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Most Cited Journal of Plastic, Reconstructive & Aesthetic Surgery Articles
The most cited articles published since 2011, extracted from Scopus.
Expression of components of the renin-angiotensin system in proliferating infantile haemangioma may account for the propranolol-induced accelerated involutionTinte Itinteang | Helen D. Brasch | Swee T. Tan | Darren J. Day
Volume 64, Issue 6, June 2011, Pages 759-765
Infantile haemangioma is a benign tumour of the microvasculature characterised by excessive proliferation of immature endothelial cells. It typically undergoes rapid proliferation during infancy followed by spontaneous slow involution during childhood often leaving a fibro-fatty residuum. In 2008, propranolol, a non-selective β-blocker, was serendipitously discovered to induce accelerated involution of a proliferating infantile haemangioma. However, the mechanism by which propranolol causes this dramatic effect is unclear. Using immunohistochemical staining, we show that the CD34 + endothelial progenitor cells of the microvessels in proliferating infantile haemangioma express angiotensin-converting enzyme and angiotensin II receptor-2, but not angiotensin II receptor-1. We have also shown using our in vitro explant model that the cells emanating from proliferating haemangioma biopsies form blast-like structures that proliferate in the presence of angiotensin II. We present here a plausible model involving the renin-angiotensin system that may account for the propranolol-induced accelerated involution of proliferating infantile haemangioma. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Low-dose propranolol for infantile haemangiomaSwee T. Tan | Tinte Itinteang | Philip Leadbitter
Volume 64, Issue 3, March 2011, Pages 292-299
In 2008, propranolol was serendipitously observed to cause accelerated involution of infantile haemangioma. However, the mechanism by which it causes this dramatic effect is unknown, the dosage empirical and the optimal duration of treatment unexplored. This study determines the minimal dosage and duration of propranolol treatment to achieve accelerated involution of problematic infantile haemangioma. Consecutive patients with problematic proliferating infantile haemangioma treated with propranolol were culled from our prospective vascular anomalies database. The patients were initially managed as inpatients and commenced on propranolol at 0.25 mg kg -1 twice daily, and closely monitored. The dosage was increased to 0.5 mg kg -1 twice daily after 24 h, if there was no cardiovascular or metabolic side effect. The dosage was increased further by 0.5 mg kg -1 day -1 until a visible effect was noticed or up to a maximum of 2 mg kg -1 day -1, and was maintained until the lesion had fully involuted or the child was 12-months old. A total of 15 patients aged 3 weeks to 8.5 months (mean, 11 weeks) underwent propranolol treatment for problematic proliferating infantile haemangioma, which threatened life (n = 1) or vision (n = 2) or nasal obstruction (n = 3) and/or caused ulceration (n = 6) and/or bleeding (n = 2) and/or significant tissue distortion (n = 12). The minimal dosage required to achieve accelerated involution was 1.5-2.0 mg kg -1 day -1. Rebound growth occurred in the first patient when the dose was withdrawn at 7.5 months of age requiring reinstitution of treatment. No rebound growth was observed in the remaining patients. No other complications were observed. Propranolol at 1.5-2.0 mg kg -1 day -1, administered in divided doses with gradual increase in the dose, is effective and safe for treating problematic proliferating infantile haemangioma in our cohort of patients. Treatment should be maintained until the lesion is completely involuted or the child is 12-months old. Larger scale studies confirming the safety and efficacy of propranolol may broaden the indications of treatment of proliferating infantile haemangioma. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Propranolol as first-line treatment for rapidly proliferating infantile haemangiomasW. J M Holmes | A. Mishra | C. Gorst | S. H. Liew
Volume 64, Issue 4, April 2011, Pages 445-451
Infantile haemangioma is the commonest childhood tumour and approximately 10% requires treatment. 1,2 Recent reports have highlighted the impressive efficacy of propranolol in treating rapidly proliferating haemangioma. The aims of our study were to prospectively assess the efficacy of propranolol as a first line treatment for problematic haemangioma, and develop a treatment regime. 31 consecutive patients with rapidly proliferating infantile haemangioma with functional impairment or cosmetic disfigurement were treated with propranolol as a first line treatment. All patients had cardiovascular pre-treatment work-up and commenced on propranolol at 3 mg/kg/day. A rapid halt in haemangioma proliferation was seen in 100% of patients and significant regression in 87% of patients. This treatment is well tolerated and has little side effects. Since this study, our unit has adopted the policy of using propranolol as a first line treatment for all problematic proliferative infantile haemangiomas. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Clinical experience with Hyaluronic acid-filler complicationsTae Hwan Park | Sang Won Seo | June Kyu Kim | Choong Hyun Chang
Volume 64, Issue 7, July 2011, Pages 892-897
Hyaluronic acid (HA) fillers have become the material of choice for soft-tissue augmentation. HA fillers are longer lasting, less immunogenic and can be broken down by hyaluronidase. These advantages make HA fillers the most common of the temporary fillers on the market. However, early and delayed complications, ranging from minor to severe, can occur following HA-filler injection. We evaluated and treated 28 cases of HA-filler-related complications that were referred to our hospital over a period of 5 years from July 2004 to October 2009. Twenty-eight patients were included in our study; 82.1% of the patients were female and 17.9% were male. Complications were roughly classified as nodular masses, inflammation, tissue necrosis and dyspigmentation. Affected locations, in descending order of frequency, were the perioral area, forehead, including glabella, nose, nasolabial fold, mentum, including marionette wrinkles, cheek area and periocular wrinkles. The most disastrous complication was alar rim necrosis following injection of the nasolabial fold. We propose two 'danger zones' that are particularly vulnerable to tissue necrosis following filler injection: the glabella and nasal ala. Although there is no definite treatment modality for the correction of HA-filler complications, we have managed them with various available treatment modalities aimed at minimising patient morbidity. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Safety of fat grafting in secondary breast reconstruction after cancerM. Rietjens | F. De Lorenzi | F. Rossetto | F. Brenelli | A. Manconi | S. Martella | M. Intra | M. Venturino | V. Lohsiriwat | Y. Ahmed | J. Y. Petit
Volume 64, Issue 4, April 2011, Pages 477-484
Background: Fat grafting is largely used to correct soft-tissue defects in any region of the human body. This study analysed its safety when the technique is used to correct defects after breast-cancer reconstruction. Methods: A total of 158 patients who underwent 194 breast fat grafting procedures were analysed. Almost all patients (98%) had a personal history of breast cancer: conservative surgery or mastectomy with breast reconstruction. In all cases, fat grafting was performed according to the Coleman's technique by a single surgeon. Results: Immediate complications included liponecrosis and infection in seven cases (3.6%) that required only daily dressings and oral antibiotics administration. In cases of fat grafting after conservative surgery, only four patients (5.9%) showed minor alterations in the postoperative mammograms, consisting of the appearance of benign images. Conclusion: Breast fat grafting can be a good solution to repair defects after breast-cancer treatment and reconstruction, and can reduce the indication for more extensive surgeries such as myocutaneous flaps. Postoperative complication rates are very low and there is little alteration in follow-up mammograms. Two points remain unclear - How much of the fat is absorbed after grafting and the potential risk of local 'dormant' tumour cells being stimulated to induce a local recurrence. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) - Steps towards an international consensusH. Birke-Sorensen | M. Malmsjo | P. Rome | D. Hudson | E. Krug | L. Berg | A. Bruhin | C. Caravaggi | M. Chariker | M. Depoorter | C. Dowsett | R. Dunn | F. Duteille | F. Ferreira | J. M Francos Martínez | G. Grudzien | S. Ichioka | R. Ingemansson | S. Jeffery | C. Lee | S. Vig | N. Runkel | R. Martin | J. Smith
Volume 64, Issue SUPPL. 1, September 2011, Page
Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Concepts in aesthetic breast dimensions: Analysis of the ideal breastP. Mallucci | O. A. Branford
Volume 65, Issue 1, January 2012, Pages 8-16
Background: This article identifies the key parameters that define the aesthetic ideal of the breast. Whilst much has previously been written on the aesthetic characteristics of the breast, thus far objective indices of beauty have not been identified. Methods: In this observational study the breasts of 100 consecutive women in three quarter profile pose, having been chosen as topless models for the attractiveness of their breasts by editors of mass print media, were analysed to identify specific proportions common to all of them. Analysis of a series of less attractive breasts was subsequently carried out looking at divergence from the 'norms' identified in the first part of the study. Results: We have identified 4 key features consistently found in all the models in the consecutive series: the proportion of the upper to the lower pole is a 45:55 ratio, the angulation of the nipple is upwards at a mean angle of 20° from the nipple meridian, the upper pole slope is linear or slightly concave, and the lower pole is convex. Conclusions: Deviation from this pattern yields a less attractive breast - the greater the deviation, the less attractive the breast. The importance of this template lies in its use as a guide for the design of aesthetic breast surgery as well as objective analysis of both good and bad results. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The safety of autologous fat transfer in breast cancer: Lessons from stem cell biologyRobert A. Pearl | Simon J. Leedham | Marc D. Pacifico
