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Daneshi K, Mansour HRK, Pacheco-Barrios N, Asaju A, Pérez Pachon M, Hoyos A, Khajuria A. A Bibliometric Analysis of the Top 100 Papers on Gluteal Augmentation. Aesthet Surg J Open Forum 2024; 6:ojae053. [PMID: 39100865 PMCID: PMC11295219 DOI: 10.1093/asjof/ojae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Background Gluteoplasty or gluteal augmentation is a popular cosmetic procedure that is used to improve the volume, shape, and contour of the buttocks. Objectives This bibliometric analysis aims to characterize emerging research trends and to assess the methodological quality of the highest impact gluteoplasty research. Methods The 100 most-cited publications in gluteoplasty were identified on Web of Science, across all available journal years (from Inception to August 2023). Study details, including the citation count, main content focus, and outcome measures, were extracted and tabulated from each publication. Oxford Centre for Evidence Based Medicine level of evidence (LOE) of each study was assessed. Results The 100 most-cited publications regarding gluteoplasty were cited by a total of 2375 publications. Citations per publication ranged from 5 to 176 (mean 23.75 ± 25.86), with the highest-cited study being authored by Simonacci, discussing autologous fat grafting (n = 176). Most publications were LOE 5 (n = 55), representative of the large number of case series and reports. The number of publications for LOE 1, 2, 3, and 4 was 1, 9, 13, and 22, respectively. The main content focus was "surgical technique" in 38 publications, followed by "outcomes" (n = 34) and "risk factors/prognosis" (n = 10). Patient-reported outcome measures (PROMs) were used in 20 publications, and 33 publications reported aesthetic outcome measures. Conclusions This analysis demonstrates a need for improvement in research methodologies regarding gluteoplasty research. This advancement would be facilitated by robust, high-quality research through randomized control trials and multicenter studies, as well as the further development of validated PROMs for gluteoplasty. Level of Evidence 2
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Affiliation(s)
| | | | | | | | | | | | - Ankur Khajuria
- Corresponding Author: Dr Ankur Khajuria, Department of Surgery and Cancer, London W2 1NY, UK. E-mail:
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2
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Wang B, He P, Zhao R. B-ultrasound-assisted gluteal fat grafting in Asians: A prospective study of quantitative results from three-dimensional imaging and B-ultrasound analysis. J Plast Reconstr Aesthet Surg 2024; 94:12-19. [PMID: 38729047 DOI: 10.1016/j.bjps.2024.04.035] [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: 11/04/2023] [Revised: 03/16/2024] [Accepted: 04/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND The increasing number of fatalities caused by gluteal fat grafting is concerning; thus, there is a need to determine ways to obtain the ideal aesthetic effect while ensuring a safe operation. In this study, three-dimensional (3D) measurements combined with B-ultrasound were used to evaluate the effect of gluteal fat augmentation in Asians, whose safety and effectiveness were confirmed using quantitative data. METHODS Thirty-five consecutive female patients were evaluated in this prospective clinical study. All patients underwent B-ultrasound-assisted gluteal fat augmentation on the subcutaneous plane alone. 3D imaging and B-ultrasound analysis of the adipose tissue thickness in the gluteal region were performed preoperatively and at 1 week, 3 months and 6 months post-operatively. RESULTS The waist circumference of the patients decreased, gluteal circumference and length of the gluteal crease increased and average waist-to-hip ratio improved from 0.78 to 0.74. At 3 months and 6 months post-operatively, the adipose tissue thickness decreased by 5.1% and 15.1%, respectively. The fat retention rates calculated using 3D imaging measurements at 3 months and 6 months post-operatively were 77.9% and 64.7%, respectively. According to the BODY-Q scale scores, patients reported a high level of satisfaction post-operatively. CONCLUSIONS B-ultrasound guidance can effectively prevent the occurrence of fatal fat embolism during gluteal fat grafting and maximise the augmentation effect. The quantitative data obtained using 3D measurements and B-ultrasound confirmed the safety and effectiveness of fat injections for gluteal augmentation under B-ultrasound guidance.
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Affiliation(s)
- Baicheng Wang
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China
| | - Ping He
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Runlei Zhao
- Department of Plastic Surgery, Peking University Third Hospital, Beijing, China.
