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Osteochondritis dissecans (OCD) of the capitellum occurs relatively infrequently but can be found in young overhead-throwing athletes, most commonly in baseball players and gymnasts. Although non-operative management can effectively treat stable lesions, unstable lesions can lead to debilitating symptoms of the elbow and diminished quality of life without surgical intervention. This article reviews methods of treating OCD of the capitellum categorized by stability, size, and patient characteristics, and seeks to familiarize the reader with the appropriate selection of osteochondral allograft versus autograft in treating large, unstable lesions. We complement this review with 3 case examples, each using either an osteochondral autograft or allograft, and discuss the decision-making methodology used in each case., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture., Methods: A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate., Results: The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature., Conclusions: Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The aim of this study was to evaluate the impact of regional anesthesia for the treatment of wrist fractures or dislocation on opioid prescription-filling patterns., Methods: Patients undergoing surgery for hand and wrist fractures or dislocations from 2010 to 2018 were identified by using a national insurance claims database. Patients were stratified by procedures conducted with and without regional anesthesia. Preoperative opioids were defined by a filled opioid prescription within 1 month prior to surgery, postoperative within 1 month following the surgery, and prolonged postoperative 3 to 6 months following surgery. Patients' demographic data, comorbidities, additional medications, 30-day emergency department (ED) visits, and hospital readmissions were analyzed., Results: A total of 24 598 patients treated with and 115 199 patients treated without a regional nerve block for wrist fractures and dislocations were identified. Regional anesthesia was associated with greater postoperative opioid prescription but fewer prolonged postoperative prescriptions. There was an increased odds of all-cause 30-day ED visits but a decreased odds of 30-day hospital readmissions when patients received a regional nerve block prior to surgery., Conclusions: In this study, receiving regional anesthesia prior to surgical intervention for wrist fractures or dislocations was associated with increased filling of postoperative opioid prescriptions, but not prolonged postoperative opioid prescriptions. Additional investigation is needed to identify and implement nonnarcotic multimodal analgesia regimens that may help decrease usage of narcotic medications surrounding these procedures., Level of Evidence: Level III, retrospective cohort study.

