United States

Background:
Complications following tissue expander (TE) placement for staged oncologic breast reconstruction remain a challenge. Innovations such as dual-port TEs with both filling and drainage ports mitigate seroma risk. Acellular dermal matrix (ADM) has also gained popularity due to superior structural support and cosmesis. ADM is a sterile, bioengineered soft tissue graft used for dermal reinforcement and regeneration. The purpose of this study was to compare outcomes between dual- and single-port TEs with the use of ADM.

Methods:
Retrospective chart review was completed for patients who underwent TE breast reconstruction by a single surgeon between January 2018 and November 2023. Demographics, cancer treatment modality, implant data, and postoperative outcomes were examined. Analysis included descriptive statistics, F-distribution tests, Welch&#39;s t-tests, Chi-squared, and Fisher Exact tests.

Results:
154 breasts were included: 118 single-port TEs (74 with ADM, 62.7%) and 36 dual-port TEs (11 with ADM, 31.0%). Premature explant was needed for 15.3% of single-port and 28.5% of dual-port TEs (p=0.328). Explant in both groups was due to infection, wound healing problems, rupture, and seroma. However, premature explant of dual-port TEs occurred predominantly without ADM (p=0.0075), contrasting single-port TEs where ADM use showed no significant difference in explant rate. Further, incidence of infection was higher in dual-port expanders without ADM (p-value=0.0071), whereas single-port TE infection trended higher with ADM use.

Conclusions:
Both single and dual-port tissue expanders are safe and effective for staged breast reconstruction, without significant differences in the rate of premature explantation. In this cohort, ADM appears protective when used with dual-port TEs. It is possible that ADM’s homogenous surface safeguards the drain port from clogging with subcutaneous fat or other tissue, decreasing risk of fluid collection and infection. Routine ADM use with dual-port TEs could reduce complications and improve patient outcomes. Additional research is needed to facilitate evidence-based decision-making on single versus dual-port TE placement and utility of ADM.

AMA Research Challenge 2024 

Enhanced Performance of Dual-Port Tissue Expanders with Use of Acellular Dermal Matrix

Background:
Complications following tissue expander (TE) placement for staged oncologic breast reconstruction remain a challenge. Innovations such as dual-port TEs with both filling and drainage ports mitigate seroma risk. Acellular dermal matrix (ADM) has also gained popularity due to superior structural support and cosmesis. ADM is a sterile, bioengineered soft tissue graft used for dermal reinforcement and regeneration. The purpose of this study was to compare outcomes between dual- and single-port TEs with the use of ADM.

Methods:
Retrospective chart review was completed for patients who underwent TE breast reconstruction by a single surgeon between January 2018 and November 2023. Demographics, cancer treatment modality, implant data, and postoperative outcomes were examined. Analysis included descriptive statistics, F-distribution tests, Welch's t-tests, Chi-squared, and Fisher Exact tests.

Results:
154 breasts were included: 118 single-port TEs (74 with ADM, 62.7%) and 36 dual-port TEs (11 with ADM, 31.0%). Premature explant was needed for 15.3% of single-port and 28.5% of dual-port TEs (p=0.328). Explant in both groups was due to infection, wound healing problems, rupture, and seroma. However, premature explant of dual-port TEs occurred predominantly without ADM (p=0.0075), contrasting single-port TEs where ADM use showed no significant difference in explant rate. Further, incidence of infection was higher in dual-port expanders without ADM (p-value=0.0071), whereas single-port TE infection trended higher with ADM use.

Conclusions:
Both single and dual-port tissue expanders are safe and effective for staged breast reconstruction, without significant differences in the rate of premature explantation. In this cohort, ADM appears protective when used with dual-port TEs. It is possible that ADM’s homogenous surface safeguards the drain port from clogging with subcutaneous fat or other tissue, decreasing risk of fluid collection and infection. Routine ADM use with dual-port TEs could reduce complications and improve patient outcomes. Additional research is needed to facilitate evidence-based decision-making on single versus dual-port TE placement and utility of ADM.

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Introduction: 
Heterotopic ossification (HO) is the formation of extra-skeletal bone within soft tissue that occurs after injuries like severe burns. Development of HO complicates healing after injury. We aimed to elucidate factors influencing the development of HO in burn survivors and effects on recovery. 

