Experimental And Clinical Investigations Pertinent To The Rejuvenation Of Female Breast And Genitalia

Clinical Investigations Related to Female Genitalia RejuvenationPart1 Exploring the Association Between Age and Female External Genitalia Parameters through A Morphometric Cross-Sectional Study on 640 Chinese Healthy Women Aged 21-70 Years OldBackgroundRecent years have witnessed an astonishing rise in female aesthetic genital surgery.The total female genital cosmetic surgery up to 4505 in the year of 2007[1-3]?However,currently there are very few basic/clinical studies on either the anatomies of female genitalia from diverse ages or the association between the vulva measurements and aging[4?5].It seems that presently the surgeons conduct the operations completely as per their subjective decision,as there are no objective criteria to be used in female rejuvenate genitoplasty and paucity of evidence-based outcome data available[4].Hence,it is of high importance to elucidate the anatomical changes in female genitalia with aging.ObjectiveThe aim of the present study was to elucidate the changes in the morphology of the female genitalia as age rise through the observational cross-section study.We try to obtain the reference range of vulva parameter for each age group and acquire the smoothing curve line between age and vulva parameters.This study also tried to determine pattern and magnitude of the changes in female genital morphometrics from 21 to 70 years,which hopefully will pave the way for evidence-based female genital rejuvenation and reconstructive surgeries(eg.tissue distribution in male-to-female transsexual operations).This knowledge can also be applied to precise diagnosis of female external genitalia aging and objective evaluation of treatments,eventually improving women's sexual and general life quality.Patients and MethodsA multicenter morphometric observational cross-sectional study was conducted on 640 healthy Chinese women ages 21-70 years old,from April 2015 to December 2016.Twelve parameters in four female genitalia areas(labia minora area,labia majora area,clitoris area as well as vestibule and perineal body area)were measured and used as dependent variables.Age and 8 other demographic and gynecological&obstetric characteristics were recorded and considered as independent variables.After several statistical analysis,we adjusted the confounders and stratified the data by the interaction factor(if needed)in the multivariate regression model,to obtain the independent association between age and female genitalia parameters.Eventually,we managed to determine the pattern and magnitude of the changes in female genital morphometrics from 21 to 70 years.Results1.The reference range(Mean±Standard Deviation and 95%Confidential Interval)of female genital parameters in different age groups are demonstrated in the main text.2.There is significant association between 10 female genitalia parameters and age(confounders were properly adjusted and data were stratified by interaction factor if needed in each parameter)a.Labia minora region1)Labia minora length(LML):for women who give birth to one child,before 32 years old,LML significantly increases 5.9mm every 10years,after 55 years old,LML significantly increases 7mm every 10years while there is no significantly between 32-55y.For women who are nullipara or give birth to more than 1 child,there is no significant association between age and LML.If linear regression model was used*to analyze the association between age and Labia minora length,LML significantly increases 1.6mm every 10years2)Labia minora width(LMW):for women whose coitus frequency is low(<twice/month)LMW significantly decreases 2mm every lOyears.For women whose coitus frequency is high(?twice/month),there is no significant association between age and LMW.3)There is no significant association between age and Labia minora apex to clitoral glans.4)Labia minora apex to perineum(ANTL):ANTL significantly decreases 2.7mm every 10years,between 33-63 years old.If linear regression model was used*to analyze the association,ANTL significantly decreases 2.1mm every 10yearsb.Labia majora region:1)Labia majora length(DLML):DLML has a positive linear association with age and significantly increases 3mm every 10years2)There is no significant association between age and Labia majora width.c.CIitoris region:1)Clitoral prepuce length(CPL):before 48 years old,CPL merely changes,and significantly decreases 0.9mm every 10years whereby after 48 years old,CPL significantly increases 5.2mm every 10years.If linear regression model was used*,CPL significantly prolongs 0.7mm every 10years between 21-70years old.2)Clitoral glans length(CGL):before 47 years old,CGL significantly increases 