), 124 +/- 21 versus 8 +/- 4 DiI-positive cells per high-power field (p < 0.05), and 106 +/- 18 versus 9 +/- 3 DiI-positive cells per high-power field (p < 0.05), respectively]. CONCLUSIONS: These data suggest that the distraction zone becomes relatively ischemic during activation and that endothelial progenitor cells home to the ischemic generate site during the activation phase and remain during the consolidation phase. Selective expansion of these stem cells may be useful in overcoming ischemic limitations of distraction osteogenesis. Moreover, their homing capability may be used to effect site-specific transgene delivery to the generate.

Sonographically guided percutaneous carpal tunnel release: an anatomic and cadaveric study.

Minimally invasive techniques have become the standard of care for multiple procedures. This paper demonstrates both the surgeons' capacity to perform an accurate anatomic evaluation of the hand and forearm (n=10) and the use of this anatomic information to accurately perform sonographically guided, percutaneous carpal tunnel release using a single-portal endoscope without direct or indirect visualization in a cadaver model (n=6). Open dissection was then performed to confirm complete ligament transection and to evaluate the surrounding structures for injury. In all 6 cadavers, the transverse carpal ligament was transected completely without injury to any surrounding structures. With further investigation, this novel technique may offer a less invasive, office-based method for the surgical treatment of carpal tunnel syndrome that may offer patients an expedited recovery.

Bilateral gluteal compartment syndrome after elective unilateral hypogastric artery ligation and revascularization of the contralateral hypogastric artery during open abdominal aortic aneurysm repair.

Gluteal compartment syndrome is an uncommon entity that has been described in the literature after drug overdose and orthopedic procedures. We describe the first case of bilateral gluteal compartment syndrome that followed pelvic revascularization after the repair of an abdominal aortic aneurysm with bilateral common and internal iliac aneurysms. The patient was treated with aggressive fluid hydration and bilateral gluteal fasciotomies with resolution. The bilateral gluteal compartment syndrome was likely caused by increased pressure on the gluteal muscles, secondary to increased patient weight combined with a period of local ischemia to the watershed areas during iliac cross-clamp.

Quantitative and reproducible murine model of excisional wound healing.

The goal of animal wound healing models is to replicate human physiology and predict therapeutic outcomes. There is currently no model of wound healing in rodents that closely parallels human wound healing. Rodents are attractive candidates for wound healing studies because of their availability, low cost, and ease of handling. However, rodent models have been criticized because the major mechanism of wound closure is contraction, whereas in humans reepithelialization and granulation tissue formation are the major mechanisms involved. This article describes a novel model of wound healing in mice utilizing wound splinting that is accurate, reproducible, minimizes wound contraction, and allows wound healing to occur through the processes of granulation and reepithelialization. Our results show that splinted wounds have an increased amount of granulation tissue deposition as compared to controls, but the rate of reepithelialization is not affected. Thus, this model eliminates wound contraction and allows rodents' wounds to heal by epithelialization and granulation tissue formation. Given these analogies to human wound healing, we believe that this technique is a useful model for the study of wound healing mechanisms and for the evaluation of new therapeutic modalities.

Ex vivo transduction of microvascular free flaps for localized peptide delivery.

Gene therapy is a promising modality for the treatment of soft tissue malignancies. Our laboratory has developed a novel technique of gene transfer using microvascular free flaps that addresses many of the current barriers preventing gene therapy from achieving widespread clinical use. Our previous work has demonstrated our ability to transduce free flaps with an adenovirus encoding the reporter gene lacZ. In this current study, we show that microvascular free flaps can be transduced with an adenovirus encoding the angiogenesis inhibitor endostatin with high levels of local flap expression. These transduced free flaps were able to serve as "biologic pumps" and were able to secrete endostatin into the serum as demonstrated by enzyme-linked immunosorbent assay. This form of "biologic brachytherapy" could provide a novel approach for the continuous delivery of therapeutic genes to a localized area while avoiding many of the practical obstacles currently limiting gene therapy.

Bone morphogenic protein-2 gene therapy for mandibular distraction osteogenesis.

Distraction osteogenesis (DO) requires a long consolidation period and has a low but real failure rate. Bone morphogenic proteins (BMPs) accelerate bone deposition in fractures and critical-sized bone defects, but their effects on mandibular DO are unknown. We investigated the effect of local delivery of adenovirus containing the gene for BMP-2 (Adbmp-2) on mandibular DO in a rat model. Rats (n = 54) were distracted to 3 mm over 6 days. At the start of consolidation (POD 10), Adbmp-2 or adenovirus containing the lacZgene (AdlacZ) was injected directly into the distraction zone. After 1, 2, and 4 weeks of consolidation, mandibles were evaluated for amount of bone deposition. Adbmp-2-treated specimens demonstrated an increased amount of new bone formation by radiographic, histologic, and histomorphometric analysis. This study demonstrates that local, adenovirally-mediated delivery of BMP-2 can increase bone deposition during DO, potentially shortening consolidation and enhancing DO in poorly healing mandibles, such as occurs postirradiation.

Endostatin inhibits ischemia-induced neovascularization and increases ischemic tissue loss.

The impact of inhibitors of tumor angiogenesis (endostatin, angiostatin) on the neovascularization required for the healing of transferred tissue has not been examined. We investigated the effect of endostatin on the functional neovascularization of random pattern flaps. C57BL6 mice were pretreated with endostatin beginning 3 days prior to surgery (n = 10), and daily injections continued throughout the study. Dorsal random cutaneous flaps were raised in both treatment and control (saline-treated) groups. The remaining cranial attachment was divided on day 9. Oxygen tension (PO2) was measured using a microprobe on days 1, 3, 5 and 16. Flaps were harvested and the vasculature was stained with CD31 on day 16. We found that endostatin significantly decreased flap survival. Mice that were treated with endostatin had fewer CD31+ blood vessels, worse flap perfusion at all time points, and lower oxygen tensions throughout the length of the flap. These findings have potential implications for the patients undergoing antiangiogenesis therapy who require surgical reconstruction.