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3
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Marangi GF, Savani L, Gratteri M, Arcari L, Segreto F, Cagli B, Cogliandro A, Vega R, Mirra C, Persichetti P. Main Factors Influencing Patient Satisfaction After Primary Breast Augmentation: A Prospective Study Based on Patient-Reported Outcome Measures. Aesthet Surg J 2024; 44:375-382. [PMID: 38114077 DOI: 10.1093/asj/sjad372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/25/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Primary breast augmentation is one of the most sought-after procedures in cosmetic surgery. It is generally related to a high degree of patient satisfaction, but it is not always obvious which factors have greater influence on patient satisfaction. OBJECTIVES The aim of this prospective study was to evaluate how anthropometric, psychological, and social parameters, in association with the main surgical variables, influenced patients' satisfaction with their breasts after surgery. METHODS Patients undergoing primary breast augmentation between October 2018 and February 2022, who completed a 12-month follow-up without complications, were enrolled in the study. For each patient we recorded: BMI, pinch test (upper pole of the breast), surgical access, implant pocket, implant volume, bra size increase, age, smoking habit, civil status, education level, pregnancies, and psychiatric disorders. Each variable was statistically correlated with patient's satisfaction, assessed by BREAST-Q questionnaire preoperatively and 12 months postoperatively. RESULTS Analyzing the data of the 131 patients, we found 3 factors affecting their satisfaction (P<.05); BMI: underweight patients were less satisfied than normal and overweight patients; pinch test: patients with a pinch test >2 cm were more satisfied; volume of the implant and bra size increase: patients with implant volume <300 cc and a less than 2 bra size increase were less satisfied than patients with larger augmentation. CONCLUSIONS BMI, pinch test, implant volume, and extent of volumetric enhancement should be taken into careful consideration by the surgeon during preoperative consultation and surgical planning, because they can be critical to patient satisfaction. LEVEL OF EVIDENCE: 3
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Vidal-Laureano N, Huerta CT, Perez EA, Earle SA. Augmented Safety Profile of Ultrasound-Guided Gluteal Fat Transfer: Retrospective Study With 1815 Patients. Aesthet Surg J 2024; 44:NP263-NP270. [PMID: 38124368 DOI: 10.1093/asj/sjad377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Gluteal augmentation with autologous fat transfer is one of the fastest growing aesthetic surgical procedures worldwide over the past decade. However, this procedure can be associated with high mortality from fatal pulmonary fat embolism events caused by intramuscular injection of fat. Ultrasound-guided fat grafting allows visualization of the transfer in the subcutaneous space, avoiding intramuscular injection. OBJECTIVES The aim of this study was to assess the safety and efficacy of gluteal fat grafting performed with ultrasound-guided cannulation. METHODS A retrospective chart review of all patients undergoing ultrasound-guided gluteal fat grafting at the authors' center between 2019 and 2022 was performed. All cases were performed by board-certified and board-eligible plastic surgeons under general anesthesia in ASA Class I or II patients. Fat was only transferred to the subcutaneous plane when over the gluteal muscle. Patients underwent postoperative follow-up from a minimum of 3 months up to 2 years. Results were analyzed with standard statistical tests. RESULTS The study encompassed 1815 female patients with a median age of 34 years. Controlled medical comorbidities were present in 14%, with the most frequent being hypothyroidism (0.7%), polycystic ovarian syndrome (0.7%), anxiety (0.6%), and asthma (0.6%). Postoperative complications occurred in 4% of the total cohort, with the most common being seroma (1.2%), local skin ischemia (1.2%), and surgical site infection (0.8%). There were no macroscopic fat emboli complications or mortalities. CONCLUSIONS These data suggest that direct visualization of anatomic plane injection through ultrasound guidance is associated with a low rate of complications. Ultrasound guidance is an efficacious adjunct to gluteal fat grafting and is associated with an improved safety profile that should be considered by every surgeon performing this procedure. LEVEL OF EVIDENCE: 3
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5
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de Matos Lourenço L, Colla LA, Ortiz de Noronha MG, Izzo TR, Sigrist R. Square technique-A treatment for cellulite with large size particle hyaluronic acid. SKIN HEALTH AND DISEASE 2024; 4:e290. [PMID: 38312247 PMCID: PMC10831568 DOI: 10.1002/ski2.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 02/06/2024]
Abstract
Gynoid lipodystrophy, also called cellulite, is defined as a metabolic disorder of the subcutaneous tissue that alters body contour. It is rare in men but affects 80%-90% of adult women.The authors describe a technique for the treatment of cellulite with non-traumatic subcisionTM of septa by cannula associated with large-gel-particle hyaluronic acid (HA). It uses a special marking, a safe plan and a specific product. The product being used is Subskin Aeskins, in a subcutaneous plan as no major blood vessels were found.The authors report good aesthetic results with the proposed technique. The patients reported a high degree of satisfaction.The product chosen has high G prime and large particles, which accounts for resistance to deformation and a high lifting power. Moreover, HA is a biocompatible, absorbable product and considered a safe filler. This technique allows the treatment of an area with various surface irregularities.The Square Technique proved to be a minimally invasive technique, with fast results, no major risks and little downtime, bringing satisfaction to patients and improving their self-confidence and quality of life.
