Minimally invasive harvest of the gracilis muscle.

Acceptance of minimally invasive plastic surgery has been predicated on decreasing morbidity while maintaining the quality and costs of outcomes. The major patient complaint about the gracilis muscle donor site has almost solely been related to the length of the thigh scar, and thus would appear to be an ideal indication for outcome improvement using minimally invasive techniques. A method of endoscopically assisted gracilis muscle harvest, therefore, was developed, starting with a transverse incision just proximal to the knee to identify the gracilis tendon. This endoscopic port allows retrograde subfascial dissection of the muscle and precise identification of its anatomic course, whereupon a small proximal medial thigh incision can be made secondarily for direct access to the vascular pedicle. This variation has now been used successfully in 10 patients. The mean proximal thigh scar length was 8.30 +/- 0.74 (SD) cm, and total surgical scars measured 11.84 +/- 0.95 cm, compared with 27.73 +/- 9.55 cm for 16 patients for whom an open method had been used. This diminished scar length was a statistically significant improvement (p < 0.05), verifying the value of the surgical endoscope as an adjunct for harvest of the gracilis muscle as a free flap.     

Donor-site morbidity comparison between endoscopically assisted and traditional harvest of free latissimus dorsi muscle flap

Endoscopically assisted harvest of free latissimus dorsi muscle flaps is being used more frequently in reconstructive microsurgery because it requires a smaller incision and leaves a more acceptable scar in the donor site. Donor-site morbidity was compared between groups of 22 latissimus dorsi muscles harvested using the endoscopically assisted technique and 26 using the traditional technique. The results revealed no statistically significant differences in the amount of intraoperative bleeding, the incidence of postoperative hematoma and seroma, and the incidence of donor-site wound infection as assessed by the surgeon. However, a patient questionnaire revealed that even though it did not reach a statistically significant difference, endoscopically assisted harvest of the latissimus dorsi muscle had less pain and allowed earlier and better movement of the upper extremity of the donor site. The patients' attitudes and feelings about the scar and overall satisfaction were also higher in the endoscopic group, which demonstrated a statistically significant difference.     

Free-style free flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

Segmental gracilis free flap based on secondary pedicles: anatomical study and clinical series

The gracilis muscle has been used extensively in reconstructive surgery, based on the proximal dominant pedicle. In the literature, little attention has been paid to the secondary distal pedicles. The distribution of the secondary pedicles of the gracilis muscle was investigated in 20 cadaver thighs. The mean number of secondary pedicles was 2.2 (range, two to three). When two pedicles were present-the most common situation-they were located at a mean distance of 12.4 and 17.5 cm from the knee joint line. The most proximal secondary pedicle was injected with barium sulfate in five specimens, and constant and abundant connections with the main pedicle were noted. A series of seven clinical cases of segmental gracilis free muscle flaps based on a secondary pedicle is reported. The flaps were successfully transferred to reconstruct traumatic defects of limited size, with one case of partial necrosis caused by a technical error. The morbidity of this flap is minimal, the scar is well hidden, the muscle need not be sacrificed, elevation is fast and straightforward under tourniquet control, and the pedicle is sizable. This flap should be considered a viable option when a small, straightforward free flap is needed.     

Sensory restoration of the skin graft on a free muscle flap: experimental rabbit study.

