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News Article | November 18, 2015
Site: www.biosciencetechnology.com

Regenerative medicine could one day allow physicians to correct congenital deformities, regrow damaged fingers, or even mend a broken heart. But to do it, they will have to reckon with the body’s own anti-cancer security system. Now UCSF researchers have found a human gene that may be a key mediator of this tradeoff, blocking both tumors and healthy regeneration. As a child, UCSF’s Jason Pomerantz, M.D., was amazed by the fact that salamanders can regenerate limbs. Now, as a plastic surgeon and stem cell researcher, he believes that insights from creatures like zebrafish and salamanders, which routinely regrow damaged tails, limbs, jaws and even hearts, may one day endow humans with heightened regenerative abilities. “In the last 10 to 15 years, as regenerative organisms like zebrafish have become genetically tractable to study in the lab, I became convinced that these animals might be able to teach us what is possible for human regeneration,” Pomerantz said. “Why can these vertebrates regenerate highly complex structures, while we can’t?” In a study published Nov. 17, 2015, in the journal eLife, Pomerantz and his team showed new evidence suggesting that mammals may have given up the ability to regenerate limbs partly in exchange for advanced cancer-fighting genes. The question of whether the regenerative powers of zebrafish and salamanders represent ancient abilities that mammals have lost, perhaps in exchange for advanced tumor-suppression systems remains an open question for biologists. Most tumor suppressor genes, being extremely useful for preventing cancer and for forming tissues during development, are broadly distributed and conserved across many different species. Recent studies, however, suggest that one, the Arf gene, arose more recently in the avian and mammalian lineage, and has no equivalent in the genomes of highly regenerative animals. To explore whether this gene might play a role in preventing tissue regeneration in humans, the researchers added human ARF to the zebrafish genome and assessed how it affected the fishes’ normal ability to regrow damaged fins after injury. They found that human ARF had no effect on the fishes’ normal development or response to superficial injury, but when the researchers trimmed off the tip of a fish’s tail fin, the gene became strongly activated and almost completely prevented fin regrowth by activating a conserved tumor-blocking pathway. “It’s like the gene is mistaking the regenerating fin cells for aspiring cancer cells,” said Pomerantz, who is an associate professor of plastic and reconstructive surgery at UCSF and surgical director of the Craniofacial Center at UCSF’s Medical Center and School of Dentistry. “And so it springs into action to block it.” It’s remarkable that ARF can so readily integrate itself into the fish’s existing tumor-blocking pathways, Pomerantz said. “Humanizing a lower vertebrate species to study regeneration has not generally been used before, and to our surprise it turned out to be remarkably tractable. The gene fits right in very cleanly and completely alters the organism's response.” The discovery, Pomerantz said, suggests that future efforts to promote regeneration in humans will likely require carefully balanced suppression of this anti-tumor system. The same pathway in humans theoretically could be blocked to enhance researchers’ ability to grow model organs from stem cells in a laboratory dish, to enhance patients’ recovery from injury. Since tumor suppressors are thought to play a role in aging by limiting the rejuvenating potential of stem cells, blocking this pathway could even be a part of future anti-aging therapies. However, any such interventions would come with significant risk of removing an important brake on the growth of tumors. “The ratio of risk and benefit has to be appropriate,” Pomerantz said. “For instance, there are certain congenital diseases that cause craniofacial deformities so severe that the risks of such a treatment might be clinically reasonable.” The research reflects a new approach to modeling the possibilities for human regeneration using highly regenerative organisms like the zebrafish. At its inception, the unprecedented work relied on an Opportunity Grant from the Sandler Foundation through the UCSF Program for Breakthrough Biomedical Research, which led to further support from the National Science Foundation. Additional funding for the work has come from the National Institutes of Health. “When we started, it was unclear that this would work,” Pomerantz said. “I am incredibly grateful for the Sandler Foundations’ bold and visionary support of this research, which could ultimately impact the human condition.” Robert Hesse, Ph.D., of UCSF was lead author on the new study.


