Thread-Lift Sutures: Still in the Lift? A Systematic Review of the Literature.

BACKGROUND: In 2006, Villa et al. published a review article concerning the use of thread-lift sutures and concluded that the technique was still in its infancy but had great potential to become a useful and effective procedure for nonsurgical lifting of sagged facial tissues. As 11 years have passed, the authors now performed again a systematic review to determine the real scientific current state of the art on the use of thread-lift sutures. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database and using the Medical Subject Headings search term "Rhytidoplasty." "Rhytidoplasty" and the following entry terms were included by this Medical Subject Headings term: "facelift," "facelifts," "face Lift," "Face Lifts," "Lift," "Face," "Lifts," "Platysmotomy," "Platysmotomies," "Rhytidectomy," "Rhytidectomies," "Platysmaplasty," "and "Platysmaplasties." The Medical Subject Headings term "Rhytidoplasty" was combined with the following search terms: "Barbed suture," "Thread lift," "APTOS," "Suture suspension," "Percutaneous," and "Silhouette suture." RefWorks was used to filter duplicates. Three of the authors (H.A.G., B.C., and B.L.) performed the search independently. RESULTS: The initial search with all search terms resulted in 188 articles. After filtering the duplicates and the articles about open procedures, a total of 41 articles remained. Of these, the review articles, case reports, and letters to the editor were subsequently excluded, as were reports dealing with nonbarbed sutures, such as Vicryl and Prolene with Gore-Tex. This resulted in a total of 12 articles, seven additional articles since the five articles reviewed by Villa et al. CONCLUSIONS: The authors' review demonstrated that, within the past decade, little or no substantial evidence has been added to the peer-reviewed literature to support or sustain the promising statement about thread-lift sutures as made by Villa et al. in 2006 in terms of efficacy or safety. All included literature in the authors' review, except two studies, demonstrated at best a very limited durability of the lifting effect. The two positive studies were sponsored by the companies that manufacture the thread-lift sutures.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging.

BACKGROUND: The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. METHODS: An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. RESULTS: Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). CONCLUSION: This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

Abdominoplasty and gluteoplasty after massive weight loss: an all-in-one technique.

INTRODUCTION: Patients requesting body-contouring surgery after massive weight loss often present with abdominal and lumbar skin excess as well as gluteal ptosis and loss of gluteal projection. In order to restore gluteal projection a circular abdominoplasty in combination with an autologous gluteal augmentation (all-in-one technique) can be performed. OBJECTIVE: To compare outcomes for patients who underwent a circular abdominoplasty with or without autologous gluteal augmentation. METHODS: In a retrospective study we analyse 24 patients who underwent a circular abdominoplasty between 2006 until 2014 at the University Hospital of Ghent, Belgium. Fourteen patients underwent a classic circular abdominoplasty (4 men and 10 women). Ten patients underwent the all-in-one technique (all women). Mean age was 43 in the classic abdominoplasty group and 41 in the all-in-one technique group. All the patients endured massive weight loss after bariatric surgery. Gluteal augmentation was performed using lumbar dermal fat rotation flaps based on perforators of the 4th lumbar artery. For statistical analysis a Fisher exact tests was used. RESULTS: Postoperative photographs showed that gluteal projection had been increased in patients who underwent the all-in-one technique. The mean operation time in this group was 3h49min versus 2h47min in the group who underwent a classic circular abdominoplasty. The mean hospital stay in both groups was 6 days. Complication rate was comparable between both the groups. CONCLUSION: The all-in-one technique is an efficient method to improve both abdominal and gluteal body contour in patients who endured massive weight loss.

Pre-expanded Anterolateral Thigh Perforator Flap for Phalloplasty.

The anterolateral thigh (ALT) perforator flap for phalloplasty is gaining popularity because it avoids the well-known scars of the radial forearm flap. However, scars are not eliminated, just moved to a different location, the thigh, that can for some patients be of great sexual value. Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.

An Update on the Surgical Treatment for Transgender Patients.

INTRODUCTION: As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options. AIM: To review current gender reassignment surgical techniques and update the clinician. METHODS: A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery. MAIN OUTCOME MEASURES: Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap. RESULTS: Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures. CONCLUSION: Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap.

The dog-ear flap as an alternative for breast reconstruction in patients who have already undergone a DIEAP flap.

