Filling the Upper Pole with the Pectoralis Major Muscle Flap in Profunda Femoris Artery Perforator Flap Breast Reconstruction.

Background and Objectives: Among many donor site options for autologous breast reconstruction, the use of the profunda femoris artery perforator (PAP) flap has become common in patients who are not suitable for the gold standard procedure, the deep inferior epigastric artery perforator flap. However, its limited volume has precluded its wide use in breast reconstruction. The aim of this report was to demonstrate the effectiveness of a method in which the anatomical position of the pectoralis major muscle was adjusted to augment the volume of the superior pole of the breast during PAP flap transfer. A comparison was made with a conventional PAP flap breast reconstruction. Materials and Methods: Fifty-nine consecutive cases where unilateral autologous breast reconstruction was performed using the vertically designed PAP flap were retrospectively reviewed. Conventional PAP flap transfer was performed in 36 patients (Group 1), and PAP flap transfer with pectoralis major muscle augmentation was performed in 23 patients (Group 2). Results: The patient satisfaction at 12 months postoperatively was statistically greater in Group 2, with the pectoralis major muscle augmentation, than in Group 1 [23/36 (64%) vs. 22/23 (96%), p = 0.005]. There were no significant differences in postoperative complication rates at the reconstructed site [2/36 (5.6%) vs. 0/23 (0%), p = 0.52]. Conclusions: Higher patient satisfaction could be achieved with pectoralis major muscle augmentation in PAP flap breast reconstruction without increasing the postoperative complication rate at the reconstructed site.

Breast Shape Evaluation After Free Flap Breast Reconstruction After More Than 10 Years Follow-up Using 3-Dimensional Imaging Device.

BACKGROUND: Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up. METHODS: The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items. RESULTS: The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old). CONCLUSION: We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

Ideal esthetic and functional full-thickness lower eyelid "like with like" reconstruction using a combined Hughes flap and swing skin flap technique.

BACKGROUND: A goal in ideal lower eyelid reconstruction is to achieve not only an esthetic recovery of the shape of the eyelid but also to obtain satisfactory eyelid function without damage to the corneal surface. In this report, we introduce our "Like with Like" reconstruction technique using a combined Hughes flap and swing skin flap. The Hughes flap is a tarsoconjunctival pedicled flap from the upper eyelid, and the swing skin flap is a kind of transposition flap based on the orbicularis muscle pedicle. PATIENTS AND METHODS: Eight patients who had more than 25% of the lower eyelid affected by a full-thickness defect were included. There were five men and three women, and the average age was 68.4years old. All patients had undergone wide tumor excision of the lower eyelid due to a malignant tumor and had also had primary two-stage eyelid reconstruction with a combined Hughes flap and swing skin flap. RESULTS: The average reconstructive time was 1:20, and no postoperative severe complications such as flap necrosis or wound dehiscence were observed. The follow-up period was an average of one year, and there were no functional problems such as ectropion, lower eyelid retraction, lid margin hypertrophy, lacrimation disorder, or corneal problems observed in any cases. Esthetically, no reconstructed eyelid bulging or asymmetry in the lid margin was observed in any of the cases. CONCLUSIONS: Combining the Hughes flap and skin swing flap technique might be the best choice for a full-thickness lower eyelid defect with regard to the esthetic and functional results.

Sequence features, structure, ligand interaction, and diseases in small leucine rich repeat proteoglycans.

Small leucine rich repeat proteoglycans (SLRPs) are a group of active components of the extracellular matrix in all tissues. SLRPs bind to collagens and regulate collagen fibril growth and fibril organization. SLRPs also interact with various cytokines and extracellular compounds, which lead to various biological functions such cell adhesion and signaling, proliferation, and differentiation. Mutations in SLRP genes are associated with human diseases. Now crystal structures of five SLRPs are available. We describe some features of amino acid sequence and structures of SLRPs. We also review ligand interactions and then discuss the interaction surfaces. Furthermore, we map mutations associated with human diseases and discuss possible effects on structures by the mutations.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

BACKGROUND: Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. METHODS: The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. RESULTS: The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). CONCLUSION: The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

Shrinking of repeating unit length in leucine-rich repeats from double-stranded DNA viruses.

