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Introduction: The profunda artery perforator (PAP) flap is a new addition to our reconstructive armamentarium. In effort to better understand patient candidacy for the PAP flap we characterized the profunda artery perforators on preoperative imaging. Methods: A retrospective review was completed of 40 preoperative posterior thigh computed tomography angiographies and magnetic resonance angiographies by four plastic surgeons. The positioning of the patient, type of study, number of perforators, and size of perforators were documented. The location was documented on an x–y-axis. Perforator course and surrounding musculature was documented. Results: In 98.8% of posterior thighs suitable profunda artery perforators were identified. The average number and size of perforators was 3.3 and 1.9 mm. The most common perforator was medial (present in 85.6% of thighs); found near the adductor magnus at 3.8 cm from midline and 5.0 cm below the gluteal fold. The second most common perforator was lateral (present in 65.4% of thighs); found near the biceps femoris and vastus lateralis at 12.0 cm from midline and 5.0 cm below the gluteal fold. Nearly 48.3% were purely septocutaneous. And 51.7% had an intramuscular course (average length 5.7 cm). Preoperative imaging corresponded to suitable perforators at the time of dissection of all PAP flaps. Thirty five PAP flaps (18 patients) were performed with 100% flap survival. Conclusion: Analysis of preoperative posterior thigh imaging confirms our intraoperative findings that a considerable number of suitable posterior thigh profunda perforators are present, emerge from the fascia in a common pattern, and are of sufficient caliber to provide adequate flap perfusion and recipient vessel size match. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.

The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap.Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape.All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue.The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar.Therapeutic, V.

Evaluation of the lymphedema patients with appropriate staging is fundamental for further treatment. Treatment includes compressive decongestive therapy for stage 0 and 1 patients, lymphovenous anastomosis for stage 1 and 2 patients, vascularized lymph node transfer for stage 2 and above patients. Wedge resection, liposuction, and the Charles procedure are alternatives or additions to physiological procedures. The selection of donor lymph node flap and recipient site depends on the patient's lymphedema status and surgeon's expertise. J. Surg. Oncol. 2016;113:923-931. © 2016 Wiley Periodicals, Inc.

The vertical distribution of aerosols is an important component of aerosol radiative forcing. Here we investigate the effects of convection transport and precipitation on the vertical aerosol distribution using observations and reanalysis data. As expected, convective mass flux is positively correlated with precipitation everywhere. Both positive and negative correlations between convective mass flux, precipitation, and aerosol vertical dispersivity exist, depending on the region. In the tropics, more (less) convective mass flux is associated with more (less) precipitation and more (less) aerosol vertical dispersivity—including more (less) aerosol above 500 hPa. In contrast, a negative relationship exists between aerosol vertical dispersivity and both convective mass flux and precipitation over the Northern Hemisphere midlatitude ocean. Aerosol vertical dispersivity in this region is related to convective mass flux and precipitation over the emission sources. We conclude that convective transport is an important mechanism controlling the global vertical dispersivity of aerosol.

Exploration of the internal mammary vessels during microsurgical reconstruction presents an ideal opportunity for identifying and sampling the internal mammary lymph node (IMLN) basin.A retrospective review of patients undergoing microsurgical breast reconstruction using the internal mammary vessels as recipient vessels was conducted from March 2000 to December 2014. Patient demographics, tumor characteristics, preoperative lymph node mapping, reconstructive timing, and outcomes were studied.A total of 524 microsurgical breast reconstructions in 516 patients were performed using the internal mammary vessels. IMLNs were sampled in 53 immediate and 42 delayed breast reconstructions. Eight (seven in the immediate and one in the delayed group) of the sampled nodes were positive for cancer metastasis, for an incidence of 8.4% in identified lymph nodes. All patients with metastatic IMLNs subsequently received local-regional radiation and chemotherapy. All patients were alive, and six were disease-free at the conclusion of the study period, which had an average follow up of 67.3 months.Incidentally encountered IMLNs during microsurgical breast reconstruction are frequently positive. With negligible downside and the possibility to provide additional information for treatment, the procedure should be encouraged. J. Surg. Oncol. 2016;114:133-139. © 2016 Wiley Periodicals, Inc.

Throughout much of the latter half of the twentieth century, the dominant mode of Northern Hemisphere (NH) extratropical wintertime circulation variability—the Arctic Oscillation (AO)—exhibited a positive trend, with decreasing high-latitude sea level pressure (SLP) and increasing midlatitude SLP. General circulation models (GCMs) show that this trend is related to several factors, including North Atlantic SSTs, greenhouse gas/ozone-induced stratospheric cooling, and warming of the Indo-Pacific warm pool. Over the last approximately two decades, however, the AO has been decreasing, with 2009/10 featuring the most negative AO since 1900. Observational and idealized modeling studies suggest that snow cover, particularly over Eurasia, may be important. An observed snow–AO mechanism also exists, involving the vertical propagation of a Rossby wave train into the stratosphere, which induces a negative AO response that couples to the troposphere. Similar to other GCMs, the authors show that transient simulations with the Community Atmosphere Model, version 3 (CAM3) yield a snow–AO relationship inconsistent with observations and dissimilar AO trends. However, Eurasian snow cover and its interannual variability are significantly underestimated. When the albedo effects of snow cover are prescribed in CAM3 (CAM PS) using satellite-based snow cover fraction data, a snow–AO relationship similar to observations develops. Furthermore, the late-twentieth-century increase in the AO, and particularly the recent decrease, is reproduced by CAM PS. The authors therefore conclude that snow cover has helped force the observed AO trends and that it may play an important role in future AO trends.