News Article | December 7, 2016
Site: www.prweb.com

When it came time to blow out his candles on his 14th birthday, Estefano Reano had only one wish: a new heart. Just 40 minutes later, the Pediatric Heart Transplant team at Joe DiMaggio Children’s Hospital surprised his family with a phone call that made his wish come true making the Weston teen the hospital’s 30th heart transplant recipient. “He was playing at home, when we got the phone call telling us there was a heart for Estefano,” said Alfonso Ospino, the teen’s stepfather. “I went to my wife with phone in hand with the news and then turned around and said to our son ‘get ready there is another gift waiting for you.'” Today, he is the living legacy of a donor family who gave this pediatric heart transplant patient with a gift of a new life with his family, physicians and medical staff and in time to go home for the holidays. Emotions were high at a press conference on Tuesday at the Conine Clubhouse, located adjacent to JDCH, where Estefano and his family were reunited with the heart transplant team. They came to express their gratitude and give moving tributes and heartfelt testimonials urging the community to become organ donors. “I am so happy to be here and I am so thankful to everyone,” said Estefano. “I want to do many things like travel and I want to one day run a sanctuary for endangered animals. I thank the family for giving someone like me a second chance to live the life that I always wanted.” “I prayed and have been grateful to be able to care for my son at home with the help of these doctors,” said Roxana Fergusson, the teen’s mom – “I know there are many children who do not have that opportunity and must live and wait for their hearts in a hospital room. Most importantly we pray for the family who donated, and I thank them for giving us this gift because I know now that my son has the heart of an angel because of them.” Members of the transplant team spoke about Estefano’s condition that led to his need for a heart transplant and the technological advances that allow children to wait longer than previously possible. According to the team of doctors at JDCH, every child’s unique conditions presents a unique situation and complexity. In the case of Estefano, he was born with a structural heart condition known as single ventricle heart defect, a condition where the heart is not using all four chambers of the heart to function normally. Estefano underwent five open heart surgeries since the age of 2. While the surgeries allowed his heart to function better and sustain. The surgeries worked for a few years until he began to further grow. A few years ago, his heart began to fail and the team assessed the need to put him on the transplant list. “Estefano waited over two years for his heart,” said Maryanne R. K. Chrisant, M.D., Director, Pediatric Cardiac Transplant, Heart Failure & Cardiomyopathy at JDCH. “He and his family realize that receiving a heart transplant is a second chance for Estefano to lead a more normal life. Estefano is looking forward to returning to school, going out to play athletics and being outside with his friends. His successful course and future dreams coincide with our 30th transplant celebration.” “As a pediatric heart transplant team here at Joe DiMaggio we have had the privilege to care for 30 children and provide them with an opportunity for a new life, and that is truly an amazing and humbling feeling,” said Frank Scholl, M.D. Surgical Director of Heart Transplantation at JDCH. “At this time of this great joy, we need to remember to thank our donor families who have given the ultimate gift to another human being, we could simply not do this without them.” A video of the surgeons and nurses singing Happy Birthday inside the operating room after a successful surgery spread rapidly after it was posted on the Joe DiMaggio Children’s Hospital Facebook page. The Pediatric Heart Transplant program at JDCH opened on December 10, 2010, when approval at the federal level from UNOS (United Network for Organ Sharing) was granted. The approval of the program was the culmination of years of strategic planning, including the formation of a pediatric cardiac transplant team with the right mix of expertise and compassion. Five days after program approval, the hospital’s first pediatric heart transplant was performed by the expert cardiac transplant team. In 1992, Joe DiMaggio himself helped Memorial Healthcare System celebrate the opening of the first Joe DiMaggio Children’s Hospital. Today’s 224-bed hospital opened in 2011 and offers a safe, compassionate and nurturing environment for young patients and their families. With more than 600 board-certified physicians on staff, the hospital’s broad range of pediatric specialties includes: Heart Institute, Center for Cancer and Blood Disorders, Cleft and Craniofacial Center, Cystic Fibrosis and Pulmonary Center, Emergency Department and Trauma Center, Endocrinology, General and Thoracic Surgery, Orthopedics, Pediatric Nephrology and Hypertension Program; Pediatric Intensive Care Unit, Wasie Neonatal Intensive Care Unit, [U18] Sports Medicine, Outpatient Services and Inpatient/Outpatient Rehabilitation Program.


