Understanding Breast Implant Illness, Before and After Explantation: A Patient-Reported Outcomes Study.

BACKGROUND: Breast implant illness (BII) after aesthetic breast augmentation remains a poorly defined syndrome encompassing a wide spectrum of symptoms. While previously published series have observed overall symptomatic improvement after breast implant removal, there is a lack of studies evaluating changes in specific symptoms over time. The purpose of this study was to gain an understanding of symptoms associated with BII, and to evaluate how these symptoms change after removal of breast implants and total capsulectomy (explantation). We hypothesized that patients presenting with BII would experience both immediate and sustained improvement in constitutional symptoms after explantation. METHODS: A retrospective study of all patients who underwent explantation by a single surgeon over 2 years was conducted. Repeated-measures analysis of variance accounting for dependency was used to compare symptoms before and after surgery. Multivariate analyses and linear regression models were used to examine the impact of patient- and implant-related factors on changes in symptoms. RESULTS: Seven hundred fifty patients met inclusion criteria. Mean preoperative survey score (26.19 ± 11.24) was significantly different from mean postoperative survey score at less than 30 days (9.49 ± 7.56) and greater than 30 days (9.46 ± 7.82, P < 0.001). Patients with a BMI greater than 30 or those with clinically detectable contracture on examination showed greater improvement on their survey scores (P = 0.039, 0.034, respectively). CONCLUSIONS: Although BII encompasses a large range of symptoms, subjects in this study demonstrated significant and sustained improvement in 11 common symptom domains. This improvement was demonstrable within the first 30 days postoperatively and was maintained beyond 30 days. The study demonstrated a strong association of explantation and specific symptom improvement within the patient population studied. Future investigation will further elucidate possible biologic phenomena to better characterize the pathophysiology and mechanism of BII.

Eleven-Year Follow-Up of Craniopagus Twins After Unsuccessful Attempt at Separation: Are They Better Off?

Craniopagus twins are a rare phenomenon and present numerous challenges in separation. Due to the paucity of data, it is paramount to evaluate outcomes based on case studies to continue improving medical and surgical management of these patients. We present a case report of craniopagus twins cared for by the senior author (A.K.G.). The patients underwent extensive surgical planning and 2 attempts at cerebroendovascular embolization to reroute shared venous sinus drainage. After the 2 endovascular procedures, attempted separation at age 41 months was aborted due to intraoperative hemodynamic instability. Eleven-year follow-up shows the twins to be developing well in regard to social and cognitive development. Nonetheless, they have had numerous physical challenges including a fall in 2016 resulting in C1-C2 subluxation in twin B leading to partial spinal cord ischemia and left-sided weakness. The separation of craniopagus twins is fraught with technical, medical, and ethical challenges. Surgical separation of the twins is not always possible without significant risk of devastating consequences to one or both twins. Follow-up of the twins 11 years later raises the question: are some craniopagus twins better off without separation?

Contact Cooling of Random-Pattern Cutaneous Flaps: Does it Increase Necrosis?

BACKGROUND: Cooling after surgery reduces pain, swelling and ecchymosis. However, the fear of adverse effects of vasoconstriction caused by cooling may prevent its use when the skin is undermined extensively, for example, after rhytidectomy. The purpose of this study is to determine whether the contact cooling of random-pattern skin flaps increases the area of necrosis observed. METHODS: Twenty-eight random-pattern skin flaps (4 × 10 cm) were raised on four pigs. Flaps were divided into three groups: control, intermittently cooled and continuously cooled. Pads connected to a ThermaZone cooling device delivered local hypothermia in the range of 4-6 °C for 24 h postoperatively. ImageJ software was used to calculate the area of necrosis on each flap on postoperative day 7, confirmed with histological analysis. RESULTS: The average areas of necrosis observed were as follows: control (17.61 cm2; SD 5.23), intermittent cooling (15.65 cm2; SD 3.76) and continuous cooling (14.16 cm2; SD 3.91). An ANOVA revealed no statistically significant differences between the three interventions (p = 0.35). CONCLUSIONS: Postoperative continuous or intermittent cooling does not increase the area of necrosis in random-pattern flaps. In fact, a trend was observed, demonstrating decreasing area of necrosis with increased periods of hypothermia. NO LEVEL ASSIGNED: 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 .

Nose elongation: a review and description of the septal extension tongue-and-groove technique.

Several articles have been published about the short nose, many of which begin with a statement about the difficulty and complexity that this deformity poses for the rhinoplasty surgeon. Regardless of the challenges, many surgeons have undertaken the task of elongating the short nose and have subsequently shared with the rhinoplasty community the subtle techniques they have developed through their experience. The authors present a review of the literature that has contributed to the understanding of the etiology, evaluation, assessment, and operative procedures in the reconstruction of the short nose, specifically with regard to septal extension grafts. Additionally, the senior author's (BG) technique and experience of nearly 30 years of practice is described.

Separation of Craniopagus Twins over the Past 20 Years: A Systematic Review of the Variables That Lead to Successful Separation.

