The British cosmetic surgeon  Tijion Esho  coined the term “Snapchat Dysmorphia” to explain the increasing trend of patients seeking cosmetic surgeries to achieve the filtered versions of themselves. [ 7 ]  Esho noticed that with the rising popularity of social media platforms and filters, more patients were coming into consultations with filtered images of themselves. [ 8 ]  In the past, patients would show up to clinics with photos of celebrities or models they wanted to look like, but in this new filtered age, patients were now making use of their heavily edited selfies as references for their cosmetic procedures. [ 9 ]  We are now living in a generation where both women and men are more visually aware than ever before [ 7 ]  and due to the accessibility of these filtered images through social media, our feelings of self-worth may be highly determined by the number of likes and followers we receive through these social media applications. Researchers have found that users that engage in image-heavy social media platforms, such as Instagram, are more likely to consider undergoing plastic surgery. [ 9 ]  As we receive and share highly curated images, these images are publicly displayed and readily judged by peers, family, and even strangers – making us more critical of our appearances and how we present ourselves online. Therefore, filtered images creates and maintains unrealistic expectations of beauty ideals which drives a greater demand for cosmetic surgeries and procedures. [ 10 ]


Because of the prevalence of digital imaging and sharing, members of the " selfie generation " can hyper-fixate and obsess over minor or even nonexistent flaws in their appearance, and that can lead to lower self-esteem and higher self-dissatisfaction as well as dysmorphia. [ 11 ]  Social media platforms provide users with an online space to not only control the ways in which they present themselves, but they can go far as to curate idealized versions of themselves. These filters reinforce a new standard of unattainable beauty, including “ Instagram Face ”, in which users can adjust their facial features and conform to an unrealistic version of themselves through social media: high cheekbones, poreless skin, cat-like eyes, plump lips, and small nose. [ 9 ]


Today, more young people, especially adolescent girls, are using these filters through social media that “beautify” their looks which promise to deliver an enhanced version of their appearances. Specifically, with the rise of selfie culture, Snapchat claimed that there are “200 million daily active users that play with or view Lenses every day to transform the way they look”, [ 12 ]  with more than 90% of young people in the U.S., France, and the U.K. currently using Snapchat filters. Body image expert Jasmine Fardouly, argues that there is a strong relationship between negative body image and the use of photo editing. Social media provides users with the tools to control how they appear online, and the constant investigation into one's self-presentation and alteration of one's images can be harmful to users’ self-esteem and body satisfaction. [ 13 ]  McLean et al. (2015) showed that adolescent girls who had higher engagement in manipulation of and investment in self-images tend to be more preoccupied with their appearance and body image, as well as association with greater eating and body-related concerns. [ 14 ]


According to research with the  Dove Self-Esteem Project , 60% of young girls felt upset that their actual appearance did not match the online, retouched version of themselves. [ 9 ]  These girls who dedicated much time to photo editing felt more anxious, less confident, and less physically attractive after comparing themselves to their idealized versions of themselves. This conflicting gap between idealized expectations and harsh realities of appearance can lead to BDD, and BDD can often lead to mental health issues, including depression, anxiety disorders, substance abuse, and suicidal behavior. [ 15 ]  By the age of 13, 80% of young girls manipulate and distort the way they look online through face-altering and editing filters. [ 16 ]  Adolescents are at high risk of depression, body image concerns, and eating disorders through social media usage – with 52% of girls using social media filters every day. [ 9 ]


With the rising debate about the potential negative impacts of social media filters and the increasing awareness of body dysmorphia, social media filters were heavily criticized for simulating explicit distortion effects to promote cosmetic surgeries. Third-party filters on Instagram such as  FixMe  allowed users to annotate their faces similar to how cosmetic surgeons may mark up areas for surgical improvement. After a public controversy around these distorted filters, in August 2020, a new policy banned filters that directly promoted cosmetic surgery. [ 12 ]


Meta , which operates  Facebook ,  Instagram ,  Threads , and  WhatsApp , has made some attempts to restrict the use of distortion effects and filters through social media. Facial distortion filters no longer appear in Instagram's “Effects Gallery,” which displays the most popular filters at that time. [ 13 ]  Any effects or  augmented reality  (AR) filters that explicitly encourage cosmetic surgery are not allowed on Instagram, as research has shown that face-altering filters can make users feel worse about their appearances. [ 17 ]


Dove's #NoDigitalDistortion campaign project supports young adolescents in building self-confidence and positive body image on social media. [ 16 ]  For example, the Dove Self-Esteem Project created a Confidence Kit: an online resource guide for discussions surrounding social media usage and body image with young people.


A study in  JAMA Facial Plastic Surgery  has also emphasized the need for plastic surgeons to screen their patients for BDD before undergoing surgery procedures to check for underlying problems of body dysmorphia. [ 18 ]  Cosmetic surgery is not a solution or treatment for BDD [ 19 ]  and it is important for cosmetic surgeons to provide interventions and discussions around achievable aesthetic goals.


Spray-on skin  is a  skin culturing  treatment for  burn , or other skin damage victims. It involves taking small samples of the patient's skin and spraying them on the wound. [ 1 ]


The treatment was developed by Marie Stoner and plastic surgeon Fiona Wood. Their technique worked quicker than previous skin culturing techniques. [ 2 ]  Wood established the company  Avita Medical  in 1993 to commercialise the procedure. [ 3 ]


After the  2002 Bali bombings , Wood used the experimental technology on victims before it had been subjected to proper clinical trials, garnering criticism from other burn specialists since at the time there was little evidence of its efficacy, and Wood had an apparent conflict of interest since she founded the company that sold the technology. [ 4 ]


A 2006  clinical trial  in US attracted only small numbers of participants and was suspended by Avita. [ 5 ]  Clinical trials commenced again in 2010 with the assistance of a grant from the US Army. [ 5 ] [ 1 ]  Participant rates for the new trial were again lower than expected. [ 1 ]


The technology is currently approved for use in Australia, Europe, Britain and North America. [ 5 ] [ 6 ]


Thumb hypoplasia  is a spectrum of congenital abnormalities of the  thumb  varying from small defects to complete absence of the thumb. [ 1 ]  It can be isolated, when only the thumb is affected, and in 60% of the cases [ 2 ]  it is associated with radial dysplasia [ 1 ]  (or radial club, radius dysplasia, longitudinal radial deficiency). Radial dysplasia is the condition in which the forearm bone and the soft tissues on the thumb side are underdeveloped or absent. [ 3 ]


In an embryo the upper extremities develop from week four of the gestation. [ 1 ]  During the fifth to eighth week the thumb will further develop. [ 4 ]  In this period something goes wrong with the growth of the thumb but the exact cause of thumb hypoplasia is unknown. [ 1 ]
One out of every 100,000 live births shows thumb hypoplasia. [ 2 ]  In more than 50% of the cases both hands are affected, otherwise mainly the right hand is affected. [ 1 ] [ 2 ]


About 86% of the children with hypoplastic thumb have associated abnormalities. [ 1 ] [ 2 ]  Embryological hand development occurs simultaneously with growth and development of the cardiovascular, neurologic and hematopoietic systems. [ 2 ]  Thumb hypoplasia has been described in 30 syndromes wherein those abnormalities have been seen. A syndrome is a combination of three or more abnormalities. Examples of syndromes with an hypoplastic thumb are  Holt–Oram syndrome ,  VACTERL association [ 1 ]  and thrombocytopenia absent radius ( TAR syndrome ). [ 2 ]


In general there are five types of thumb hypoplasia, originally described by Muller in 1937 and improved by Blauth, Buck-Gramcko and Manske. [ 1 ]


-  Type I : the thumb is small, normal components are present but undersized. [ 3 ]  Two muscles of the thumb, the  abductor pollicis brevis  and  opponens pollicis , are not fully developed. [ 2 ] [ 3 ]  This type requires no surgical treatment in most cases. [ 1 ] [ 5 ]


-  Type II  is characterized by a tight web space between the thumb and index finger which restricts movement, [ 5 ]  poor  thenar  muscles and an unstable middle joint of the thumb  metacarpophalangeal joint . [ 3 ]  This unstable thumb is best treated with reconstruction of the mentioned structures. [ 1 ]


-  Type III  thumbs are subclassified into two subtypes by Manske. Both involve a less developed first metacarpal and a nearly absent thenar musculature. [ 2 ]  Type III-A has a fairly stable  carpometacarpal joint  and type III-B does not. [ 1 ] [ 2 ] [ 3 ]  The function of the thumb is poor. [ 2 ]  Children with type III are the most difficult patients to treat because there is not one specific treatment for the hypoplastic thumb. The limit between  pollicization  and reconstruction varies. Some surgeons have said that type IIIA is amenable to reconstruction and not type IIIB. Others say type IIIA is not suitable for reconstruction too. [ 4 ]  Based on the diagnosis the doctor has to decide what is needed to be done to obtain a more functional thumb, i.e. reconstruction or pollicization. In this group careful attention should be paid to anomalous tendons coming from the forearm (extrinsic muscles, like an aberrant long thumb flexor –  flexor pollicis longus ). [ 3 ] [ 4 ] [ 5 ]


-  Type IV  is called a pouce flottant, floating thumb. [ 1 ] [ 2 ] [ 3 ] [ 5 ]  This thumb has a  neurovascular bundle  which connects it to the skin of the hand. [ 1 ] [ 3 ] [ 5 ]  There's no evidence of thenar muscles and rarely functioning tendons. [ 4 ] [ 5 ]  It has a few rudimentary bones. [ 4 ] [ 5 ]  Children with type IV are difficult to reconstruct. [ 1 ] [ 4 ]  This type is nearly always treated with an index finger pollicization to improve hand function. [ 1 ] [ 5 ]


-  Type V  is no thumb at all [ 2 ] [ 3 ]  and requires pollicization. [ 1 ] [ 5 ]


The cause is unknown, and likely related to genetic abnormalities. Children with Fanconi anemia can sometimes display hypoplasia of the thumb. [ citation needed ]


Three main points in diagnosing thumb hypoplasia are: width of the first web space, instability of the involved joints and function of the thumb. [ 5 ]  Thorough  physical examination  together with anatomic verification at operation reveals all the anomalies. [ 1 ] [ 5 ]  An X-ray of the hand and thumb in two directions is always mandatory. [ 5 ]  When the pediatrician thinks the condition is associated with some kind of syndrome other tests will be done. [ 1 ]  More subtle manifestations of types I and II may not be recognized, especially when more obvious manifestations of longitudinal radial deficiency in the opposite extremity are present. Therefore, a careful examination of both hands is important. [ 3 ]


