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Hassan B, Schuster CR, Ascha M, Del Corral G, Fischer B, Liang F. Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery. Ann Plast Surg 2024; 92:174-180. [PMID: 37917575 DOI: 10.1097/sap.0000000000003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
PURPOSE Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications. METHODS The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes. RESULTS Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively. CONCLUSIONS Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.
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Affiliation(s)
- Bashar Hassan
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
| | | | - Mona Ascha
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Baltimore
| | - Beverly Fischer
- The Advanced Center for Plastic Surgery, Lutherville-Timonium, MD
| | - Fan Liang
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
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Rezaei SJ, Boskey ER, Ganor O. Body mass index and benign breast surgeries: a survey of plastic surgeons’ knowledge and attitudes. JPRAS Open 2023; 36:46-54. [PMID: 37102187 PMCID: PMC10123250 DOI: 10.1016/j.jpra.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
Background The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients. Methods An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022. Results There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher. Conclusions Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.
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Barger BT, Pakvasa M, Lem M, Ramamurthi A, Lalezari S, Tang C. Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report. Case Reports Plast Surg Hand Surg 2023; 10:2185621. [PMID: 36926352 PMCID: PMC10013424 DOI: 10.1080/23320885.2023.2185621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
We present a case of a 32-year-old transgender male who underwent chest masculinization, complicated by purulent soft tissue infection of bilateral chest incisions. Cultures tested positive for non-typhoidal Salmonella, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Herein, we discuss multiple factors contributing to the complexity of treating this patient's clinical course.
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Affiliation(s)
- Branden T Barger
- School of Medicine, University of California, Riverside, CA, USA
| | - Mikhail Pakvasa
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
| | - Melinda Lem
- School of Medicine, University of California, Irvine, CA, USA
| | - Aishu Ramamurthi
- Medical College of Wisconsin, Affiliated Hospitals, Inc., Graduate Medical Education, Milwaukee, WI, USA
| | - Shadi Lalezari
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
| | - Cathy Tang
- Department of Plastic and Reconstructive Surgery, University of California, Orange, CA, USA
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Ederer IA, Spennato S, Nguyen CT, Wehle A, Wachtel C, Kiehlmann M, Hacker S, Kueenzlen L, Kuehn S, Rothenberger J, Rieger UM. A Single-Center 10-Year Experience of 180 Transmasculine Patients Undergoing Gender-Affirming Mastectomy While Continuing Masculinizing Hormone Replacement Therapy. Aesthetic Plast Surg 2022; 47:946-954. [PMID: 36510021 DOI: 10.1007/s00266-022-03213-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gender-affirming mastectomy is a fundamental step in the transition process of transmasculine patients following the initiation of hormone replacement therapy. Its perioperative management, however, remains underreported and controversial. In this study, a large series of mastectomies in transmen maintaining hormonal therapy is presented. METHODS Over a 10-year study period, a consecutive series of 180 transmasculine patients undergoing chest masculinizing surgery was evaluated. Demographical and surgical data were collected and analyzed for potential factors influencing outcome. RESULTS The overall rate of complications was 15.5%. Patients who underwent periareolar incision mastectomy were significantly more likely to develop any type of complication than patients with a sub-mammary incision (28.6% vs. 13.2%, p = 0.045). Hematoma was the most common reason for surgical revision. It occurred significantly more often among the periareolar group (21.4% vs. 7.9%, p = 0.041). Duration and type of hormonal therapy did not differ between patients with or without complications. In a multivariate regression analysis, smoking and type of incision were identified as significant predictors of the all-cause complication rate, whereas the influence of BMI and resection weight diminished after adjusting for confounding factors. CONCLUSION There is scarcity of information concerning the influence of perioperative hormonal therapy in patients undergoing chest wall masculinization. The observed complication rates-with special regard to hematoma-were comparable to current reports; yet further research is needed to profoundly evaluate this topic and provide evidence-based recommendations for the perioperative management of HRT of transmasculine patients. LEVEL OF EVIDENCE IV 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 http://www.springer.com/00266 .
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Affiliation(s)
- Ines Ana Ederer
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany.
| | - Stefano Spennato
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany.,Department of Plastic Surgery and Hand Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Cam-Tu Nguyen
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany.,Department of Plastic and Hand Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrej Wehle
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Carolin Wachtel
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Marcus Kiehlmann
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Stefan Hacker
- Department of Plastic, Aesthetic and Reconstructive Surgery, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Lara Kueenzlen
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Shafreena Kuehn
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Jens Rothenberger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
| | - Ulrich M Rieger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt am Main, Germany
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Riddle MC, Safer JD. Medical considerations in the care of transgender and gender diverse patients with eating disorders. J Eat Disord 2022; 10:178. [PMID: 36414965 PMCID: PMC9682795 DOI: 10.1186/s40337-022-00699-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.
