bluuebunny/crossref_metadata_2025_split huggingface dataset:
Lower Extremity Free Flaps for Breast Reconstruction
Authors: Dayan Joseph H. , Allen Robert J. 
Published: October 2017

Summary:
Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.
Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction
Authors: Colwell Amy S. , Christensen Joani M. 
Published: October 2017

Summary:
Breast reconstruction following mastectomy has evolved to preserve the native skin and nipple of the breast and create a natural-appearing reconstruction in 1 or 2 surgeries. Nipple-sparing procedures appear to be oncologically safe with low risks of cancer recurrence. In our series of 2,182 nipple-sparing mastectomies, there was no development or recurrence of cancer in the nipple. Direct-to-implant single-stage surgery offers the patient a complete reconstruction at the time of mastectomy. Patient selection centers on preoperative breast anatomy combined with postoperative goals for size and uplift of the breast. The best candidates for nipple-sparing mastectomy and direct-to-implant breast reconstruction include those with grade I–II breast ptosis and those desiring to stay approximately the same breast size. The choice of incision and width of the implant play key roles in nipple centralization. Partial muscle coverage with acellular dermal matrix remains the most common technique to support the implant and offers the advantage of more soft-tissue coverage in the upper pole. With experience, complications and revisions are similar in this approach compared with more traditional 2-stage tissue expander-implant reconstruction. Thus, nipple-sparing mastectomy and direct-to-implant breast reconstruction is emerging as a preferred method of breast reconstruction when the breast skin envelope is sufficiently perfused.
Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy
Authors: Losken Albert , Hart Alexandra M. , Chatterjee Abhishek 
Published: October 2017

Summary:
The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.
Updates in Head and Neck Reconstruction
Authors: Largo Rene D. , Garvey Patrick B. 
Published: October 2017

Learning Objectives:
After reading this article, the participant should be able to: 1. Have a basic understanding of virtual planning, rapid prototype modeling, three-dimensional printing, and computer-assisted design and manufacture. 2. Understand the principles of combining virtual planning and vascular mapping. 3. Understand principles of flap choice and design in preoperative planning of free osteocutaneous flaps in mandible and midface reconstruction. 4. Discuss advantages and disadvantages of computer-assisted design and manufacture in reconstruction of advanced oncologic mandible and midface defects.

Summary:
Virtual planning and rapid prototype modeling are increasingly used in head and neck reconstruction with the aim of achieving superior surgical outcomes in functionally and aesthetically critical areas of the head and neck compared with conventional reconstruction. The reconstructive surgeon must be able to understand this rapidly-advancing technology, along with its advantages and disadvantages. There is no limit to the degree to which patient-specific data may be integrated into the virtual planning process. For example, vascular mapping can be incorporated into virtual planning of mandible or midface reconstruction. Representative mandible and midface cases are presented to illustrate the process of virtual planning. Although virtual planning has become helpful in head and neck reconstruction, its routine use may be limited by logistic challenges, increased acquisition costs, and limited flexibility for intraoperative modifications. Nevertheless, the authors believe that the superior functional and aesthetic results realized with virtual planning outweigh the limitations.
An Algorithm for Managing Intraosseous Vascular Anomalies of the Craniofacial Skeleton
Authors: Isaac Kathryn V. , Teshima Tara Lynn , Aviv Richard I. , Fazl Mahmood , da Costa Leodante , Mainprize Todd , Antonyshyn Oleh 
Published: October 2017

Background:
Intraosseous vascular anomalies (IOVA) are rare in the craniofacial skeleton and present a diagnostic and therapeutic challenge. This study aims to describe the clinical management based on a large case series.

Methods:
A retrospective chart review was performed and 9 IOVA were identified over a 15-year period. Data on demographics, diagnostic features, clinical management, and outcomes were reviewed.

Results:
Five frontal bone IOVA and 4 orbital IOVA were identified. The postoperative follow-up ranged from 4 months to 4 years. All 9 lesions were diagnosed with computed tomography (CT) imaging. Magnetic resonance imaging (MRI) was used to delineate soft tissue involvement in 2 patients presenting with oculo-orbital dystopia and ophthalmoplegia. En bloc excision was performed in all patients. Preoperative interventional embolization was critical in the successful resection of an orbital IOVA following 2 previously failed attempts that were aborted secondary to hemorrhage. Intraoperative 3-dimensional stereotactic navigation was used for the accurate en bloc excision of a frontal IOVA to prevent injury to the frontal sinus. Reconstruction of esthetic and functional deformities was successfully accomplished.