Corticosteroid injections (CSIs) are used in a wide variety of upper extremity pathologies for both diagnostic and treatment purposes. Many patients ask about pain associated with the procedure before agreeing to proceed. The purpose of this study was to correlate perceived pain tolerance and resilience with patient-reported injection pain during and immediately after injection., Methods: One-hundred patients indicated for a CSI for an upper extremity condition were recruited for the study. Patients completed a Brief Resilience Scale, Patient-Reported Outcomes Measurement Information System pain interference form, and assessment of pain tolerance before injection. Physicians predicted pain tolerance and resilience for each patient. Immediately after the procedure, patients completed a second survey, assessing pain during and 1 minute after injection., Results: Physician-predicted patient resilience and pain tolerance was lower than that self-reported by patients. Pain with injection was inversely correlated with physician-predicted pain tolerance and resilience but not with patient-reported pain tolerance. Injection pain ratings did not correspond with patients' willingness to undergo subsequent injections., Conclusions: Procedural pain is an important consideration for many patients, especially in awake procedures. Appropriate counseling is crucial to support informed consent and enhance patient outcomes. This study demonstrated that a physician's clinical experience can be used to predict a patient's pain with CSI and should be considered when counseling patients., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Social media provides unique insight into the facilities, personnel, and culture of plastic surgery residency programs. Applicants can gain a more holistic view of programs based on their social media accounts. This study aims to evaluate the relationship between the popularity of a program's Instagram account and the program's Doximity ranking and to investigate the factors which contribute to greater viewership, with a special focus on diversity., Methods: Using Doximity's 2021-2022 Residency Navigator, a list of all integrated plastic surgery residency programs was obtained, and their social media accounts were documented. Instagram accounts were analyzed for metrics, post content, and website links. A 15-month period of posts was analyzed, then grouped into eight categories. Diversity was assessed using average Fitzpatrick skin type for each post containing photographs of people., Results: Of the 88 programs, 85 (96.6%) had an Instagram account at the time of analysis. Analysis of Instagram post content found that personnel and social function posts had significantly more likes than other categories. Posts with average Fitzpatrick type greater than or equal to III also had significantly more likes. Linear regression demonstrated a positive relationship between higher Doximity rank and number of followers; however, there was no clear relationship between rank and posts per week or engagement score., Conclusions: Plastic surgery social media accounts may make a positive impact on followers. It is important to understand the factors that can increase engagement and broaden viewership. Tailoring posts based on content popularity and highlighting diversity may help to accomplish these goals., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Infections involving thoracic aortic grafts are difficult to treat and have devastating consequences. The traditional approaches to surgical management include aggressive debridement with graft explantation and replacement. Despite treatment, the reported morbidity and mortality rates are high. The purpose of this study was to present our experience with an innovative approach to aortic graft salvage in the setting of sternal wound infection using antibiotic impregnated polymethylmethacrylate beads followed by definitive wound closure with flap coverage. A retrospective review identified patients with surgical wounds after aortic graft or cardiac valve placement over a 7-year period at a single institution. Patients were treated using an algorithm consisting of repeated surgical debridement and placement of antibiotic beads followed by flap coverage after suppression of the infection. A total of 20 patients were treated for surgical wounds, including 19 sternal and one thoracotomy wound. Culture positive surgical site infections were documented in 16 patients. One patient required a bead exchange before definitive closure. There were no in-hospital mortalities. All but two patients achieved successful infection suppression and wound closure with flap coverage. The use of antibiotic beads with serial debridement and flap closure may offer a valid option for aortic graft salvage in the setting of infected sternal wounds in the appropriate patient population. The proposed algorithm showed that patients may be successfully treated, and their infection suppressed without the need for graft removal. Mortality rates were lower from those previously reported in the literature., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Mastopexy and reduction mammaplasty are commonly performed procedures in plastic surgery with many variations in incision pattern, pedicle design, and additional support maneuvers. Aesthetically pleasing on table results are widely accomplished; however, the longevity of the outcome and sustained correction of ptosis or pseudoptosis is not universal. A systematic review of mastopexy and reduction mammaplasty procedures was performed to investigate which techniques provided the greatest long-term correction of ptosis., Methods: A broad search of the literature was performed using the PubMed database from inception to December of 2021. Study characteristics, number of patients, number of breasts, technique, outcome, and average follow-up time were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale when applicable., Results: The primary search yielded 1123 articles. After two levels of screening, 24 articles were identified for analysis. This included 16 case series, seven cohort studies, and one randomized controlled study. From these studies, 1235 patients and 2235 breasts were analyzed. The majority of articles reported on a change in the nipple to inframammary fold and sternal notch to nipple distances., Conclusions: In the analytical studies, superior and superomedial pedicles tended to provide greater long-term stability than inferior pedicles. Mesh, dermal suspension flaps, and muscular slings showed promise in providing additional support over standard techniques. No single procedure is ideal for all patients; however, this systematic review provides a valuable description of techniques and long-term outcomes to guide surgical planning., (© 2022 The Author(s).)