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Affiliation(s)
- Megan C Riddle
- Eating Recovery Center, 1231 116Th Ave NE, Bellevue, WA, 98004, USA. .,Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195-6560, USA.
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, 275 7Th Ave 12Th Floor, New York, NY, 10001, USA
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Bigarella LG, Ballardin AC, Couto LS, de Ávila ACP, Ballotin VR, Ingracio AR, Martini MP. The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis. Aesthet Surg J 2022; 42:795-807. [PMID: 35037936 DOI: 10.1093/asj/sjab397] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory. OBJECTIVES The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures. METHODS We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes. RESULTS Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction. CONCLUSIONS Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.
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Affiliation(s)
| | | | - Luísa Serafini Couto
- School of Medicine, Universidade de Caxias do Sul (UCS) , Caxias do Sul , Brazil
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Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns. Plast Reconstr Surg Glob Open 2022; 10:e4356. [PMID: 35646495 PMCID: PMC9132529 DOI: 10.1097/gox.0000000000004356] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
Background: Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques. Methods: Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups. Results: In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique. Conclusions: Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.
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Bekisz JM, Boyd CJ, Daar DA, Cripps CN, Bluebond-Langner R. Hematoma following gender-affirming mastectomy: A systematic review of the evidence. J Plast Reconstr Aesthet Surg 2022; 75:3108-3121. [PMID: 35725957 DOI: 10.1016/j.bjps.2022.04.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/25/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence. METHODS A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE). RESULTS The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma. CONCLUSIONS Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jonathan M Bekisz
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States
| | - Carter J Boyd
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States
| | - David A Daar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States
| | - Courtney N Cripps
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States.
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Knudson SA, DeLeon A, Crane CN, Santucci RA. Minimal Impact Double Incision with Free Nipple Graft Technique for Gender-Affirming Top Surgery. Plast Reconstr Surg 2022; 149:152e-153e. [PMID: 34846366 DOI: 10.1097/prs.0000000000008618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Rothenberg KA, Gologorsky RC, Hojilla JC, Tang A, Cohan CM, Beattie G, Yokoo KM. Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions? Ann Plast Surg 2021; 87:24-30. [PMID: 33559996 PMCID: PMC8936918 DOI: 10.1097/sap.0000000000002712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications. STUDY DESIGN All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions. RESULTS One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30-34.9 kg/m2, 9.4%), class II (BMI of 35-39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery. CONCLUSIONS Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.
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Affiliation(s)
- Kara A Rothenberg
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Rebecca C Gologorsky
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | | | - Annie Tang
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Caitlin M Cohan
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Genna Beattie
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Karen M Yokoo
- Department of Plastic Surgery, Kaiser Permanente Northern California, Richmond, CA
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Surgical and patient-reported outcomes following double incision and free nipple grafting for female to male gender affirmation: does obesity make a difference? J Plast Reconstr Aesthet Surg 2020; 74:1743-1751. [PMID: 33341390 DOI: 10.1016/j.bjps.2020.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/27/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The efficacy of chest wall contouring in alleviating symptoms of gender dysphoria in transmale and nonbinary patients is well established. As the popularity and indications for these procedures continue to increase, more surgeons are performing these surgeries on obese patients. The aim of this study was to investigate the association of obesity on postoperative and patient-reported outcomes. METHODS A retrospective chart review was performed for 97 consecutive masculinizing mastectomies by a single surgeon using the double incision and free nipple graft technique (DIFNG). Surgical outcomes were collected using electronic records and patient-reported outcomes using BODY-Q questionnaires. RESULTS DIFNG mastectomies were performed in 97 patients from 2016 to 2019, of which 43(44%) were obese and 54(56%) were non-obese. The average follow-up time was 62(12 - 112) months in obese patients and 61(10 - 127) months in non-obese patients. There was no difference in minor and major complication rates between non-obese and obese patients [minor: 4(7%) vs 5(12%), p = 0.19) and major: 0(0%) vs 1(2%), p = 0.46]. BODY-Q data was available for 33(77%) of obese and 43(80%) of non-obese patients. There was no difference in scores for each module of the BODY-Q between obese and non-obese patients (p>0.05). CONCLUSION Chest wall contouring using the DIFNG technique continues to be safe and effective for the management of gender dysphoria in transmale and nonbinary patients. Considering that obese patients have comparable surgical and patient-reported outcomes as non-obese patients, it is our practice to routinely offer the DIFNG technique to healthy obese patients with BMI's between 30 and 40.
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