Conclusion:
The diagnosis of IOVA relies primarily on clinical assessment and CT imaging. Further interpretation of the involvement of periorbital, facial, and intracranial soft tissue is best defined by MRI. Multidisciplinary care with interventional radiology and neurosurgery must be considered for ensuring the safe and adequate en bloc excision of craniofacial IOVA.
Defining and Correcting Asymmetry in Isolated Unilateral Frontosphenoidal Synostosis: Differences in Orbital Shape, Facial Scoliosis, and Skullbase Twist Compared to Unilateral Coronal Synostosis
Authors: Mundinger Gerhard S. , Skladman Rachel , Wenger Tara , Birgfeld Craig C. , Gruss Joseph S. , Lee Amy , Ellenbogen Richard , Hopper Richard A. 
Published: October 2017

Introduction:
Isolated frontosphenoidal synostosis (FS) is a rare cause of fronto-orbital plagiocephaly that can be challenging to distinguish from isolated unicoronal synostosis (UC). The purpose of this paper is to analyze differences in fronto-orbital dysmorphology between the 2 conditions, to describe approaches for surgical correction, and to report surgical outcomes between FS and UC patients in a casecontrol fashion.

Methods:
Patients treated for craniosynostosis over a 12-year period at our institution were retrospectively evaluated under institutional review board approval. Frontosphenoidal synostosis patients who underwent bilateral fronto-orbital correction of anterior plagiocephaly with minimum 2-year follow-up, adequate pre-, and minimum 2-year postoperative computed tomography scans were included in the case-control portion of the study. These patients were randomly age-matched to UC patients meeting the same inclusion criteria. Preoperative and postoperative orbital shape and volumetric analysis was performed using Mimics software.

Results:
Twelve FS patients were treated during the study period. Seven of these patients met casecontrol inclusion criteria with average follow-up of 47.5 months. The characteristic FS orbit was a relatively wide, short, and shallow trapezoid, while the characteristic UC orbit was a relatively narrow, tall, and deep parallelogram. Frontosphenoidal synostosis orbits were significantly wider, shorter, shallower, and smaller than UC orbits. Surgical correction tailored to the differential dysmorphologies resulted in statistical equalization of these differences between affected and contralateral control orbits at follow-up, with the exception of UC orbital width, which remained significantly narrower than unaffected contralateral control. One patient in each group required cranioplasty for skull defects at follow-up, while no patient underwent surgical readvancement.

Conclusions:
Frontosphenoidal synostosis and UC orbital shape differ significantly, and can be normalized using fronto-orbital advancement tailored to the distinct orbital dysmorphologies of these 2 groups.
Cell Polarity and PAR Complex Likely to Be Involved in Dexamethasone-Induced Cleft Palate
Authors: Ma Li , Shi Bing , Zheng Qian 
Published: October 2017

Abstract
Accumulating studies demonstrated that PAR complex contributed to the establishment and maintenance of cell polarity which was fundamental to many aspects of cell and developmental biology. The purpose of this study was to investigate whether dexamethasone (DEX) could downregulate the PAR complex and disrupt cell polarity in palatal epithelium during palatal fusion in mice. The C57BL/6J mice were selected for the experiment. Pregnant mice in control group and DEX-treated group were injected intraperitoneally with 0.9% sodium chloride 0.1 mL, which contained DEX 6 mg/kg respectively, every day from E10 to E12. The palatal epithelia morphology was observed with hematoxylin and eosin and scanning electron microscopy. Immunofluorescence staining, western blot, and real-time polymerase chain reaction were performed to detect the expression of PAR3/PAR6/aPKC. After being treated with DEX, the palatal shelves showed delayed development and became shorter and smaller. During the process of palatogenesis, PAR3 and PAR6 expressed in the palatal epithelium, and aPKC expressed in both the epithelium and the mesenchyme. Dexamethasone could downregulate the expression levels of PAR3/PAR6/aPKC in both protein and gene level. In conclusions, DEX affected the PAR complex of mouse embryonic palate, and could perturb the PAR complex and the cell polarity of medial edge epithelium cells, and caused the failure of palatal fusion.
Rigid External Distractor-Aided Advancement After Simultaneously Performed LeFort-III Osteotomy and Fronto-Orbital Advancement
Authors: Safi Ali-Farid , Kreppel Matthias , Kauke Martin , Grandoch Andrea , Nickenig Hans-Joachim , Zöller Joachim 
Published: October 2017