Leucine-rich repeats (LRRs) are present in over 563,000 proteins from viruses to eukaryotes. LRRs repeat in tandem and have been classified into fifteen classes in which the repeat unit lengths range from 20 to 29 residues. Most LRR proteins are involved in protein-protein or ligand interactions. The amount of genome sequence data from viruses is increasing rapidly, and although viral LRR proteins have been identified, a comprehensive sequence analysis has not yet been done, and their structures, functions, and evolution are still unknown. In the present study, we characterized viral LRRs by sequence analysis and identified over 600 LRR proteins from 89 virus species. Most of these proteins were from double-stranded DNA (dsDNA) viruses, including nucleocytoplasmic large dsDNA viruses (NCLDVs). We found that the repeating unit lengths of 11 types are one to five residues shorter than those of the seven known corresponding LRR classes. The repeating units of six types are 19 residues long and are thus the shortest among all LRRs. In addition, two of the LRR types are unique and have not been observed in bacteria, archae or eukaryotes. Conserved strongly hydrophobic residues such as Leu, Val or Ile in the consensus sequences are replaced by Cys with high frequency. Phylogenetic analysis indicated that horizontal gene transfer of some viral LRR genes had occurred between the virus and its host. We suggest that the shortening might contribute to the survival strategy of viruses. The present findings provide a new perspective on the origin and evolution of LRRs.

The Feasibility of Harvesting an Innervated Profunda Artery Perforator Flap for Breast Reconstruction.

The profunda artery perforator (PAP) flap has become an alternative option for breast reconstruction. Reliable perforators arise through the adductor magnus muscle, and dissection of the perforator is straightforward. Recently, we have found that the PAP flap with the sensory nerves can be harvested as an innervated flap. We discuss the feasibility of PAP flap neurotization. We reviewed 13 patients for whom innervated PAP flap harvesting was considered. The average age was 50.7 years. There are 3 different patterns of innervated PAP flap harvesting, Type 1: including a sensory nerve that can be found in the adipose tissue around the PAP flap, Type 2: including a sensory nerve that runs along the medial femoral circumflex system, and Type 3: including a sensory nerve that runs along the profunda artery perforators. The average flap harvest time was 2:11 ± 0:31, and a sensory nerve was identified in 10 of 13 cases (77%). No sensory nerves were found in the other 3 cases. The length of the included sensory nerve was 5.5 ± 1.6 mm on average. Types 1 and 2 were found in 3 patients (30%), Type 3 was found in 2 patients (20%), and combined Types 1 and 3, 2 and 3 were found in one patient each (10%). As sensory nerves run around the PAP flap or close to the perforators, it is easy to perform flap neurotization with the PAP flap. We believe that the PAP flap could be an alternative option to achieve sensate breast reconstruction.

An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report.

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

An anatomical study of the lymph-collecting vessels of the medial thigh and clinical applications of lymphatic vessels preserving profunda femoris artery perforator (LpPAP) flap using pre- and intraoperative indocyanine green (ICG) lymphography.

