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The estimation of surgical blood loss is routinely performed during and after surgical procedures and has morbidity and mortality implications related to the risk of under- and over-resuscitation. The strategies for estimating surgical blood loss include visual estimation, the gravimetric method, the colorimetric method, formula-based methods, and other techniques (e.g., cell salvage). Currently, visual estimation continues to be the most widely used technique. In addition, unique considerations exist when these techniques are applied to various clinical settings such as massive transfusion, cardiac surgery, and obstetrics. Ultimately, when using estimated surgical blood loss to guide perioperative fluid management and transfusion thresholds, it is also important to mitigate the risks associated with resuscitation by targeting a goal-directed fluid therapy approach by utilizing markers of fluid-responsiveness to optimize stroke volume (cardiac output) and delivery of oxygen., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

The cause, or causes, of the Pleistocene megafaunal extinctions have been difficult to establish, in part because poor spatiotemporal resolution in the fossil record hinders alignment of species disappearances with archeological and environmental data. We obtained 172 new radiocarbon dates on megafauna from Rancho La Brea in California spanning 15.6 to 10.0 thousand calendar years before present (ka). Seven species of extinct megafauna disappeared by 12.9 ka, before the onset of the Younger Dryas. Comparison with high-resolution regional datasets revealed that these disappearances coincided with an ecological state shift that followed aridification and vegetation changes during the Bølling-Allerød (14.69 to 12.89 ka). Time-series modeling implicates large-scale fires as the primary cause of the extirpations, and the catalyst of this state shift may have been mounting human impacts in a drying, warming, and increasingly fire-prone ecosystem.

Extended-release liposomal bupivacaine is frequently used in surgical infiltration for postoperative pain control. The manufacturer recommends against subsequent local anesthetics within 96 hours. We administered epidural bupivacaine one day after local liposomal bupivacaine infiltration for staged hemipelvectomy without symptoms of LAST. Further pharmacokinetic and clinical safety studies are needed., Competing Interests: Dr. Harbell was an educational consultant for the American Society of Regional Anesthesia and Pain Medicine ending in 2020. The remaining authors report no conflicts of interest., (© 2022 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

As the face ages, there is thinning of the epidermis, volume loss and rearrangement of the soft tissues, and malabsorption of the skeletal framework. It is essential to have a thorough understanding of the aging process for successful facial augmentation and rejuvenation. Alloplastic implants can be used to provide a long-lasting solution for augmentation of skeletal deficiencies, restoration of facial irregularities, and rejuvenation of the face. In this study, we describe the ideal implant characteristics along with the advantages and disadvantages of various implant materials. We also present techniques in nasal and premaxillary augmentation, midface augmentation, mandibular augmentation, and lip augmentation. Additionally, computer-aided design and manufacturing as well as bioprinting are emerging technologies with growing applications in facial plastic and reconstructive surgery. We discuss their role in the creation of patient-specific custom implants. The overall goal of facial rejuvenation is to address multiple aspects of the facial aging process including deficiencies in the skin, soft tissues, and skeletal framework. The use of alloplastic implants alone or synergistically with additional surgical procedures can restore a wide range of anatomical deficits that occur with age., Competing Interests: None declared., (Thieme. All rights reserved.)

Health systems across the United States are adopting intensive care unit telemedicine programs to improve patient outcomes. Research demonstrates the potential for decreased mortality and length of stay for patients of these remotely monitored units. Financial models and studies point to cost-effectiveness and the possibility of cost savings in the face of abundant startup costs. Questions remain as to the true financial implications of these programs and targeted populations that may see the greatest benefit. Despite recent growth, widespread adoption may be limited until these unknowns are answered., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis., Background: Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy., Design/methods: Each muscle involved in the standardized PREEMPT injection paradigm is reviewed with a thorough description of each muscle's anatomy (ie, muscle description and location, innervation, vascular supply) and function. Key insights based on clinical experience are also provided to help improve outcomes., Results: The identification of the muscles in the PREEMPT injection paradigm should be based on each patient's unique anatomy and injections should be administered using the advised techniques. A thorough examination of the patient prior to treatment is also critical to determine if any preexisting conditions may increase the risk for unwanted outcomes and appropriate expectations should be communicated., Conclusions: Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient's baseline condition to anticipate the risk for unwanted outcomes that may result from treatment., (© 2017 Allergan plc. Headache published by Wiley Periodicals, Inc. on behalf of American Headache Society.)