Abstract
Due to the complex development of the craniofacial skull, corrective surgery is a major challenge for patients with severe craniofaciostenosis. Although fronto-orbital advancement and simultaneous LeFort-III osteotomy in combination with distraction osteogenesis have been reported as a safe and successful method to obtain good esthetic and functional results, there is a lack of studies evaluating this method.
Our retrospective study included 12 patients with syndromic craniofaciostenosis, who were primarily treated at our department in accordance with a standardized treatment protocol, consisting of a simultaneous fronto-orbital advancement with LeFort-III osteotomy in combination with a rigid external distractor (RED-II). Distraction distance, duration of operation, postoperative complications, perioperative hemoglobin concentration, esthetic outcome, and the subjective Whitaker Scale were used to evaluate the success of our surgical method.
The esthetic outcome of all of our patients was assessed as good. Furthermore, the surgical outcome was assigned I for 11 patients and II for 1 patient, who suffered from wound healing disturbance at the left temporal site, which required revision 2 weeks postoperatively. The mean skeletal advancement of the midface was 16.4 mm, ranging from 12 to 20 mm.
Our standardized treatment protocol, consisting of fronto-orbital advancement in combination with LeFort-III osteotomy and application of a rigid external distractor device (RED-III) for patients with severe syndromic craniofaciostenosis, goes along with low infection rates and more predictable and precise esthetic and functional outcomes than the conventional surgical technique without distraction osteogenesis.
How Many Observations are Needed to Assess a Surgical Trainee's State of Operative Competency?
Authors: Williams Reed G. , Swanson David B. , Fryer Jonathan P. , Meyerson Shari L. , Bohnen Jordan D. , Dunnington Gary L. , Scully Rebecca E. , Schuller Mary C. , George Brian C. 
Published: October 2017

Objective:
To establish the number of operative performance observations needed for reproducible assessments of operative competency.

Background:
Surgical training is transitioning from a time-based to a competency-based approach, but the number of assessments needed to reliably establish operative competency remains unknown.

Methods:
Using a smart phone based operative evaluation application (SIMPL), residents from 13 general surgery training programs were evaluated performing common surgical procedures. Two competency metrics were investigated separately: autonomy and overall performance. Analyses were performed for laparoscopic cholecystectomy performances alone and for all operative procedures combined. Variance component analyses determined operative performance score variance attributable to resident operative competency and measurement error. Generalizability and decision studies determined number of assessments needed to achieve desired reliability (0.80 or greater) and determine standard errors of measurement.

Results:
For laparoscopic cholecystectomy, 23 ratings are needed to achieve reproducible autonomy ratings and 17 ratings are needed to achieve reproducible overall operative performance ratings. For the undifferentiated mix of procedures, 60 ratings are needed to achieve reproducible autonomy ratings and 40 are needed for reproducible overall operative performance ratings.

Conclusion:
The number of observations needed to achieve reproducible assessments of operative competency far exceeds current certification requirements, yet remains an important and achievable goal. Attention should also be paid to the mix of cases and raters in order to assure fair judgments about operative competency and fair comparisons of trainees.
Carotid Artery Reactivity Predicts Events in Peripheral Arterial Disease Patients
Authors: van Mil Anke C. C. M. , Pouwels Sjaak , Wilbrink Jelmer , Warlé Michiel C. , Thijssen Dick H. J. 
Published: October 2017

Objective:
Patients with peripheral arterial disease (PAD) have increased risk on future cerebro- and cardiovascular events. Our aim was to examine whether carotid artery reactivity (CAR; a novel, simple procedure to examine endothelial function) predicts cardiovascular events in PAD patients.

Background:
Increased risk for future cardiovascular events in PAD patients is likely related to endothelial dysfunction, highlighting the necessity for simple assessment of endothelial function.

Methods:
A total of 172 PAD patients (68 ± 10 years, 67% male) underwent the CAR, which involves ultrasound measurement of carotid artery diameter during sympathetic stimulation produced by 90-second hand immersion in 4°C ice-water (ie, cold pressor test). CAR-responses were dichotomized into carotid constriction or dilation. We recorded cardiac and cerebrovascular events, mortality, and clinical progression to percutaneous transluminal angioplasty or loss of patency during 12-month follow-up.

Results:
Eighty-two PAD patients demonstrated carotid constriction and 90 patients demonstrated dilation. PAD patients with carotid constriction showed more cardiovascular events compared to patients with dilation (Kaplan-Meier Log rank; P < 0.05). Cox proportional hazard models showed that patients with carotid constriction continued to show higher risk for cardiovascular events [hazard ratio: 4.1; 95% confidence interval (CI), 1.3–12.5] and clinical progression (hazard ratio: 2.0; 95% CI, 1.2–3.3), even after adjustment for other risk factors. Ankle brachial pressure index and carotid intima-medial thickness alone did not predict (cardiovascular) event or improve risk assessment beyond that provided by CAR.

Conclusion:
Carotid vasoconstriction identifies PAD patients with a 4-fold increased risk for future cardiovascular events and 2-fold increased risk for clinical deterioration. CAR provides a simple, novel strategy to predict cardiovascular events and progression in PAD patients.