When it comes to treatment it is important to differentiate a thumb that needs stability, more web width and function, or a thumb that needs to be replaced by the index finger. [ 4 ]  Severe thumb hypoplasia is best treated by pollicization of the index finger. [ 3 ] [ 5 ]  Less severe thumb hypoplasia can be reconstructed by first web space release, ligament reconstruction and muscle or tendon transfer. [ 3 ] [ 5 ]


It has been recommended that pollicization is performed before 12 months, but a long-term study of pollicizations performed between the age of 9 months and 16 years showed no differences in function related to age at operation. [ 3 ]


It is important to know that every reconstruction of the thumb never gives a normal thumb, because there is always a decline of function. [ 4 ]  When a child has a good index finger, wrist and fore-arm the maximum strength of the thumb will be 50% after surgery in comparison with a normal thumb. [ 3 ] [ 4 ]  The less developed the index finger, wrist and fore-arm is, the less strength the reconstructed thumb will have after surgery. [ 3 ] [ 4 ]


Tissue expansion  is a technique used by  plastic ,  maxillofacial  and reconstructive  surgeons  to cause the body to grow additional  skin ,  bone , or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion (see tissue inflammation below). [ citation needed ]


Skin expansion is a common surgical procedure to grow extra skin through controlled mechanical overstretch. It creates skin that matches the color, texture, and thickness of the surrounding tissue, while minimizing scars and risk of rejection. [ 1 ]


When skin is stretched beyond its physiological limit,  mechanotransduction  pathways are activated. This leads to  cell  growth as well as to the formation of new cells. In some cases, this may be accomplished by the implantation of inflatable balloons under the skin. By far the most common method, the surgeon inserts the inflatable expander beneath the skin and periodically, over weeks or months, injects a  saline  solution to slowly stretch the overlaying skin. The growth of tissue is permanent, but will retract to some degree when the expander is removed. [ 2 ]  Topically applied tissue expansion devices also exist. These have the benefit of being inexpensive and do not require a surgical procedure to implant them under the skin. [ 3 ]


Breast reconstruction  surgery, for example, can use this technique when the  mammary gland  is removed by surgery ( mastectomy ). Later, a more permanent breast implant filled with saline or silicone gel is inserted under the expanded skin pocket. [ citation needed ]


In other applications, excess skin is grown purposely by expansion on the back or the buttocks, so that it can be harvested later for  transplantation  to another site where skin was lost due to  trauma , extensive  wounds ,  surgery ,  burns , etc.


Stretching the skin beyond normal expansion invokes several mechanotransduction pathways which increase mitotic activity and promote collagen synthesis. As a result, the skin surface area increases.  Continuum mechanics  approaches can be used to model skin growth during tissue expansion and non-linear  finite element methods  can be used to computationally simulate different tissue growth scenarios. [ 4 ]


Tissue growth due to skin expansion can be modeled as anisotropic surface area growth as described by the following equations: [ citation needed ]


where

 F

 e

 {\displaystyle F^{e}}

  is elastic area stretch that is reversible and

 F

 g

 {\displaystyle F^{g}}

  is irreversible area growth described by: [ citation needed ]


where

 n

 0

 {\displaystyle n_{0}}

  is a vector in the direction of skin thickness. We assume that the skin does not grow in the thickness direction for area growth is equal to volume growth or

 θ

 g

 =
 d
 e
 t
 (

 F

 g

 )
 =

 J

 g

 {\displaystyle \theta ^{g}=det(F^{g})=J^{g}}

 . [ 4 ]
We also assume that the newly created skin will have the same density, stiffness, and microstructure as the original, non-expanded skin. [ 5 ]


Recent studies have demonstrated that using topical tissue expansion can reduce the need for a split thickness skin graft after harvesting a forearm free flap. [ 6 ]  The authors noted that this results in less pain as well as reduced healing time. This method has also been shown to be cost effective [ 3 ]  as well as improve cosmetics. [ citation needed ]


Tissue expansion has been used on the scalp for treating scalp scarring and baldness, in lieu of hair transplantation when there is insufficient donor hair to transplant on the scar or the scar tissue is not vascularized to support hair growth. [ 7 ] [ 8 ]  For instance, in a patient who had  melanomas  removed from the scalp resulting in  alopecia  defects (hair loss), tissue expansion can be used to allow for the removal of scars and complete hair coverage. The two main indications for choosing tissue expansion over hair grafting are the size and shape of the defect relative to potential supply of donor hair, and the quality and thickness of the scar tissue. Areas of significant scarring and/or tissue atrophy, which is likely to make hair grafting unsuccessful, are best excised and replaced by normal expanded scalp skin. According to research from Dr Jeffrey Stuart Epstein while he was a professor at  University of Miami , theoretically there is no limit to the amount of tissue that can be created with tissue expansion, provided the process is conducted gradually. [ 9 ] [ unreliable medical source? ]


Tissue expansion has also been used for the technique of  foreskin restoration , which is usually non-surgical and applies tension externally using specialized devices to replace circumcised tissues with new cells. [ 10 ]


Non-surgical tissue expansion techniques can expand one's surviving penile skin, making it a longer tube so it can function like a  foreskin . [ 11 ]


Men who have been circumcised stretch and apply tension to their shaft and foreskin remnants to expand and elongate tissue in efforts to produce a functional foreskin. This form of tissue expansion can take years, as the amount of skin growth required is typically around 15 in 2 . [ 12 ]


Bone  is another tissue that can be expanded relatively easily, by using external devices which are slowly separated using mechanical contraptions, so that bone grows in response to elongation ( bone distractor ). Other techniques and external devices have been studied and have shown some success, such as in the  fitbone surgery . [ 13 ]  This technique was pioneered in 1951 by the  Russian   physician   Ilizarov , and is called the  Ilizarov apparatus . It is capable of lengthening limbs in cases of pathological loss of bone, asymmetry of limbs,  dwarfism , short stature, etc. In reconstructive and cosmetic surgery, bone expanders have been used to elongate the  mandibula  in cases of  congenital disorders ,  trauma ,  tumors , etc. Other newer devices such as the  orthofix  and  intramedullary skeletal kinetic distractor  (ISKD) are also used for limb lengthening. It can add over 6 inches per bone, but is expensive, painful, and time-consuming (each procedure lasts around 8–12 months). [ citation needed ]


Muscle tissue may also expand and grow, in a process known as  stretch-induced  myofibrillogenesis. [ 14 ] [ 15 ]


Inflammation, in the biological sense, refers to the cellular response of the body to disturbances, be they internal or external. In the case of  asthma  or  chronic bronchitis  the human body responds to allergens or pollutants by flooding the bronchial tree and airway walls with mononuclear cells. The layers of the airway wall, including the inner epithelial tissue lining thickens and expands anywhere from 10% to 300% of healthy individuals, and obstructs air flow. [ 16 ]  Enduring the disease long term coupled with airway hyperresponsiveness (smooth muscle contraction or  Bronchial hyperresponsiveness ) leads to chronic continuous inflammation and thickening, and noticeable airway remodeling consisting of stiffer airways and lost elasticity. [ 17 ]  Inflammation in a constricted cylinder, as with an airway, eventually folds over on itself, leading to mechanically studied buckling patterns and growth relationships within tissue linings. [ 18 ] [ 19 ]


Tissue expansion is a common technique used for  breast reconstruction . [ 20 ]  This essentially involves expansion of the breast skin and muscle using a temporary  tissue expander . [ 21 ]  Three to four weeks after the  mastectomy , a saline solution will be injected into the expander to gradually fill it. This process is supported by a tiny valve mechanism located inside the expander and it will continue until its size is slightly larger than the other breast. Typically it can take several weeks to months to complete the process. This tissue expander is removed after a few months and microvascular flap reconstruction or the insertion of a permanent breast implant is done at the time. Chemotherapy or radiation is sometimes recommended by the medical/radiation oncologist following mastectomy. These treatments delay the tissue expansion process by approximately four to eight weeks. Tissue expanders have silicone outer shells and either an internal valve or external port to allow for saline fluid injections. [ citation needed ]


Research dedicated to alternative skin grafts is currently within the purview of tissue engineering. Multiple engineered tissue-derived and tissue-like substances have made it through the FDA and into the market, though financial success has been moderate. [ 22 ]  Limitations of this strategy include long incubation times, as well as difficulty in mimicking that exact mechanical and biological properties of functional skin. [ 23 ]  However, benefits range from decreased donor site morbidity (as a result of no longer needing to harvest from skin expansion) as well as a ready-available source of materials for emergency medicine in the case of traumatic burn or injury. There remains much clinical interest today in developing inexpensive engineered skin grafts that possess the mechanical and biological properties of skin. [ citation needed ]


Triphalangeal thumb  ( TPT ) is a  congenital  malformation where the  thumb  has three  phalanges  instead of two. The extra phalangeal bone can vary in size from that of a small pebble to a size comparable to the phalanges in non-thumb digits. The true  incidence  of the condition is unknown, but is estimated at 1:25,000 live births. [ 1 ]  In about two-thirds of the patients with triphalangeal thumbs, there is a hereditary component. [ 2 ]  Besides the three phalanges, there can also be other malformations. It was first described by Columbi in 1559. [ 3 ]


The triphalangeal thumb has a different appearance than normal thumbs. The appearance can differ widely; the thumb can be a longer thumb, it can be deviated in the radio-ulnar plane ( clinodactyly ), or thumb strength can be diminished. In the case of a five-fingered hand it has a finger-like appearance, with the position in the plane of the four fingers,  thenar muscle  deficiency, and additional length. There is often a combination with radial  polydactyly .


Generally, triphalangeal thumbs are non-opposable. In contrast to most people with  opposable thumbs , a person suffering from TPT cannot easily place his or her thumb opposite the other four digits of the same hand. The opposable thumb's ability to effortlessly utilize fingers in a "pinch" formation is critical in precision gripping. For the thumb to adequately grip, certain thumb criteria must be met (e.g. suitable position and length, stable  joints  and good  thenar muscle  strength). [ 4 ]  Because triphalangeal thumbs cannot easily oppose and do not possess many of the optimal qualities found in most opposable thumbs, they tend to cause the hand to be less effective in use and, therefore, prove to be more problematic in daily life.


