Halley Darrach is a plastic and reconstructive surgery resident (2020-2027) at Stanford Health. She is currently completing a professional development year with ReSurge International, a nonprofit dedicated to increasing global access to reconstructive surgery through surgeon education and sustainable, local-driven initiatives.

Dr. Darrach received her medical degree from Johns Hopkins and her bachelor's in cellular biology from California State University Northridge. While at Hopkins, she completed a dedicated research fellowship studying oncologic reconstruction outcomes under the mentorship of Dr. Justin Sacks and worked as a medical illustrator designing patient and surgeon education tools.

Prior to residency, she spent several years conducting astrobiology research at the Jet Propulsion Laboratory and was the first hire at a biotech startup company, where she helped adapt NASA technology for medical and counterterrorism applications. Outside of the OR, she enjoys figure drawing, long-distance swimming, and travelling the world in search of new favourite cuisines.

Dr. Darrach's research interests include gender affirming surgery, oncologic reconstruction, ethnic plastic surgery, societal perceptions of deformity, and use of medical illustration in patient and surgeon education.

All Publications

  • Travel distance and national access to gender-affirming surgery. Surgery Johnstone, T., Thawanyarat, K., Eggert, G. R., Navarro, Y., Rowley, M. A., Lane, M., Darrach, H., Nazerali, R., Morrison, S. D. 2023


    Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location.Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery.Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014.Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.

    View details for DOI 10.1016/j.surg.2023.09.008

    View details for PubMedID 37839968

  • Identifying Public Perceptions, Attitudes, and Concerns About Breast Implants and Their Complications: A National Survey with Implications for Practice. Plastic and reconstructive surgery Lee, E., Khavanin, N., Xun, H., Abousy, M., Darrach, H., Kraenzlin, F., Jenny, H., Yang, R., Sacks, J. M. 2022


    Aesthetic and reconstructive implant-based breast surgeries are among the most common plastic surgery procedures. Our study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States.500 women were recruited through's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants.Of our cohort (average age 37.8±11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation (p<0.001). Almost 75% believe implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "Less Likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications (p<0.001).The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. Our study identifies public perceptions of common breast implant-associated complications and primary long-term concerns - highlighting the importance of education on post-operative complications in informed consent and surgical decision making.

    View details for DOI 10.1097/PRS.0000000000009820

    View details for PubMedID 36194058

  • An overview of common peroneal nerve dysfunction and systematic assessment of its relation to falls. International orthopaedics Capodici, A., Hagert, E., Darrach, H., Curtin, C. 2022


    Compression of the peroneal nerve is recognized as a common cause of falls. The superficial course of the peroneal nerve exposes it to trauma and pressure from common activities such as crossing of legs. The nerve can be exposed also to distress due to metabolic problems such as diabetes. The purpose of our manuscript is to review common peroneal nerve dysfunction symptoms and treatment as well as provide a systematic assessment of its relation to falls.We pooled the existing literature from PubMed and included studies (n = 342) assessing peroneal nerve damage that is related in any way to falls. We excluded any studies reporting non-original data, case reports and non-English studies.The final systematic assessment included 4 articles. Each population studied had a non-negligible incidence of peroneal neuropathy. Peroneal pathology was found to be consistently associated with falls.The peroneal nerve is an important nerve whose dysfunction can result in falls. This article reviews the anatomy and care of the peroneal nerve. The literature review highlights the strong association of this nerve's pathology with falls.

    View details for DOI 10.1007/s00264-022-05593-w

    View details for PubMedID 36169699

  • Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction). Annals of surgery Oles, N., Darrach, H., Landford, W., Garza, M., Twose, C., Park, C. S., Tran, P., Schechter, L. S., Lau, B., Coon, D. 2022; 275 (1): e67-e74


    To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment.Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress.A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes.Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications.Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.

    View details for DOI 10.1097/SLA.0000000000004717

    View details for PubMedID 34914663

  • Use of a Wearable Posture-Correcting Device to Train Residents in Plastic Surgery: A Novel Approach to Surgical Ergonomics and Prevention of Associated Musculoskeletal Disorders. Plastic and reconstructive surgery Kokosis, G., Gould, A., Darrach, H., Chopra, K., Hollenbeck, S. T., Lee, B. T., Coon, D. 2022; 149 (1): 166e-168e

    View details for DOI 10.1097/PRS.0000000000008655

    View details for PubMedID 34846364

  • Quantifying the Effect of Topical Nitroglycerin on Random Pattern Flap Perfusion in a Rodent Model: An Application of the ViOptix Intra.Ox for Dynamic Flap Perfusion Assessment and Salvage. Plastic and reconstructive surgery Khavanin, N., Yesantharao, P., Kraenzlin, F., Darrach, H., Sacks, J. M. 2021


    Near-infrared spectroscopy can detect changes in tissue oxygenation postoperatively that predict flap necrosis. The authors hypothesized that this technology can be applied along with topical nitroglycerin to measure an improvement in tissue oxygenation that correlates with tissue salvage.Dorsal, random pattern flaps measuring 10 × 3 cm were raised using Sprague-Dawley rats. Tissue oxygenation was measured after flap elevation in 10 locations using the ViOptix Intra.Ox. Animals were divided into three groups that received 30 mg of topical nitroglycerin daily, twice-daily, or not at all. Oxygenation measurements were repeated on postoperative day 1 and animals were euthanized on day 7 and evaluated for tissue necrosis.Tissue necrosis was greatest in controls (51.3 mm) compared to daily (28.8 mm) and twice-daily nitroglycerin (18.8 mm; p = 0.035). Three flap perfusion zones were identified: healthy (proximal, 50 mm), necrotic (distal, 20 mm), and watershed. Immediate postoperative tissue oxygenation was highest in healthy tissue (57.2 percent) and decreased to 33.0 and 19.3 percent in the watershed and necrotic zones, respectively (p < 0.001). One day after treatment with nitroglycerin, oxygenation in the healthy zone did not increase significantly (mean difference, -1.5 percent). The watershed (17.8 percent; p < 0.001) and necrotic zones (16.3 percent; p <0.001) did exhibit significant improvements that were greater than those measured in control tissues (7.9 percent; both p < 0.001).Serial perfusion assessment using the ViOptix Intra.Ox measured a significant improvement in flap oxygenation after treatment with topical nitroglycerin. Within the watershed area of the flap, this increase in tissue oxygenation was associated with the salvage of ischemic tissue.