Transplantation of a muscle flap with free skin graft for wound coverage is a common procedure in reconstructive microsurgery. However, the grafted skin has little or no sensation. Restoration of the sensibility of the grafted skin on the transferred muscle is critically important, especially in palmar hand, plantar foot, heel, and oral cavity reconstruction. The purpose of this study was to investigate the possibility of sensory restoration of the grafted skin on a trimmed muscle surface that has been sensory neurotized after sensory nerve-to-motor nerve transfer, using the rabbit gracilis muscle as an animal model. The ipsilateral saphenous nerve (sensory) was transferred to the motor nerve of the gracilis muscle for sensory neurotization. A 4 x 4-cm2 area of skin island over the midportion of the gracilis muscle was harvested as a full-thickness skin graft. The upper half of the gracilis muscle was then excised, becoming a rough surface. The harvested skin was reapplied on the trimmed rough surface of the muscle. After 6 months, retrograde and antegrade horseradish peroxidase labeling studies were performed through skin and muscle injection. The group with a free skin graft was compared with the group with an intact surface of the gracilis muscle. This study clearly shows that sensory nerves can regenerate and penetrate into the trimmed muscle surface and grow into the overlying grafted skin. However, if the muscle surface is intact as with the compared group, sensory reinnervation of the grafted skin is not possible.     

Endoscopically assisted "components separation" for closure of abdominal wall defects

The repair of ventral hernia defects of the abdominal wall challenges both general and plastic surgeons. Ventral herniation is a postoperative complication in 10 percent of abdominal surgeries; the repair of such defects has a recurrence rate as high as 50 percent. The "components separation" technique has successfully decreased the recurrence rates of ventral abdominal hernias. However, this technique has been associated with midline dehiscence and a prolonged postoperative stay at the authors' institutions. The purpose of this study was to determine whether endoscopically assisted components separation could minimize operative damage to the vasculature of the abdominal wall and decrease postoperative wound dehiscence. The study group consisted of seven patients who underwent endoscopically assisted components separation; the control group consisted of 30 patients who underwent open components separation. The two groups were similar regarding demographic data and defect size. The endoscopic group had a higher initial success rate than the open group (100 versus 77 percent). Recurrence rates were not significantly different between the two groups. However, the endoscopically assisted components separation patients had fewer postoperative and long-term complications. In the authors' experience, endoscopically assisted components separation has proved to be a safe and effective method for the repair of complicated and recurrent midline ventral hernias.     

Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction

The anatomic topography of the perforators within the rectus muscle and the anterior fascia largely determines the time needed to harvest the perforator free flap and the difficulty of the procedure. In 100 consecutive cases, the topographic patterns of the perforators were investigated. In 65 percent, a short intramuscular course was seen. In 16 percent, a perforator at the tendinous intersection was encountered. In 9 percent, the largest perforator was found to have a long intramuscular course. In 5 percent, a subfascial course was found, and in another 5 percent, a paramedian course was found. In 74 percent of flaps, just one perforator was used, whereas two perforators were dissected in 20 percent. Only in 6 percent of flaps were three perforators used. A long intramuscular course (>4 cm) lengthens the dissection substantially, especially when the intramuscular course is in a step-wise pattern. The subfascial course requires precarious attention at the early stage of the perforator dissection when splitting the fascia. The perforators at the tendinous intersections are the most accessible and require a short but intense dissection in the fibrotic tissue of intersection. A paramedian perforator, medial to the rectus muscle, is a septocutaneous rather than a musculocutaneous perforator. The straightforward dissection almost extends up to the midline. Therefore, dissection always is performed at one side and, if no good perforators are present, continued at the intact contralateral side. The size of these perforators and their location in the flap determine the choice. One perforator with significant flow can perfuse the whole flap. If in doubt, two perforators can be harvested, especially if they show a linear anatomy so that muscle fibers can be split. The only interference with the muscle exists in splitting the muscle fibers. A perforator that lies in the middle of the flap is preferable. For a large flap, a perforator of the medial row provides better perfusion to zone 4 than one of the lateral row because of the extra choke vessel for the lateral row perforators. The clinical appearance of the perforators is the key element in the dissection of the perforator flap. Perforator topography determines the overall length and difficulty of the procedure.     