Malformations of the upper extremities can occur in the third to seventh embryonic week. [ 5 ]  In some cases the TPT is hereditary. In these cases, there is a mutation on  chromosome 7q 36. [ 6 ]  If the TPT is hereditary, it is mostly inherited as an autosomal dominant trait, [ 7 ]  non-opposable and bilateral. [ 2 ]  The sporadic cases are mostly opposable and unilateral. [ 8 ]


Triphalangeal thumb can occur in syndromes but it can also be isolated. The triphalangeal thumb can appear in combination with other malformations or syndromes. [ 5 ]


Syndromes include:


Malformations include: [ 5 ]


There are multiple classifications for the triphalangeal thumb. The reason for these different classifications is the heterogeneity in appearance of the TPT.
The classification according to Wood  [ 9 ]  describes the shape of the extra phalanx: delta (Fig. 4), rectangular or full phalanx (Table 1). With the classification made by Buck-Gramcko a surgical treatment can be chosen (Table 1). Buck-Gramcko differentiates between six different shapes of the extra phalanx and associated malformations. [ 10 ]


Table 1 : Classifications of Wood  [ 9 ]  and Buck-Gramcko  [ 10 ]


The goals of surgical treatment are: reducing length of the thumb, creating a good functioning, a stable and non-deviated joint and improving the position of the thumb if necessary. Hereby improving function of the hand and thumb.


In general the surgical treatment is done for improvement of the thumb function. However, an extra advantage of the surgery is the improvement in appearance of the thumb. In the past, surgical treatment of the triphalangeal thumb was not indicated, [ 11 ]  but now it is generally agreed that operative treatment improves function and appearance. Because an operation was not indicated in the past, there's still a population with an untreated triphalangeal thumb. The majority of this population doesn't want surgery, because the daily functioning of the hand is good. [ 11 ]  The main obstacle for the untreated patients might not be the diminished function, but the appearance of the triphalangeal thumb. [ 11 ]
The timing of surgery differs between Wood and Buck-Gramcko. Wood advises operation between the age of six months and two years, [ 12 ]  while Buck-Gramcko advises to operate for all indications before the age of six years. [ 13 ]


Upper-limb surgery in tetraplegia  includes a number of surgical interventions that can help improve the quality of life of a patient with  tetraplegia .


Loss of upper-limb function in patients with following a  spinal cord injury  is a major barrier to regain autonomy. The functional abilities of a tetraplegic patient increase substantially for instance if the patient can extend the elbow. This can increase the workspace and give a better use of a manual wheelchair. To be able to hold objects a patient needs to have a functional pinch grip, this can be useful for performing daily living activities. [ 1 ]
A large survey in patients with tetraplegia demonstrated that these patients give preference to improving upper extremity function above other lost functions like being able to walk or sexual function. [ 1 ]


Surgical procedures do exist to improve the function of the tetraplegic patient's arms, but these procedures are performed in fewer than 10% of the tetraplegic patients. [ 2 ]  Each tetraplegic patient is unique, and therefore surgical indication should be based on the remaining physical abilities, wishes and expectations of the patient. [ 3 ]


In 2007 a resolution was presented and accepted at the world congress in reconstructive hand surgery and rehabilitation in tetraplegia, that stated that every patient with tetraplegia should be examined and informed about the options for reconstructive surgery of the tetraplegic arms and hands. This resolution demonstrates mostly the necessity to increase the awareness on this subject amongst physicians. [ 4 ]


Reconstructive surgery of the upper limb in tetraplegic patients began during the mid-20th century. The first attempts at regaining gripping function of the hand probably took place in Europe at the end of the 1920s [ 5 ]  with the construction of flexor-hinge splints. [ 6 ]


In the early 1940s, a surgeon called Sterling Bunnell (1882–1957) was probably one of the first to refer to the reconstruction of gripping function for the tetraplegic hand. He described surgeries of combining tenodeses and tendon transfers to restore hand function. He also advocated transferring the m. brachioradialis to the wrist extensors when these muscles are paralyzed. [ citation needed ]


In the 1950s, understanding of the tenodesis effect (See  Tenodesis grasp ) influenced the development of surgical techniques such as the static flexor tenodesis. These procedures provided the basic functions of grasp and pinch. [ 7 ] [ 8 ] [ 9 ]  Tendon transfers were developed to accomplish both digital release and gripping functions in two surgical stages. The originators of these procedures were Lipscomb  et al.  [20], Zancolli, [ 10 ] [ 11 ] [ 12 ]  House  et al. [ 13 ] [ 14 ]  House  et al.  contributed important clinical investigations while showing the value of different surgical procedures. [ citation needed ]


According to Zancolli, [ 11 ]  transfer of the m. brachioradialis to the m. extensor carpi radialis tendons was proposed by Vulpius and Stoffel in 1920. In tetraplegia, this was first proposed by Wilson. [ 11 ]   and first described fully by Freehafer. [ 7 ]


In 1967, Alvin Freehafer of Cleveland, Ohio, contributed valuable ideas towards achieving independence in the arms of tetraplegic patients. He and his team published the results of six patients who underwent transfer of the m. brachioradialis to restore active wrist extension. [ 15 ]  In 1974, Freehafer et al. [ 16 ]  recommended opposition transfers and finger-flexion transfers.


In 1971, surgery of the tetraplegic upper limb experienced a revival after Moberg's clinical investigations. His main contributions were (1) to restore elbow extension through transfer of the posterior deltoid to triceps (the initial procedure); and (2) to reconstruct a key pinch. [ 17 ]  Moberg's idea of posterior deltoid transfer to restore elbow extension has been used extensively by many surgeons, such as Bryan [ 18 ]  and DeBenedetti. [ 19 ]


In 1983, Douglas Lamb of Edinburgh, Scotland, gave great headway to surgery of the tetraplegic upper extremity when Lamb and Chan recommended reconstruction of elbow extension by transferring the posterior deltoid to the triceps according to Moberg's technique, which was published in 1975. [ 20 ]


A publication by Friedenberg [ 21 ]  was the starting point for future indications of biceps-to-triceps transfers, including those of Zancolli, [ 22 ]  Hentz  et al. , Kuts  et al. , Allieu  et al.  and Revol et al.


Another major change was the change to one-step procedures, reconstructiong opening and closing phases at the same time. Especially Jan Friden, from Gothenburg, with major experience in this area championed this thought, partially driven by the transport problems in Sweden during winter, it saved the patients an operation and minimized hospital stay.


The development of hand surgery for tetraplegia has received important contributions through published reports and by the international conferences initiated with the influence of Erik Moberg from Goteborg, Sweden. Conferences have been of great interest because of the convergences of hand surgeons interested in the field, promoting discussion and comparison of different surgical methods and experiences. [ 23 ]


A common goal of surgical reconstruction of the arms in patients with tetraplegia is to restore elbow extension, key pinch and palmar grip. Restoration of these functions, results in increasing a patient's independence. [ 24 ]


Elbow extension is an important part of upper limb surgical reconstruction in patients with tetraplegia.  Although gravity can extend the arm, active elbow extension is needed to maintain a stable arm while extended in space. This is needed to reach for something or replace an object. [ 25 ]  Other functional gains include: increasing available workspace, performing pressure relief maneuvers, propelling a manual wheelchair, enhancing self-care and leisure activities, and promoting independent transfer. Elbow extension against gravity further enhances these activities above the shoulder level and reachable workspace. [ 26 ]


The key pinch is a simple grasp in which the thumb applies force to an object to hold it against the lateral side of the index finger. [ 24 ]  Restoring this function allows a patient to hold objects such as a fork or pen that are necessary for activities of daily living such as eating, self-grooming and self-catheterization.


Palmar grip allows the patient to grasp objects in the palm of the hand and secure the object by flexing the fingers at the metacarpal joint. This gives the patient the possibility to hold objects such as a cup and also permits use of the hand for wheelchair propulsion. [ 1 ]  A social aspect of regaining the palmar grip is that the patient is able to give a handshake.


Spinal cord injuries are classified as complete and incomplete by the American Spinal Injury Association (ASIA) classification.  The ASIA scale grades patients based on their functional impairment as a result of the injury, grading a patient from A to D. This has considerable consequences for surgical planning and therapy. [ 27 ]


More information on  classification of tetraplegia  can be found on the tetraplegia page.


A group of hand surgeons realized in the 1970s that the level of injury did not predict the number of available muscles in the upper limb very well. Therefore, the international classification was established in 1979, at the Edinburgh meeting. It was called "The international classification (IC) of hand surgery in tetraplegic patients" (table 2) and it describes the number of possible transferable muscles. To measure and evaluate hand strength each muscle is tested and all muscles with a  BMRC grade  of M4 or more are recorded. [ 3 ]


Table 2:  International Classification of Hand surgery in Tetraplegic Patients [ 3 ]


A muscle not included in the International Classification, but of great importance, is the triceps muscle. When assessing a patient pre-operatively the triceps strength must also be recorded. An active triceps means a patient can reach in space, and the elbow can be stabilized against gravity and against other muscles to be transferred. (see further) [ 3 ]


Furthermore, to classify patients it is essential to record sensation in at least the thumb and index pulpa. Patients with a  two point discrimination  of less than 10mm are classified as cutaneous sensation (OCu) and patients with a two-point discrimination of more than 10mm are classified as ocular sensation (O) (meaning that control of the to be operated limb cannot be performed by normal sensation, but is controlled visually). [ 28 ]


Therefore, patients are classified as: O or OCu, IC gr(0-X), Triceps + or –


For example: a patient has sensation of 8 mm in thumb and index pulpa, and has a good brachioradialis, extensor carpi radialis longus and brevis and a pronator teres (all of M4) but no Triceps. This patient is classified as OCu 4, Tr -.