BACKGROUND: Attempted separation of craniopagus twins has continued to be associated with devastating results since the first partially successful separation with one surviving twin in 1952. To understand the factors that contribute to successful separation in the modern era of neuroimaging and modern surgical techniques, the authors reviewed and analyzed cases reported since 1995. METHODS: All reported cases of craniopagus twin separation attempts from 1995 to 2015 were identified using PubMed (n = 19). In addition, the Internet was searched for additional unreported separation attempts (n = 5). The peer-reviewed cases were used to build a categorical database containing information on each twin pair, including sex; date of birth; date of surgery; multiple- versus single-stage surgery; angular versus vertical conjoining; nature of shared cerebral venous system; and the presence of other comorbidities identified as cardiovascular, genitourinary, and craniofacial. The data were analyzed to find factors associated with successful separation (survival of both twins at postoperative day 30). RESULTS: Vertical craniopagus is associated with successful separation (p < 0.001). No statistical significance was attributed to the nature of the shared cerebral venous drainage or the other variables examined. Multiple-stage operations and surgery before 12 months of age are associated with a trend toward statistical significance for successful separation. CONCLUSIONS: The authors' analysis indicates that vertical craniopagus twins have the highest likelihood of successful separation. Additional factors possibly associated with successful separation include the nature of the shared sinus system, surgery at a young age, and the use of staged separations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Use of negative pressure wound therapy with instillation in the management of cervical necrotizing fasciitis.

BACKGROUND: Cervical necrotizing fasciitis is an aggressive infection that can be rapidly fatal if aggressive therapies are not initiated early. Negative pressure wound therapy has been established as an effective tool in promoting wound healing, but its use in the acutely infected wound has been avoided because it limits frequent irrigations and standard dressing changes. METHODS: We discuss a novel application of negative pressure wound therapy with instillation in an immunocompromised patient with extensive cervical necrotizing fasciitis. RESULTS: The negative pressure wound therapy with instillation provided pain relief by minimizing the frequency of dressing changes, increased the speed of healing, helped to control infection, and facilitated the development of a healthy wound bed sufficient for reconstruction with a split thickness skin graft. CONCLUSION: The role of negative pressure wound therapy with instillation continues to expand and can be used in the management of both acute and chronic wounds in the head and neck.

The phylogeography of Amazonia revisited: new evidence from riodinid butterflies.

A fully resolved cladogram for 19 species in the Charis cleonus group of riodinid butterflies, which have closely parapatric ranges throughout the Amazon basin, is used to derive an area cladogram for the region. This represents the first comprehensive species-level analysis using insects and results in a hypothesis of Amazonian area relationships that is the most detailed to date. The Charis area cladogram is interpreted as supporting an historical vicariant split between the Guianas and the remainder of the Amazon and then between the upper and lower Amazon. The latter two clades can be further divided into the six most widely recognized areas of endemism and even smaller endemic centers within these, some of which, especially along the Madeira and lower Amazon Rivers, have never been previously hypothesized for butterflies. The overall pattern of historical interrelationships indicated is Guiana + ((Rondjnia + (Pará + Belém)) + (Imeri + (Napo + Inambari))). The area relationships for riodinid butterflies show substantial congruence with those presented from the literature for amphibians, reptiles, birds, primates, rodents, and marsupials, suggesting a common vicariant history for these organisms. A summary area cladogram generated by combining area cladograms for all the aforementioned groups of organisms indicated the pattern of historical interrelationships to be (Guiana + (Rondjnia + (Pará + Belém))) + (Imeri + (Napo + Inambari)). Charis cleonus group species distributions are noticeably larger around the upland periphery of Amazonia and smaller in the central and lower regions. A significant positive correlation between the proportion of range area above 100 m and total range size for each species is used to suggest that past sea-level rises may explain smaller range sizes in low-lying regions and that riverine barriers have been important in shaping the current distribution of C. cleonus group species.

Extinction and biogeography in the Caribbean: new evidence from a fossil riodinid butterfly in Dominican amber.

We describe a new species of extinct riodinid butterfly, Voltinia dramba, from Oligo-Miocene Dominican amber (15-25 Myr ago). This appears to be the first butterfly to be taxonomically described from amber, and the first adult riodinid fossil. The series of five specimens represents probably the best-preserved fossil record for any lepidopteran. The phenomenon of extant Voltinia females ovipositing on arboreal epiphytes probably explains the discovery of multiple female V. dramba specimens in amber. Voltinia dramba appears to be one of many extinct butterfly species on Hispaniola. The northwestern Mexican distribution of the explicitly hypothesized sister species, the extant V. danforthi, supports the hypothesis that V. dramba reached Hispaniola by the 'proto-Greater Antillean arc', dating the divergence of V. dramba and V. danforthi to 40-50 Myr ago. This date is contemporaneous with the oldest known butterfly fossils, and implies a more ancient date of origin for many of the higher-level butterfly taxa than is often conceded.

