Identification of brain areas in mice with peak neural activity across the acute and persistent phases of post-traumatic headache.

BACKGROUND: Post-traumatic headache is very common after a mild traumatic brain injury. Post-traumatic headache may persist for months to years after an injury in a substantial proportion of people. The pathophysiology underlying post-traumatic headache remains unknown but is likely distinct from other headache disorders. Identification of brain areas activated in acute and persistent phases of post-traumatic headache can provide insights into the underlying circuits mediating headache pain. We used an animal model of mild traumatic brain injury-induced post-traumatic headache and c-fos immunohistochemistry to identify brain regions with peak activity levels across the acute and persistent phases of post-traumatic headache. METHODS: Male and female C57BL/6 J mice were briefly anesthetized and subjected to a sham procedure or a weight drop closed-head mild traumatic brain injury . Cutaneous allodynia was assessed in the periorbital and hindpaw regions using von Frey filaments. Immunohistochemical c-fos based neural activity mapping was then performed on sections from whole brain across the development of post-traumatic headache (i.e. peak of the acute phase at 2 days post- mild traumatic brain injury), start of the persistent phase (i.e. >14 days post-mild traumatic brain injury) or after provocation with stress (bright light). Brain areas with consistent and peak levels of c-fos expression across mild traumatic brain injury induced post-traumatic headache were identified and included for further analysis. RESULTS: Following mild traumatic brain injury, periorbital and hindpaw allodynia was observed in both male and female mice. This allodynia was transient and subsided within the first 14 days post-mild traumatic brain injury and is representative of acute post-traumatic headache. After this acute post-traumatic headache phase, exposure of mild traumatic brain injury mice to a bright light stress reinstated periorbital and hindpaw allodynia for several hours - indicative of the development of persistent post-traumatic headache. Acute post-traumatic headache was coincident with an increase in neuronal c-fos labeling in the spinal nucleus of the trigeminal caudalis, primary somatosensory cortex, and the nucleus accumbens. Neuronal activation returned to baseline levels by the persistent post-traumatic headache phase in the spinal nucleus of the trigeminal caudalis and primary somatosensory cortex but remained elevated in the nucleus accumbens. In the persistent post-traumatic headache phase, coincident with allodynia observed following bright light stress, we observed bright light stress-induced c-fos neural activation in the spinal nucleus of the trigeminal caudalis, primary somatosensory cortex, and nucleus accumbens. CONCLUSION: Examination of mild traumatic brain injury-induced changes in peak c-fos expression revealed brain regions with significantly increased neural activity across the acute and persistent phases of post-traumatic headache. Our findings suggest mild traumatic brain injury-induced post-traumatic headache produces neural activation along pain relevant pathways at time-points matching post-traumatic headache-like pain behaviors. These observations suggest that the spinal nucleus of the trigeminal caudalis, primary somatosensory cortex, and nucleus accumbens may contribute to both the induction and maintenance of post-traumatic headache.

A1 Pulley Tenderness as a Modification to Tenderness along the Flexor Sheath in Diagnosing Pyogenic Flexor Tenosynovitis.

Background: Pyogenic flexor tenosynovitis (PFT) is frequently diagnosed by physical examination according to the Kanavel signs. This study proposes a modification of the Kanavel sign "tenderness over the course of the flexor sheath" by including palpation of the A1 pulley to increase specificity for diagnosis. Methods: A retrospective review was performed over 8 months for patients in the emergency department who received a consult to hand surgery to rule out PFT. Two cohorts, nonPFT infections and PFT infections, were studied for the presence or absence of the four Kanavel signs, as well as tenderness specifically over the A1 pulley on the affected digit(s) or T1 pulley of the thumb. Results: There were a total of 33 patients in the two cohorts (21 nonPFT, 12 PFT) with statistically significant differences with regard to the presence of all the Kanavel signs. A1 pulley tenderness had the greatest odds ratio, positive predictive value, specificity, and accuracy when compared with all Kanavel signs. When used in conjunction with each Kanavel sign, there was an increase in specificity in all four signs. Receiver operating characteristic analysis revealed increased area under the curve with A1 pulley tenderness added, indicating improved ability to classify hand infections as PFT versus nonPFT. Conclusion: Although the classic Kanavel signs have shown reliable clinical utility, this study finds that tenderness at the A1 pulley can be a useful specification of "tenderness over the course of the flexor sheath" to help with the diagnosis of PFT.

Enhanced psychostimulant response, but not social avoidance, depends on GluA1 AMPA receptors in VTA dopamine neurons following intermittent social defeat stress in rats.