The pre-operative assessment of patients has turned more patient-goal oriented. This means that the patients are asked to define their goals before surgery. In order to evaluate this the  Canadian Occupational Performance Measure  (COPM) was developed. This test is based on the World Health Organisation's framework of measuring health and disability:  The International Classification of Function  (ICF): This framework measures health and disability by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. [ 29 ]  Functional deficits can be measured according to the level of loss of structure and function, the level of activity limitations, and the level of restriction in social participation. Reaching or gripping represents the integration of strength, sensation and range of motion, and therefore occur at the individual level rather than at the organ system level. For this reason, reaching and gripping are on the ICF level of activities. However, this level includes a broad range of activities, from basic activities (for example grasping and moving objects) to complex activities (such as dressing, grooming). It is useful to make a distinction between basic activities and complex activities. [ 29 ]


As mentioned above, The Canadian Occupational Performance Measure (COPM) is used to measure a tetraplegic patient's performance and satisfaction before and after upper limb surgery. [ 26 ]  This is done by identifying important goals of hand surgery and evaluating patient-perceived performance and satisfaction of hand surgery for these goals. Goals are identified through an interview between the therapist and the patient based on past experience. Published reports [ 26 ]  are provided about the expected outcomes of elbow extension transfers on strength and function of patients with a spinal cord injury. For each goal, the subject rated performance and satisfaction using a 10-point Likert scale, in which 1 was negative ("cannot perform", "not satisfied") and 10 was positive ("performs very well", "very satisfied"). After surgery, performance and satisfaction are rated again for each goal.


A positive change is seen in patient-perceived performance and satisfaction with self-identified goals after tendon transfers. A good example of the use of the COPM can be found in a report published by Scott Kozin, [ 26 ]  thirty-three goals for surgery were established. Following the biceps-to-triceps transfer, improvement in at least one goal was seen in all patients. Performance and satisfaction were greatly improved (an improvement of at least 4 points) in certain activities of daily living, including reaching for objects, recreational activities, wheelchair propulsion, and transfers. Although improvement was seen in most goals, a reduction was reported in 2 goals (one pertaining to dressing and the other to transfer). After tendon transfers, the total mean score statistically increased from 2.6 to 5.6 for performance (p .001) and from 1.8 to 5.7 for satisfaction (p .001). [ 26 ]


General indications for functional surgery of the hand and arm in tetraplegic patients:

There are different views on optimal timing of surgery after a spinal cord injury. The general consensus is to operate the patient when he or she is neurologically stable. Some surgeons try to operate a patient as early as possible. The advantages of this are that the patient can take advantage of the new functional possibilities before new adjustments and adaptations develop. Other surgeons operate when it becomes feasible. This is usually 12–18 months after injury (can be shortened to 6–7 months) and only after stabilization of motor function. Important spasticity (see further) and neurovegetative complications (i.e. bladder function, bowel function, pulmonary function and pressure sores) must have been treated already. The patient must be able to sit in a wheelchair so that he/she can move the arm against gravity. Usually a compromise is found between the patient's wishes and the surgeon when timing the surgery. [ 3 ]


An indication for biceps-to-triceps surgery is when the patient plateaud for more than 3 months in their motor recovery. It is usually the choice of procedure for patients who have a flexion contractures greater than 45 degrees. The procedure will release the contracture and allows for active flexion by transferring the biceps. [ 25 ]


It is important that the psychological condition of the patient is evaluated before surgery. The dramatic change in the patient's life requires a psychological adjustment. This should be evaluated and addressed before surgery. Follow-up by a psychologist is necessary.  Patient must be psychologically ready to understand the surgical planning, aims and possible outcomes. The patient must be motivated, well-informed, in sound psychological condition and must have a precise and realistic need for rehabilitation. Individual factors must be taken into account. (age, profession, hobbies, education, family support and social background). This is especially important in associated brain injury. [ 3 ]


Contraindications for surgery are severe pressure sores, severe spasticity, inability to stabilize the trunk.


Spasticity, if present, can be very important. It is not a contraindication per se, but severe spasticity must be treated first depending in which muscle groups it is present. Spascticity can be treated with botox or myotomies. In some cases spastic tone can be useful to facilitate hand grasp and grip. Harmful spasticity that does not respond to medication or surgical treatment is a contraindication. The shoulder muscles, pectoralis major and latissimus dorsi, must be evaluated. The shoulder must not only have good motor condition but also good proprioceptive control. The trophicity and articular condition of the upper limb must also be considered. A poor condition requires a preoperative rehabilitation program. [ 3 ]


Before any hand surgery is performed, the patient should be able to actively extend the elbow. Therefore, if there is no active elbow extension, elbow extension reconstruction surgery should precede any hand surgery.


A contraindication specifically for posterior deltoid to triceps transfer is a flexion contracture of the elbow, biceps to triceps transfer might then be a possible transfer for elbow extension reconstruction.


The contraindications for biceps-to-triceps transfer relate to the muscle balance surrounding the elbow. The m. supinator and m. brachialis function is a prerequisite for this surgery. If one of these muscles is nonfunctional the patient will lose forearm supination and elbow flexion if the tendon is transferred.


In general, reconstruction of the upper limb can only be performed if active elbow extension is present. This stabilizes the elbow and gives the patient a reach. It will also allow the transfer of the other muscles crossing the elbow joint (like the m. brachioradialis and m. extensor carpi radialis longus). It is also an operation whose results allow the patient to gain confidence in the rest of the treatment. [ 3 ] [ 4 ]


Wrist-related tenodesis effect ( Tenodesis grasp ) means that wrist flexion passively opens the hand and wrist extension passively closes the hand. (see pictures below) Wrist-related tenodesis effect is the key point of any functional surgery in a paralyzed hand, therefore active wrist extension is required and reconstruction of this active wrist extension is of utmost importance for the tetraplegic hand. [ 30 ]  If no active wrist extension is available (IC group 0 and 1), the brachioradialis (only IC group 1) can be transferred to achieve wrist extension. [ 30 ]


Active tendon transfers are possible if m. extensor carpi radialis longus and m. extensor carpi radialis brevis are present. The use of the m. extensor carpi radialis longus and the m. brachioradialis are possible to restore hand function. [ 30 ]


There are two major techniques used to gain elbow extension.


Deltoid-to-triceps transfer:
For this transfer, the posterior part of the deltoid muscle is released from its origin and attached to the triceps muscle (usually by means of a tendon graft or a synthetic graft) leaving the rest of the deltoid muscle intact. This transfer is usually very successful because the line of pull of the posterior deltoid muscle is in the same direction as the triceps muscle. Also, there is hardly any loss of function. [ 30 ]


The deltoid muscle is usually innervated by the fifth and sixth cervical nerve roots and is therefore often functional in patients with tetraplegia, though the triceps muscle, which is innervated by the seventh cervical root, is paralysed. Because of the location at the back of the arm, the posterior part of the deltoid muscle can give strength in the same direction as the triceps muscle and is therefore theoretically a good donor to regain elbow extension.


Not only the direction of the strength provided by the donormuscle is important, Smith  et al.  showed that the matching between the original functional properties of the donor and recipient muscles affects the outcome of the transfer. [ 31 ] [ 32 ]  Therefore, Fridén studied the architectural properties of the deltoid and triceps muscle in cadavers and concluded that the posterior deltoid would be a very suitable transfer to provide elbow extension. [ 4 ]


Since the tendon of the triceps is not long enough to reach the posterior deltoid muscle, an interposition graft is needed. Different procedures have been described to achieve the transfer. Moberg  [ 5 ]  used free tendon grafts from the long toe extensors to connect the posterior deltoid to the triceps, other interposition grafts have been described, including fascia lata and a triceps tendon turnup. [ 33 ] [ 34 ]  One should keep in mind that many patients hold out a hope for a cure and are therefore concerned about incurring a significant donor defect that could cause impairment if they recovered a lowerextremity function. [ 35 ]
The first part of the surgery should be to make an incision along the posterior border of the deltoid. The muscle is exposed to its insertion on the humerus. Next the part of the muscles that originates from the spina scapulae, the posterior one third to one half, is isolated from the anterior portion of the muscle. The insertion of the posterior deltoid is then elevated of the muscle and the distance between the mobilized deltoid tendon to the olecranon is measured to determine the length of the interposition graft needed. The interposition graft must now be harvested from its donor site. It should be 5 to 10 cm longer than the gap.
After this a longitudinal incision should be made over the triceps tendon in which two transverse slits are made. One end of the graft should be wrapped around the posterior deltoid and sutured securely to it, after which the grafted is passed through an intercutaneous tunnel towards the triceps tendon, woven through the transverse slits and sutured securely to the triceps tendon and itself.
Once the graft is securely in place, the wound is closed and a long armcast is applied with the elbow at 10 degrees of flexion.


This tendon transfer has a high risk of being stretched, during the postsurgical period. It is extremely important that a challenging and precise post-surgical rehabilitation program is implemented, in order to maximize the results and prevent the tendon from becoming stretched. [ 36 ]


Biceps-to-triceps transfer:
The biceps muscle can only be used for this transfer if the other elbow flexors are intact (m. brachialis and m. brachioradialis). [ 30 ]  This procedure is typically performed under general anesthesia but can be performed under supraclavicular brachial plexus blockade. The incision depends on whether there is a contracture that needs to be released. If this is the case a wide exposure of the anterior side of the elbow joint is needed. The distal side of the incision should allow complete dissection of the tendon of the biceps. The primary tendon of the biceps is released from its insertion on the radius and then rerouted medial or lateral. If the ulnar nerve is functional a lateral route is favored to prevent compression, however, the lateral route can cause compression of the radial nerve. A second incision is made to expose the triceps insertion and the triceps is dissected from its insertion on the olecranon. A hole is then drilled in the olecranon and a gauge wire is then looped in the hole. The biceps is routed through a skin tunnel to the posterior side and woven into the triceps tendon to create more length. Then the tendon is inserted to the olecranon. [ 25 ]


Restoration of key pinch:
In general for key pinch the thumb has to be activated. In the lower groups according to the International Classification (IC groups 0–1) this can be done onyby means of tenodesis. In IC groups 2 and higher the m. brachioradialis is used to strengthen the thumb flexor. [ 30 ]  Usually the thumb extensor is fixed to the extensor retinaculum and the carpometacarpal joint is fused in the right position. [ 3 ]


Restoration of palmar grip:
When active wrist extension is present, it must not be weakened. Therefore, the extensor carpi radialis longus can only be used on patients in IC 3 and higher where active extension is supplied by both the extensor carpi radialis longus and the extensor carpi radialis brevis. In IC 2 patients active extension of the wrist depends only on the m. extensor carpi radialis longus, therefore this muscle must not be used for a transfer in this group of patients. [ 30 ]


The brachioradialis muscle is a versatile motor muscle and is used for different transfers in tetraplegic patients. In IC 1 it is used to restore wrist extension, while in IC 2–8 it is used to restore finger extension (m.extensor digitorum communis) and finger (m.flexor digitorum profundus) or thumb flexion (m.flexor pollicis longus). [ 30 ]  Surgical techniques in this type of  hand surgery  are mainly the same for the different transfers. [ 30 ]


Technique for transferring the m. extensor carpi radialis longus: the m. extensor carpi radialis longus tendon is divided at its insertion on the second metacarpal. The muscle is separated, and freed entirely from the surrounding tissues. The m. extensor carpi radialis longus tendon is strongly attached to the planned tendon under maximum tension. The m. extensor carpi radialis longus can be transferred to the flexor digitorum profundus or flexor pollicis longus. [ 30 ]


Technique for transferring the m. brachioradialis: The brachioradialis is freed entirely from the surrounding tissues up to the elbow to get extra excursion. The brachioradialis tendon is strongly attached to the planned tendon. [ 30 ]


The post-operative regimens depend on the surgical procedures used. However, they tend to constrain the tetraplegic patient considerably. During most regimens they are not allowed to drive hand-driven wheelchairs, or to make transfers alone, because of the risk of rupturing a tendon suture.


