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Vaccari S, Balza A, Andreoletti S, Fondrini R, Caimi E, Klinger F, Vinci V. Literature Review: Venous Thromboembolism Prophylaxis in Plastic Surgery. Aesthetic Plast Surg 2023; 47:2902-2906. [PMID: 37474820 DOI: 10.1007/s00266-023-03508-7] [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: 04/23/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023]
Abstract
Venous thromboembolism (VTE) is a postoperative complication experienced in all branches of surgery, including plastic surgery. Its occurrence can be lowered with adequate prophylaxis in the light of the patient's risk category and the type of surgery that will be performed. Nevertheless, thromboembolic prophylaxis is not routinely administered in plastic surgery. The prevention of VTE has gained significant attention in the past 5 years due to increased knowledge about the disease process and the alarming incidence rates. This literature review is specifically aimed at carrying out a synopsis of VTE prophylaxis trials conducted on plastic surgery patients. Antithrombotic agents have generally been avoided by plastic surgeons due to the increased risk of bleeding or hematomas; however, the prevalence of clinically important bleeding has not been found to increase with their use, as it emerges from numerous studies. VTE events can lead to increased morbidity and mortality rates, as well as a rise in healthcare costs. As it emerges from multiple studies, as a preventive measure against VTE, it is strongly advised to use mechanical prophylaxis along with low-molecular-weight heparin as the primary treatment option for plastic surgery patients who are at a greater risk. Up to date though, this practice is not commonly embraced by physicians. Preventing VTE is crucial, and measures to do so are necessary. However, there is no clear evidence to support the use of anticoagulation for plastic surgery patients, and some surgeons are hesitant to use it due to potential bleeding in extensive dissection areas.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)
- Stefano Vaccari
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Reconstructive and Aesthetic Plastic Surgery School, Humanitas Clinical and Research Hospital, University of Milan, Via Manzoni 56, Rozzano, 20090, Milan, Italy
| | - Arianna Balza
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
| | - Stefania Andreoletti
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Reconstructive and Aesthetic Plastic Surgery School, Humanitas Clinical and Research Hospital, University of Milan, Via Manzoni 56, Rozzano, 20090, Milan, Italy
| | - Riccardo Fondrini
- Plastic Surgery Unit, Department of Medical Biotechnology and Translational Medicine BIOMETRA, Reconstructive and Aesthetic Plastic Surgery School, Humanitas Clinical and Research Hospital, University of Milan, Via Manzoni 56, Rozzano, 20090, Milan, Italy
| | - Edoardo Caimi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Francesco Klinger
- Department of Health Sciences, Ospedale San Paolo, University of Milan, Via Antonio di Rudinì, 8, 20142, Milan, Italy
| | - Valeriano Vinci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, Rozzano, 20089, Milan, Italy
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Patel HS, Camacho JM, Shifchik A, Kalmanovich J, Burke E, Harb S, Patrus A, Cheng D, Behnam A. From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery. Cureus 2023; 15:e41557. [PMID: 37554601 PMCID: PMC10405759 DOI: 10.7759/cureus.41557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/08/2023] [Indexed: 08/10/2023] Open
Abstract
Thromboembolism is a feared complication in plastic surgery and is linked to higher rates of morbidity and mortality. Despite extensive research, there is a lack of consistency between recommendations and clinical protocols to be implemented pre and post-surgery to reduce the incidence of thromboembolism. A systematic literature review was conducted using Pubmed and Scopus databases to determine the risk factors, screening methods, and existing treatment models for thromboembolism prevention. Articles in non-English languages were excluded. Analysis indicated that predominant risk factors include age (>35), elevated body mass index, coagulation disorders, smoking, estrogen therapies, genetic predisposition, vascular endothelium damage, stasis, and use of general anesthesia in patients with a history of cancer. Implementation of a proper prophylactic protocol is dependent on understanding the interplay between the aforementioned risk factors and the utilization of well-defined, evidence-based guidelines, such as the 2005 Caprini Risk Assessment Model and ultrasound surveillance. The literature review revealed that mechanical prophylaxis is the primary prevention method, followed by thromboprophylaxis for patients with higher Caprini scores. Plastic surgeons often underestimate the present risk stratification tools available for the prophylactic intervention of thromboembolism due to the fear of bleeding or hematoma complications postoperatively. In summary, this literature review emphasizes the importance of plastic surgeons selecting protocols that is inclusive of the patient's risk profile to yield a reduced risk of thromboembolism.
