Letter to the editor: applications of rib sparing technique in internal mammary vessels exposure of abdominal free flap breast reconstructions: a 12-year single-center experience of 215 cases

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An Algorithm for Selecting Buoy Skin Paddle Design for Flap Monitoring in Total Autologous Breast Reconstruction After Nipple-Sparing Mastectomy

Introduction: Monitoring buried flaps in reconstructive breast surgery is challenging, and the ideal technique is controversial. Established options include leaving an exterior (“buoy” or “sentinel”) skin paddle versus invasive implantable devices to avoid removing the paddle later. Technical modifications and an algorithm for strategic skin paddle positioning to circumvent this while avoiding complex monitoring equipment are proposed. Patients and methods: Patients in whom buoy skin paddles were utilized for breast flap monitoring by a single surgeon were reviewed. Indications, demographic details, precise monitoring paddle location, and flap outcomes were evaluated. An algorithm and classification system were then formulated. Results: Thirteen buoy skin paddles were utilized in seven patients (mean age: 43.5 years; range: 31-65) to monitor reconstructive flaps performed for risk-reducing mastectomies (four patients and seven breasts), therapeutic mastectomy (one breast), and revision surgery (three patients and five breasts). The flaps comprised seven deep inferior epigastric artery perforators (DIEPs), four superficial inferior epigastric arteries (SIEAs), and two pedicled latissimus dorsi (LDs) (mean free flap weight: 809 g; average mastectomy weight (n = 10 breasts): 467 g; range: 248-864). The skin paddles were located horizontally along the inframammary crease or vertically inferior to the nipple-areola or both. All flap transfers were successful with no re-explorations. All patients declined the monitoring paddle excision, and none have requested breast mound revision for poor cosmesis or contour deformities. Conclusion: Vertical and horizontal skin paddles proved reliable for buried flap monitoring without recourse to invasive and expensive equipment. When designed appropriately, they do not require revision surgery. An algorithmic classification of skin paddle location to enable this is proposed

The prognostic value of tricuspid valve annular motion in large malignant pericardial effusions

Background and objectives: Although collapsing of the right atrium (RA) and/or right ventricle (RV), as far as flow velocity paradox through the tricuspid valve (TV), are common findings in the echocardiogram (ECHO) of threatened tamponade, their prognostic value remains controversial. We investigated whether an interrogation of the TV annular motion offers any additional prognosticators in cases of large malignant pericardial effusions (PE).Subjects and methods: 96 patients with newly diagnosed lung cancer and neoplastic PE, not in clinical tamponade, underwent a respirophasic conventional and tissue Doppler imaging (TDI) of the TV annulus. Ra and RV collapsing, TV flow velocity paradox, TV annular plane systolic excursion (TAPSE), and TV annular velocities Sa, Ea, Aa were assessed. In a period of one month, 37 patients (group A) developed clinical tamponade, versus 59 patients (group B) who did not. The independent value of each ECHO parameter in predicting tamponade was estimated by univariate and multivariate analysis.Results: Collapsing of Ra and RV were more frequent in group A (84% vs 69% and 41% vs 20% respectively), whereas the trans-tricuspid flow velocity paradox was similar in both groups. TAPSE and Sa were higher in group A (p < 0.001). The velocities Ea and Aa demonstrated an excessive respirophasic fluctuation (ΔEa and ΔAa), with inspiratory increase and expiratory decrease. ΔEa and ΔAa were higher in group A (p < 0.001). In multivariate analysis, TAPSE, expiratory Ea and Aa, as well as ΔAa, were independent predictors of tamponade.Conclusion: Large neoplastic PE manifest an enhanced longitudinal motility of TV annulus. Early progression to tamponade is likely, and parameters deriving from the TDI of the RV free wall present considerable predictive value

First use of Braxon® acellular dermal matrix for complex revision aesthetic breast surgery-revision augmentation mastopexy.