Volume 65, Issue 3, March 2012, Pages 283-288
Autologous fat grafting is versatile tool in plastic surgery and is increasing used for reconstruction following breast conserving surgery for breast cancer. Part of the reconstructive qualities of the transferred fat may be due to the presence of adipose derived mesenchymal stem cells (ADMSC) playing an angiogenic and an adipogenic role. In this context it must be considered if autologously engrafted fat tissue could contribute to carcinogenesis following breast conserving surgery. In this article we review the current stem cell biology evidence on engraftment, transdifferentiation and potential carcinogenic contribution in the breast and other solid organ stem cell niches in an attempt to highlight possible areas of concern. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Fat grafting accelerates revascularisation and decreases fibrosis following thermal injurySteven M. Sultan | Jason S. Barr | Parag Butala | Edward H. Davidson | Andrew L. Weinstein | Denis Knobel | Pierre B. Saadeh | Stephen M. Warren | Sydney R. Coleman | Alexes Hazen
Volume 65, Issue 2, February 2012, Pages 219-227
Background: Fat grafting has been shown clinically to improve the quality of burn scars. To date, no study has explored the mechanism of this effect. We aimed to do so by combining our murine model of fat grafting with a previously described murine model of thermal injury. Methods: Wild-type FVB mice (n = 20) were anaesthetised, shaved and depilitated. Brass rods were heated to 100 °C in a hot water bath before being applied to the dorsum of the mice for 10 s, yielding a full-thickness injury. Following a 2-week recovery period, the mice underwent Doppler scanning before being fat/sham grafted with 1.5 cc of human fat/saline. Half were sacrificed 4 weeks following grafting, and half were sacrificed 8 weeks following grafting. Both groups underwent repeat Doppler scanning immediately prior to sacrifice. Burn scar samples were taken following sacrifice at both time points for protein quantification, CD31 staining and Picrosirius red staining. Results: Doppler scanning demonstrated significantly greater flux in fat-grafted animals than saline-grafted animals at 4 weeks (fat = 305 ± 15.77 mV, saline = 242 ± 15.83 mV; p = 0.026). Enzyme-linked immunosorbent assay (ELISA) analysis in fat-grafted animals demonstrated significant increase in vasculogenic proteins at 4 weeks (vascular endothelial growth factor (VEGF): fat = 74.3 ± 4.39 ng ml -1, saline = 34.3 ± 5.23 ng ml -1; p = 0.004) (stromal cell-derived factor-1 (SDF-1): fat = 51.8 ± 1.23 ng ml -1, saline grafted = 10.2 ± 3.22 ng ml -1; p < 0.001) and significant decreases in fibrotic markers at 8 weeks (transforming growth factor-ß1(TGF-ß) : saline = 9.30 ± 0.93, fat = 4.63 ± 0.38 ng ml -1; p = 0.002) (matrix metallopeptidase 9 (MMP9): saline = 13.05 ± 1.21 ng ml -1, fat = 6.83 ± 1.39 ng ml -1; p = 0.010). CD31 staining demonstrated significantly up-regulated vascularity at 4 weeks in fat-grafted animals (fat = 30.8 ± 3.39 vessels per high power field (hpf), saline = 20.0 ± 0.91 vessels per high power field (hpf); p = 0.029). Sirius red staining demonstrated significantly reduced scar index in fat-grafted animals at 8 weeks (fat = 0.69 ± 0.10, saline = 2.03 ± 0.53; p = 0.046). Conclusions: Fat grafting resulted in more rapid revascularisation at the burn site as measured by laser Doppler flow, CD31 staining and chemical markers of angiogenesis. In turn, this resulted in decreased fibrosis as measured by Sirius red staining and chemical markers. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in managementDeok Woo Kim | Eul Sik Yoon | Yi Hwa Ji | Seung Ha Park | Byung Il Lee | Eun Sang Dhong
Volume 64, Issue 12, December 2011, Pages 1590-1595
Skin necrosis following the inadvertent arterial injection of hyaluronic acid (HA) is a serious complication. It is not clear whether or not subcutaneous injections of hyaluronidase decrease skin necrosis in HA-induced vascular complications. We had four cases of HA-induced vascular complications, two of which were treated with hyaluronidase the next day. All of the patients had skin necrosis and scarring. We performed an animal study with rabbit ears in which HA filler was injected into the auricular arteries of both ears. Five rabbits each received a subcutaneous injection of 750 IU of hyaluronidase 4 and 24 h after the filler injection. The hyaluronidase-treated ears in the 4-h intervention group had significantly smaller necrotic areas (p < 0.05), while the 24-h intervention group had no differences in the area of necrosis. Hyaluronidase reduced the vascular complications of HA fillers when used early, but there was no benefit to hyaluronidase injection after 24 h. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Adipose-derived stem cells enhance primary tendon repair: Biomechanical and immunohistochemical evaluationCagri A. Uysal | Morikuni Tobita | Hiko Hyakusoku | Hiroshi Mizuno
Volume 65, Issue 12, December 2012, Pages 1712-1719
Background: Primary tendon repair aims at increased tensile strength at the time of mobilisation. Tendon repair and regeneration using mesenchymal stem cells have been described in different studies; however, adipose-derived stem cell (ASC) use for tendon regeneration and repair has recently been taken into consideration. In this study, we sought to determine whether ASCs would be beneficial in primary tendon healing. Materials and methods: Both the Achilles tendons of rabbits (n = 6) were incised and consequently repaired. To the left side was applied platelet-rich plasma (PRP) gel and to the right side autologous ASC-mixed PRP. The tensile strength was measured on the 4th week. The samples were taken for immunohistochemical evaluation of collagen type I, transforming growth factor beta (TGF-β) 1, 2, 3, fibroblast growth factor (FGF) and vascular endothelial growth factor (VEGF). Results: The tensile strengths in control and experimental groups were found out to be 29.46 ± 3.66 and 43.06 ± 3.80 kgf. Collagen type I, FGF and VEGF levels were statistically higher, whereas TGF-β1, 2, 3 were lower in the experimental group. Conclusion: ASCs enhance primary tendon healing; however, the complex interaction and the cascades by which ASCs could increase collagen type I, FGF and VEGF and decrease TGF-β levels should further be investigated. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Simultaneous multi-site lymphaticovenular anastomoses for primary lower extremity and genital lymphoedema complicated with severe lymphorrheaTakumi Yamamoto | Isao Koshima | Hidehiko Yoshimatsu | Mitsunaga Narushima | Makoto Miahara | Takuya Iida
Volume 64, Issue 6, June 2011, Pages 812-815
Primary lower extremity and genital lymphoedema (GL) is difficult to manage, especially when complicated with severe lymphorrhea. With abundant experience of treatment for lower-extremity lymphoedema (LEL), we performed simultaneous multi-site lymphaticovenular anastomoses (LVAs) for GL with severe lymphorrhea. In two cases of primary LEL and GL, LVAs were performed via 2-cm-long skin incisions using two to three operating microscopes under local anaesthesia. Symptoms of oedema and lymphorrhea improved clinically. LVA is a minimally invasive surgery, which is effective for the treatment of LEL and GL even in primary cases with severe lymphorrhea. Simultaneous multi-site LVAs can serve as the most effective therapy for lymphoedema. © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Capsular contracture - What are the risk factors? A 14 year series of 1400 consecutive augmentationsAnne Dancey | Abdul Nassimizadeh | Paul Levick
Volume 65, Issue 2, February 2012, Pages 213-218
The modern era of breast augmentation and reconstruction began in 1963, with the introduction of silicone implants by Cronin and Gerow. To date, the demand for cosmetic augmentation continues to increase exponentially. However, whilst the surgical techniques and quality of mammary prosthesis have improved dramatically in recent years, patients are still confronted with significant potential complications. We performed a retrospective study of 1400 consecutive primary breast augmentations performed between March 1995 and March 2009 by a single surgeon. We specifically examined the incidence of capsular contracture and the possible causative factors. Follow up ranged from 1 to 16 years. The mean age at the time of surgery was 32.8 years and fill volume was between 195 ml and 800 ml. Our capsular contracture rate was in the order of 26.9%. BMI >30, fill volumes >350 ml, smoking and alcohol consumption did not significantly increase capsular contracture rate. Implant type, pregnancy, infection and delayed haematoma significantly increased the risk of capsular contracture. Our series has given us a unique insight into the frequency of capsular contracture and identified several risk factors. To our knowledge, this is the first report of pregnancy having a significant effect on capsular contracture. We now counsel patients thoroughly into the detrimental effects of pregnancy on the implant. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Adipose-tissue grafting to the post-mastectomy irradiated chest wall: Preparing the ground for implant reconstructionI. Sarfati | T. Ihrai | G. Kaufman | C. Nos | K. B. Clough
Volume 64, Issue 9, September 2011, Pages 1161-1166
Introduction: Breast implant reconstruction after radiotherapy carries a high risk of failure and complication. Nevertheless, it may be the only alternative for patients who are not suitable for autologous reconstruction or who refuse this option. As clinical and experimental studies have demonstrated that grafting adipose tissue (lipofilling) in an irradiated area improves the quality of the skin, we made the assumption that preliminary fat grafting of the chest wall might reduce the complication and failure rates of implant reconstruction by improving the implant coverage. Patients and methods: From 2007 to 2009, 28 patients had fat transfer to the chest wall, prior to implant reconstruction. All patients had had mastectomy and irradiation for breast cancer. Lipofilling was initiated 6 months after the end of radiotherapy. The mean number of fat-grafting sessions was 2 (range 1-3). An average volume of 115 cc (70-275 cc) was injected each time. Once the chest wall's skin seemed to have gained enough thickness, implant reconstruction was performed. Results: The mean follow-up period was 17 months. Three minor complications occurred. Implant explantation was performed in one case for exposition. The cosmetic results were good and very good in >80% of the cases. Conclusion: This study points out the benefits of fat grafting to the irradiated chest wall prior to implant placement and demonstrates that lipofilling prepares the ground to implant breast reconstruction. This approach could be considered as an alternative to flap reconstruction for selected patients. © 2010 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Indocyanine green (ICG)-enhanced lymphography for evaluation of facial lymphoedemaTakumi Yamamoto | Takuya Iida | Nana Matsuda | Kazuki Kikuchi | Hidehiko Yoshimatsu | Makoto Mihara | Mitsunaga Narushima | Isao Koshima
