Functional Analysis of Anuran Pelvic and Thigh Anatomy Using Musculoskeletal Modelling of Phlyctimantis maculatus.

Using their abundant musculature, frogs are able to exhibit outstanding behavioural versatility. However, understanding the dynamic motion of their 30 + hindlimb muscles, with multi-joint action, and curved pathways, is challenging. This is particularly true in walking, a relatively understudied, but complex frog gait. Building on prior musculoskeletal modelling work we construct and analyse a 3D musculoskeletal model of the spine, pelvis, and hindlimb of Phlyctimantis maculatus (previously known as Kassina maculata) to simulate the natural motion of muscle pathways as joints rotate during locomotion. Combining experimental kinematics and DICE-CT scan data we use several simulations conducted in MuJoCo to decouple femur and pelvic motions, generating new insights into the functional mechanics of walking in frogs. Outputs demonstrate pelvic lateral rotation about the iliosacral joint influences moment arm magnitude in the majority of hindlimb muscles. The extent of pelvic influence depends on femoral angle which changes muscle function in some instances. The workflow presented here can be used to help experimentalists predict which muscles to probe with in vivo techniques towards a better understanding of how anuran musculoskeletal mechanics enable multiple behaviours.

Constraining the External Capture to the

The ^{12}C(α,γ)^{16}O reaction is one of the most crucial reactions in nuclear astrophysics. The E2 external capture to the ^{16}O ground state (GS) has not been emphasized in previous analyses but may make a significant contribution to the ^{12}C(α,γ)^{16}O cross section depending on the value of the GS asymptotic normalization coefficient (ANC). In the present work, we determine this ANC to be 337±45 fm^{-1/2} through the ^{12}C(^{11}B,^{7}Li)^{16}O reaction using a high-precision magnetic spectrograph. This sheds light on the existing large discrepancy of more than 2 orders of magnitude between the previously reported ANC values. Based on the new ANC, we experimentally constrain the GS external capture and show that through interference with the high energy tail of the 2^{+} subthreshold state, a substantial enhancement in the GS S_{E2}(300) factor can be obtained (70±7 keV b) compared to that of a recent review (45 keV b), resulting in an increase of the total S factor from 140 to 162 keV b, which is now in good agreement with the value obtained by reproducing supernova nucleosynthesis calculations with the solar-system abundances. This work emphasizes that the external capture contribution for the ground state transition cannot be neglected in future analyses of the ^{12}C(α,γ)^{16}O reaction.

Happy and Unhappy Patients: A Quantitative Analysis of Online Plastic Surgeon Reviews for Breast Augmentation.

BACKGROUND: Online reviews have become modern versions of the word-of-mouth recommendation, and prospective patients are increasingly consulting them before making decisions about their surgical care. The authors' objectives were to (1) identify trends in the use of online reviews, and (2) important reasons for patient satisfaction and dissatisfaction with aesthetic surgery. The authors selected breast augmentation as the primary procedure of interest. METHODS: Reviews of the top 10 to 20 most reviewed plastic surgeons in each of six large metropolitan areas were obtained from Google, Yelp, and RealSelf. Reviews were assessed for predefined dimensions of satisfaction and dissatisfaction. RESULTS: A total of 1077 breast augmentation reviews were obtained. Ratings were distributed bimodally, with peaks at five stars and one star. The majority of reviews were positive (87.5 percent). Relative popularity of Google versus Yelp varied across geographic regions, and average rating varied by platform. Between 2011 and 2016, the number of online reviews for breast augmentation grew at an average rate of 42.6 percent per year. Aesthetic outcome was the most commonly cited dimension (69.8 percent of reviews), whereas cost was mentioned in only 7.8 percent of reviews. A substantial minority of negative Yelp (37 percent) and Google (9.4 percent) reviews were written by patients who did not actually undergo surgery. Free-text analysis of heterogeneous reviews (containing positive and negative attributes) classified dimensions as critical, redeemable, or protective. CONCLUSION: As the influence of online review platforms continues to grow, understanding drivers of positive and negative reviews may help surgeons improve patient satisfaction.

Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment.

Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient's experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended "cocktails" for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.

Further evidence that human acellular dermal matrix decreases inflammatory markers of capsule formation in implant-based breast reconstruction.