Background: Recent changes to the plastic surgery residency training requirements along with a general call for expanded education in cosmetic surgery have encouraged many institutions to incorporate resident aesthetic clinics into their curricula. Although the safety and satisfaction rates of resident aesthetic clinics have been well-studied, their financial viability has not. This study reviews the financial viability of the resident aesthetic clinic at the authors' institution through a cost analysis., Methods: Billing data were analyzed for all patient visits to the resident aesthetic clinic of the authors' institution during calendar year 2018. Data were extracted, including type and anatomical location of each procedure, charges collected, and supplies used. A financial analysis was performed based on fixed and variable costs and gross revenue., Results: A total of 100 unique patients were seen in the clinic over a 1-year period, resulting in 53 operations. This included 15 face, four breast, and 34 body contouring procedures. In addition, 160 cosmetic injections were performed. The gross revenue was $69,955 and the net revenue was $36,600., Conclusions: The resident aesthetic clinic at the authors' institution proved to be financially viable. The authors encourage other institutions to more closely examine the financial state of their resident aesthetic clinics as well. Furthermore, the authors hope that this analysis demonstrates to other programs that, with certain practice models, cost should not be a barrier to initiating and maintaining this valuable training tool., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Iliac crest autograft has been the gold standard for harvest of fusion materials in spine surgery. The benefits of a vascularized version of this bone graft-including delivery of stem cells, ability to deliver antibiotics to the fusion bed, and relative ease of harvest-make this technique superior to free bone transfer in the achievement of augmented spinal fusion., Objective: To present a brief summary of similar existing concepts before describing the novel technique of this vascularized posterior iliac crest bone graft., Methods: Vascularized posterior iliac crest bone graft can be harvested from the same midline lumbar incision used for thoracolumbar spinal fusion, through lateral dissection around the paraspinals to the iliac crest. Recipient sites in the posterolateral bony spinal gutters may be as rostral as T12 and caudal as the sacrum. The ability to cover multiple lumbar levels can be achieved with desired lengths of the donor iliac crest., Results: Over 14 vascularized iliac crest bone grafts have been performed to augment lumbar fusion for salvage after pseudoarthrosis. Operative time and bleeding are reduced compared to free flap procedures, and no patients have experienced any complications related to these grafts. Indocyanine green (ICG) angiography has been utilized in a novel way to ensure the vascularity of the bone graft prior to arthrodesis., Conclusion: While long-term follow-up will be required to fully characterize fusion rates and patient morbidity, this innovative surgical option augments spinal fusion in patients with, or at increased risk for, pseudoarthrosis., (© Congress of Neurological Surgeons 2021.)

Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM)., (Copyright © 2020. Published by Elsevier Ltd.)

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Autologous breast reconstruction with deep inferior epigastric perforator flaps is considered a standard of care in the treatment after mastectomy, yet vascular anatomy is highly variable and perforator selection remains challenging. The use of preoperative imaging can influence surgical planning and assist intraoperative decision-making. However, this imaging can inevitably uncover incidental findings. The purpose of this study was to analyze incidental findings, evaluate correlation with patient factors, and examine effects on overall care., Methods: A retrospective review was performed on 350 consecutive patients who received magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) as a preoperative evaluation for deep inferior epigastric perforator flap breast reconstructions done between August 2015 and June 2019. Radiology reports were analyzed for incidental findings. Patient charts were reviewed for patient history, genetic history, cancer treatment, and type of reconstruction., Results: Of the 350 patients meeting the criteria, 56.9% were noted to have incidental findings on preoperative imaging, 12.9% received additional imaging, and 4.0% underwent additional interventions. There was no difference in the percentage of patients with incidental findings between immediate and delayed reconstructions or between CTA and MRA. Five patients were found to have malignancies., Conclusions: Preoperative CTA and MRA is a valuable tool to optimize outcomes and efficiency in breast reconstruction with abdominal perforator flaps. However, this imaging can also be beneficial to the overall wellness of the patient. With the high prevalence of incidental findings on preoperative imaging, it is important to counsel patients and adjust surgical plans, if necessary., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The Millard rotation-advancement cleft lip repair is the most commonly performed cleft lip repair. An extended perialar incision allows for further advancement of the lateral lip element and improved positioning of the alar base. There is a lack of data evaluating differences in nasal alar growth when the perialar incision is utilized. This study compares the long-term effects of a perialar incision on the alar surface area of unilateral cleft lip patients who underwent a Millard cleft lip repair., Methods: Thirty-seven patients with a diagnosis of unilateral cleft lip treated with a Millard primary lip repair were studied. A perialar incision was utilized in 16 patients while 21 patients underwent a standard Millard repair. 3dMD facial images were taken at least 10 years after the initial lip repair. Using the patient's non-cleft side as an internal control, the Alar Ratio (AR) was calculated, defined as the cleft alar surface area divided by the non-cleft alar surface area., Results: The AR was significantly greater in the standard Millard repair group compared to the perialar incision group, 0.74 and 0.64 respectively (P = .02). The incomplete cleft population demonstrated a more profound difference between the treatment groups (0.82 and 0.62, respectively)., Conclusions: This study reveals an association between a perialar incision and decreased alar surface area. Long-term follow up results suggest a perialar scar restricts alar growth leading to significant asymmetry between the cleft and non-cleft sides. Therefore, surgical technique must be carefully considered prior to utilizing a perialar incision during unilateral cleft lip repair.