Evidence from both human and animal studies demonstrates the importance of social stress in the development of addiction-related behaviour. In rats, intermittent social defeat stress causes long-lasting psychostimulant cross-sensitization. Our recent data reveal heightened expression of AMPA receptor (AMPAR) GluA1 subunit in rat ventral tegmental area (VTA), which occurs concurrently with social stress-induced amphetamine (AMPH) cross-sensitization. In addition, social stress in rats induced social avoidance behaviour. The present study evaluated the effects of intermittent social defeat stress on GluA1 expression in VTA dopamine (DA) neurons, then utilized Cre-dependent virus-mediated gene transfer to determine the functional role of homomeric GluA1-AMPARs in these neurons. Social defeat stress exposure induced GluA1 expression in VTA DA neurons, as demonstrated by a greater density of GluA1/tyrosine hydroxylase (TH) double-labelling in VTA neurons in stressed rats. Additionally, functional inactivation of VTA GluA1 AMPARs in DA neurons prevented stress-induced cross-sensitization, or augmented locomotor response to low dose AMPH challenge (1.0 mg/kg, i.p.), but had no effect on social stress-induced social avoidance behaviour. Furthermore, wild-type overexpression of GluA1 in VTA DA neurons had the opposite effect; locomotor-activating effects of AMPH were significantly augmented, even in the absence of stress. Taken together, these results suggest that stress-induced GluA1 expression in VTA DA neurons is necessary for psychostimulant cross-sensitization, but not for social avoidance. This differential effect suggests that different neural pathways are implicated in these behaviours. These findings could lead to novel pharmacotherapies to help prevent stress-induced susceptibility to substance abuse.

Automated 3D Analysis of Zygomaticomaxillary Fracture Rotation and Displacement.

BACKGROUND: The zygomaticomaxillary complex (ZMC) can experience a multitude of deforming forces. There is limited understanding on which deformities alter patient outcomes. This study utilized an automated, three-dimensional analysis to elucidate which fracture patterns and rotational deformities are most prevalent and associated with postoperative complications. METHODS: This study was a 7-year retrospective review of patients with unilateral ZMC fractures who underwent surgical intervention. Patient demographics, injury mechanisms, presenting symptoms, and postoperative outcomes were collected. Segmentation was completed using Mimics software. The lateral-medial, superior-inferior, and anterior-posterior axes were manually identified on the zygoma and then displacement, rotational direction, and rotational degrees were automatically calculated using Geomagic software. Total displacement score was generated by summation of individual displacement scores at each of the five sutures. RESULTS: Eighty-one patients satisfied inclusion criteria. The most prevalent rotational pattern of the zygoma was medially-superiorly-posteriorly (P < 0.001). When comparing rotation along the three axes, the zygoma had the greatest rotation along the lateral-medial axis compared with the superior-inferior (P = 0.003) and anterior-posterior (P < 0.001) axes. Within each axis, the zygoma was more likely to rotate medially than laterally (P = 0.003) and posteriorly than anteriorly (P = 0.01). Multivariate analysis identified total displacement scores and degrees rotated along the lateral-medial axis as significant predictors of facial complications and reoperation. CONCLUSIONS: This study suggests that patients with unilateral ZMC fractures who undergo surgical intervention are at an increased risk for adverse outcomes with greater rotation along the lateral-medial axis and higher total displacement scores. Additionally, the automated analysis method described can provide objective data to better characterize ZMC fractures.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy.

PURPOSE: Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy. METHODS: A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed. RESULTS: One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values. CONCLUSIONS: Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Revision periarterial sympathectomy for recurrent digital ischaemia: a report with 11 patients.

Following periarterial sympathectomy, patients with recurrent digital ischemia due to vasospastic or vaso-occlusive disease have few remaining treatment options. We performed a retrospective review from 1997 to 2019 to determine the safety and efficacy of revision periarterial sympathectomy. Eleven patients were identified who underwent revision periarterial sympathectomy, performed on average 84 months after their initial procedure. Preoperatively, all patients had worsening ischemic pain and five had non-healing digital ulcers. Revision digital periarterial sympathectomy alone was performed in seven patients, while four had a more extensive sympathectomy. Mean follow-up after revision was 23 months (range 3 to 76). Eight patients had symptomatic improvement and four healed their digital ulcers. Three patients developed new ulcers during follow-up, of which two healed with conservative management and one required three digital amputations. Revision periarterial sympathectomy is effective in providing symptomatic improvement and digital ulcer healing with minimal postoperative complications.Level of evidence: IV.

A Qualitative Study of Developing Competency in Thyroid Surgery: A Resident's Perspective With 5 Year Follow Up.