BACKGROUND: Human acellular dermal matrix (HADM; previously termed "acellular cadaveric dermis") may limit inflammatory changes believed to play a role in capsular contracture, a common complication of implant-based breast reconstruction. OBJECTIVES: Differences between HADM and native breast capsule specimens were evaluated by immunohistochemical analysis of key inflammatory markers involved in capsule formation. METHODS: Twenty consecutive patients underwent immediate, 2-stage, implant-based breast reconstruction with dual-plane HADM. During tissue expander-implant exchange, full-thickness biopsies of biointegrated HADM and native breast capsule (internal control) from the tissue-expander envelope were obtained. Immunohistochemical analysis was performed for endothelial cells (CD31), B cells (CD20), T cells (CD3), macrophages (CD68), collagen I and III, and myofibroblasts (α-smooth muscle actin). Observed levels of marker labeling were semiquantitatively scored from 0 (none) to 3 (severe) by a blinded histopathologist and were statistically analyzed with the Wilcoxon rank sum test. RESULTS: A bilateral sample was obtained from 1 patient; all other samples were unilateral. Compared with capsule samples from native breast tissue, HADM samples had significantly lower levels of all inflammatory markers (P < .001). CONCLUSIONS: These lower levels of inflammatory markers support previous evidence that HADM may inhibit inflammatory and profibrotic signaling characteristics of breast capsule development and decrease the risk of capsular contracture. Further investigation is needed to determine the mechanism by which HADM inhibits these inflammatory cells, whether HADM reduces the incidence of breast capsular contracture, and if so, the longevity of this effect.

Young Plastic Surgeons Forum member survey: Part I. Investing in the future: attitudes toward the Plastic Surgery Foundation.

BACKGROUND: Professional and social changes have resulted in decreased involvement in organizations. Little is currently known about young plastic surgeons' attitudes toward the Plastic Surgery Foundation and its sponsored activities. The authors gathered opinions of young plastic surgeons to determine factors related to participation. METHODS: A 21-question online survey was e-mailed to all 2155 members of the Young Plastic Surgeons Forum. Questions were related to demographics, current involvement, and initiatives in education, research, funding, and health policy. RESULTS: Of 2155 forum members, 397 responded (19 percent response rate). Most had not contributed to the Plastic Surgery Foundation. The primary reason cited was financial hardship, and respondents noted this would change with increased practice revenue. Involvement in American Society of Plastic Surgeons committees correlated with contribution to Plastic Surgery Foundation. The main educational initiatives favored by Young Plastic Surgeons included critical analysis of literature/evidence-based medicine, statistical analysis, and compensation issues. According to respondents, primary areas for organizational focus should be clinical research, increased representation of young surgeons, and leadership development. Respondents would be more willing to donate if they could earmark their contributions for specific purposes, including leadership training, clinical research, and medical missions. CONCLUSIONS: Methods to recruit and retain young surgeons into the American Society of Plastic Surgeons and in contributing to the Plastic Surgery Foundation should include opportunities to participate at a decreased cost, focus on compensation issues, clinical research, leadership development, and increased young surgeon representation. These data should be used to guide efforts to increase young member involvement.

Young Plastic Surgeons Forum member survey: Part II. Advocacy in plastic surgery: opinions toward the ASPS and PlastyPAC.

BACKGROUND: Given the continued evolution of the American health system, the authors explored young plastic surgeons' attitudes on challenges affecting the specialty and the future role of organized plastic surgery and its advocacy mission. METHODS: A 21-question online survey was distributed to all members of the Young Plastic Surgeons Forum. Questions were related to demographics, attitudes toward policy issues, participation in the American Society of Plastic Surgeons, and its advocacy efforts. RESULTS: The survey was e-mailed to 2155 Forum members, of which 397 responded (19% response rate). Young plastic surgeons appear to be interested in American Society of Plastic Surgeons and PlastyPAC, as evidenced by a higher than normal response rate to this survey and rate of contribution. However, a lack of awareness about the details of the organizations and mechanisms for involvement remains. Scope-of-practice issues and encroachment on the specialty by noncore providers remain the top concern of young plastic surgeons. Other top concerns were financial barriers to participation in advocacy efforts and concerns with return on investment on PlastyPAC contributions. A majority received minimal or no public policy education on issues affecting plastic surgery during training. A minority currently participate in American Society of Plastic Surgeons advocacy efforts. CONCLUSIONS: These data represent the first such collection of opinions from Young Plastic Surgeons members regarding goals and directions of the American Society of Plastic Surgeons and PlastyPAC. These organizations are in a uniquely strong position to enlist participation from and provide for the future success of the profession's younger members.

The role of acellular dermal matrices in capsular contracture: a review of the evidence.

Despite advances in breast implant surgery, capsular contracture remains a challenging sequela of reconstructive and cosmetic breast implant surgery. Although there are established modalities for treatment, most recently, acellular dermal matrix products have been suggested to have a role in preventing or diminishing the pathologic process of capsular contracture. In this article, the author presents a review of the literature to highlight the level of evidence on the role of acellular dermal matrices in the treatment of capsular contracture.

Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery.