The oxygen reduction reaction (ORR) in alkaline media has been investigated on chalcogen-modified ruthenium nanoparticles (Ru/C, Se/Ru/C, Se/RuMo/C, S/Ru/C, S/RuMo/C) synthesized in-house via aqueous routes. In acidic medium, it is well known that modification by a chalcogen prevents the oxidation of the underlying transition-metal (Ru) surface, thereby promoting direct molecular O2 adsorption on the Ru metal. On an unmodified Ru catalyst in alkaline media, the surface oxides on Ru mediate the 2e– reduction of molecular O2 to a stable peroxide anion (HO2–) intermediate via an outer-sphere electron-transfer mechanism. This increases the activity of HO2– near the electrode surface and decreases the overpotential for ORR by effectively carrying out the reduction of HO2– to OH– at the oxide-free ruthenium metal site. An increase in ORR activity of Ru is observed by modification with a chalcogen; however, the increase is not as significant as observed in acidic media. Ternary additives, such as Mo, were found...

With technological advances in magnetic resonance angiography (MRA), spatial resolution of 1-mm perforating vessels can reliably be visualized and accurately located in reference to patients' anatomic landmarks without exposing patients to ionizing radiation or iodinated contrast, resulting in optimal perforator selection, improved flap design, and increased surgical efficiency. As their experience with MRA in breast reconstruction has increased, the authors have made changes to their MRA protocol that allow imaging of the vasculature in multiple donor sites (buttock, abdomen, and upper thigh) in one study. This article provides details of this experience with multiple donor site contrast-enhanced MRA.

Radiation therapy is a cornerstone of oncologic treatment. Skin tolerance is often the limiting factor in radiotherapy. To study these issues and create modalities for intervention, the authors developed a novel murine model of cutaneous radiation injury.The dorsal skin was isolated using a low-pressure clamp and irradiated. Mice were followed for 8 weeks with serial photography and laser Doppler analysis. Sequential skin biopsy specimens were taken and examined histologically. Tensiometry was performed and Young's modulus calculated.High-dose radiation isolated to dorsal skin causes progressive changes in skin perfusion, resulting in dermal thickening, fibrosis, persistent alopecia, and sometimes ulceration. There is increased dermal Smad3 expression, and decreased elasticity and bursting strength.This model of cutaneous radiation injury delivers reproducible localized effects, mimicking the injury pattern seen in human subjects. This technique can be used to study radiation-induced injury to evaluate preventative and therapeutic strategies for these clinical issues.

Diabetes is characterized by several poorly understood phenomena including dysfunctional wound healing and impaired vasculogenesis. p53, a master cell cycle regulator, is upregulated in diabetic wounds and has recently been shown to play a regulatory roles in vasculogenic pathways. We have previously described a novel method to topically silence target genes in a wound bed with small interfering (si)RNA. We hypothesized that silencing p53 results in improved diabetic wound healing and augmentation of vasculogenic mediators. Paired 4-mm stented wounds were created on diabetic db/db mice. Topically applied p53 siRNA, evenly distributed in an agarose matrix, was applied to wounds at postwound day 1 and 7 (matrix alone and nonsense siRNA served as controls). Animals were sacrificed at postwound days 10 and 24. Wound time to closure was photometrically assessed, and wounds were harvested for histology, immunohistochemistry, and immunofluorescence. Vasculogenic cytokine expression was evaluated via Western blot, reverse transcription-polymerase chain reaction, and enzyme-linked immunosorbent assay. The ANOVA/t-test was used to determine significance (p≤ 0.05). Local p53 silencing resulted in faster wound healing with wound closure at 18±1.3 d in the treated group vs. 28±1.0 d in controls. The treated group demonstrated improved wound architecture at each time point while demonstrating near-complete local p53 knockdown. Moreover, treated wounds showed a 1.92-fold increase in CD31 endothelial cell staining over controls. Western blot analysis confirmed near-complete p53 knockdown in treated wounds. At day 10, VEGF secretion (enzyme-linked immunosorbent assay) was significantly increased in treated wounds (109.3±13.9 pg/mL) vs. controls (33.0±3.8 pg/mL) while reverse transcription-polymerase chain reaction demonstrated a 1.86-fold increase in SDF-1 expression in treated wounds vs. controls. This profile was reversed after the treated wounds healed and before closure of controls (day 24). Augmented vasculogenic cytokine profile and endothelial cell markers are associated with improved diabetic wound healing in topical gene therapy with p53 siRNA.

