Strain-invariant stretchable radio-frequency electronics.

Wireless modules that provide telecommunications and power-harvesting capabilities enabled by radio-frequency (RF) electronics are vital components of skin-interfaced stretchable electronics1-7. However, recent studies on stretchable RF components have demonstrated that substantial changes in electrical properties, such as a shift in the antenna resonance frequency, occur even under relatively low elastic strains8-15. Such changes lead directly to greatly reduced wireless signal strength or power-transfer efficiency in stretchable systems, particularly in physically dynamic environments such as the surface of the skin. Here we present strain-invariant stretchable RF electronics capable of completely maintaining the original RF properties under various elastic strains using a 'dielectro-elastic' material as the substrate. Dielectro-elastic materials have physically tunable dielectric properties that effectively avert frequency shifts arising in interfacing RF electronics. Compared with conventional stretchable substrate materials, our material has superior electrical, mechanical and thermal properties that are suitable for high-performance stretchable RF electronics. In this paper, we describe the materials, fabrication and design strategies that serve as the foundation for enabling the strain-invariant behaviour of key RF components based on experimental and computational studies. Finally, we present a set of skin-interfaced wireless healthcare monitors based on strain-invariant stretchable RF electronics with a wireless operational distance of up to 30 m under strain.

Preoperative rib cartilage imaging in 3-dimensional chest computed tomography for auricular reconstruction for microtia.

BACKGROUND: There are several methods that may be used to confirm the status of rib cartilage, such as physical examinations or chest radiography, for subjects with microtia. However, these methods are limited because of clinicians' inability to gain accurate information about the rib cartilage. We performed 3-dimensional chest computed tomography to preoperatively evaluate the accuracy of rib cartilage imaging. METHODS: A total of 37 patients preparing for auricular reconstruction using a rib cartilage graft underwent preoperative 3-dimensional rib cage computed tomography (3-D rib CT). The 3-D rib CT was performed in cases of secondary revisional reconstruction, those with a history of surgery using rib cartilage, in those with a history of trauma related to the rib cage, older patients with question of calcification of rib cartilage, or those with a suspected rib cartilage anomaly on physical examination. Preoperatively, the appropriateness of using the rib cartilage were evaluated. RESULTS: With the aid of the 3-D rib CT, successful autogenous auricular reconstruction was achieved in 36 patients. Framework fabrication in combination with a porous polyethylene implant and autogenous rib cartilage was performed in the remaining patient as planned preoperatively. By analyzing the 3-D rib CT image preoperatively, auricular reconstruction using a recycled rib cartilage graft with newly harvested rib cartilage was performed successfully in 13 of 14 secondary revisional cases. Based on preoperative CT images, modified surgical planning in terms of cartilage harvest and framework fabrication was needed in 8 of 11 patients who had a history of operation using rib cartilage and in 3 of 5 subjects with suspected rib cage anomalies on physical examination. Successful reconstruction was achieved using the modified surgical plan. CONCLUSIONS: A preoperative 3-D rib CT helps in surgical planning for autogenous auricular reconstruction for microtia, especially in patients with suspicious rib cartilage status.

Association of protein expression in isolated milk epithelial cells and cis-9, trans-11 conjugated linoleic acid proportions in milk from dairy cows.

BACKGROUND: The effects of the individual variation among dairy cows on the synthesis of cis-9, trans-11 conjugated linoleic acid (CLA) are still not well characterised. Therefore, the protein expression profiles of isolated milk epithelial cells (MECs) were detected by two-dimensional electrophoresis and their correlation with the various proportion of cis-9, trans-11 CLA were evaluated. RESULTS: Although animals were offered the same diet, the proportion of cis-9, trans-11 CLA in group High (1.02 ± 0.10%) was twice as high as that in group Low (0.59 ± 0.14%) (P < 0.05). MECs with the characteristics of native epithelial cells were successfully isolated from the milk and these cells had no obvious RNA degradation or were hardly contaminated with leucocytes or blood red cells. Moreover, the protein expression pattern of cathelicidin 5 in isolated MECs was positive, whereas annexin I (confirmed by real-time polymerase chain reaction), ZW10 interactor and κ-casein were negatively related to the proportion of cis-9, trans-11 CLA in the milk fat. CONCLUSION: The varied individual content of cis-9, trans-11 CLA in cows may be associated with annexin I. These findings may provide some theoretical basis for studies concerning the effects of the individual variation among dairy cows of the synthesis of cis-9, trans-11 CLA. © 2013 Society of Chemical Industry.