News Article | November 18, 2015
Site: phys.org

As a child, UCSF's Jason Pomerantz, MD, was amazed by the fact that salamanders can regenerate limbs. Now, as a plastic surgeon and stem cell researcher, he believes that insights from creatures like zebrafish and salamanders, which routinely regrow damaged tails, limbs, jaws and even hearts, may one day endow humans with heightened regenerative abilities. "In the last 10 to 15 years, as regenerative organisms like zebrafish have become genetically tractable to study in the lab, I became convinced that these animals might be able to teach us what is possible for human regeneration," Pomerantz said. "Why can these vertebrates regenerate highly complex structures, while we can't?" In a study published Nov. 17, 2015, in the journal eLife, Pomerantz and his team showed new evidence suggesting that mammals may have given up the ability to regenerate limbs partly in exchange for advanced cancer-fighting genes. The question of whether the regenerative powers of zebrafish and salamanders represent ancient abilities that mammals have lost, perhaps in exchange for advanced tumor-suppression systems remains an open question for biologists. Most tumor suppressor genes, being extremely useful for preventing cancer and for forming tissues during development, are broadly distributed and conserved across many different species. Recent studies, however, suggest that one, the Arf gene, arose more recently in the avian and mammalian lineage, and has no equivalent in the genomes of highly regenerative animals. To explore whether this gene might play a role in preventing tissue regeneration in humans, the researchers added human ARF to the zebrafish genome and assessed how it affected the fishes' normal ability to regrow damaged fins after injury. They found that human ARF had no effect on the fishes' normal development or response to superficial injury, but when the researchers trimmed off the tip of a fish's tail fin, the gene became strongly activated and almost completely prevented fin regrowth by activating a conserved tumor-blocking pathway. "It's like the gene is mistaking the regenerating fin cells for aspiring cancer cells," said Pomerantz, who is an associate professor of plastic and reconstructive surgery at UCSF and surgical director of the Craniofacial Center at UCSF's Medical Center and School of Dentistry. "And so it springs into action to block it." It's remarkable that ARF can so readily integrate itself into the fish's existing tumor-blocking pathways, Pomerantz said. "Humanizing a lower vertebrate species to study regeneration has not generally been used before, and to our surprise it turned out to be remarkably tractable. The gene fits right in very cleanly and completely alters the organism's response." The discovery, Pomerantz says, suggests that future efforts to promote regeneration in humans will likely require carefully balanced suppression of this anti-tumor system. The same pathway in humans theoretically could be blocked to enhance researchers' ability to grow model organs from stem cells in a laboratory dish, to enhance patients' recovery from injury. Since tumor suppressors are thought to play a role in aging by limiting the rejuvenating potential of stem cells, blocking this pathway could even be a part of future anti-aging therapies. However, any such interventions would come with significant risk of removing an important brake on the growth of tumors. "The ratio of risk and benefit has to be appropriate," Pomerantz said. "For instance, there are certain congenital diseases that cause craniofacial deformities so severe that the risks of such a treatment might be clinically reasonable." The research reflects a new approach to modeling the possibilities for human regeneration using highly regenerative organisms like the zebrafish. At its inception, the unprecedented work relied on an Opportunity Grant from the Sandler Foundation through the UCSF Program for Breakthrough Biomedical Research, which led to further support from the National Science Foundation. Additional funding for the work has come from the National Institutes of Health. "When we started, it was unclear that this would work," Pomerantz said. "I am incredibly grateful for the Sandler Foundations' bold and visionary support of this research, which could ultimately impact the human condition." Explore further: Sex over survival: Reproductive trait in fish impedes tissue regeneration More information: Robert G Hesse et al. The human ARF tumor suppressor senses blastema activity and suppresses epimorphic tissue regeneration, eLife (2015). DOI: 10.7554/eLife.07702


