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Niu EF, Honig SE, Wang KE, Amro C, Davis HD, Habarth-Morales TE, Broach RB, Fischer JP. Obesity as a Risk Factor in Cosmetic Abdominal Body Contouring: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2024; 48:2121-2131. [PMID: 37644187 DOI: 10.1007/s00266-023-03602-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/07/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The incidence of obesity is on the rise around the globe. Outside of the massive weight loss (MWL) patient population, knowledge of risk factors associated with abdominal body contouring (BC) is limited. This systematic review and meta-analysis assesses the impact of obesity has on cosmetic abdominal BC outcomes. METHODS A systematic review conducted in accordance with PRISMA 2020 was done. PubMed, Embase, Scopus, and COCHRANE databases were reviewed under search syntax "obesity," "abdominoplasty," "panniculectomy," and "body contouring" for articles. Cosmetic was defined as abdominoplasty or panniculectomy outside the context of MWL. Obesity was defined as BMI ≥ 30 kg/m2. Studies reporting postoperative outcomes with less than 50% of their population involving MWL patients were included. Postoperative outcomes were assessed by pooled analysis and meta-analysis. RESULTS Of 3088 initial studies, 16 met inclusion criteria, and nine were used for pooled and meta-analysis. Meta-analysis demonstrated that obesity was associated with more seromas (OR 1.45, 1.06-1.98, p = 0.02), hematomas (OR 2.21, 1.07-4.57, p = 0.03), and total surgical site occurrences (OR 1.99, 1.30-3.04, p = 0.0016). There was no significant difference in odds of any other complications. Analysis by obesity class showed no significant increase in odds in seromas or wound dehiscence. CONCLUSIONS This review demonstrates obesity increased odds of postoperative complications following cosmetic abdominal BC. However, risk of complications does not continue to increase with higher obesity class. A BMI ≥ 30 kg/m2 should not be a strict contraindication to cosmetic abdominal BC. Instead, plastic surgeons should evaluate patients on a case-by-case basis. 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 .
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Affiliation(s)
- Ellen F Niu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Stephanie E Honig
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Katherine E Wang
- Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY, USA
| | - Chris Amro
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Harrison D Davis
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Theodore E Habarth-Morales
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, PCAM South Pavilion 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Cadwell JB, Ahsanuddin S, Ayyala HS, Ignatiuk A. Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases. Obes Surg 2021; 31:3660-3666. [PMID: 34106398 PMCID: PMC8187133 DOI: 10.1007/s11695-021-05468-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/27/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
Purpose With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI). Methods The 2012–2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications. Results Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients. Conclusion A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05468-w.
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Affiliation(s)
- Joshua B Cadwell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite E1620, Newark, NJ, 07103, USA
| | - Salma Ahsanuddin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite E1620, Newark, NJ, 07103, USA
| | - Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite E1620, Newark, NJ, 07103, USA
| | - Ashley Ignatiuk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite E1620, Newark, NJ, 07103, USA.
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Wiedner M, Richter DF. Invited Discussion on: Quality of Life and Complications in the Morbidly Obese Patient following Post-Bariatric Body Contouring. Aesthetic Plast Surg 2021; 45:1113-1114. [PMID: 33469700 DOI: 10.1007/s00266-020-02094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
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4
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de Macedo JLS, Rosa SC, Canedo LR, Casulari LA. What Is the Impact of Residual Obesity on the Risk for Postoperative Body-Contouring Surgery Complications in Postbariatric Patients? Obes Surg 2021; 30:4149-4154. [PMID: 32451919 DOI: 10.1007/s11695-020-04711-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND There are an increasing number of patients presenting for plastic surgery after massive weight loss, and many of these patients have residual obesity that may compromise outcomes. The impact of residual obesity on the development of postoperative complications in postbariatric patients undergoing plastic surgery procedures is unclear. METHODS We report the outcomes of 207 patients who underwent plastic surgery following RYGB from January 2011 to December 2018. RESULTS Two hundred and seven patients (196 females, 11 males) with a mean age of 42 years underwent 335 separate operations. The average BMI at the time of plastic surgery was 27.43 kg/m2. The average weight loss was 47.08 kg. The prevalence of comorbidities was 26.6% and the most important presurgery comorbidities were arterial hypertension (10.1%) and diabetes mellitus (4.8%). Of the 207 patients who underwent surgery, 78.3% (168/207) underwent abdominoplasty and 45.0% underwent mammoplasty. The overall rate of complications was 27.5%. The prevalence of postoperative complications was not significantly different between patients with a BMI ≥ 30 kg/m2 and patients with a BMI < 30 kg/m2 (33.3% vs 25.9%, respectively; p = 0.344). CONCLUSION In this group of patients, with specified anthropometric and clinical profiles, the residual obesity did not influence the incidence of postoperative complications in postbariatric patients after plastic surgery.