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Affiliation(s)
| | | | | | | | - Rosa Sigrist
- Hospital das Clínicas da Faculdade de Medicina da USPUniversidade de São PauloSão PauloBrazil
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6
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Kaye KO, Paprottka F, Moellhoff N, Fertsch S, Frank K, Casabona G. Radiofrequency and pulsed electromagnetic field application following liposuction-Clinical evaluation of performance and safety. J Cosmet Dermatol 2023; 22:3298-3304. [PMID: 37909850 DOI: 10.1111/jocd.15937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/25/2023] [Accepted: 07/12/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE With more than 1.5 million performed procedures, liposuction was the second most performed esthetic surgical procedure all over the world in males and in females in the year 2020. The objective of this open-label, evaluator-blinded study was to assess the efficacy and safety of an energy-based device that combines multipolar radiofrequency with pulsed electromagnetic field (PEMF) in patients that underwent liposuction. MATERIALS AND METHODS A total of 30 subjects, of whom 24 were females (80%), with a mean age of 48.4 ± 11.0 years (range: 27-69 years) and a mean weight of 69.5 ± 11.7 kg underwent unilateral treatment with radiofrequency and application of PEMF after bilateral liposuction. One month after the last of a total of six weekly treatments, skin elasticity, visco-elasticity and net elasticity, as well as subject reported satisfaction on a 5-point scale ranging from -1 (worse) to 3 (very much improved) and esthetic improvement ranging from 0 (very unsatisfied) to 4 (very satisfied) rated by three independent reviewers were assessed. RESULTS Three independent and blinded reviewers rated the improvement of the treated side on average as 1.17 + 0.07 compared with baseline. Subjects were very satisfied with their treatment, with a mean score of 3.24 (0.03) out of 4 at the 1-month follow-up visit. Cutometer measurements showed no significant changes. CONCLUSION This study revealed that the subjective satisfaction with the results of the application of RF and PEMF after liposuction is high, while at the same time the esthetic appearance as rated by independent raters improved on the treated side.
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Affiliation(s)
| | | | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany
| | - Sonia Fertsch
- Department of Plastic Surgery, SANA Clinic Düsseldorf Gerresheim, Düsseldorf, Germany
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7
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Guo Y, Hu Z, Chen J, Zhang J, Fan Z, Qu Q, Miao Y. Feasibility of adipose-derived therapies for hair regeneration: Insights based on signaling interplay and clinical overview. J Am Acad Dermatol 2023; 89:784-794. [PMID: 34883154 DOI: 10.1016/j.jaad.2021.11.058] [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: 02/17/2021] [Revised: 09/13/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022]
Abstract
Dermal white adipose tissue (dWAT) is a dynamic component of the skin and closely interacts with the hair follicle. Interestingly, dWAT envelops the hair follicle during anagen and undergoes fluctuations in volume throughout the hair cycle. dWAT-derived extracellular vesicles can significantly regulate the hair cycle, and this provides a theoretical basis for utilizing adipose tissue as a feasible clinical strategy to treat hair loss. However, the amount and depth of the available literature are far from enough to fully elucidate the prominent role of dWAT in modulating the hair growth cycle. This review starts by investigating the hair cycle-coupled dWAT remodeling and the reciprocal signaling interplay underneath. Then, it summarizes the current literature and assesses the advantages and limitations of clinical research utilizing adipose-derived therapies for hair regeneration.
