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Awad KG, Nahmias J, Aryan N, Lucas AN, Fierro N, Dhillon NK, Ley EJ, Smith J, Burruss S, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Tuli R, Santorelli JE, Emigh B, Schellenberg M, Inaba K, Duncan TK, Diaz G, Tay-Lasso E, Zezoff DC, Grigorian A. Outcomes of severely injured pregnant trauma patients: a multicenter analysis. Updates Surg 2024:10.1007/s13304-024-01817-3. [PMID: 38554224 DOI: 10.1007/s13304-024-01817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/04/2024] [Indexed: 04/01/2024]
Abstract
Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.
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Affiliation(s)
- Kyrillos G Awad
- Department of Surgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Negaar Aryan
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Alexa N Lucas
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Sigrid Burruss
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA
| | - Alden Dahan
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Areti Tillou
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Rahul Tuli
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego School of Medicine, University of California, San Diego, CA, USA
| | - Brent Emigh
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA
| | - Erika Tay-Lasso
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Danielle C Zezoff
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Areg Grigorian
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
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Aryan N, Grigorian A, Matsushima K, Schellenberg M, Nahmias J, Emigh B, Inaba K. Mechanisms of Injury in Adolescent Trauma Patients With a Positive Marijuana Screen. Am Surg 2023; 89:5565-5569. [PMID: 36878692 DOI: 10.1177/00031348231157807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND Marijuana use among adolescents may have increased after its legalization in the United States. An association between violence and marijuana use in adults has been demonstrated in previous reports. We hypothesized that adolescent trauma patients presenting with a positive marijuana screen (pMS) are more likely to have been injured by gunfire or knives and will have more severe injuries overall, compared to patients with a negative marijuana screen (nMS). METHODS The 2017 Trauma Quality Improvement Program database was queried for adolescent (13-17 years old) pMS patients and compared to adolescents who tested negative for all substance/alcohol. Patients with positive polysubstance/alcohol were excluded. RESULTS From 8257 adolescent trauma patients, 2060 (24.9%) had a pMS with a higher rate of males in the pMS group (76.3% vs 64.3%, P < .001). The pMS group presented more frequently after gun (20.3% vs 7.9%, P < .001) or knife trauma (5.7% vs 3.0%, P < .001) and less frequently after falls (8.9% vs 15.6%, P < .001) and bicycle collisions (3.3% vs 4.8%, P = .002). The rate of serious thoracic injury (AIS ≥3) was higher for pMS patients (16.7% vs 12.0%, P < .001), and more pMS patients required emergent operation (14.9% vs 10.6%, P < .001). DISCUSSION In our adolescent patient population, one quarter tested positive for marijuana. These patients are more likely to be injured by guns and/or knives suffering serious injuries, and often require immediate operative intervention. A marijuana cessation program for adolescents can help improve outcomes in this high-risk patient group.
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Affiliation(s)
- Negaar Aryan
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine School of Medicine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine School of Medicine, Orange, CA, USA
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine School of Medicine, Orange, CA, USA
| | - Brent Emigh
- Department of Surgery, Division of Trauma and Critical Care, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Kenji Inaba
- Department of Surgery, Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
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Aryan N, Grigorian A, Lucas AN, Tay-Lasso E, Zezoff DC, Fierro N, Dhillon NK, Ley EJ, Smith J, Dahan A, Johnson A, Ganske W, Biffl WL, Bayat D, Castelo M, Wintz D, Schaffer KB, Zheng DJ, Tillou A, Coimbra R, Santorelli JE, Schellenberg M, Inaba K, Emigh B, Duncan TK, Diaz G, Burruss S, Tuli R, Nahmias J. Outcomes for advanced aged (35 and older) versus younger aged pregnant trauma patients: A multicenter study. Am J Surg 2023; 226:798-802. [PMID: 37355376 DOI: 10.1016/j.amjsurg.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/25/2023] [Accepted: 06/01/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Effects of advanced maternal age (AMA) pregnancies (defined as ≥35 years) on pregnant trauma patients (PTPs) are unknown. This study compared AMA versus younger PTPs, hypothesizing AMA PTPs have increased risk of fetal delivery (FD). METHODS A retrospective (2016-2021) multicenter study included all PTPs. Multivariable logistic regression was used to evaluate risk of FD after trauma. RESULTS A total of 950 PTPs were included. Both cohorts had similar gestational age and injury severity scores. The AMA group had increased injuries to the pancreas, bladder, and stomach (p < 0.05). There was no difference in rate or associated risk of FD between cohorts (5.3% vs. 11.4%; OR 0.59, CI 0.19-1.88, p > 0.05). CONCLUSION Compared to their younger counterparts, some intra-abdominal injuries (pancreas, bladder, and stomach) were more common among AMA PTPs. However, there was no difference in rate or associated risk of FD in AMA PTPs, thus they do not require increased observation.