A new species of Euptychia Hübner, 1818 (Lepidoptera: Nymphalidae: Satyrinae: Satyrini) from Mount Roraima, Guyana.

A new nymphalid species in the subtribe Euptychiina, Euptychia roraima Nakahara, Fratello & Harvey n. sp., is described from Mount Roraima, Guyana. Both internal and external morphology of E. roraima are compared against several Euptychia species and the relationship between E. roraima and congeners is briefly discussed. A strong case is put forth for further and extensive exploration of the Pantepui region concerning its poorly known butterfly fauna.

Unilateral congenital blepharoptosis repair by anterior levator advancement and resection: an educational review.

BACKGROUND: Simple congenital blepharoptosis is caused by levator muscle dysgenesis and commonly presents unilaterally. A complete preoperative evaluation, including ophthalmic, neurologic, and levator function examinations, is essential for ensuring proper diagnosis and selecting the correct procedure. Correction is frequently delayed until the anatomical structures of the eye are fully developed and the child can cooperate with the preoperative examination between the ages of 3 and 5 years, except in cases of visual disturbances. After the preoperative evaluation, the proper treatment can be selected from commonly described procedures, including levator advancement, tarsomyectomy, and frontalis suspension. METHODS: The authors provide a description of the pediatric levator advancement procedure and demonstrate the procedure with supplemental video content. RESULTS: Levator advancement provides appropriate correction for moderate blepharoptosis repair in pediatric patients with fair to good levator function. CONCLUSIONS: Levator advancement in children presents unique challenges because of difficulty performing the preoperative examination and the inability of the patient to provide intraoperative cooperation for proper lid placement because of general anesthesia.

Sample introduction in gas chromatography using a coiled wire filament.

A simple device for field sampling and concentration of analytes for subsequent introduction into an injection port for gas chromatographic (GC) analysis has been developed. It consists of a tiny, coiled platinum wire filament (CWF) that is attached to a retractable plunger wire, which fits inside a syringe needle housing. Sampling is accomplished by dipping the end of the CWF in a liquid sample, which is drawn into the wire coil by capillary action, and introducing it into the injection port either before or after allowing the solvent to evaporate. The CWF can be used with or without a nonvolatile chemical coating. A major advantage of this sampling device is that nonvolatile sample matrix components remain on the wire coil, reducing the required injection port and liner cleaning frequency and contamination of the head of the chromatographic column. The coil itself can be easily cleaned between analyses by rinsing and/or burning off residual material in a small flame. The sampling coil facilitates specifically designed chemical reactions in the injection port, such as thermochemolysis and methylation. Applications demonstrated in this work include: (1) direct introduction of samples with little or no pre-treatment, (2) simultaneous thermochemolysis and methylation of lipid-containing samples such as bacteria and bacterial endospores for analysis of biomarkers, and (3) solid phase micro-extraction (SPME) using temporary wire coatings. The CWF allowed for significant reduction in sample preparation time, in most cases to less than a few minutes. The peak shapes examined for polycyclic aromatic hydrocarbon analytes (PAHs) were significantly better (asymmetry factors <1.3) when using the CWF sampling technique compared to splitless and on-column injection techniques (asymmetry factors >1.3). Extraction efficiencies for SPME (especially for high boiling point components such as PAHs) improved by an average of 2.5 times when using the CWF compared to the performance of commercially available SPME fibers. Coiled wire filaments and GC injection port liners were used for more than 100 Bacillus endospore thermochemolysis methylation analyses without the need for cleaning or replacement.

Integration of DNA barcoding into an ongoing inventory of complex tropical biodiversity.

Inventory of the caterpillars, their food plants and parasitoids began in 1978 for today's Area de Conservacion Guanacaste (ACG), in northwestern Costa Rica. This complex mosaic of 120 000 ha of conserved and regenerating dry, cloud and rain forest over 0-2000 m elevation contains at least 10 000 species of non-leaf-mining caterpillars used by more than 5000 species of parasitoids. Several hundred thousand specimens of ACG-reared adult Lepidoptera and parasitoids have been intensively and extensively studied morphologically by many taxonomists, including most of the co-authors. DNA barcoding - the use of a standardized short mitochondrial DNA sequence to identify specimens and flush out undisclosed species - was added to the taxonomic identification process in 2003. Barcoding has been found to be extremely accurate during the identification of about 100 000 specimens of about 3500 morphologically defined species of adult moths, butterflies, tachinid flies, and parasitoid wasps. Less than 1% of the species have such similar barcodes that a molecularly based taxonomic identification is impossible. No specimen with a full barcode was misidentified when its barcode was compared with the barcode library. Also as expected from early trials, barcoding a series from all morphologically defined species, and correlating the morphological, ecological and barcode traits, has revealed many hundreds of overlooked presumptive species. Many but not all of these cryptic species can now be distinguished by subtle morphological and/or ecological traits previously ascribed to 'variation' or thought to be insignificant for species-level recognition. Adding DNA barcoding to the inventory has substantially improved the quality and depth of the inventory, and greatly multiplied the number of situations requiring further taxonomic work for resolution.