OBJECTIVE Progenitor cells (PCs) contribute to postnatal neovascularization and tissue repair. Here, we explore the mechanism contributing to decreased diabetic circulating PC number and propose a novel treatment to restore circulating PC number, peripheral neovascularization, and tissue healing. RESEARCH DESIGN AND METHODS Cutaneous wounds were created on wild-type (C57BL/J6) and diabetic (Leprdb/db) mice. Blood and bone marrow PCs were collected at multiple time points. RESULTS Significantly delayed wound closure in diabetic animals was associated with diminished circulating PC number (1.9-fold increase vs. 7.6-fold increase in lin−/sca-1+/ckit+ in wild-type mice; P < 0.01), despite adequate numbers of PCs in the bone marrow at baseline (14.4 ± 3.2% lin−/ckit+/sca1+ vs. 13.5 ± 2.8% in wild-type). Normal bone marrow PC mobilization in response to peripheral wounding occurred after a necessary switch in bone marrow stromal cell-derived factor-1α (SDF-1α) expression (40% reduction, P < 0.01). In contrast, a failed switch mechanism in diabetic bone marrow SDF-1α expression (2.8% reduction) resulted in impaired PC mobilization. Restoring the bone marrow SDF-1α switch (54% reduction, P < 0.01) with plerixafor (Mozobil, formerly known as AMD3100) increased circulating diabetic PC numbers (6.8 ± 2.0-fold increase in lin−/ckit+, P < 0.05) and significantly improved diabetic wound closure compared with sham-treated controls (32.9 ± 5.0% vs. 11.9 ± 3% at day 7, P > 0.05; 73.0 ± 6.4% vs. 36.5 ± 7% at day 14, P < 0.05; and 88.0 ± 5.7% vs. 66.7 ± 5% at day 21, P > 0.05, respectively). CONCLUSIONS Successful ischemia-induced bone marrow PC mobilization is mediated by a switch in bone marrow SDF-1α levels. In diabetes, this switch fails to occur. Plerixafor represents a potential therapeutic agent for improving ischemia-mediated pathology associated with diabetes by reducing bone marrow SDF-1α, restoring normal PC mobilization and tissue healing.

Purpose To evaluate the accuracy of magnetic resonance angiography (MRA) for preoperative mapping of rectus and gluteal muscle perforating arteries prior to autologous flap breast reconstruction. Materials and Methods Preoperative MRA on 25 consecutive patients undergoing perforator artery-based autologous breast reconstruction was performed at 1.5 T using 3D liver accelerate volume acquisition (LAVA) of abdominal or gluteal regions acquired during injection of 20 mL of gadobenate dimeglumine with bolus timing optimized using MR fluoroscopy or SmartPrep. Perforator artery size and coordinates relative to umbilicus or top of gluteal crease on 3D MRA were compared to findings at surgery. Reconstructed breast volume estimates from MRA were also compared to weights at harvesting. Results In all, 132 perforator arteries were found at surgery to be located within 1 cm of the coordinates measured on MRA and were surgically verified to be suitable for flap perfusion. Surgery verified the arterial course and caliber through the rectus and gluteal muscles visualized on MRA in 48 of 49 arteries. Volume rendering of 3D MRA predicted a breast reconstruction volume with a mean difference of 47 g compared to measurements at harvesting. Conclusion MRA accurately maps rectus and gluteal muscle perforator arteries for preoperative planning of autologous flaps for breast reconstruction. J. Magn. Reson. Imaging 2010;31:1176–1184. © 2010 Wiley-Liss, Inc.

Preoperative imaging is essential for abdominal perforator flap breast reconstruction because it allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. The benefits of visualizing the vasculature preoperatively also extend to gluteal artery perforator flaps. Initially, our practice used computed tomography angiography (CTA) to image the gluteal vessels. However, with advances in magnetic resonance imaging angiography (MRA), perforating vessels of 1-mm diameter can reliably be visualized without exposing patients to ionizing radiation or iodinated intravenous contrast. In our original MRA protocol to image abdominal flaps, we found the accuracy of MRA compared favorably with CTA. With our increased experience with MRA, we decided to use MRA to image gluteal flaps. Technical changes were made to the MRA protocol to improve image quality and extend the field of view. Using our new MRA protocol, we can image the vasculature of the buttock, abdomen, and upper thigh in one study. We have found that the spatial resolution of MRA is sufficient to accurately map gluteal perforating vessels, as well as provide information on vessel caliber and course. This article details our experience with preoperative imaging for gluteal perforator flap breast reconstruction.

The study of human autologous fat grafting has been primarily anecdotal. In this study, the authors aim to develop a murine model that recapitulates human fat grafting to study the fate of injected fat and the cell populations contained within.The authors' method of fat harvesting and refinement has been described previously. The authors injected nude and tie2/lacZ mice with 2 ml of human lipoaspirate placed on the dorsal surface in a multipass, fan-like pattern. Fatty tissue was injected in small volumes of approximately 1/30 ml per withdrawal. The dorsal skin and associated fat was excised at various time points. Sections were stained with hematoxylin and eosin and cytochrome c oxidase IV. Transgenic tie2/lacZ samples were stained with X-galactosidase. At the 8-week time point, volumetric analysis was performed.Volumetric analysis at the 8-week time point showed 82 percent persistence of the original volume. Gross analysis showed it to be healthy, nonfibrotic, and vascularized. Hematoxylin and eosin analysis showed minimal inflammatory or capsular reaction, with viable adipocytes. Fat grafted areas were vascularized with multiple blood vessels. Cytochrome c oxidase IV human-specific stain and beta-galactosidase expression revealed these vessels to be of human origin.The authors have developed a murine model with which to study the fate of injected lipoaspirate. There is a high level of persistence of the grafted human fat, with minimal inflammatory reaction. The fat is viable and vascularized, demonstrating human-derived vessels in a mouse model. This model provides a platform for studying the populations of progenitor cells known to reside in lipoaspirate.