Do we have to dissect infraorbital nerve from periorbita in orbital floor fracture?

The aim if this study was to see whether we have to dissect the infraorbital nerve from periorbita in orbital floor fractures.Orbital floors were reconstructed in 174 patients. Among them, 31 patients were treated with horseshoe-shaped synthetic sheets. Preoperative and postoperative findings including hypesthesia, diplopia, Hertel exophthalmometry, and occurrence of complications were checked.After the subciliary incision through skin and orbicularis oculi muscle, the skin-muscle flap was elevated just superficial to the orbital septum to the arcus marginalis. The periosteum was incised and elevated to expose the fracture site. The orbital branch of the infraorbital artery was identified. The periorbita was not separated from the infraorbital nerve, and the orbital branch of the infraorbital artery was preserved. The sheet was trimmed in horseshoe shape as the cleft fits to the infraorbital groove.On physical examination before surgery, diplopia was the most common (58.1%) associated complication, followed by hypesthesia (35.5%), limited ocular movement (9.7%), enophthalmos (3.2%), and hematoma (3.2%).Even if the fracture site is the posterior half, the periorbita does not have to be separated from the infraorbital nerve to avoid injury of the orbital branch of the infraorbital artery. Instead, the fracture site might be covered by a horseshoe-shaped sheet.

Experience of violence from the clients and coping methods among ICU nurses working a hospital in South Korea.

PURPOSE: It is difficult to develop a good defense system that can prevent nurses from experiencing physical and verbal violence from patients and families in intensive care units, which are closed spaces. This study aimed to identify intensive care nurses' experience of violence from patients and families and investigate their coping methods, if there are any, in a tertiary hospital in South Korea. METHODS: This study used a mixed methods design utilizing both a survey for collecting quantitative data and individual interviews for a qualitative one. A total of 200 intensive care nurses participated in the survey, with thirty of them taking part in individual interviews. Survey data were analyzed using SPSS 21.0 program, and qualitative data with qualitative content analysis method. RESULTS: In the survey, 99.5% of the nurses reported that they had experienced violence from the patients and 67.5% from their visitors (families or relatives). Verbal violence were reported more than physical ones. They showed moderate or severe responses to violence, scoring an average of 2.98±0.63 out of 5. The qualitative data were analyzed to draw 4 themes, 8 categories, and 17 subcategories. The four themes were perception of violence, coping with violence experience, coping resources, and caring mind after violence experience. CONCLUSION: While intensive care nurses experience unpredicted violence from patients and their visitors, they fail to cope well with the experience. The safe working environment of intensive care units is expected to contribute to quality care and an improvement of expertise in nursing.

Management of chest deformity caused by microtia reconstruction: Comparison of autogenous diced cartilage versus cadaver cartilage graft partial filling techniques.

BACKGROUND: Efforts to prevent chest wall deformity after costal cartilage graft are ongoing. In this study, we introduce a new method to prevent donor site deformation using irradiated cadaver cartilage (ICC) and compare this method to the autogenous diced cartilage (ADC) technique. METHODS: Forty-two pediatric patients comprised the ADC group (n = 24) and the ICC group (n = 18). After harvesting costal cartilage, the empty perichondrial space was filled with autologous diced cartilage in the ADC group and cadaver cartilage in the ICC group. Digital photographs and rib cartilage three-dimensional computed tomography (CT) data were analyzed to compare the preventive effect of donor site deformity. We compared the pre- and postoperative costal cartilage volumes using 3D-CT and graded the volumes (grade I: 0%-25%, grade II: 25%-50%, grade III: 50%-75%, and grade IV: 75%-100%). RESULTS: The average follow-up period was 20 and 24 months in the ADC and ICC groups, respectively. Grade IV maintenance of previous costal cartilage volume was evident postoperatively in 22% of patients in the ADC group and 82% of patients in the ICC group. Intercostal space narrowing and chest wall depression were less in the ICC group. There were no complications or severe resorption of cadaver cartilage. CONCLUSIONS: ICC support transected costal ring and prevented stability loss by acting as a spacer. The ICC technique is more effective in preventing intercostal space narrowing and chest wall depression than the ADC technique. CLINICAL TRIAL REGISTRY: Samsung Medical Center Institution Review Board, Unique protocol ID: 2009-10-006-008. This study is also registered on PRS (ClinicalTrials.gov Record 2009-10-006).