Methods: 
Using the TriNetX database, a large, federated research network of de-identified patient data, we compared burned patients who developed HO after injury and those who did not. Cohorts were propensity-matched by age, gender, race, ethnicity, and % total body surface area (TBSA) burned. We then evaluated incidences of outcomes after injury among both cohorts.

Results:
Of the population, 0.12% developed HO after injury with most identified greater than 6 months from injury. HO was more common in those with head, upper extremity, or lower extremity burn involvement (p<0.0001). The HO group was older (48.1 vs 19.5 yrs. vs 32.5 vs 22.8 yrs., p<0.001), and male (60.3% vs 51.1%, p<0.001). African American burn patients were more likely to develop HO (22.2% vs 17.5%, p<0.001) than not. Additionally, those with HO exhibited a more than doubled risk of neuropathy, limited joint mobility, and documented edema than those who did not. Additionally, risk of skin breakdown, pain, and depression was higher in those who developed HO while additional reconstructive operations was interestingly lower. 

Discussion: 
Burn survivors more likely to develop HO are older, male, and have greater injury severity. Identification of HO was more likely greater than 6 months from injury. After propensity matching for burn severity and demographic factors, those with HO have comparatively poorer outcomes.

Heterotopic Ossification After Burn Injury Results in Worse Outcomes

Introduction: Plastic surgeons face an elevated risk of involvement in malpractice cases compared to other specialties. Fear of malpractice litigation may influence surgeon behavior and decision-making, potentially contributing to heightened healthcare costs. This study aimed to determine the prevalence and characteristics of malpractice litigation associated with breast implants. 

Methods: A comprehensive search involving the Westlaw Campus Research legal database was conducted to identify all cases involving malpractice complaints and breast implants. All available malpractice cases involving breast implants/prostheses from the earliest available documentation to February 1st, 2024 were retrieved and screened. Cases were included if a patient initiated a medical malpractice or negligence case after undergoing breast augmentation or reconstruction involving implants. Class action suits and cases with limited information were excluded. The extracted data from the cases included the date of the earliest available documentation, initiation location, patient gender, patient vital status, indication for implant(s), involved medical specialties, types of alleged negligence, diagnostic and postoperative complaints, autoimmune-related complaints, involvement of capsular contracture along with subsequent open/closed capsulectomy, and case outcomes. Descriptive statistics were calculated. 

Results: 650 cases were identified after the exclusion of duplicates; 128 cases met the inclusion criteria. Cases were most commonly initiated in the state of Texas (N=17, 13.3%) and New York (N=13, 10.2%) and documentation was dated 1967-2023. All of the cases involved female patients; one woman identified as transgender. Three (2.3%) patients were deceased at the time of the trial. Plastic surgeons were most commonly the defendant(s) (N=113, 88.3%). Malpractice claims were most frequently associated with the initial breast implant placement (N=89, 69.5%), rather than a breast implant removal with or without replacement (N=26, 20.3%). Negligent technique, improper informed consent, and poor postoperative management were cited as reasons for alleged malpractice in 90 (70.3%), 65 (50.8%), and 64 (50.0%) of the cases, respectively. Patients alleged that they did not receive the type of implant (saline vs. silicone) or size of implant they requested in 7 (5.5%) and 5 (3.9%) of the cases, respectively. 20 (15.6%) of the cases were ruled in favor of the plaintiff prior to appeal; 5 cases involved implant-based reconstruction, while 15 cases involved cosmetic implant-based augmentation. Eight patients claimed that their implants led to the development of cancer, autoimmune conditions, or other health conditions; only one case led to a ruling in favor of the plaintiff in 2001. 

Conclusion: 
These findings underscore the importance of comprehensive preoperative education, specifically addressing implant types, demystifying information about breast implant-associated illness, and setting realistic goals surrounding implant sizing. Surgeons should maintain heightened vigilance when patients present with abnormal postoperative changes in the breast tissue. Thorough work-up and placement of appropriate referrals should be conducted to prevent delays in potential breast cancer diagnoses. 


Implant Injustice: An Analysis of Breast Implant Malpractice Litigation

Background: Soft tissue sarcomas (STS) are malignant tumors that originate in soft tissues, managed with surgical resection as first-line treatment. Time to intervention (TTI) is crucial to the overall survival as metastases can develop in about 50% of STS patients. In the US, the median TTI is 22 days for STS patients, with longer TTI associated with poorer outcomes.1-3 While low-income public insurance and academic centers have individually been associated with increased TTI, no studies have investigated the combined impact of these factors.2,4-5 

Methods: We performed a single academic institution retrospective chart review of patients who underwent surgical STS resection between 2013 and 2023 with Medicaid or Medicare insurance. TTI was calculated from date of diagnosis to date of surgical resection. 