Breast reconstruction in patients who have previously undergone deep inferior epigastric artery perforator flap (DIEAP) reconstruction or abdominoplasty is often challenging. Depending on patients' body habitus, several second-choice flaps have been described such as the transverse upper gracilis (TUG) flap, profundus femoris artery perforator (PFAP) flap, superior gluteal artery perforator (SGAP) flap, and lumbar artery perforator (LAP) flap. Patients who have undergone a DIEAP flap reconstruction or abdominoplasty occasionally present with dog ears on both sides of the abdominal scar. The adipose tissue and skin of these dog ears are supplied by perforators of the deep circumflex iliac artery (DCIA). The DCIA flap was first described in 1979 by Taylor. We introduce this abdominal "dog-ear" flap for autologous breast reconstruction.

Hormonal and surgical treatment in trans-women with BRCA1 mutations: a controversial topic.

INTRODUCTION: Male-to-female transgender persons (trans-women) receive livelong cross-sex hormonal treatment in order to induce and maintain secondary female characteristics. One of the concerns of long-term estrogen treatment is the induction of carcinomas of estrogen-sensitive tissues such as the breast. BRCA1 mutations have been shown to account for a large proportion of inherited predispositions to breast cancer. AIM: The aim of this case report is to discuss the hormonal and surgical options in the treatment of trans-women with a genetic predisposition for breast cancer. METHOD: We describe a case of a trans-woman who was found to be a carrier of a BRCA1 mutation. RESULTS: The patient underwent a breast augmentation. She refused a prophylactic mastectomy followed by a primary breast reconstruction. She also underwent a vaginoplasty and a bilateral castration. Androgen blocking treatment was stopped after surgery; estradiol treatment however was continued. CONCLUSIONS: This case points to the importance of routine investigation of family history in trans-women. Trans-women with BRCA mutations should be carefully monitored and if cancers develop, this should be reported. Follow-up should be according to the guidelines for breast cancer screening in biological women, and the guidelines for prostate cancer and colon cancer screening in men.

A targeted approach to sentinel lymph node biopsies in the parotid region for head and neck melanomas.

INTRODUCTION: Cutaneous melanoma is on the rise in the United States, and the head and neck region is the primary site in 20% of patients. Lymph node status is the best indicator of prognosis for melanoma. In the head and neck, sentinel lymph node (SLN) biopsy presents particular challenges, with the parotid region posing difficulties that include locating the lymph nodes, less frequent visualization of blue dye, and the possibility of higher morbidity because of the proximity of lymph nodes to important neurovascular structures. Surgical approaches to the SLN dissection in the parotid region are variable, and may include superficial or total parotidectomies. Parotid-sparing SLN biopsies for head and neck melanomas were evaluated to determine rates of local recurrence. METHODS: The charts of 301 patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma were reviewed. The location of the primary melanoma was noted, and the sentinel lymph node dissections from the operative reports were documented. Demographic and outcome data were recorded, including course of melanoma management, local recurrence, and postoperative course. RESULTS: Fifty-eight patients underwent SLN biopsy of lymph nodes in the parotid region. Parotid-sparing SLN biopsies comprised 94.8% of total surgical approaches for SLN biopsies in the parotid region. Of the remaining patients who underwent SLN biopsies in the parotid region, 5.17% had a superficial parotidectomy and none had a total parotidectomy. Sentinel lymph nodes were found in all depth layers of the parotid, and LNs were dissected out successfully without the need to remove the parotid in the most cases. The parotid region recurrence rate was 0% for SLN biopsies that either included or spared the parotid gland. There were no localized complications from the sentinel lymph node biopsies. CONCLUSIONS: The parotid-sparing SLN biopsy was performed without any local recurrence in the parotid region. The parotid-sparing SLN biopsy can be carried out in a safe, efficient manner without affecting the rate of local recurrence or postoperative complication. This less-invasive SLN biopsy procedure precludes the complications associated with parotidectomies and may reduce the morbidity for patients with melanomas of the head and neck.

Level I sparing radical neck dissections for cutaneous melanoma in the lymphoscintigram era.