Volume 64, Issue 11, November 2011, Pages 1541-1544
The use of platelet-rich plasma in plastic surgery: A systematic reviewC. E. Sommeling | A. Heyneman | H. Hoeksema | J. Verbelen | F. B. Stillaert | S. Monstrey
Volume 66, Issue 3, March 2013, Pages 301-311
Objective: The study's aim was to evaluate the available evidence regarding the use of platelet-rich plasma in plastic and reconstructive surgery, through implementation of a systematic review of the literature. Data sources: PubMed and The Cochrane Library were searched using MeSH terms: 'platelet rich plasma' and 'plastic surgery' for all publications up to July 2011. All English, German, French and Dutch papers were included. In addition, the reference lists of relevant articles were searched for potentially appropriate publications. Study selection: Included studies needed to report on topics related to plastic and reconstructive surgery, mentioning at least one clinical end point. Both in vivo and in vitro comparative studies, performed in humans or animals, were included. A total of 82 publications were found, of which 40 studies met the inclusion criteria and were relevant to be used in this systematic review. Data extraction: Data from retrieved studies were reviewed and tabulated according to year of publication, study design, human or animal studies, characteristics of the population, mode of application, outcomes and preparation method. Data synthesis: A total of 15 randomised controlled trials and 25 case-control studies were found. Thirty-six publications demonstrated favourable outcomes with the use of platelet-rich plasma. The included articles were divided into three topics related to plastic surgery: wound healing, fat grafting and bone grafting. Conclusions: This systematic review describes a substantially beneficial effect of platelet-rich plasma for several indications, including a better wound healing rate, an increased survival rate of fat grafts and an enhancement of bone graft regeneration. © 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
Immediate breast reconstruction using porcine acellular dermal matrix (Strattice™): Long-term outcomes and complicationsC. Andrew Salzberg | Courtney Dunavant | Nadia Nocera
Volume 66, Issue 3, March 2013, Pages 323-328
Background: There has been limited reported experience with the use of Strattice™ (LifeCell Corp., Branchburg, NJ), a porcine-derived acellular dermal matrix, in implant-based breast reconstruction. The purpose of this study is to evaluate our experience with this matrix. Methods: Patients who underwent immediate single-stage or two-stage implant-based breast reconstruction with the assistance of Strattice were included in this study. Patient charts were reviewed for indications for mastectomy, adjunctive radiotherapy use, implant or expander volume, length of follow-up period, and type and incidence of complications during the follow-up period. Biopsies of Strattice were taken for histological analyses. Results: A total of 105 reconstructions were performed in 54 patients: 77% were prophylactic and 23% were oncologic. All, but 4, reconstructions were single stage. Mean implant volume of single-stage reconstructions were 444.1 (range: 150-700 cc) and mean expander volume after completion of expansion was 400 (range: 350-450). Mean follow-up period was 41.3 months (range: 35.5-48.4 months). Total complication rate was 8.6%. Complications occurred in 9 breasts: implant loss or explantation (3.8%), infection (3.8%), skin breakdown or necrosis (2.9%), seroma (1.9%), implant exposure (1.0%), and delayed skin healing (1.0%). Histological analyses of implanted Strattice revealed a viable matrix with fibroblast infiltration and revascularization. Conclusions: Over a mean 3.5-year follow-up period, low complication rates and good outcomes were observed with the use of Strattice that are comparable to those reported with human acellular dermal matrices. © 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): A review of 9305 patients from the 2005-2010 ACS-NSQIP datasetsJohn P. Fischer | Jonas A. Nelson | Joseph M. Serletti | Liza C. Wu
Volume 66, Issue 11, November 2013, Pages 1504-1512
Background Early loss of an implant is a serious complication following breast reconstruction. We assess perioperative risk factors associated with tissue expander (TE) loss following immediate breast reconstruction (IBR) using the ACS-NSQIP datasets. Methods We reviewed the 2005-2010 ACS-NSQIP databases identifying encounters for CPT codes for IBR using TE (19357). Patients were identified as experiencing a "loss of graft/prosthetic" based on a defined dataset variable. Patients who experienced a TE loss were compared to those who did not with respect to peri-operative characteristics. Results 9305 patients were identified who were on average 51.0 ± 10.5 years. Average length of stay was 1.7 ± 1.7 days. Patients experiencing early TE loss tended to have higher BMI (P < 0.0001) and ages (P < 0.001), more often be obese (P < 0.001), be active smokers (P < 0.001), and have hypertension (P = 0.001). Patients experiencing TE loss also more frequently had longer operative times (P = 0.0002), total length of stay (P = 0.004), superficial surgical site infections (P = 0.004), and deep surgical infections (P < 0.0001). A multivariate regression analysis determined age (>55 years) (OR = 2.0, P = 0.004), obesity (BMI≥30 kg/m2) (OR = 1.7, P = 0.03), active smoking (OR = 4.0, P < 0.001), prolonged operative time (>1 SD above average) (OR = 2.2, P = 0.002), superficial wound infection (OR = 4.0, P = 0.002), and deep wound infection (OR = 9.1, P < 0.001) were associated with early TE loss. Discussion Early TE loss is a complex multifactorial process likely related to identifiable preoperative, modifiable risk factors and postoperative complications. This analysis highlights previous work demonstrating of the added risk of age, obesity, and active smoking. © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Improvement of skin-graft survival after autologous transplantation of adipose-derived stem cells in ratsA. Zografou | C. Tsigris | O. Papadopoulos | N. Kavantzas | E. Patsouris | I. Donta | D. Perrea
Volume 64, Issue 12, December 2011, Pages 1647-1656
Background: Skin grafts are frequently used for a variety of indications in plastic and reconstructive surgery. Their necrosis is a common complication, while different therapies have been proposed. Currently, adipose-derived stem cells (ASCs) hold great promise for their angiogenic potential and role during tissue repair. In this study, autologous transplantation of ASCs was used in skin grafts in rats to determine if it increases angiogenesis, skin-graft survival and wound healing. Methods: ASCs were isolated, cultured, labelled with fluorescent dye and injected under full-thickness skin grafts in 10 rats (group 1), while 10 others served as controls (group 2). Skin grafts were analysed after 1 week. Collagen's framework was assessed with Masson's trichrome stain and angiogenesis with von Willebrand factor (vWF) immunohistochemistry. In addition, immunohistochemical staining intensity of vascular endothelial growth factor (VEGF) and transforming growth factor b3 (TGFb3) was assessed in all grafts. Results: Mean area of graft necrosis was significantly less in group 1 than in group 2 (6.12% vs. 32.62%, p < 0.01). Statistically significant increase of microvessel density, collagen density, VEGF and TGFb3 expression was noted in group 1 compared with group 2 (all: p < 0.01). Conclusions: These findings suggest that autologous ASCs transplantation increases full-thickness skin-graft survival and shows promise for use in skin-graft surgery. This might be both due to in situ differentiation of ASCs into endothelial cells and increased secretion by ASCs of growth factors, such as VEGF and TGFb3 that enhance angiogenesis and wound healing. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Efficacy, safety and complications of autologous fat grafting to healthy breast tissue: A systematic reviewRene D. Largo | Laurent A H Tchang | Valentina Mele | Arnaud Scherberich | Yves Harder | Reto Wettstein | Dirk J. Schaefer
Volume 67, Issue 4, January 2014, Pages 437-448
Background: Fat grafting for primary breast augmentation is growing in popularity due to its autologous properties and its side benefit of removing unwanted fat from other areas, although volume gain is unpredictable and patient safety remains unclear. Objective: The aim of this study was to provide an evidence-based overview of autologous fat grafting to healthy breast tissue with focus on volume gain, safety and complications. Design: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data sources: The MEDLINE, Cochrane Library and EMBASE databases were searched for clinical studies on autologous fat grafting to healthy breast tissue within the last 30 years. Data extraction: Clinical articles were evaluated for indication, pre- and postoperative work-up, surgical technique, volume gain (efficacy), complications, radiographic changes and oncological safety. The level of evidence was assessed according to the Oxford Centre for Evidence-based Medicine 2011. Results: A total of 36 articles involving 1453 patients with a mean follow-up period of 16.3 months (1-156 months) were included. No randomised controlled studies were found. Six percent of the patients undergoing fat grafting to healthy breast tissue experienced major complications requiring a surgical intervention or hospitalisation. Two patients with breast cancer (0.1%) after fat grafting for cosmetic purposes were reported. Average breast volume gain ranged from 55% to 82% relative to the grafted fat volume. Conclusions: The prevalence of complications and re-operations in fat grafting to healthy breast tissue compared favourably to implant-based breast augmentation. Although no increased incidence of breast cancer was found, long-term breast cancer screening and the implementation of publicly accessible registries are critically important to proving the safety of fat grafting. © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Liposuction for chronic lymphoedema of the upper limb: 5 Years of experienceMark V. Schaverien | Kirsty J. Munro | Paul A. Baker | D. Alex Munnoch