Overexpression of stromal cell-derived factor-1 enhances endothelium-supported transmigration, maintenance, and proliferation of hematopoietic progenitor cells.

To clarify the direct effects of aberrant overexpression of stromal cell-derived factor-1 (SDF-1) by the human endothelium on circulating progenitor cells, we overexpressed the SDF-1 gene in human umbilical vein endothelial cells using an adenoviral vector (HUVEC/AdeSDF-1) and examined the endothelium-supported trafficking and growth of hematopoietic progenitor cells (HPCs) in mobilized peripheral blood (mPB). In culture, the HUVEC/AdeSDF-1 monolayers induced the migration of mPB CD34(+) cells underneath the endothelium within a few hours, whereas HUVEC monolayers that expressed the LacZ gene (HUVEC/AdeLacZ) did not have this effect. In the Transwell system, the HUVEC/AdeSDF-1 cells supported a higher level of spontaneous transmigration of mPB CD34(+) cells than did the HUVEC/AdeLacZ cells. The co-culturing of mPB CD34(+) cells with HUVEC/ AdeSDF-1 cells led to a greater expansion of CD45(+) cells and colony-forming cells and reduced cellular apoptosis. Furthermore, the co-culturing of mPB CD34(+) cells with HUVEC/AdeSDF-1 cells led to the formation of numerous cobblestone-like areas, whereas co-cultures of mPB CD34(+) cells and HUVEC/AdeLacZ supported only a few cobblestone-like areas. These results indicate that SDF- 1 produced by endothelial cells plays an important role not only in the transmigration but also in the growth of HPCs that are in contact with endothelial cells. Our findings suggest that the enhanced expression and production of SDF-1 in the endothelium are essential steps for stem cell or progenitor cell recruitment to specific tissues and for the maintenance of these cells in situ.

Interferon gamma has dual potential in inhibiting or promoting survival and growth of hematopoietic progenitors: interactions with stromal cell-derived factor 1.

We explored the possibility that interferon gamma (IFN-gamma) has bidirectional functions in the survival and growth of hematopoietic progenitors, especially with regard to interactions with stromal cell-derived factor 1 (SDF-1). IFN-gamma partially rescued normal bone marrow CD34+ cells and colony-forming cells from apoptosis induced by serum and hematopoietic growth factor (HGF) deprivation, and SDF-1 further enhanced cell survival. Short-term IFN-gamma treatment of CD34+ cells in the absence of serum and HGFs enhanced the clonal growth of the cells in synergy with SDF-1. In contrast, IFN-gamma inhibited the clonal growth of hematopoietic progenitor cells in a standard methylcellulose clonogenic assay and inhibited the HGF-mediated survival of normal CD34+ cells. The addition of SDF-1 did not alter these outcomes. IFN-gamma did not enhance SDF-1-induced activation of PI3K/Akt or up-regulate the expression of CXCR4 or its function in bone marrow CD34+ cells. IFN-gamma up-regulated Socs1 messenger RNA expression in normal CD34+ cells, which was further enhanced with the addition of HGFs. These results indicate that IFN-gamma, partly in concert with SDF-1, exerts dual effects on the survival and growth of hematopoietic progenitor cells; the effects of IFN-gamma on hematopoietic progenitor cells can differ, depending on the particular in vitro experimental conditions, especially the presence of HGFs.

[The effects of the inhalation method using essential oils on blood pressure and stress responses of clients with essential hypertension].

PURPOSE: The purpose of this study was to identify the effects of aromatherapy on blood pressure and stress responses of clients with essential hypertension. METHOD: There were fifty-two subjects divided into an essential oil group, placebo group, and control group by random assignment. The application of aromatherapy was the inhalation method of blending oils with lavender, ylangylang, and bergamot once daily for 4 weeks. To evaluate the effects of aromatherapy, blood pressure and pulse were measured two times a week and serum cortisol levels, catecholamine levels, subjective stress, and state anxiety were measured before and after treatment in the three groups. Data was analyzed by repeated measures of ANOVA, one-way ANOVA, and chi(2)-test using the SPSS 10.0 program. RESULTS: The blood pressure, pulse, subjective stress, state anxiety, and serum cortisol levels among the three groups were significantly statistically different. The differences of catecholamine among the three groups were not significant statistically. CONCLUSION: The results suggest that the inhalation method using essential oils can be considered an effective nursing intervention that reduces psychological stress responses and serum cortisol levels, as well as the blood pressure of clients with essential hypertension.