0.2mm every 10years,while there is no significant association between after 47 years old.If linear regression model was used*,between 21-70years old,CGL significantly prolongs 0.1mm every lOyears.3)Clitoral glans width(CGW):for women whose coitus frequency is low(<twice/month)CGW significantly decreases 0.3mm every 10years.For women whose coitus frequency is high(?twice/month),there is no significant association between age and CGW.d.Vestibule and perineum region:1)Clitoris to vagina(C2V):after 64 years old,C2V significantly decreases 8.7mm every lOyears,while there is no significant association between before 64 years old.2)Vagina to perineum(V2P):after 50 years old,V2P significantly decreases 1.2mm every 10years,while there is no significant association between before 50 years old.3)Perineal body length(PBL):for women who have had vaginal delivery,PBL significantly increases 2mm every 10years.For women who never had vaginal delivery history,there is no significant association between age and PBL.Conclusions1)There is sagging tendency in the female genitalia organs of vertical directionFrom 21-70 years old,labia minora length*prolongs 1.6mm,labia majora length prolongs2.6mm,clitoral prepuce length*increase0.7mm,clitoral glans length increases 0.1mm and perineal body length droops 2mm,every 10 years.2)There is atrophy tendency in the female genitalia organs of horizontal directionFrom 21-70 years old,labia minora width decreases 2mm and clitoral glans width narrow 0.3mm every 10years.3)parity/vaginal delivery is the interaction factor for the association between age and labia minora length/perineal body length while Coitus frequency is the interaction factor for the association between age and labia minora width/clitoral glans width.4)Menopause and hormonal change may be critical factor influencing the association between age and Clitoral prepuce length/Vagina to perineum/Clitoris to vagina.These female genitalia parameters are associated with age,but in non-linear model.Here,we demonstrated the average coefficients obtained from linear regression model between age and parameters,to facilitate the comparison between different parameters.However,the coefficients obtained from smoothing curve line and segmented linear regression model analysis are more precise and reliable.Part 2 Outcome Evaluation Study of a Novel Surgical Technique of Hymenoplasty--Suture Three Stratums around the Introitus(STSI)MethodBackgroundVirgin represents youth and innocence,and hymen reconstruction surgery is one of the most common conducted female genitalia rejuvenation surgeries[6-8]There are tremendous kinds of surgical techniques of hymenoplasty to date[7,10-12].However,the hymen is a thin,bloodless,elastic mucosa surrounding the opening of the vaginal introitus and the incision healing is pretty low after traditional hymenoplasty[9].We invented a new surgical techuique of hymenoplasty-Suture Three Stratums around the Introitus(STSI)Method to increase the healing rate and improve the surgical outcome[6,13,14]Objective:This study aimed to describe the new surgical technique of hymenoplasty—STSI Method(typel and typeII)in detail.Furthermore,an outcome evaluation study was conducted to assess the safety and effectiveness of this novel surgical technique.Patients and Methods:The authors conducted a prospective study on 131 consecutive patients who received the reported method of STSI hymenoplasty at our hospital from January 2011-July 2014.The pre-and post-operative photos were collected and one-month countercheck and long-term follow-up were conducted.Results:The characteristics of STSI method are as follows[6,13-15]:? Resects the hymen transversely and sutures the wound in a vertical direction,which increases the wound area and thus increases the blood supply;? The additional fascia layer can both increase the blood supply and bear most of the tension among the three layers;? The hymenal mucosa(the first and third stratum)is sutured by mattress suture[16],which is generally considered to be a favorable technique for incision healing;? STSI hemenoplasty Type 1 is used when the cleft(s)are located in any site from 4 o'clock to 8 o'clock in the lithotomy position[13]while Type 2 is suitable for those patients whose clefts are located at 3 o'clock and/or 9 o'clock[14].One of the 131 patients suffered from complication of bleeding and the gap was successfully sutured to achieve hemostasis 17h after surgery.About 90.8%(118/130)of the patients came back to clinic for one-month countercheck and 93.2%(110/118)of them regained intact hymen.We successfully connected 75 patients(57.3%,75/131)through telephone and 70(93.3%,70/75)of them had sex intercourse then.The long-term follow-up showed that 92.8%(65/70)of