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Find video protocols related to scientific articles indexed in Pubmed.
Accelerated diversification of non-human primate malarias in Southeast Asia: adaptive radiation or geographic speciation?
Mol. Biol. Evol.
PUBLISHED: 11-13-2014
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Although parasitic organisms are found worldwide, the relative importance of host specificity and geographic isolation for parasite speciation has been explored in only a few systems. Here we study Plasmodium parasites known to infect Asian non-human primates, a monophyletic group that includes the lineage leading to the human parasite Plasmodium vivax and several species used as laboratory models in malaria research. We analyze the available data together with new samples from three sympatric primate species from Borneo: the Bornean orangutan and the long-tailed and the pig-tailed macaques. We find several species of malaria parasites, including three putatively new species in this biodiversity hotspot. Among those newly discovered lineages, we report two sympatric parasites in orangutans. We find no differences in the sets of malaria species infecting each macaque species indicating that these species show no host specificity. Finally, phylogenetic analysis of this data suggests that the malaria parasites infecting Southeast Asian macaques and their relatives are speciating three to four times more rapidly than those with other mammalian hosts such as lemurs and African apes. We estimate that these events took place in approximately a 3 to 4 million years period. Based on the genetic and phenotypic diversity of the macaque malarias, we hypothesize that the diversification of this group of parasites has been facilitated by the diversity, geographic distributions, and demographic histories of their primate hosts.
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An Update on Midface Advancement Using Le Fort II and III Distraction Osteogenesis.
Semin Plast Surg
PUBLISHED: 11-11-2014
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Le Fort II and III distraction osteogenesis (DO) is a powerful tool in the craniofacial armamentarium that is most often employed to treat patients with craniofacial syndromes such as Crouzon, Apert, or Pfeiffer syndrome who present with midfacial retrusion, shallow orbits, exorbitism, malocclusion, obstructive sleep apnea and facial imbalance. In this article, the authors will provide the reader with an update on techniques for the treatment of various forms of midfacial retrusion.
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Analysis of risk factors associated with 30-day readmissions following pediatric plastic surgery - a review of 5,376 procedures.
Plast. Reconstr. Surg.
PUBLISHED: 10-31-2014
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Unplanned surgical readmissions represent a benchmark outcome for healthcare systems, and pose a considerable cost burden for healthcare systems. The aim of this study is to evaluate risk factors associated with readmission following pediatric plastic surgery using a prospective, validated, national database.
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Screening for obstructive sleep apnea in children treated at a major craniofacial center.
J Craniofac Surg
PUBLISHED: 08-28-2014
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Timely diagnosis of obstructive sleep apnea (OSA) in patients with craniofacial disorders may help prevent long-term adverse sequelae of upper airway obstruction, namely pulmonary hypertension, failure to thrive, and impaired neurocognitive development. Currently, little is known about the incidence of OSA in this high-risk population. A prospective study examining the incidence of positive screening for OSA in patients cared for by the craniofacial team at a large, urban referral center was performed. From January 2011 to August 2013, all patient families were asked to complete the Pediatric Sleep Questionnaire. This validated tool has a sensitivity of 85% and specificity of 87% in predicting a positive sleep study when the ratio of positive-total responses is 0.33 or greater. Screening results were evaluated via Chi-squared and Fisher tests according to demographic and clinical variables. A total of 234 children seen in our craniofacial clinic completed the Pediatric Sleep Questionnaire. The mean screening age was 8.38 years, and 47% were male (110/234). Total incidence of positive OSA screening was 28.2% (66/234). Of the total population, 128 patients had an underlying syndrome (54.7%), whereas 106 patients were nonsyndromic (45.3%). Both groups were at equivalent risk for screening positive for OSA (28.1% versus 28.3%, P = 1.0). Among children with a craniofacial diagnosis, patients with a cleft lip and/or palate were at equivalent risk for screening positive for OSA as patients without a cleft (25.5% versus 32.6%, P = 0.24). The OSA symptoms affect almost one third of patients seen by our craniofacial team. Syndromic and nonsyndromic patients seem to be at equivalent risk as those patients with and without an oropharyngeal cleft. Future work will correlate these findings with formal polysomnography and may serve to heighten awareness of OSA in this at-risk population.
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Utility of screening for obstructive sleep apnea syndrome in children with craniofacial disorders.
Plast. Reconstr. Surg.
PUBLISHED: 08-28-2014
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Children with craniofacial disorders are at increased risk for obstructive sleep apnea syndrome. Methods for diagnosing obstructive sleep apnea syndrome in this population remain controversial. Sleep studies are the criterion standard but are impractical for all patients. The utility of obstructive sleep apnea syndrome questionnaires such as the Pediatric Sleep Questionnaire is unknown in children with craniofacial disorders. The authors hypothesized that the Pediatric Sleep Questionnaire would be a sensitive tool for detecting obstructive sleep apnea syndrome in children with craniofacial abnormalities.
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Earlier evidence of spheno-occipital synchondrosis fusion correlates with severity of midface hypoplasia in patients with syndromic craniosynostosis.
Plast. Reconstr. Surg.
PUBLISHED: 08-28-2014
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The spheno-occipital synchondrosis is an important driver of facial and cranial base growth. The current study characterizes its fusion in patients with Apert, Crouzon, and Pfeiffer syndromes and correlates early fusion with the presence, and degree, of midface hypoplasia.
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Treatment of large calvarial defects with bone transport osteogenesis: a preclinical sheep model.
J Craniofac Surg
PUBLISHED: 08-15-2014
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Bone transport osteogenesis (BTO), distraction of a free portion of bone across a defect, offers an autologous solution to large cranial defects that may allow treatment without permanent hardware implantation. This study establishes a sheep model to evaluate the feasibility and distraction kinetics of BTO.
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Screening for obstructive sleep apnea in children with syndromic cleft lip and/or palate.
J Plast Reconstr Aesthet Surg
PUBLISHED: 07-31-2014
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Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive sleep apnea (OSA). While 30% of CL/P occurs in the context of underlying genetic syndromes, few studies have investigated the prevalence of OSA in this high-risk group. This study aims to determine the incidence and risk factors of positive screening for OSA in this complex patient population.
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Patient risk factors for ambulatory cleft lip repair: an outcome and cost analysis.
Plast. Reconstr. Surg.
PUBLISHED: 07-29-2014
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The purpose of this study was to identify variables that may preoperatively predict successful outcomes in ambulatory cleft lip repair and to quantify the potential cost savings.
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A modified V-Y chondromucosal composite flap for correction of secondary cleft nasal deformity: photogrammetric analysis of a case-control study.
Plast. Reconstr. Surg.
PUBLISHED: 07-17-2014
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Secondary cleft nasal deformity is a combination of the inherent cleft defects and the effects of operations to address the primary nasal deformity. The authors revisited a modified V-Y chondromucosal flap to restore symmetric nostril shape and balanced tip projection.
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Maxillary involvement in hemifacial microsomia: an objective three-dimensional analysis of the craniofacial skeleton.
