Cosmetic gynecology-a systematic review and call for standardized outcome measures.

OBJECTIVE: Cosmetic gynecology, a field which has garnered substantial attention over recent years, lacks a universally accepted nomenclature. The aim of this systematic review is to evaluate techniques, outcome measures reported, and adverse events in patients undergoing cosmetic gynecology procedures and offer recommendations to improve reporting metrics. METHODS: A systematic literature search was performed using electronic databases from inception to April 2019. The search was based on 51 unique cosmetic gynecology keywords such as: "labiaplasty," "vaginal rejuvenation," and "liposuction mons pubis." All English full-text prospective and retrospective observational and interventional studies with at least five subjects that describe a cosmetic gynecology procedure were included. Only full-text articles were included. This protocol has been registered with PROSPERO (CRD 42019131860). RESULTS: A total of 1837 articles were identified from the search strategy with 42 included in the quantitative synthesis. Procedures described included: labia minora reduction with or without clitoral hood reduction, labia majora augmentation, surgical vaginal caliber reduction, mons pubis reduction/suspension, and energy-based therapy for vaginal laxity or vulvar laxity. Efficacy and satisfaction metrics were highly variable ranging from validated questionnaires to no outcome subjectively or objectively quantified. Complication rates varied by procedure but were generally low and ranged between Clavien-Dindo grades I-III. CONCLUSIONS: Although there is a breadth of literature on cosmetic gynecology surgical techniques and short-term complication rates, the terminology and outcome measures utilized are heterogeneous. To address this, standardized terminology along with uniform cosmetic and functional endpoints must be developed.

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies.

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important.

Why complex pelvic organ prolapse should be repaired vaginally.

PURPOSE OF REVIEW: Vaginal surgery is the true minimally invasive surgery in the treatment of pelvic organ prolapse (POP); however, the robotic industry and decreased resident training in vaginal surgery may result in the loss of skills among our graduates. There are a number of procedures that are well accepted in the management of prolapse, because they are minimally invasive and with few complications compared with the abdominal approach. In this review, we will discuss various vaginal techniques for complex POP. In our opinion, the most minimally invasive approach is vaginal surgery. RECENT FINDINGS: There are no recent significant findings on the vaginal approach to complex pelvic organ surgery and mostly case series about success of robotic procedures. There are a significant number of studies exploring the benefits of robotic surgery. It has been observed that the operating times are longer and there is a learning curve. Although there are advantages to robotic surgery, one must not overlook the significant cost associated with obtaining the robot, the maintenance and the cost of disposable instruments. There is limited evidence to show that robotic surgery did not benefit women with benign gynecological disease in terms of effectiveness or safety. SUMMARY: POP is a vaginal problem, which is best treated vaginally. There are many well designed studies that support the vaginal approach to primary POP.

The surgical anatomy of ulnar and median nerve communications in the palmar surface of the hand.

OBJECT: Sensation in the palmar surface of the digits is supplied by the median and ulnar nerves, with the boundary classically being the midline of the ring finger. Overlap and variations of this division exist, and a communicating branch between the ulnar and median nerve could potentially explain further variations in digital sensory innervations. The aim of this study was to examine the origin and distribution of the communicating branch between the ulnar and median nerves and to apply such findings to the risk involved in surgical procedures in the hand. METHODS: The authors grossly and endoscopically examined 200 formalin-fixed adult human hands obtained in 100 cadavers, and a communicating branch was found to be present in 170 hands (85%). Of the specimens with communicating branches, the authors were able to identify four notable types representing different points of connections of the branches. The most common, Type I (143 hands, 84.1%), featured a communicating branch that originated proximally from the ulnar nerve and proceeded distally to join the median nerve. Type II (12 hands, 7.1%) designated a communicating branch that originated proximally from the median nerve and proceeded distally to join the ulnar nerve. Type III (six hands, 3.5%) designated a communicating branch that traversed perpendicularly between the median and ulnar nerves in such a way that it was not possible to determine which nerve served as the point of origin. Type IV (nine hands, 5.3%) designated a mixed type in which multiple communicating branches existed, arising from both ulnar and median nerves. CONCLUSIONS: According to the origin and distribution of these branching patterns, the investigators were able to define a risk area in which the communicating branch(es) may be subject to iatrogenic injury during common hand procedures.

Gross anatomical, CT and MRI analyses of the buccal fat pad with special emphasis on volumetric variations.

The use of the buccal fat pad (BFP) has increased in popularity in recent years because of its reliability, ease of harvest, and low complication rate during oral and maxillofacial procedures. The aim of this study was to evaluate the volumetric variations of the BFP with a CT and MRI, as well as the thickness, weight and volume with conventional methods. We have examined the BFP from 80 formalin fixed adult cadavers (mean age 59) derived from both males (45) and females (35). In addition, we also examined 20 cadaveric BFPs using MR and CT imaging. Digital image analysis software was used to measure the volumetric distribution and to characterize the morphology of BFP. The BFP can be divided into three lobes (anterior, intermediate, and posterior) and has four extensions (buccal, pterygoid, pterygopalatine, and temporal). The BFP is fixed by six ligaments, to the maxilla, posterior zygoma, inner and outer rim of infraorbital fissure, temporalis tendon, and buccinator membrane. The mean volume in males was 10.2 ml and ranged 7.8-11.2 ml, while in females the mean volume was 8.9 ml and ranged 7.2-10.8 ml. Additionally, the mean thickness was 6 mm, with a mean weight of 9.7 g. These facts may be important when considering the use of the BFP in reconstruction, particularly whether the correct volume has been removed from each side in aesthetic, oral, or maxillofacial procedures.

An unusual innervation of pectoralis minor and major muscles from a branch of the intercostobrachial nerve.

Variations of the branching pattern of the intercostobrachial nerve have been known to complicate dissection during mastectomy and other procedures involving the axilla. We present a unilateral case of a 73-year-old Caucasian female, in which the intercostobrachial nerve gives rise to an additional medial pectoral branch, which partially innervates the pectoralis minor muscle, as well as the abdominal head of pectoralis major muscle. Clinical consequences of such a variation may include motor losses, in addition to the commonly reported sensory losses, resulting from accidental or intentional dissection of the intercostobranchial nerve.

Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome.

In view of the paucity of literature, this study was undertaken to reappraise the gross anatomy of the sacrotuberous ligament (STL), with the objective of providing an accurate anatomical basis for clinical conditions involving the STL. We studied the gross anatomy of the STL in 50 formalin fixed cadavers (100 sides) during the period of 2004-2005. All specimens exhibited an STL with a ligamentous part and (87%) of specimens exhibited a membranous (falciform) segment, which extended towards the ischioanal fossa. The variations of the falciform extensions were classified into three types. In Type I (69%), the falciform process extended towards and along the ischial ramus to terminate at the obturator fascia. In Type II (108%), the falciform process extended along the ischial ramus, fused with the obturator fascia and continued towards the ischioanal fossa. In addition, the medial border of the falciform process descended to fuse with the anococcygeal ligament, forming a continuous membrane. Lastly, in Type III (13%), the falciform process of the STL was absent. The above mentioned data could have an important implication to the understanding of the relationship between the pudendal nerve and the sacrotuberous ligament and their relevance to pudendal nerve entrapment syndrome.