In this article, David Garlan, Robert Allen, and John Ockerbloom reflect on the state of architectural mismatch, a term they coined in their 1995 IEEE Software article, "Architectural Mismatch: Why Reuse Is So Hard." Although the nature of software systems has changed dramatically since the earlier article was published, the challenge of architectural mismatch remains an important concern for the software engineering field.

The tremendous variability of the inferior epigastric arterial system makes accurate imaging of the vasculature of the anterior abdominal wall an essential component of optimal perforator selection. Preoperative imaging of the abdominal vasculature allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. Abdominal wall perforators of 1-mm diameter can be reliably visualized without exposing patients to ionizing radiation or iodinated intravenous contrast through advances in magnetic resonance imaging angiography (MRA). In this study, MRA imaging was performed on 31 patients who underwent 50 abdominal flaps. For each flap, the location, relative to the umbilicus, of the three largest perforators on both the left and right sides of the abdomen was determined with MRA. Vessel diameter and anatomic course were also evaluated. Postoperatively, a survey was completed by the surgeon to assess the accuracy of the MRA with respect to the intraoperative findings. All perforators visualized on MRA were found at surgery (0% false-positive). In 2 of 50 flaps, the surgeon transferred a flap based upon a vessel not visualized on the MRA (4% false-negative). This article details our experience with MRA as a reliable preoperative imaging technique for abdominal perforator flap breast reconstruction.

Results are presented from a new homogenization of data since 1959 from 527 radiosonde stations. This effort differs from previous ones by employing an approach specifically designed to minimize systematic errors in adjustment, by including wind shear as well as temperature, by seasonally resolving adjustments, and by using neither satellite information nor station metadata. Relatively few artifacts were detected in wind shear, and associated adjustments were indistinguishable from random adjustments. Temperature artifacts were detected most often in the late 1980s–early 1990s. Uncertainty was characterized from variations within an ensemble of homogenizations and used to test goodness of fit with satellite data using reduced chi squared. The meridional variations of zonally aggregated temperature trend since 1979 moved significantly closer to those of the Microwave Sounding Unit (MSU) after data adjustment. Adjusted data from 5°S to 20°N continue to show relatively weak warming, but the error is quite large, and the trends are inconsistent with those at other latitudes. Overall, the adjusted trends are close to those of MSU for the temperature of the lower troposphere (TLT). For channel 2, they are consistent with two analyses (Remote Sensing Systems, p = 0.54, and the University of Maryland, p = 0.32) showing the strongest warming but not with the University of Alabama dataset (p = 0.0001). The troposphere warms at least as strongly as the surface, with local warming maxima at 300 hPa in the tropics and in the boundary layer of the extratropical Northern Hemisphere (ENH). Tropospheric warming since 1959 is almost hemispherically symmetric, but since 1979 it is significantly stronger in ENH and weaker in the extratropical Southern Hemisphere (ESH). ESH trends are relatively uncertain because of poor sampling. Stratospheric cooling also remains stronger than indicated by MSU and likely excessive. While this effort appears not to have detected all artifacts, trends appear to be systematically improved. Stronger warming is shown in the Northern Hemisphere where sampling is best. Several suggestions are made for future attempts. These results support the hypothesis that trends in wind data are relatively uncorrupted by artifacts compared to temperature, and should be exploited in future homogenization efforts.

Deriving their name from the Greek word plastikos, meaning related to molding, plastic surgeons have made their reputation by transplanting tissues from one area of the body to another to "remold" defects caused by trauma, congenital anomaly, or disease. Dr. Joseph Murray, a plastic surgeon, performed the first successful kidney transplant between identical twins in 1954. The authors present three cases involving the transplantation of perforator flaps from one identical twin to another for breast reconstruction, including cases using both deep inferior epigastric perforator and superficial inferior epigastric artery flaps.Three sets of recipient monozygotic twins that had breasts treated with mastectomies underwent reconstruction using transplanted tissue from their donor monozygotic twins. All sets of twins underwent DNA testing to determine that they were monozygotic; therefore, no immunosuppressive therapy was indicated.The three sets of recipient monozygotic twins underwent successful breast reconstruction using perforator flap transplants from their donor monozygotic twins. The operations included two unilateral reconstructions (one using a deep inferior epigastric perforator flap and the other using a superficial inferior epigastric artery flap) and one bilateral deep inferior epigastric perforator reconstruction. Their hospital courses were unremarkable.Transplant surgery continues to evolve in the twenty-first century. The authors present three cases of breast reconstruction using skin flap transplantation as a new option for breast reconstruction.