The late Pleistocene megafaunal extinction of approximately 12,000 years ago, included the demise of Smilodon fatalis, a hypercarnivore from the Rancho La Brea deposits, which has been studied across time by looking at different deposits or pits to determine morphological size and shape changes and trends during this time. To better understand functional aspects of these changes, this study focused on a measure of jaw strength over time, which can give an indication of morphological changes within the jaw that cannot be seen using surface morphometrics. By radiographing dentaries, cortical bone can be seen, which provides an estimate of resistance to bending forces while biting, and can be measured and used as an indicator of jaw strength. Measurements were taken at repeatable locations on the dentary of the depth of the cortical bone, and of a standardized measure of cortical bone, which allows for the comparison between different individuals. Specimens included those of five different pits ranging from about 37 Kybp to 13 Kybp (just before the extinction of S. fatalis). No significant difference was found in the depth of jaws at any of the measurement points from any of the pits. However, significant differences were found in both the actual thickness of cortical bone, and the standardized thickness of cortical bone at the lower P4 between pit 13 (which had the lowest amount of bone) and pit 61/67 (which had the highest). These conclusions support other studies that have shown that individuals in pit 13 were under physiological and perhaps dietary stress, which may be reflected in the deposition of cortical bone, while the opposite trend is seen in the individuals in pit 61/67. Our results further support findings suggesting Smilodon did not appear to be morphologically most vulnerable right before its extinction., Competing Interests: The authors have declared that no competing interests exist.

Variation is the raw material for natural selection, but the factors shaping variation are still poorly understood. Genetic and developmental interactions can direct variation, but there has been little synthesis of these effects with the extrinsic factors that can shape biodiversity over large scales. The study of phenotypic integration and modularity has the capacity to unify these aspects of evolutionary study by estimating genetic and developmental interactions through the quantitative analysis of morphology, allowing for combined assessment of intrinsic and extrinsic effects. Data from the fossil record in particular are central to our understanding of phenotypic integration and modularity because they provide the only information on deep-time developmental and evolutionary dynamics, including trends in trait relationships and their role in shaping organismal diversity. Here, we demonstrate the important perspective on phenotypic integration provided by the fossil record with a study of Smilodon fatalis (saber-toothed cats) and Canis dirus (dire wolves). We quantified temporal trends in size, variance, phenotypic integration, and direct developmental integration (fluctuating asymmetry) through 27,000 y of Late Pleistocene climate change. Both S. fatalis and C. dirus showed a gradual decrease in magnitude of phenotypic integration and an increase in variance and the correlation between fluctuating asymmetry and overall integration through time, suggesting that developmental integration mediated morphological response to environmental change in the later populations of these species. These results are consistent with experimental studies and represent, to our knowledge, the first deep-time validation of the importance of developmental integration in stabilizing morphological evolution through periods of environmental change.

Alloplastic facial implants and injectable fillers are currently used for facial rejuvenation and augmentation. Their respective roles in augmentation and volume replacement of the chin and midface are discussed. Treatment goals, patient selection, procedures, and patient recovery are detailed. In addition, there is a segment for surgeons presenting a decision algorithm for selecting surgical versus less-invasive or nonsurgical approaches for midface rejuvenation., (Copyright © 2013. Published by Elsevier Inc.)