News Article | November 28, 2016
Site: www.prweb.com

The message on the shirt Naida Revelo wore in her first 5K run made it clear what motivated the grandmother to take on the physical challenge: “Joe D’s Saved My Grandson’s Life.” Revelo was among the more than 6,000 people who participated in the 2016 Tour de Broward, with each having their own reasons for cycling, running, or walking. A similar number is expected again in 2017, each of them united by a desire to support Joe DiMaggio Children’s Hospital, the region’s largest pediatric facility serving Broward, Palm Beach, and northern Miami-Dade counties. The same facility that has impacted many lives. “This is an opportunity for the South Florida community to assist our efforts to provide safe, high quality, cost-effective, patient and family-centered care,” said Memorial Healthcare System President & CEO Aurelio M. Fernandez, III, FACHE. “We want everyone in our community to get involved.” The event – which takes place Sunday, February 26, at Miramar Regional Park – has raised more than $2.5 million in its previous seven years for Joe DiMaggio Children's Hospital, a facility that provides care regardless of one’s ability to pay. Sponsored by ANF Group, Tour de Broward consists of 50 and 100K bicycle rides, a 5K timed run, 3K walk, and the “Power of Play Kid Zone,” a sports-themed, fun area for children 13 or younger. The 100K ride starts at 7:00 a.m., run at 8:00 am and walk at 9:00 a.m. Pre-registration and day-of registration fees range from $15-$50, depending on the event and sign-up date. Participants can register in advance at http://www.tourdebroward.com or at the park on the day of the event. Pre-registration takes place until noon Saturday, February 25. For runners and riders there is an additional fundraising commitment, however, some exceptions apply. Please refer to Event Information on the Tour de Broward website at http://www.tourdebroward.com. Due to construction at the park, all participant and volunteer parking will be held on the grounds of Memorial Hospital Miramar, 1901 SW 172 Ave., Miramar, Florida. There will be no parking permitted at the park. Shuttles will be provided. To learn about sponsorship opportunities, call (954) 265-7241. For general information about the event, call (954) 905-5633. In 1992, Joe DiMaggio himself helped Memorial Healthcare System celebrate the opening of the first Joe DiMaggio Children’s Hospital. Today’s 224-bed hospital opened in 2011 and offers a safe, compassionate and nurturing environment for young patients and their families. With more than 600 board-certified physicians on staff, the hospital’s broad range of pediatric specialties includes: Heart Institute, Center for Cancer and Blood Disorders, Cleft and Craniofacial Center, Cystic Fibrosis and Pulmonary Center, Emergency Department and Trauma Center, Endocrinology, General and Thoracic Surgery, Orthopedics, Pediatric Nephrology and Hypertension Program; Pediatric Intensive Care Unit, Wasie Neonatal Intensive Care Unit, [U18] Sports Medicine, Outpatient Services and Inpatient/Outpatient Rehabilitation Program.


News Article | December 1, 2016
Site: www.marketwired.com

Board certified plastic surgeon Kevin Cook, MD discusses the many options available when considering breast augmentation and responds to common patient inquiries MIDLAND, TX--(Marketwired - Dec 1, 2016) - For Midland plastic surgeon Kevin Cook, MD, breast augmentation is one of the most common procedures he performs. According to Dr. Cook, adult women of all ages come to his practice seeking to enhance the appearance of their bustline. Whether they desire fuller breasts, more shapely curves, or a more youthful lift to their breasts, he listens to their motivations and goals and carefully explains their breast augmentation options. He believes that the more informed his patients are about the procedure, the easier the process is to navigate. One of the most common questions Dr. Cook hears is: which breast implants will give me the look I want? When it comes to breast implants, there are so many different choices for patients to make, he explains. Silicone or saline; round or anatomical; smooth or textured; the options can seem endless, but the bottom-line for many of his patients is which one is going to best meet their physical and cosmetic requirements. During the initial patient consultation, he emphasizes the plastic surgeon really has to understand the body he or she is working with, and how it will likely respond to different implants and breast augmentation techniques. He notes that walking the patient through the various types of implants, incision methods, and implant placement options is vital to reaching a mutual conclusion that can yield optimal results. Often, patients also ask Dr. Cook which augmentation approach he thinks is best for achieving the end result they desire. In some cases, his patients have not considered adding a breast lift to their procedure to elevate the bustline, reduce drooping, reshape the breasts, and add volume with one surgery, he explains. Ultimately, Dr. Cook's consultation process culminates in a discussion about the cost of breast augmentation surgery. At this point in the process, he and his staff are able to calculate a price based on the variables he and the patient have discussed. The cost of each procedure can vary, he explains, and it is important to receive a customized quote that lays out financial obligations very clearly. He also advises that, if patients are concerned about affording the cost of the surgery, exploring any financing options offered through the practice may be beneficial. About Kevin Cook, MD Dr. Kevin Cook is a board-certified plastic and reconstructive surgeon and the medical director of Midland Plastic Surgery Center. He earned his medical degree from the University of Texas Medical Branch (UTMB) in Galveston. After medical school, Dr. Cook began his specialized training in all aspects of plastic surgery at the University of Cincinnati. He furthered his surgical experience by completing a fellowship in craniofacial surgery at the Craniofacial Center in Dallas. At his practice, Dr. Cook offers a wide range of options for improving the appearance of the breasts, body, face, and skin. He also provides reconstructive surgery services for patients affected by facial trauma and cancer. He is available for interview upon request. For more information about Dr. Kevin Cook and Midland Plastic Surgery Center please visit midlandplasticsurgery.com and facebook.com/midlandplasticsurgery. To view the original source of this press release, click here: http://www.midlandplasticsurgery.com/breast-augmentation/midland-plastic-surgeon-answers-patients-questions-about-breast-augmentation