Result: Data was collected from 69 patients who underwent surgical STS resection; 20 patients were diagnosed and referred from outside hospitals, and 28 patients received preoperative radiation therapy (PRT). 90% of STS patients were diagnosed by biopsy and 10% by imaging. The most common STS diagnoses included “undifferentiated pleomorphic sarcoma” (25%) and “myxofibrosarcoma” (20%). Of the 41 patients that underwent STS surgical resection only, 56% had high grade (grade 2 or 3) STS and had a median TTI of 40 days. Among the PRT patients, 89% had high grade STS and median TTI of 104 days. 

Conclusion: The median TTI for surgical resection of STS in Medicare and Medicaid patients at a single academic institution was higher compared to the median TTI for STS in the US.

Increased Time to Intervention for Medicaid and Medicare Patients with
Localized Soft Tissue Sarcoma at a Single Academic Institution

Optimizing the ACS NSQIP Risk Calculator in Microsurgical Free Flap Breast Reconstruction

Background: Pre-operative risk indexes such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) have become increasingly popular for predicting patient-specific postoperative risks in plastic surgery. This study aimed to assess the accuracy of the ACS NSQIP tool in microsurgical breast reconstruction with subsequent analysis of the most significant patient-level risk variables that drive these predictions. 

Methods: A retrospective review of 98 microvascular free flap breast reconstructions performed between 2018-2022 was completed. 94 patients were included in the analysis. Univariate analysis between complication and non-complication groups was completed to identify significant differences in predictions. Receiver operating characteristic (ROC) curves on these predictions were subsequently completed to evaluate the accuracy of ACS NSQIP. Multivariate regression analysis was performed on pre-operative patient data utilized in the NSQIP risk calculator to identify any significant relationships between predictor variables and observed adverse postoperative events.

Results: Univariate analysis revealed the ACS NSQIP calculator most accurately predicted any complication (p=0.0432) and surgical site infection (p=0.0216) of the 12 outcomes analyzed by the authors. ACS NSQIP predicted “any” complications with a diagnostic accuracy of 63.1%, sensitivity of 61.3%, and specificity of 71.0%. It also predicted surgical site infection with a diagnostic accuracy of 71.6%, sensitivity of 57.1%, and specificity of 84.9%. Subsequent multivariate linear regression analysis of significant predictions revealed that non-white individuals were 6.68 times more likely to have any complication (95% CI 1.89-23.62; p=.003) and 6.38 times more likely to have a serious complication (95% CI 1.81-22.53; p=.004).

Conclusion: The NSQIP Risk Calculator was found to be significant in predicting “any complications” and “surgical site infections'' amongst our institution’s microsurgical breast reconstruction cohort, with minorities experiencing an approximate seven-fold increase in complications. Further analysis of the patient-level risk factors that drive these predictions may optimize the accuracy of this index and provide a powerful tool in pre-operative counseling by plastic surgeons.

Optimizing the ACS NSQIP Risk Calculator in Microsurgical Free Flap Breast
Reconstruction

Background
The Goldilocks mastectomy is a breast reconstruction technique that utilizes the remaining breast tissue post-mastectomy to create a new, smaller breast mound. For this reason, the Goldilocks technique is well-suited for patients with large, ptotic breasts. This procedure is often paired with free nipple grafting (FNG), a technique in which the nipple-areolar complex (NAC) is removed entirely and relocated as a skin graft. In cases where only one NAC can be preserved, the nipple can be split into halves and fashioned into two separate nipples prior to graft placement.

When FNG is employed in conjunction with Goldilocks mastectomy, it is often performed as a secondary procedure. However, the surgical risks and recovery time can be reduced when these procedures are performed concurrently. A single-stage operation can also allow for earlier radiation treatment or the avoidance of grafting on irradiated skin.