Climate models and theoretical expectations have predicted that the upper troposphere should be warming faster than the surface. Surprisingly, direct temperature observations from radiosonde and satellite data have often not shown this expected trend. However, non-climatic biases have been found in such measurements. Here we apply the thermal-wind equation to wind measurements from radiosonde data, which seem to be more stable than the temperature data. We derive estimates of temperature trends for the upper tropospheretothelowerstratospheresince1970.Overtheperiodofobservations,wefindamaximumwarmingtrendof0.65±0.47K per decade near the 200hPa pressure level, below the tropical tropopause. Warming patterns are consistent with model predictions except for small discrepancies close to the tropopause. Our findings are inconsistent with the trends derived from radiosonde temperature datasets and from NCEP reanalyses of temperature and wind fields. The agreement with models increases confidence in current model-based predictions of future climate change. It has long been recognized that radiosonde temperature data are a ected by non-climatic artifacts due to station relocations, observation time changes and radiosonde type or design changes 1 . Several investigators have attempted to detect and adjust (that is homogenize) these artefacts using a variety of tools, including statistical procedures, station metadata, various indicators of natural variability (such as volcanic eruptions, vertical coherence) and forecasts from a climate data assimilation system 2‐6 . Despite these attempts, most analyses of radiosondes continue to show less warming of the tropical troposphere since 1979 than reported at the surface 1 . At least one satellite dataset also implies this 7 . By contrast, theoretical and model expectations 7,8 indicate that the troposphere should warm somewhat faster than the surface. Recently, time-varying biases were shown to remain in the radiosonde temperature data, including a daytime cooling bias related to solar heating of the instrument (especially in the stratosphere) 9 . They were significantly larger than the average adjustments that had previously been made, and comparable to the above discrepancies, calling into question whether the adjustments had been adequate. A similar cooling bias was also found in night-time soundings 10,11 . Subsequent attempts to produce better homogenized records have yielded more warming than before 5,12,13

The utility of the thermal wind equation (TWE) in relating tropospheric (850–300 hPa) wind and temperature on climatological time scales is assessed, based on data from 59 radiosonde stations in the western tropical Pacific during 1979–2004. Observed long-term mean and seasonal variations closely obey geostrophic balance; incorporating additional (ageostrophic) terms yields negligible improvement. The authors conclude that observed winds offer a useful constraint on the horizontal structure of monthly and longer temperature variations (although the reverse is not true close to the equator where f → 0). This conclusion is also supported by general circulation model output. Wind data show a slowing of the midlatitude jets in the Maritime Continent region since 1979, indicating that tropical thicknesses and temperature have increased less than those poleward of 25°N/S. This pattern is consistent with Microwave Sounding Unit temperature trends in the region but is exaggerated south of the equator in trends obtained directly from the temperature data. The latter are however sensitive to which stations are used and how the data are averaged, and the discrepancy is fairly small in a homogenized climatology from the Hadley Centre (HadAT). The discrepancy is most easily explained by spurious cooling at stations in the near-equatorial western Pacific. These results support the use of the wind field as a way of overcoming heterogeneities in the temperature records in the monitoring of climate change patterns.

Noble metal chalcogens are the preferred choice of electrocatalyst materials over pure metals and metal alloys in many industrial processes involving operation in highly corrosive environment. The depolarised electrolysis of hydrochloric acid represents one of such processes; in this case, rhodium sulfide is incorporated into gas diffusion electrode structure for use as oxygen-consuming cathode. An increased dispersion of the rhodium/ sulfurcompoundisanevidentgoaltoobtainhighlyactivecatalystsystemswhilemaintainingsimilaractivity.InstudyingtheeffectofRhxSyloadingon carbononoxygenreductionreactionactivity,itisparamounttounderstandandoptimizethestructuresensitivityofthereaction.Doingsowillnotonly aidindeterminingtheoptimalmetalloadingbutmoreimportantlywillcontrolthecommercialviabilityoftheelectrocatalyst.Inthepresentwork,the RhxSyloadingonVulcanXC72-RwasstudiedintermsofmorphologicalcharacteristicsandORRactivity.Physicochemicalcharacterizationsuggests that the preparation methodology of such chalcogens plays a fundamental role in terms of chemical structure. ORR kinetics was addressed using a seriesofrotatingdiskelectrodeexperimentsin1 MHClelectrolyte,inwhichtheoptimalRhxSyloadingwasfoundtobeat15 wt.%,avaluetwotimes lower with respect to the commercially available 30 wt.% material. Any higher dispersion results in no significant increase in the overall electrocatalytic performance. Based on the increased Rh utilization and enhanced activity found for the low-loading RhxSy/C samples, we report a significant development in terms of materials and material employment for the oxygen depolarized electrolysis of HCl. # 2007 Elsevier B.V. All rights reserved.

Several Rh- and Ru-based carbon-supported chalcogenide electrocatalysts were evaluated as oxygen-depolarized cathodes for HCl electrolysis applications. The roles of both crystallinity and morphology of the electrocatalysts were explored by investigating several synthetic processes for materials, specifically patented E-TEK methods and the non-aqueous method. The activity of the electrocatalysts for ORR was evaluated via RDE studies in 0.5 M HCl, and compared to state of the art Pt/C and Rh/C systems. RhxSy/C, CoxRuySz/C, and RuxSy/C materials synthesized from the E-TEK methods exhibited appreciable stability and activity for ORR under these conditions. The amorphous non-aqueous moieties, while exhibiting little depolarization due to the presence of high concentrations of Cl− in the RDE studies, were unsuitable for operation in a true ODC HCl electrolyzer cell because of irreversible dissolution resulting from the high concentration (∼5 M) of HCl. In contrast, the Ru-based materials from the E-TEK methods were unaffected by the depolarizing conditions of an uncontrolled shutdown. These Ru-based electrocatalysts, being on the order of seven times less expensive than the state of the art RhxSy material, may prove to be of economic benefit to the HCl electrolysis industry.