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Affiliation(s)
- Jefferson Lessa Soares de Macedo
- Department of Plastic and Reconstructive Surgery, Asa Norte Regional Hospital, SQS 213 Bloco H Apto 303. Asa Sul, CEP, Brasília, DF, 70 292-080, Brazil.
| | - Simone Corrêa Rosa
- Department of Plastic and Reconstructive Surgery, Asa Norte Regional Hospital, SQS 213 Bloco H Apto 303. Asa Sul, CEP, Brasília, DF, 70 292-080, Brazil.,Post-Graduation Course in Health Sciences, University of Brasília, Brasília, DF, Brazil
| | | | - Luiz Augusto Casulari
- Post-Graduation Course in Health Sciences, University of Brasília, Brasília, DF, Brazil
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Koudoufio M, Feldman F, Ahmarani L, Delvin E, Spahis S, Desjardins Y, Levy E. Intestinal protection by proanthocyanidins involves anti-oxidative and anti-inflammatory actions in association with an improvement of insulin sensitivity, lipid and glucose homeostasis. Sci Rep 2021; 11:3878. [PMID: 33594093 PMCID: PMC7886900 DOI: 10.1038/s41598-020-80587-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022] Open
Abstract
Recent advances have added another dimension to the complexity of cardiometabolic disorders (CMD) by directly implicating the gastrointestinal tract as a key player. In fact, multiple factors could interfere with intestinal homeostasis and elicit extra-intestinal CMD. As oxidative stress (OxS), inflammation, insulin resistance and lipid abnormalities are among the most disruptive events, the aim of the present study is to explore whether proanthocyanidins (PACs) exert protective effects against these disorders. To this end, fully differentiated intestinal Caco-2/15 cells were pre-incubated with PACs with and without the pro-oxidant and pro-inflammatory iron/ascorbate (Fe/Asc). PACs significantly reduce malondialdehyde, a biomarker of lipid peroxidation, and raise antioxidant SOD2 and GPx via the increase of NRF2/Keap1 ratio. Likewise, PACs decrease the inflammatory agents TNFα and COX2 through abrogation of NF-κB. Moreover, according to crucial biomarkers, PACs result in lipid homeostasis improvement as reflected by enhanced fatty acid β-oxidation, diminished lipogenesis, and lowered gluconeogenesis as a result of PPARα, γ and SREBP1c modulation. Since these metabolic routes are mainly regulated by insulin sensitivity, we have examined the insulin signaling pathway and found an upregulation of phosphoPI3K/Akt and downregulation of p38-MAPK expressions, indicating beneficial effects in response to PACs. Taken together, PACs display the potential to counterbalance OxS and inflammation in Fe/Asc-exposed intestinal cells, in association with an improvement of insulin sensitivity, which ameliorates lipid and glucose homeostasis.
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Affiliation(s)
- Mireille Koudoufio
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada.,Department of Nutrition, Université de Montréal, Montreal, QC, H3T 1A8, Canada.,Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Francis Feldman
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada.,Department of Nutrition, Université de Montréal, Montreal, QC, H3T 1A8, Canada.,Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Lena Ahmarani
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada.,Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Edgard Delvin
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada.,Department of Biochemistry, Université de Montréal, Montreal, QC, H3C 3J7, Canada
| | - Schohraya Spahis
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada.,Department of Nutrition, Université de Montréal, Montreal, QC, H3T 1A8, Canada.,Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Yves Desjardins
- Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada
| | - Emile Levy
- Research Centre, CHU Sainte-Justine, Université de Montréal, 3175 Ste Catherine Road, Montreal, QC, H3T 1C5, Canada. .,Department of Nutrition, Université de Montréal, Montreal, QC, H3T 1A8, Canada. .,Institute of Nutrition and Functional Foods (INAF), Université Laval, Quebec, QC, G1V 0A6, Canada.
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6
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Unplanned 30-day readmission rates after plastic and reconstructive surgery procedures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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7
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Crane DP, Inglesby D, Lauzon S, Carrol EA, Herrera FA. The effects of obesity on plastic and reconstructive surgical outcomes. J Plast Reconstr Aesthet Surg 2019; 73:783-808. [PMID: 31870720 DOI: 10.1016/j.bjps.2019.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/01/2019] [Accepted: 11/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel P Crane
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Dani Inglesby
- Medical University of South Carolina, College of Medicine, Charleston, SC 29425, United States
| | - Steven Lauzon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Elizabeth A Carrol
- Medical University of South Carolina, College of Medicine, Charleston, SC 29425, United States
| | - Fernando A Herrera
- Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC 29425, United States; Ralph H Johnson VA Medical Center, Charleston, SC 29425, United States.