Prepectoral breast reconstruction was first done in the early 1960s; however, while initial results were promising, high complication rates led surgeons to move toward submuscular implant placement. We soon came to find that submuscular implant placement was not without its own set of drawbacks. Surgeons have since revisited the efficacy of prepectoral breast reconstruction in light of new surgical and technological advances. Following these advancements, complication profiles for prepectoral breast reconstruction have drastically improved. Despite this change, surgeons recognize that prepectoral implant placement is not for everyone and patient selection is critical to success. As increasing numbers of these procedures continue to be done, we must now look to conduct direct comparisons between submuscular and prepectoral breast implant placement so that surgeons can make evidence-based decisions on patient selection and operative planning., (© Thieme Medical Publishers.)

The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high incidence of capsular contracture and complication rates. With the introduction of acellular dermal matrix (ADM), plastic surgeons are again considering the advantages of prepectoral implant placement. A systematic review was conducted to examine complication profiles in prepectoral breast reconstruction alone versus prepectoral with ADM or mesh. A systematic review of the PubMed database was performed from inception to March 2017 to identify literature on postmastectomy patients undergoing prepectoral breast reconstruction with and without ADM or mesh. Study characteristics, complication rates, and outcomes were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale, and complication profiles were analyzed using the random-effects model. Twenty-seven studies met criteria for inclusion out of 550 identified for review. For 1881 total breasts, the complication rate with ADM was 23.4%, while the rate without an additional implant material was 27.5%. The difference in the capsular contracture rate with and without ADM was 2.3% and 12.4%, respectively. The use of ADM in prepectoral breast reconstruction correlated with lower capsular contracture and overall complications rates; however, rates of implant loss, infection, and mastectomy flap necrosis were higher with the use of ADM. Results were variable across studies, and in general, the quality of evidence reported was low. Because the methodology for outcome assessment was inconsistent, there is a need for further investigation with comparative studies and standardized outcome reporting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Despite incredible advances in medical innovation and education, many students finish medical school, and physicians finish residency, without sound business acumen regarding the financial realities of the modern profession. The curriculum in medical schools and residency programs too often neglects teaching the business of medicine. This overview addresses how physicians can utilize effective negotiation strategies to help develop a medical practice or add value to an existing practice or institution. The authors applied the six foundations of effective negotiating, detailed by Richard Shell in his Bargaining for Advantage , to the medical field to demonstrate the processes involved in effective negotiating. They then outlined a strategy for physicians to adopt when negotiating and showed how this strategy can be used to add value. The six foundations include: developing a personal bargaining style, setting realistic goals, determining authoritative standards, establishing relationships, exploring the other party's interests, and gaining leverage. As physicians complete training, the ability to solely focus on medical knowledge and clinical patient care disappears. It is crucial that physicians invest the time and energy into preparing for the business aspects of this profession in much the same way they prepare for the clinical care of patients. This overview seeks to define the basics of negotiation, characterize the application of negotiation principles toward clinical medicine, and lay the foundation for further discussion and investigation.

