Waist-to-hip ratio is a better predictor than body mass index for morbidity in abdominally based breast reconstruction.

BACKGROUND: Body mass index is a universally recognized measure of obesity. However, it does not take body fat distribution (BFD) into account, which has been established as a significant risk factor in both medicine and surgery. The objective of this study was to compare previously developed anthropometric measures of BFD with body mass index in predicting morbidity with abdominally based microsurgical breast reconstruction. METHODS: A review of patients who underwent abdominally based breast reconstruction was performed. Multivariate logistic regression was performed to determine the relationship between complications (recipient, donor, total) with body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio, conicity index, and abdominal volume index. RESULTS: A total of 325 patients who underwent 442 flaps were analyzed. Waist circumference (OR, 1.16; 95% CI 1.07-1.76), waist-to-hip ratio (OR, 1.94; 95% CI 1.25-3.35), and waist-to-height ratio (OR, 1.19; 95% CI 1.01-1.70) were significant risk factors for recipient site complications. Body mass index (OR, 1.14; 95% CI 1.01-1.56), and waist-to-hip ratio (OR, 2.01; 95% CI 1.30-3.95) were significant risk factors for donor site complications. Waist-to-hip ratio (OR, 1.87; 95% CI 1.22-4.00) was the only measure found to be a significant risk factor for experiencing any complication. A waist-to-hip ratio >0.84 was associated with increased risk. CONCLUSIONS: Waist-to-hip ratio is a significant risk factor for recipient and donor site morbidity in abdominally based breast reconstruction. It is a readily calculable and clinically significant measure distinct from body mass index that should be considered for use in clinical care and research.

The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the history and physiology of perforator flaps. 2. Understand the concept of "free-style" perforator flaps and principles in design and harvest. 3. Understand the uses of perforator flaps in reconstruction and applications in new settings. 4. Understand new principles in single and multiple perforator flap harvest and adjunct techniques that can be used in perforator flaps. 5. Highlight pertinent anatomy and techniques for selected perforator flaps described. SUMMARY: Extended knowledge of vascular anatomy has propagated the development of perforator flaps, which preserve muscle function and reduce morbidity. This has been achieved through the exemplary works of Manchot, Salmon, Milton, Taylor, and many others. With over 350 clinically relevant perforators in the body, this has created new flap options and a sense of creative freedom for reconstruction tailored toward a specific defect, without constraints of specific landmarks and using a "free-style" approach. Dominant perforators may be found in zones of high perforator density or "hot spots," which can help to conceptualize local flap options and aid flap design. This article aims to outline the history, physiology, and principles of flap design and harvest, and highlight traditional and evolving concepts and modifications of contemporary and traditional flaps that are changing reconstructive practice. This is a broad overview focusing on clinical applications, highlighting key concepts in a selection of new or evolving flaps being used in clinical practice and providing source references to acquire detailed flap descriptions.

Extracorporeal Septoplasty: External and Endonasal Techniques.

Severe septal deformities are among the most challenging problems faced by rhinoplasty surgeons. Extracorporeal septoplasty (ES)--also known as subtotal septal reconstruction--involves removal of the native deformed septum and replacement with a reconstructed neoseptum. Several techniques and multiple variations have been described in the literature. We present an overview of ES, pertinent anatomical structures and deformities, and the external versus endonasal approach, and describe some of our techniques.

Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications.

BACKGROUND: Keystone flaps have demonstrated growing clinical applications in reconstructive surgery in the past decade. This article highlights flap modifications and their versatility for clinical applications and management of complex defects. METHODS: A retrospective chart review was conducted of consecutive patients undergoing keystone flap reconstruction at the authors' institution from January of 2012 to December of 2014. Patient demographics, indications, and operative and postoperative details were abstracted. RESULTS: Forty-two keystone flaps were performed in 36 patients. Indications included malignant melanoma (n = 14), soft-tissue sarcoma (n = 12), benign pathologic conditions (e.g., exposed hardware, enterocutaneous fistula, tissue necrosis) (n = 6), and nonmelanoma skin cancer (n = 4). Twenty-eight percent received neoadjuvant irradiation, and 70 percent of these were for sarcoma. Locoregional adjunct flaps were performed in eight patients. The deep fascia was nearly completely in a circumferential manner in 18 of 36 patients (50 percent), in 92 percent of the sarcoma reconstructions, and located mainly in the lower extremity. Average defect size was 215 cm (range, 4 to 1000 cm). Average defect size was 474 cm and 35.8 cm after sarcoma and malignant melanoma resection, respectively. Average flap size was 344 cm (range, 5 to 1350 cm). Ninety percent of cases had flap sizes exceeding the traditional 1:1 ratio. There was no flap loss or partial necrosis. Mean time to mobilization was 1.8 days, and mean hospital length of stay was 6.8 days. CONCLUSIONS: Keystone flaps offer an excellent versatile tool for reconstructive surgeons. Fundamental principles behind the vascular basis of the keystone flap and its modifications permit their greater utility in complex wounds in the settings of large oncologic resections, irradiation, and trauma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Systematic Review of Comparison of Autologous, Allogeneic, and Synthetic Augmentation Grafts in Nipple Reconstruction.