Case Presentation
Here, we present the successful application of FNG in conjunction with the Goldilocks mastectomy in a single-stage procedure. The patient was a 55-year-old female with bilateral, retropectoral breast implants who wore a DD size bra. After presentation with microcalcifications in the left breast and diagnosis of ductal carcinoma in situ, bilateral mastectomy was suggested. The patient requested a reconstructive procedure in which her implants could be removed while still preserving the shape and aesthetics of her breasts. Because cancer was present in the left NAC, only the right nipple could be preserved for grafting. Therefore, single-stage, bilateral Goldilocks mastectomy with nipple-splitting and subsequent FNG was suggested as a treatment option. The procedure was explained to the patient, and she was informed of the associated risks. She chose to proceed with surgery. The procedure was successfully performed using a single-stage approach. The patient did not suffer any complications and had good wound healing, which led to a pleasing cosmetic result and eliminated the need to return to the hospital for further treatment.

Discussion
The decision to perform FNG concurrently with a Goldilocks mastectomy provides several benefits. A FNG addresses the cosmetic impact of NAC removal, and the single-stage approach reduces overall recovery time, minimizes infection risk, and promotes a faster return to daily life. In this case, the patient’s desire for implant removal was accommodated while also providing total breast reconstruction in a single operation. The single-stage method helped to minimize postoperative complications and optimize the aesthetic outcome, ultimately yielding high patient satisfaction and improved quality of life.

Single-Stage Breast Reconstruction: The Application of Free Nipple Grafting in Goldilocks Mastectomy

Abstract Title 
Surgical Outcomes of Fresh Frozen Cartilage Use in Rhinoplasty: A Systematic Review 

Background 
Despite high satisfaction rates, rhinoplasty has a 5-15% revision rate, which is often complicated by insufficient cartilage. This challenge can be addressed with the use of cartilage grafts, including autologous cartilage and irradiated homologous costal cartilage. Recently, fresh frozen costal cartilage (FFCC) has emerged as a promising alternative, providing reduced donor site morbidity and preserved biomechanical properties. The purpose of this review is to systematically synthesize the existing literature on FFCC for rhinoplasty, focusing on surgical outcomes to inform clinicians and guide future research. 

Methods 
A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search input, “(fresh frozen) AND (rhinoplasty)” was utilized to identify relevant articles in six electronic databases: Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, Google Scholar, PubMed, Scopus, and Web of Science. Database searching yielded 83 records. Three independent reviewers screened and assessed identified articles based on pre-established eligibility criteria. Eligible studies reported original patient outcomes of rhinoplasty utilizing FFCC and provided sufficient data regarding outcomes. Extracted data included study design, patient demographics, technical details, and surgical outcomes. 

Results 
A total of five studies were included in the review, and collectively encompassed data for a total of 766 patients (83.9% female, 16.1% male) who underwent rhinoplasty with FFCC. This included 72 primary rhinoplasties (9.4%) and 694 revision procedures (90.6%). Across the 766 patients, there were 13 cases (1.7%) of infection, nine cases (1.2%) of warping and seven cases (0.9%) of cartilage resorption. Of studies reporting cartilage graft displacement, there was only one case (0.1%). Additionally, the reoperation rate ranged from 0.5% to 16% with an average of 2.3% (n=18) across the studies. 

Conclusion 
With comparable outcomes and low complication and reoperation rates, FFCC represents a safe and reliable alternative to autologous rib grafts for rhinoplasty. However, given the novelty of this technique, additional studies with larger patient populations and long-term follow-up are needed to validate these findings.

Surgical Outcomes of Fresh Frozen Cartilage Use in Rhinoplasty: A Systematic Review​

Introduction: Interest has grown in transcutaneous osseointegrated (TOI) upper extremity prosthetics as an alternative to traditional socket prosthetics. As of 2023, no upper extremity TOI prosthetic have received FDA approval in the United States. This study examines demographics and postoperative outcomes in patients who have received upper extremity TOI prosthetics globally.
Methods: The PubMed, EMBASE, and Cochrane databases were queried for cases of upper limb TOI prosthetics with variations in terms for osseointegration, prosthetics, and upper extremity anatomy. Studies were included if demographic and outcome data on patients with at least one amputation and TOI prosthetic at any site of the upper limb were present. Studies that pertained only to endoprostheses or lower extremity TOI, had incomplete information on multiple patients, exclusively reported biomechanical or material data, or were in non-English languages were excluded. Site and etiology of limb loss, age, sex, history of infection at TOI site, and subsequent surgery on the site were recorded. Descriptive statistics were calculated. 
Results: The search returned 1,314 articles, of which 907 were screened after duplicate exclusion. Ultimately, 27 studies with 95 patients were analyzed. Patients were predominantly male (N=70, 73.6%) and age at prosthetic placement ranged from 10 to 68 years. The most common prosthetic sites were the thumb (N=33, 35.7%) and humerus (N=21, 22.1%). Eleven patients required secondary surgery; 10 were for hardware problems (e.g., loosening, breakage) and one was a soft tissue revision. Infections between surgery and first follow-up were reported in 11.5% of patients. Only 46.3% of studies explicitly discussed infection outcomes following TOI. 
Conclusion: TOI prosthetics have been used with some success internationally, but clinical data is limited and reports are inconsistent. Lack of approval in the U.S. has made analysis of outcomes difficult. While infection is a valid concern, implant hardware is a frequently reported cause of subsequent surgeries at TOI prosthetic sites. 