J Craniofac Surg
PUBLISHED: 07-10-2014
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The aim of our study is to better understand the maxillary involvement in relation to the mandibular deformation in hemifacial microsomia (HFM). To do so, consecutive patients with HFM treated at The Children's Hospital of Philadelphia from 2000 to 2012 were included in our study. Both two-dimensional and three-dimensional analyses of the bony and sinus structures of the midface and mandible were performed using three-dimensional segmentation software. Patients were stratified into groups based on the Kaban-Pruzansky classification--mild (0-1), moderate (2A), and severe (2B-3)--as well as rank ordering based on overall severity. Analyses involved paired t-tests within severity groups, 1-way analysis of variance when assessing across groups (ipsilateral/contralateral ratio), and regression to assess for trends. Thirty patients were included (4 mild, 12 moderate, and 14 severe). The mandibular volume ratio differed across all patient groups (P < 0.001) and trended with rank order (P < 0.001). No significant difference in maxillary bony volume ratio was found across all patient groups (P = 0.16). In patients with severe disease, the maxillary bone volume was found to be significantly decreased on the ipsilateral side as compared with the contralateral side (P = 0.0123). There was no difference in maxillary sinus volume between ipsilateral and contralateral sides within any patient groups or in comparing across groups (P = 0.10). No significant trend was found in the volume ratio of mandible and maxilla (P = 0.41). To conclude, the maxillary sinus seems to show no difference in volume when comparing between laterality and severity groupings. These findings suggest that there may be alternative influences other than the vascular insult acting as the driving force behind the mandibular deformity and the additional classic clinical findings of HFM.
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The prevalence of strabismus in unilateral coronal synostosis.
Childs Nerv Syst
PUBLISHED: 06-16-2014
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While there is a clear correlation between unilateral coronal synostosis (UCS) and ocular motility abnormalities, the literature provides little information as to the true epidemiology of strabismus, or the underlying etiology of these paralleled pathologies. The purpose of this study is to investigate the rate of oculomotor abnormalities associated with UCS and its management.
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An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis.
Plast. Reconstr. Surg.
PUBLISHED: 05-29-2014
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The authors evaluated the complications, revisions, and long-term aesthetic outcomes of patients with isolated metopic synostosis.
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Sustained delivery of rhBMP-2 by means of poly(lactic-co-glycolic acid) microspheres: cranial bone regeneration without heterotopic ossification or craniosynostosis.
Plast. Reconstr. Surg.
PUBLISHED: 03-14-2014
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Commercially available recombinant human bone morphogenetic protein 2 (rhBMP2) has demonstrated efficacy in bone regeneration, but not without significant side effects. The authors used rhBMP2 encapsulated in poly(lactic-co-glycolic acid) (PLGA) microspheres placed in a rabbit cranial defect model to test whether low-dose, sustained delivery can effectively induce bone regeneration.
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The temporal region in unilateral coronal craniosynostosis: a volumetric study of short- and long-term changes after fronto-orbital advancement.
Plast. Reconstr. Surg.
PUBLISHED: 03-14-2014
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The temporal region is significantly affected by both restricted and compensatory growth in unilateral coronal craniosynostosis. Recurrent deformity in this region after fronto-orbital advancement often requires a revision operation in adolescence. The authors performed a three-dimensional analysis of the temporal region in patients with unilateral coronal craniosynostosis to define the baseline deformity and the immediate and long-term changes after fronto-orbital advancement.
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A preliminary report on the use of antibiotic-impregnated methyl methacrylate in salvage cranioplasty.
J Craniofac Surg
PUBLISHED: 02-25-2014
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In the setting of recurrent infection and multiple failed reconstruction attempts, the choice of the ideal reconstructive material for salvage cranioplasty remains a source of controversy in the literature. The purpose of this study is to establish the safety and utility of antibiotic-impregnated polymethyl methacrylate (PMMA) for salvage cranioplasty.A prospectively maintained database of all patients who underwent salvage cranioplasty using vancomycin and tobramycin-impregnated methyl methacrylate from January 2011 to July 2013 was reviewed. Vancomycin and tobramycin were mixed in PMMA, which was then applied to a rigidly fixed titanium mesh for reconstruction. Patients' demographics, indications, and outcomes of this technique were evaluated.Nine patients (mean age: 47 years) underwent vancomycin and tobramycin-impregnated PMMA reconstruction with a mean follow-up of 9.3 months (range 3.5-23 months). On average, these patients underwent 4 procedures (range: 1-15), which included repeat craniotomy, debridement for infection, and failed reconstructions over the course of 3.6 years (range: 7 months to 14 years) before salvage cranioplasty. All patients required salvage cranioplasty due to infection, with the most common bacteria isolated in culture being Propionibacterium acnes (n = 3), multiresistant coagulase-negative Staphylococcus (n = 3), methicillin-resistant Staphylococcus aureus (n = 2), and Enterobacter (n = 2). The average size of the craniectomy defect was 130 cm(2), and there were no incidences of postoperative infection, postoperative complications, or need for revisions.To conclude, in short-term follow-up, vancomycin and tobramycin-impregnated PMMA reconstruction appears safe and effective in salvage cranioplasty. Our early report represents a proof of concept--the true test is whether these short-term successes translate to stable long-term results.
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Plastic surgery residency websites: a critical analysis of accessibility and content.
Ann Plast Surg
PUBLISHED: 02-11-2014
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Medical students applying for plastic surgery residency utilize the Internet to manage their residency applications. Applicants often apply to many programs and rely on advice from colleagues, mentors, and information gathered from plastic surgery residency websites (PSRWs). The purpose of the present study was to evaluate integrated and combined PSRWs with respect to accessibility, resident recruitment, and education.
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The spheno-occipital synchondrosis fuses prematurely in patients with Crouzon syndrome and midface hypoplasia compared with age- and gender-matched controls.
J. Oral Maxillofac. Surg.
PUBLISHED: 02-01-2014
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Premature closure of the spheno-occipital synchondrosis (SOS) has been associated with midface hypoplasia in animal models and patients with specific forms of syndromic craniosynostosis. The present study aimed to characterize SOS fusion in patients with Crouzon syndrome.
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The mandibular deformity in hemifacial microsomia: a reassessment of the Pruzansky and Kaban classification.
Plast. Reconstr. Surg.
PUBLISHED: 01-29-2014
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The authors examined hemifacial microsomia using three-dimensional computed tomography and the Kaban modification of the Pruzansky classification to determine its relationship with traditional evaluation and its reproducibility among evaluators.
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Bone tissue engineering by way of allograft revitalization: mechanistic and mechanical investigations using a porcine model.
J. Oral Maxillofac. Surg.
PUBLISHED: 01-14-2014
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"Allograft revitalization" is a process in which cadaveric bone is used to generate well-vascularized living bone. We had previously found that porcine allograft hemimandibles filled with autologous adipose-derived stem cells (ASCs) and recombinant human bone morphogenetic protein-2-soaked absorbable collagen sponge (rhBMP-2/ACS) were completely replaced by vascularized bone, provided the construct had been incubated within a periosteal envelope. The present study sought to deepen our understanding of allograft revitalization by investigating the individual contributions of ASCs and rhBMP-2 in the process and the mechanical properties of the revitalized allograft.
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Premature closure of the spheno-occipital synchondrosis in Pfeiffer syndrome: a link to midface hypoplasia.