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Affiliation(s)
- Yilong Guo
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China
| | - Zhiqi Hu
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China
| | - Jian Chen
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China
| | - Jiarui Zhang
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China
| | - Zhexiang Fan
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China
| | - Qian Qu
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China.
| | - Yong Miao
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, China.
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8
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César Durán Vega H. Buttock and Full Body Contouring Harmony. Clin Plast Surg 2023; 50:573-585. [PMID: 37704325 DOI: 10.1016/j.cps.2023.05.002] [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] [Indexed: 09/15/2023]
Abstract
The concept of the gluteal framework has significantly enhanced our understanding of the gluteal anatomy. The buttock does not constitute a bulging area in the human body. To be attractive, it must harmonize with all elements of the human body around it. Nevertheless, the changes in patient desires and demands, in addition to innovations in surgical technique open a field of opportunity to achieve more beautiful and natural results. In this work, the main updates in the management of body contouring are condensed, including new safe and aesthetic fat infilration techniques.
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Affiliation(s)
- Héctor César Durán Vega
- ASAPS, ASPS, AMCPER, FILACP, Centro Medico de Las Americas CMA, Consultorio#317 Calle 54 #365 x 33-a y Av. perez Ponce Colonia Centro, Merida, Yucatán CP 97000, Mexico; Hospital Eme Red hospitalaria, Calle 33 Número 496, Consultorio 229, Entre 56 y 56 A, Centro, 97000 Mérida, Yucatán, México.
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9
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Wang HC, Long X. Filler-induced non-thrombotic pulmonary embolism after genital aesthetic injection. J COSMET LASER THER 2022; 24:66-72. [PMID: 35969584 DOI: 10.1080/14764172.2022.2112231] [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: 10/15/2022]
Abstract
Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.
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Affiliation(s)
- Hayson Chenyu Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Cotofana S, Kaminer MS. Anatomic Update on the
3‐Dimensionality
of the Subdermal Septum and its Relevance for the Pathophysiology of Cellulite. J Cosmet Dermatol 2022; 21:3232-3239. [DOI: 10.1111/jocd.15087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sebastian Cotofana
- Department of Clinical Anatomy Mayo Clinic College of Medicine and Science Rochester MN USA
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11
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Hexsel D, Dini TD, Belem L, Correa IT, Brandão A. Gluteal Subcutaneous Adipose Tissue in Women of Different Ages and Body Mass Index observed by Magnetic Resonance Imaging. J Cosmet Dermatol 2022; 21:2169-2175. [PMID: 35181990 DOI: 10.1111/jocd.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/27/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Magnetic resonance Imaging (MRI) is a recognized method to assess the morphological characteristics of subcutaneous adipose tissue (SAT). This study aimed to assess objectively different characteristics of SAT of women with different ages and body mass index (BMI) using MRI. MATERIALS AND METHODS Retrospective, observational study. Pelvic-MRI exams of 133 women aged between 15 and 80 years, with BMI 16 to 30 kg/m2 were assessed. RESULTS There was a moderate positive correlation between the total fat thickness and the BMI (r = 0.64; p<0.0001) considering the entire sample. Within the different age groups, strong positive correlation was observed for age groups 15 to 30 years (r=0.76; p<0.0001) and 46 to 60 years (r=0.75; p<0.0001), and moderate positive correlation in the others (r=0.61; p<0.0001 [31-45 years] and r=0.53; p<0.0001 [>61 years-old]). There was no correlation between age and fat layer thickness. Correlation between deep fat layer thickness and BMI showed similar pattern to that of the total fat layer. Within the different BMI groups, SAT thickness tends to decrease with aging in patients with low BMI. CONCLUSION Inside each age group, the average thickness of the total fat layer increases according to BMI. The results suggest that BMI influences the thickness of SAT throughout life and how SAT changes with age in patients with different BMI. In patients with moderate BMI, the thickness of SAT remains stable.
