Characterizing Olfactory Dysfunction in Patients with Unilateral Cleft Lip Nasal Deformities.

Background: Unilateral cleft lip nasal deformity (uCLND) is associated with olfactory dysfunction, but the underlying etiology remains poorly understood. Objective: To investigate the etiology of uCLND-associated olfactory dysfunction using clinical, computational, and histologic assessments. Methods: Inclusion criteria: uCLND patients >16 years undergoing septorhinoplasty. Exclusion criteria: prior septoplasty or rhinoplasty, pregnancy, sinusitis. Measured outcomes: patient-reported scores, rhinomanometry, smell identification and threshold tests, computational fluid dynamics (CFD) airflow simulations, and histologic analysis of olfactory epithelium. Results: Five uCLND subjects were included: 18-23 years, three male and two female, four left-sided cleft and one right-sided cleft. All subjects reported moderate to severe nasal obstruction. Smell identification and threshold tests showed varying degrees of hyposmia. Nasal resistance was higher on the cleft side versus noncleft side measured by rhinomanometry (median 3.85 Pa-s/mL, interquartile range [IQR] = 21.96, versus 0.90 Pa-s/mL, IQR = 5.17) and CFD (median 1.04 Pa-s/mL, IQR = 0.94 vs. 0.11 Pa-s/mL, IQR = 0.12). Unilateral olfaction varied widely and was dependent on unilateral percentage olfactory airflow. Biopsies revealed intact olfactory neuroepithelium. Conclusions: uCLND-associated olfactory dysfunction appears to be primarily conductive in etiology and highly susceptible to variations in nasal anatomy. Clinical Trial Registration number: NCT04150783.

Early Simultaneous Cross Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis after Tumor Resection.

We describe a new approach for facial reanimation after skull base tumor resection with known facial nerve sacrifice, involving simultaneous masseter nerve transfer with selective cross facial nerve grafting (CFNG) within days after tumor surgery. This preliminary study compared outcomes of this approach versus a staged procedure involving a masseter nerve "babysitter" performed in a delayed timeline. Methods: Patients undergoing masseter nerve transfer and CFNG for facial paralysis after skull base tumor resection were consented to participate in video interviews. Facial Clinimetric Evaluation (FaCE) Scale (0-100) patient-reported outcome, eFACE, and Facial Grading Scale scores were compared. Results: Nine patients had unilateral facial paralysis from resection of a schwannoma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days after resection), whereas four underwent two-stage reanimation including a babysitter procedure (mean 218 days after resection). Postoperative FaCE scale and Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative mean eFACE scores were similar for both groups for smile (early: 71.5 versus delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7 versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group (76.4 versus 91.1; P = 0.04). Conclusions: Early simultaneous masseter nerve transfer and CFNG provides reanimated movement sooner and in fewer stages than a staged approach in a delayed timeline. The early technique appears to result in similar clinician- and patient-reported outcomes compared with delayed procedures; however, in this preliminary study, the early approach was associated with greater synkinesis, meriting further investigation.

Defining Our Terms: Are Postoperative Complications Adequately Defined in the Rhinoplasty Literature?

BACKGROUND: Rhinoplasty is one of the most common aesthetic surgical procedures, and yet its postoperative complication profile remains somewhat ill-defined and underreported. The purpose of this study was to examine the quality of complication reporting in the rhinoplasty literature and provide a framework for future complication classification. METHODS: Studies were identified from a previously published 2019 systematic review conducted at Duke University Medical Center. Each included study was again reviewed to determine the reported complications and definitions. Reported complications were analyzed to determine occurrence rate, definition presence/absence, definition location, subjectivity/objectivity, and presence of severity grading system. RESULTS: A total of 30 studies were included. Overall, 63% (n = 19) of studies failed to provide a single definition for any reported complications. The remaining 11 studies (37%) provided at least one definition for their reported complications. Grading/severity scales were included by 8 studies. A specific complication was identified as a "primary outcome" in 15 cases. Definitions were included for 11 (73%) of these 15 complications. Complications denoted as "primary outcomes" were significantly more likely to have an included definition (p <0.01). CONCLUSIONS: Postoperative complications following rhinoplasty are inadequately defined in the available literature, with over sixty percent of studies failing to define a single-reported complication. When complication definitions are included, they are often subjective in nature and rarely include a grading or severity scale. In the absence of standardized rhinoplasty complication definitions, comparing complication rates across studies is exceedingly difficult, and the ability to conduct high-quality meta-analyses is limited. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Functional Nasal Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective. SUMMARY: The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

A global molecular phylogeny yields insights into the dispersal and invasion history of Junonia, a butterfly genus with remarkable dispersal abilities.

