Techniques of inserting deep inferior epigastric perforator flap obliquely in immediate breast reconstruction after total mastectomy.

Objective: This study aimed to share the experience of inserting a deep inferior epigastric perforator (D.I.E.P) flap obliquely in immediate breast reconstruction after total mastectomy. Method: Forty patients underwent immediate breast reconstruction with flap D.I.E.P after total mastectomy. The flaps were placed obliquely, with the upper edge facing downward and inward. After being placed in the recipient region, parts of the flap at both ends were removed, the upper end was fixed into the II-III intercostal space next to the sternum, and the lower end was folded to create a projection of the lateral lower pole of the breast. The flap pedicle was anastomosed to the thoracodorsal vessels (TDVs) if the contralateral flap pedicle was used; conversely, the mammary vessels (IMVs) were used. Satisfaction with breast shape was assessed after 6 months using the BREAST-Q questionnaire. Results: A total of 37/40 flaps were well vascularized; 36/37 patients with a survival flap were interviewed, showing that the average BREAST-Q evaluation score of satisfaction with breast shape was 62.22 (51-78). The number of answers for satisfied and very satisfied with breast shape accounted for 94.44%. Conclusion: Inserting the D.I.E.P flap obliquely has the advantage of being easy to shape the breast contour, creating a moderate projection and symmetry to the opposite breast. The author suggested using the IMVs as the receiving vessels when using the pedicle of the flap on the ipsilateral side and the TDVs when the contralateral pedicle flap was used.

The modulation of Pacific Decadal Oscillation on ENSO-East Asian summer monsoon relationship over the past half-millennium.

Monsoon precipitation affects natural and social systems in East Asia, one of the most densely populated regions in the world. Monsoon precipitation variability is strongly influenced by El Niño-Southern Oscillation (ENSO) and may be related to the phase of the Pacific Decadal Oscillation (PDO). However, a collective understanding of the long-term PDO-ENSO-monsoon relationship remains limited because related studies are almost exclusively based on short instrumental records. Although paleoclimate proxies for PDO and ENSO are currently available, there is a lack of high-quality proxies for East Asian summer monsoon (EASM) precipitation. Moreover, the strengthening of the ENSO-EASM relationship since the 1970s has raised the question of anthropogenic impact. Reconstructing EASM precipitation is thus crucial to understanding its variability under natural and anthropogenic forcings. In this study, we addressed these challenges using tree ring oxygen isotopes of red cypress (Chamaecyparis formosensis Matsum), a long-lived endemic tree species in Taiwan. We developed an annual-resolved and well-validated EASM precipitation proxy from 1533 CE to 2011 which explained 49 % of the variance in instrumental precipitation. In comparison with multiple paleoclimate proxies, we revealed that PDO persistently modulated the ENSO-EASM relationship over the past half-millennium. The ENSO-EASM relationship was enhanced during the positive PDO phases and dynamically weakened during the negative PDO phases, notably in the early-17th, 18th, and early to mid-20th centuries. The strengthened relationship since the 1970s concurred with an unusually high PDO and ENSO and fell within its natural variability. Nevertheless, as the amplitude of the PDO is predicted to weaken under warming, the modulation effects may become less predictable.