Objectives: To describe common patterns of facial asymmetry and to augment the facial analysis paradigm for improved preoperative counseling and surgical planning., Methods: We conducted a frontal photographic analysis of 50 patients who were seeking various types of facial cosmetic surgical procedures. The horizontal zonal thirds of the face were analyzed, and the bilateral data points were compared in regard to brow height, width of midface at maximum distance, malar eminence height,nasal alar height, and mandible width measured from the oral commissure to the gonial angle., Results: Forty-five patients demonstrated measurable asymmetry of the midface. The malar eminence was found to be more superiorly positioned and defined on the narrower side of the face in all cases. In contrast, the contralateral wider side of the face appeared flatter, with a more hypoplastic, inferiorly positioned malar eminence.Also, the wider side of the face more often demonstrated a wider mandibular dimension and a superiorly displaced ala. The upper third of the face, in regard to brow height, was the most variable and showed little correlation to the lower two-thirds of the face., Conclusion: This facial analysis exercise can assist the surgeon in (1) preoperative counseling, (2) managing expectations,(3) choosing appropriate-sized implants for improved symmetry, and (4) offering a more detailed assessment during the counseling of patients before faceliftsurgery

Whereas traditional concepts of facial aging focus on the descent of soft tissue secondary to gravitational effects, it is now well established that volumetric changes involving different levels of soft tissue loss reveal craniofacial skeletal deficiencies that, together, contribute to the changes evident in the aging face. Thus, effective facial rejuvenation requires a comprehensive paradigm that identifies and addresses all anatomic elements involved in the aging process. Contemporary practices in facial rejuvenation have expanded far beyond the rhytidectomy procedure to involve deeper and more fundamental levels of dissection for the purpose of elevating and replacing volume. Alloplastic implants offer a long-term, multidimensional solution to facial rejuvenation by concomitantly augmenting skeletal deficiency, restoring lost soft tissue volume, and smoothing irregularities in the facial contour. Facial augmentation using implants represents a straightforward, simple procedure with minimal risks and long-lasting benefits. By applying accurate and judicious techniques for preoperative analysis, selecting the appropriate implant, and with correct surgical placement of the implants, the facial plastic surgeon can achieve successful facial volumization and restore the youthful appearance of the aging patient., (© Thieme Medical Publishers.)

Chronic migraine (CM) is a prevalent and disabling neurological disorder. Few prophylactic treatments for CM have been investigated. OnabotulinumtoxinA, which inhibits the release of nociceptive mediators, such as glutamate, substance P, and calcitonin gene-related peptide, has been evaluated in randomized, placebo-controlled studies for the preventive treatment of a variety of headache disorders, including CM. These studies have yielded insight into appropriate patient selection, injection sites, dosages, and technique. Initial approaches used a set of fixed sites for the pericranial injections. However, the treatment approach evolved to include other sites that corresponded to the location of pain and tenderness in the individual patient in addition to the fixed sites. The Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) injection paradigm uses both fixed and follow-the-pain sites, with additional specific follow-the-pain sites considered depending on individual symptoms. The PREEMPT paradigm for injecting onabotulinumtoxinA has been shown to be safe, well-tolerated, and effective in well-designed, controlled clinical trials and is the evidence-based approach recommended to optimize clinical outcomes for patients with CM., (© 2010 American Headache Society.)

The population of the United States is becoming increasingly more diverse as there is an ever expanding influx of various ethnic groups and races that comprise the general population. As a result, the singular concept of Nordic beauty that dominated the United States media throughout the middle of the twentieth century has given way to a more diverse multiracial aesthetic. There is also a growing trend in aesthetic surgery toward ethnic feature preservation and avoidance of a "westernized" look that was more popular in previous years. Today's facial plastic surgeon must be familiar with these trends and aesthetic goals within this rapidly growing patient population. This article describes the anatomy of the Asian and Latino face and describes the techniques of midface alloplastic augmentation., (Copyright 2010 Elsevier Inc. All rights reserved.)

Over the past four decades, revolutionary improvements in the design and manufacture of facial implants have broadened the application of midface augmentation. The contemporary practice of facial rejuvenation reflects a 20-year culmination of rapid advances made in the understanding and treatment of midface aging. This article highlights the practice of malar and submalar augmentation: when and how it should be used.