Fearon J.A.,Craniofacial Center | Podner C.,Craniofacial Center
Plastic and Reconstructive Surgery | Year: 2013

Background:: The authors catalogued phenotypic variability among children with Apert syndrome, reviewed surgical outcomes (particularly with respect to their treatment goals of avoiding preventable developmental delays and reducing operative interventions), and examined correlations that might stimulate improved treatment paradigms. Methods:: A case series review of all Apert syndrome patients, treated by a single surgeon, including phenotypic variations, mutational analyses, developmental assessments, and surgical treatments, was performed. Results:: Over a 20-year period, 135 Apert syndrome patients were treated (32 percent from birth). A fairly even distribution of mutations was noted (S252W, n = 20; P253R, n = 18). Of 268 hands, 60 percent were type I, 21 percent were type II, and 19 percent were type III. Fifty percent had palatal anomalies. Three separate skull configuration types were identified, and 29 percent had acquired Chiari malformations, 24 percent had anomalies of the septum pellucidum, and 12 percent had anomalies of the corpus callosum. Cranial and midfacial procedures were performed significantly earlier at outside centers (6.2 months versus 12.6 months, and 5.3 years versus 7.5 years). No significant correlations were noted between development and gene mutation, hand or skull phenotypes, intracranial anomalies, and timing of initial skull surgery. A significant correlation was noted between adverse development and ventriculoperitoneal shunts, tracheostomies, and more operative interventions. Higher development strongly correlated with treatment at our center from birth. CONCLUSION:: Treatment goals focused on the prevention of avoidable developmental delays (from raised intracranial pressure and sleep apnea) and reducing operative interventions may potentially improve developmental outcomes. Clinical Question/Level of Evidence:: Therapeutic, III. © 2012 by the American Society of Plastic Surgeons.


Fearon J.A.,Craniofacial Center | Varkarakis G.,Craniofacial Center
Plastic and Reconstructive Surgery | Year: 2012

Background: The deficient abdominal wall musculature associated with prune belly syndrome often results in numerous functional disabilities, including diminished cough, impaired bladder and bowel function, and poor posture and balance. Traditional abdominoplasties focus on static fascial excisions or plications. The authors sought to assess their preliminary experience with a new abdominoplasty technique that incorporates standard fascial tightening with bilateral pedicled rectus femoris muscle transfers. Methods: This case series review included all patients treated with prune belly syndrome at the authors center. Physical presentation, operative procedures, hospitalization, complications, and postoperative functional status were assessed, and a systematic analysis of published surgical series was performed. Results: Over a 16-year period, the authors treated 13 patients with prune belly syndrome. All underwent standard "vest over pants" fascial plications, with 11 of 13 undergoing additional rectus femoris muscle transpositions at a mean age of 4 years (range, 12 months to 13 years). Hospitalization averaged 9.3 days, and the average follow-up was over 1.5 years. The authors identified three minor complications (chylous leak, fungal urinary tract infection, and partial umbilical necrosis), yielding a complication rate similar to those identified in our systematic analysis of published standard abdominoplasties. Postoperatively, all transposed muscles were palpably functional, one patient was successfully weaned off a ventilator, and all demonstrated improvements with balance and ambulation. Conclusion: The authors preliminary review suggests that this new procedure, which supplements the standard prune belly abdominoplasty with bilateral rectus femoris transposition flaps, is not associated with substantially higher complication rates yet does appear to have the potential to provide functional improvements. Clinical Question/Level of Evidence: Therapeutic, IV. © 2012 by the American Society of Plastic Surgeons.