J Craniofac Surg
PUBLISHED: 01-11-2014
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The spheno-occipital synchondrosis (SOS) is a critical component of midfacial and cranial base growth. Premature closure has been associated with midface hypoplasia in animal models and syndromic craniosynostosis subpopulations with Apert and Muenke syndromes. To link premature SOS closure and midface hypoplasia in patients with Pfeiffer syndrome, a retrospective case-control study was performed in patients treated at a large craniofacial center between 1982 and 2012 diagnosed with Pfeiffer syndrome. At least 1 computed tomography (CT) scan was required to assess SOS patency. Age-/sex-matched control CT scans were also assessed for SOS patency. Three independent reviewers with high interrater reliability (? = 0.88) graded SOS patency as open, partially closed, or completely closed. Wilcoxon rank sum test compared the Pfeiffer patients with control subjects. A total of 63 CT scans in 16 patients with Pfeiffer syndrome, all with midface hypoplasia, and 63 age-/sex-matched control scans, none of whom had midface hypoplasia, met inclusion criteria. Earliest partial SOS closure in patients with Pfeiffer syndrome was seen at 5 days compared with control subjects at 7.07 years. Earliest age at complete fusion was 2.76 years in the Pfeiffer cohort and 12.74 years in control subjects. Average age at partial closure was significantly younger (4.99 ± 3.33 years; n = 31 scans) in patients with Pfeiffer syndrome compared with control subjects (10.92 ± 3.53 years) (P = 0.0005), whereas average age at complete closure (11.90 ± 7.04 years) was not significantly different than that in control subjects (16.07 ± 3.39 years). Although definitive causality cannot be concluded, a strong correlation exists between midface hypoplasia and premature SOS closure in Pfeiffer syndrome.
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The impact of a parent liaison at a major craniofacial center.
J Craniofac Surg
PUBLISHED: 11-14-2013
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The psychosocial impact of craniofacial disfigurement affects both the developing child and his/her family. The Facial Reconstruction Center at the Childrens Hospital of Philadelphia has employed a Parent Liaison (PL) to provide psychosocial support to families and has been an invaluable resource in this regard. We hypothesize that a PL impacts the overall outcome of the surgery by building trust between the parents and medical institution, and increasing satisfaction. An anonymous satisfaction survey was sent to families of craniofacial patients treated between January 1976 and June 2012. All patients who had undergone at least 1 craniofacial procedure had addresses on file and were included in this study. Statistical analyses were performed using the Mann-Whitney U test.During the study, 441 surveys were mailed to families meeting the inclusion criteria. A total of 151 families returned completed surveys (34.2%), and 121 surveys were included for analysis (27.4%). In rating overall satisfaction, families who met with the PL had statistically higher scores than those who had not (P = 0.0011). Parents who met with the PL preoperatively reported greater satisfaction in time spent answering questions (P = 0.0029) and the perception that questions were adequately answered (P = 0.0039). No statistical difference was observed in postoperative preparedness between families that did and did not meet the PL. The results demonstrate that the PL is beneficial in the education, experience, and satisfaction of families treated at a large Craniofacial Center. The PL complements the surgeons treatment of the physical by adding psychosocial support.
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Monobloc minus Le Fort II for single-stage treatment of the Apert phenotype.
J Craniofac Surg
PUBLISHED: 09-11-2013
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Treatment of the Apert syndrome phenotype aims to correct airway obstruction, exorbitism, elevated intracranial pressure, midface hypoplasia, and malocclusion. Cranial vault expansion prevents elevated intracranial pressure, normalizes head shape, and protects the globes, but variation exists in surgical timing and osteotomy to treat the midface. We present the case of an 11-year-old female patient with Apert syndrome and no prior surgical interventions who presented with severe turribrachycephaly, exorbitism, severe midface retrusion, and apertognathia. A monobloc distraction with simultaneous Le Fort II distraction was planned using computer-aided design and modeling (CAD/CAM) techniques to provide for concurrent distraction of the segments in independent vectors without bony interferences. Monobloc minus Le Fort II distraction was performed without intraoperative complications. Surgical time was 340 minutes with an estimated blood loss of 1100 mL. Distraction began on postoperative day 5 at a rate of 1.5 mm/day for the Le Fort II via an external Halo distractor and 1 mm/day for the monobloc segment via internal distractors anchored bitemporally. The monobloc was distracted a total of 17 mm in a horizontal vector, while the Le Fort II segment was distracted 18 mm horizontally and 5 mm inferiorly. The Halo distractor was removed 3 months following the procedure and the internal distractors 1 month later. Monobloc minus Le Fort II distraction enables correction of the Apert phenotype with a single-stage approach, potentially decreasing the burden of care with improved results. Utilization of CAD/CAM modeling allows for accurate planning of multisegment distraction in independent vectors without concerns for bony interferences.
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Posterior vault distraction with midface distraction without osteotomy as a first stage for syndromic craniosynostosis.
J Craniofac Surg
PUBLISHED: 07-16-2013
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Syndromic craniosynostosis (SC) may cause intracranial hypertension, exorbitism, midfacial hypoplasia associated with airway obstruction, and class III malocclusion. Current treatment strategies for SC involve expansion of the cranial vault and orbits, and midfacial advancement to relieve symptoms and sequelae of obstructive sleep apnea. We present a case of a 12-week-old female patient with Saethre-Chotzen syndrome who presented with bicoronal craniosynostosis, severe turribrachycephaly, midface hypoplasia, and a history of obstructive sleep apnea (apnea-hypopnea index = 14). Posterior vault distraction and simultaneous transfacial pin placement under 3D CT surgical navigation was planned to concurrently relieve intracranial pressure and address airway obstruction by distraction of the midface without osteotomy. An uncomplicated surgery was completed in 290 minutes with an estimated blood loss of 340 mL. Midface distraction was initiated on postoperative day 1 at a rate of 1 mm per day for 21 days, which translated to 13 mm of midfacial advancement. Posterior vault distraction was initiated on postoperative day 5 at a rate of 1 mm per day for 25 days with a resultant 25 mm of posterior vault expansion. Transfacial pin and external distractors were removed after 6 weeks, and posterior vault distractors were removed after 8 weeks of consolidation. Craniometric comparison of 3D-CT scan demonstrated an increase in cranial vault volume of 47%, and the patient was able to be weaned from her home oxygen requirement. This is the first report of simultaneous posterior vault distraction with midfacial advancement across open facial sutures using surgical navigation as an initial stage in treating syndromic craniosynostosis.
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The evolutionary history of Plasmodium vivax as inferred from mitochondrial genomes: parasite genetic diversity in the Americas.
Mol. Biol. Evol.
PUBLISHED: 06-02-2013
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Plasmodium vivax is the most prevalent human malaria parasite in the Americas. Previous studies have contrasted the genetic diversity of parasite populations in the Americas with those in Asia and Oceania, concluding that New World populations exhibit low genetic diversity consistent with a recent introduction. Here we used an expanded sample of complete mitochondrial genome sequences to investigate the diversity of P. vivax in the Americas as well as in other continental populations. We show that the diversity of P. vivax in the Americas is comparable to that in Asia and Oceania, and we identify several divergent clades circulating in South America that may have resulted from independent introductions. In particular, we show that several haplotypes sampled in Venezuela and northeastern Brazil belong to a clade that diverged from the other P. vivax lineages at least 30,000 years ago, albeit not necessarily in the Americas. We propose that, unlike in Asia where human migration increases local genetic diversity, the combined effects of the geographical structure and the low incidence of vivax malaria in the Americas has resulted in patterns of low local but high regional genetic diversity. This could explain previous views that P. vivax in the Americas has low genetic diversity because these were based on studies carried out in limited areas. Further elucidation of the complex geographical pattern of P. vivax variation will be important both for diversity assessments of genes encoding candidate vaccine antigens and in the formulation of control and surveillance measures aimed at malaria elimination.