OBJECTIVES: The Accreditation Council for Graduate Medical Education has guidelines on assessing surgical qualifications based on experience. Attending surgeons have various assumptions on how their trainees learn and acquire surgical skills. This study primarily investigates the resident's perspective on gaining experience and achieving competency in thyroid surgical procedures. METHODS: A qualitative study using semi-structured interviews was designed to derive themes that discuss the acquisition of competency in thyroid surgery. After IRB approval, data was collected from 2012 to 2014 at 4 academic centers in the Washington, DC area. Fourteen chief residents specializing in either general surgery or otolaryngology were interviewed until saturation was achieved. These semi-structured interviews were transcribed and broken up into codes utilizing Moustakas' analysis. A comprehensive list of master themes in regards to achieving competency in thyroid surgery was developed. A follow up survey of the surgeons was undertaken at 5 years to determine if the perceptions during residency persisted in practice. RESULTS: Surgical specialty residents experience and learn thyroid surgery in 5 learning themes:1. Self-directed learning is significant during residency.2. Repetition with graduated autonomy is key.3. Effective mentors are competent surgeons who challenge residents and use positive teaching techniques.4. Residents employ active learning through the "see one, do one, teach one" philosophy.5. Learning from complexity is of importance to residency training.After several years in practice, the most important theme in learning after residency was repetition of cases. CONCLUSIONS: This study demonstrates how residents progress in approaching competency in thyroid surgery. Adult learning strategies are preferred, and programs should incorporate tailored techniques to meet the individual needs of the residents. Perceptions of what is most important shifted in long-term follow up. Further study is needed to assure competency in residency and in practice.

Operative risk stratification in the obese female undergoing implant-based breast reconstruction.

The prevalence of obesity is growing, and breast reconstruction in the obese patient is becoming the norm rather than the exception. Our aim was to evaluate implant reconstruction outcomes in the obese female in the presence of coincident surgical risk factors and identify potential risk-reducing interventions. A review of consecutive obese women (BMI ≥ 30) who underwent mastectomy and implant breast reconstruction was performed. Patient demographics, comorbidities, oncologic treatments, and reconstructive procedures and their complications were recorded. A total of 151 women (242 breast reconstructions) were included with mean follow-up of 28 months. Average BMI was 36. Eighty percent of cases were immediate and 20% delayed. ADMs were utilized in 58% of cases. About 25% of patients had diabetes with one-third achieving perioperative glycemic control. About 18% of women were active smokers, and 33% had radiotherapy. Major and minor complications occurred in 42% and 11% of patients, respectively. About 24% of reconstructed breasts required implant removal. Obese patients with prior radiation were three times as likely to develop infection (P = 0.008) and 2.5× as likely to undergo explantation (P = 0.002). Skin flap necrosis was three times as likely in obese smokers (P = 0.01). Increased rates of wound breakdown were identified in obese patients with increasing age (P = 0.005), smoking (P = 0.0035), and radiation (P = 0.023). In the obese radiated and smoking patient subgroups, surgical modifications (use of autologous tissue, delayed breast reconstruction timing, and no ADM) were associated with reduction in the relative risk for implant complications. While obesity alone increases implant breast reconstruction complication rates, the presence of additional risk factors compounds these rates. The use of surgical modifications may reduce the occurrence of perioperative complications in the obese female with coincident surgical risk factors undergoing implant breast reconstruction.

Broadening applications and insights into the cross-paramedian forehead flap over a 19-year period.