The nymphalid butterfly genus Junonia has remarkable dispersal abilities. Occurring on every continent except Europe and Antarctica, Junonia are often among the only butterflies on remote oceanic islands. The biogeography of Junonia has been controversial, plagued by taxonomic disputes, small phylogenetic datasets, incomplete taxon sampling, and shared interspecific mitochondrial haplotypes. Junonia originated in Africa but its route into the New World remains unknown. Presented here is, to our knowledge, the most comprehensive Junonia phylogeny to date, using full mitogenomes and nuclear ribosomal RNA repeats from 40 of 47 described species. Junonia is monophyletic and the genus Salamis is its probable sister clade. Genetic exchange between Indo-Pacific Junonia villida and New World Junonia vestina is evident, suggesting a trans-Pacific route into the New World. However, in both phylogenies, the sister clades to most New World Junonia contain both African and Asian species. Multiple trans-Atlantic or trans-Pacificinvasions could have contributed to New World diversification. Hybridization and lateral transfer of mitogenomes, already well-documented in New World Junonia, also occurs in at least two Old World lineages (Junonia orithya/Junonia hierta and Junonia iphita/Junonia hedonia). Variation associated with reticulate evolution creates challenges for phylogenetic reconstruction, but also may have contributed to patterns of speciation and diversification in this genus.

A systematic analysis of surgical interventions for the airway in the mature unilateral cleft lip nasal deformity: a single case study.

PURPOSE: Individuals with unilateral cleft lip nasal deformity (uCLND) often require rhinoplasty in adolescence to correct nasal obstruction. The intent of this study is to identify sites of greatest nasal obstruction and evaluate the effects of isolated and combinations of simulated surgical procedures on these sites using computational fluid dynamics (CFD). METHODS: Computed tomography imaging of an adolescent subject with uCLND was converted to an anatomically accurate three-dimensional nasal airway model. Initial analysis was performed to identify anatomic sites of obstruction based on CFD computed resistance values. Virtual surgery procedures corresponding to common uCLND surgical interventions were simulated. Resulting airspace models were then analyzed after conducting airflow and heat transfer simulations. RESULTS: The preoperative model had 21 obstructed sites with a nasal resistance of 0.075 Pa s/mL. Following simulated surgical procedures with functional interventions alone and in combinations, the three virtual surgery models with most improved nasal airflow were inferior turbinate reduction (ITR) with posterior septoplasty (resistance = 0.054 Pa s/ml, reduction in 14 of 21 obstructed sites), ITR with anterior septoplasty (resistance = 0.058 Pa s/ml, reduction in 8 of 21 obstructed sites), and ITR with both anterior and posterior septoplasty (resistance = 0.052 Pa s/ml, reduction in 17 of 21 obstructed sites). CONCLUSION: This study introduces a new technique for analysis of the impact of different simulated surgical interventions on uCLND-induced nasal obstruction. In this subject, simulated septoplasty with ITR on the non-cleft side provided maximal relief of nasal obstruction. The proposed technique can be further studied for possible utility in analyzing potential surgical interventions for optimal relief of nasal obstruction in patients with uCLND.

Dorsal Hump Reduction and Midvault Reconstruction.

Dorsal hump reduction is one of the most common techniques used in modern rhinoplasty, yet it carries a high propensity for untoward aesthetic and functional sequelae, as evidenced by a nontrivial revision rate. Component dorsal hump reduction with stepwise deconstruction and manipulation of component parts allows for an adaptable and precise approach to variances in anatomy and in desired aesthetic result. Secondary changes must be anticipated and addressed at the index operation to avoid negative results and prevent the need for revision. Adequate reconstruction of the midvault is paramount to achieving optimal aesthetic and functional outcomes.

Cutaneous Reconstruction of the Nasal Distal Third: Alternative Local Flaps for a Complex Region.

Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Two or Three? Approaches to Staging of the Paramedian Forehead Flap for Nasal Reconstruction.