In general the elbow extension reconstructions are immobilised for a few weeks and then slowly allowed to flex the elbow in the following weeks, at a rate of 10 degrees per week.
After 10 weeks the patient is allowed to move freely again. [ 30 ]


After the posterior deltoid-triceps transfer, a cast is applied with the elbow at 10 degrees of flexion. The cast should be worn for 4 to 6 weeks and then exchanged for an elbow brace with an adjustable range of motion. [ 35 ]


After the biceps-to-triceps surgery the patient's arm is immobilized for 3–5 weeks in slight flexion, this only counts for patient who could fully extend their arm before the operation. Otherwise the patient is immobilized in maximum extension and casted. This stays on for 10–14 days and a second cast is applied in further extension. After the immobilization the patient is given a protective polyaxial brace, which allows the patient to begin active limited flexion and still keep the full extension. This brace is worn by day and at night the patient wears a semi-firm splint that keeps the arm in maximal extension. [ 25 ]


With the emergence of the one step procedures for the hand, the post-operative rehabilitation programmes became even more important, since early movement is essential. Patients are mobilised 24 hrs post-operatively, with protective splints. The regimen takes approximately 12 weeks, before the hand is allowed to be fully loaded. Patients are not required to stay as an in-patient for the entire regimen, but can be treated as an outpatient after 1–4 weeks, depending on the centre where the procedures are performed.


Vaginoplasty  is any surgical procedure that results in the construction or reconstruction of the  vagina . It is a type of  genitoplasty .  Pelvic organ prolapse  is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of  malignant growths  or  abscesses  to restore a normal vaginal structure and function. Surgery to the vagina is done to correct  congenital defects  to the vagina,  urethra   and  rectum . It may correct protrusion of the  urinary bladder  into the vagina ( cystocele ) and protrusion of the rectum ( rectocele ) into the vagina. [ 1 ]  Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.


Congenital disorders  such as  adrenal hyperplasia  can affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty. [ 2 ]  Other candidates for the surgery include babies born with a microphallus, people with  Müllerian agenesis  resulting in  vaginal hypoplasia ,  trans women , and women who have had a vaginectomy after malignancy or trauma. [ 3 ] [ 4 ]


Vaginoplasty is the description of the following surgical interventions:


In some instances, extra tissue is needed to reconstruct or construct the vagina. These grafts used in vaginoplasty can be an  allotransplantation , a  heterograft , or an  autologous  material. [ 9 ] [ 10 ]  A woman can use an autologous in vitro cultured tissue taken from her vaginal vestibule as transplanted tissue to form the lining of the reconstructed vagina. [ 9 ]  A reconstructed or newly constructed vagina is called a  neovagina . [ 11 ]


Conditions such as  congenital adrenal hyperplasia  virilize genetic females due to a  21-hydroxylase  deficiency. Specific procedures include: clitoral reduction,  labiaplasty , normalizing appearance, vagina creation, initiating vaginal dilation. [ 12 ]   Vaginal atresia , or congenital absence of the vagina, can be another reason for surgery to construct a normal and functional vagina. [ 13 ]  Vaginoplasty is used as part of the series of surgeries needed to treat those girls and women born with the  bladder located outside of their abdomen . After the repairs, women have been able to give birth but are at risk of prolapse. [ 1 ]


There are human rights concerns about vaginoplasties and other genital surgeries in children who are not old enough to consent, [ 14 ] [ 15 ]  including concern with post-surgical sexual function, [ 16 ]  and assumptions of  cisnormativity . [ 17 ]  There is no consensus attitude among clinicians about their necessity, timing, method or evaluation. [ 12 ]  Vaginoplasties may be performed in children or adolescents with  intersex  conditions or  disorders of sex development . [ 18 ]


Non-surgical vagina creation was used in the past to treat the  congenital  absence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameter  dilators . The procedure took several months and was sometimes painful. It was not effective in every instance. [ 2 ]  Uncommon growths, cysts, septums in the vagina can also require vaginoplasty. [ 19 ]


Radiological cancer treatment  can result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored. [ 3 ]


A canal is surgically constructed between the  urinary bladder  and  urethra  in the anterior portion of the pelvic region and the  rectum . A skin graft is used from another area of the person's body. The graft is removed from the  thigh ,  buttocks , or  inguinal  region. Other materials have been used to create the lining of the new vagina. These have been cutaneous  skin flaps ,  amniotic membranes , and  buccal mucosa . [ 3 ] [ 9 ]


Several techniques may be used in  gender-affirming surgery   to create a neovagina.


Inversion of the penile skin is the method most often selected to create a neovagina by surgeons performing gender-affirming surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the neovagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap. [ 4 ]


The penile inversion technique was pioneered by  Georges Burou  in his Morocco clinic in the 1950s. [ 20 ]   By the 1970s he had performed hundreds of them, and gave his first public presentation of his technique to a conference at Stanford University in 1973, [ 21 ]  after which it gradually became the predominant technique worldwide.


Bowel vaginoplasty is another common vaginoplasty technique. It is also used for vaginoplasty in cisgender women. [ 22 ]  As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal, penile and urethral tissue. However, in bowel vaginoplasty a segment of  rectosigmoid colon  is grafted into a surgically created canal to form the neovagina. [ 23 ]


Transgender peritoneal vaginoplasty,  a.k.a.  peritoneal pull-down or pull-through (PPT), is based on neovaginal techniques documented in the 1970s and 80s [ 25 ] [ 26 ] [ 27 ]  for cisgender women born without a vaginal canal due to  agenesis / atresia , [ 28 ] [ 29 ]  which were referred to as the "Davydov" procedure [ 29 ] [ 30 ]  or "Rothman's" method. [ 31 ]  A 2022 review states, "In the last 5 years, peritoneal flap vaginoplasty has emerged as a promising technique". [ 32 ]


This form of vaginoplasty utilizes tissue of the  peritoneum  to form the canal lining of the neovagina. [ 33 ] [ 29 ]


For trans women who had their  puberty blocked , insufficient penile and scrotal skin may be available for traditional penile inversion. In such cases, peritoneal vaginoplasty remedies the issue of insufficient tissue. [ 33 ] [ 28 ] [ 29 ] [ 34 ]  Peritoneal vaginoplasty can be used as a surgical revision to increase or restore vaginal depth in persons who have had a previous vaginoplasty. [ 33 ] [ 29 ] [ 34 ] [ 35 ] [ 36 ]


Penile- scrotal  skin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used. [ citation needed ]


Critics have labeled such surgery as the "designer vagina". The  American College of Obstetricians and Gynecologists  issued a warning against these procedures in 2007 [ 38 ]  as did the  Royal Australian and New Zealand College of Obstetricians and Gynaecologists , [ 39 ]  and a commentary in the  British Medical Journal  strongly criticized the "designer vagina" in 2009. [ 39 ] [ 40 ]   The  Society of Obstetricians and Gynaecologists of Canada  published a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013. [ 41 ]


The World Health Organization describes any medically unnecessary surgery to the vaginal tissue and organs as  female genital mutilation . [ 42 ]


Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance. [ 40 ]


An  imperforate hymen  is the presence of tissue that completely covers the vaginal opening. It is cut to allow menstrual flow to exit during a short surgical procedure. [ 1 ]  A  hymenorrhaphy  is the surgical procedure that reconstructs the hymen.


In this procedure, a  Foley catheter  is  laparoscopically  inserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina. [ citation needed ]


In treating  Müllerian agenesis , the Vecchietti procedure is a  laparoscopic  surgical technique that produces a  vagina  of dimensions (depth and width) comparable to those of a normal vagina (ca. 8 cm deep). [ 43 ] [ 44 ]  A small, plastic sphere called an olive is threaded ( sutured ) against the vaginal area; the threads are drawn though the vaginal skin, up through the  abdomen , and through the  navel . There, the threads are attached to a traction device, and then daily are drawn tight so that the olive is pulled inwards and stretches the vagina, by approximately 1 cm per day, thereby creating a vagina, approximately 7 cm deep by 7 cm wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time. [ 45 ]  The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy. [ 46 ]  In  vaginal hypoplasia , traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments. [ 47 ] [ 19 ]


Other surgical techniques that have been developed include ileal neovagina (Monti's technique), Creatsas vaginoplasty, Wharton–Sheares–George neovaginoplasty, or the Davydov procedure. The most widely used is the Vecchietti laparoscopic procedure. Sometimes sexual intercourse can result in the dilation of a newly constructed vagina. [ 9 ]


The most techniques of vaginoplasty are using inflatable vaginal expanders or vaginal stents to design the vaginal diameter and length. [ 48 ] [ 49 ]  At the end of the procedure the device stays in place to maintain the neovagina against the pelvic wall which also favors the process of microscopic neovascularization and reduces the risks of hematoma. In post-operative setting the expander can be used regularly to prevent post-operative vaginal retraction. [ 50 ]  Solid vaginal dilators can also be used immediately after surgery to keep the passage from attachments, and regularly thereafter to maintain the viability of the neovagina. The frequency required to use decreases over time, however remains obligatory lifelong. [ 51 ] [ 52 ]


Reconstructive vaginoplasty in children and adolescents carries the risk of  superinfection . [ 19 ]


In adults, rates and types of  complications  varied with gender-affirming surgery.  Necrosis  of the clitoral region was 1–3%. Necrosis of the surgically created vagina was 3.7–4.2%. Vaginal shrinkage occurred was documented in 2–10% of those treated.  Stricture , or narrowing of the vaginal orifice was reported in 12–15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two  scrotal  flaps has been described. Posterior vaginal wall is a rare complication.  Genital pain  was reported in 4–9%. Rectovaginal  fistula  is also rare with 1% documented. Vaginal prolapse was seen in 1–2% of people  assigned male at birth  undergoing this procedure. [ 4 ]


The ability of emptying the  bladder  was affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported that  voiding  got worse. Those reporting a negative outcome who experienced loss of bladder control and  urinary incontinence  were 19%.  Urinary tract infections  occurred in 32% of those treated. [ 4 ]


Reports of people seeking vaginoplasty go back to the 2nd century. [ 53 ] [ 54 ]   The first modern vaginoplasty was performed in 1931 on  Dora Richter . [ 53 ] [ 55 ] [ 56 ]   Lili Elbe  also underwent a vaginoplasty the same year. [ 57 ]


Vulvoplasty , also known as  zero-depth vaginoplasty , [ 1 ]  is a  plastic surgery  procedure for altering the appearance of one's  vulva  or constructing a vulva from  penile  and  scrotal  tissue (a neovulva).