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Affiliation(s)
- Negaar Aryan
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Alexa N Lucas
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Erika Tay-Lasso
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Danielle C Zezoff
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
| | - Nicole Fierro
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Navpreet K Dhillon
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jennifer Smith
- Division of Trauma and Critical Care, Harbor-UCLA Hospital, Torrance, CA, USA.
| | - Alden Dahan
- University of California, Riverside School of Medicine, Riverside, CA, USA.
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
| | - William Ganske
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
| | - Walter L Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Dunya Bayat
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Matthew Castelo
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA.
| | - Diane Wintz
- Department of Surgery, Sharp Memorial Hospital, San Diego, CA, USA.
| | | | - Dennis J Zheng
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Areti Tillou
- Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, CA, USA.
| | - Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego School of Medicine, San Diego, CA, USA.
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Brent Emigh
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA; Warren Alpert Medical School at Brown University, Department of Surgery, Division of Trauma, USA.
| | - Thomas K Duncan
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA.
| | - Graal Diaz
- Department of Trauma, Ventura County Medical Center, Ventura, CA, USA.
| | - Sigrid Burruss
- Department of Trauma, Acute Care Surgery, Surgical Critical Care, Loma Linda Medical Center, Loma Linda, CA, USA.
| | - Rahul Tuli
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, University of California Riverside School of Medicine, CA, USA.
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, California, USA.
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Aryan N, Grigorian A, Kong A, Schubl S, Dolich M, Santos J, Lekawa M, Nahmias J. Diagnostic Peritoneal Aspiration or Lavage in Stratified Groups of Hypotensive Blunt Trauma Patients. Am Surg 2023; 89:4007-4012. [PMID: 37154296 DOI: 10.1177/00031348231175132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Some reports suggest Diagnostic peritoneal aspiration (DPA) or lavage (DPL) may better select which hypotensive blunt trauma patients (BTPs) require operation, compared to ultrasonography. However, whether both moderately hypotensive (systolic blood pressure [SBP] < 90 mmHg) and severely hypotensive (SBP < 70 mmHg) patients benefit from DPA/DPL is unclear. We hypothesized DPA/DPL used within the first hour increases risk of death for severely vs moderately hypotensive BTPs. METHODS The 2017-2019 Trauma Quality Improvement Program database was queried for BTPs ≥ 18 years old with hypotension upon arrival. We compared moderately and severely hypotensive groups. A multivariable logistic regression analysis was performed controlling for age, comorbidities, emergent operation, blood transfusions, and injury profile. RESULTS From 134 hypotensive patients undergoing DPA/DPL, 66 (49.3%) had severe hypotension. Patients in both groups underwent an emergent operation (43.9% vs 58.8%, P = .09) in a similar amount of time (median, 42-min vs 54-min, P = .11). Compared to the moderately hypotensive group, severely hypotensive patients had a higher rate and associated risk of death (84.8% vs 50.0%, P < .001) (OR 5.40, CI 2.07-14.11, P < .001). The strongest independent risk factor for death was age ≥ 65 (OR 24.81, CI 4.06-151.62, P < .001). DISCUSSION Among all BTPs undergoing DPA/DPL within the first hour of arrival, an over 5-fold increased risk of death for patients with severe hypotension was demonstrated. As such, DPA/DPL within this group should be used with caution, particularly for older patients, as they may be better served by immediate surgeries. Future prospective research is needed to confirm these findings and elucidate the ideal DPA/DPL population in the modern era of ultrasonography.