The paramedian forehead flap is a historic cornerstone of plastic surgery and a mainstay of complex nasal reconstruction. Although initially described as a 2-stage procedure, several procedural advancements and modifications have been proposed, with the most notable being the addition of a third, intermediate stage. Proponents of this 3-stage approach argue that the addition of an intermediate stage improves flap perfusion, expands lining and structural support options, and provides superior aesthetic outcomes. Although this technique has grown in popularity, studies comparing the 2- versus 3-stage approach are relatively scarce in the literature. Existing comparative studies seem to suggest that the 3-stage paramedian forehead flap may have advantages in large, complex nasal defects and patients at high risk for vascular compromise. Additionally, comparative analyses with respect to aesthetic outcome were found to be largely equivocal, suggesting that surgeon comfort and preference should guide flap selection.

The complete mitochondrial genome of the file ramshorn snail Planorbella pilsbryi (Mollusca: Gastropoda: Hygrophila: Planorbidae).

The file ramshorn snail Planorbella pilsbryi Baker, 1926 (Gastropoda: Hygrophila: Planorbidae) is a widespread herbivorous North American freshwater snail found in diverse habitats, including standing and moving water bodies. Genome skimming by Illumina sequencing allowed the assembly of a complete nuclear rRNA repeat sequence and a complete circular mitogenome of 13,720 bp from P. pilsbryi consisting of 75.3% AT nucleotides, 22 tRNAs, 13 protein-coding genes, 2 rRNAs and a control region in the typical order found in panpulmonate snails. Planorbella pilsbryi COXI features a rare TTG start codon while COXII, CYTB, ND2, ND3, and ND5 exhibit incomplete stop codons completed by the addition of 3' A residues to the mRNA. Phylogenetic reconstruction of mitochondrial protein-coding gene and rRNA sequences places P. pilsbryi as sister taxon to Planorbella duryi (Planorbidae) within family Planorbidae, which is consistent with previous phylogenetic hypotheses.

Phylogenetic analysis of the complete mitochondrial genome of the Blomfild's Beauty butterfly Smyrna blomfildia (Fabricius 1781) (Insecta: Lepidoptera: Nymphalidae: Nymphalini).

The Blomfild's Beauty butterfly Smyrna blomfildia (Fabricius 1781) (Lepidoptera: Nymphalidae: Nymphalini) is a sexually dimorphic species found in Mexico, Central, and South America. Males are territorial and are more vibrantly colored than females. Genome skimming by Illumina sequencing allowed the assembly of a complete circular mitochondrial genome (mitogenome) of 15,149 bp from S. blomfildia consisting of 83.9% AT nucleotides, 13 protein-coding genes, 22 tRNAs, two rRNAs, and a control region in the typical butterfly gene order. The S. blomfilda COX1 gene features an atypical start codon (CGA) while ATP6, COX1, COX2, CYTB, ND1, ND3, ND4, and ND5 display partial stop codons completed by the addition of 3' A residues to the mRNA. Bayesian phylogenetic reconstruction places Smyrna as a member of the tribe Nymphalini and sister to a clade containing genera Araschnia, Vanessa, Polygonia, and Aglais, which differs from its classic taxonomic placement in tribe Coeini.

Phylogenetic analysis of the complete mitochondrial genome of the Japanese peacock butterfly Aglais io geisha (Stichel 1907) (Insecta: Lepidoptera: Nymphalidae).

The peacock butterfly Aglais io (Linnaeus, 1758) (Nymphalidae: Nymphalinae: Nymphalini) is a colorful and charismatic flagship butterfly species whose range spans from the British Isles and Europe through temperate Asia and the Far East. In Europe, it has been used as a model species for studying the effects of GMO maize pollen on caterpillar growth and survivorship. The Japanese subspecies, Aglais io geisha (Stichel 1907), is not as well studied as its European counterpart. Genome skimming by Illumina sequencing allowed the assembly of a complete circular mitochondrial genome (mitogenome) of 15,252 bp from A. io geisha consisting of 80.6% AT nucleotides, 13 protein-coding genes, 22 tRNAs, two rRNAs, and a control region in the gene order typical of butterfly species. Aglais io geisha COX1 gene features an atypical start codon (CGA) while COX1, COX2, CYTB, ND1, ND3, ND4, and ND5 display incomplete stop codons finished by the addition of 3' A residues to the mRNA. Bayesian phylogenetic reconstruction places A. io geisha within a clade with European A. io mitogenomes in the tribe Nymphalini, which is consistent with previous phylogenetic hypotheses.

Mathematical modeling of the eyespots in butterfly wings.