BACKGROUND: Acellular cadaveric dermis in implant-based breast reconstruction provides an alternative to total submuscular placement. To date, there has been no detailed in vivo human analysis of the histopathologic sequelae of acellular cadaveric dermis in implant-based breast reconstruction. Based on clinical observations, we hypothesize that acellular cadaveric dermis decreases the inflammatory response and foreign body reaction normally seen around breast implants. METHODS: Twenty patients underwent tissue expander reconstruction using the "dual-plane" acellular cadaveric dermis technique (AlloDerm). During implant exchange, intraoperative biopsy specimens were obtained of (1) biointegrated acellular cadaveric dermis and (2) native subpectoral capsule (internal control). Histopathologic analysis was performed. Masked biopsy specimens were scored semiquantitatively by an experienced histopathologist to reflect observed granulation tissue formation, vessel proliferation, chronic inflammatory changes, capsule fibrosis, fibroblast cellularity, and foreign body giant cell inflammatory reaction. Scores were analyzed statistically using the Wilcoxon signed rank test. RESULTS: Acellular cadaveric dermis (AlloDerm) had statistically diminished levels for all parameters compared with corresponding native breast capsules (p<0.001). CONCLUSIONS: This represents the first detailed histopathologic comparative analysis between biointegrated acellular cadaveric dermis and native capsules in implant-based breast reconstruction. These histopathologic findings suggest that certain properties intrinsic to acellular cadaveric dermis may limit capsule formation by diminishing inflammatory changes that initiate capsule formation. Further investigation is needed to determine whether acellular cadaveric dermis reduces the incidence of breast capsular contracture.

Efficient atmospheric cleansing of oxidized organic trace gases by vegetation.

The biosphere is the major source and sink of nonmethane volatile organic compounds (VOCs) in the atmosphere. Gas-phase chemical reactions initiate the removal of these compounds from the atmosphere, which ultimately proceeds via deposition at the surface or direct oxidation to carbon monoxide or carbon dioxide. We performed ecosystem-scale flux measurements that show that the removal of oxygenated VOC via dry deposition is substantially larger than is currently assumed for deciduous ecosystems. Laboratory experiments indicate efficient enzymatic conversion and potential up-regulation of various stress-related genes, leading to enhanced uptake rates as a response to ozone and methyl vinyl ketone exposure or mechanical wounding. A revised scheme for the uptake of oxygenated VOCs, incorporated into a global chemistry-transport model, predicts appreciable regional changes in annual dry deposition fluxes.

Effective breast reconstruction in female veterans.

BACKGROUND: Despite increasing female veteran numbers, literature regarding reconstruction after breast cancer is lacking. The purpose of this study was to examine breast reconstruction referral rates and reconstruction outcomes at a tertiary Veterans Affairs hospital. METHODS: Female breast cancer patients (1997-2008) were identified. Demographics, tumor stage, oncologic therapies, reconstructive timings and procedures, and complications were noted. RESULTS: Eighty-two women underwent mastectomy (46%) or breast conservation (43%). The referral rates to plastic surgery were 61% (mastectomy) and 32% (overall). Reconstruction rates were 42% (mastectomy) and 22% (overall). Sixty-nine percent were suitable candidates and chose immediate (67%) or delayed (33%) reconstruction, with implant-based (44%), autologous (39%), or autologous plus implants (17%). There were complications (28%) but no mortalities. Comorbidities were not correlated with outcomes. CONCLUSIONS: Breast reconstruction can be effectively delivered within the Veterans Affairs system. It is essential that sufficient Veterans Affairs resources be deployed to address the increasing reconstructive needs of female veterans.

A prognostic model for the risk of development of upper extremity compartment syndrome in the setting of brachial artery injury.

A potentially devastating sequela of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985-2001. Objective characteristics of each case were extracted and analyzed using multivariate logistic regression. Three variables were found to be significant in the final model: estimated intraoperative blood loss as a continuous variable, and presence of a multiple arterial injury and presence of an open fracture as categorical variables. Odds ratio were 1.12, 5.79, and 2.68, respectively. We used these variables to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having CS for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively. Applying multivariate regression analysis to the largest series of brachial artery injuries to date, we have developed a predictive scoring model of CS.

Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.

Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Evidence-based patient safety advisory: liposuction.

Liposuction is considered to be one of the most frequently performed plastic surgery procedures in the United States, yet despite the popularity of liposuction, there is relatively little scientific evidence available on patient safety issues. This practice advisory provides an overview of various techniques, practices, and management strategies that pertain to individuals undergoing liposuction, and recommendations are offered for each issue to ensure and enhance patient safety.

Perioperative considerations for patient safety during cosmetic surgery - preventing complications.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.A review of the Joint Commission's Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.After review of the present paper, the reader should be able to introduce the Joint Commission's Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patient's experience and surgical outcome.

Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery.

Through its oversight of residency education in the United States, the Accreditation Council for Graduate Medical Education has mandated new structural changes in resident education with its newly created core competencies and an emphasis on outcomes-based education. These core competencies represent the central areas in which the Accreditation Council for Graduate Medical Education believes a plastic surgery resident should receive adequate and appropriate education and training. In addition, as part of this outcomes-based education, residents are to be evaluated on their level of mastery in these core competencies. Increasingly, the Accreditation Council for Graduate Medical Education will assess the ability of residency programs to integrate the teaching and evaluating of the core competencies in their accreditation process of plastic surgery residency programs. This shift in residency evaluation initiated by the Outcomes Project by the Accreditation Council for Graduate Medical Education will have a significant impact in how plastic surgery residents are taught and, as importantly, evaluated in the coming years. The objectives of this work were as follows: (1) to outline the different methods available to foster a core competency-based plastic surgery training curriculum and (2) to serve as a primer to help both full-time academic and clinical faculty to further develop their curriculum to successfully teach and constructively evaluate their residents in the core competencies in accordance with the Accreditation Council for Graduate Medical Education guidelines. At the conclusion of this review, the reader should have a better understanding of what is necessary to formulate and help foster a plastic surgery core competency curriculum, particularly with an emphasis on the contemporary methods used for outcomes evaluations.

Paget disease of a nipple graft following completion of a breast reconstruction with a nipple-sharing technique.

Surgical treatment of breast cancer can have a profound impact on patients both physically and psychologically. Postmastectomy breast reconstruction can significantly decrease the psychologic distress that a breast cancer patient experiences. Whereas breast mound reconstruction was initially thought to be sufficient, surgeons and patients have recognized the importance of nipple-areolar reconstruction. The following is a case report of a patient who developed Paget disease of a left nipple graft after left mastectomy and reconstruction with a TRAM flap and nipple sharing from the right breast. This case report provides a unique 14-year retrospective review of a clinical course and to our knowledge is the first reported case in the English literature of Paget disease developing in a nipple reconstructed from the contralateral nipple using the nipple-sharing technique.

Single-stage reconstruction of Achilles tendon injuries and distal lower extremity soft tissue defects with the reverse sural fasciocutaneous flap.

OBJECTIVE: Complex wounds of the lower extremity with concomitant Achilles tendon injury can be difficult to reconstruct. We favour the reverse sural artery fasciocutaneous flap because in a single step, flap elevation affords Achilles tendon exposure and adequate soft tissue for reconstruction. It also provides significant time and resource savings for both plastic and orthopaedic surgical teams. MATERIALS AND METHODS: Our case series involved four consecutive patients who presented with Achilles tendon injuries and concomitant complex soft tissue defects. The reverse sural artery flap was planned in conjunction with the orthopaedic service to facilitate their approach for Achilles tendon repair. Outcome was measured as flap survival, time for flap elevation and total operative time. RESULTS: Partial flap loss occurred in one patient. The Achilles repair was performed successfully in all cases. The mean time for flap elevation and Achilles exposure was 43 min (range, 37-52 min). Total operative time was 287 min (range, 211-347 min). CONCLUSION: The reverse sural artery fasciocutaneous flap is a durable, efficient option for simultaneous Achilles tendon reconstruction and wound coverage. Simple flap elevation provides necessary exposure of the Achilles tendon for repair while the flap itself provides ample soft tissue with a reliable blood supply. In our experience, the reverse sural artery fasciocutaneous flap affords a practical method to address two reconstructive challenges in a single procedure.

Ontogenetic scaling of foot musculoskeletal anatomy in elephants.

This study quantifies the shape change in elephant manus and pes anatomy with increasing body mass, using computed tomographic scanning. Most manus and pes bones, and manus tendons, maintain their shape, or become more gracile, through ontogeny. Contrary to this, tendons of the pes become significantly more robust, suggesting functional adaptation to increasingly high loads. Ankle tendon cross-sectional area (CSA) scales the highest in the long digital extensor, proportional to body mass(1.08+/-0.21), significantly greater than the highest-scaling wrist tendon (extensor carpi ulnaris, body mass(0.69+/-0.09)). These patterns of shape change relate to the marked anatomical differences between the pillar-like manus and tripod-like pes, consistent with differences in fore- and hindlimb locomotor function. The cartilaginous predigits (prepollux and prehallux) of the manus and pes also become relatively more robust through ontogeny, and their pattern of shape change does not resemble that seen in any of the 10 metacarpals and metatarsals. Their CSAs scale above isometry proportional to body mass(0.73+/-0.09) and body mass(0.82+/-0.07) respectively. We infer a supportive function for these structures, preventing collapse of the foot pad during locomotion.