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Affiliation(s)
- Doris Hexsel
- Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil
| | - Taciana Dal'Forno Dini
- Dermatology Residency Program, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luciana Belem
- Fonte Imagem Clinic, Rio de Janeiro, Brazil.,National Cancer Institute, Casa de Saúde São José, Rio de Janeiro, RJ, Brazil
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12
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Lourenço LM, Noronha MGO, Colla LA, Izzo TR, Sigrist R, Braz A. LL body contour technique—A new way of gluteal contouring and augmentation with hyaluronic acid filler. J Cosmet Dermatol 2022; 21:1967-1972. [DOI: 10.1111/jocd.14763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 01/02/2023]
Affiliation(s)
| | | | | | | | - Rosa Sigrist
- Private Practice in Ultrasound São Paulo SP Brazil
| | - André Braz
- Private Practice in Dermatology Rio de Janeiro RJ Brazil
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13
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Schelke L, Velthuis PJ, Lowry N, Rohrich RJ, Swift A, Gotkin RH, Moellhoff N, Frank K, Dumbrava M, Cotofana S. The mobility of the superficial and deep midfacial fat compartments: An ultrasound-based investigation. J Cosmet Dermatol 2021; 20:3849-3856. [PMID: 34365716 DOI: 10.1111/jocd.14374] [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] [Received: 07/06/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Understanding the mobility of the midface and the separate contributions of the superficial and deep fat compartments is essential for natural esthetic outcomes following soft tissue filler or fat grafting procedures. A study was designed that used ultrasound imaging to demonstrate in vivo visualization and quantification of distances and movements in the midface. METHODS A total of 48 midfaces of 24 healthy Caucasian volunteers, all naïve of esthetic procedures, (22 females; 46.85 (9.8) years; 22.83 (3.1) kg/m2 ) were scanned using 18 MHz ultrasound imaging. Distances between bony landmarks (inferior orbital rim, infraorbital foramen) were used as markers to measure the cranial movement of the superficial (superficial nasolabial and superficial medial cheek fat compartment) and the deep (deep pyriform space, deep medial check fat compartment, deep lateral cheek fat compartment) midfacial fat compartments between resting and smiling facial position. RESULTS The superficial midfacial fat compartment moved, on average, 3.7 mm (p < 0.001) cranially, whereas the deep midfacial fat compartments moved, on average, 0.1 mm (p > 0.05) during smiling. No gender differences in mobility were identified (p > 0.05). CONCLUSION The results obtained are in line with previous cadaveric investigations and revealed, in a highly statistically significant fashion, that the superficial midfacial fat compartments move in cranial direction whereas the deep fat compartment did not display similar positional changes. These results help to guide facial injectable treatments and to understand why, in the midface, a deep supraperiosteal approach should be favored when augmenting the deep midfacial fat compartments.
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Affiliation(s)
- Leonie Schelke
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands.,Private Practice, Amsterdam, The Netherlands
| | - Peter J Velthuis
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Natalia Lowry
- Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, NY, USA
| | | | - Arthur Swift
- Westmount Institute of Plastic Surgery, Montreal, Quebec, Canada
| | | | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Mihai Dumbrava
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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14
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Che DH, Xiao ZB. Gluteal Augmentation with Fat Grafting: Literature Review. Aesthetic Plast Surg 2021; 45:1633-1641. [PMID: 33216176 DOI: 10.1007/s00266-020-02038-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The buttock is the second sex feature of the human body, and the graceful buttock curve gives people confidence. Although the safety of gluteal augmentation with autologous fat grafting is still controversial, the proportion of operations is increasing year by year. PURPOSE To provid a comprehensive and detailed review of the literature on gluteal augmentation with fat grafting. METHODS A comprehensive review of the published literature through September of 2020 was performed in PubMed database, with the search terms "gluteal augmentation," "buttock augmentation," "Brazilian buttock lift," "fat grafting," "fat transfer," "gluteal AND aesthetic," "gluteal AND anatomy." RESULTS A total of 64 articles were included. On the basis of the information obtained, surgical recommendations are proposed to achieve buttocks as close as possible to aesthetic standard and improve surgical safety. CONCLUSION With a good grasp of the anatomical structure of the buttocks, complications can be reduced. At the same time, based on the theoretical basis of buttock aesthetics, better postoperative results can be obtained. 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)
- De-Hui Che
- Department of Plastic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150081, China
| | - Zhi-Bo Xiao
- Department of Plastic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150081, China.