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A craniometric analysis of posterior cranial vault distraction osteogenesis.
Plast. Reconstr. Surg.
PUBLISHED: 05-30-2013
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Posterior cranial vault distraction osteogenesis has replaced fronto-orbital advancement in some centers as the first-line treatment in patients with syndromic craniosynostosis. Despite this fact, little has been written about its craniometric effects on children with syndromic craniosynostosis.
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Application of a robotic telemanipulator to perform posterior pharyngeal flap surgery: a feasibility study.
Plast. Reconstr. Surg.
PUBLISHED: 05-22-2013
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The instrumentation used during surgery to address velopharyngeal dysfunction has changed little over the past century. Recent advances in the use of robotic surgical systems in transoral surgery have expanded the use of these instruments beyond their traditional laparoscopic applications. The purpose of this study was to evaluate the feasibility of performing superiorly based, "Hogan"-style posterior pharyngeal flaps using a robotic surgical telemanipulator system. The authors hypothesize that use of this surgical platform provides equivalent safety, improved exposure, and more comfortable surgeon ergonomics compared with traditional methods of flap harvest and inset.
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Anatomic study of full facial and scalp allografts without cutaneous facial scars.
J Plast Surg Hand Surg
PUBLISHED: 05-06-2013
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Abstract Conventional reconstructive procedures for face and scalp reconstruction fall short of aesthetic and functional goals because of the unique quality and quantity of facial and scalp soft tissue. The purpose of this cadaver study was to demonstrate the feasibility of a flap design for full face and scalp composite tissue allotransplantation, without cutaneous facial scars. Six fresh human cadavers were dissected with sagittal scalp and mucosal incisions for full face and scalp harvest without cutaneous facial incisions. Sub-galeal and sub-SMAS dissection allowed for inclusion of the external carotid and internal jugular systems. Time of facial-scalp flap harvesting, length of the arterial and venous pedicles, length of sensory nerves (that were included in the facial flaps) and approximate surface area of the flaps were measured. Three of six flaps were transferred to recipient cadavers and the time of transfer was recorded. As a proof of concept, the external carotid arteries of one of six cadavers was flushed to remove clots and perfused with a radio-opaque latex polymer, Microfil (Flow Tech Inc.), to study flap perfusion by X-ray imaging. In the donor cadaver, the mean harvesting time of the total facial-scalp flap was 105 ± 19 minutes. The mean length of the supraorbital, infraorbital, mental and great auricular nerves were 1.3 ± 0.2, 1.3 ± 0.1, 1.3 ± 0.1, and 4.8 ± 0.6 cm, respectively. The mean length of the external carotid artery and external jugular vein were 8.7 ± 0.3 and 9.2 ± 0.4 cm, respectively. The approximate area of the harvested flap was 1063 ± 60 cm(2). In preparation for full face and scalp allotransplantation in humans, this study has demonstrated the feasibility of a full face and scalp flap without visible facial incisions.
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Dissection in the subgaleal and subperiosteal plane: implications on scalp wound healing.
J Plast Surg Hand Surg
PUBLISHED: 04-26-2013
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Craniofacial reconstruction often involves the use of dissection in the subperiosteal or subgaleal plane to access the cranial vault and facial skeleton. Clinically, physical changes to the periosteal layer and underlying cortex were observed in the re-operative field. This article compares aspects of wound healing, structural integrity of the progenitor periosteal layer, and underlying bony changes when elevating a subgaleal or subperiosteal flap in a Lewis rat calvarial model. Cranial dissection in the subperiosteal or subgaleal plane was performed on 14 Lewis rats. En bloc resection of the calvarium and overlying soft tissue was harvested at days 0, 1, 3, 7, 14, 28, and 56. Samples underwent SEM imaging and were analysed histologically after trichrome and haematoxylin and eosin staining. One sample of native periosteum underwent cellular expansion to determine periosteal cell regenerative capability. Up to 56 days, subperiosteal dissection results in diffuse hypercellularity within the cambial layer (p < 0.001). There are irregular cortical changes at the periosteal interface and increased disorganised bone remodelling at the temporal ridges. Subgaleal dissection did not reveal any underlying bony changes, and cell counts were not significantly different from controls (p < 0.001). Subperiosteal dissection causes structural and cellular changes to the periosteum and underlying bone composition with a possible influence on its regenerative capability.
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Monobloc minus Le Fort II for single-stage treatment of the Apert phenotype.
J Craniofac Surg
PUBLISHED: 03-26-2013
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Treatment of the Apert syndrome phenotype aims to correct airway obstruction, exorbitism, elevated intracranial pressure, midface hypoplasia, and malocclusion. Cranial vault expansion prevents elevated intracranial pressure, normalizes head shape, and protects the globes, but variation exists in surgical timing and osteotomy to treat the midface. We present the case of an 11-year-old female patient with Apert syndrome and no prior surgical interventions who presented with severe turribrachycephaly, exorbitism, severe midface retrusion, and apertognathia. A monobloc distraction with simultaneous Le Fort II distraction was planned using computer-aided design and modeling (CAD/CAM) techniques to provide for concurrent distraction of the segments in independent vectors without bony interferences.Monobloc minus Le Fort II distraction was performed without intraoperative complications. Surgical time was 340 minutes with an estimated blood loss of 1100 mL. Distraction began on postoperative day 5 at a rate of 1.5 mm/day for the Le Fort II via an external Halo distractor and 1 mm/day for the monobloc segment via internal distractors anchored bitemporally. The monobloc was distracted a total of 17 mm in a horizontal vector, while the Le Fort II segment was distracted 18 mm horizontally and 5 mm inferiorly. The Halo distractor was removed 3 months following the procedure and the internal distractors 1 month later. Monobloc minus Le Fort II distraction enables correction of the Apert phenotype with a single-stage approach, potentially decreasing the burden of care with improved results. Utilization of CAD/CAM modeling allows for accurate planning of multisegment distraction in independent vectors without concerns for bony interferences.
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The effect of fluctuating selection on the genealogy at a linked site.
Theor Popul Biol
PUBLISHED: 03-18-2013
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The genealogical consequences of temporally fluctuating selection at linked neutrally-evolving sites are studied using coalescent processes structured by genetic backgrounds. Surprisingly, although between-generation fluctuating selection and within-generation fecundity variance polymorphism lead to indistinguishable allele frequency dynamics at the selected site, I show that these two scenarios affect the genealogical structure of the population in distinctive ways. Whereas coalescence times are elevated at the selected site when heterozygotes have lower within-generation fecundity variance than either homozygote, fluctuating selection typically depresses the depth of the genealogy at tightly-linked sites. More importantly, these results indicate that fluctuating selection will have a characteristic signature combining an excess of selected variation at the affected site and a slight reduction in neutral variation at tightly linked sites. This observation suggests that it may be possible to distinguish balanced polymorphisms maintained by environmental variation from those maintained by heterozygote advantage.
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Design of a modified monobloc composite facial allograft technique in facial reconstruction.
Plast. Reconstr. Surg.