Accurate correction and restoration of facial contour defects have historically posed arduous challenges for reconstructive and aesthetic surgeons, but technological innovations in the design and manufacture of facial prostheses have significantly improved the precision, fit, and reliability of these restorative devices. This article discusses the experience with and benefits obtained by the use custom implants created using CT imaging and computer-aided design and manufacture.

Objective: To evaluate the presence of imprinted facial lines in identical twin sisters, one of whom had received botulinum toxin type A (Botox) treatment in the forehead and glabellar region regularly for 13 years and one of whom had not. Crow's feet were also compared., Methods: One twin received Botox in the forehead and glabellar region (approximately 2 to 3 times each year over the past 13 years) and in the crow's feet (twice in past 2 years). Her twin received Botox only twice (in the forehead and glabellar region, 3 and 7 years ago)., Results: Imprinted forehead and glabellar lines were not evident in the regularly treated twin but were evident in the minimally treated twin. Crow's feet were less noticeable when the regularly treated twin smiled (even at 7 months after treatment) than when the minimally treated twin smiled. Untreated facial areas (eg, nasolabial folds) showed comparable aging in both twins. Neither twin experienced adverse effects., Conclusions: Long-term treatment with Botox can prevent the development of imprinted facial lines that are visible at rest. Botox treatment can also reduce crow's feet. Treatment is well tolerated, with no adverse events reported during 13 years of regular treatment in this study.

Facial wasting syndrome is part of a lipodystrophy that occurs as a complication of highly active antiretroviral therapy. The loss of subcutaneous fat in the cheeks and temples results in a hollow-eyed, bony, emaciated appearance that is characteristic of the results of treatment of human immunodeficiency virus. Cessation of therapy results in a rebound in viral load and subsequent morbidity. The appearance of facial wasting syndrome is optimally treated with custom-designed implants that are made using high-resolution computed tomography combined with surgeon input and computer-aided design and manufacturing technology. Twenty-two patients with facial wasting syndrome were treated using either submalar implants (in more moderate cases) or custom-designed implants (in more severe cases). In each patient, the appearance of volumetric soft tissue restoration was successfully achieved, returning a permanent and more healthful appearance to the face.

Migraine is a common headache disorder with profound implications on patients' quality of life and the overall health care system. Traditional treatment options have been less than optimal and many migraine patients lack confidence in over-the-counter and prescribed medications. BTX-A has shown promise as an efficacious, well-tolerated, long-lasting preventive therapy. Completed placebo-controlled trials showed that BTX-A injections for migraine resulted in fewer headaches, reduced headache severity and duration, reduced migraine-associated symptoms, and reduced use of migraine medications. Because the administration of BTX-A is nonsystemic, reported adverse events have been rare and mild. Larger trials are currently underway to further evaluate BTX-A efficacy and to determine optimal dosing and injection sites. Based on the collective experience of clinicians in neurology, facial plastic surgery, and otolaryngology, as well as supporting evidence from completed and ongoing clinical trials and theorized mechanism of action, an effective BTX-A approach for treatment of migraine is emerging. With further refinement to its use as prophylactic therapy, BTX-A can potentially be a primary option for candidate migraine sufferers and prescribing clinicians.

An open-label study and 2 double-blind, placebo-controlled studies have provided supporting evidence of botulinum toxin type A (BTX-A) as an effective, well-tolerated treatment for migraine. Observed durations of benefit were consistent with known properties of BTX-A. Findings suggest that response may vary by features of preinjection headaches, such as migraine frequency. The precise mechanism by which BTX-A provides pain relief is hypothesized to be related not only to acetylcholine inhibition but also to a blocking action on the parasympathetic nervous system. Additional studies that control factors likely to be related to response may lead to better understanding of the BTX-A effect on migraine and an optimal treatment protocol.

Botulinum toxin A (BTX-A) is a potent neurotoxin produced by the bacterium Clostridium botulinum. There are eight antigenically distinct serotypes, and they share a similar structure--a light chain with an associated molecule of zinc and a heavy chain linked by a disulfide bond. Each serotype has a separate site of action within the nerve ending. Only serotype A (Botox, Allergan, Irvine, CA) is available for clinical use in the United States.