Acellular dermal matrices (ADMs) have ushered in a paradigm shift in prosthetic breast reconstruction; however, there has hitherto been no reported use of Braxon® ADM in aesthetic breast surgery. Here, we describe the case of a 42-year-old woman who presented for revision of her bilateral aesthetic augmentation-mastopexy following multiple revision surgeries. The predominant concerns were persistent pain, implant malposition and a wide intermammary distance. Her predicament was worsened by inability to tolerate monopolar diathermy owing to a spinal stimulator-the least invasive operation was sought and Braxon® ADM met this criterion. The procedure was a success, and she remains symptom-free, with soft breasts and stable implant positions. Braxon® ADM, with its preformed shape, total implant-wrapping design and easy suture fixation, lends itself to easy use in cosmetic breast surgery. Its role in cosmetic breast surgery has yet to be established, but this case marks the beginning of this endeavor

An unusual “venous circle” of the internal mammary vein encountered during microvascular anastomosis and implications for practice

The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a ‘venous circle’

Characterization of laboratory and real driving emissions of individual Euro 6 light-duty vehicles – Fresh particles and secondary aerosol formation

Emissions from passenger cars are one of major sources that deteriorate urban air quality. This study presents characterization of real-drive emissions from three Euro 6 emission level passenger cars (two gasoline and one diesel) in terms of fresh particles and secondary aerosol formation. The gasoline vehicles were also characterized by chassis dynamometer studies. In the real-drive study, the particle number emissions during regular driving were 1.1–12.7 times greater than observed in the laboratory tests (4.8 times greater on average), which may be caused by more effective nucleation process when diluted by real polluted and humid ambient air. However, the emission factors measured in laboratory were still much higher than the regulatory value of 6 × 10^(11) particles km^(−1). The higher emission factors measured here result probably from the fact that the regulatory limit considers only non-volatile particles larger than 23 nm, whereas here, all particles (also volatile) larger than 3 nm were measured. Secondary aerosol formation potential was the highest after a vehicle cold start when most of the secondary mass was organics. After the cold start, the relative contributions of ammonium, sulfate and nitrate increased. Using a novel approach to study secondary aerosol formation under real-drive conditions with the chase method resulted mostly in emission factors below detection limit, which was not in disagreement with the laboratory findings

Vertical Profiles of Aerosol Optical and Microphysical Properties During a Rare Case of Long-range Transport of Mixed Biomass Burning-polluted Dust Aerosols from the Russian Federation-kazakhstan to Athens, Greece

Multi-wavelength aerosol Raman lidar measurements with elastic depolarization at 532 nm were combined with sun photometry during the HYGRA-CD campaign over Athens, Greece, on May-June 2014. We retrieved the aerosol optical [3 aerosol backscatter profiles (baer) at 355-532-1064 nm, 2 aerosol extinction (aaer) profiles at 355-532 nm and the aerosol linear depolarization ratio (δ) at 532 nm] and microphysical properties [effective radius (reff), complex refractive index (m), single scattering albedo (ω)]. We present a case study of a long distance transport (~3.500-4.000 km) of biomass burning particles mixed with dust from the Russian Federation-Kazakhstan regions arriving over Athens on 21-23 May 2014 (1.7-3.5 km height). On 23 May, between 2-2.75 km we measured mean lidar ratios (LR) of 35 sr (355 nm) and 42 sr (532 nm), while the mean Ångström exponent (AE) aerosol backscatter-related values (355nm/532nm and 532nm/1064nm) were 2.05 and 1.22, respectively; the mean value of δ at 532 nm was measured to be 9%. For that day the retrieved mean aerosol microphysical properties at 2-2.75 km height were: reff=0.26 μm (fine mode), reff=2.15 μm (coarse mode), m=1.36+0.00024i, ω=0.999 (355 nm, fine mode), ω=0.992(355 nm, coarse mode), ω=0.997 (532 nm, fine mode), and ω=0.980 (532 nm, coarse mode)

ContextAware Queries Using Query by Browsing and Chiromancer

In this paper we present Chiromancer, a relationally complete visual query language for the Palm handheld platform, based on the Query by Browsing paradigm. We discuss the suitability of the relational model as the description model of all aspects of a pervasive environment, and hence the suitability of Chiromancer as a generic access and application development tool for such an environment 1. We briefly introduce the QBB paradigm and an overview of the Chiromancer design. We demonstrate the context-awareness aspects of our proposal by examining the implementation of some examples from the research literature using Chiromancer. Finally, we provide a conclusion as well as some suggestions for future work. 1