the patients were satisfied with the outcome of the surgery in the first intercourse and the blood loss rate was 59.4%(41/69).Conclusions:The reported new surgical technique-STSI method achieved effective restoration of an intact hymen in the vast majority of patients.Our study proved that the STSI technique is an effective,enduring,and safe method with satisfactory outcomes,which is well worthy of further clinical application.Experimental Investigations Related to Pre-/Post-Conditioning of Recipient Area forAutologous Fat Grafting Breast RejuvenationPart3 Delivery of External Volume Expansion(EVE)through Micro-deformational Interfaces Safely Induces Angiogenesis in a Murine Model of Diabetic SkinBackgroundThe commercial External Volume Expansion(EVE)device Brava(a bra-like vacuum-based external tissue expander)developed by Khouri et al[24,25]has been used preceding fat grafting as a method for improving fat survival,and achieve good clincal ourcome[35,40.41]The Centers for Disease Control and Prevention(CDC)report that 9.4%of the U.S.population is diabetic[17,42,43]Moreover,a 69%increase of prevalence of DM is expected between 2010 and 2030 in developing countries[18]Statistically,of the over 130,000 fat grafting procedures reported in 2016 by the American Society of Plastic Surgeons,13,000 might have been in diabetic patients[18,19]Choi et al[18,20]demonstrated in a rodent model that diabetes causes a 5-time higher failure rate of adipose tissue grafts compared to non-diabetic controls,which may be due to the damaged micro-vascular network of tissues and endothelial cell dysfunction(ECD)in diabetic model[21-23].ECD can be halted only correcting the diabetic status.Yet,by locally increasing the density of blood vessels,it is possible to improve tissue vascularization and functional outcomes.This scenario highlights the need for plastic surgeons to integrate existing treatments with therapeutic strategies specifically targeting the challenges posed by diabetes.Objective:This study aims to explore a novel method for tissue preconditioning in diabetic patients to develop a non-invasive,cost-effective,and patient-ready treatment to effectively precondition intact soft tissues in diabetic patients in preparation of surgeries with the goal of reducing the rate of subsequent surgical complications and improving outcomes.We investigated the effects of EVE on a murine model of diabetes type-2 and tested whether the adoption of micro-deformational interfaces of EVE(F-EVE and M-EVE)optimizes its angiogenic properties while limiting complications to tissues.Materials and Methods:EVE stimulation was conducted in accordance to a previously optimized protocol(kinetic,suction level,and duration of treatment)that has shown to maximize the angiogenic stimuli to tissues while limiting the rate of cutaneous complications caused by the treatment in wild-type animals.In the present study,adult diabetic mice(Db/Db)received stimulation with EVE on their dorsal skin using a standard Cup-shaped silicone interface(C-EVE),a polyurethane Foam-shaped interface(F-EVE),or a silicone Micro-array chamber interface(M-EVE);controls received no treatment.Suction was delivered by a pump connected to the interface through a silicone tube.Briefly,we used a 25mmHg suction and 0.5 hours-long stimulation sessions repeated for 6 times a day with 1 hour long breaks in between;the treatment was continued for 5 days.Skin damage was visually assessed on the last day of stimulation and five days later.At a five-day follow-up,skin specimens(n = 5/group)were procured and analyzed by histology to assess angiogenesis(CD 31 endothelial marker),adipose tissue(Perilipinadipocytic marker)and skin remodeling(H&E and Masson trichrome staining),and inflammation(CD 45 pan-leukocyte marker).Results:On Post-Stimulation Day 5,EVE significantly increased the density of blood vessels in the skin of analyzed samples compared to controls(33-80%higher than controls,depending on groups).This outcome was independent from the treatment interface adopted,as all experimental groups statistically differed from controls.Yet,samples treated with F-EVE and C-EVE showed a higher increment in vascularity than M-EVE(respectively:for F-EVE +80%with 65 ±13 blood vessels/10x magnification field,p<0.001;for C-EVE +58%with 57±18 blood vessels/10× magnification field,p<0.001;and for M-EVE+33%with 48 ±9 blood vessels/10× magnification field,p=0.04)when compared to controls(36 ±14 blood vessels/10× magnification field).Furthermore,samples that had undergone stimulation with C-EVE showed a significantly higher thickness compared to controls(+270%,respectively:260 ±120 ?m for C-EVE vs.70±20 for controls;p<0.0001).No relevant complications were observed using F-EVE