Volume 65, Issue 7, July 2012, Pages 935-942
Background: Lymphoedema of the upper limb is a well-recognised complication of axillary surgery for breast cancer. Effective long-term treatment of lymphoedema by liposuction has previously been demonstrated. In this study we present our first five years of experience using this technique in treatment of upper limb lymphoedema. Methods: A prospective analysis of the results of 12 patients who underwent liposuction followed by compression therapy for chronic unilateral upper limb oedema with up to five years of follow-up was carried out. Hospital Anxiety and Depression Score questionnaires and a Visual Analogue Score for overall well-being were also completed pre- and post-operatively. Results: The mean duration of lymphoedema was seven years (range, 1-14), commencing at a mean of one year (range, 0-5) after axillary surgery. The mean excess arm volume at admission was 1391 ml and the ratio of the lymphoedematous to the unaffected arm was 1·48. The mean total aspirate volume was 1713 ml, of which 87 percent was fat. At one year the mean percentage volume reduction compared with the normal arm was 101 percent, meaning that the volume of both of patients' arms was virtually equivalent, and this reduction was stable with up to 5 years of follow-up. Postoperatively there were reductions in anxiety (p < 0.05) and depression scores, and an improvement in overall well-being. Discussion: Our first five years of experience of liposuction combined with application of compression garments has demonstrated significant, reproducible, and stable reduction of upper limb oedema with improvement of overall well-being and reduction in measurable anxiety and depression. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The PIP mammary prosthesis: A product recall studyMg Berry | Jan J. Stanek
Volume 65, Issue 6, June 2012, Pages 697-704
Introduction: Concerns about the durability of silicone breast implants manufactured by Poly Implant Prothèse (PIP) have been expressed for several years prior to their formal withdrawal from the market in March 2010. Although precise details of what elements were at fault remain unclear, concerns have been raised about both the elastomer and the filler gel. Media speculation has focussed on device safety, longevity and, recently, a possible association with lymphoma, specifically anaplastic large cell lymphoma (ALCL). There is however, no actual data concerning these implants with which to guide and inform when concerned patients seek advice. Patients and methods: PIP mammary prostheses were used by the senior author for both primary and revision breast augmentation (BA) during the period January 2000-August 2005. A database of patients was constructed and attempts made to contact each patient offering a free consultation and referral for ultrasound scan (USS). Chief outcome measures included secondary surgery, the implant rupture rate and time to rupture. Results: 453 consecutive patients with PIP devices were identified. Of this number 30 had already undergone implant exchange for a variety of reasons. 180 (39.7%) could not be contacted and 19 had undergone explantation elsewhere, including the NHS. Of those who could be contacted, 47 declined consultation as they had no concerns. 97 had neither clinical signs nor radiographic evidence of implant rupture and elected to remain under regular review. At the time of writing, 38 have undergone implant exchange after ultrasonographic indication of rupture and the overall patient rupture rate for the PIP implant is 15.9-33.8%. This cohort correlates reduced implant longevity with each successive year from 2000 and no cases of ALCL have been diagnosed. Discussion: Long-term studies such as this are difficult to undertake for a number of reasons as they place a significant additional burden of resources on a practice. They are, however, essential from an industry perspective both for the provision of information and supporting audit and professional standing. Being only a single-handed practice, this initial study is the tip of an iceberg that may affect 40,000 women in the UK with PIP implants, but it does provide some hard data with which to guide our patients. It is also believed to be the first independent product recall study in aesthetic breast surgery. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Development of micro-injection as an innovative autologous fat graft technique: The use of adipose tissue as dermal fillerP. S A Nguyen | C. Desouches | A. M. Gay | A. Hautier | G. Magalon
Volume 65, Issue 12, December 2012, Pages 1692-1699
Background: Autologous fat graft, by virtue of its volumetric qualities and its action on skin trophicity, can be considered as a gold standard implant. Current techniques do not allow very superficial or subdermal injections of adipose tissue. The authors report technical modifications that enable fat transfer through a 25-gauge cannula. The viability of grafted fat was assessed after subcutaneous injection on a murine model. Methods: Micro-fat grafting consists of harvesting fat tissue using a multiperforated cannula with holes of 1 mm. Fat tissue is refined as described by SR Coleman and transferred through a micro-cannula. Initially, human fat was first harvested using two different procedures: Coleman's technique and the modified harvesting technique. Preliminary comparative histologic analyses were performed. Sixteen nude mice received human fat tissue: one side was filled with 0.7 cc through a 17-G cannula using Coleman's technique, and the opposite side was grafted using smaller cannulae (20G, 23G and 25G) following the modified harvesting technique. Mice were euthanised at 12 weeks and skin biopsies were performed. Results: Experimental fat grafts on mice were observed and analysed: macroscopically, the fat tissue of each side showed the same healthy aspect. Haematoxylin-eosin- saffron staining revealed intact adipocytes and anti-CD31 antibody immunohistochemical staining highlighted an abundant neo-vessel network. Conclusion: Fat graft obtained by the modified technique maintains a normal histologic structure. Fat injection with micro-cannulae extends the application of lipostructure to the superficial layers of the skin. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: A meta-analysisAlexander Egeberg | Mads Klovgaard Rasmussen | Jens Ahm Sorensen
Volume 65, Issue 11, November 2012, Pages 1474-1480
Background: Countless studies have compared the use of autologous tissue for breast reconstruction; however, rates of donor-site morbidity differ greatly. This study examined the donor-site morbidity of superficial inferior epigastric artery (SIEA), deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps when used for unilateral breast reconstruction. Methods: Searches in PubMed and Medline as well as three manual search strategies for English-language articles published from 1 January 1995 to 1 January 2011 resulted in 2154 publications. Four levels of screening identified five studies suitable for the meta-analysis. StatsDirect software was used to perform the Mantel-Haenszel fixed-effect model. Results: Only one study reported rates of donor-site morbidity for SIEA flaps. It was therefore impossible to perform any analysis regarding SIEA flaps. Five studies reported rates for both DIEP and MS-TRAM flaps and were used to estimate pooled relative risk (RR) and confidence intervals (CIs) of bulging. There was a 20% reduced risk of bulging when DIEP flaps were used compared to MS-TRAM flaps (RR 0.80, 95% CI 0.48-1.35). Subgroup analysis demonstrated that the risk of bulging in DIEP flap patients was one-third of MS-TRAM flap patients (RR 0.29; 95% CI 0.06-1.36), when rates were reported by clinical examinations. However, when rates were reported by surveys there was no difference in bulge formation between DIEP and MS-TRAM flap patients (RR 1.04; 95% CI 0.59-1.79). The adjusted RR of hernia in DIEP flap patients was approximately one-half of MS-TRAM flap patients (RR 0.43; 95% CI 0.07-2.63). Conclusion: This analysis demonstrated a clear trend towards a favourable outcome when DIEP flaps were used compared to MS-TRAM flaps. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The methodological quality of randomized controlled trials in plastic surgery needs improvement: A systematic reviewRiaz A. Agha | Christian F. Camm | Eric Edison | Dennis P. Orgill
Volume 66, Issue 4, April 2013, Pages 447-452
Background: Our objective was to assess the methodological quality of randomized controlled trials (RCTs) in Plastic Surgery. Methods: An information specialist searched MEDLINE for the period of 1 January 2009 to 30 June 2011 for the MESH heading "Surgery, Plastic" with limitations for English language, human studies and randomized controlled trials. Results were manually searched for RCTs involving surgical techniques. The papers were then scored with the authors' seven point extended version of the Linde Internal Validity Scale (ELIVS). Secondary scoring was then performed and discrepancies resolved by consensus. Results: 57 papers met the inclusion criteria. The median ELIVS score was 3.0 with a range of 1.0-6.5. Compliance was poorest with use of intention to treat analysis (4%), blinding of patients (23%) and the handling and reporting of patient withdrawals (25%). There was no statistically significant correlation between journal ELIVS score and 2010 impact factor or number of authors (Spearman rho 0.10 and 0.27 respectively). Multicentre trials had a higher average ELIVS score than single centre ones (3.6 vs 2.7) although this did not reach significance. There was no correlation between the volume of RCTs performed in a particular country and methodological quality. Conclusion: The methodological quality of RCTs in Plastic Surgery needs improvement. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.