Physiological concentrations of trans-11 18:1 vaccenic acid suppress pro-inflammatory markers under acute inflammation in isolated ICR mice splenocytes.

Direct influences of dietary trans-11 18:1 vaccenic acid (TVA) at physiological concentrations of 50-200 µM were evaluated for cell growth, cytotoxic activity, and cytokine production in leukocytes isolated from the mouse spleen. TVA supplementation for 24 h induced growth of splenocytes at concentrations of 50-200 µM, except for 100 µM. The cytokines TNFα, IFNγ, and IL-10 of splenocytes were stimulated by 100 µM TVA. Induced production of TNFα in splenocytes challenged with lipopolisaccharides was suppressed by 100 µM TVA. Physiological levels of TVA had direct effects on growth and cytokine production in splenocytes. Further in vivo studies are needed to improve understanding of the precise influence of trans fatty acids on production of pro-inflammatory markers under acute inflammation conditions.

Effects of dietary trans-9 octadecenoic acid, trans-11 vaccenic acid and cis-9, trans-11 conjugated linoleic acid in mice.

The aim of the present study was to investigate the effects of dietary trans fatty acids in mice. Following the administration of a 0.5/100 g diet of trans-9 octadecenoic acid (EA), trans-11 vaccenic acid (TVA) or cis-9, trans-11 conjugated linoleic acid (CLA) for 4 weeks, the body weights and the weights of the liver, testis and mediastinal adipose tissue (MAT) of the animals gradually decreased (P<0.05). The EA group exhibited the lowest levels of magnesium and triglycerides (P<0.05). CLA increased villus length (P<0.05), while EA and TVA decreased villus length (P<0.05). The TVA group exhibited the lowest levels of low-density lipoprotein and tumor necrosis factor-α (P<0.05). Taken together, EA, TVA and CLA affected the physiological conditions of mice differently. The potential effects of three well-known fatty acids, including trans-9 octadecenoic acid (EA), trans-11 vaccenic acid (TVA) and cis-9, trans-11 conjugated linoleic acid (CLA), in animals or humans remain to be elucidated. Therefore, in the present study, 32 animals were randomly divided into four groups and administered a 0.5/100 g diet of EA, TVA or CLA for 4 weeks. The results demonstrated that the body weights and the weights of the liver, testis and mediastinal adipose tissue (MAT) of the animals gradually decreased (P<0.05). Blood was collected individually via the external jugular veins and the EA group exhibited the lowest levels of magnesium and triglycerides (P<0.05). CLA increased villus length (P<0.05), while EA and TVA decreased villus length (P<0.05). The TVA group exhibited the lowest levels of low-density lipoprotein and tumor necrosis factor-α (P<0.05). Taken together, EA, TVA and CLA affected the physiological conditions of mice differently and these may further our understanding of the various effects of these fatty acids on animals and humans.

CXC chemokine receptor 4 expression and function in human anaplastic thyroid cancer cells.