This study aims to characterize the evolution and trends in free flap breast reconstruction at our institution.The authors reviewed and analyzed a registry of free flap breast reconstructions performed at a large urban academic center.Between 1979 and mid-2014, a total of 920 patients underwent breast reconstruction with 1,254 flaps. The mean age was 47.7 years (range, 16-79 years). Over the past 10 years, patients were older than all patients seen in the prior decade (average age 48.9 vs. 46.1 years, p = 0.002). Overall, 82% of flaps were performed at our university hospital, 17% at a major urban county hospital, and 1% at other sites. A total of 99% patients received postmastectomy reconstruction for an existing cancer diagnosis or prophylaxis. There has been a significant increase in reconstructions, with 579 flaps performed over the past 5 years alone. There has been a fundamental shift in the predominant flap of choice over time. Perforator flaps have increased in popularity at our institution, with 74% of all reconstructions over this past 5 years being perforator based. Perforator flaps were more likely to be chosen over nonperforator flaps in older versus younger patients (p = 0.0008). There has been a steady increase in bilateral reconstructions since the first one was performed in 1987 (p = 0.002).Over the past 35 years, our institution has seen a significant evolution in free flap-based breast reconstruction. Besides a massive increase in flap numbers we have seen a significant trend toward bilateral reconstructions and perforator-based flaps.

The anterolateral thigh flap (ALT) was first described in 1984 for use in patients suffering neck burn contracture.1 Since that time it has proven to be advantageous in numerous different reconstructive scenarios. Despite this versatility, one criticism of the ALT is the propensity for flap thickness adjustments. Several solutions to this problem have been proposed: primary thinning, secondary liposuction, and, recently, the adipofascial ALT flap (aALT). The aALT is harvested in a similar fashion to the standard fasciocutaneous ALT; however, the skin and subcutaneous adipose tissue are removed from the flap prior to transfer, leaving an ultra-thin flap on the range of 0.5-2.8-cm.2 Herein, we describe our experience using the aALT for reconstruction of oncologic defects of the hand and foot.

BACKGROUND The abdominal donor site has consistently demonstrated excellent aesthetic outcomes when used for autologous breast reconstruction. However, a consistent point of dissatisfaction is the location and appearance of the abdominal donor-site scar, which can be a frequent cause of distress for the patient. The authors consider the appearance of the donor-site to be as important to the overall reconstructive effort as that of the breast, and believe it worthwhile to achieve an aesthetically pleasing result. Thus, the authors present here their technique for aesthetic revision of the abdominal donor site after autologous breast reconstruction. METHODS This is a series of 51 patients who underwent autologous tissue breast reconstruction with deep inferior epigastric perforator flaps. All patients subsequently underwent abdominal donor-site revision during the second stage of their reconstruction, including excision and lowering of the abdominal scar, and liposuction of the abdomen and mons pubis to achieve optimum contouring. RESULTS The donor-site scars were lowered an average of 5.93 cm (range, 5 to 7 cm). The average procedural time was 27 minutes. No wound dehiscence, seromas, hematomas, or infections were reported postoperatively. CONCLUSIONS With this report, the authors put forth a new obtainable standard for autologous tissue breast reconstruction donor-site aesthetics, and propose a conceptual shift that includes the trunk aesthetic unit as an integral part of the overall reconstructive outcome. The authors' results here demonstrate that this is a safe, successful, and reproducible procedural adjunct to the second stage of breast reconstruction.

BACKGROUND The process of harvesting and performing microsurgical anastomosis in a deep inferior epigastric perforator (DIEP) flap for breast reconstruction can be a lengthy procedure, which could affect outcomes and patient safety. We hypothesize that the implementation of a high volume center, preoperative planning, and the adaptation of key intraoperative components will optimize the efficiency of perforator flap surgery for breast reconstruction. METHODS A retrospective review of 68 consecutive patients who underwent 104 DIEP flaps for immediate or delayed breast reconstruction was performed. Standardized preoperative planning, including computed tomography/magnetic resonance imaging angiogram, operating room setup, and operative technique, was followed. The times of flap harvest, internal mammary vessel harvest, microsurgical anastomosis, flap inset, wound closure, and total length of procedure were reviewed as well as patient outcomes. RESULTS The average length of surgery for a unilateral DIEP was 3 hours and 21 minutes and for a bilateral DIEP was 5 hours and 46 minutes. In bilateral DIEP flaps, a significantly longer operative time was noted in immediate (363 ± 14 minutes) compared to delayed (296 ± 17 minutes) (P < 0.05) reconstruction and between procedures performed by 1 surgeon (400 ± 29 minutes) versus 2 surgeons (326 ± 11 minutes) (P < 0.05). Interestingly, no significant difference in operative time was seen in DIEP flaps performed on patients with a body mass index (BMI) less than 30 (193 ± 7.6, 352 ± 17 minutes) versus a BMI greater than 30 (213 ± 11, 333 ± 14 minutes) in both unilateral and bilateral procedures, respectively. CONCLUSIONS Efficiency is optimized by preoperative planning with computed tomography/magnetic resonance imaging angiogram, a dedicated operating room team, including 2 microsurgeons and a systematic approach for surgery. The BMI may not significantly affect the duration of surgery.