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ANN ARBOR -- With two regular season games (including Ohio State) and a bowl game remaining, the mailbag questions are starting to take on different forms.
Plenty of talk about next season, and what might change. Plenty of talk about missed opportunities, and who is at fault.
And, of course, plenty of talk about Al Borges in general.
With that, onto the mailbag.
(This week's video answer has to do with everyone who asked me to give an opinion on the Fitz Toussaint-Derrick Green-De'Veon Smith debate).
Question: OLine problems - any help in redshirts for next year or incoming freshmen? -- xprtobserver
A: Well, I suppose it's not ridiculous to start taking a look at what next season has in store.
Assuming all underclassmen return (and I'll assume that until proven otherwise), Michigan's still going to be incredibly young up front. Even younger, actually, in a way than it is right now. Taylor Lewan and Michael Schofield will be gone, and there won't be one scholarship senior offensive lineman on this roster.
A rough sketch of what things could look like? I believe you'll see Erik Magnuson, currently a redshirt freshman right guard, bounce out to right tackle. You'll more than likely see current redshirt freshman Ben Braden, who competed at guard in the fall but fell short, step in and try to win that left tackle job.
At guard? My guess is Kyle Bosch has done enough as a true freshman to keep himself atop the depth chart at least going into the spring. The other guard? Could be interesting. You'll have Kyle Kalis, who will be a third-year sophomore and possibly Graham Glasgow, currently a redshirt sophomore center, possibly playing guard.
Why would Glasgow move to guard? Well, because highly-touted current true freshman Pat Kugler is a center. Don't be surprised if Michigan gives him every opportunity to shore up that center spot, which really hasn't been a position of consistency since David Molk graduated in 2011.
Outside of that, Jack Miller and Joey Burzyznski will be competing for time. Chris Bryant, too. But don't expect any of the current true freshmen to magically just appear as starters out of necessity. Michigan will be young, but it doesn't have to be that young.
At some point, they're going to have to pick a five and let it soak up some chemistry. Sooner rather than later.
Question: Nick? Do you think UM will be able to run at Iowa due to Iowa's style of defense? -- azwolverine1
A: Good question, AZ.
What AZ is referring to is Iowa's generally basic approach to playing defense. Unlike Michigan State and Nebraska and even Northwestern last week, Iowa doesn't do a lot of blitzing. It doesn't run a ton of stunts.
The Hawkeyes just line up and try to beat you, man on man. A pretty old-school approach, but one that's worked for the most part this year, as the Hawkeyes have the No. 9-ranked defense nationally.
But, from a targeting standpoint (no, not that targeting), Michigan should have an easier job of engaging blocks at the line of scrimmage if Iowa isn't moving a ton and showing different looks.
This has been Michigan's biggest problem up front this year. When defenders are lined up and they stay there, the Wolverines have been able to engage and sustain blocks. When they're moving and switching and twisting, Michigan's been swinging and missing. It makes sense -- it's tougher to block a moving target, or two moving targets in some cases.
If Iowa plays straight up, it could be easier mentally for these guys.
Of course, Iowa would probably be foolish not to blitz those A gaps at least once or twice. Everyone else has, and it's worked more than it hasn't.
Question: As the D-line is progressing and forming continuity, is this the week that Jake Ryan truly takes over as the leader on Defense? -- iamcris
A: Cris has a bit of a point, I don't think we've seen anything even close to the Jake Ryan we saw last season. And that's to be expected. He came back from that injury extremely early, and while he's shown no relapse there health-wise, he hasn't been the same player.
Maybe it's rust. Safe bet most of it is. But I think Ryan really needs a full offseason of training and getting used to being an every day player again before we can pass full judgement.
And, honestly, I'm not sure if you'll see him reach his peak this season. He's only played five games, and wasn't at full strength at the beginning of that -- or, at least wasn't given full snaps just then.
I don't know, it's tough to say. I don't know how Ryan feels overall, only he does. But I do know the defense, in general, has been very, very good along the front seven over the past few weeks with only a few exceptions. I really like the way James Ross is playing, I think Desmond Morgan is quietly having a wonderful year. I think the front four is getting better.
Greg Mattison is doing what Greg Mattison does -- he's making guys better.
Question: So when is Borges going to stop blaming everyone else and man up? There are young players doing well at every school in the country. There comes a time when youth or lack of execution gets played out. That time was weeks ago. It's not week three anymore. There are young players on defense and Mattison doesn't make excuses. -- AJ
A: I took my shots at Borges for this very reason last week, and I don't back off from them. But, for the most part on Saturday, he's right.
A lot of that had to do with execution.
I didn't loathe Borges' overall gameplan against Northwestern. I didn't agree with a few decisions here or there, but I thought his plan was pretty OK. It was good enough to win. He established a running game, to a degree.
He tried to keep things simple for Gardner, as much as he could, and the offensive line. Tried to keep Michigan out of 2nd and long and 3rd and long. And he did that.
But when it came down to 3rd and short, guys just didn't get it done. Missed blocks, or blocks that just weren't good enough. There were a few dropped passes. Gardner forced a few throws. He looked a bit timid early on.
The decisions I had a problem with was what he called on 4th and 2, for one. That bootleg will never work unless Michigan is going to run something else off of it. Or at least set it up. Everyone knows what it is. Also, the decision to go I-form play-action on 3rd and 11 with Justice Hayes in the backfield down near the end zone? What was that? We know Hayes isn't running the ball. Don't get it.
Of course, at this point, we can sit here and nit pick every single call Borges makes, because the season has been so rough for his unit -- or, at least its only gotten worse.
I guess my whole point with Borges holding himself somewhat accountable is this: When it comes to blaming something on execution, the clear answer there would be to roll up your sleeves in practice and make sure they execute it right. No amount of play card shuffling is going to teach Kyle Kalis how to stay on a block. It's not going to help Devin Gardner's comfort in the pocket, or Erik Magnuson's reads at guard.
You're a coach. Execution is on you, just as much as the gameplan is. That's always been my point.
Question: Has Gardner developed the ability yet to recognize a blitz or a heavy pressure situation at the line of scrimmage and check out of a play (if necessary) to take advantage of the soft spots in the defense that a "blitzing situation" will present? -- A Boy Named Suh
A: I'll say this until I'm blue in the face.
Tempo. Tempo. Tempo. Tempo. Tempo.
(Catches breath).
Tempo. Tempo. Tempo. Tempo. Tempo.
You cannot make pre-snap reads if you're slow out of the huddle and you're sauntering up to the line of scrimmage late in the play clock. Michigan, all season, has played with absolutely zero tempo offensively.
It's late getting the call in. It's late getting the play called. Late out of the huddle. Late to the line. No hop in the step. And when you get to the line slowly, the defense owns you mentally in a lot of ways.
Defenses don't need a lot of time to read what you're doing. But offenses do, in fact, need more time to see what defenses have cooking.
Does Gardner have the ability to make a check at the line? Absolutely he does. But does he often give himself enough time to do this? No. He doesn't.
Play with tempo. Play with pace. I'm not saying you go no-huddle. But you get the call in, you shout it out, you run to the line and you adjust accordingly.
That's football, kids.
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Relax in picturesque Sainte-Marie and Ile aux Nattes after your Madagascan adventures.
White-sand beaches? Swaying palms? Crystal-clear lagoons? Sainte-Marie and Iles aux Nattes are the epitome of a tropical island paradise and is just the place to unwind after a Madagascan adventure. When you're not enjoying daily massages (using traditional Malagasy oils), learn about traditional Madagascan cuisine in a cooking class, tour the lagoon in a dugout canoe, or wander around the pirate's cemetery. Or if that's all a bit much, relax with a book at your lodge while lemurs swing overhead and birds sing in the trees. Looking for heaven? You've found it here.
- Start
- Ile Sainte-Marie, Madagascar
- Finish
- Ile Sainte-Marie, Madagascar
- Countries
- Madagascar
- Themes
- Short Breaks
- Code
- Keep your eyes open for marine life on a lagoon tour in a dugout canoe
- Create authentic Madagascan cuisine in a cooking class
- Relax with an included massage
This itinerary is valid for departures from 01 January 2016 to 31 December 2016. View the itinerary for departures between 01 January 2017 - 31 December 2017
Day 1 Ile aux Nattes
Île aux Nattes (also officially, but less commonly, called Nosy Nato) is a small island south of Île Sainte-Marie and is just 3km in diameter.