BACKGROUND: Many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. METHODS: MEDLINE, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking postoperative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Thirty-one studies met the inclusion criteria. After evidence review, one study represented two of nine stars on the Newcastle-Ottawa Scale, two studies represented three stars, six studies represented four stars, seven studies represented five stars, 11 studies represented six stars, and four studies represented seven stars. CONCLUSIONS: The results of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence is low. Synthetic materials have higher complication rates and allogeneic grafts have nipple projection comparable to that of autologous grafts. Further investigation with high-level evidence is necessary to determine the optimal material for nipple reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Red breast syndrome: a review of available literature.

UNLABELLED: There is scant literature regarding a recently identified clinical entity termed red breast syndrome. Its clinical presentation has been described as a non-infectious, self-limited erythema of a post-mastectomy breast reconstructed using acellular dermal matrix. Its incidence, risk factors, pathophysiology, clinical course, management, and long-term sequelae are largely unknown. We present a review of the available literature on this phenomenon and highlight some opportunities for further research. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Primary repair of facial dog bite injuries in children.

OBJECTIVES: The management of dog bite wounds is controversial, and current data on risk of infection are variable and inconsistent. Furthermore, the use of prophylactic or empiric antibiotics for the treatment of these wounds is debatable. We investigate the rate of wound infections and other complications after primary repair of pediatric facial dog bite injuries. METHODS: We reviewed 87 consecutive patients aged 18 years or younger who had facial dog bite injuries from January 2003 to December 2008. Variables examined were age, sex, setting of repair, number of sutures used for repair, whether surgical drains were used, and antibiotic administration. End points measured were incidence of wound infection, need for scar revision, and any wound complications. RESULTS: The mean age of patients was 6.8 years, and the majority were women (53%). All facial injuries were primarily repaired at the time of presentation either in the emergency department (ED; 46%), operating room (OR; 51%), or an outpatient setting (3%). All patients received an antibiotic course, none of the patients developed wound infection, and no subsequent scar revisions were performed. Three patients repaired in the OR underwent placement of a total of 4 closed-suction drains. The mean (SD) age of patients repaired in the OR was significantly younger than those repaired in the ED (5.7 [3.9] vs 8.0 [4.5] years, respectively; P < 0.01). The number of sutures used were greater for patients repaired in the OR than in the ED (66.4 [39.6] vs 21.7 [12.5], respectively; P < 0.01). CONCLUSIONS: Intuitively, younger patients and patients with greater severity injuries are more likely to undergo repair in the OR, and this was supported by our data. Overall, we found that primary repair of pediatric facial dog bite injuries, including complex soft-tissue injuries, is safe when performed in conjunction with antibiotic administration; however, further cross-specialty studies are needed to fully characterize these end points in a larger population.

N-Labelled proteins by cell-free protein synthesis. Strategies for high-throughput NMR studies of proteins and protein-ligand complexes.

[(15)N]-heteronuclear single quantum coherence (HSQC) spectra provide a readily accessible fingerprint of [(15)N]-labelled proteins, where the backbone amide group of each nonproline amino acid residue contributes a single cross-peak. Cell-free protein synthesis offers a fast and economical route to enhance the information content of [(15)N]-HSQC spectra by amino acid type selective [(15)N]-labelling. The samples can be measured without chromatographic protein purification, dilution of isotopes by transaminase activities are suppressed, and a combinatorial isotope labelling scheme can be adopted that combines reduced spectral overlap with a minimum number of samples for the identification of all [(15)N]-HSQC cross-peaks by amino acid residue type. These techniques are particularly powerful for tracking [(15)N]-HSQC cross-peaks after titration with unlabelled ligand molecules or macromolecular binding partners. In particular, combinatorial isotope labelling can provide complete cross-peak identification by amino acid type in 24 h, including protein production and NMR measurement.

Amino-acid type identification in 15N-HSQC spectra by combinatorial selective 15N-labelling.