    View details for DOI 10.1097/PRS.0000000000008050

    View details for PubMedID 34014864

  • The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model. Plastic and reconstructive surgery Khavanin, N., Darrach, H., Kraenzlin, F., Yesantharao, P. S., Sacks, J. M. 2021


    Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is one of several novel devices that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis.Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis.Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively.Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.

    View details for DOI 10.1097/PRS.0000000000007894

    View details for PubMedID 33835088

  • Perspectives of 281 patients with Mayer-Rokitansky-Küster-Hauser Syndrome on uterine transplantation. Fertility and sterility Fischer, N., Xun, H., Lossie, A., Fadavi, D., Darrach, H., Yesantharao, P., Kraenzlin, F., Singh, B., Sacks, J. M., Segars, J. H. 2021


    To investigate the personal, ethical, and financial perspectives of individuals with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), a congenital uterine factor infertility condition, regarding uterine transplantation (UTx).Cross-sectional, quantitative survey.A 60-item anonymous electronic questionnaire was disseminated via social media sites.International members of the Beautiful You MRKH Foundation.None.The survey contained UTx educational materials followed by questions assessing participants' baseline knowledge, global perceptions, financial concerns, and ethical considerations regarding UTx.We received 281 responses, with a mean participant age of 28.2 ± 9.8 years. After reviewing the education material, most participants considered receiving a UTx (73%), believed that it should be an option for all women with uterine factor infertility (86%), and believed that it should be covered by health insurance (78%). Respondents perceived the benefits of the procedure to outweigh the risks (67%) and considered it to be an ethical procedure (82%). Almost one-half (49%) were willing to spend more than $10,000 out of pocket to receive the procedure. When asked to rank the risk of UTx to self, donor, and fetus in order of personal importance, 21% ranked their own safety last.There is a profound desire in the MRKH community for UTx to become more widely available and affordable. MRKH patients may represent a vulnerable population requiring special considerations for informed consent and rigorous evaluation for UTx. Providers caring for MRKH patients should be prepared to provide education about UTx and to thoughtfully engage with news and media outlets to communicate evidence-supported information.

    View details for DOI 10.1016/j.fertnstert.2020.10.044

    View details for PubMedID 33468312

  • Pectoral placement of tissue expanders affects inpatient opioid use. The breast journal Darrach, H., Kraenzlin, F. S., Khavanin, N., He, W., Lee, E., Sacks, J. M. 2021


    Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. A retrospective review was performed of patients undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OME]), and discharge prescriptions. Comparisons were made using chi-squared and student's t tests where appropriate. Two hundred and thirty-one patients were identified, (mean age 48.8 years), 222 of which met inclusion criteria. 89 underwent subpectoral and 133 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid-naïve. The rate of bilateral procedures did not differ between cohorts (P = .194). Overall, 94% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (P = .0753). Two subpectoral and two prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an "as needed" (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs 44.5 OME, P = .0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs 336.99 subpectoral, P = .3197). Prepectoral expander placement appears to be associated with decreased inpatient opioid use postoperatively. This may represent an opportunity to improve patient satisfaction and safety by decreasing outpatient opioid prescriptions.

    View details for DOI 10.1111/tbj.14149

    View details for PubMedID 33438303

  • Diagnostic and Therapeutic Use of Botox for Breast Reconstruction. Archives of clinical and medical case reports Ma, I. T., Yesantharao, P., Darrach, H. M., Seither, J. G., He, H., Nguyen, D. H. 1800; 5 (5): 759-770


    Introduction: Breast reconstruction is most commonly performed using implant-based reconstruction. Patients with subpectoral implant placement with or without latissimus dorsi (LD) muscle coverage can experience muscle pain and animation deformity. Due to minimal literature describing the use of botulinum toxin (BTX-A) treatment for these side effects from implant-based reconstruction, we report our outcomes.Methods: A retrospective chart review of breast reconstructive patients for a single surgeon was performed. Patients who underwent BTX-A injection for muscular pain, spasm, or animation deformity were identified and outcomes reviewed. They were also stratified based on radiation treatment and type of muscle flap used.Results: Eleven patients were identified who had a submuscular pectoralis pocket and/or a pedicled latissimus dorsi flap. Nineteen breasts were treated. The average amount of time from the patient's last surgery to BTX-A injection was 11.2 months. 25-100 units were used per injection with an average of 60 units. Non-irradiated patients had signifycantly lower post-injection capsular contracture Baker grades and significantly lower amounts of BTX-A were injected. Patients who had both pectoralis major muscle and LD implant-reconstruction were significantly less likely to have improvement in pain/tightness. Most patients reported improvement or resolution of their pain and/or animation deformities.Conclusion: Implant-based reconstruction using the pectoralis major and/or LD muscles can be plagued with muscular pain, spasm, and animation deformities. The use of BTX-A is a diagnostic and therapeutic modality for these post-breast reconstruction patients with most patients having resolution of symptoms without the need for additional surgery.