BACKGROUND AND OBJECTIVES: The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. The complications that can occur after the PAP flap harvest include donor-site lymphedema, seroma, or cellulitis. The aim of this study was to evaluate and establish a safer technique for the elevation of lymphatic vessels preserving profunda femoris artery perforator (LpPAP) flap using pre- and intraoperative ICG lymphography. In this article, we also evaluate the anatomical relationship between the PAP flap and lymph-collecting vessels. METHODS: From July of 2018 to January of 2019, 24 patients with soft tissue defects after tumor resection underwent reconstruction using PAP flaps. The lymph-collecting vessels at the medial thigh area were identified using pre- and intraoperative ICG lymphography. A PAP flap was elevated taking care not to damage lymph-collecting vessels. After flap elevation, the anatomical correlation between lymph-collecting vessels and the anterior edge of the gracilis muscle was measured. The postoperative complications were assessed. RESULTS: PAP flaps survived completely in all cases. In all cases, using intraoperative ICG lymphography, surgeons confirmed that the lymph-collecting vessels in the medial thigh region were left intact. There were no donor site complications such as lymphedema, lymphorrhea, or cellulitis. CONCLUSION: The elevation technique of an LpPAP flap is effective in reducing the risk of damage to lymph-collecting vessels, and thus reducing chances of postoperative lymphorrhea or iatrogenic lower limb lymphedema.

The Reconstruction after a Giant Phyllodes Tumor Resection Using a DIEP Flap.

A phyllodes tumor of the breast is a rare neoplasm, accounting for 0.3%-1% of all breast cancers. The size is 4-5 cm on average but sometimes the tumor grows more and involves the entire breast. As for treatment, complete surgical resection is the standard for localized breast phyllodes tumors. The reconstruction of a large defect is challenging. Herein, we present a case where a deep inferior epigastric artery perforator (DIEP) flap was used in breast reconstruction for a 48-year-old woman who was suffering from a giant phyllodes tumor. Immediate reconstruction was performed after tumor excision; the specimen weighed 4,230 g and the skin defect was 22 × 24 cm. The deep inferior epigastric artery and vein were anastomosed to the right internal mammary artery and vein, and the superficial inferior epigastric vein was anastomosed to the right lateral thoracic vein. The postoperative course was uneventful and the DIEP flap survived completely. In the setting of the reconstruction for a large defect, we must make maximum use of the limited human tissue available and ensure minimum damage, while also considering the functional and aesthetic outcome of the donor site. Various ideas and technologies have been reported that can assist in achieving this goal, but few reports have commented especially on the reconstruction of giant phyllodes tumor using autologous tissues. There were some other options for the way of the reconstruction such as a latissimus dorsi flap and a rectus abdominis flap. Compared with these approaches, using a DIEP flap has some disadvantages such as the need for the microsurgical skill and the risk of postoperative hernia. However, a DIEP flap provides the enough tissue to cover the large defect without any damage of the muscle. To our knowledge, this case was the largest phyllodes tumor reconstruction ever, in terms of the amount of the skin needed and resected tissue involved. Although more studies and longer follow-up will be required in the future, this case may show the usefulness of DIEP flaps for reconstruction of a giant phyllodes tumor.

Use of the Profunda Femoris Artery Perforator Flap for Reconstruction after Sarcoma Resection.

Soft tissue sarcomas are rare neoplasms that can occur on any part of the body. The operative position for the resection is determined depending on the site of the soft tissue sarcomas; intraoperative repositioning may be needed for reconstruction. We present the profunda femoris artery perforator (PAP) flap harvest technique (wherein the flap can be used in any position), and suggest that the PAP flap transfer can eliminate the need for intraoperative repositioning. METHODS: From December 2018 to January 2020, 7 patients with an average age of 68 years underwent reconstructions using a PAP flap after wide resection of STS. The mean defect size was 11.3 × 16.5 cm (range, 5.5-25 × 11-26 cm). The location of the defects was the medial thigh in 2 patients, the posterior thigh in 1, the popliteal fossa in 1, the groin in 1, and the buttock in 2. The PAP flap was elevated in the supine "frog-leg" position, the prone position, the jack-knife position, or the lateral "crisscross" position; the lateral decubitus position with the donor lower extremity on the bottom. RESULTS: Of the 7 cases, the operations were performed in the supine "frog-leg" position in 3 cases, the prone position in 2 cases, the jack-knife position in 1 case, and the lateral "crisscross" position in 1 case. There were no intraoperative position changes in all cases. The mean size of the PAP flap was 8.7 × 19.9 cm (range, 6-11 × 17-24 cm). One patient had donor site dehiscence, which was treated conservatively. The PAP flaps survived completely in all cases. The mean follow-up period was 10.5 months (range, 6-17 months). CONCLUSION: Since the PAP flap elevation is feasible in every position, the PAP flap can be considered a versatile reconstruction option after sarcoma resection.