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8
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Ngaage LM, Elegbede A, Tadisina KK, Gebran SG, Masters BM, Rada EM, Nam AJ, Scalea JR, Niederhaus SV, Singh D, Bromberg JS, Bartlett ST, Rasko YM. Panniculectomy at the time of living donor renal transplantation: An 8-year experience. Am J Transplant 2019; 19:2284-2293. [PMID: 30720924 DOI: 10.1111/ajt.15285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 01/25/2023]
Abstract
Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Adekunle Elegbede
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital/University of Maryland Medical Center, Baltimore, Maryland
| | - Kashyap K Tadisina
- Division of Plastic Surgery, Saint Louis University School of Medicine, St Louis, Missouri
| | - Selim G Gebran
- Division of Plastic & Reconstructive Surgery, R Adams Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brian M Masters
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland
| | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Arthur J Nam
- Division of Plastic & Reconstructive Surgery, R Adams Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Silke V Niederhaus
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Devinder Singh
- Division of Plastic Surgery, Anne Arundel Medical Center, Annapolis, Maryland
| | - Jonathan S Bromberg
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen T Bartlett
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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9
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Validation of the American College of Surgeons National Surgical Quality Improvement Program Risk Model for Patients Undergoing Panniculectomy. Ann Plast Surg 2019; 83:94-98. [PMID: 30633014 DOI: 10.1097/sap.0000000000001759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Panniculectomy procedures have been reported to significantly improve quality of life, increase mobility, and improve hygiene in patients with a significant pannus formation. The primary aims of this study were to determine which preoperative risk factors may be used to differentiate postoperative complication rate among patient cohorts and to validate utilization of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk calculator in patients undergoing panniculectomies. METHODS This retrospective study included all patients who underwent a panniculectomy procedure at our institution from 2005 to 2016. Baseline characteristics, preoperative risk factors, medical comorbidities, and postoperative complications were collected via retrospective chart review. RESULTS Two hundred sixty-four patients who underwent a panniculectomy were identified. The odds ratios of any postoperative complication were 8.26, 7.76, and 16.6 for patients with classes 1, 2, and 3 obesity, respectively (P < 0.05). Statistical modeling was utilized to evaluate the predictive performance of the ACS-NSQIP Surgical Risk Calculator. We calculated the C-statistic for the ACS-NSQIP model to be only 0.61, indicating that although the model is associated with the risk of complication, it does not have a strong predictive value for this particular procedure. DISCUSSION This study is one of the first to characterize postoperative complication rate based on extremum of body mass index for panniculectomy patients. Our results show that the utilization of the ACS-NSQIP Risk Calculator in this particular patient population underestimates the complication risk as a whole, which may necessitate the future development of a separate risk assessment model for this procedure.
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What Is the Impact of Comorbidities on the Risk for Postoperative Body-Contouring Surgery Complications in Postbariatric Patients? Obes Surg 2018; 29:552-559. [PMID: 30367325 DOI: 10.1007/s11695-018-3554-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is an increasing number of patients presenting after massive weight loss for plastic surgery, and many of these patients have residual diseases that may compromise outcomes. This study aims to evaluate the impact of comorbidities on the development of postoperative complications in postbariatric patients undergoing plastic surgery procedures at the Federal District North Wing Regional Hospital, Brasília, Brazil. METHODS Descriptive, analytical, and prospective study was performed on patients who underwent plastic surgery following RYGB from January 2011 to December 2016. Measures included BMI (body mass index) before RYGB and before plastic surgery, medical complications and comorbidities. RESULTS One hundred thirty-nine patients (130 female, 9 male) with a mean age of 41 years underwent 233 separate operations. The average BMI at the time of plastic surgery was 27.44 kg/m2. The average weight loss was 47.02 kg, and the mean pre-weight-loss BMI (max BMI) was 45.17 kg/m2. The most important pre-plastic comorbidities were arterial hypertension (11.5%), degenerative arthropathy (5.4%), diabetes mellitus (5.0%), and metabolic syndrome (4.3%). Of the 139 patients operated upon, 76.97% underwent abdominoplasty followed by mammoplasty (42.46%). The overall rate of complications was 26.65%. Initially, on univariate regression analyses, comorbidities influenced the development of postoperative complications. However, after multiple logistic regression, the most important comorbidities failed to predict an increased risk of complications. CONCLUSION In this group of patients, with these anthropometric and clinical profiles, the most important comorbidities (diabetes, arterial hypertension, and metabolic syndrome) failed to influence the incidence of postoperative complications in postbariatric patients after plastic surgery.
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11
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Hurwitz DJ. Discussion: Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database. Aesthetic Plast Surg 2018; 42:21-22. [PMID: 29270689 DOI: 10.1007/s00266-017-1033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Dennis J Hurwitz
- University of Pittsburgh Medical Center and Hurwitz Center for Plastic Surgery, 3109 Forbes Avenue, Pittsburgh, PA, 15213, USA.
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