Ile aux Nattes can be explored on foot in less than 3 hours and has unspoiled beaches with white powdery sand beaches, coconut and other palm trees scattered along the shore and a turquoise lagoon protected by coral reefs which offers a home to a large variety of exotic marine life.
One of the best things about Ile Aux Nattes is that there are absolutely no motor cars or any other forms of modern transport to invade your sense of tranquility and peace.
Your accommodation for the next 2 nights is at the Les Lémuriens Ecolodge. With only 6 bungalows the lodge is located right on the beach and offers a unique and relaxing experience of Ile aux Nattes.
After an orientation walk around the island, perhaps visit the pirate's cemetery and then return to your lodge accommodation for an afternoon massage.
Day 2 Ile aux nattes
In the afternoon, treat yourself to another traditional Malagasy massage at the lodge before enjoying a cooking lesson with the chef. With influences from Southeast Asia, Africa and Europe, cuisine in Madagascar is varied; expect to see meat stews, rice and beans, and barbecued seafood on most menus, while rum remains the drink of choice!
Day 3 Ile aux nattes
Meals2 breakfasts
TransportCanoe, Van
AccommodationHotel (2 nights)
Included activities
- Orientation walk
- Cooking Lesson
- Dugout Canoe Lagoon Tour
- Massage
- Complimentary Departure Transfer
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Jonathan Dayton vs Cranford in the Union County Tournament game on 2-20-11
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Mar-aia McKearp (13) of Cranford (cq) tries to catch Anna Lies (15) of Dayton in the game between Jonathan Dayton and Cranford at the Union County Girls basketball Tournament game in Rahway, NJ 2/20/11 (William Perlman/The Star-Ledger) TO PURCHASE THIS PHOTO, CALL THE STAR-LEDGER PHOTO LIBRARY AT 973-392-1530


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The Mystery Artist: The Grave
With origins in Luxembourg, The Mystery Artist is in fact a Portuguese band.
Unquietness, their second album is available as a free download through Enough Records, an excellent Portuguese netlabel. And though the album was released in 2010, the band is gaining some attention again. Maybe because we are tired of non-sense music, and The Mystery Artist will give many good reasons to listen and enjoy music.
The Mystery Artist
Main site| Blog | Facebook | MySpace | Enough Records (release enrmp253)


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Set Sail With a Happy Hour Cruise on the Potomac
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International Gem and Jewelry Show at Dulles Expo Center
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Great time with friends. Bartender was nice and friendly, and so were the crewmen.
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AwfulAwful ..boat did not show up ..had to board another boat which SUCKED!
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Boat left 10minutes early missed the boat. Paid $28.00 to go on another.
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That was fun! We really had a great time. Such an amazing view. Nice and friendly people and we enjoyed wathing them dancing.
DC Cruises sail rain or shine.
It is recommended that you not to wear narrow-heeled shoes.


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Coast 101.3 and Trustco Bank present 1,000 Toys for 1,000 smiles Toy Drive.
We need your help to collect toys for abused and foster children who live right here on the Treasure Coast. Without your help, these kids will have nothing to open on Christmas Day.
We encourage you to participate in Bring a Toy to Work Day. Let's give these kids some love for the Holiday's and some hope for the Future. 1,000 Toys for 1,000 smiles from Trustco Bank and Coast 101.3
For a list of needed toys for 2015: Click Here
Been collecting toys at your office? Please register here: Click Here
All toys are donated to the Childrens Home Society of the Treasure Coast.
To drop toys off, visit any one of the following locations:
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Guardians of Middle-Earth
How can I maximize Ori's effectiveness?
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- Guardians of Middle-Earth
- How can I maximize Ori's effectiveness?
However I feel like I'm mainly lucking out on opponent stupidity rather than really utilizing him correctly.
What should I gem him with and who are some characters he counters hard?
I lied there are no boobs.
infinitexx 4 years ago#2
I have trouble killing people 1v1 with him unless they're stupid (can scare them off easy enough), but that stun makes him a deadly partner for anyone, or if someone else has a controlling effect he can use the ultimate without tagging them first for large damage.
Posted from my Xbox360 with 360FAQS v1.1
While i am in no way best with Ori. i honestly havent used him in awhile. But for me. its always having your Abilities opens. Thus having the max Cooldown you can have till its maxed out. Then put some ability power/penetrations. and some resistance as well.
Also since your As it is Written refreshes with the other abilities use them in order. i try to use A, X (which ever is the shield), A, B, A, Y, A and if you are lucky your other abilities should be open by then.
I walk alone in the universe as the last of The Time Lords!
Think_Phone 4 years ago#4
the most important thing for ori is knowing when to use which ult. the stun is great for if they're tower diving you or you have some teammates that can dogpile whoever is caught in it, but people seem to only use the stun regardless of the situation from what I've seen which is quite dumb I probably use it about 1/4 of the time the damage the ult can do is massive if someone is caught in it for the whole duration. it's very easy to sneak into the middle of a group of distracted people and just wipe them all out.
Paranoia keeps things interesting.
Think_Phone 4 years ago#5
also for the gems and relics I like to go full ap it really adds a lot more oomph to him. maybe some cooldown would help but they're not too long as is and you can refresh one of his main damage skills fairly easily.
I really like that one relic sauron can unlock. you don't use an ability for 10 seconds, then the next time you use one you get 120 more ability power on that skill and for 5 seconds afterwards. I use that as my second relic, +70 ap as the first one, and the 14 per sapphire for the last one. for the gems its all +24 ap except the one purple slot and the last one where I just have a 16 cause I am an idiot who likes even numbers and this whole set up gets you at 410 exactly
Paranoia keeps things interesting.
I max is "X" ability first, Shield second, Ult third and "A" ability fourth.
Sure his DoT gets the highest AP ratio, but its also not on a target longer than .5 seconds before you wipe it off for a more powerful version of any other spell.
I've used relics that simply raise flat AP, or Ability penetration. Reducing cooldowns can help him out as well. The only times I think ive ever done 'bad' with Ori, is when I don't have a lane partner to support my stuns effectively.
XBL GT: Danja
Think_Phone 4 years ago#7
I go X first then try to balance out the other two. The A is gets wiped if you use another spell but ideally you hit them with it immediately after anyway, I've gotten plenty of kills after a fight is disengaged because my A keeps ticking on a low hp guy.
Paranoia keeps things interesting.
NeonYoshi11 4 years ago#8
don't try and 1v1 anyone until you get your powers leveled up a bit.
Try and just control a lane and be cautious and play defense.
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The Watermelon Woman (1997)
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as Fae Richards/The Watermelon Woman
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as Shirley
Critic Reviews for The Watermelon Woman
All Critics (6) | Top Critics (1) | Fresh (6) | Rotten (0)
...a unique film and a real time capsule of the 1990s when movie geeks hung out at video stores.
The narrative, abot a black lesbian director, is elliptical and circular, borrowing its format from Jim McBride's seminal David Holtzman's Diary, at the end of which, the viewers realize they have been watching a fake documentary.
Quote not available.
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Audience Reviews for The Watermelon Woman
The Watermelon Woman is a fascinating look at the way black lesbian women communicate today and how the depictions of black women in the media and classic films inform their current situations. The fact that it goes several layers of fiction deep, fabricating a gay black actress from the 1930s and having actors present themselves as if they actually knew her or knew of her while simultaneously including a narrative from the present acts as a brilliant comment on the ways in which the histories of black and lesbian women have been documented over time. The performances are a little stiff, but that really doesn't matter in a film so filled with ideas and so intelligently put together.
Entertaining, low-budget indie about a black lesbian (likeable Cheryl Dunye, more or less playing herself) trying to make her first film as well as find a stable relationship.
A very warm, funny and insightful comedy about the lack of representation of black lesbians throughout film history. Cheryl Dunye is amiable and energetic, and while the film may not be the most technically impressive work, it's a pleasure to spend time with.
The Watermelon Woman Quotes
There are no approved quotes yet for this movie.


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h-Caldesmon as a Specific Marker for Smooth Muscle TumorsComparison With Other Smooth Muscle Markers in Bone Tumors
Caldesmon is a protein widely distributed in smooth and non–smooth muscle cells and is thought to regulate cellular contraction. Its isoform, highmolecular- weight caldesmon (h-CD), was demonstrated to be specific for smooth muscle cells and smooth muscle tumors of the soft tissue and to never be expressed in myofibroblasts. We performed an immunohistochemical study to examine h-CD expression in the following bone tumors: conventional and nonconventional osteosarcoma, 13; malignant fibrous histiocytoma of bone, 5; giant cell tumors of bone, 5; chondroblastoma, 3; metastatic leiomyosarcoma, 2; and rhabdomyosarcoma, 1. Frequent immunoreactivity for muscle actin (alpha-smooth muscle actin or muscle-specific actin) was seen in 11 of 13 osteosarcomas and all other tumors, whereas h-CD was expressed intensely only in 2 leiomyosarcomas. h-CD is considered a specific and useful marker to distinguish smooth muscle tumor from bone tumors with myoid differentiation.