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15
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Xu Y, Fan P, Xu X, Jiang F, Zhang W, Yin X, Liu H, Wang P, Wang Y. [Study of modified subcutaneous lumbar spine index as a predictor for short-term effectiveness in transforaminal lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:878-885. [PMID: 34308597 DOI: 10.7507/1002-1892.202101154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the value of modified subcutaneous lumbar spine index (MSLSI) as a predictor for short-term effectiveness of transforaminal lumbar interbody fusion (TLIF) in treatment of lumbar degenerative disease (LDD). Methods Between February 2014 and October 2019, 450 patients who were diagnosed as LDD and received single-segment TLIF were included in the study. Based on the MSLSI measured by preoperative lumbar MRI, the patients were sorted from small to large and divided into three groups ( n=150). The MSLSI of group A was 0.11-0.49, group B was 0.49-0.73, and group C was 0.73-1.88. There was no significance in gender, age, disease duration, diagnosis, surgical segment, and improved Charlson comorbidity index between groups ( P>0.05). There were significant differences in the subcutaneous adipose depth of the L 4 vertebral body and body mass index (BMI) between groups ( P<0.05). The operation time, intra-operative blood loss, length of incision, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, total drainage volume, antibiotic use time after operation, walking exercise time after operation, hospital stay, the incidences of surgical or non-surgical complications in the three groups were compared. Pearson correlation analysis was used to analyze the correlation between MSLSI and BMI, and partial correlation analysis was used to study the relationship between MSLSI, BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L 4 vertebral body and complications. The Receiver Operating Characteristic (ROC) curve was used to evaluate the value of SLSI and MSLSI in predicting the occurrence of complications after TLIF in treatment of LDD. Results There was no significant difference in operation time, length of incision, antibiotic use time after operation, walking exercise time after operation, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, and total drainage volume between groups ( P>0.05). The amount of intra-operative blood loss in group C was higher than that in groups A and B, and the hospital stay was longer than that in group B, with significant differences ( P<0.05). Surgical complications occurred in 22 cases (14.7%), 25 cases (16.7%), and 39 cases (26.0%) of groups A, B, and C, respectively. There was no significant difference in the incidence between groups ( χ 2=0.826, P=0.662). The incidences of nerve root injury and wound aseptic complications in group C were higher than those in groups A and B, and the incidence of nerve root injury in group B was higher than that in group A, with significant differences ( P<0.05). There were 13 cases (8.7%), 7 cases (4.7%), and 11 cases (7.3%) of non-surgical complications in groups A, B, and C, respectively, with no significant difference ( χ 2=2.128, P=0.345). There was no significant difference in the incidences of cardiovascular complications, urinary system complications, central system complications, and respiratory system complications between groups ( P>0.05). There was a correlation between MSLSI and BMI in 450 patients ( r=0.619, P=0.047). Partial correlation analysis showed that MSLSI was related to wound aseptic complications ( r=0.172, P=0.032), but not related to other surgical and non-surgical complications ( P>0.05). There was no correlation between BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L 4 vertebral body and surgical and non-surgical complications ( P>0.05). ROC curve analysis showed that the area under ROC curve (AUC) of MSLSI was 0.673 (95%CI 0.546-0.761, P=0.025), and the AUC of SLSI was 0.582 (95%CI 0.472-0.693, P=0.191). Conclusion MSLSI can predict the short-term effectiveness of TLIF in treatment of LDD. Patients with high MSLSI suffer more intra-operative blood loss, longer hospital stay, and higher incidence of nerve root injury and postoperative incision complications.