Introduction: The majority of patients with 22q11.2 deletion syndrome suffer from velopharyngeal insufficiency (VPI). Patients with 22q11.2 deletion syndrome (22qDS) commonly present with a large central velopharyngeal gap in the setting of poor velar and pharyngeal wall motion. The posterior pharyngeal flap is considered the most effective technique to treat VPI in this complex patient group. This study aims to critically evaluate success rates of surgical management of VPI in 22qDS patients and discuss options for management of a failed posterior pharyngeal flap (PPF) with persistent VPI., Methods: A systematic review was performed through MEDLINE and Scopus to examine the outcomes of PPF surgery to treat VPI in patients with 22qDS. Complications were defined as persistent VPI, hyponasal speech, and obstructive sleep apnea. To demonstrate an approach to management, the authors outline a recent patient with a failed PPF in this patient population at the authors' institution., Results: The authors comprehensively reviewed 58 articles, 13 of which contained relevant information with extractable data. Of the 159 patients with 22qDS who underwent PPF to treat VPI, successful outcomes were reported in 135 patients (80%; range: 0%-100%). Complications were reported in 14% of patients, with need for revision operations in 3%., Discussion: Surgical management of VPI in patients with 22qDS is challenging, with variable success rates reported in the literature. If unsuccessful, the surgeon faces additional challenges with the revision surgery including a scarred PPF donor site, distorted palatal recipient site, and further medialization of internal carotid arteries. Surgical revision of a failed PPF requires meticulous preoperative planning and technical execution.

The demand for aesthetic augmentation with soft tissue fillers has greatly increased in recent years and has led to an expansion in the number of products available. Unfortunately, an increase in adverse events has followed. These can be categorized into early, late, and delayed. Early infectious complications generally present as a localized skin infection, cellulitis, or abscess. Fillers can also serve as a focus for chronic infection, which is associated with the development of foreign body granulomas, a late complication. Bacterial colonization and indolent infections of the filler site can lead to biofilms that are extremely difficult to treat. Therefore, it is important to focus on prevention through eliciting a thorough patient history including an injection history, practicing sterile technique, and minimizing tissue trauma. Looking forward, much can be done to curtail complication rates. Early teaching and training, a central recording registry for complications, and a standardized filler passport for patients are suggested.

Cranial fasciitis is an uncommon, benign fibroproliferative condition of the scalp or skull that arises in children. Clinically, it manifests as a firm, nontender, subcutaneous, enlarging mass. The purpose of our study was to review the literature on cranial fasciitis to create a diagnostic algorithm using the latest patient at our institution as an example. The authors conducted a systematic review examining all published cases of cranial fasciitis in English literature. The authors then created a diagnostic algorithm to help distinguish cranial fasciitis from other similarly presenting cranial masses. To demonstrate this algorithm, the authors detailed the latest patient with cranial fasciitis at our institution. The authors extracted data from 53 published reports documenting 72 patients of cranial fasciitis. Our patient presented similarly to what was reported in the literature. A 7-week-old boy presented with 2 small parietal scalp masses that were noted shortly after birth. After noncontrast computed tomography imaging, the enlarging masses were resected and found to have eroded the outer cranial vault cortex. Histological analysis revealed cranial fasciitis. The differential diagnosis for an enlarging scalp mass in an infant or child is broad. Cranial fasciitis cannot be diagnosed based on clinical presentation alone. Imaging is usually employed to further characterize lesions after initial examination but histopathological analysis is essential for diagnosis. The locally invasive nature of cranial fasciitis makes it difficult to distinguish from malignant conditions such as sarcomas. However, if the diagnosis of cranial fasciitis is considered early, patients can achieve prompt clinical resolution following simple resection.