    View details for DOI 10.26502/acmcr.96550419

    View details for PubMedID 34988384

  • Selfies and Surgery: How Photo Editing Impacts Perceptions of Facial Plastic Surgery Capabilities. Facial plastic surgery & aesthetic medicine Chen, J., Ishii, L. E., Liao, D., Huynh, P. P., Darrach, H., Kumar, A. R., Ishii, M. 2020

    View details for DOI 10.1089/fpsam.2020.0464

    View details for PubMedID 33372838

  • Public Perceptions on Breast Implant-Associated Anaplastic Large Cell Lymphoma. Plastic and reconstructive surgery Lee, E., Khavanin, N., He, W., Darrach, H., Kraenzlin, F., Jenny, H., Yang, R., Sacks, J. M. 2020; 146 (1): 30-37


    Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has entered the spotlight, as several high-profile media outlets have begun to relay the evolving science to the public. This study aimed to gauge the baseline knowledge and concern regarding BIA-ALCL among adult laywomen within the United States.Mechanical Turk was used to survey 500 American women on self-reported demographics, prior experience with breast implants, and 11 questions regarding their knowledge and concern regarding BIA-ALCL. Responses were reviewed for quality control before study inclusion.Overall, 12 percent of respondents had received breast implants and 73 percent knew someone with implants; 13.6 percent of respondents (including 51.7 percent of respondents with implants) had previously heard of BIA-ALCL. After providing information about its risk, 58.4 percent of respondents were still willing to receive a reconstructive implant and 45.8 percent a cosmetic implant; 35.8 percent reported they would be less likely to receive an implant. Of the respondents with breast implants, 66.7 percent reported some degree of concern regarding BIA-ALCL and 35.0 percent are strongly considering removing their implants. Those who had heard of BIA-ALCL consumed information from several sources, predominantly health professionals or media/health care blogs. Different sources of information were not associated with a respondent's degree of concern.Only a minority of American women have heard of BIA-ALCL and understand its association with breast implants. As plastic surgeons who perform breast reconstruction, we can promote the spread of information through the popular media and health care blogs to address this growing concern, particularly among women with existing breast implants.

    View details for DOI 10.1097/PRS.0000000000006889

    View details for PubMedID 32590638

  • Comparison of the ViOptix Intra.Ox Near Infrared Tissue Spectrometer and Indocyanine Green Angiography in a Porcine Bowel Model. Journal of reconstructive microsurgery Khavanin, N., Almaazmi, H., Darrach, H., Kraenzlin, F., Safar, B., Sacks, J. M. 2020; 36 (6): 426-431


     This study aims to directly compare measurements of tissue oxygenation obtained using the Intra.Ox (Vioptix Inc., Fremont, CA) near infrared spectrometer with the perfusion assessment of the indocyanine green (ICG)-based SPY Elite imaging system (Stryker Co., Kalamazoo, MI) in a porcine bowel model. Two live minipigs underwent laparotomy and isolation of a 30-cm segment of a large bowel. Standardized oximetry measurements were taken along the segment of bowel immediately before, after, and serially for 30 minutes following transection. A 0.5 mg/kg dose of ICG was then injected intravenously and the SPY Elite system was used to visualize and quantify tissue perfusion. Pearson's correlation coefficients were calculated using the outcomes. Transected and ligated bowel yielded mean Intra.Ox measurements of 61% oxygenation at the proximal base of the limb and 27.8% at the distal edges. Analysis of the relative ICG fluorescence using the SPY Elite's proprietary software yielded perfusion estimates of 64.8% proximally and 6.8% distally. Intra.Ox and SPY Elite measurements demonstrate a Pearson product-moment correlation of 0.929. Repeat measurements at 15-mm intervals along the tissue yielded decreasing Intra.Ox measurements along the length of the flap that correlate to SPY Elite measurements (r = 0.645). Both the Intra.Ox and the SPY detected clinically relevant changes in bowel oxygenation following transection and ligation. The use of intravenous ICG dye did not appear to affect measurements of tissue oxygenation obtained using the Intra.Ox.

    View details for DOI 10.1055/s-0040-1702163

    View details for PubMedID 32088921

  • Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes. Annals of plastic surgery Kraenzlin, F., Darrach, H., Khavanin, N., Kokosis, G., Aliu, O., Broderick, K., Rosson, G. D., Manahan, M. A., Sacks, J. M. 2020


    Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane.An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286).A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01).Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

    View details for DOI 10.1097/SAP.0000000000002415

    View details for PubMedID 32568752

  • Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results. Plastic and reconstructive surgery Coon, D., Lee, E., Fischer, B., Darrach, H., Landford, W. N. 2020; 145 (6): 1343-1353


    A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results.All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction.Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch-to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result.Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high.Therapeutic, IV.