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Affiliation(s)
- Heli S Patel
- Allopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Justin M Camacho
- Department of Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Anastassia Shifchik
- Allopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | | | - Emma Burke
- Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Salam Harb
- Allopathic Medicine, Nova Southeastern University Dr. Kiran C Patel College of Allopathic Medicine, Davie, USA
| | - Alan Patrus
- Allopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Daniel Cheng
- Plastic and Reconstructive Surgery, Tower Health Medical Group, Wyomissing, USA
| | - Amir Behnam
- Plastic and Reconstructive Surgery, Tower Health Medical Group, Wyosmissing, USA
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Speck NE, Hellstern P, Farhadi J. Microsurgical Breast Reconstruction in Patients with Disorders of Hemostasis: Perioperative Risks and Management. Plast Reconstr Surg 2022; 150:95S-104S. [PMID: 35943960 PMCID: PMC10262037 DOI: 10.1097/prs.0000000000009499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/23/2021] [Indexed: 10/15/2022]
Abstract
BACKGROUND Surgical and technological advances have resulted in the widespread adoption of microsurgical breast reconstruction. Many comorbidities that potentially might impair vasculature and wound healing are no longer considered contraindications for these procedures. However, some uncertainty still prevails regarding the perioperative management of patients with disorders of hemostasis. METHODS The authors combined a literature review with a retrospective chart review of patients with disorders of hemostasis who had undergone microsurgical breast reconstruction at the senior author's (J.F.) center between 2015 to 2020. Several disorders associated with thrombotic and/or hemorrhagic complications were identified, and a standardized risk assessment and management strategy was developed in cooperation with a hematologist. RESULTS Overall, 10 studies were identified comprising 29 patients who had a defined disorder of hemostasis and underwent microsurgical breast reconstruction. Seventeen microsurgical breast reconstructions were performed on 11 patients at the senior author's (J.F.) center. High factor VIII levels, heterozygous factor V Leiden, and heterozygous prothrombin mutation G20210A were the most common genetic or mixed genetic/acquired thrombophilic conditions. As expected, hereditary antithrombin, protein C, or protein S deficiencies were rare. Among hemorrhagic disorders, thrombocytopenia, platelet dysfunction, and von Willebrand disease or low von Willebrand factor levels were those factors most frequently associated with increased perioperative bleeding. CONCLUSIONS Patients should be screened for elevated risk of thrombosis or bleeding before undergoing microsurgical breast reconstruction, and positive screening should prompt a complete hematologic evaluation. Interdisciplinary management of these disorders with a hematologist is essential to minimize risks and to obtain optimal reconstructive results. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, IV.
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Affiliation(s)
- Nicole E. Speck
- From the Plastic Surgery Group; Center of Hemostasis and Thrombosis Zurich; and University of Basel
| | - Peter Hellstern
- From the Plastic Surgery Group; Center of Hemostasis and Thrombosis Zurich; and University of Basel
| | - Jian Farhadi
- From the Plastic Surgery Group; Center of Hemostasis and Thrombosis Zurich; and University of Basel
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Body Contouring in Massive Weight Loss Patients Receiving Venous Thromboembolism Chemoprophylaxis: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3746. [PMID: 34414056 PMCID: PMC8367044 DOI: 10.1097/gox.0000000000003746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/08/2021] [Indexed: 11/26/2022]
Abstract
Venous thromboembolism (VTE) events are the leading cause of morbidity and mortality in plastic surgery. Currently, there is no consensus regarding the use of VTE chemoprophylaxis in the context of the risk for bleeding following specific body contouring procedures. Furthermore, there is increasing popularity of these procedures in the massive weight loss (MWL) patient population, who may be at higher risk due to multiple risk factors. The purpose of this study was to stratify the incidence of VTE and bleeding events among individual, specific body contouring procedures in MWL patients receiving chemoprophylaxis. Methods A systematic review was designed according to PRISMA guidelines. We screened all articles published between 1988 and 2018 reporting chemoprophylaxis status, VTE, and bleeding events in MWL patients undergoing body contouring procedures. Results Thirty-one publications were reviewed. The VTE incidence for any procedure was too low to reach significance. Overall, hematoma incidence in single-procedure patients (8.7%) was significantly higher than concomitant-procedure patients (4.2%, P < 0.01). However, when stratified into operative and nonoperative hematomas, no significant difference between single- and concomitant-procedure groups overall was demonstrated for either category. Individually, only thighplasty patients had a higher rate of operative hematomas when undergoing thighplasty alone (5.3%) compared with thighplasty with concomitant procedures (0.6%, P < 0.05). Conclusions Overall, MWL patients undergoing single body contouring procedures (among abdominoplasty, belt lipectomy, thighplasty) were found to have a higher risk of hematoma compared with those undergoing combined contouring procedures. However, stratified hematoma data revealed no differences in overall risk between single- and multiple-procedure operations.