Anaplastic thyroid carcinomas (ATCs) are highly aggressive, extremely lethal human cancers with poor therapeutic response. Chemokines are a superfamily of small cytokine-like proteins that induce, through their interaction with G protein-coupled receptors, cytoskeletal rearrangement, firm adhesion to endothelial cells, and directional migration. In this study, we characterized the expression of CXC chemokine receptor 4 (CXCR4) and analyzed its functions in ARO cells, a human ATC cell. The normal primary cultured thyroid cells and ATC cell lines expressed CXCR4 and stromal cell-derived factor (SDF)-1 alpha transcripts, detected by RT-PCR. Fluorescence activated cell sorting analysis of CXCR4 expression in normal and ATC cells showed that ARO cells expressed significant levels of CXCR4. FRO, NPA, and normal thyroid cells did not express membrane CXCR4, as determined by fluorescence activated cell sorting analysis. To identify the functional role of CXCR4 in ARO cells, we treated ARO cells with SDF-1 alpha and analyzed the signaling pathways, cellular migration, and proliferation. SDF-1alpha enhanced the migration but did not affect the proliferation of ARO cells or activate the Janus kinase/signal transducer and activator of transcription signaling pathways. However, SDF-1 alpha/CXCR4 activation resulted in phosphorylation of the p70S6 kinase and its target protein, ribosomal S6 protein, and also activation of the ERK1/ERK2 signaling pathways. Furthermore, SDF-1 alpha/CXCR4- mediated activation of the p70S6 kinase and phosphorylation of the S6 protein were inhibited by treatment with an mTOR/FRAP inhibitor. The specificity of the CXCR4-mediated migration of ARO cells was demonstrated by the dose-dependent inhibition of migration by neutralizing anti-CXCR4. The ATC cells, FRO and NPA, which do not express CXCR4, did not demonstrate significant SDF-1 alpha-mediated migration in vitro. In addition, the CXCR4-mediated migration of ARO cells was inhibited by treatment with pertussis toxin (a Gi-protein inhibitor) and PD 98059 (a mitogen-activated ERK kinase inhibitor) but not by LY294002 and wortmanin, phosphatidylinositol 3-kinase inhibitors. These findings suggest that a subset of ATC cells expresses functional CXCR4, which may be important in tumor cell migration and local tumor invasion.

Perineal perforator-based island flaps: the next frontier in perineal reconstruction.

BACKGROUND: Perineal reconstruction is a challenging prospect. Conventional flap reconstruction often involves the sacrifice of a source artery and muscle, resulting in significant donor morbidity. Perforator flaps sought to overcome this but required tedious dissection. In this article, the authors introduce a new concept in perineal reconstruction using perforator-based island flaps. METHODS: The perineal perforator-based island flap is raised based on perforators that most commonly arise from the perineal artery. The flap is designed in the inguinal and gluteal folds in order to achieve aesthetic, tension-free primary closure of the donor site. Eleven patients underwent perineal reconstruction using this approach. Patients ranged in age from 8 to 75 years, with a female-to-male ratio of 10:1. RESULTS: All 11 operations were performed by a single surgeon (S.Y.M.H.). There were no cases of flap loss or donor-site complications, as defined by wound infection, dehiscence, or keloid formation. All 11 patients reported excellent satisfaction with regard to donor-site aesthetics. CONCLUSIONS: Perineal perforator-based island flaps represent one of the most successful outcomes of the perforator concept. There is no sacrifice of donor vessels or muscle and minimal donor morbidity. The flap is also easily harvested and allows for challenging free-form flap design because it is based on reliable perforators. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Identification of biomarkers for endometriosis in plasma from patients with endometriosis using a proteomics approach.

The present study aimed to examine potential biomarkers for the diagnosis of endometriosis. A plasma-based proteomic approach, including 2-dimentional electrophoresis and mass spectrometry, was used. Samples were obtained from patients with (n=15) and without (n=15) endometriosis, or from mice with surgically induced endometriosis. Seven spots corresponding to six differentially expressed proteins were identified in the human plasma samples. However, only haptoglobin (Hp) was identified to be significantly decreased in the plasma levels of patients with endometriosis (P<0.05) and in mice with surgically induced endometriosis (P<0.05). The results demonstrated that Hp was downregulated in females with endometriosis, and it therefore, may be a useful diagnostic tool as a biomarker of endometriosis.

Identification of proteins involved in the pancreatic exocrine by exogenous ghrelin administration in Sprague-Dawley rats.

The aims of study were to investigate the effects of intraperitoneal (i.p.) infusion of ghrelin on pancreatic α-amylase outputs and the responses of pancreatic proteins to ghrelin that may relate to the pancreatic exocrine. Six male Sprague-Dawley rats (300 g) were randomly divided into two groups, a control group (C, n = 3) and a treatment group (T, 10.0µg/kg BW, n = 3). Blood samples were collected from rat caudal vein once time after one hour injection. The concentrations of plasma ghrelin, cholecystokinin (CCK) and alfa-amylase activity were evaluated by enzyme immunoassay (EIA) kit. Two-dimensional gel electrophoresis (2-DE) analysis was conducted to separate the proteins in pancreas tissue. Results showed that the i.p. infusion of ghrelin at doses of 10.0 µg/kg body weight (BW) increased the plasma ghrelin concentrations (p = 0.07) and elevated the plasma CCK level significantly (p < 0.05). Although there was no statistically significant, the α-amylase activity tended to increase. The proteomics analysis indicated that some pancreatic proteins with various functions were up- or down- regulated compared with control group. In conclusion, ghrelin may have role in the pancreatic exocrine, but the signaling pathway was still not clear. Therefore, much more functional studies focus on these found proteins are needed in the near future.