The thin latissimus dorsi perforator-based free flap for resurfacing

The authors present their experience with "thin" latissimus dorsi perforator-based free flaps for resurfacing defects. Perforator-based free flaps have been used for various kinds of reconstruction by presenting important donor structures. The thin latissimus dorsi perforatorbased free flap included only the skin and superficial adipose layer to reduce its bulkiness by dissection through the superficial fascial plane. This flap was used in 12 clinical cases, without flap necrosis or other serious postoperative complications. All of the patients were examined by preoperative power Doppler ultrasound in the spectral Doppler mode to search for the most reliable perforator. This noninvasive ultrasound technique determines the exact location and course of and ensures the reliable flow of the perforators; therefore, it greatly assists microsurgeons in saving operation time and in selecting the most suitable design for perforator flap reconstruction. We used perforators that were identified several centimeters from the lateral border of the latissimus dorsi muscle. The thin flap dimensions could be safely designed for flaps measuring up to 20 cm in length and 8 cm in width for primary closure of the donor site. Generally, a long pedicle is not required for resurfacing reconstructions, where small recipient arteries in the bed are acceptable for anastomosis with pedicles. However, pedicle dissection to the proximal vessels through the latissimus dorsi muscle was required when it was necessary to match the recipient vein for anastomosis. The authors conclude that this thin latissimus dorsi perforator-based free flap has great potential for resurfacing because of its constant thickness, easy elevation with the help of power Doppler ultrasound information, and proper flap size for moderate defects caused by scar contracture release, superficial tumor ablation, and so on.     

Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction

An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.     

Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach.

Different techniques can be used to repair contracture of burn scars on the elbow, including local or distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders. Among these, a pedicled adipofascial flap based on the most proximal two to four perforators of the ulnar artery (located 1 to 5 cm from the origin of the artery) can be anastomosed to form a sort of axially patterned blood supply within the fascia and subcutaneous fat. Therefore, no major vessel in the forearm need ever be severed. In addition, use of this type of flap preserves muscle function. The pedicled adipofascial flap described in this article allows for early rehabilitation because the flap is thin and pliable. Additional advantages are the easy and quick dissection and completion of the procedure in one stage. A detailed anatomic dissection of the flap was performed on 16 upper extremities from fresh cadavers; an injection study was also performed to determine the location and dimensions of the pedicle flap and its area of reach around the elbow. In the past 3 years, 14 flaps were used in 13 patients to repair elbow defects after release of burn scar contractures. Flap dimensions ranged from 4 x 7 cm to 6 x 14 cm (mean flap size, 74 cm). The results were very satisfactory.     

Extended approach to the vascular pedicle of the gracilis muscle flap: anatomical and clinical study

Dissection of the proximal gracilis vascular pedicle proceeds in a dark tunnel-like space deep to the adductor longus. With the application of a previously described technique for an extended approach to the lateral arm free flap, the authors describe a novel technique that improves observation and thus facilitates dissection of the proximal gracilis vascular pedicle. A retrospective review of data for 18 consecutive patients who underwent gracilis muscle free flap harvesting with this modified technique between March of 1999 and October of 2001 was conducted, to assess flap viability and patient outcomes. A cadaveric dissection was also performed, to study the anatomical features of the region in depth and to test the proposed flap modification. After the standard incision has been made, the dominant pedicle is exposed on the medial aspect of the gracilis muscle, running in a fascial cleft between the adductor longus and the adductor magnus. Intramuscular branches to the adductor longus are divided. A space is bluntly created anterior and lateral to the adductor longus by separating the fibrous connections to the surrounding adductor and sartorius muscles on both sides of the vascular pedicle. The gracilis muscle is then divided and passed deep to the adductor longus, into this space. With this new position, the final dissection of the pedicle can easily be performed. The confluence of the venae comitantes is frequently encountered, providing a larger-caliber single vein for microvascular anastomosis. The ages of the patients ranged from 9 to 70 years. The majority (14 of 18 patients) had traumatic wounds. The free flap survival rate was 100 percent. One minor complication of a seroma at the donor site was observed. One major complication of venous thrombosis was detected on postoperative day 3, with complete flap salvage. No other complications were noted. This technique is safe and permits direct approach to and excellent observation of the proximal aspect of the gracilis pedicle, without the need for headlights or deep retractors. An additional benefit is the frequent finding of a single larger vein from the merging of the venae comitantes close to the deep femoral vessels.     