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Affiliation(s)
- Yuzhu Xu
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Pan Fan
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xuanfei Xu
- Department of Nulear Medicine, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Feng Jiang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Wei Zhang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiangjie Yin
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hang Liu
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Peiyang Wang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yuntao Wang
- Department of Spine Surgery, Zhongda Hospital Affiliated to Southeast University, Nanjing Jiangsu, 210009, P.R.China.,Medical School, Southeast University, Nanjing Jiangsu, 210009, P.R.China
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Wang C, Wang X, Huang J, Yu N, Long X. Severe fat embolism after autologous fat grafting in vaginal tightening and breast augmentation surgery. J Int Med Res 2021; 48:300060520949109. [PMID: 32811245 PMCID: PMC7441288 DOI: 10.1177/0300060520949109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Autologous fat grafting has become increasingly popular in the field of aesthetic surgery because of its biocompatibility and low donor site morbidity. However, some fatal complications may occur following the surgery. We herein describe a woman who developed severe fat embolism after autologous fat grafting for vaginal tightening and breast augmentation surgery. The patient developed symptoms of dyspnea and hypoxemia. Computed tomography pulmonary angiography showed multiple filling defects in the bilateral pulmonary arteries and branches with a maximum size of approximately 1.2 × 0.7 cm. Fat embolism was assumed to have occurred by injection of fat directly into the vessels around the vagina. Further research is needed to elucidate the anatomical mechanism underlying this phenomenon.
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Affiliation(s)
- Chenyu Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuzuo Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Nanze Yu
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections. Plast Reconstr Surg 2021; 147:765e-776e. [PMID: 33890889 DOI: 10.1097/prs.0000000000007857] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although injectable soft-tissue fillers are frequently used for facial rejuvenation, there is a dearth of objective data evaluating the tissue-lifting effects. Current practices for efficacy evaluation include some subjectivity. This study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifiable, objective setting. METHODS Twenty fresh hemifaces obtained from 10 Caucasian body donors (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers following a predefined treatment algorithm. Three-dimensional surface scanning procedures were performed to assess postinjection effects. RESULTS Injections in the medial face [i.e., forehead, medial midface, and perioral (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jawline) changed the local surface volume by 0.45, 0.02, and -0.38 cc, and created local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections, however, created additional regional lifting effects by co-influencing neighboring lateral facial regions, which was not observed for medial face injections. CONCLUSIONS This cadaveric study provides evidence that soft-tissue fillers, although typically classified as volumizers, can induce lifting effects of the face. Whereas temporal deep supraperiosteal injections have limited lifting effects, the combined effects of subdermal injections of the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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18
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Influence of BMI, Age, and Gender on the Thickness of Most Common Thinned Flaps. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3409. [PMID: 33968546 PMCID: PMC8099397 DOI: 10.1097/gox.0000000000003409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Abstract
Background: Since the description of superficial fascia flap harvesting, a new window of opportunity has been open in obese patients, where a higher subcutaneous thickness of tissue is present. To our knowledge, the impact of body mass index on superficial fascial flaps has not been reported. Methods: We recruited 122 patients from April 2019 to January 2020. From these patients, the 3 most common thinned flaps were selected: the superficial circumflex iliac perforator flap; the anterolateral thigh flap at the perforator A, B, and C; and the thoracodorsal flap. Two vertical measures were registered: the distance from the skin to the superficial fascia, and from this point to the deep fascia. Results: The average flap measurement presented here was within the range, as previous clinical studies. The superficial fatty layer thickness in the superficial circumflex iliac perforator and anterolateral thigh flap was somewhat similar in thickness between overweight and obese patients, showing a minimal increase with higher body mass index. The anterolateral thigh flap was found thicker among women, and no statistical difference was shown between age groups in any of the flaps. Conclusions: A better understanding of the fat layers’ thickness will result in better planning, minimizing secondary debulking procedures, decreasing operative time, and reducing general complications among obese patients. Thus, a better understanding of flap structure and physiology in obese patients will lower complications and give more predictable results.
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Alfertshofer M, Frank K, Melnikov DV, Möllhoff N, Gotkin RH, Freytag DL, Heisinger S, Giunta RE, Schenck TL, Cotofana S. Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging. Facial Plast Surg 2021; 37:395-399. [PMID: 33706385 DOI: 10.1055/s-0041-1725166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m2. Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both p < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.