Women with congenital disorders or women post- vulvectomy  or with  genital trauma  may receive vulvoplasty for medical reasons.


Women who experience vulvar discomfort may also receive vulvoplasty.


In  gender-affirming surgery , some male-to-female  transgender  patients receive vulvoplasty without  vaginoplasty  to reconstruct the exterior of female genitalia. [ 2 ]


During  clitoroplasty , a  clitoris  is made from the tissue of the  glans penis . [ 3 ]


Labiaplasty  can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty. [ 4 ] [ 5 ]  The  labia minora  are typically constructed from genital skin and the  labia majora  using skin from the  scrotum . [ 3 ]


The  urinary meatus  in trans women is created by shortening the urethra and positioning it above the neovagina in such a way that the urine will descend downward while urinating in a seated position. [ 6 ]


A  walking-stalk skin flap  or  waltzing tube pedicle  is a reconstructive technique in which the skin and soft tissue to be used for the  flap  is formed into a tubular pedicle and moved from the source to the target site by anchoring at both ends, periodically severing one end and anchoring it closer to the flap target site.  As antibiotics had not yet been invented when this procedure was developed, wrapping the flap in a tube was important because the risk of infection was reduced. [ 1 ]   The technique was invented by  Harold Gillies  and developed by  Archibald McIndoe  for the treatment of battle injuries. Archibald Mcindoe was widely recognised for many of these techniques. [ 2 ]


The technique is now largely redundant due to advances in  vascular surgery  and  microsurgery .


Walter Ernest O'Neil Yeo  (20 October 1890 – December 1960) was an English sailor in the First World War, who is thought to have been one of the first people to benefit from advanced  plastic surgery , namely a skin  flap . [ 1 ]


Yeo was born in  Plymouth ,  Devon , to Petty Officer Francis Yeo and his wife Rhoda Sarah Yeo ( née  Jarman). He had two elder sisters, Adelaide and Elsie. Three weeks after his birth, his father was killed aboard  HMS  Serpent  while on route to  Sierra Leone , after hitting rocks off  Cape Vilan , Spain. Three of the 176 people on board survived the shipwreck. His mother was later an alemaker at the  Royal William Victualling Yard .


Yeo entered into the  Royal Navy  aged 15. As he was under 18, he was rated as a boy, second class. His sub-rating was that of  bugler  until 1911. His date of formally joining was 1 October 1906. He signed up for 12 years' service, and this period would only start when he turned 18. Thus the date of his adult service, and hence the start of his 12 years' service, started on his 18th birthday in 1908. He had his initial training aboard  HMS  Ganges  (shore establishment) , and first went to sea aboard  HMS  Dido  (1896)  in 1907, by this time a boy, first class. He was rated  ordinary seaman  on his 18th birthday and conducted his adult training at  HMS Vivid (shore establishment 1890) . [ 2 ]


He was assigned to  HMS  Bellerophon  (1907)  in 1911, and was promoted to  leading seaman  in 1912. After further training back at HMS  Vivid I , he joined  HMS  Warspite  (03)  on 1 April 1915, becoming a  petty officer  whilst aboard on 20 May 1915. [ 2 ]  He would be promoted to acting  warrant officer  in June 1917 as a gunner. [ 1 ]


Yeo was wounded on 31 May 1916, during the  Battle of Jutland , while manning the guns aboard the battleship  HMS  Warspite . [ 1 ]  He sustained terrible facial injuries, including the loss of upper and lower eyelids. [ 1 ]  There is some uncertainty as to where he was first admitted to hospital, due to the poor documentation. However, he is known to have been admitted to Plymouth Hospital while waiting for a place at  Queen Mary's Hospital  in  Sidcup , Kent, which was granted on 8 August 1917.  He was treated by  Harold Gillies , the first man to transfer skin from undamaged areas on the body. [ 1 ]  Gillies's notes on this case indicate that the main disfigurement was severe  ectropion  as well as waxy scar tissue of the forehead and nose. Gillies opened a specialist ward at Queen Mary's Hospital for the treatment of the facially wounded. [ 1 ]  Yeo is thought to have been one of the first patients to be treated with this newly developed technique, a form of skin transplantation called a 'tubed pedicle' flap. [ 1 ]


During the long process of surgery, a 'mask' of skin was transplanted across Yeo's face and eyes, including new eyelids. The operation to replace the skin of the midface and forehead took place in multiple stages. The first stage was the outlining of the graft as well as placement of a  stent  to contour for the  nasal dorsum  on 12 November 1917. On post-operative day five, a serious infection was noted as well as complications with the stent requiring surgical intervention. On 30 November, the second stage of the surgery was performed which consisted of excision of the scar tissue of the face and transfer of the graft. Again, post-operative infection was a major complication. Gillies described the flap as "floating in  pus  at one point" which required extensive care to salvage most of the tissue. In January 1918, the  pedicles  were returned to the chest with the surgery deemed a success. Minor revisions were performed in the following months to improve the aesthetics of the graft. [ 3 ]  By July 1919, he was found to be fit for active service again and was recorded as having completed courses in September 1919. He underwent a further operation in August 1921, after which his disfigurement was recorded as 'improved, but still severe', and he was recommended for medical discharge, which took place on 15 December 1921. Yeo later received further treatment for a  corneal ulcer  at the Royal Naval Hospital in Plymouth in 1938.


Yeo married Ada Edwards in 1914, and had two daughters with her: Lilian Evelyn Yeo, born 21 October 1914, and Doreen Y. Yeo, born in 1919. He died in his hometown, Plymouth, where he had spent the majority of his life, in 1960 at the age of seventy.


Z-plasty  is a versatile  plastic surgery  technique that is used to improve the functional and cosmetic appearance of  scars . It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central element) is made along the line of the greatest tension or contraction, and triangular flaps are raised on opposite sides of the two ends and then transposed. The length and angle of each flap are usually the same to avoid mismatched flaps that may be difficult to close. Some possible complications of Z-plasty include flap  necrosis ,  haematoma  (blood clot) formation under the flaps, wound infection, trapdoor effect and sloughing (necrosis) of the flap caused by wound tension and inadequate blood supply.


Z-plasties can be functional (elongate and relax scars) or cosmetic (realign scars to make them less noticeable). They can be single or multiple.  Variations include skew and planimetric Z-plasties.


The transposition of two triangular flaps


The incisions are designed to create a Z shape with the central limb aligned with the part of the scar that needs lengthening or re-aligning. The traditional 60° angle Z-plasty will give a theoretical lengthening of the central limb of 75%. [ 1 ]  Single or multiple z-plasties can be used. Specific modifications include the double-opposing z-plasty (sometimes called a "jumping man" flap) which can be useful for release of webbing of the medial canthus or release of 1st web space contractures. It is one of the techniques used in scar revision, especially in  burn scar contracture .


The lengthening of a scar. Used to help relax or release linear burn scar contractures. The technique is dependent on the availability of mobile adjacent skin.


The irregularisation of a scar to make it less noticeable. Re-alignment of the central element can place the scar in natural skin tension lines and thereby disguise it. One of a family of similar techniques (such a W plasty).


The first Z-plasty was performed by  Horner  in 1837, followed by  Denonvilliers  in 1854, both for correction of  ectropion . [ 2 ]   The first standard double transposition Z-plasty was reported by Berger in 1904, and McCurdy introduced the term in 1913.