PUBLISHED: 03-01-2013
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Composite facial allografts have become increasingly popular in the reconstruction of complex facial defects. Good to excellent aesthetic results can be achieved, particularly when a foundation of donor skeleton has been transferred. The authors propose using a conventional craniofacial technique (monobloc osteotomy) to transfer a thin monocortical foundation of bone, even in lieu of a skeletal defect, to improve the recipient periorbital and malar aesthetics.
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An international survey of craniofacial surgeons: current trends in practice.
J Craniofac Surg
PUBLISHED: 01-26-2013
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Craniofacial surgery is a diverse subspecialty of plastic surgery that focuses on a wide range of head and neck pathology in children and adults. The purpose of this study was to define the characteristics of this group of surgeons and to compare subgroups within the specialty.
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Does conventional posterior vault remodeling alter endocranial morphology in patients with true lambdoid synostosis?
J Craniofac Surg
PUBLISHED: 01-26-2013
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True lambdoid synostosis (TLS) produces a consistent morphology that includes occipital flattening, an ipsilateral occipitomastoid prominence, and a mild contralateral hemifacial deficiency that minimally improves with surgery. Prior studies have demonstrated that dysmorphic middle and posterior cranial fossae contribute to the craniofacial scoliosis characteristic of TLS. We hypothesize that these endocranial features remain after surgery, causing the persistent hemifacial deficiency seen in these patients.
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The Muenke syndrome mutation (FgfR3P244R) causes cranial base shortening associated with growth plate dysfunction and premature perichondrial ossification in murine basicranial synchondroses.
Dev. Dyn.
PUBLISHED: 10-22-2011
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Muenke syndrome caused by the FGFR3(P250R) mutation is an autosomal dominant disorder mostly identified with coronal suture synostosis, but it also presents with other craniofacial phenotypes that include mild to moderate midface hypoplasia. The Muenke syndrome mutation is thought to dysregulate intramembranous ossification at the cranial suture without disturbing endochondral bone formation in the skull. We show in this study that knock-in mice harboring the mutation responsible for the Muenke syndrome (FgfR3(P244R)) display postnatal shortening of the cranial base along with synchondrosis growth plate dysfunction characterized by loss of resting, proliferating and hypertrophic chondrocyte zones and decreased Ihh expression. Furthermore, premature conversion of resting chondrocytes along the perichondrium into prehypertrophic chondrocytes leads to perichondrial bony bridge formation, effectively terminating the postnatal growth of the cranial base. Thus, we conclude that the Muenke syndrome mutation disturbs endochondral and perichondrial ossification in the cranial base, explaining the midface hypoplasia in patients.
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Comparative analysis of tranexamic acid use in minimally invasive versus open craniosynostosis procedures.
J Craniofac Surg
PUBLISHED: 10-01-2011
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Intraoperatively administered tranexamic acid (TXA) lessens blood loss during orthopedic and cardiovascular surgery. Its use for craniosynostosis surgery warrants investigation. Therefore, we analyzed our use of TXA during minimally invasive (MI) and open craniosynostosis procedures.
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Synthesis and characterization of cyano-substituted carborane-based compounds. Molecular structure of [1-(4-C7H7)-12-(C5H3-3-(CN)-3,4-(CH3)2)-C2B10H10].
Dalton Trans
PUBLISHED: 09-22-2011
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The reaction of cyanogen chloride with [1-(4-C(7)H(7))-12-(C(5)H(3)-3,4-(CH(3))(2))-C(2)B(10)H(10)] (7) was found to yield two new C(5)-substituted carborane cluster-based compounds, [1-(4-C(7)H(7))-12-(C(5)H(2)-3-(CN)-3,4-(CH(3))(2))-C(2)B(10)H(10)] (8) and [1-(4-C(7)H(7))-12-(C(5)H-2,4-(CN)(2)-3,4-(CH(3))(2))-C(2)B(10)H(10)] (9). This cyano-substitution pattern is in contrast to the known substitution for the analogous organic quinarene[5.6.7] system. The observed unique cluster-based products may be understood by a combination of steric and electronic effects. Compounds 8 and 9 were characterized by complete multinuclear NMR, (1)H-(1)H COSY NMR, (1)H-(13)C HMQC NMR, FTIR, UV-Vis, IR, MS data and a single crystal analysis for 8 [X-ray data for 8: C(17)H(25)B(10)N, monoclinic, space group P2(1)/n with cell constants a = 8.6794(17) Å, b = 11.021(2) Å, c = 43.175(9) Å, ? = 91.00(3)°, V = 4129.2(14) Å(3), Z = 8, R(1) = 0.0729, wR(2) = 0.1464].
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Neonates with tongue-based airway obstruction: a systematic review.
Otolaryngol Head Neck Surg
PUBLISHED: 09-16-2011
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In this systematic review, the authors summarize the current evidence in the literature regarding diagnosis, treatment, and long-term outcomes in neonates with tongue-based airway obstruction (TBAO) and assess the level of evidence of included studies.
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Comparison of spring-mediated cranioplasty to minimally invasive strip craniectomy and barrel staving for early treatment of sagittal craniosynostosis.
J Craniofac Surg
PUBLISHED: 07-21-2011
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The treatment of sagittal craniosynostosis has evolved from early strip craniectomy to total cranial vault remodeling and now back to attempts at minimally invasive correction. To optimize outcomes while minimizing morbidity, we currently use 2 methods of reconstruction in patients younger than 9 months: spring-mediated cranioplasty (SMC) and minimally invasive strip craniectomy with parietal barrel staving (SCPB). The purpose of this study was to compare the safety and efficacy of the 2 methods. Hospital records of our first 7 SMCs and our last 7 SCPBs were analyzed for demographics, the type of operation performed, estimated blood loss, transfusion requirements, operative time, length of stay in the intensive care unit, length of hospital stay, preoperative cephalic index, postoperative cephalic index, and complications. The techniques were then compared using analysis of variance.All 14 patients successfully underwent cranial vault remodeling with significant improvement in cephalic index. Demographics, length of stay in the intensive care unit (P = 0.15), preoperative cephalic index (P = 0.86), and postoperative cephalic index (P = 0.64) were similar between SMC and SCPB. Spring-mediated cranioplasty had statistically significantly shorter operative time (P = 0.002), less estimated blood loss (P < 0.001), and shorter length of hospital stay (P = 0.009) as compared with SCPB. Complications included 1 spring dislodgment in an SMC that did not require additional management and 1 undercorrection in the SCPB group. Both SMC and SCPB are safe, effective means of treating sagittal craniosynostosis. Spring-mediated cranioplasty has become our predominant means of treatment of scaphocephaly in patients younger than 9 months because of its improved morbidity profile.
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TbISWI regulates multiple polymerase I (Pol I)-transcribed loci and is present at Pol II transcription boundaries in Trypanosoma brucei.