INTRODUCTION: Excision of regional lymph nodes (LNs) in the neck as part of the management for tumors of the head and neck dates back to the 19th century. Crile originally reported the technique of performing a radical neck block dissection in 1905, with notable modifications to the extensive dissection reported throughout the 20th century by Suarez, Ballantyne, Ariyan, and Shah among others. These modifications have aimed to reduce the morbidity encountered by performing the radical neck dissection while balancing the need to remove diseased structures in the head and neck. In this report, we evaluate the outcomes of performing a functional radical neck dissection while sparing the level I LNs as indicated by lymphoscintigraphy. METHODS: The charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. The location of the primary melanoma and clinical course was noted. Those patients who underwent neck dissections were documented and the extent of the dissections from the operative reports was noted. Demographic and outcome data were recorded, including clinical course of melanoma presentation, local recurrence, and postoperative management. Student t test and χ tests were used to determine statistical significance between groups. P values less than 0.05 were considered statistically significant. RESULTS: A total of 41 patients who were documented to have had a head and neck primary melanoma underwent a functional radical neck dissection. Level I dissections were deemed necessary in 39% of these cases, whereas 61% of patients received functional radical neck dissections with sparing of level I LNs. Specific recurrence of melanoma in the submandibular basin was equivocal for LN sparing dissections (n=1) as compared to excision of level I LNs (n=1) (4% vs 6.25%, P=0.488). Follow-up metastatic rates between the 2 groups were also comparable (44% vs 56%, P=0.328). Overall metastatic rate in follow-up for all patients undergoing LN dissection was 48.8%. There was no statistically significant difference between the average age of patients at diagnosis, Breslow depth, Clark level, and staging between patients who underwent functional radical neck dissections with either excision or sparing of level I LNs. CONCLUSIONS: Clinical and pathological presentation between patients who needed level I sparing dissections and those who did not, failed to demonstrate a statistically significant difference allowing for an adequate comparison. Our results indicate that if lymphoscintigraphy does not show drainage to level I LNs, the functional radical neck dissection can be tailored to spare level I LNs without affecting local recurrence. When not indicated by lymphoscintigram, sparing of level I nodes can be performed safely without changing clinical outcomes, while saving operating room time and minimizing potential damage to the buccal branch of facial nerve and the submandiblular gland.

Benjamin Alcock and the pudendal canal.

The anatomy of the pudendal nerve is complex and difficult to visualize. Entrapment of the pudendal nerve is believed to occur in a canal, the pudendal canal or Alcock's canal, yet in the literature this term is used to refer to several different anatomic locations. We present a brief history of Benjamin Alcock, and we compare Alcock's original description of the pudendal canal with our findings from a cadaveric study. It is concluded that Alcock's canal for the pudendal nerve, as Alcock described it related to the pudendal artery, should be that portion of the pudendal nerve within the obturator internus fascia. This definition now permits future medical and surgical approaches to use the appropriate terminology for this anatomic location.

Cystitis due to the use of ketamine as a recreational drug: a case report.

INTRODUCTION: Ketamine is a derivative of phencyclidine and is a dissociative anaesthetic. Its use as a recreational drug is on the increase among young adults attending clubs and parties. CASE PRESENTATION: We describe the case of a 20-year-old man who presented with a 7-month history of urinary frequency, nocturia, urgency, suprapubic discomfort during micturition and episodes of severe haematuria shortly after commencing weekly recreational ketamine use. Complementary examinations were negative except for a thickened bladder wall on ultrasound examination and mild inflammatory changes on cystoscopy. So far only nine cases of ketamine-associated ulcerative cystitis have been described. CONCLUSION: We expect that in the future an increasing number of cases of cystitis caused by ketamine use will be seen in young adults.

Factors associated with carcinoma of the oesophagus at Mulago Hospital, Uganda.

BACKGROUND: In Uganda, as in many other parts of the world cancer of the oesophagus (CAE) is on the rise. Squamous cell carcinoma and adenocarcinoma are the common subtypes. Risk factors for this cancer have been identified but not studied systematically in Uganda. Identification of these factors would enable establishment of preventive measures. OBJECTIVE: To determine the prevalence, histological features and associated factors for CAE among patients referred to the endoscopic unit of Mulago hospital, Kampala, Uganda. METHODS: We performed a 1-year cross-sectional study in 2004 and 2005 of all patients presenting for oesophageal-gastro-duodenoscopy (EGD) at Mulago Hospital. Demographic characteristics, behavioural practices, endoscopy findings and histology results where biopsies were performed were collected using a study tool. Data analysis was done using STATA 8 statistical package. RESULTS: Two hundred nineteen patients were enrolled in the study, three were excluded because they could not tolerate the endoscopy procedure. Fifty five (19%) of the 287 had histologically proven CAE. Squamous cell carcinoma was found in 100% of tumours of the upper third, 91% middle third, and 73% lower third of the oesophagus. Four patients had a histological diagnosis of adenocarcinoma of the oesophagus. Factors that were associated with CAE included age (OR 1.63, CI 1.34-1.98, p value <0.001), smoking (OR 3.63, CI 1.82-7.23, p value <0.001) and gender (OR 2.17, CI 1.07-4.41, p value 0.032). CONCLUSION: Many patients referred for EGD in Uganda had esophageal cancer most of which were.squamous cell type. Smoking, male gender and older age were risk factors. Preventive measures should target stopping smoking.

Vena cava inferior thrombosis detected by venous hum: a case report.

We describe a patient in which a venous hum, heard during abdominal auscultation, lead to the diagnosis of a vena cava inferior thrombosis.