Zygoma reduction , also known as cheekbone reduction surgery, is a surgery used to reduce the facial width by excising part of the  zygomatic bone  and arch. Wide cheekbones are a characteristic facial trait of Asians, whose skull shapes tend to be more brachycephalic (broad, short skull) in comparison with Caucasian counterparts, whose skull shapes tend to be more dolichocephalic (narrow and long).This surgery is popular among Asians due to their inherent wide cheekbones. Due to the advanced surgical skills of Korean surgeons who perform facial contouring surgeries, the number of Asian people undergoing this surgery is increasing. [ 1 ]


The goal of a zygoma reduction surgery is not to flatten out the cheekbone but rather it is used to reduce the facial width while simultaneously creating a more three-dimensional projection to suit the overall facial contour of an individual. [ 2 ]  The  infraorbital nerve  supplies skin and mucous membranes to the middle portion of the face and also supplies sensation to the skin of the cheek, upper lip, nose and upper teeth. Therefore, special care should be taken to avoid contact with the infraorbital nerve, as damage to this nerve can result in possible loss of sensation or dysesthesia. [ 3 ]


Before surgery, the zygoma type should be identified in order to create a surgical plan suited to the individual. Vital points that factor in the evaluation are the zygomatic width, volume, and position which determine the surgical technique best suited to the individual. [ 2 ]  The surgeon evaluates the surgery candidate in person whilst simultaneously examining clinical photos,  X-ray  and  CT scans  in frontal, lateral, three-quarter oblique and basal views. The assessment of the three-quarter oblique view is the most important as it determines the level of projection of the zygomatic bone. [ 2 ]  Further attention should be paid in evaluation of the skin, subcutaneous fat, muscles and the underlying structure to accurately formulate the surgical plan. Depending on the skin thickness and soft tissues, additional liposuction or lifting procedures may be recommended in conjunction with the zygoma reduction surgery. [ 2 ]


During consultation process, it is essential that the surgeon discusses the surgery outcome, and ensure that the candidate's surgery expectations are realistic. [ 4 ]  MMP (maximal malar projection) is the most protruded portion of the outer contour of zygomatic complex in the basal three-quarters view. MMP is measured using either the Hinderer Analysis or Wilkinson Analysis methods. Using these methods, the MMP is calculated to find the ideal placement of the zygomatic body and arch. [ 2 ]


Once the MMP is calculated and the new position of the zygoma bone is planned then the surgery method is planned. The surgery is performed under  general anesthesia  through  orotracheal intubation . [ 4 ]


The osteotomy method is based on an individual's bone structure. There is the standard L-shaped Osteotomy method, the High L-shaped osteotomy method (link), High L-shaped osteotomy with orbital rim shaving and High L-shaped osteotomy with tripod osteotomy. High L-shaped osteotomy zygoma reduction provides the most precise level of osteotomy, with the least amount of scarring. [ 2 ]


Zygoma reduction surgical approach can be divided into two types, external or intraoral approach. External approach requires incision made externally, which will cause visible scarring. Intraoral approach is the most favored approach as the incision site will be hidden inside the mouth. For some cases, both an intraoral and external approach is required to achieve maximum shaving of the zygomatic body and arch. [ 5 ]


Onizuka et al. [ 6 ]  introduced zygoma reduction surgery using the intraoral approach in 1983. The High L-shaped osteotomy technique also uses an intraoral approach. The incision is made on the lateral edge of the infraorbital rim to access the zygomatic bone. [ 7 ]


Preauricular approach requires an incision to be made on the sideburns to access the zygomatic arch. Based on the zygoma shape and classification, the surgeon can ascertain whether intraoral and preauricular approach are both required to sufficiently decrease the zygoma protrusion. [ 8 ]


"Double bladed" reciprocating saw is used for this procedure to produce symmetric osteotomy. The saws come in different sizes ranging from two to 7 millimeters. Pre-bent titanium plates and screws are used to fixate the zygoma bone and arch in its new position. [ 9 ]


Post-surgery symptoms include haematoma, swelling, numbness, reduced sensation and usually clear within three to six months after surgery. Complications like asymmetry, infection, motor nerve injury, excessive scarring, and malunion can also occur, albeit it is a rare possibility. [ 9 ]


Certain candidates are prone to requiring additional surgery in conjunction with the zygoma reduction surgery. Soft tissue sagging is one of the main issues and the can be aggravated depending on the candidate's age, skin thickness and elasticity level, and excess cheek fat. Depending on the severity of the aforementioned factors, the surgeon may recommend additional procedures like lifting, buccal fat removal, fat graft etc. to combat any issues that may arise from having surgery. [ 4 ]


S. Park (ed.), Facial Bone Contouring Surgery, © Springer Nature Singapore Pte Ltd. 2018  ISBN   978-981-10-2725-3


Caesarean delivery on maternal request   (CDMR) is a  caesarean section birth  requested by the  pregnant  woman without a  medical reason . [ 1 ]


The concept of "Caesarean delivery on maternal request" (CDMR) is not well-recognized in health care, and consequently, when it occurs there are no mechanisms in place for reporting it for research or distinguishing it in  medical billing . [ 2 ]


Over the last century, delivery by Caesarean section (CS) has become increasingly safer; the medical reasons, therefore, for selecting a CS delivery over a vaginal birth are less likely to be those of necessity, and more likely to be motivated by other factors, such as considerations of pain in vaginal delivery and the effects of childbirth on vaginal muscle tone. Until recently, [ when? ]  an  elective caesarean section  was done on the basis of medical grounds; however, the existence of CDMR makes the mother's preference the determining factor for the delivery mode.


An elective Caesarean will be agreed in advance. An elective Caesarean can be suggested by either the mother or her obstetrician, often as a result of a change in the medical status of the mother or baby. The term is used by the press and on the web in a number of different ways, but any Caesarean section which is not an emergency is classified as elective. The mother in essence has agreed to it but may not have chosen it. [ citation needed ]


The popular media suggest that many women are opting for Caesareans in the belief that it is a practical solution. [ 3 ]  The ethical view that a woman has the right to make decisions regarding her body has empowered women to make a choice regarding the method of her childbirth. [ 4 ]


The movement for CDMR may have started in  Brazil . [ 3 ]  It has been estimated that possibly 4-18% of all CSs are done on maternal request; however, estimates are difficult to come by. [ 1 ]  The global nature of the CDMR phenomenon was underlined by a study that showed that in southeast China about 20% of women chose this mode of delivery. [ 5 ]


Increasingly, caesarean sections are performed in the absence of obstetrical or medical necessity at the patient's request, and the term  Caesarean delivery on maternal request  has been used. [ 1 ]  Another term that has been used is "planned elective cesarean section". [ 6 ]  As of 2006 [update] , there is no ICD code, thus the extent of the use of this indication is difficult to determine. The mother is the only party who may request such an intervention without indication. [ citation needed ]


Caesarean sections are in some cases performed for reasons other than  medical necessity . These can vary, with a key distinction being between hospital- or doctor-centric reasons and mother-centric reasons. Critics of doctor-ordered Caesareans worry that Caesareans are in some cases performed because they are profitable for the hospital, because a quick Caesarean is more convenient for an obstetrician than a lengthy vaginal birth, or because it is easier to perform surgery at a scheduled time than to respond to nature's schedule and deliver a baby at an hour that is not predetermined. [ 7 ]  It is through these lenses that CDMR can sometimes be viewed as an example of  unnecessary health care .


Non-medically indicated scheduling of childbirth before 39 weeks gestation brings "significant risks for the baby with no known benefit to the mother." Hospitals should institute strict monitoring of births to comply with full term (more than 39 weeks gestation) elective C-section guidelines. In review, three hospitals following policy guidelines brought elective early deliveries down 64%, 57%, and 80%. [ 8 ]  The researchers found many benefits but "no adverse effects" in the health of the mothers and babies at those hospitals. [ 8 ] [ 9 ]


In this context, it is worth remembering many studies have shown operations performed out-of-hours tend to have more complications (both surgical and anaesthetic). [ 10 ]  For this reason, if a Caesarean is anticipated to be likely to be needed for a woman, it may be preferable to perform this electively (or pre-emptively) during daylight operating hours, rather than wait for it to become an emergency with the increased risk of surgical and anaesthetic complications that can follow from emergency surgery.


Another contributing factor for doctor-ordered procedures may be fear of  medical malpractice  lawsuits. Italian gynaecologist Enrico Zupi, whose clinic in Rome, Mater Dei, was under  media attention  for carrying a record of Caesarian sections (90% over total birth), explained: "We shouldn't be blamed. Our approach must be understood. We doctors are often sued for events and complications that cannot be classified as malpractice. So we turn to  defensive medicine . We will keep acting this way as long as medical mistakes are not depenalized. We are not  martyrs . So if a pregnant woman is facing an even minimum risk, we suggest she gets a C-section". [ 11 ]


Studies of  United States  women have indicated married white women giving birth in private hospitals are more likely to have a Caesarean section than poorer women, although they are less likely to have complications that may lead to a Caesarean section being required. The women in these studies have indicated their preference for Caesarean section is more likely to be partly due to considerations of pain and vaginal tone. [ 12 ]  In contrast, a 2004 study in the  British Medical Journal  retrospectively analysed a large number of Caesarean sections in England and stratified them by social class. Their finding was Caesarean sections are not more likely in women of higher social class than in women in other classes. [ 13 ]  Some have suggested, due to the comparative risks of Caesarean section with an uncomplicated vaginal delivery, women should be discouraged or forbidden from choosing it. [ 14 ]


Some 42% of obstetricians [ clarification needed ]  believe the media and women are responsible for the rising Caesarean section rates. [ 15 ]  A study conducted in  Sweden , however, concludes that relatively few women wish to deliver by Caesarean section. [ 16 ]


Requirements for a  second opinion  from an additional doctor before giving a caesarean section has a small effect on reducing the rate of unnecessary caesarean sections. [ 17 ]  Communities of health care providers who peer review each other and come to agreement about the necessity of caesarean sections tend to use them less frequently. [ 17 ]  When medical guidelines are shared by local community leaders which mothers trust, then those mothers are more likely to have vaginal delivery after having had a previous caesarean delivery. [ 17 ]  When mothers have access to childbirth classes and relaxation classes mothers are more likely to use vaginal delivery when the pregnancy is otherwise low risk. [ 17 ]


A meeting of experts sponsored by the  NIH  in March, 2006 attempted to address the medical issues and  found "insuffient evidence to evaluate fully the benefits and risks" of CDMR versus vaginal delivery, and thus was not able to come to a consensus about the general advisability of a cesarean delivery by demand. [ 1 ]  The available evidence suggests certain differences as follows:


Proponents for CDMR point out that it facilitates the birth process by performing it at a scheduled time under controlled circumstances, with typically less bleeding, and less risk of trauma to the baby. [ 1 ]  Furthermore, there is some evidence that urinary  stress incontinence  as a long-term result of damage to the  pelvic floor  is increased after vaginal birth. Opponents to CS feel that it is not natural, that the costs are higher,  infection  rates are higher, hospitalization longer, and rates for  breastfeeding  decrease. Also, once a CS has been done, subsequent deliveries will likely be also by CS, each time at a somewhat higher risk. Further, babies born after a vaginal delivery tend to be at a lower risk for the  infant respiratory distress syndrome . [ 1 ]