    View details for DOI 10.1097/PRS.0000000000006819

    View details for PubMedID 32459763

  • Exploring Patient Motivations and Impact of Asian Blepharoplasty. Facial plastic surgery : FPS Huynh, P. P., Ishii, M., Juarez, M., Fung, N., Bater, K., Darrach, H., Nellis, J. C., Bonham, L. W., Lay, P. C., Ishii, L. E. 2020; 36 (3): 242-248


    To date, patient motivations for Asian blepharoplasty and the surgery's impact on quality of life have not been quantified. Here, we employed structured interviews and a web-based survey to better characterize patient motivations for Asian blepharoplasty and the impact of Asian blepharoplasty on self-reported domains of happiness, self-esteem, attractiveness, social life, and professional life. Structured interviews were conducted to inform a web-based survey regarding Asian blepharoplasty. Survey respondents used visual analog scales to rate their satisfaction with their eye shape, motivations for undergoing Asian blepharoplasty, and perceived outcomes after surgery. A total of 315 participants (mean 25.7 [18-58] years) of East or Southeast Asian descent were included. 185 participants expressed no desire for Asian blepharoplasty, 76 expressed some desire, and 54 had already undergone surgery. There were statistically significant differences regarding baseline satisfaction, perceived social limitation, and perceived professional limitations regarding eye shape (p < 0.0001). The Looking Glass Self index (comprised of media exposure, low self-esteem, and negative stereotypes related to eye shape) is negatively associated with preoperative satisfaction with eye shape (rho = -0.29, p < 0.01). The desire for social-professional advancement and the Looking Glass Self index significantly predict self-reported improvements in professional and social life, respectively (both p < 0.01). Asian blepharoplasty may be driven by functional, social, or economic patient motivations. Some patients may see Asian blepharoplasty as a potential solution for sociological concerns. These expectations should be further explored in physician-patient discussions regarding candidacy for surgery and establishing expectations for postoperative outcomes.

    View details for DOI 10.1055/s-0039-3401804

    View details for PubMedID 31853906

  • Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery. The Laryngoscope Liao, D., Ishii, L. E., Chen, L. W., Chen, J., Juarez, M., Darrach, H. M., Kumar, A. R., Russell, J. O., Tufano, R. P., Ishii, M. 2020; 130 (6): 1603-1608


    Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T2 = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T2 = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T2 = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.NA Laryngoscope, 130:1603-1608, 2020.

    View details for DOI 10.1002/lary.28305

    View details for PubMedID 31660610

  • Prepectoral 2-stage Breast Reconstruction with Carbon Dioxide Tissue Expansion PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Kraenzlin, F. S., Darrach, H., Chopra, K., Rosson, G. D., Broderick, K. P., Sacks, J. M. 2020; 8 (5)
  • Risk and Reward: Public Perception of Gluteal Fat Grafting Safety. Aesthetic plastic surgery Fadavi, D., He, W., Kraenzlin, F., Darrach, H., Shetty, P., Xun, H., Sacks, J. M. 2020


    This study aims to understand how sociodemographic factors influence perceptions of "Brazilian Butt Lift" (BBL), the cosmetic procedure with the highest reported mortality rate, among adult women. We also investigate whether education about risks changes willingness to receive this procedure.A Qualtrics© survey including education about BBL was administered on Amazon Mechanical Turk, with inclusion criteria of female sex.Survey data from 489 female participants were included. 78.1% of participants found the BBL mortality rate to be higher than expected. 70.1% of the original 177 willing or neutral participants became unwilling to undergo a BBL after education. Multivariate logistic regression indicated that individuals who were more willing to undergo BBL after education were individuals who have a diagnosis of body dysmorphic disorder (OR 60.5, p = 0.02) or have an acquaintance who received a BBL (OR 230.2, p < 0.01).Overall, survey participants were less willing to undergo BBL after learning its risks, indicating the critical role of patient education during informed consent. Additionally, individuals who are unhappy with their body shape, or who feel cultural or social pressure to attain a certain body shape, may accept higher levels of risk to improve their looks, suggesting patient motivation for the procedure may limit even the most effective informed consent process. In light of these findings, the surgical community may consider regulating the BBL procedure and improving safety using evidence-based risk reduction techniques. Ensuring that patients fully understand the risks associated with the BBL procedure is critical for both surgeon and patient.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

    View details for DOI 10.1007/s00266-020-01728-9

    View details for PubMedID 32346781

  • Normal Gaze Patterns of the Face in Lateral View. Facial plastic surgery & aesthetic medicine Huynh, P. P., Ishii, M., Juarez, M., Liao, D., Darrach, H. M., Fung, N., Nellis, J. C., Byrne, P. J., Boahene, K. D., Papel, I. D., Kontis, T. C., Ishii, L. E. 2020; 22 (2): 80-85


    Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.

    View details for DOI 10.1089/fpsam.2019.29019.huy

    View details for PubMedID 32130065

  • Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-Reviewed Literature and Methods of Assessing Patient-Centered Outcomes (Part 1: Breast/Chest, Face, and Voice). Annals of surgery Oles, N., Darrach, H., Landford, W., Garza, M., Twose, C., Park, C. S., Tran, P., Schechter, L. S., Lau, B., Coon, D. 2020


    : To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment.Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. While some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research.A systematic review was performed following PRISMA guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data was pooled to assess currently reported complication, satisfaction, and other outcome rates.Overall, 15,186 references were identified, 4,162 papers advanced to abstract review, and 1,826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. While 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers.This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have aggregated a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the two primary barriers to high-quality research where improvement efforts should be focused.

    View details for DOI 10.1097/SLA.0000000000004728

    View details for PubMedID 33443903

  • Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation. Journal of reconstructive microsurgery Darrach, H. n., Yesantharao, P. S., Persing, S. n., Kokosis, G. n., Carl, H. M., Bridgham, K. n., Seu, M. n., Stifler, S. n., Sacks, J. M. 2020


     Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

    View details for DOI 10.1055/s-0040-1713667

    View details for PubMedID 32623705

  • Objectively measuring social attention of thyroid neck scars and transoral surgery using eye tracking. The Laryngoscope Juarez, M. C., Ishii, L., Nellis, J. C., Bater, K., Huynh, P. P., Fung, N., Darrach, H., Russell, J. O., Ishii, M. 2019; 129 (12): 2789-2794