BACKGROUND: Forehead flap reconstruction of large nasal defects can be challenging. The senior author has used a paramedian forehead flap modification using the supratrochlear artery on the contralateral side of the defect. METHODS: A 9-year retrospective review (2008-2016) was performed for patients undergoing nasal reconstruction with the cross-paramedian forehead flap. Outcomes were analyzed by comparing our previous reviews, which allows us to analyze patient outcomes for over 19 years. RESULTS: Fifty-three patients were identified. The aasal defect was most frequently due to basal cell carcinoma (n = 37, 69.8%). Twenty-three (43%) patients were smokers, and nine (17%) had diabetes. The mean defect size was 12.9 cm2, involving an average of 2.6 nasal subunits. One-third of the patients had cartilage defects (n = 18) and mucosal lining defects (n = 19). Periorbital involvement was present in five patients. Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), flap dehiscence (n = 2), and postoperative infection (n = 1). Only two of the partial flap losses were considered significant, as they required additional reconstructive procedures for soft tissue coverage. Complications were 12 times as likely as those in diabetes (OR = 11.97, p = 0.007, 95% CI 1.94-72.44), six times as likely as those in cartilage defects (OR = 6.4, p = 0.007, 95% CI 1.64-24.92), and nearly five times as likely as those in mucosal lining defects (OR = 4.8, p = 1.27-18.09, 95% CI 1.27-18.09). Thirty-one patients required revisions most commonly for flap debulking (n = 16). CONCLUSION: The cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and complex defects in addition to those with periorbital extension. SUMMARY: Coverage of distal nasal defects after tumor extirpation remains a challenge to the reconstructive surgeon. Our institution uses the cross-paramedian forehead flap for these defects. This flap is based on the supratrochlear artery on the contralateral side of the defect and is oriented obliquely across the forehead for additional length and an improved donor site scar at the level of the eyebrow. The technique and outcomes were published in 2009, and this manuscript serves as an update on outcomes and applications during the past 9 years. By including all our data, we can analyze outcomes for over 19 years. During the past 9 years, 53 patients underwent the cross-paramedian forehead flap technique between 2008 and 2016. These patients were found to have an average defect size of 12.9 cm2 and an average loss of 2.6 nasal subunits. Cartilage defects were present in 34.6% (n = 18) and mucosal defects were present in 36.5% (n = 19) of patients. Five patients had periorbital reconstruction with the forehead flap, of which three patients underwent a single-stage islandized forehead flap reconstruction. Given the large defect size, additional local flaps were frequently used, including nasolabial flaps (n = 16) and cheek rearrangement (n = 11). Complications included partial flap loss (n = 6), donor site dehiscence (n = 4), and postoperative infection (n = 1). Only two of these partial flap losses were considered significant, as they required additional reconstructive procedures to address areas of soft tissue loss. Increased rates of complications were associated with the presence of diabetes and defect characteristics, which reflects increased complexity including mucosal and cartilage loss. When comparing with our prior review of this technique, the more recent population have had increasing complexity of the nasal defects with a large surface area involvement. Overall, the cross-paramedian forehead flap is a reliable option in the armamentarium of the reconstructive surgeon for large and distal nasal defects.

Outcomes Analysis of Chief Cosmetic Clinic Over 13 Years.

BACKGROUND: Adequate resident training in aesthetic surgery has become increasingly important with rising demand. Chief resident aesthetic clinics allow hands on experience with an appropriate amount of autonomy. The purpose of this study was to compare resident cosmetic clinic outcomes to those reported in the literature. Furthermore, we sought to assess how effective these clinics can be in preparing residents in performing common aesthetic surgery procedures. METHOD: A retrospective chart review of 326 patients and 714 aesthetic procedures in our chief cosmetic clinic over a 13-year period was performed, and complication and revision rates were recorded. In addition, an electronic survey was sent to 26 prior chief residents regarding their experience and impressions of the chief resident aesthetic clinic. RESULT: A total of 713 procedures were performed on 326 patients. Patient ages ranged from 5 to 75 years old (mean, 40.8 years old) with a mean follow-up of 76.2 days. On average, there were 56 procedures performed per year. Of the 714 total procedures performed, there were 136 minor procedures and 578 major procedures. Of the 136 minor procedures, there were no complications and there was 1 revision of a cosmetic injection. Of the 578 major procedures, the overall complication rate was 6.1% and the revision rate was 12.8%. Complication and revision rates for each individual surgery were further analyzed and compared with the literature. The complication rates for these procedures fell within the reference ranges reported. In regards to the chief resident survey, there was a 77% response rate. All respondents reported that the chief resident clinic positively affected their residency education and future practice. Ninety percent of respondents felt "very comfortable" performing facelifts, body contouring, and aesthetic breast surgery. No respondents completed a subsequent cosmetic fellowship, and 60% stated that their positive experience in chief clinic contributed to their decision not to pursue a cosmetic fellowship. CONCLUSIONS: Chief resident clinics can provide results with acceptable complication and revision rates that fall within the acceptable ranges in the literature. In addition, it provides a valuable experience that leaves residents with high comfort levels in performing key procedures in aesthetic surgery.

The patient's perioperative perspective during the treatment of obstructive sleep apnea: a pilot study.