Polyproline II Helix as a Recognition Motif of Plant Peptide Hormones and Flagellin Peptide flg22.

BACKGROUND: Plant peptide hormones play a crucial role in plant growth and development. A group of these peptide hormones are signaling peptides with 5 - 23 amino acids. Flagellin peptide (flg22) also elicits an immune response in plants. The functions are expressed through recognition of the peptide hormones and flg22. This recognition relies on membrane localized receptor kinases with extracellular leucine rich repeats (LRR-RKs). The structures of plant peptide hormones - AtPep1, IDA, IDL1, RGFs 1- 3, TDIF/CLE41 - and of flg22 complexed with LRR domains of corresponding LRR-RKs and co-receptors SERKs have been determined. However, their structures are well not analyzed and characterized in detail. The structures of PIP, CEP, CIF, and HypSys are still unknown. OBJECTIVE: Our motivation is to clarify structural features of these plant, small peptides and Flg22 in their bound states. METHODS: In this article, we performed secondary structure assignments and HELFIT analyses (calculating helix axis, pitch, radius, residues per turn, and handedness) based on the atomic coordinates from the crystal structures of AtPep1, IDA, IDL1, RGFs 1- 3, TDIF/CLE41 - and of flg22. We also performed sequence analysis of the families of PIP, CEP, CIF, and HypSys in order to predict their secondary structures. RESULTS: Following AtPep1 with 23 residues adopts two left handed polyproline helices (PPIIs) with six and four residues. IDA, IDL1, RGFs 1 - 2, and TDIF/CLE41 with 12 or 13 residues adopt a four residue PPII; RGF3 adopts two PPIIs with four residues. Flg22 with 22 residues also adopts a six residue PPII. The other peptide hormones - PIP, CEP, CIF, and HypSys - that are rich in proline or hydroxyproline presumably prefer PPII. CONCLUSION: The present analysis indicates that PPII helix in the plant small peptide hormones and in flg22 is crucial for recognition of the LRR domains in receptors.

Successful Balanced Gait after Reconstruction of the Weight-bearing Mid Plantar Region Using a Free Contralateral Medial Plantar Flap.

Although soft tissue sarcoma, especially in the sole of the foot, is a rare disease, weight-bearing region reconstruction considering postoperative gait is needed. For functionally satisfactory sole reconstruction, it is important to cover the weight-bearing region with a nonbulky but durable skin paddle that can withstand a significant amount of shear pressure. We herein present a case in which a free contralateral medial plantar flap was used for reconstruction of the weight-bearing mid plantar region for a 41-year-old man who suffered from mid-foot sarcoma. Gait analysis was performed 6 months after the operation with the lower limb loading gauge sheet, and the result indicated that postoperative balanced gait was obtained. The free medial plantar flap transfer after sole sarcoma resection has several advantages. First, the characteristic of this flap with solid anchoring to deep tissue to resist shearing makes it possible to lower the chances of postoperative ulceration. Second, the medial plantar flap has optimal thickness and good color and texture match for sole reconstruction. Third, a sensate flap can be achieved if the medial plantar nerve is included. Although further clinical investigations such as long-term follow-up will be required to confirm its efficacy, this method would be one option for treating sole sarcoma.

Leucine Rich Repeat Proteins: Sequences, Mutations, Structures and Diseases.