Eukaryotic Cell
PUBLISHED: 05-13-2011
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The unicellular eukaryote Trypanosoma brucei is unusual in having very little transcriptional control. The bulk of the T. brucei genome is constitutively transcribed by RNA polymerase II (Pol II) as extensive polycistronic transcription units. Exceptions to this rule include several RNA Pol I transcription units such as the VSG expression sites (ESs), which are mono-allelically expressed. TbISWI, a member of the SWI2/SNF2 related chromatin remodeling ATPases, plays a role in repression of Pol I-transcribed ESs in both bloodstream- and procyclic-form T. brucei. We show that TbISWI binds both active and silent ESs but is depleted from the ES promoters themselves. TbISWI knockdown results in an increase in VSG transcripts from the silent VSG ESs. In addition to its role in the repression of the silent ESs, TbISWI also contributes to the downregulation of the Pol I-transcribed procyclin loci, as well as nontranscribed VSG basic copy arrays and minichromosomes. We also show that TbISWI is enriched at a number of strand switch regions which form the boundaries between Pol II transcription units. These strand switch regions are the presumed sites of Pol II transcription initiation and termination and are enriched in modified histones and histone variants. Our results indicate that TbISWI is a versatile chromatin remodeler that regulates transcription at multiple Pol I loci and is particularly abundant at many Pol II transcription boundaries in T. brucei.
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Oxidized low-density lipoprotein promotes osteoblast differentiation in primary cultures of vascular smooth muscle cells by up-regulating Osterix expression in an Msx2-dependent manner.
J. Cell. Biochem.
PUBLISHED: 01-27-2011
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We have previously shown that oxidized low-density lipoproteins (oxLDLs) act synergistically with ?-glycerophosphate to induce the osteogenic differentiation of primary bovine aortic smooth muscle cells (BASMCs). In the present study, we attempt to resolve the mechanism responsible for this effect by examining the expression of several osteoblast-specific transcription factors. Thus, by culturing BASMCs in the absence or presence of ?-glycerophosphate and/or oxLDL, we demonstrate that ?-glycerophosphate induces both Runx2 and Osterix (Osx) expression. In contrast, oxLDL has no effect on Runx2 expression but rather it enhances ?-glycerophosphate-induced osteoblast differentiation by further up-regulating Osx expression. In an attempt to elucidate the mechanism responsible for this latter effect, we examined the ability of oxLDL to affect Msh homeobox 2 (Msx2) expression. Similar to its effect on Osx expression, oxLDL was found to synergistically enhance ?-glycerophosphate-induced Msx2 expression in an extracellular signal-regulated kinase 1 and 2 (Erk 1 and 2)-dependent manner. Furthermore, oxLDLs ability to enhance both ?-glycerophosphate-induced Osx expression and alkaline phosphatase activity was prevented when the BASMCs were first transfected with Msx2-specific siRNA. Taken together, these findings suggest a plausible mechanism by which oxLDL may promote osteoblast differentiation and vascular calcification in vivo.
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Bilateral orbitozygomatic reconstruction with tissue-engineered bone.
J Craniofac Surg
PUBLISHED: 09-22-2010
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Critical defects of the craniomaxillofacial region and long bones are often treated with bone grafts and vascularized osteocutaneous free flaps. These lengthy operations may be associated with considerable donor site morbidity and often have suboptimal functional and aesthetic results. The allure of providing an exact replica of a missing bone that incorporates to become indistinguishable from self, has the capacity to heal and grow, is resistant to infection, and with minimal morbidity is a "holy grail" to all surgeons who work with bone. This is a report of a 14-year-old adolescent boy with Treacher Collins syndrome whose bilateral orbitozygomatic defects were treated with engineered bone made from a combination of human bone allograft, adipose-derived mesenchymal stem cells, bone morphogenic protein-2, and periosteal grafts. This single-stage reconstruction was followed by an exuberant amount of postoperative swelling that persisted for 3 weeks. He had slight lid malposition postoperatively as well but has had no long-term negative effects from the surgery. His reconstruction has remained stable during a 6-month follow-up, and a recent biopsy of the engineered bone demonstrated healthy, lamellar bone. These data are the first to demonstrate revitalization of large volume allograft bone in humans and have positive implications for craniofacial bone tissue engineering. The combination of adipose-derived stem cells, bone morphogenic protein-2, bone allograft, and periosteum may provide an alternative method to both osteocutaneous free flaps and large structural allografts with less morbidity and improved long-term results.
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Clinical applications of stem cells in craniofacial surgery.
Facial Plast Surg
PUBLISHED: 09-17-2010
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Few areas of translational medicine carry as much excitement and hope as stem cell therapies. Because of recent advances in material science and stem cell and developmental biology that help to target molecules and pathways to restore the bodys regenerative capacity, the "engineering" of missing tissue is quickly becoming a reality. Classically, tissue engineering has been thought to require external regenerative resources including a scaffold, cells, and growth factors. The allure of providing an exact replica of a missing bone that incorporates to become indistinguishable from self, has the capacity to heal and grow, is resistant to infection, and has minimal morbidity is a "holy grail" to all surgeons who work with bone. This article attempts to shed light on the use of stem cells for craniofacial reconstruction, including important principles learned from other scientific disciplines, relevant animal models for tissue engineering, early clinical reports from our experience and that of others, and future directions.
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A coalescent dual process in a Moran model with genic selection, and the lambda coalescent limit.
Theor Popul Biol
PUBLISHED: 05-19-2010
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The genealogical structure of neutral populations in which reproductive success is highly-skewed has been the subject of many recent studies. Here we derive a coalescent dual process for a related class of continuous-time Moran models with viability selection. In these models, individuals can give birth to multiple offspring whose survival depends on both the parental genotype and the brood size. This extends the dual process construction for a multi-type Moran model with genic selection described in Etheridge and Griffiths (2009). We show that in the limit of infinite population size the non-neutral Moran models converge to a Markov jump process which we call the lamda-Fleming-Viot process with viability selection and we derive a coalescent dual for this process directly from the generator and as a limit from the Moran models. The dual is a branching-coalescing process similar to the Ancestral Selection Graph which follows the typed ancestry of genes backwards in time with real and virtual lineages. As an application, the transition functions of the non-neutral Moran and lamda-coalescent models are expressed as mixtures of the transition functions of the dual process.
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Porcine allograft mandible revitalization using autologous adipose-derived stem cells, bone morphogenetic protein-2, and periosteum.
Plast. Reconstr. Surg.
PUBLISHED: 05-05-2010
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Critical defects of the craniomaxillofacial region are often treated with vascularized osteocutaneous free flaps. These lengthy operations may be associated with considerable donor-site morbidity and suboptimal functional and aesthetic results. To overcome these issues, this study investigates an engineered vascularized bone flap using allograft bone, adipose-derived stem cells, and recombinant human bone morphogenic protein (rhBMP)-2 and compares two alternative blood supplies.
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Endoscopic monobloc advancement with ultrasonic osteotomy: a feasibility study.
J Craniofac Surg
PUBLISHED: 03-11-2010
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The monobloc procedure has been criticized owing to its tendency for cerebrospinal fluid leak, relapse, infection, and incomplete ossification. Such risks have been decreased through gradual advancement of the monobloc via distraction osteogenesis. This cadaver study was undertaken to develop an endoscopic, ultrasonic monobloc osteotomy to further minimize risks and potentially improve outcomes.
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The vastus intermedius periosteal (VIP) flap: a novel flap for osteoinduction.