    Measure the social attention of thyroid neck scars and transoral surgery using eye tracking.Observers viewed images of patients with thyroid neck scars, control patients with no scars, and patients who underwent transoral thyroidectomy as an eye-tracking monitor recorded their eye movements. Hotelling's multivariate analysis, followed by planned posthypothesis testing, were used to compare fixation times for the central triangle (CT), peripheral face, and neck between the three groups. To assess if these gaze patterns would normalize with transoral surgery, a two-sample t test was done to assess for differences in neck fixations between control and transoral patients and between transoral and traditional thyroidectomy.One hundred and thirty participants completed the eye-tracking experiment (mean age 24.3 years, 65 females). Observers directed the majority of their attention to the CT in both control and scar patients. Observers paid more attention to the neck (103.72 ms, P < .0001, 95% confidence interval [CI] [55, 152] ms) and less to the peripheral face (115.50 ms, P = .01, 95% CI [19, 211] ms) in patients with neck scars than in control patients. Furthermore, transoral surgery eliminated this attentional distraction wherein there was no difference in the fixation time to the neck (-39.198 ms P = .16, 95% CI [-93.978, 15.5816] ms) between controls and those who underwent transoral surgery.Observers directed their gaze away from the face and toward the neck in patients with thyroid neck scars. Furthermore, this distraction was eliminated with tranoral surgery. These findings shed light onto the altered observer perceptions of patients with thyroid neck scars.NA Laryngoscope, 129:2789-2794, 2019.

    View details for DOI 10.1002/lary.27933

    View details for PubMedID 30900247

  • Latissimus Denervation: A Review of Evidence. Journal of reconstructive microsurgery Lopez, C. D., Kraenzlin, F., Frost, C., Darrach, H., Aravind, P., Sacks, J. M. 2019; 35 (8): 609-615


     Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. Among the many reconstructive options available, the latissimus dorsi flap has experienced a renewal in popularity because of its favorable properties and outcomes when used for breast reconstruction. However, a limitation unique to latissimus-based reconstruction is inappropriate breast animation postoperatively, due to persistent thoracodorsal innervation of the latissimus dorsi muscle after transfer to the mastectomy site. A comprehensive literature search of PubMed and MEDLINE was conducted for studies investigating the role of thoracodorsal denervation in latissimus-based breast reconstruction. Data on surgical techniques, type of intervention, objective outcome measurements, and patient satisfaction-based outcomes were reported. Additional data included patient sample size, follow-up length, and treatment of thoracodorsal nerve (e.g., resection versus transection and length of transection) when applicable. Sixty-six search results were reviewed for inclusion and nine qualified after exclusion criteria for a total of 361 patients undergoing either unilateral or bilateral latissimus flap reconstruction. Successful thoracodorsal denervation rates were included in most studies and outcomes measurements were heterogeneous. Eight out of nine studies included patient-reported symptoms of breast animation postoperatively. Based on these findings, a systematic approach is presented. We present this review to elucidate successful practices, identify current gaps in knowledge, and offer a systematic approach to this clinical challenge.

    View details for DOI 10.1055/s-0039-1688748

    View details for PubMedID 31067584

  • Cost Utility of Breast Tissue Expansion using Carbon Dioxide versus Saline: An Analysis of Infection Risk. Plastic and reconstructive surgery. Global open Chopra, K., Slavin, B., Khavanin, N., Kraenzlin, F., Darrach, H., Holton, L., Landford, W. N., Singh, D. P. 2019; 7 (10): e2501


    The AeroForm System, a needle-free, patient-controlled carbon dioxide-filled tissue expander, represents a novel option for tissue expansion in 2-stage breast reconstruction. This technology has previously been found to decrease time to expansion, health-care utilization, and infection rates. The purpose of this study was to determine the economic impact of the reduced infection rate observed with the AeroForm tissue expander as compared with saline tissue expansion.A decision model incorporating costs, quality-adjusted life years, and clinical outcomes of infection was designed to evaluate the cost-efficacy of AeroForm tissue expanders versus conventional saline expanders. All statistical calculations were performed in the R statistical computing environment.Pooled infection rates from the published literature following saline and AeroForm tissue expander placement were 5.83% and 2.62%, respectively. Cost-utility analysis resulted in a baseline expected savings of $253.29 and an expected gain of 0.00122 quality-adjusted life years with AeroForm tissue expanders. One-way sensitivity analysis revealed that AeroForm tissue expanders were dominant when the surgical site infection rate was greater than 4.56% with traditional saline expanders.Clinical benefits of an innovation are no longer sufficient to justify its acquisition costs. Novel technologies must also demonstrate favorable economic outcomes. This cost-utility analysis demonstrates that the use of AeroForm expanders is likely a cost-saving technology for 2-stage breast reconstruction.

    View details for DOI 10.1097/GOX.0000000000002501

    View details for PubMedID 31772910

    View details for PubMedCentralID PMC6846316

  • Extension of the Question Mark Temporal Craniectomy Trauma Incision to Bicoronal Incision for Delayed Cranioplasty. The Journal of craniofacial surgery Musavi, L., Wang, H., Darrach, H., Steinberg, J. P. 2019; 30 (7): 2296

    View details for DOI 10.1097/SCS.0000000000005630

    View details for PubMedID 31107390

  • Intraoperative Perfusion Assessment in Mastectomy Skin Flaps: How Close are We to Preventing Complications? Journal of reconstructive microsurgery Khavanin, N., Qiu, C., Darrach, H., Kraenzlin, F., Kokosis, G., Han, T., Sacks, J. M. 2019; 35 (7): 471-478


     Mastectomy flap necrosis is the source of considerable morbidity and cost following breast reconstruction. A great deal of effort has been put forth to predicting and even preventing its incidence intraoperatively. A review of the literature was performed evaluating the evidence of mastectomy skin flap perfusion technologies. Multiple technologies have leveraged spectroscopy and/or angiography to provide real-time assessment of flap perfusion, including indocyanine green, fluorescein, and light-based devices. This manuscript endeavors to review the evidence on mastectomy skin flap perfusion analysis, highlighting the benefits, and downsides of the current technologies and identifying exciting areas of future research and development.