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

乳腔镜腋窝淋巴结清扫术与常规淋巴结清扫术治疗乳腺癌的临床效果

目的:通过对比两种不同的临床治疗乳腺癌的效果,提出临床治疗乳腺癌更可靠的方案,为临床治疗和相关研究提供参考。方法:选取我院2010年12月至2014年12月期间我院临床收治的乳腺癌患者56例,根据患者临床治疗手术方法情况,分成了研究组和对照组,研究组患者给予乳腔镜腋窝淋巴结清扫术,对照组患者均给予常规的腋窝淋巴结清扫术,观察和比较两者患者实施不同手术治疗后的手术时间、住院费用、术中出血量和并发症发生情况。结果:研究组患者的手术时间长于对照组,研究组患者的住院费用高于对照组,而患者术中出血量研究组患者也低于对照组患者,组问比较差异均具有统计学意义(P0.05);两组患者术后并发症的发生率比较,差异无统计学意义(P0.05)。结论:与常规腋窝淋巴结清扫术相比较,乳腔镜手术所需时间较长,并且治疗费用偏高,临床上应给予患者的个体差异情况有针对性的选择实施。     

The innervated gracilis musculocutaneous flap for total tongue reconstruction

A functional neotongue following total glossectomy requires both soft-tissue bulk and reconstruction of muscle function. We used innervated transverse gracilis musculocutaneous flaps to reconstruct total glossectomy defects in eight patients. The obturator nerve to the gracilis muscle was approximated to the hypoglossal nerve to reinnervate the gracilis muscle by using microsurgical technique. The cutaneous paddle of the gracilis flap easily supplies sufficient bulk to replace the total glossectomy defect. Follow-up of patients ranged from 3 to 47 months. All patients were able to resume oral feeding. Electromyographic studies performed on one patient showed reinnervation of the flap with active elevation of the posterior pharynx. Ultimately, seven patients died because of recurrence of their disease. The innervated gracilis musculocutaneous flap may benefit patients who have a total glossectomy by allowing them to achieve a more functional recovery.     

Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer.     

A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.     

Free-flap reconstruction of large defects of the scalp and calvarium

Beyond a certain size, full-thickness defects of scalp are not amenable to local flap repair. Staged distant flaps have now been virtually eliminated by free-flap reconstruction. The authors present 12 patients in whom full-thickness scalp defects with an average area of 275 cm2 were reconstructed utilizing free flaps. Nine patients had corresponding large calvarial defects. Ten patients had reconstruction with free latissimus dorsi muscle flaps and overlying skin grafts, and one patient had reconstruction with a scapular free flap. Of the 12 patients, 8 had extirpative surgery for tumor with immediate reconstruction and the remaining 4 had reconstruction for chronic radionecrosis of the scalp, usually associated with infected osteoradionecrosis of the calvarium. Of this latter group, 2 patients underwent simultaneous acrylic cranioplasty. The technique and results are discussed.     

Hemisoleus and reversed hemisoleus flaps

This paper reports an anatomic study of the soleus muscle and clinical applications of the findings derived from the study. Soleus neurovascular anatomy was studied in 86 limbs by dissection and specimen angiography. A consistently present bipenniform muscle morphology was found with medial and lateral subunits that had independent distal neurovascular supplies. This anatomic feature allows surgically splitting the muscle for transfer of one-half the muscle as a flap (hemisoleus muscle flaps). A series of 33 patients using both medial and lateral hemisoleus flaps in both proximally and distally based transfer is analyzed and illustrative examples are presented. The primary value of this technique is the ability to retain one-half the innervated soleus muscle in situ to preserve foot plantar flexion power in ambulatory patients. In addition, hemisoleus flaps have an extended arc of rotation as compared with that of conventional soleus muscle flaps.