An open-label study and 2 double-blind, placebo-controlled studies have provided supporting evidence of botulinum toxin type A (BTX-A) as an effective, well-tolerated treatment for migraine. Observed durations of benefit were consistent with known properties of BTX-A. Findings suggest that response may vary by features of preinjection headaches, such as migraine frequency. The precise mechanism by which BTX-A provides pain relief is hypothesized to be related not only to acetylcholine inhibition but also to a blocking action on the parasympathetic nervous system. Additional studies that control factors likely to be related to response may lead to better understanding of the BTX-A effect on migraine and an optimal treatment protocol.

Objective: The object of this clinical experience was to evaluate the correlation between pericranial botulinum toxin type A (BOTOX, Allergan Corp, Irvine, CA) administration and alleviation of migraine headache symptoms., Study Design and Setting: A nonrandomized, open-label study was performed at 4 different test sites. The subjects consisted of 106 patients, predominantly female, who either (1) initially sought BOTOX treatment for hyperfunctional facial lines or other dystonias with concomitant headache disorders, or (2) were candidates for BOTOX treatment specifically for headaches. Headaches were classified as true migraine, possible migraine, or nonmigraine, based on baseline headache characteristics and International Headache Society criteria. BOTOX was injected into the glabellar, temporal, frontal, and/or suboccipital regions of the head and neck. Main outcome measures were determined by severity and duration of response. The degrees of response were classified as: (1) complete (symptom elimination), (2) partial > or =50% reduction in headache frequency or severity), and (3) no response [neither (1) nor (2)]. Duration of response was measured in months for the prophylactic group., Results: Among 77 true migraine subjects treated prophylactically, 51% (95% confidence interval, 39% to 62%) reported complete response with a mean (SD) response duration of 4.1 (2.6) months; 38% reported partial response with a mean (SD) response duration of 2.7 (1.2) months. Overall improvement was independent of baseline headache characteristics. Seventy percent (95% confidence interval, 35% to 93%) of 10 true migraine patients treated acutely reported complete response with improvement 1 to 2 hours after treatment. No adverse effects were reported., Conclusions: BOTOX was found to be a safe and effective therapy for both acute and prophylactic treatment of migraine headaches. Further research is needed to explore and develop the complete potential for the neuroinhibitory effects of botulinum toxin.

Since Botulinum toxin A became a mainstay therapy for blepharospasm, its use in treating other dystonic conditions, spasticity disorders, as well as hyperfunctional lines of the face has increased exponentially in recent years. The following article summarizes our experience in establishing a safe and reliable method of administration of botulinum toxin A for treating hyperfunctional lines of the face.

The principles, method, and benefits of combining three-dimensional computed tomography (CT) and computer-aided design/computer-aided manufacture (CAD/CAM) technology for development of custom-designed prostheses are applied in the repair of posttraumatic and congenital facial contour deficiencies. Each prosthesis is generated to fit the bone defect exactly, with external contours adjusted to compensate for overlying soft-tissue disparities. Three representative case reports from a series of 17 demonstrate the applications and advantages of using this technique. Some patients had residual defects after primary repair of posttraumatic deformities. Others had defects after orthognathic relapses for congenital deformities. Without a relatively minor surgery and a high degree of predictability, many of these patients would not have pursued further treatment. All but one of the surgeries were performed on an outpatient basis, providing an accurate, simple, and cost-effective method of contour restoration with limited morbidity and reduced operative time.

The use of submalar augmentation in facial rejuvenation surgery satisfies the need for enhancement of the midface to obtain longer lasting and better results from rhytidectomy. Submalar augmentation is a new surgical technique that positions anatomically designed silicone implants over the midthird of the face. It provides the appearance of restoring midfacial soft tissue and reduces the depth of anterior facial folds. The enhanced underlying bone structure avoids exerting excessive tension on the skin during face-lift surgery, thus preventing distortion of midfacial architecture. Submalar augmentation is a procedure that has been used as a supplementary enhancement to rhytidectomy in 56 patients over six and one-half years. Only minimal complications have been reported, all of which have been satisfactorily resolved. To date, no implant has been rejected or permanently removed. In our experience, when performed in conjunction with rhytidectomy, submalar augmentation has greatly enhanced and prolonged the results of face-lift surgery, and has significantly increased patient satisfaction.