Transcutaneous Osseointegration for Upper Extremity: A Systematic Review of the Literature

Background: Peripheral nerve injuries present a major challenge due to limited functional and sensory recovery with current treatments. Human amniotic and umbilical cord membranes show promise in tissue regeneration but are limited by the quantity and variety of growth factors they release. This study evaluates the efficiency of umbilical cord and placental membranes as biological scaffolds for lysozyme delivery. The assessment includes investigating the binding capacity of double-walled microspheres (DWMS) loaded with lysozyme to the membranes and characterizing the subsequent lysozyme release kinetics.

Methods: Lysozyme, chosen for its similar properties to glial-derived neurotrophic factor (GDNF), was encapsulated in biodegradable poly lactic-co-glycolic acid (PLGA)/poly lactic acid (PLA) microspheres using a water-oil-water emulsion solvent evaporation technique. The binding capacity and release kinetics of lysozyme from DWMS bound to cryopreserved and lyophilized umbilical cord and placental membranes were assessed over 1, 6, and 24 hours, using the Bicinchoninic Acid assay.

Results: Our findings demonstrated that lysozyme-loaded DWMS bound similarly to both cryopreserved and lyophilized umbilical cord membranes. However, placental membranes soaked for 1 and 24 hours exhibited significantly higher lysozyme release (p<0.05) compared to non-loaded membranes. Notably, placental membranes soaked for 24 hours released 1.57 times more lysozyme than those soaked for 1 hour at the 72-hour mark. Furthermore, lysozyme release from both cryopreserved and lyophilized umbilical cord membranes was significantly greater after 6 and 24 hours of DWMS treatment compared to placental membranes (p<0.05). Cryopreserved umbilical cord membranes specifically showed a greater release than lyophilized membranes when assessed at these time points (p<0.05).

Conclusion: Placental membranes demonstrated superior efficacy as scaffolds for lysozyme-loaded DWMS delivery, particularly with longer incubation periods. Cryopreserved umbilical cord membranes were more effective than lyophilized ones, suggesting that preservation methods impact therapeutic potential. These findings highlight a novel approach for enhancing peripheral nerve regeneration through improved drug delivery systems.

Umbilical Cord & Placental Membranes as Biological Scaffolds for Drug Delivery in Nerve Regeneration

Using Digested and Lyophilized Bone Matrices for Enhanced Retention and Sustained Release of BMP-2 for Bone Regeneration
Background
Human recombinant bone morphogenetic protein 2 (rhBMP-2) is an FDA-approved growth factor that promotes bone formation but includes safety risks like inflammation and ectopic bone formation. Current research aims to enhance rhBMP-2 delivery strategies, as prolonged, controlled release improves bone healing and reduces side effects compared to short-term release. Currently, collagen sponges are often used for the delivery of rhBMP-2 but suffer from poor structural stability and inadequate release profiles. A previous study developed a sponge- like matrix from decellularized, demineralized, and enzymatically digested porcine bone, demonstrating biocompatibility and bone regeneration. In this study, we created a similar digested and lyophilized bone matrix (DLBM) while adding synthetic BMP2 (sBMP2) and stabilizing with glutaraldehyde (GL) crosslinking in the hopes of creating a safe and efficacious BMP2 delivery system.
Methods
The digested and lyophilized bone matrix (DLBM) was fabricated using established methods, with synthetic BMP2 peptide (sBMP2) infused and stabilized through glutaraldehyde (GL) crosslinking. This DLBM/BMP2/GL construct was compared to a DLBM/BMP2 scaffold without crosslinking. Over four weeks, we assessed in vitro degradation and BMP2 release of both constructs at various time points. The in vivo efficacy of the DLBM/BMP2/GL scaffold was evaluated using a non-healing tibial defect model in a rat model, analyzing bone growth via CT and histology after eight weeks.
Results
In vitro degradation experiments showed that the DLBM/BMP2/GL scaffold retained significantly more of its original mass (~40%) compared to the non-GL scaffold (~17%). Additionally, we found significantly higher retention of sBMP2 in the DLBM/BMP2/GL scaffold at all time points. CT analysis and histological examinations further indicated that the DLBM/BMP2/GL scaffold exhibited enhanced regenerative capability over the DLBM scaffold in vivo, demonstrating improved efficacy.