PURPOSE: This study aims to determine patients' pre-operative and post-operative experiences relating to surgical treatment for obstructive sleep apnea (OSA), while understanding how patients' perceptions influence their outcome and satisfaction. METHODS: This is a phenomenological qualitative study using a semi-structured interview to evaluate patients who failed continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea and underwent airway surgery. Meaningful codes from the interviews were organized into overarching themes of patient experiences. The same surgeon in a tertiary care otolaryngology practice treated all patients. All patients underwent a modified or traditional uvulopalatopharyngoplasty (UPPP) between 2009 and 2013. Patients were diagnosed with OSA by polysomnogram and had failed CPAP use. Patients were interviewed regarding their experience with OSA, CPAP, and surgery. Thematic saturation was reached after 17 patients. RESULTS: Six themes exemplify patient's experience of OSA and treatment: (1) OSA impacted patients personally and professionally, (2) CPAP discomfort limited its therapeutic use, (3) patients had personal motivations for undergoing surgery, (4) patient knowledge influenced their perceptions, (5) post-operative challenges exceeded patient expectations, and (6) post-operative outcomes reflected positive effect on patients. CONCLUSIONS: Patients' experiences prior to surgery can largely influence their perceived outcome and satisfaction. Post-operative sleep studies may not capture the full outcome of the patients' response to surgery. This study suggests that the patient's subjective reported outcomes should be used in conjunction with objective post-operative sleep studies.

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management.

OBJECTIVE: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. METHODS: In this retrospective institutional review board-approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. RESULTS: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93. CONCLUSION: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

Anaplastic Large Cell Lymphoma: Emerging Consent and Management Patterns among American and International Board Certified Plastic Surgeons.

BACKGROUND: Although literature and case reports regarding anaplastic large cell lymphoma (ALCL) continue to increase, changes in plastic surgery practice patterns have not been assessed. METHODS: A 19-question survey was sent electronically to U.S. and international board-certified plastic surgeons. Data were analyzed using chi-square test and logistic regression analysis. RESULTS: A total of 1383 surgeons (U.S., 715; international, 668) responded, at a rate of 13.5 percent, and 36.2 percent of U.S. physicians aspirate late seromas and send for cytologic analysis and 9.5 percent had personal experience with ALCL, equating to at least 193 self-reported cases. Overall, 26.9 percent discuss ALCL risk at the initial consultation every time, and 36.4 percent include ALCL in the informed consent. Compared to U.S. counterparts, Australian, French, and German physicians were five times as likely to include ALCL in consent. Physicians in an academic practice and those frequently (>40 percent) using textured implants were more likely to discuss ALCL in the preoperative consultation. Physicians with personal or colleague experience with ALCL were twice as likely to include ALCL in the consent process. CONCLUSIONS: Only one-third of surgeons are managing late seroma according to U.S. Food and Drug Administration guidelines. ALCL cases are likely being underreported. Collectively, plastic surgeons remain hesitant to change consent pattern. However, specific countries have adapted their consenting processes. Working in academia and frequent textured implant use makes one more likely to discuss ALCL in consultation. Personal or colleague experience makes one twice as likely to include ALCL in the consent.

Lateral Approach to the Popliteal Artery for Free Tissue Transfer to the Lower Extremity.

Free tissue transfer to the proximal leg and knee requires appropriate recipient vessel selection. The popliteal vessels have historically been unpopular choices, due to their remote location often necessitating vein grafts, and need for prone positioning. In this report, we describe a lateral approach to the above-knee popliteal vessels, which was utilized for 2 cases of free tissue transfer to the lower extremity. Neither prone positioning nor vein grafts were needed. The lateral approach to the above-knee popliteal vessels and their branches is a viable option for the otherwise recipient vessel-depleted lower extremity.

Parvalbumin increases in the medial and lateral geniculate nuclei of aged rhesus macaques.

Subcortical auditory structures in the macaque auditory system increase their densities of neurons expressing the calcium binding protein parvalbumin (PV) with age. However, it is unknown whether these increases occur in the thalamic division of the auditory system, the medial geniculate nucleus (MGN). Furthermore, it is also unclear whether these age-related changes are specific to the macaque auditory system or are generalized to other sensory systems. To address these questions, the PV immunoreactivity of the medial and lateral geniculate nuclei (LGN) from seven rhesus macaques ranging in age from 15 to 35 was assessed. Densities of PV expressing neurons in the three subdivisions of the MGN and the six layers of the LGN were calculated separately using unbiased stereological sampling techniques. We found that the ventral and magnocellular subdivisions of the MGN and all six layers of the LGN increased their expressions of PV with age, although increases in the MGN were greater in magnitude than in the LGN. Together, these results suggest that the MGN shows age-related increases in PV expression as is seen throughout the macaque ascending auditory system, and that the analogous region of the visual system shows smaller increases. We conclude that, while there are some similarities between sensory systems, the age-related neurochemical changes seen throughout the macaque auditory system cannot be fully generalized to other sensory systems.