or M-EVE but C-EVE lead to substantial skin damage on the last day of stimulation and five days later,as well as caused intense inflammation,fibrosis of the subcutaneous tissue,and dermal collagen deposition.No effect on adipose tissue was observed in any of the groups.Conclusions:Our results confirmed that EVE increases the density of blood vessels in stimulated diabetic skin,and all our experimental groups lead to a significantly higher density of blood vessels(33-80%higher)compared to control skin.However,utilizing C-EVE in diabetic skin with an optimized regimen validated by previous study is not sufficient to avoid severe cutaneous injuries.Instead,only the use of micro-deformational interfaces of treatment(F-EVE and M-EVE)limited the rate and the severity of complications caused by the treatment.Thus,our study demonstrated that the adoption of EVE with micro-deformational interfaces allows the effective and safe preconditioning of tissues with ECD and could improve outcomes in diabetic patients at high-risk for surgical complications.Part 4:Delayed Post-conditioning with External Volume Expansion(EVE)Improves Survival of Adipose Tissue Grafts In a Murine ModelBackgroundSeveral clinic and basic investigations demonstrate that non-invasive external suction(External Volume Expansion,EVE)is a beneflIcal method to pre-operatively(pre-conditioning)increase the vascular density(angiogenesis)and the proliferation of adipocytes(adipogenesis)at the recipient site of a subsequent graft and improves their survival at follow-up[28,33,34,37,41]Acting through the similar mechanisms,the post-operative use of EVE(post-conditioning)has also been postulated to improve outcomes in fat grafting.Yet,the sub-critical ischemic stimuli that allow EVE to trigger angiogenesis in well-vascularized tissues(pre-conditioning)might have deleterious results when applied to non-vascularized grafted tissues(post-conditioning),paradoxically causing further damage to tissues.The uncertainty of post-operative use ofEVE highlights the need for evidence-based guidelines.Despite post-conditioning of adipose tissue grafts with EVE has been empirically adopted in clinical practice,no controlled research has examined its actual effects on transferred tissues and whether it might improve graft survival.Objective:This study aimed to investigate the effect of action of EVE post-conditioning on fat grafts,and also optimized the most effective timing of application of the treatment.better understanding of the mechanism of action of EVE post-conditioning could highlight whether these effects are beneficial or deleterious to the grafts,and-if beneficial-In addition,evidence-based research could help optimize the most effective parameters of application(e.g.timing)of the treatment.Clarifying such mechanisms would not only be of substantial scientific interest but also of significant clinical value,for example in all those cases(acute trauma,unplanned surgeries)in which EVE cannot be performed before a fat grafting procedure and also highlight whether EVE post-conditioning can act synergistically with pre-conditioning to further enhance graft survival.Methods:Forty-two 8-week-old athymic(nu/nu)mice received dorsal subcutaneous grafts of human lipoaspirate(0.3 ml each)bilaterally before undergoing EVE(left dorsum)or no treatment(right dorsum,controls).EVE was started either on the same day of(Immediate group),two days after(Early group),or one week after surgery(Delayed group).Stimulation was performed using previously optimized parameters(cycles of 0.5 hours on/1 hour off,repeated 6 times/day for 5 days)and a suction of 25 mmHg[34].At follow-up,procured grafts were analyzed for volume retention,remodeling,adipogenesis,and angiogenesis using histology.Volume retention was also assessed by MRI.Results:At a 28 days follow-up delayed post-conditioning with EVE significantly improved the survival of grafts by 18%compared to controls(viable graft thickness ratio:0.58 ±0.15 vs.0.49 ±0.13)and increased the density of blood vessels within the graft(+63%:blood vessels/10x magnification field:44 ±12 vs 27 ±11).Other groups did not lead to significant changes.Comparable outcomes(0.52 ±0.11 Vs.0.39 ±0.19;p=0.021)were obtained when analyzing grafts procured at a longer follow-up(56 days).Conclusions:Post-operative delayed(lweek)application of EVE modestly improves the survival of adipose tissue grafts by inducing adipogenis and angiogenis.We hope that these insights might support the development of novel evidence-based strategies in fat grafting and lead to improved outcomes for patients,although additional studies will be required to better elucidate and optimize the biological mechanisms of action of graft post-conditioning with EVE.