- Caldesmon
- Actin
- Leiomyosarcoma
- Bone tumor
- Osteosarcoma
- Malignant fibrous histiocytoma
- Giant cell tumor of bone
- Chondroblastoma
- © American Society of Clinical Pathologists


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Tax Trails - Amended Returns
After filing your return, you may realize you made an error or omitted something from your return. The IRS often finds and corrects errors during the processing of returns. However, there are certain situations in which you may need to file an amended return if you wish to correct an error or make other changes to your return.
Note: Do not use this tax trail if you are amending a form other than Form 1040, Form 1040A, U.S. Individual Income Tax Return, Form 1040EZ, Income Tax Return for Single and Joint Filers With No Dependents, Form 1040NR, U.S. Nonresident Alien Income Tax Return, or Form 1040NR-EZ, U.S. Income Tax Return for Certain Nonresident Aliens With No Dependents.
You can check the status of your Form 1040X, Amended U.S. Individual Income Tax Return, using the Where's My Amended Return? (WMAR) online tool or the toll-free telephone number 866-464-2050 three weeks after you file your amended return. Both tools are available in English and Spanish and track the status of amended returns for the current year and three prior years.
You must enter your taxpayer identification number (usually your social security number), date of birth, and ZIP code in either tool to prove your identity. Once you authenticate, you can view the status of your amended return across three processing stages: Received, Adjusted, and Completed.
The WMAR online tool includes an illustrated graphic that visually communicates where your amended return resides within the processing stages. As a reminder, amended returns take up to 16 weeks to process and up to three weeks from the date you mailed it to show up in our system. There's no need to call the IRS unless the tool specifically tells you to do so.


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Latest Updates
October 15, 2012
Among those scheduled to be executed was Saeed Sedeghi, a shop worker sentenced to death in June after an unfair trial on drugs-related charges.
October 12, 2012
A new Amnesty International report slams the UK government's plans for a substantial extension of the use of secret evidence in the justice system.
October 12, 2012
The decision by Argentina's Supreme Court to allow a rape survivor to have her pregnancy terminated is a step forward for women's rights.
October 11, 2012
In 2011, Mexico's National Human Rights Commission (CNDH) received 1,669 reports of torture and ill-treatment by police and security forces.


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GM's Electric Chevy Bolt To Go 238 Miles Per ChargeThe Chevrolet Bolt, General Motors' Tesla-fighting electric hatchback for the masses, will be able to go 238 miles on a single charge.
University Of North Texas Team Helps Develop Drug-Sniffing CarOn patrol through a small neighborhood of old trailer homes, there was a clue something was wrong. We couldn't see it, or smell it -- but the car we were in could.
Tesla Autos To Debut Affordable Model 3 Electric CarWith a starting price of $35,000 -- before government incentives -- the Model 3 is less than half the cost of Tesla's previous models.
Fort Worth Tesla Motors Gallery Open Todayhe wait is over, Fort Worth now has their own Tesla Motors gallery. The high-end electric-car manufacturer is celebrating the grand opening of its gallery on University Drive.
New Law Allows Direct Sale Of Tesla Cars In New JerseyNew Jersey Governor Chris Christie signed a measure Wednesday that would allow the sale of Tesla and other zero-emission cars in the state, a legislative move that wasn't successful here in Texas.
Electric-Car Drivers Trading Gas For Solar PowerOwners of electric vehicles have already gone gas-free. Now, a growing number are powering their cars with sunlight.
Tesla Selects Nevada For Battery PlantIt seems North Texas has lost out. Tesla Motors has chosen Nevada as the site for a massive, $5 billion factory that will pump out batteries for a new generation of electric cars.
Texas To Continue Pursuit Of Tesla Battery Factory Governor Rick Perry's office says it continues to negotiate with Tesla Motors to build an electric car battery factory in Texas, despite Tesla's announcement Thursday that it has broken ground on a Nevada site.
New Tesla For The Price Of A Prius?Electric Automaker Unveils Tesla Model 3 Sedan For $35,000
High-End Electric Automaker Tesla Opening Local 'Store Front'It's considered one of the safest cars on the road, but you won't find a Tesla at any care dealership in Texas. Tesla Motors designs and manufactures electric vehicles. Now the company is opening a new storefront at NorthPark Center in Dallas.
Consumer Reports Gives Highest Ever Rating To Electric Sports CarAn all-electric sports car has performed better than just about any vehicle ever tested in the history of Consumer Reports. A car made by Tesla Motors got a rating just one point shy of the highest mark possible.
Kroger Installing Electric Car Charging StationsA new partnership with Kroger stores means North Texans driving electric cars will soon have more options when it comes to recharging their vehicles.


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For anyone who plays bass guitar, buying a new instrument is an important decision. Ideally, the guitar needs to suit the player in terms of both performance level and budget. A little research is all that is required to ensure that the match of musician and musical instrument is a harmonious one.
About Bass Guitars
The roots of the modern electric bass guitar reach back as far as the 1930s. However, it was not until the 1950s that the advantages of the smaller horizontal fretted guitars saw them begin to replace their much larger upright acoustic counterparts. The swinging sixties saw an explosion in the popularity of these guitars, with many new manufacturers producing models with greater performance and increasingly avant garde styling. Over the years, seemingly every possible variation in the number of strings, frets, pickups, body styles and materials has been tried, usually to good effect, but not always.
Today, there is a great deal of variation in the bass guitars that are available. The first task of any prospective purchaser is to familiarise themselves with these differences. This will enable them to make an informed decision about which features will enhance their playing experience and which they can do without.
Bass Guitar Variations
The particular bass guitar a player chooses is governed by many factors, such as the style of music they intend to play, their budget, and their level of experience. The main considerations when choosing a bass guitar are as follows.
Number of Strings
The most common arrangement for a bass guitar is to have 4 strings that tuned E, A, D, G from low to high. A 5-string bass usually has an additional lower string tuned to B. 6-string basses usually have an another higher string, usually tuned to B or C. The most affordable of these will be the most common configuration of 4 strings. It is also the most suitable for a beginner and will therefore likely retain its value well.
Acoustic or Electric
Electric bass is easier to play than acoustic bass for the simple reason that the strings are generally closer to the frets and therefore easier to push down to get a clean sound. Acoustic basses use heavier gauge strings as these are needed to resonate the body of the guitar to produce the required volume. However, acoustic basses have the advantages of a warmer sound, and that additional equipment, such as an amplifier, is not always required. For a beginner, ease of playing means that the electric bass is almost certainly the better choice.
Body Style
Perhaps the most important factor affecting the choice of body style is whether the bass is to be played seated or standing. If the guitar is to be mainly played seated, the bass should be shaped to rest comfortably on the leg. If the bass is more likely to be played standing, the top of the body should easily accommodate the arm passing over it. If looking at more outlandish finishes, it is worth considering whether these could affect resale value and so eventually make the bass harder to sell on.
Pickups and Controls
Some bass guitars have two pickups, while others have only one. As each pickup will usually have its own volume control, this allows the player to select a mix of the two. While the dual pickup guitar may be more versatile in the sound it can produce, the single pickup model has the advantage of being easier to pick up and play. The number of pickups does not greatly affect the price of more affordable guitars, so the choice of how many pickups are desirable will be down to the individual player.
There are two kinds of pickups to choose from, passive and dynamic. Passive pickups have a warm, full tone while active pickups are clearer and more percussive. Active pickups offer more control at the expense of some of the fat, punchy sound of the more traditional passive ones.
Fretted or Fretless
Bass guitar necks can be devoid of frets like the acoustic basses from which they were originally developed. Playing a fretless bass requires more skill and therefore should only be a purchase consideration for the most experienced of bass players.
Choosing an Affordable Guitar
The level of experience of a player and the size of their budget will determine how they go about getting the best value for money. They will also need to bear in mind how to ensure the instrument holds its resale value. In the future, should they ever need to trade in the guitar, it will then be able to make the best contribution possible to the cost of any future upgrade.
The Beginner Route
Buying a used bass guitar can offer greater value for money but should probably not be the first choice for a beginner. Part of the experience they will gain as a bass player will be the ability to determine a good second-hand bass and to correctly assess its value.
A better route for a beginner looking for the best value is to look for a new bass as part of a package. When buying a guitar as part of a package, the instrument is bundled with other equipment, such as, for example, an amp, tuner, stand, and gig bag. If the budget allows it, buying these together can work out significantly cheaper than getting them individually.