    View details for DOI 10.1055/s-0039-1679958

    View details for PubMedID 30791063

  • Association Between the Use of Social Media and Photograph Editing Applications, Self-esteem, and Cosmetic Surgery Acceptance. JAMA facial plastic surgery Chen, J., Ishii, M., Bater, K. L., Darrach, H., Liao, D., Huynh, P. P., Reh, I. P., Nellis, J. C., Kumar, A. R., Ishii, L. E. 2019; 21 (5): 361-367


    Social media platforms and photograph (photo) editing applications are increasingly popular sources of inspiration for individuals interested in cosmetic surgery. However, the specific associations between social media and photo editing application use and perceptions of cosmetic surgery remain unknown.To assess whether self-esteem and the use of social media and photo editing applications are associated with cosmetic surgery attitudes.A population-based survey study was conducted from July 1 to September 19, 2018. The web-based survey was administered through online platforms to 252 participants.Each participant's self-esteem was measured using the Rosenberg Self-esteem Scale (scores range from 0-30; higher scores indicate higher self-esteem) and the Contingencies of Self-worth Scale (scores range from 1-7; higher scores indicate higher self-worth). Cosmetic surgery attitude was measured using the Acceptance of Cosmetic Surgery Scale (scores range from 1-7; higher scores indicate higher acceptance of cosmetic surgery). Unpaired, 2-tailed t tests were used to assess the significance of self-esteem and cosmetic surgery attitude score differences among users of various social media and photo editing applications. Structural equation modeling was used to assess the association between social media investment and cosmetic surgery attitudes.Of the 252 participants, 184 (73.0%) were women, 134 (53.2%) reported themselves to be white, and the mean age was 24.7 (range, 18-55) years. Scores on the Rosenberg Self-esteem Scale from users and nonusers across applications were compared, with lower self-esteem scores noted in participants who reported using YouTube (difference in scores, -1.56; 95% CI, -3.01 to -0.10), WhatsApp (difference in scores, -1.47; 95% CI, -2.78 to -0.17), VSCO (difference in scores, -3.20; 95% CI, -4.98 to -1.42), and Photoshop (difference in scores, -2.92; 95% CI, -5.65 to -0.19). Comparison of self-esteem scores for participants who reported using other social media and photo editing applications yielded no significant differences. Social media investment had a positive association with consideration of cosmetic surgery (R, 0.35; 95% CI, 0.04-0.66). A higher overall score on the Acceptance of Cosmetic Surgery Scale was noted in users of Tinder (difference in means, 0.79; 95% CI, 0.34-1.23), Snapchat (difference in means, 0.39; 95% CI, 0.07 to 0.71), and/or Snapchat photo filters (difference in means, 0.44; 95% CI, 0.16-0.72). Increased consideration of cosmetic surgery but not overall acceptance of surgery was noted in users of VSCO (difference in means, 0.84; 95% CI, 0.32-1.35) and Instagram photo filters (difference in means, 0.38; 95% CI, 0.01-0.76) compared with nonusers.This study's findings suggest that the use of certain social media and photo editing applications may be associated with increased acceptance of cosmetic surgery. These findings can help guide future patient-physician discussions regarding cosmetic surgery perceptions, which vary by social media or photo editing application use.NA.

    View details for DOI 10.1001/jamafacial.2019.0328

    View details for PubMedID 31246236

    View details for PubMedCentralID PMC6604085

  • Re-visiting post-breast surgery pain syndrome: risk factors, peripheral nerve associations and clinical implications. Gland surgery Kokosis, G., Chopra, K., Darrach, H., Dellon, A. L., Williams, E. H. 2019; 8 (4): 407-415


    Aesthetic and reconstructive breast surgery is among the most common operations performed by plastic surgeons. The prevalence of persistent pain after breast surgery remains underappreciated by plastic surgeons. Post breast surgery pain syndrome (PBSPS) is reported to range between 20-60%. It is the purpose of this paper to revisit chronic pain as a combination of the breast intervention and relate this to the peripheral nerve(s) transmitting the pain message, in order to understand the underlying etiology and to improve breast pain treatment outcomes.

    View details for DOI 10.21037/gs.2019.07.05

    View details for PubMedID 31538066

    View details for PubMedCentralID PMC6723018

  • The Use of Racial and Ethnic Terms-Reply. JAMA facial plastic surgery Darrach, H., Ishii, M., Ishii, L. E. 2019; 21 (4): 345

    View details for DOI 10.1001/jamafacial.2019.0131

    View details for PubMedID 31169863

  • Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Xun, H., Lopez, J., Darrach, H., Redett, R. J., Manson, P. N., Dorafshar, A. H. 2019; 77 (7): 1423-1432


    In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population.A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance.A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15 yr; average age, 7 ± 4.73 yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture.CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).