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Janis JE, Jefferson RC, Kraft CT. Panniculectomy: Practical Pearls and Pitfalls. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3029. [PMID: 32983784 PMCID: PMC7489615 DOI: 10.1097/gox.0000000000003029] [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: 04/21/2020] [Accepted: 06/08/2020] [Indexed: 02/03/2023]
Abstract
Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective.
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Affiliation(s)
- Jeffrey E. Janis
- From the Ohio State University Wexner Medical Center, Department of Plastic Surgery, Columbus, Ohio
| | - Ryan C. Jefferson
- From the Ohio State University Wexner Medical Center, Department of Plastic Surgery, Columbus, Ohio
| | - Casey T. Kraft
- From the Ohio State University Wexner Medical Center, Department of Plastic Surgery, Columbus, Ohio
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Randomized Trial of Deep Vein Thrombosis Chemoprophylaxis with Bemiparin and Enoxaparin in Patients with Moderate to High Thrombogenic Risk Undergoing Plastic and Reconstructive Surgery Procedures. Aesthetic Plast Surg 2020; 44:820-829. [PMID: 31853609 DOI: 10.1007/s00266-019-01573-5] [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: 10/08/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a common complication during postoperative convalescence characterized by hypercoagulability, vascular endothelium damage and blood stasis. It increases noticeably in peri/postoperative phases of surgery procedures. Pulmonary embolism secondary to iliofemoral DVT is a frequent cause of death. METHODS Adult patients scheduled for plastic and reconstructive surgery (PRSx) with moderate to high thrombogenic risk were selected. We evaluated the efficacy and safety of bemiparin compared to enoxaparin as chemoprophylaxis for DVT. Following balanced general anesthesia techniques, patients were randomly assigned for subcutaneous enoxaparin 40 IU (Group-E) or bemiparin 3500 IU (Group-B) q24h starting 6 h after procedure conclusion for at least 10 days. All patients were evaluated for DVT through Doppler ultrasound mapping of the lower limbs. RESULTS Seventy-eight patients were evaluated, mostly women (83%), physical status ASA II (59%), ASA III (10%); Caprini's thrombogenic risk score 3-4 (moderate) 58%, 5-6 (high) 29%, > 6 (too high) 13%; demographics, clinical variables and scores were similar between groups. Median drainage time in breast surgery was 4 days in both groups (p = 0.238). In the case of abdominal surgery, median was 14 days in Group-E versus 13 days in Group-B (p = 0.059). No DVT was detected in either group. CONCLUSIONS DVT was prevented with bemiparin, without significant bleeding increase nor adverse events; moreover, the cost of bemiparin is lower than enoxaparin. Bemiparin can be considered as alternative drug for DVT chemoprophylaxis in PRSx procedures. 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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Rosenfield LK, Davis CR. Evidence-Based Abdominoplasty Review With Body Contouring Algorithm. Aesthet Surg J 2019; 39:643-661. [PMID: 30649214 DOI: 10.1093/asj/sjz013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a "one-size-fits-all" abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.