Aesthetically pleasing nipple-areola reconstruction is a satisfying part of a two-stage breast reconstruction. The up to 50% [Banducci DR, Le TK, Hughes KC. Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction. Ann Plast Surg 1999;43(5):467-9; discussion 469-70] postoperative shrinkage following a conventional nipple reconstruction is a well-known problem. Augmentation of the nipple with autologous banked cartilage seems to be a promising solution. From 2000-2003, 17 patients underwent a nipple-areola-complex reconstruction following secondary breast reconstruction using free perforator flaps. The rib cartilage harvested during the preparation of the internal thoracic vessels was banked subcutaneously and six months later replanted under the 'arrow flap' after contouring it in a 'mushroom' shape. One year later the shrinkage of the nipple in comparison to the intraoperative status was measured. In addition, patients were asked about their personal palpation impression and the aesthetic outcome. The average height decreased one year postoperatively about 25%. Thirteen of 17 patients judged the aesthetic outcome as very good, 16 nipples healed without cartilage protrusion and no patient felt discomfortable stiffness of the nipple. Our concept of a nipple augmentation with rib cartilage improves the projection and allows a more correct judgement of the later nipple shrinkage. We consider this technique to be an aesthetically satisfying and safe method, which could be used with any kind of breast reconstruction.

Perforator free flaps harvested from the abdomen or buttock are excellent options for breast reconstruction. They enable the reconstructive surgeon to recreate a breast with skin and fat while leaving muscle at the donor site undisturbed. The gluteal artery perforator free flap using buttock tissue was first introduced by the authors' group in 1993. Of the 279 gluteal artery perforator flaps, the authors have performed for breast reconstruction, 220 have been based on the superior gluteal artery and 59 have been based on the inferior gluteal artery. The authors have found that for some women with excess tissue in the upper buttock and hip area, use of the gluteal artery perforator flap resulted in an improvement at the donor site, whereas for others the aesthetic unit of the buttock was clearly disrupted. Therefore, the authors have recently been placing the scar in the inferior buttock crease to improve donor-site aesthetics.The authors have now performed 31 in-the-crease inferior gluteal artery perforator free flaps for breast reconstruction and found that the results are very favorable.The removal of tissue from the inferior buttock results in a tightened, lifted appearance. The resultant scar is well concealed within the infrabuttock crease, and exposure or injury of the sciatic nerve has not occurred. Extended beveling at this site is also possible, with less risk of causing an unsightly depression. The final aesthetic result of the scar lying within the inferior buttock crease is very favorable. All patients report satisfaction with the donor site. Complications included one total flap loss, two reoperations for venous congestion, one hematoma, two cases with delayed wound healing at the recipient site, and one with delayed wound healing at the buttock.The in-the-crease inferior gluteal artery perforator flap from the buttock is now the authors' primary alternative to the deep inferior epigastric perforator flap from the abdomen for breast reconstruction.

Ultra-low Pt and Pt based alloy/mix (Pt-Co and Pt-Cr) electrodes were prepared by dual ion-beam assisted deposition (Dual IBAD) method. Activity enhancement, based on normalization with electrochemical surface area and mass activity is reported relative to a commercial gas diffusion electrode containing carbon supported Pt electrocatalysts. Mass specific power density of 0.297 gPt/kW is reported with 250 Aå IBAD deposit at 0.65 V. Based on the morphological differences, which enable such enhanced activities and the mass manufacturability of this electrode system; we report a significant new development in terms of materials for PEMFC application.

Summary Background Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. Indications Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). Anatomy and technique IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. Conclusions IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients.

Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor site morbidity. For breast reconstruction, the abdomen typically is our primary choice as a donor site. The deep inferior epigastric perforator (DIEP) flap remains our first choice as an abdominal perforator flap and has become a mainstay for the repair of mastectomy defects. It allows the transfer of the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrifice of the rectus muscle or fascia. We discuss our current techniques and specific issues related to the surgery. We present the results of 1095 cases of free tissue transfers from the abdomen for reconstruction of the breast.

Background Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The deep inferior epigastric artery (DIEP) and superficial inferior epigastric artery (SIEA) flaps transfer the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrificing the rectus muscle or fascia. Gluteal artery perforator (GAP) flaps allow transfer of tissue from the buttock, also with minimal donor-site morbidity. Indications Most women requiring tissue transfer to the chest for breast reconstruction or other reasons are candidates for perforator flaps. Absolute contraindications to perforator flap breast reconstruction include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). Anatomy and Technique The DIEP flap is supplied by intramuscular perforators from the deep inferior epigastric artery and vein. The SIEA flap is based on the SIEA and vein, which arise from the common femoral artery and saphenous bulb. GAP flaps are based on perforators from either the superior or inferior gluteal artery. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest and the donor site is closed without the use of mesh or other materials. Conclusions Perforator flaps allow the safe and reliable transfer of abdominal tissue for breast reconstruction. J. Surg. Oncol. 2006;94:441–454. © 2006 Wiley-Liss, Inc.