Butterfly wing color patterns are a representative model system for studying biological pattern formation, due to their two-dimensional simple structural and high inter- and intra-specific variabilities. Moreover, butterfly color patterns have demonstrated roles in mate choice, thermoregulation, and predator avoidance via disruptive coloration, attack deflection, aposematism, mimicry, and masquerade. Because of the importance of color patterns to many aspects of butterfly biology and their apparent tractability for study, color patterns have been the subjects of many attempts to model their development. Early attempts focused on generalized mechanisms of pattern formation such as reaction-diffusion, diffusion gradient, lateral inhibition, and threshold responses, without reference to any specific gene products. As candidate genes with expression patterns that resembled incipient color patterns were identified, genetic regulatory networks were proposed for color pattern formation based on gene functions inferred from other insects with wings, such as Drosophila. Particularly detailed networks incorporating the gene products, Distal-less (Dll), Engrailed (En), Hedgehog (Hh), Cubitus interruptus (Ci), Transforming growth factor-ß (TGF-ß), and Wingless (Wg), have been proposed for butterfly border ocelli (eyespots) which helps the investigation of the formation of these patterns. Thus, in this work, we develop a mathematical model including the gene products En, Hh, Ci, TGF-ß, and Wg to mimic and investigate the eyespot formation in butterflies. Our simulations show that the level of En has peaks in the inner and outer rings and the level of Ci has peaks in the inner and middle rings. The interactions among these peaks activate cells to produce white, black, and yellow pigments in the inner, middle, and outer rings, respectively, which captures the eyespot pattern of wild type Bicyclus anynana butterflies. Additionally, our simulations suggest that lack of En generates a single black spot and lack of Hh or Ci generates a single white spot, and a deficiency of TGF-ß or Wg will cause the loss of the outer yellow ring. These deficient patterns are similar to those observed in the eyespots of Vanessa atalanta, Vanessa altissima, and Chlosyne nycteis. Thus, our model also provides a hypothesis to explain the mechanism of generating the deficient patterns in these species.

The Association between Away Rotations and Rank Order in the Integrated Plastic Surgery Match.

BACKGROUND: Given the competition in the integrated plastic surgery Match, away rotations are ubiquitous among plastic surgery applicants to differentiate their applications. This study aimed to characterize how performing an away rotation affects rank order and Match outcomes for integrated plastic surgery programs. METHODS: An online survey was designed and distributed to the top 25 integrated plastic surgery programs in the United States as determined by Doximity. Programs were polled about away rotation structure, position of rotators on their 2018 to 2019 rank list, and composition of current resident classes. RESULTS: Twenty-five programs completed the survey (response rate, 100 percent). On average, programs interviewed 34.9 applicants (range, 22 to 50 applicants) and ranked 32.8 applicants (range, 10 to 50 applicants). Most "ranked-to-match" positions were occupied by home students or away rotators (60.9 percent). Rank order of home students, away rotators, and nonrotators varied significantly (p < 0.001), with median rank order of home students [5 (interquartile range, 1 to 9)] and rotators [14 (interquartile range, 6 to 27)] higher than nonrotators [17 (interquartile range, 10 to 29)]. Rank orders of away rotators tended to follow a bimodal distribution. Furthermore, 64.4 percent of integrated residents were either a home student or away rotator at their matched integrated program, with 20 percent of residency programs composed of greater than 70 percent of away rotators/home students across postgraduate years 1 through 6 classes. CONCLUSIONS: For integrated plastic surgery programs, the majority of ranked-to-match students on rank lists and current residents were either home students or away rotators at their respective program. Performing well on an away rotation appears to confer significant benefit to the applicant applying in the integrated plastic surgery Match.

Analysis of nasal air conditioning in subjects with unilateral cleft lip nasal deformity.

This study evaluated the impact of unilateral cleft lip nasal deformity (uCLND) on the ability of the nasal passages to warm and humidify inspired environmental air using computational fluid dynamics (CFD) modeling. Nasal air conditioning was simulated at resting inspiration in ten individuals with uCLND and seven individuals with normal anatomy. The overall heat and water transfer through nasal mucosa was significantly greater (p = 0.02 for both heat and moisture fluxes) on the non-cleft side than on the cleft side. Unilateral median and interquartile range (IQR) for heat flux (W/m2) was 190.3 (IQR 59.9) on the non-cleft side, 160.9 (IQR 105.0) on the cleft side, and 170.7 (IQR 87.8) for normal subjects. For moisture flux (mg/(s·m2), they were 357.4 (IQR 112.9), 298.7 (IQR 200.3) and 320.8 (IQR 173.0), respectively. Significant differences of SAHF50 between cleft side of uCLND and normal existed except for anterior region. Nevertheless, air conditioning ability in subjects with uCLND was generally comparable to that of normal subjects.