The field of plastic surgery originally developed out of the necessity to reconstruct the human body after the destruction of war. However, injured soldiers were not the only people who desired a change in appearance. After World War II, many people in Asian countries sought to attain a more Western look through surgery. Along with eyes, the nose was the main focus for these cosmetic procedures. In this article, the authors examine the evolution of Asian rhinoplasty from its original description in 1964 to the present. The characteristic anatomical differences between the Western and Asian nose are identified in relation to the technical challenges for rhinoplasty surgeons. Then the benefits and risks of the two major surgical approaches, autograft versus alloplast, are detailed. Finally, the coevolution of techniques and implant usage is traced from a dorsum-only implant, to an L-shaped implant, a cartilaginous cap graft with a one-piece rhinoplasty, an I-shaped implant, and a two-piece augmentation rhinoplasty. Outlining these changes demonstrates the advancement of the field of plastic surgery and the growing expectations of the patient. These advancements have provided the tools necessary to better align a patient's aesthetic goals and their unique anatomical presentation with a specific surgical approach.

Nearly all animals face a tradeoff between seeking food and mates and avoiding predation. Optimal escape theory holds that an animal confronted with a predator should only flee when benefits of flight (increased survival) outweigh the costs (energetic costs, lost foraging time, etc.). We propose a model for prey risk assessment based on the predator's stage of attack. Risk level should increase rapidly from when the predator detects the prey to when it commits to the attack. We tested this hypothesis using a predator--the echolocating bat--whose active biosonar reveals its stage of attack. We used a prey defense--clicking used for sonar jamming by the tiger moth Bertholdia trigona--that can be readily studied in the field and laboratory and is enacted simultaneously with evasive flight. We predicted that prey employ defenses soon after being detected and targeted, and that prey defensive thresholds discriminate between legitimate predatory threats and false threats where a nearby prey is attacked. Laboratory and field experiments using playbacks of ultrasound signals and naturally behaving bats, respectively, confirmed our predictions. Moths clicked soon after bats detected and targeted them. Also, B. trigona clicking thresholds closely matched predicted optimal thresholds for discriminating legitimate and false predator threats for bats using search and approach phase echolocation--the period when bats are searching for and assessing prey. To our knowledge, this is the first quantitative study to correlate the sensory stimuli that trigger defensive behaviors with measurements of signals provided by predators during natural attacks in the field. We propose theoretical models for explaining prey risk assessment depending on the availability of cues that reveal a predator's stage of attack.

Anaeromyxobacter dehalogenans strain 2CP-C is a versaphilic delta-Proteobacterium distributed throughout many diverse soil and sediment environments. 16S rRNA gene phylogenetic analysis groups A. dehalogenans together with the myxobacteria, which have distinguishing characteristics including strictly aerobic metabolism, sporulation, fruiting body formation, and surface motility. Analysis of the 5.01 Mb strain 2CP-C genome substantiated that this organism is a myxobacterium but shares genotypic traits with the anaerobic majority of the delta-Proteobacteria (i.e., the Desulfuromonadales). Reflective of its respiratory versatility, strain 2CP-C possesses 68 genes coding for putative c-type cytochromes, including one gene with 40 heme binding motifs. Consistent with its relatedness to the myxobacteria, surface motility was observed in strain 2CP-C and multiple types of motility genes are present, including 28 genes for gliding, adventurous (A-) motility and 17 genes for type IV pilus-based motility (i.e., social (S-) motility) that all have homologs in Myxococcus xanthus. Although A. dehalogenans shares many metabolic traits with the anaerobic majority of the delta-Proteobacteria, strain 2CP-C grows under microaerophilic conditions and possesses detoxification systems for reactive oxygen species. Accordingly, two gene clusters coding for NADH dehydrogenase subunits and two cytochrome oxidase gene clusters in strain 2CP-C are similar to those in M. xanthus. Remarkably, strain 2CP-C possesses a third NADH dehydrogenase gene cluster and a cytochrome cbb(3) oxidase gene cluster, apparently acquired through ancient horizontal gene transfer from a strictly anaerobic green sulfur bacterium. The mosaic nature of the A. dehalogenans strain 2CP-C genome suggests that the metabolically versatile, anaerobic members of the delta-Proteobacteria may have descended from aerobic ancestors with complex lifestyles.