J Reconstr Microsurg
PUBLISHED: 02-25-2010
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Periosteums role in fracture healing is widely recognized, and its function in bone tissue engineering shows great potential. Here we introduce a novel periosteal free flap to be used as an abundant source of periosteum in the engineering and repair of bone. The descending branch of the lateral femoral circumflex vessels were isolated on 11 fresh human cadavers, preserving perforators to the vastus intermedius muscle. A cuff of vastus intermedius and approximately 75% of the circumference of the femoral periosteum were harvested from 6 cm proximal to the knee to 8 cm distal to the greater trochanter. Flap pedicle length and periosteal dimensions were measured. The pedicle arteries were injected with radiopaque dye, and radiographs were taken. A musculoperiosteal flap was elevated with visible descending perforators in each case. Mean flap surface area was 128 cm(2) (+/-99-143 cm(2)). Average pedicle length was 8 cm (+/-6-11 cm). Dye injection confirmed that the flaps blood supply was the descending branch of the lateral femoral circumflex artery. This anatomical study confirms the vascular supply of this large musculoperiosteal flap. Future work will test its efficacy as an osteoinductive agent in bone repair and tissue engineering in humans.
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Endoscopically assisted Le Fort III osteotomy using an ultrasonic scalpel: a feasibility study in cadavers.
J Craniofac Surg
PUBLISHED: 11-04-2009
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Drawbacks to conventional Le Fort III osteotomy include bleeding, infection, relapse, and scar at the coronal incision. We performed an endoscopically assisted Le Fort III osteotomy with an ultrasonic scalpel in cadavers to develop a new technique that minimizes such complications. Endoscopically assisted Le Fort III osteotomy was performed in 3 fresh, adult human cadavers. Access incisions included the transconjunctival lower lid with lateral canthotomy, the lateral upper gingivobuccal sulcus, and a stab incision in the medial aspect of the upper eyelid. Osteotomies at the zygomaticofrontal suture, the lateral orbital wall, the orbital floor, and the medial orbital wall were carried out with an ultrasonic scalpel under direct and endoscopic visualization from the trasconjunctival incision. The zygomatic arch and the pterygomaxillary region were osteotomized via the upper gingivobuccal sulcus incisions. The nasofrontal junction and the septum were accessed and cut via a stab incision in the medial upper eyelids. Disimpaction was completed with minor digital pressure inferiorly.Each of the 3 Le Fort III osteotomies was complete, and mobility was checked by manual examination. There was a steep learning curve to the operation, but the final cadaver dissection took 99 minutes to complete. The ultrasonic scalpel provided for maximal ease in cutting bone and minimal disruption to adjacent soft tissues as judged by postoperative direct examination. This cadaver study demonstrates the feasibility of a minimally invasive, endoscopically assisted Le Fort III osteotomy using an ultrasonic scalpel. Further experimental work combined with refinements in technique and equipment will help bring this advancement into clinical application.
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Bilateral sciatic nerve axonotmesis after gluteal lipoaugmentation.
Ann Plast Surg
PUBLISHED: 09-12-2009
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The number of lipoaugmentation procedures, and specifically the number of gluteal lipoaugmentations, has risen dramatically over the past decade. Though gluteal lipoaugmentation confers a pleasing hourglass profile with seemingly minimal risk, its risks have not been fully realized. We report the case of a healthy 35-year-old woman who suffered axonotmesis of the sciatic nerve due to direct lipoinjection into and around the nerve sheath. She was treated expectantly in our Peripheral Nerve Clinic for 3 months without evidence of improvement. Subsequently, she underwent internal and external neurolysis. Eighteen weeks after her neurolysis, she continues to demonstrate signs of severe peripheral neuropathy, but has begun to show signs of nerve regeneration. This is the first reported case of sciatic nerve axonotmesis due to gluteal lipoaugmentation. It highlights the importance of a thorough knowledge of gluteal anatomy and a consciousness of the risks involved with lipoaugmentation of deep structures.
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Endoscopically assisted Le Fort I osteotomy using an ultrasonic scalpel: a feasibility study in cadavers.
J. Oral Maxillofac. Surg.
PUBLISHED: 06-18-2009
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Drawbacks to conventional Le Fort I osteotomy include bleeding, infection, and relapse. The open approach predisposes itself to each of these complications through various means. We performed an endoscopically assisted Le Fort I osteotomy with an ultrasonic scalpel in cadavers to develop a new technique that minimizes such complications.
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Apples and oranges-midface hypoplasia and the Le Fort I osteotomy in cleft lip and palate patients: a classification scheme and treatment protocol.
Cleft Palate Craniofac. J.
PUBLISHED: 05-16-2009
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To present a classification and treatment protocol for cleft lip and palate patients with midface hypoplasia.
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The genealogical consequences of fecundity variance polymorphism.
Genetics
PUBLISHED: 05-11-2009
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The genealogical consequences of within-generation fecundity variance polymorphism are studied using coalescent processes structured by genetic backgrounds. I show that these processes have three distinctive features. The first is that the coalescent rates within backgrounds are not jointly proportional to the infinitesimal variance, but instead depend only on the frequencies and traits of genotypes containing each allele. Second, the coalescent processes at unlinked loci are correlated with the genealogy at the selected locus; i.e., fecundity variance polymorphism has a genomewide impact on genealogies. Third, in diploid models, there are infinitely many combinations of fecundity distributions that have the same diffusion approximation but distinct coalescent processes; i.e., in this class of models, ancestral processes and allele frequency dynamics are not in one-to-one correspondence. Similar properties are expected to hold in models that allow for heritable variation in other traits that affect the coalescent effective population size, such as sex ratio or fecundity and survival schedules.
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Banking a hemi-abdominal DIEP flap: a pilot report of indications, technique, and utility.
Microsurgery
PUBLISHED: 03-11-2009
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We present a pilot report of "banking" the contralateral hemi-abdominal deep inferior epigastric perforator (DIEP) flap under the abdominal closure in patients undergoing unilateral autologous breast reconstruction when a hemi-abdominal flap suffices. Four patients undergoing unilateral autologous breast reconstruction with a hemi-abdominal DIEP or superficial inferior epigastric artery flap had their contralateral hemi-abdominal flap left in position, or "banked," under their abdominal closure to be used in case of failure. This novel method may be of assistance when a free microvascular hemi-abdominal flap is felt to be threatened or suspect. It provides a life-boat for the younger and experienced surgeon alike, and most importantly, for the breast cancer survivor. Economic analysis of the technique reveals that the contralateral hemi-abdominal flap should be banked more often than intuition alone would suggest.
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A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications.
J Reconstr Microsurg
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Large, complex scalp defects represent a significant reconstructive challenge, thus a variety of free tissue transfer techniques have been employed to optimally provide soft tissue coverage. The aim of this study is to determine factors associated with complications.
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Repairing critical-sized rat calvarial defects with progenitor cell-seeded acellular periosteum: a novel biomimetic scaffold.
Surgery
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Many types of scaffolds have been used in bone tissue engineering, with none emerging as favorites. We propose the use of acellular periosteum as a biologic scaffold to allow for progenitor cell adherence, migration, and proliferation in vitro and to test the construct in vivo in a rat calvarial defect model.
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Utility of the ultrasonic scalpel in mandibular distraction osteogenesis.