Clinical Trial Registration:

www.trialregister.nl/trialreg/index.asp, NTR-4117.
Usefulness of the Transoral Anvil Delivery System for Esophagojejunostomy After Laparoscopic Total Gastrectomy: A Single-institution Comparative Study of Transoral Anvil Delivery System and the Overlap Method
Authors: Yoshikawa Kozo , Shimada Mitsuo , Higashijima Jun , Tokunaga Takuya , Nishi Masaaki , Takasu Chie , Kashihara Hideya , Ishikawa Daichi 
Published: October 2017

Purpose:
Many reconstruction techniques have been reported after laparoscopic total gastrectomy (LTG), but it is not clear which anastomosis technique is most useful, and no standard methods have been established. This study examined whether LTG using the transoral anvil delivery system (TOADS) is a feasible and safe procedure for gastric cancer.

Materials and Methods:
A series of 47 patients underwent the overlap method and 36 underwent the hemi-double-stapling technique with TOADS. Intraoperative and postoperative outcomes were compared between the 2 groups.

Results:
In the TOADS group, operation time for reconstruction was shorter (16±3 vs. 45±10 min, P=0.003), and blood loss was reduced (45±15 vs. 126±13 mL, P=0.0002). There were no significant differences in intraoperative complications, conversion to open surgery, and intraoperative anastomosis-related complications between the 2 groups. Furthermore, there were no significant differences in the incidence of complications, reoperation, mortality, and postoperative hospital stay.

Conclusion:
LTG using TOADS for gastric cancer may be a technically feasible surgical procedure with acceptable morbidity.
Information theory, evolutionary innovations and evolvability
Authors: Wagner Andreas 
Published: October 2017

How difficult is it to ‘discover’ an evolutionary adaptation or innovation? I here suggest that information theory, in combination with high-throughput DNA sequencing, can help answer this question by quantifying a new phenotype's information content. I apply this framework to compute the phenotypic information associated with novel gene regulation and with the ability to use novel carbon sources. The framework can also help quantify how DNA duplications affect evolvability, estimate the complexity of phenotypes and clarify the meaning of ‘progress’ in Darwinian evolution.
This article is part of the themed issue ‘Process and pattern in innovations from cells to societies’.
The conceptual foundations of network-based diffusion analysis: choosing networks and interpreting results
Authors: Hoppitt Will 
Published: October 2017

Network-based diffusion analysis (NBDA) is a statistical technique for detecting the social transmission of behavioural innovations in groups of animals, including humans. The strength of social transmission is inferred from the extent to which the diffusion (spread) of the innovation follows a social network. NBDA can have two goals: (a) to establish whether social transmission is occurring and how strong its effects are; and/or (b) to establish the typical pathways of information transfer. The technique has been used in a range of taxa, including primates, cetaceans, birds and fish, using a range of different types of network. Here I investigate the conceptual underpinnings of NBDA, in order to establish the meaning of results using different networks. I develop a model of the social transmission process where each individual observation of the target behaviour affects the rate at which the observer learns that behaviour. I then establish how NBDAs using different networks relate to this underlying process, and thus how we can interpret the results of each. My analysis shows that a different network or networks are appropriate depending on the specific goal or goals of the study, and establishes how the parameter estimates yielded from an NBDA can be interpreted for different networks.This article is part of the themed issue ‘Process and pattern in innovations from cells to societies’.
Cooperation and cheating as innovation: insights from cellular societies
Authors: Aktipis Athena , Maley Carlo C. 
Published: October 2017

The capacity to innovate is often considered a defining feature of human societies, but it is not a capacity that is unique to human societies: innovation occurs in cellular societies as well. Cellular societies such as multicellular bodies and microbial communities, including the human microbiome, are capable of innovation in response to novel opportunities and threats. Multicellularity represents a suite of innovations for cellular cooperation, but multicellularity also opened up novel opportunities for cells to cheat, exploiting the infrastructure and resources of the body. Multicellular bodies evolve less quickly than the cells within them, leaving them vulnerable to cellular innovations that can lead to cancer and infections. In order to counter these threats, multicellular bodies deploy additional innovations including the adaptive immune system and the development of partnerships with preferred microbial partners. What can we learn from examining these innovations in cooperation and cheating in cellular societies? First, innovation in social systems involves a constant tension between novel mechanisms that enable greater size and complexity of cooperative entities and novel ways of cheating. Second, cultivating cooperation with partners who can rapidly and effectively innovate (such as microbes) is important for large entities including multicellular bodies. And third, multicellularity enabled cells to manage risk socially, allowing organisms to survive in challenging environments where life would otherwise be impossible. Throughout, we ask how insights from cellular societies might be translated into new innovations in human health and medicine, promoting and protecting the cellular cooperation that makes us viable multicellular organisms.
This article is part of the themed issue ‘Process and pattern in innovations from cells to societies’.