Conclusion
Our study underscores the potential of the DLBM/BMP2/GL scaffold as a promising platform for bone tissue engineering. We found that a sponge-like matrix, comprised of the digested and lyophilized bone matrix (DLBM) of pig bone, could effectively retain BMP2 peptide after chemical crosslinking using glutaraldehyde (DLBM/BMP2/GL). Further, we found a much more sustainable and controllable release profile of the BMP2 from the DLBM/BMP2/GL matrix when compared to the same BMP2-infused DLBM structure without any chemical crosslinking applied. Our in vivo evaluations demonstrate the improved biocompatibility, osteogenicity, and bone regenerative capacity of the DLBM/BMP2/GL scaffold compared to DLBM alone. Overall, our findings contribute to advancing innovative strategies for optimizing bone tissue engineering outcomes, thereby enhancing clinical efficacy and safety in bone repair and regeneration applications.

Using Digested and Lyophilized Bone Matrices for Enhanced Retention and Sustained Release of BMP-2 for Bone Regeneration

Background 
Vaginal rejuvenation refers to a variety of procedures that aim to improve genitourinary function or cosmetics. Local estrogen is the current standard of care to address complaints of vulvovaginal atrophy and vaginal laxity. However, energy-based treatments have become an emerging treatment option. Following an FDA statement in 2018 expressing concern over alleged lack of supporting evidence, laser and radiofrequency treatment of the vagina remains somewhat controversial.
Methods
The PubMed, EMBASE, and CENTRAL databases were queried for English-language studies published between November 2018 and June 2024 with terms associated with vaginal rejuvenation, including but not limited to, “vaginal” or “vagina” and “genitourinary syndrome of menopause” or “rejuvenation” or “vulvovaginal atrophy” or “vaginal atrophy”. Searches also included “laser” or “erbium-doped yttrium aluminum garnet” or “diode” or “carbon dioxide” or “CO2” or “radiofrequency” or “thermal”. 
Studies were included if they included at least one patient 18 years of age and older undergoing laser or radiofrequency therapy of the vagina for a specific vaginal or lower urinary complaint. Studies with purely cosmetic indications were excluded, as were studies with combined therapies, animal or cadaver models, or participants with active infectious or neoplastic pathology of the genitourinary system. Additionally, studies must have been available in full text and reported clinical outcome data, including standardized measures of patient reported outcomes and qualitative symptom data. Studies that did not explicitly report the presence or absence of adverse effects were excluded. 
Results
A total of 1374 studies were identified (EMBASE=792, PubMed=376, CENTRAL=206). 337 duplicates were excluded and 1059 studies were ultimately screened. 77 studies were included with a total number of 5,143 patients. 27 of these were randomized controlled trials, 40 were prospective interventional studies, and 10 were retrospective studies. A majority (79%) used laser treatment for vaginal rejuvenation. Indication for rejuvenation was stress urinary incontinence in 18 studies and genitourinary syndrome of menopause or its related symptoms in 
the remaining. 93.5% (N=72/77) of the studies reported improvements in patient-reported outcomes. Just under half (49.4%) of the studies reported at least minor or transient adverse effects of the treatment. These included vaginitis, leukorrhea, vaginal pain, dysuria, and urinary tract infection.
Conclusion 
Laser and radiofrequency treatment of the vagina has demonstrated improvement in patientreported outcomes for genitourinary symptoms associated with vaginal atrophy and urinary incontinence. Adverse effects of vaginal rejuvenation in the literature are minor, suggesting that this is a safe and effective option for patients with post-menopausal complaints requiring vaginal rejuvenation.

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