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Affiliation(s)
- Negaar Aryan
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Allen Kong
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Sebastian Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Matthew Dolich
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Jeffrey Santos
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Michael Lekawa
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine, Orange, CA, USA
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Abouzari M, Aryan N, Djalilian HR. The Bidirectional Relationship Between Migraine and Meniere Disease. JAMA Otolaryngol Head Neck Surg 2022; 148:894. [PMID: 35900735 PMCID: PMC9463098 DOI: 10.1001/jamaoto.2022.1995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mehdi Abouzari
- Department of Otolaryngology–Head and Neck Surgery,
University of California, Irvine, USA
| | - Negaar Aryan
- Department of Otolaryngology–Head and Neck Surgery,
University of California, Irvine, USA
| | - Hamid R. Djalilian
- Department of Otolaryngology–Head and Neck Surgery,
University of California, Irvine, USA
- Department of Biomedical Engineering, University of
California, Irvine, USA
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Khoshnevis J, Cuomo R, Karami F, Dashti T, Kalantar Motamedi A, Kalantar Motamedi M, Azargashb E, Aryan N, Sadeghi P. Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial. J INVEST SURG 2022; 35:1217-1223. [PMID: 34991417 DOI: 10.1080/08941939.2021.2022252] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The treatment of anal fistula has been a conundrum for surgeons over the years. Various methods such as fistulotomy, fistulectomy, seton, ligation of the intersphincteric fistula tract (LIFT), advancement flaps, fibrin glue, and plugs are well-known techniques. Yet, they may be followed by several considerable complications, including incontinency and recurrence. METHODS In this study, the outcomes of the "Jump" and "Seton" techniques are compared. A randomized controlled trial consisting of 130 cases with cryptoglandular anal fistula randomly sorted into two groups was conducted. Group A underwent the "Jump technique" while group B underwent the "Seton technique." Outcomes, incontinency and recurrences in particular, were evaluated after a year of treatment. Data were analyzed by Fisher Exact, Chi-Square and Mann Whitney Tests. RESULTS Group A with 65 cases underwent the "Jump technique" while group B with 65 cases underwent the "Seton Method." Recurrence was reported in 12 (20%) cases in group A and 10 (15.6%) cases in group B (p=0.687). Overall incontinence was reported in 3 (4.6%) cases in group A and 18 (27.7%) cases in group B (P=0.001). The total St. Mark's scores for incontinency of group A (0.092±0.52) and group B (1.8±02.47) significantly differed (p<0.001). CONCLUSIONS The "Jump technique", named after a runner who jumped over hurdles, has obviated these complications. The "Jump technique" had satisfactory results and can be utilized as a first-line approach for all types of fistulas. Moreover, it can be redone for cases with recurrences without affecting the continence, paving the way to change the technique during operations.
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Affiliation(s)
- Jalaluddin Khoshnevis
- General Surgery Department, Shohadaye Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Roberto Cuomo
- Plastic and Reconstructive Surgery Division, Department of Medicine, Surgery and Neuroscience; ''Santa Maria alle Scotte" Hospital, University of Siena, Siena, Italy
| | - Farzaneh Karami
- General Surgery Department, Shohadaye Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Terifeh Dashti
- Clinical Research Development Center of Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammadreza Kalantar Motamedi
- General Surgery Department, Shohadaye Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Eznollah Azargashb
- Community Medicine Department, Shahid Beheshti University of Medical Sciences, Faculty of Medicine, Tehran, Iran
| | - Negaar Aryan
- General Surgery Department, Shohadaye Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payam Sadeghi
- Plastic Surgery Department, Cleveland Clinic, Cleveland, OH, USA
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Abstract
PURPOSE In the current study, the authors attempt to thoroughly investigate the concept of beauty from different perspectives in different historical periods and offer their personal thoughts about it. METHODS The authors performed a comprehensive and across-the-board literature review about 'beauty', including beauty from a philosophical perspective, beauty perception by human mind, beauty from a biopsychological perspective, beauty of the face, body and breast, models of beauty and beauty in cosmetic surgery. RESULTS From Plato to modern neuro-psychological studies, the concept of beauty has always been a theme for adamant debates and passionate thoughts. Different aspects of beauty, from intellectual to pure physical, have received a tremendous amount of attention. The true definition of the concept of beauty is still ambiguous, and there is not a unanimous explanation for it. It seems that the definition of beauty differs in every individual's mind and over the history of humankind. CONCLUSION Although beauty is a very important concept and the seek for achieving it is a very natural behavior, one must remember that the importance of beauty should not overshadow the fact that every human being is made up of similar internal organs. We strongly encourage the reader to look beyond the hedge, to be aware that each of us is made up of internal organs, beyond the external appearance. Level of Evidence V 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 Table of Contents or online Instructions to Authors www.springer.com/00266.
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