Mutations in the genes encoding Leucine Rich Repeat (LRR) containing proteins are associated with over sixty human diseases; these include high myopia, mitochondrial encephalomyopathy, and Crohn's disease. These mutations occur frequently within the LRR domains and within the regions that shield the hydrophobic core of the LRR domain. The amino acid sequences of fifty-five LRR proteins have been published. They include Nod-Like Receptors (NLRs) such as NLRP1, NLRP3, NLRP14, and Nod-2, Small Leucine Rich Repeat Proteoglycans (SLRPs) such as keratocan, lumican, fibromodulin, PRELP, biglycan, and nyctalopin, and F-box/LRR-repeat proteins such as FBXL2, FBXL4, and FBXL12. For example, 363 missense mutations have been identified. Replacement of arginine, proline, or cysteine by another amino acid, or the reverse, is frequently observed. The diverse effects of the mutations are discussed based on the known structures of LRR proteins. These mutations influence protein folding, aggregation, oligomerization, stability, protein-ligand interactions, disulfide bond formation, and glycosylation. Most of the mutations cause loss of function and a few, gain of function.

Super Secondary Structure Consisting of a Polyproline II Helix and a ß-Turn in Leucine Rich Repeats in Bacterial Type III Secretion System Effectors.

Leucine rich repeats (LRRs) are present in over 100,000 proteins from viruses to eukaryotes. The LRRs are 20-30 residues long and occur in tandem. LRRs form parallel stacks of short ß-strands and then assume a super helical arrangement called a solenoid structure. Individual LRRs are separated into highly conserved segment (HCS) with the consensus of LxxLxLxxNxL and variable segment (VS). Eight classes have been recognized. Bacterial LRRs are short and characterized by two prolines in the VS; the consensus is xxLPxLPxx with Nine residues (N-subtype) and xxLPxxLPxx with Ten residues (T-subtype). Bacterial LRRs are contained in type III secretion system effectors such as YopM, IpaH3/9.8, SspH1/2, and SlrP from bacteria. Some LRRs in decorin, fribromodulin, TLR8/9, and FLRT2/3 from vertebrate also contain the motifs. In order to understand structural features of bacterial LRRs, we performed both secondary structures assignments using four programs-DSSP-PPII, PROSS, SEGNO, and XTLSSTR-and HELFIT analyses (calculating helix axis, pitch, radius, residues per turn, and handedness), based on the atomic coordinates of their crystal structures. The N-subtype VS adopts a left handed polyproline II helix (PPII) with four, five or six residues and a type I ß-turn at the C-terminal side. Thus, the N-subtype is characterized by a super secondary structure consisting of a PPII and a ß-turn. In contrast, the T-subtype VS prefers two separate PPIIs with two or three and two residues. The HELFIT analysis indicates that the type I ß-turn is a right handed helix. The HELFIT analysis determines three unit vectors of the helix axes of PPII (P), ß-turn (B), and LRR domain (A). Three structural parameters using these three helix axes are suggested to characterize the super secondary structure and the LRR domain.

A Rare Chest Wall Deformity after Usage of a Tissue Expander for Breast Reconstruction.

A 2-stage breast reconstruction using a breast tissue expander and prosthesis is a simple method of breast reconstruction with little donor-site morbidity and short surgery time. In this report, we present a rare case of chest wall deformity, which appeared during breast skin expansion with tissue expander. We present a case of a 31-year-old woman who underwent a 2-stage breast reconstruction with a tissue expander and breast prosthesis. She had a former history of autologous microtia reconstruction using costal cartilages to create a framework of the ear at the age of 10. During expansion, the woman developed an abnormal hollowing of the chest wall. Even though it was difficult to select an ideal size for the breast prosthesis, an excellent breast shape was obtained by measuring the actual breast projection that we needed, using ultrasound sonography. The patient was satisfied with the final result. In this case, the patient suffered from a postoperative chest wall deformity due to cartilage harvesting. This unfavorable result highlights the need for careful preoperative evaluation of risk factors that may lead to chest wall deformity when patients will have tissue expansion as a part of breast reconstruction. When thoracic deformity occurs, surgeons should realize that choosing an adequate implant becomes rather difficult. Ultrasound sonography helps surgeons in measuring the actual breast projection preoperatively.