Subsequent to the NIH report a large review from the USA of almost 6 million births was published that suggested that neonatal mortality is 184% higher in babies born by cesarean section. [ 18 ]  This study was harshly criticized for excluding cases where unforeseen complications arose during labor from its cohort of vaginal deliveries, thereby retrospectively removing poor outcomes and artificially lowering the neonatal mortality rate in the vaginal delivery population, and for using birth certificate data instead of more reliable documentation, such as hospital discharge forms, to define cesarean sections with "no indicated risk", and thereby inappropriately including emergent cesarean sections in their "elective cesarean" cohort. [ 19 ] [ 20 ] [ 21 ]  In response to this criticism, the authors published a second paper analyzing the same cohort, in which they did not systematically exclude vaginal deliveries in which unexpected complications arose, and concluded that the increased risk of neonatal mortality associated with cesarean section was 69%, rather than 184%. However, they did not address the inadequacies of their data set, and did not attempt to determine the degree of error introduced when identifying elective cesarean sections by birth certificate. [ 22 ]   A study published in the February 13, 2007 issue of the  Canadian Medical Association Journal  found that between 1991 and 2005, women who had scheduled cesarean sections for breech birth had a 2.7% rate of severe morbidity, compared with 0.9% for women who had planned vaginal deliveries. [ 23 ]


Caesarean section , also known as  C-section , cesarean, or  caesarean delivery , is the  surgical procedure  by which one or more babies are  delivered  through an incision in the mother's abdomen. It is often performed because  vaginal delivery  would put the mother or child at risk. [ 2 ]  Reasons for the operation include  obstructed labor ,  twin pregnancy ,  high blood pressure  in the mother,  breech birth ,  shoulder presentation , and problems with the  placenta  or  umbilical cord . [ 2 ] [ 3 ]  A caesarean delivery may be performed based upon the shape of the mother's  pelvis  or history of a previous C-section. [ 2 ] [ 3 ]  A trial of  vaginal birth after C-section  may be possible. [ 2 ]  The  World Health Organization  recommends that caesarean section be performed only when medically necessary. [ 3 ] [ 4 ]


A C-section typically takes 45 minutes to an hour. [ 2 ]  It may be done with a  spinal block , where the woman is awake, or under  general anesthesia . [ 2 ]  A  urinary catheter  is used to drain the  bladder , and the skin of the  abdomen  is then cleaned with an  antiseptic . [ 2 ]  An  incision  of about 15 cm (6 inches) is then typically made through the mother's lower abdomen. [ 2 ]  The  uterus  is then opened with a second incision and the baby delivered. [ 2 ]  The incisions are then  stitched  closed. [ 2 ]  A woman can typically begin  breastfeeding  as soon as she is out of the  operating room  and awake. [ 5 ]  Often, several days are required in the hospital to recover sufficiently to return home. [ 2 ]


C-sections result in a small overall increase in poor outcomes in low-risk pregnancies. [ 3 ]  They also typically take about six weeks to heal from, longer than vaginal birth. [ 2 ]  The increased risks include breathing problems in the baby and  amniotic fluid embolism  and  postpartum bleeding  in the mother. [ 3 ]  Established guidelines recommend that caesarean sections not be used before 39  weeks of pregnancy  without a medical reason. [ 6 ]  The method of delivery does not appear to have an effect on subsequent  sexual function . [ 7 ]


In 2012, about 23 million C-sections were done globally. [ 8 ]  The international healthcare community has previously considered the rate of 10% and 15% to be ideal for caesarean sections. [ 4 ]  Some evidence finds a higher rate of 19% may result in better outcomes. [ 8 ]  More than 45 countries globally have C-section rates less than 7.5%, while more than 50 have rates greater than 27%. [ 8 ]  Efforts are being made to both improve access to and reduce the use of C-section. [ 8 ]  In the United States as of 2017, about 32% of deliveries are by C-section. [ 9 ]  The surgery has been performed at least as far back as 715 BC following the death of the mother, with the baby occasionally surviving. [ 10 ]  A popular idea is that the Roman statesman  Julius Caesar  was born via caesarean section and is the namesake of the procedure, but if this is the true etymology, it is based on a misconception: until the modern era, C-sections seem to have been invariably fatal to the mother, and Caesar's mother  Aurelia  not only survived her son's birth but lived for nearly 50 years afterward. [ 11 ] [ 12 ]  There are many ancient and medieval legends, oral histories, and historical records of laws about C-sections around the world, especially in Europe, the Middle East and Asia. [ 13 ] [ 14 ]  The first recorded successful C-section (where both the mother and the infant survived) was performed on a woman in Switzerland in 1500 by her husband,  Jakob Nufer , though this was not recorded until 8 decades later. [ 13 ]  With the introduction of antiseptics and  anesthetics  in the 19th century, survival of both the mother and baby, and thus the procedure, became significantly more common. [ 10 ] [ 15 ]


Caesarean section (C-section) is recommended when  vaginal delivery  might pose a risk to the mother or baby. C-sections are also carried out for personal and social reasons on  maternal request  in some countries.


Complications of labor and factors increasing the risk associated with vaginal delivery include:


Other complications of pregnancy, pre-existing conditions, and concomitant disease, include:


The prevalence of caesarean section is generally agreed to be higher than needed in many countries, and physicians are encouraged to actively lower the rate, as a caesarean rate higher than 10–15% is not associated with reductions in maternal or infant mortality rates, [ 4 ]  although some evidence support that a higher rate of 19% may result in better outcomes. [ 8 ]


Some of these efforts are: emphasizing a long  latent phase  of labor is not abnormal and not a justification for C-section; a new definition of the start of active labor from a cervical dilatation of 4 cm to a dilatation of 6 cm; and allowing women who have previously given birth to push for at least 2 hours, with 3 hours of pushing for women who have not previously given birth, before  labor arrest  is considered. [ 3 ]   Physical exercise  during pregnancy decreases the risk. [ 19 ]  Additionally, results from a 2021 systematic review of the evidence on outpatient  cervical ripening  found that in women with low-risk pregnancies, the risk of cesarean delivery with harms to the mother or child were not significantly different from when done in an inpatient setting. [ 20 ]


Adverse outcomes in low-risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of caesarean section deliveries. [ 3 ]


In those who are low risk, the  risk of death  for caesarean sections is 13 per 100,000 vs. for vaginal birth 3.5 per 100,000 in the developed world. [ 3 ]  The United Kingdom  National Health Service  gives the risk of death for the mother as three times that of a vaginal birth. [ 21 ]


In Canada, the difference in serious morbidity or mortality for the mother (e.g. cardiac arrest, wound hematoma, or hysterectomy) was 1.8 additional cases per 100. [ 22 ]  The difference in in-hospital maternal death was not significant. [ 22 ]


A caesarean section is associated with risks of postoperative  adhesions , incisional hernias (which may require surgical correction), and wound infections. [ 23 ]  If a caesarean is performed in an emergency, the risk of the surgery may be increased due to a number of factors. The patient's stomach may not be empty, increasing the risk of anaesthesia. [ 24 ]  Other risks include severe blood loss (which may require a blood transfusion) and  post-dural-puncture spinal- headaches . [ 23 ]


Wound infections occur after caesarean sections at a rate of 3–15%. [ 25 ]  The presence of  chorioamnionitis  and  obesity  predisposes the woman to develop a surgical site infection. [ 25 ]


Women who had caesarean sections are more likely to have problems with later pregnancies, and women who want larger families should not seek an elective caesarean unless medical indications to do so exist. The risk of  placenta accreta , a potentially life-threatening condition which is more likely to develop where a woman has had a previous caesarean section, is 0.13% after two caesarean sections, but increases to 2.13% after four and then to 6.74% after six or more.  Along with this is a similar rise in the risk of emergency hysterectomies at delivery. [ 26 ]


Mothers can experience an increased incidence of  postnatal depression , and can experience significant psychological trauma and ongoing  birth-related post-traumatic stress disorder  after obstetric intervention during the birthing process. [ 27 ]  Factors like pain in the first stage of labor, feelings of powerlessness, intrusive emergency obstetric intervention are important in the subsequent development of psychological issues related to labor and delivery. [ 27 ]


Women who have had a caesarean for any reason are somewhat less likely to become pregnant again as compared to women who have previously delivered only vaginally. [ 28 ]


Women who had just one previous caesarean section are more likely to have problems with their second birth. [ 3 ]   Delivery after previous caesarean section  is by either of two main options: [ 29 ]


Both have higher risks than a vaginal birth with no previous caesarean section. A vaginal birth after caesarean section (VBAC) confers a higher risk of  uterine rupture  (5 per 1,000), blood transfusion or  endometritis  (10 per 1,000), and  perinatal death  of the child (0.25 per 1,000). [ 30 ]  Furthermore, 20% to 40% of planned VBAC attempts end in caesarean section being needed, with greater risks of complications in an emergency repeat caesarean section than in an elective repeat caesarean section. [ 31 ] [ 32 ]  On the other hand, VBAC confers less  maternal morbidity  and a decreased risk of complications in future pregnancies than elective repeat caesarean section. [ 33 ]


There are several steps that can be taken during abdominal or pelvic surgery to minimize postoperative complications, such as the formation of  adhesions . Such techniques and principles may include:


Despite these proactive measures, adhesion formation is a recognized complication of any abdominal or pelvic surgery. To prevent adhesions from forming after caesarean section,  adhesion barrier  can be placed during surgery to minimize the risk of adhesions between the uterus and ovaries, the small bowel, and almost any tissue in the abdomen or pelvis. This is not current UK practice, as there is no compelling evidence to support the benefit of this intervention.


Adhesions can cause long-term problems, such as:


The risk of adhesion formation is one reason why vaginal delivery is usually considered safer than elective caesarean section where there is no medical indication for section for either maternal or fetal reasons.


Non-medically indicated (elective) childbirth before 39 weeks gestation "carry significant risks for the baby with no known benefit to the mother." Newborn mortality at 37 weeks may be up to 3 times the number at 40 weeks, and is elevated compared to 38 weeks gestation. These early term births were associated with more death during infancy, compared to those occurring at 39 to 41 weeks (full term). [ 34 ]  Researchers in one study and another review found many benefits to going full term, but no adverse effects in the health of the mothers or babies. [ 34 ] [ 35 ]


The  American Congress of Obstetricians and Gynecologists  and medical policy makers review research studies and find more incidence of suspected or proven  sepsis , RDS, hypoglycemia, need for respiratory support, need for NICU admission, and need for hospitalization > 4–5 days. In the case of caesarean sections, rates of respiratory death were 14 times higher in pre-labor at 37 compared with 40 weeks gestation, and 8.2 times higher for pre-labor caesarean at 38 weeks. In this review, no studies found decreased neonatal morbidity due to non-medically indicated (elective) delivery before 39 weeks. [ 34 ]