J Craniofac Surg
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The purpose of this study was to describe our technique of bilateral mandibular distraction for micrognathia and to highlight the ultrasonic scalpel as an alternative to conventional saws in performing osteotomies for mandibular distraction osteogenesis. To do so, we retrospectively reviewed all patients who underwent mandibular distraction with an ultrasonic scalpel for tongue-based upper airway obstruction due to micrognathia between 2010 and 2011. Study outcome measures include operative blood loss, length of surgery, postoperative complications, and avoidance of a tracheostomy. Excel (Microsoft) was used to calculate averages, P values (2-tailed Student t test), and SDs for operative data, sleep studies, and cephalometric analysis. Nine patients--7 females and 2 males--were distracted for a mean distance of 17 ± 6 mm. Mean blood loss was 15 ± 7 mL, and the average length of surgery was 111 ± 27 minutes. One patient returned to the operating room for debridement/washout of a wound infection, but distraction was continued without sequelae. There were no other postoperative complications. Resolution of airway obstruction was evidenced by clinical examination and avoidance of a tracheostomy in all cases. Based on these data, we feel that mandibular distraction with univector, internal distractors, and ultrasonic osteotomies at the mandibular angle is safe and efficacious at relieving tongue-based upper airway obstruction and avoiding a tracheostomy.
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A systematic review of the use of antifibrinolytic agents in pediatric surgery and implications for craniofacial use.
Pediatr. Surg. Int.
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A systematic review aimed to evaluate the efficacy and safety of aprotinin, epsilon-aminocaproic acid (EACA), and tranexamic acid (TXA) in reducing perioperative blood loss, risk for transfusion, and total perioperative transfusion volume in major pediatric surgery. Medline, Embase, and Cochrane Reviews were searched for relevant articles published from January 1990 to January 2012. Additional studies were identified by cross-referencing citations and extracting data from recent published reviews. Data were recorded and analyzed using Cochranes RevMan5.1 software. Thirty-four studies were included in this review of which 21 provided level 1b evidence, 11 were level 2b, and two were level 3b. As compared to control groups, antifibrinolytics reduced perioperative blood loss by standardized mean difference (SMD) of -0.70 (-0.89, -0.50; p<0.00001), total transfusion volume by SMD of -0.78 (-0.95, -0.61; p < 0.00001), and Odds Ratio (OR) for transfusion was 0.39 (0.23, 0.64; p=0.002). The OR for adverse events attributable to treatment was not statistically significant across groups (OR = 0.96; p = 0.58). Antifibrinolytics are effective in reducing blood loss and transfusion requirements in major pediatric surgery. TXA and EACA also appear to have reasonable side-effect profiles. Application to craniofacial surgery is promising, though further investigation is necessary.
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Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure.
Plast. Reconstr. Surg.
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The purpose of this study is twofold: (1) to stratify preoperative risk factors that predict successful free flap salvage and (2) to identify perioperative strategies that correlate with successful salvage.
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Effect of transfusion guidelines on postoperative transfusion in children undergoing craniofacial reconstruction surgery.
Pediatr Crit Care Med
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To assess the effect of implementation of population-specific postoperative management guidelines on postoperative transfusion in children undergoing cranial vault reconstruction surgery.
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Correction of the bilateral question mark ear deformity using double-opposing z-plasty and a chondrocutaneous flap.
Cleft Palate Craniofac. J.
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Objective: To describe an alternative technique for correcting a rare and complex ear deformity. Introduction: The question mark ear deformity has been described as a congenital cleft between the helix and the lobule in addition to a prominent ear. Here we describe a novel technique using double-opposing Z-plasty and a chondrocutaneous flap to correct the deformity without significant reduction in auricle height or creation of a donor-site defect. Methods: An anterior/posterior double-opposing Z-plasty and a superiorly based chondrocutaneous flap were designed at the level of the cleft. Flaps were raised full thickness, and Mustarde and Furnas sutures were placed to reduce the prominence. The flaps were then transposed and reapproximated. Of note, all anterior and posterior skin flaps were used in the repair to minimize diminution of ear height. Pre- and postoperative measurements and photographs of the ears were taken. Results: Postoperatively, all flaps were viable, and there was no evidence of skin necrosis. The total length of the left ear was reduced by only 3 mm (53 to 50 mm), and the right ear was reduced by 1 mm (52 to 51 mm). The patients pain was successfully managed as an outpatient, and there were no infectious complications. The resultant scars healed aesthetically and are minimally visible. The patient and her parents are satisfied with the results. Conclusion: Our technique addresses all components of the question mark ear deformity and does not create a visible donor-site deformity.
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Soft-tissue refinements in the treatment of unicoronal craniosynostosis: the rotational forehead flap.
Plast. Reconstr. Surg.
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Unicoronal craniosynostosis is characterized by ipsilateral superior and posterior displacement of the supraorbital rim and frontal bone, ipsilateral widening of the palpebral fissure, ipsilateral superior displacement of the brow, and contralateral brow depression. In the literature, surgical treatment has focused on bony anatomy, with little written about soft-tissue correction. Over the last 25 years, the senior author (L.A.W.) has incorporated soft-tissue refinements, including a rotational flap of the forehead, elevating the contralateral brow, depressing the ipsilateral brow, and equilibrating the supratarsal sulci in unicoronal craniosynostosis. This rotational forehead repositioning is a simple innovation that has provided for improved orbital and brow symmetry on long-term follow-up.
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Differential closure of the spheno-occipital synchondrosis in syndromic craniosynostosis.
Plast. Reconstr. Surg.
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The spheno-occipital synchondrosis is a driver of cranial base and facial growth. Its premature fusion has been associated with midface hypoplasia in animal models. The authors reviewed computed tomographic scans of patients with Apert and Muenke syndrome, craniosynostosis syndromes with midface hypoplasia, to assess premature fusion of the spheno-occipital synchondrosis when compared with normal controls.
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Analysis of the long-term outcomes of nonsyndromic bicoronal synostosis.
Plast. Reconstr. Surg.
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Isolated nonsyndromic bicoronal synostosis is a relatively rare entity that produces a characteristic turribrachycephalic skull shape. The purpose of this study was to evaluate the long-term outcomes of the isolated nonsyndromic bicoronal synostosis patients treated at the authors institution.
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Perioperative morbidity in posterior cranial vault expansion: distraction osteogenesis versus conventional osteotomy.
Plast. Reconstr. Surg.
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The treatment of multisuture syndromic craniosynostosis is in evolution, with an increasing prevalence of reports on posterior vault expansion with distraction osteogenesis over conventional osteotomy. The purported benefits of distraction osteogenesis include less perioperative morbidity. The authors conducted this preliminary study to compare the perioperative course in children undergoing posterior cranial vault expansion with distraction osteogenesis versus conventional osteotomy.
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Congenital myofibroma masquerading as an ulcerated infantile hemangioma in a neonate.
Pediatr Dermatol
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We report a case of a solitary infantile myofibroma masquerading as an ulcerated infantile hemangioma. Infantile myofibroma is a rare soft tissue tumor that has a good prognosis in the solitary form. It may be difficult to distinguish clinically from more common tumors of infancy such as an infantile hemangioma or from other rare entities and therefore requires a biopsy for definitive diagnosis.
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JoVE Visualize is a tool created to match the last 5 years of PubMed publications to methods in JoVE's video library.

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In developing our video relationships, we compare around 5 million PubMed articles to our library of over 4,500 methods videos. In some cases the language used in the PubMed abstracts makes matching that content to a JoVE video difficult. In other cases, there happens not to be any content in our video library that is relevant to the topic of a given abstract. In these cases, our algorithms are trying their best to display videos with relevant content, which can sometimes result in matched videos with only a slight relation.