Kulewicz M.,Craniofacial Center | Dudkiewicz Z.,Craniofacial Center
International Journal of Oral and Maxillofacial Surgery | Year: 2010

This study compared craniofacial morphology between three groups of children with complete unilateral cleft lip and palate, treated with different surgical protocols. The study included 66 10-year-old children (42 boys and 20 girls) with a complete unilateral cleft lip and palate (22 patients in each of the three groups). Children aged 7 months underwent one-stage surgery, performed by a single surgeon. During surgery, the soft and hard palate and the lip underwent correction. The difference between the groups depended on the hard palate closure. Group I patients had the mucoperiosteal flap elevated on both sides of the cleft. Group II patients had the mucoperiosteal flap elevated on the non-cleft side, and had only a minimal 2-3 mm mucoperiosteal flap elevated on the cleft side. Group III patients had mucoperiostium elevated from the septum vomer to create a single-layered caudally pedicled flap, and had only a minimal 2-3 mm palatal flap elevated on the cleft side. Craniofacial morphology was defined using lateral cephalometric analysis. Significant craniofacial morphological differences were identified between groups I, II and III. Group III demonstrated the most favourable morphology. This indicates that the technique of hard palate closure has significant influence on craniofacial growth and development. © 2009 International Association of Oral and Maxillofacial Surgeons.


Fearon J.A.,Craniofacial Center
Plastic and Reconstructive Surgery | Year: 2014

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Make the appropriate diagnosis for each of the single-sutural synostoses, based on the physical examination. 2. Explain the functional concerns associated with these synostoses and why surgical correction is indicated. 3. Distinguish between the different types of surgical corrections available, the timing for these various interventions, and in what ways these treatments achieve overall management objectives. 4. Identify the basic goals involved in caring for the syndromic synostoses. SUMMARY: This article provides an overview of the diagnosis and management of infants with craniosynostosis. This review also incorporates some of the treatment philosophies followed at The Craniofacial Center in Dallas, but is not intended to be an exhaustive treatise on the subject. It is designed to serve as a reference point for further in-depth study by review of the reference articles presented. This information base is then used for self-assessment and benchmarking in parts of the Maintenance of Certification process of the American Board of Plastic Surgery. Copyright © 2014 by the American Society of Plastic Surgeons.


Fearon J.A.,Craniofacial Center | Cook T.K.,Craniofacial Center | Herbert M.,Craniofacial Center
Plastic and Reconstructive Surgery | Year: 2014

BACKGROUND: Hypotensive anesthesia is routinely used during craniosynostosis corrections to reduce blood loss. Noting that cerebral oxygenation levels often fell below recommended levels, the authors sought to measure the effects of hypotensive versus standard anesthesia on blood transfusion rates. METHODS: One hundred children undergoing craniosynostosis corrections were randomized prospectively into two groups: a target mean arterial pressure of either 50 mm Hg or 60 mm Hg. Aside from anesthesiologists, caregivers were blinded and strict transfusion criteria were followed. Multiple variables were analyzed, and appropriate statistical testing was performed. RESULTS: The hypotensive and standard groups appeared similar, with no statistically significant differences in mean age (46.5 months versus 46.5 months), weight (19.25 kg versus 19.49 kg), procedure [anterior remodeling (34 versus 31) versus posterior (19 versus 16)], or preoperative hemoglobin level (13 g/dl versus 12.9 g/dl). Intraoperative mean arterial pressures differed significantly (56 mm Hg versus 66 mm Hg; p < 0.001). The captured cell saver amount was lower in the hypotensive group (163 cc versus 204 cc; p = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 g/dl versus 9.3 g/dl). Fifteen of 100 patients (15 percent) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive [nine of 53 (17.0 percent)] and standard anesthesia [six of 47 (13 percent)] group (p = 0.056). CONCLUSIONS: No significant difference in transfusion requirements was found between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension. Copyright © 2014 by the American Society of Plastic Surgeons.

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