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Affiliation(s)
- Lorne K Rosenfield
- University of California, San Francisco, CA
- Stanford University, Stanford, CA
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Xie SM, Small K, Stark R, Constantine RS, Farkas JP, Kenkel JM. Personal Evolution in Thighplasty Techniques for Patients Following Massive Weight Loss. Aesthet Surg J 2017; 37:1124-1135. [PMID: 29044362 DOI: 10.1093/asj/sjx060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Lockwood described the importance of Colles' fascia anchoring in medial thighplasty to reduce morbidity associated with the procedure. However, this maneuver may still have complications including traumatic dissection, prolonged edema, and potential wound healing ramifications form increased tension. Alternatively, we suggest orienting tension in medial thighplasty for massive weight loss (MWL) patients in the horizontal vector rather than a vertical direction, negating the need for Colles' fascia anchoring. OBJECTIVES To compare the morbidities, complications, and outcomes between Colles' fascia suture fixation (CFSF) and horizontal vector fixation (HVF) in medial thighplasties in MWL patients. METHODS A retrospective chart review was conducted on an Institutional Review Board approved database of MWL patients who had medial thighplasty between October 2004 and March 2014. Patient demographics and surgical outcomes were reviewed between those MWL patients with CFSF and HVF. RESULTS Of 65 post-MWL patients, 26 (40.0%) patients were in the CFSF group, and 39 (60.0%) patients were in the HVF group. The 2 groups had statistically equivocal preoperative characteristics and comorbidities. Intraoperatively, the HVF group had increased use of barbed suture (92.3% vs 30.6%, P < 0.0001) and liposuction (71.8% vs 26.9%, P < 0.0001). Postoperatively, the HVF group had decreased incidence of infection (5.1% vs 23.0%, P = 0.051) and lymphocele/seroma (10.3% vs 34.6%, P = 0.0257). No statistical differences were observed for dehiscence, necrosis, or hematoma. CONCLUSIONS HVF for medial thighplasty in MWL patients is a safe and effective procedure, with a lower complication profile than CFSF. Furthermore, the incorporation of barbed sutures and/or liposuction may help to achieve optimal results. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Shelly M Xie
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Kevin Small
- Plastic Surgery, New York Bariatric Group, Roslyn Heights, NY
| | - Ran Stark
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX
| | | | | | - Jeffrey M Kenkel
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX
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Venous thromboembolic events: How low can you go? Am J Surg 2017; 213:706-710. [DOI: 10.1016/j.amjsurg.2016.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/14/2016] [Accepted: 10/24/2016] [Indexed: 01/04/2023]
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Benefits and Risks of Prophylaxis for Deep Venous Thrombosis and Pulmonary Embolus in Plastic Surgery. Plast Reconstr Surg 2016; 137:709-730. [DOI: 10.1097/01.prs.0000475790.54231.28] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Grant DW, Mlodinow A, Ver Halen JP, Kim JYS. Catastrophic Outcomes in Free Tissue Transfer: A Six-Year Review of the NSQIP Database. PLASTIC SURGERY INTERNATIONAL 2014; 2014:704206. [PMID: 25478221 PMCID: PMC4248358 DOI: 10.1155/2014/704206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/31/2014] [Accepted: 11/02/2014] [Indexed: 11/17/2022]
Abstract
Background. No studies report robust data on the national incidence and risk factors associated with catastrophic medical outcomes following free tissue transfer. Methods. The American College of Surgeons (ACS) multicenter, prospective National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent free tissue transfer between 2006 and 2011. Multivariable logistic regression was used for statistical analysis. Results. Over the 6-year study period 2,349 patients in the NSQIP database underwent a free tissue transfer procedure. One hundred and twenty-two patients had at least one catastrophic medical outcome (5.2%). These 122 patients had 151 catastrophic medical outcomes, including 93 postoperative respiratory failure events (4.0%), 14 pulmonary emboli (0.6%), 13 septic shock events (0.5%), 12 myocardial infarctions (0.5%), 6 cardiac arrests (0.3%), 4 strokes (0.2%), 1 coma (0.0%), and 8 deaths (0.3%). Total length of hospital stay was on average 14.7 days longer for patients who suffered a catastrophic medical complication (P < 0.001). Independent risk factors were identified. Conclusions. Free tissue transfer is a proven and safe technique. Catastrophic medical complications were infrequent but added significantly to length of hospital stay and patient morbidity.
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Affiliation(s)
- David W. Grant
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Alexei Mlodinow
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Jon P. Ver Halen
- Division of Plastic and Reconstructive Surgery, Baptist Cancer Center, Vanderbilt Ingram Cancer Center, St. Jude Children's Research Hospital, Memphis, TN 38139, USA
| | - John Y. S. Kim
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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