As the player moves from beginner to intermediate in their playing, they will begin to realise the limitations of the instrument they are playing and wish to upgrade. Buying and using the stand and gig bag that come with most packages will ease this process by helping to preserve the guitar's resale value.
The More Experienced Player
Buying a good affordable guitar suitable for an experienced player is altogether more tricky. The budget will necessarily be larger, perhaps partly compensated for by the sale of their outgoing equipment. The new guitar will likely be subject to more exposure to the hardships of transportation, so it is a good time to consider upgrading from a gig bag to a hard case.
If the budget permits, upgrading to a premium name should be the aim. A branded guitar will give the expected level of performance at the given price point and will also retain its value better. It is also worth considering insurance when buying a more expensive instrument, particularly if it is to be relied on for income.
Buying a used guitar can result in a better instrument for the money. However, the buyer will need to do their homework and know exactly what they need to look out for. Stretching the budget in this way can be a route to achieving the best sound for your money if it also allows the amp to be upgraded at the same time.
Find Bass Guitars on eBay
To buy a new bass guitar, go to the eBay homepage. Begin by opening the All Categories tab and then clicking on the link for Musical Instruments followed by Guitars, and then Bass. View the bass guitars for sale, or refine the search further by using the options on the left side of the page. For example, it is possible to view only the bass guitars which fall within your particular budget. Another alternative is to enter specific terms into the search bar at the top of any eBay page to locate a particular instrument or brand of interest. For example, to find an unused Fender bass guitar, simply type "Fender bass guitar new" into the search field.
Which particular model appeals to an individual bass player will be a personal decision for them, largely based on the style of music to be played and their personal taste. However, buying an affordable bass guitar is no different to buying anything on a budget and is inevitably going to involve some degree of compromise. Whether a prospective buyer chooses to buy a new or used instrument will depend not just on their budget, but also on their ability to assess whether the used guitar represents good value for money.
Beginners should focus on getting the best value for money they can, but not at the expense of a guitar that will soon become an obstacle to making progress with their playing. Bundles and packages can offer a cheap way to take that first step. More experienced players can use their greater knowledge to source a good used guitar, which will give both greater affordability and performance for a given price point.
No matter which particular bass guitar is chosen, taking good care of the instrument can significantly affect the overall affordability of the purchase. When the time comes to trade it in, an instrument that has been cared for will hold far more of its value than one which has been neglected, meaning the next bass guitar can be that much better.


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GoldenEye: Rogue Agent
(Xbox, PS2, GC, DS)
A first-person shooter exploring the villainous side of the James Bond universe.
Latest Updates
June 05, 2008
Latest Updates
January 21, 2005
July 16, 2004
Latest Updates
June 05, 2008
GoldenEye: Rogue Agent Blogs
Skyfall reviewby Thomas Geraghty November 09, 2012 0 4
Project 25: Top 25 32/64 Bit Games (10-6)by Jason Velez April 12, 2012 0 1
What FPS is your favorite?by chase helms August 04, 2011 8 5
Golden Eye... Why?by Charlie Jackson November 30, 2010 4 2
GoldenEye gets remade, trailer leaks all over the placePlace your bets now on how disappointed people will be when this game hits.
by Doug Whatever June 14, 2010 2 0
GoldenEye Anyone?by TJ Cothron February 01, 2009 0 0
1UP Review
GoldenEye: Rogue Agent Review
Score: B
This agent works alone.January 21, 2005
User Reviews> Write a Review of This Game
If I wanted Shit I'd be checking my toliet
Score: F
by Ron ismyname
Though the double wielding give's that "look at me I'm halo 2ing your ass" feel. I'm dissapointed in the fact anyone would see James Bond die in a....ah-I dunno-A...
Read more
June 05, 2008 0 0
why it sucks
Score: F
by Dominick Sabatino
this game i am ashamed of. It does not deserve to share the soame name as the clasic n64 title. I am very angy at EA because the allowed it to happen. The controls suck! Just...
Read more
January 18, 2005 0 0
Score: F
by Gre g
I really have to say, even being a big James Bond fan, that this game really really sucks! I can't believe the gameplay in this game! First of all, I can't even aim at a guy...
Read more
January 01, 2005 0 0
Score: B+
by Dennis Graham
YaY another james bond game, i hope that they keep on coming up with new things for these games :D, keep em comming.
December 17, 2004 0 0
A bad guy, an equally bad game.
Score: C+
by Ryan Commeans
I was fed up with this game the first time I picked it up. I think the bright blue bursts that fly from enemies when they are injured did this game in, coupled with a few...
Read more
December 16, 2004 0 0
Score: B+
by james king
I LOVE All JAMES BOND GAMES starting from the Original N64 Classic Golden eye which ive loved because it was different than other shooters and it had tons of extras like...
Read more
December 11, 2004 0 0
Makes ya think
Score: A
by David McCollum
In this shooter, you always have to think. "What should I do here? Do I throw my enemy off into the water with my throw power, or do I use my shield and charge him"...
Read more
December 08, 2004 0 0
My Rating
Score: B-
by Jason Lataillade
Oh yeah, here is my rating.
November 29, 2004 0 0
My Rating
Score: B-
by Jason Lataillade
Oh yeah, here is my rating.
November 29, 2004 0 0
Okie Dokie!
Score: B-
by Barton Moxness
I must admit some of you guys are a little to hard on this game. It's not the best game ever, but i think it completes the goal of the game, to make a basic 1st Person Shooter...
Read more
November 26, 2004 0 0
Latest News for GoldenEye: Rogue Agent
Activision Registers New "GoldenEye" Domain
The domain name clearly seems to refer to the James Bond movie, but which GoldenEye videogame series?April 24, 2010 23 22
Layoffs and Restructuring at EA LA
EA's Southern Cali office "rebalanced".January 26, 2005 0 8
Latest Previews for GoldenEye: Rogue Agent
GoldenEye: Rogue Agent Preview
Killin' like a villain.November 17, 2004 0 1
GoldenEye: Rogue Agent Preview
No bonding.November 17, 2004 0 1
GoldenEye: Rogue Agent Preview
More thoughts on life as a James Bond bad guy.November 08, 2004 0 0
GoldenEye: Rogue Agent Preview
We've gone rogue with a near-complete version.November 05, 2004 0 0
GoldenEye: Rogue Agent Preview
Human shields, explosions, gunfire and more.September 01, 2004 0 0
GoldenEye: Rogue Agent Preview
Can the multiplayer match N64 GoldenEye?July 16, 2004 0 0
GoldenEye: Rogue Agent Preview
Has James Bond finally met his match?July 15, 2004 0 0
GoldenEye: Rogue Agent Preview
Shaken, stirred, or straight no chaser?May 09, 2004 0 1


text: Keystone XL Pipeline President Obama Rejects Keystone XL Pipeline Plan By Bill Chappell • Nov 6, 2015 Ending a process that has lingered for much of his time in the Oval Office, President Obama announced Friday that the U.S. has rejected TransCanada's application for a permit to complete the Keystone XL pipeline. 5 Things To Know About The Keystone XL Pipeline By Scott Horsley • Nov 3, 2015 After spending years as a political football in the U.S., the Keystone XL pipeline's would-be builder is now asking for a timeout in the review process. Why now? Changing politics in the U.S. and Canada, falling oil prices and mounting pressure from environmentalists have marked a turnaround for the company, which had pushed for approval of the project, and its supporters. Here are five things to know about where the pipeline stands now: 1. Geography gives the U.S. government a say Senate OKs Keystone XL Pipeline, Setting Up Fight With Obama By Krishnadev Calamur • Jan 29, 2015 Updated at 5:04 p.m. ET The Senate in a bipartisan 62-to-36 vote approved Thursday the Keystone XL pipeline project, setting up a faceoff with the White House, which has threatened a presidential veto. Nine Democrats joined 53 Republicans to pass the measure, which now must be reconciled with a version passed last month by the House. The Senate vote is also not enough to override a presidential veto. Northwest Senators Vote On Party Lines As Senate Rejects Keystone XL Pipeline By Chris Lehman • Nov 18, 2014 Listen Listening... / 1:06 Northwest lawmakers voted along party lines as the U.S. Senate voted Tuesday to reject a plan to approve the Keystone XL oil pipeline. Fourteen Democrats voted with all 45 Republicans in the Senate to approve it, but the plan was one vote shy of the minimum needed to send the measure to the president. Bill McKibben of 350.org to Lead Climate Change Rally in Seattle By Bellamy Pailthorp • Sep 20, 2013 Steve Liptay Photo Listen Listening... / 7:04 This Saturday, environmental activist and author Bill McKibben will lead a rally against fossil fuel exports and the Keystone XL pipeline in Seattle. Known as one of the first voices to warn of the dangers of global warming, McKibben is on tour with his new book, Oil and Honey. He is also the founder of an international organization called 350.org, which he created to fight climate change. McKibben says 350 is "the most important number in the world, but nobody knew it until 2008, when Jim Hansen and his team at NASA published a paper saying we now know enough about carbon to know how much in the atmosphere is too much."