To explore the feasibility of radar-based extreme precipitation climatologies, prototype radar areal reduction factor (ARF) curves are developed and compared to those based on traditional rain gauge networks. For both the radar and gauge data, increasing the spatial density of observations has little influence on the ARF relationship. However, independently, considerable differences between radar ARF and gauge ARF exist. Radar ARF decays at a faster rate (with increasing area) than gauge ARF. For a basin size of 20,000 km2, the percent difference between radar ARF and gauge ARF ranges from 11 to 32%. This implies that radar-derived estimates of extreme point precipitation are disproportionately larger than radar-derived estimates of extreme areal precipitation, as compared to the corresponding relationship based on rain gauges. Between-station variance of same-day extreme precipitation, as well as the coefficient of variation tends to be larger for the radar-derived areal extreme events, favoring a smaller radar areal precipitation. Smaller radar ARF is also favored because, on average, a higher percentage of gauges have coincident annual maxima than do the radar pixels that correspond to these gauges. Radar ARF curves computed based on gauge-calibrated radar data decay at an even faster rate than the unadjusted radar ARF. The accuracy of the calibrated radar data for these extreme events is suspect, however. Areal precipitation amounts for the 2-, 5- and 10-year return period were computed by fitting an extreme value distribution to the areal radar, (and separately gauge), maxima from 5 years of available data. In one study area, the radar estimates tend to exceed those based on the gauge, whereas in a different region the gauge estimates tend to exceed those based on the radar. These results emphasize that a smaller radar ARF does not necessarily imply a lower radar mean areal precipitation.

National Oceanic and Atmospheric Administration Technical Paper-29, published in the late 1950s, remains the most com- monly used reference for estimating extreme areal precipitation from station data in the United States. Although a number of alternative methods have been proposed over the intervening years, a rigorous evaluation of the assumptions used in the compilation of TP-29 has not been presented. Overall, TP-29 areal reduction factors provide a conservative means of relating station precipitation extremes to basin average values. For watershed areas less than 1000 km 2 , reevaluated areal reduction factors, are in close agreement with the TP-29 values. For larger watersheds, which TP-29 does not address, the areal reduction factors continue to decay exponentially. The areal reduction factors were found to be particularly sensitive to return period and season, with less extreme areal precipitation relative to the corre- sponding station precipitation at longer return periods and during the warm season. The reevaluated factors exhibit modest differences between study areas in North Carolina and New Jersey. The influence of station density, interpolation method, and topographical rainfall biases appears insignificant.

This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.

Fujino was the first to introduce gluteal tissue as a free flap for breast reconstruction. The use of the musculocutaneous flap from the buttock in breast reconstruction has been championed by Shaw. Despite the initial enthusiasm for this area as a donor site, few other large series exist on the subject. Two decades of experience with this region as a donor site led to recognition of advantages and drawbacks. Furthermore, use of both the superior and inferior gluteal musculocutaneous flap was associated with certain important donor site complications and the use of vein grafts to allow for microvascular anastomosis. The evolution of free tissue transfer has progressed to the level of the perforator flap. This reconstructive technique allows elevation of tissue from any region consisting only of fat and skin. This minimizes donor site morbidity by allowing preservation of the underlying muscle and coverage of important structures in the region such as nerves. The superior and inferior gluteal perforator flaps have been used at our institution for breast reconstruction since 1993. The superior gluteal artery perforator (S-GAP) flap is our preferred method of breast reconstruction when the abdomen is not available or preferable. We report the result of this flap over the past 9 years and point out important surgical refinements, advantages, disadvantages, and lessons learned during this time.

Due to its increasing popularity, more and more articles on the use of perforator flaps have been reported in the literature during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are no definitions and standard rules on terminology and nomenclature, which creates confusion when surgeons try to communicate and compare surgical techniques. This article attempts to represent the opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in Gent, Belgium, on September 29, 2001. It stipulates not only the definitions of perforator vessels and perforator flaps but also the correct nomenclature for different perforator flaps. The authors believe that this consensus is a foundation that will stimulate further discussion and encourage further refinements in the future.

The care plan for patients who are faced with a diagnosis of breast cancer requires a multidisciplinary approach. The plastic surgeon has become a critical member of this team, especially for the patient who requires mastectomy. The autogenous breast reconstruction plan for these patients requires versatile reconstructive options and commitment to minimize donor site morbidity. The deep inferior epigastric artery perforator (DIEP) flap was an important development in the evolution of breast reconstruction techniques using skin and fat only. Sparing of the rectus abdominus musculature greatly reduces donor site morbidity compared with musculocutaneous flaps. The patient who has undergone a DIEP flap breast reconstruction enjoys a short recovery period with minimal postoperative pain and a resultant high rate of satisfaction. The authors have used the flap in more than 800 breast reconstructions; the procedure has proven to be safe, reproducible, and especially suited to bilateral reconstructions.