    View details for DOI 10.1016/j.joms.2019.02.034

    View details for PubMedID 30910715

  • Stretched Earlobe Piercings Negatively Impact Casual Observer Perceptions. Facial plastic surgery : FPS Fung, N., Ishii, M., Huynh, P., Juarez, M., Bater, K., Darrach, H., Papel, I. D., Kontis, T., Nellis, J. C., Ishii, L. 2019; 35 (3): 299-305


    Patients with stretched earlobes seek reconstruction to mitigate social stigma. To date, there have been no studies measuring the impact of stretched earlobe piercings on casual observer perceptions. One-hundred seventy-three casual observers were enrolled via public-access web sites. Participants were randomly shown frontal and profile views of six subjects with stretched earlobe piercings and four controls. Participants evaluated photos for first impressions using a survey containing choices regarding personal attributes. Latent class analysis was performed to categorize observer ratings. Analysis of variance (ANOVA), bootstrap analysis, and permutations testing were used to evaluate the relationship between perceived attractiveness, success, and approachability scoring and stretched earlobe status. Latent class analysis categorized responses into three classes: positive, negative, and neutral. Patients with stretched earlobe piercings were significantly less likely to be classified as positive by observers without body modifications (i.e., tattoos and piercings) in comparison to control photos (30.9 and 40.1%, p = 0.007) and more likely to be classified as negative (38.5 and 28.1%, p = 0.002). These changes were abolished when photos were evaluated by observers with body modifications (p > 0.05). ANOVA revealed that stretched earlobe piercings and observer body modification status have a significant effect on rated approachability (F [1,1726] = 4.08, p = 0.04) and successfulness (F[1,1726] = 9.67, p = 0.002; F [1,1726] = 70.33, p < 0.0005). No significance was found for rated attractiveness (p > 0.05). Patients with stretched earlobe piercings were more likely to be classified as having negative affect display and being less approachable and successful compared with controls when evaluated by observers without body modifications. This effect was abolished when photos were evaluated by observers with body modifications. These findings validate patient motivations for seeking stretched earlobe repair.

    View details for DOI 10.1055/s-0039-1688798

    View details for PubMedID 31121609

  • Comparison of keystone flaps and skin grafts for oncologic reconstruction: A retrospective review. Journal of surgical oncology Darrach, H., Kokosis, G., Bridgham, K., Stone, J. P., Lange, J. R., Sacks, J. M. 2019; 119 (7): 843-849


    Two common options for the closure of complex defects are local flaps and skin grafting. The keystone flap, a fasciocutaneous flap based on perforators, has demonstrated compelling ease of use, reproducibility, and low complication rates without requiring a distant donor site. Our objective for this study was to compare postoperative outcomes for keystone flaps and skin grafts in cancer resection.A retrospective review was conducted of patients undergoing keystone flap closure or skin grafting for soft tissue defects resulting from cancer resection at a single institution from June 2017 to June 2018. Patient demographics, operative indications, length of stay, time to heal, and complications were reviewed.A total of 34 patients were identified having undergone either keystone reconstruction (n = 16) or skin graft (n = 18) after oncologic resection. Patients undergoing keystone flap reconstruction had significantly shorter mobility restriction and healing times. Length of hospital stay and overall complication rates were not significantly different.The keystone flap is an adaptable tool that can safely be used for the coverage of complex defects with faster healing, shorter mobility restriction, and comparable complication rates to skin grafting without the need for a distant donor site.

    View details for DOI 10.1002/jso.25394

    View details for PubMedID 30729527

  • Objectively Measuring Observer Attention in Severe Thyroid-Associated Orbitopathy: A 3D Study. The Laryngoscope Liao, D., Ishii, M., Darrach, H. M., Bater, K. L., Smith, J., Joseph, A. W., Douglas, R. S., Joseph, S. S., Ishii, L. E. 2019; 129 (5): 1250-1254


    Measure the attentional distraction of facial deformity related to severe thyroid-associated orbitopathy using three-dimensional (3D) images and eye-tracking technology.Observers recruited at an academic tertiary referral center viewed 3D facial images of patients with severe thyroid-associated orbitopathy (TAO) and controls without TAO. An infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis, followed by planned posthypothesis testing, was used to compare fixation durations for predefined regions of interest, including the eyes, nose, mouth, central triangle, and remaining face without the central triangle between severe TAO patients and controls.One hundred sixteen observers (mean age 26.4 years, 51% female) successfully completed the eye-tracking experiment. The majority of their attention was directed toward the central triangle (eyes, nose, mouth). On multivariate analysis, there were significant differences in the distribution of attention between control and severe TAO faces (T2  = 49.37; F(5,922) = 9.8314, P < 0.0001). On planned posthypothesis testing, observers attended significantly more to the eyes (0.77 seconds, P < 0.0001, 95% confidence interval [CI], 0.51, 1.03 seconds) and less to the nose (-0.42 seconds, P < 0.0001, 95% CI, -0.23, -0.62 seconds) in severe TAO patients. There was no significant difference in time spent on the mouth, the total time spent on the central triangle, or time spent in the remaining face between the two groups.Severe TAO distracted observer attention toward the eyes compared to control patients. These data lend insight into how TAO may alter observers' perceptions of these patients. Future studies should investigate how these changes in observer gaze patterns may reflect the social perception of TAO patients.NA Laryngoscope, 129:1250-1254, 2019.

    View details for DOI 10.1002/lary.27447

    View details for PubMedID 30151919

  • Reconstructive limb-salvage surgery after lower extremity soft tissue sarcoma resection: A 20-year experience. Journal of surgical oncology Bridgham, K. M., El Abiad, J. M., Lu, Z. A., Bhat, D., Darrach, H., Morris, C. D., Levin, A. S., Sacks, J. M. 2019; 119 (6): 708-716


    Reconstructive surgery is often required following lower extremity soft tissue sarcoma resection. The relationship between the method of plastic surgery reconstruction and postoperative wound healing or functional oncologic outcomes in this patient population is poorly understood.We performed a retrospective review on all adult patients that underwent soft tissue reconstruction following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution.One hundred and thirty-six patients were identified. Wound complications occurred within 6-months postoperatively in 72 patients (52.9%). Average time to heal was 13.0 weeks. Limb survival was 94.9%. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease, respectively. There was no significant difference in the incidence of overall wound complications, time to heal, limb survival, local recurrence, or metastatic disease between the different reconstructive methods.In our cohort, the utilization of different reconstructive techniques did not correlate with a difference in postoperative wound complications or oncologic outcomes. Local flaps can effectively reconstruct the majority of lower extremity sarcoma defects that cannot be closed primarily. However, alternative reconstructive techniques may be utilized when indicated without a significant increase in postoperative morbidity in this patient population.