The functional sequelae of rhinoplastic surgery are emphasized and the functional and anatomical causes of postoperative nasal obstruction are discussed. A maneuver to improve the airway and decrease the incidence of postoperative nasal obstruction is presented.

Often in rhinoplasty, adequate osteotomies and mobilization of the nasal bones fail to close the dorsum--leaving an open roof deformity. Preexisting conditions and certain anatomical relationships contribute to this problem. The various methods of correcting the deformity are discussed and the author's approach presented.

We report an unusual complication of nasal surgery. A rare, localized Pseudomonas infection of the nose developed after a routine submucous resection and nasal reconstruction in a healthy 56-year-old woman. We emphasize the need for early aggressive management in the treatment of Pseudomonas infections of the nose.

Different types of alloplastic implants are currently being utilized in performing mentoplasty. A review of the literature points out the number of prostheses that have been used. Each type of material has inherit physical properties which determine its characteristics for use as a chin implant. The type of implant and method selected in chin augmentation depends upon accurate preoperative evaluation and full understanding of the properties of alloplastic substances. Five hundred and thirty-nine cases of chin augmentation utilizing different materials and methods were reviewed over a nine year period. The limitations of mentoplasty as well as the advantages, disadvantages, and in selected cases, the indications for the use of a particular implant are discussed.

Thirty patients were treated by tympanic neurectomy, chorda tympanectomy, or both for a variety of conditions. Out of six patients with gustatory sweating treated by tympanic neurectomy, two patients were relieved of symptoms, two were improved, and two remained unchanged. In five cases of benign recurrent painful parotid swelling, only two patients noted improvement in symptoms. Seventeen patients suffered from drooling. Out of 12 postresection head and neck patients, 5 (41%) were improved following such surgery. Two of four cerebral palsy children initially had a good result. However, the long term follow-up of the patients demonstrated that the drooling recurred. An additional patient who suffered from drooling caused by bulbar weakness following a cerebrovascular accident had fewer problems with salivary secretions postoperatively. The pertinent anatomy and pathophysiology is outlined. The possible reasons for the relatively disappointing results achieved are discussed.

Seventeen patients suffered from drooling that either occurred as a sequelae of extensive head and neck cancer resections or was due to neurological disorders. In these patients, a tympanic neurectomy and/or chorda tympanectomy was performed in an attempt to eliminate the drooling. The conditions in five of 12 (41%) patients with head and neck cancer were improved following such surgery. Two of four children with cerebral palsy initially had a good result. However, the long-term follow-up of the patients demonstrated that the drooling recurred. An additional patient suffering from bulbar weakness and drooling owing to a cerevrobascular accident had less problems with salivary secretions. The results were relatively disappointing; there are several possible explanations for this.

Submalar augmentation is a new approach that effectively deals with many of the problems encountered in midfacial rejuvenation. This study reports the results of 78 patients who were successfully treated over 6 years by submalar augmentation. This procedure consists of inserting newly designed Silastic (silicone rubber) implants over the midface to create the appearance of restoring the vibrant and youthful fullness of the middle third of the face while avoiding distortion of normal facial anatomy. When used alone, it provides an alternative to rhytidectomy in the 38- to 50-year age group. The benefits of submalar augmentation are such that it should be considered a standard part of the surgical approach to facial rejuvenation.

A case report of mucoepidermoid carcinoma of the larynx is presented and the literature reviewed. The inherent difficulties in histologic diagnosis are noted and the clinical behavior and treatment of mucoepidermoid carcinoma are discussed. At the present time, mucoepidermoid carcinoma of the larynx should be regarded as a separate entity, its treatment based on histological grade as well as clinical behavior.