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Affiliation(s)
- Michael Alfertshofer
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Konstantin Frank
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Dmitry V Melnikov
- Plastic Surgery Department, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Nicholas Möllhoff
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | | | - David Lysander Freytag
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Stephan Heisinger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Wien, Austria
| | - Riccardo E Giunta
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Thilo L Schenck
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Sebastian Cotofana
- Department of Medical Education, Albany Medical College, Albany, New York
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20
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Nikolis A, Frank K, Guryanov R, Gombolevskiy V, Morozov S, Makhmud K, Chernina V, Gotkin RH, Green JB, Cotofana S. Differences in Temporal Volume between Males and Females and the Influence of Age and BMI: A Cross-Sectional CT-Imaging Study. Facial Plast Surg 2021; 37:632-638. [PMID: 33684952 DOI: 10.1055/s-0041-1725201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The temple has been identified as one of the most compelling facial regions in which to seek aesthetic improvement-both locally and in the entire face-when injecting soft tissue fillers. OBJECTIVE The objective of this study is to identify influences of age, gender, and body mass index (BMI) on temporal parameters to better understand clinical observations and to identify optimal treatment strategies for treating temporal hollowing. METHODS The sample consisted of 28 male and 30 female individuals with a median age of 53 (34) years and a median BMI of 27.00 (6.94) kg/m2. The surface area of temporal skin, the surface area of temporal bones, and the temporal soft tissue volume were measured utilizing postprocessed computed tomography (CT) images via the Hausdorff minimal distance algorithm. Differences between the investigated participants related to age, BMI, and gender were calculated. RESULTS Median skin surface area was greater in males compared with females 5,100.5 (708) mm2 versus 4,208.5 (893) mm2 (p < 0.001) as was the median bone surface area 5,329 (690) mm2 versus 4,477 (888) mm2 (p < 0.001). Males had on average 11.04 mL greater temporal soft tissue volume compared with age and BMI-matched females with p < 0.001. Comparing the volume between premenopausal versus postmenopausal females, the median temporal soft tissue volume was 46.63 mL (11.94) versus 40.32 mL (5.69) (p = 0.014). CONCLUSION The results of this cross-sectional CT imaging study confirmed previous clinical and anatomical observations and added numerical evidence to those observations for a better clinical integration of the data.
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Affiliation(s)
- Andreas Nikolis
- Division of Plastic Surgery, McGill University Faculty of Medicine, Montreal, Quebec, Canada
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University, Munich, Germany
| | - Robert Guryanov
- Department of Plastic Surgery, I. M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Victor Gombolevskiy
- Moscow Health Care Department, Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies, Moscow, Russian Federation
| | - Sergey Morozov
- Moscow Health Care Department, Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies, Moscow, Russian Federation
| | - Kamal Makhmud
- Private Practice, Medlaz Clinic, Moscow, Russian Federation
| | - Valeria Chernina
- Moscow Health Care Department, Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies, Moscow, Russian Federation
| | | | - Jeremy Blair Green
- Skin Associates of South Florida, Skin Research Institute, Coral Gables, Florida
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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21
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O'Neill RC, Abu-Ghname A, Davis MJ, Chamata E, Rammos CK, Winocour SJ. The Role of Fat Grafting in Buttock Augmentation. Semin Plast Surg 2020; 34:38-46. [PMID: 32071578 PMCID: PMC7023974 DOI: 10.1055/s-0039-3401038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autologous fat grafting is now considered the gold standard for buttock augmentation. Although a variety of techniques are currently being used by surgeons around the world, methods of fat grafting to the buttocks remain unsystematized, poorly understood, and controversial in terms of their safety and efficacy. Nonetheless, buttock augmentation by fat grafting has a satisfaction rate of 97.1%, and its mean complication rate has been estimated to be around 7 to 10%, with serious complications occurring in less than 1% of cases. Fat emboli are one such serious complication, with several reports in the literature discussing morbidity and mortality, specifically with intramuscular injection. With the increasing popularity of fat grafting for buttock augmentation, it is more important than ever to continue researching and learning to safeguard the satisfaction and safety of our patients.
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Affiliation(s)
- Rebecca C. O'Neill
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J. Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward Chamata
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Charalambos K. Rammos
- Division of Plastic Surgery, Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois
| | - Sebastian J. Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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