The efficiency of cell-free protein synthesis combined with combinatorial selective 15N-labelling provides a method for the rapid assignment of 15N-HSQC cross-peaks to the 19 different non-proline amino-acid types from five 15N-HSQC spectra. This strategy was explored with two different constructs of the C-terminal domain V of the tau subunit of the Escherichia coli DNA polymerase III holoenzyme, tauC16 and tauC14. Since each of the five 15N-HSQC spectra contained only about one third of the cross-peaks present in uniformly labelled samples, spectral overlap was much reduced. All 15N-HSQC cross-peaks of the backbone amides could be assigned to the correct amino-acid type. Availability of the residue-type information greatly assisted the evaluation of the changes in chemical shifts observed for corresponding residues in tauC16 vs. those in tauC14, and the analysis of the structure and mobility of the C-terminal residues present in tauC16 but not in tauC14.

SWET for secure water suppression on probes with high quality factor.

Water suppression by selective preirradiation is increasingly difficult to achieve on probeheads with high quality factor because of the opposing forces of radiation damping. Here we show that a simple modification to the WET scheme provides reliable water suppression in aqueous solutions of proteins and peptides with minimal saturation of the H(alpha) protons. The scheme is shown to work also with dilute peptide solutions. It is recommended to maintain the water suppression during the evolution time of COSY experiments by weak selective irradiation that causes only minimal Bloch-Siegert shifts. The new water-suppression scheme suppresses the water magnetization by spatial scrambling. Traditional water suppression by preirradiation is similarly based more on water scrambling due to the radiofrequency inhomogeneity than on relaxation effects.

Rapid pulse length determination in high-resolution NMR.

The 90 degrees (1H) pulse length can be determined in a single scan using a simple homo-gated decoupling/nutation experiment. We show that the method is fast, accurate and readily amenable to automation.

Integron-associated mobile gene cassettes code for folded proteins: the structure of Bal32a, a new member of the adaptable alpha+beta barrel family.

The wide-ranging physiology and large genetic variability observed for prokaryotes is largely attributed, not to the prokaryotic genome itself, but rather to mechanisms of lateral gene transfer. Cassette PCR has been used to sample the integron/gene cassette metagenome from different natural environments without laboratory cultivation of the host organism, and without prior knowledge of any target protein sequence. Since over 90% of cassette genes are unrelated to any sequence in the current databases, it is not clear whether these genes code for folded functional proteins. We have selected a sample of eight cassette-encoded genes with no known homologs; five have been isolated as soluble protein products and shown by biophysical techniques to be folded. In solution, at least three of these proteins organise as stable oligomeric assemblies. The tertiary structure of one of these, Bal32a derived from a contaminated soil site, has been solved by X-ray crystallography to 1.8 A resolution. From the three-dimensional structure, Bal32a is found to be a member of the highly adaptable alpha+beta barrel family of transport proteins and enzymes. In Bal32a, the barrel cavity is unusually deep and inaccessible to solvent. Polar side-chains in its interior are reminiscent of catalytic sites of limonene-1,2-epoxide hydrolase and nogalonic acid methyl ester cyclase. These studies demonstrate the viability of direct sampling of mobile DNA as a route for the discovery of novel proteins.

Photostimulation alters c-Fos expression in the dorsal raphe nucleus.

Retinal afferents to the dorsal raphe nucleus (DRN) have been described in a number of species, including Mongolian gerbils, but functional correlates of this optic pathway are unknown at present. To determine whether temporally modulated photostimulation can affect c-Fos expression in the gerbil DRN, quantitative analysis of c-Fos-immunoreactive (c-Fos-ir) neurons was conducted following 60-min exposure to pulsed (2 Hz) photostimulation at selected times over the 12:12 h light/dark cycle. For comparison, c-Fos expression was also analyzed in the subnuclei of the lateral geniculate complex and in the suprachiasmatic nucleus (SCN). In the DRN, a substantial reduction was observed in the number of c-Fos immunoreactive (c-Fos-ir) neurons during the light period and early dark period in photostimulated vs. control animals. Similar results were obtained in the intergeniculate leaflet (IGL) and ventral lateral geniculate (VLG). However, no significant changes were observed in the number of c-Fos-ir neurons in the dorsal lateral geniculate nucleus or suprachiasmatic nucleus (SCN) following photostimulation, except for an increase in the middle of the dark period. These findings indicate that photic stimulation can lead to a suppression or down-regulation of c-Fos expression in the DRN that is probably mediated via the direct retinal pathway to the DRN in this species. The similarity between c-Fos expression profiles in the DRN and IGL/VGL suggest that efferent projections from the DRN may modulate c-Fos expression to visual stimulation in these subnuclei of the lateral geniculate complex.