Vitamin D binding protein plays an important role in the progression of endometriosis.

Endometriosis, characterized by the growth of the endometrial gland and stroma outside the uterine cavity, is a gynecological disorder affecting 6­10% of women of reproductive age. However, the pathogenesis of endometriosis and the molecular mechanisms involved in the progression of this disease remain to be clarified. Therefore, in this study two-dimensional gel electrophoresis (2­DE) combined with mass spectrometry (MS) were applied to explore endometrial proteins with a role in the progression of endometriosis. Expression of global proteins in ectopic endometrial tissue (n=13; endometriosis group) was compared with that of the normal endometrial tissue (n=6; control group). Sixteen differently expressed proteins, including Vitamin D binding protein (DBP), with various functions were primarily identified in the ectopic endometrial tissue. DBP was confirmed to be significantly increased in the ectopic endometrial tissue compared with that in the normal endometrial tissue (P<0.05). Results of the present study therefore showed that DBP may play an important role in the progression of endometriosis.

Identification of biomarkers for endometriosis in eutopic endometrial cells from patients with endometriosis using a proteomics approach.

Endometriosis is a gynecological disease defined as the presence of endometrial tissue outside the uterine cavity, which is caused by various factors. Proteomic analysis of two sets of eutopic endometrial cells collected from the menstrual blood of females with (n=6; n=3) or without (n=6; n=3) endometriosis was performed to identify novel potential biomarkers for endometriosis. The data revealed that samples from endometriosis patients had stem cell characteristics, as they had higher mRNA expression levels of octamer-binding transcription factor 4 (Oct-4), C-X-C chemokine receptor type 4 (CXCR4), SRY-box containing gene 2 (SOX2) and mesenchymal-epithelial transition factor (MET) compared with that of the normal controls. Three proteins, collapsin response mediator protein 2 (CRMP2), ubiquitin carboxyl-terminal hydrolase isozyme L1 (UCH-L1) and myosin regulatory light polypeptide 9 (MYL9), were simultaneously identified from the two sets of samples from females with or without endometriosis by two-dimensional electrophoresis (2-DE). A difference in CRMP2 expression was confirmed with western blotting. Taken together, the results suggest that CRMP2 plays a role in the pathogenesis of endometriosis.

Reliable harvesting of a large thoracodorsal artery perforator flap with emphasis on perforator number and spacing.

BACKGROUND: Thoracodorsal artery perforator flaps are useful for covering extensive defects because of their generous donor-site dimensions. However, large flaps increase the risk of partial flap necrosis, and a reliable means of sizing thoracodorsal artery perforator flaps has not been devised. The authors reviewed a series of large thoracodorsal artery perforator flap transfers performed under various reconstructive conditions to evaluate surgical outcomes and placed emphasis on flap design and harvesting technique. METHODS: A consecutive series of large thoracodorsal artery perforator flaps (>20 cm long) performed between November of 2005 and March of 2010 were included in this study. Patient charts, operative records, and photographs were reviewed. RESULTS: A total of 20 flaps with an average size of 25 × 11 cm in 20 patients were identified; the largest flap measured 32 × 13 cm. The average number of perforators included was 2.6 per flap (range, one to four). Four different harvesting techniques were used, depending on perforator numbers and locations. All large flaps survived without sizable partial flap necrosis. Complications included wound dehiscence in one donor and two recipient sites; all healed after wound repair. Tip necrosis of a small area developed but healed with conservative wound care. CONCLUSIONS: This study reports the clinical safety of large thoracodorsal artery perforator flaps with customized thickness control, which can be reliably harvested beyond 20 cm in length by carefully considering perforator numbers and locations. To optimize tissue perfusion in these large flaps, effort is required to capture multiple perforators from various sources and to obtain an ideal arrangement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.