    View details for DOI 10.1002/jso.25358

    View details for PubMedID 30644559

  • Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty. JAMA facial plastic surgery Darrach, H., Ishii, L. E., Liao, D., Nellis, J. C., Bater, K., Cobo, R., Byrne, P. J., Boahene, K. D., Papel, I. D., Kontis, T. C., Ishii, M. 2019; 21 (2): 96-102


    The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied.To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology.In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness.The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time.Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times.Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group.NA.

    View details for DOI 10.1001/jamafacial.2018.1697

    View details for PubMedID 30629094

    View details for PubMedCentralID PMC6439802

  • The role of fat grafting in prepectoral breast reconstruction. Gland surgery Darrach, H., Kraenzlin, F., Khavanin, N., Chopra, K., Sacks, J. M. 2019; 8 (1): 61-66


    Prepectoral breast reconstruction has reemerged as a promising alternative to submuscular implants, as they place the patient at lower risk for pain, muscular impairment, and animation deformity. However, the thinner amount of overlying tissue in prepectoral reconstruction presents its own unique set of challenges. A "rippling" deformity is seen in some prepectoral patients, which is typically corrected with fat grafting. This report details our recommended technique for fat grafting in the prepectorally implanted patient.

    View details for DOI 10.21037/gs.2018.10.09

    View details for PubMedID 30842929

    View details for PubMedCentralID PMC6378260

  • Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty. JAMA facial plastic surgery Chen, D., Ishii, M., Nellis, J., Bater, K., Darrach, H., Liao, D., Joseph, A., Byrne, P., Boahene, K., Papel, I., Kontis, T., Ishii, L. E. 2019; 21 (1): 27-31


    Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures.To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society.Cross-sectional survey administered via public online forums to 228 casual observers.Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes.Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001).There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures.NA.

    View details for DOI 10.1001/jamafacial.2018.1526

    View details for PubMedID 30543344

    View details for PubMedCentralID PMC6439737

  • Muscle-derived stem cells: important players in peripheral nerve repair. Expert opinion on therapeutic targets Musavi, L., Brandacher, G., Hoke, A., Darrach, H., Lee, W. P., Kumar, A., Lopez, J. 2018; 22 (12): 1009-1016


    Stem cell therapy for peripheral nerve repair is a rapidly evolving field in regenerative medicine. Although most studies to date have investigated stem cells originating from bone marrow or adipose, skeletal muscle has recently been recognized as an abundant and easily accessible source of stem cells. Muscle-derived stem cells (MDSCs) are a diverse population of multipotent cells with pronounced antioxidant and regenerative capacity. Areas covered: The current literature on the various roles MDSCs serve within the micro- and macro-environment of nerve injury. Furthermore, the exciting new research that is establishing MDSC-cellular therapy as an important therapeutic modality to improve peripheral nerve regeneration. Expert opinion: MDSCs are a promising therapeutic agent for the repair of peripheral nerves; MDSCs not only undergo gliogenesis and angiogenesis, but they also orchestrate larger pro-regenerative host responses. However, the isolation, transformation, and in-vivo behavior of MDSCs require further evaluation prior to clinical application.

    View details for DOI 10.1080/14728222.2018.1539706

    View details for PubMedID 30347175

  • Prepectoral Breast Reconstruction CURRENT BREAST CANCER REPORTS Bhat, D., Darrach, H., Sacks, J. M. 2018; 10 (2): 48–54
  • Spectroscopy and viability of Bacillus subtilis spores after ultraviolet irradiation: implications for the detection of potential bacterial life on Europa. Astrobiology Noell, A. C., Ely, T., Bolser, D. K., Darrach, H., Hodyss, R., Johnson, P. V., Hein, J. D., Ponce, A. 2015; 15 (1): 20-31


    One of the most habitable environments in the Solar System outside of Earth may exist underneath the ice on Europa. In the near future, our best chance to look for chemical signatures of a habitable environment (or life itself) will likely be at the inhospitable icy surface. Therefore, it is important to understand the ability of organic signatures of life and life itself to persist under simulated europan surface conditions. Toward that end, this work examined the UV photolysis of Bacillus subtilis spores and their chemical marker dipicolinic acid (DPA) at temperatures and pressures relevant to Europa. In addition, inactivation curves for the spores at 100 K, 100 K covered in one micron of ice, and 298 K were measured to determine the probability for spore survival at the surface. Fourier transform infrared spectra of irradiated DPA showed a loss of carboxyl groups to CO2 as expected but unexpectedly showed significant opening of the heterocyclic ring, even for wavelengths>200 nm. Both DPA and B. subtilis spores showed identical unknown spectral bands of photoproducts after irradiation, further highlighting the importance of DPA in the photochemistry of spores. Spore survival was enhanced at 100 K by ∼5× relative to 298 K, but 99.9% of spores were still inactivated after the equivalent of ∼25 h of exposure on the europan surface.

    View details for DOI 10.1089/ast.2014.1169

    View details for PubMedID 25590531