One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Reconstruction of soft-tissue defects using serratus anterior adipofascial free flap

The serratus anterior muscle has been suggested as a versatile and reliable flap for reconstruction of head and neck and extremity injuries. The adipofascial layer overlying the serratus anterior muscle is the anatomic layer, which is supplied by the same branch of thoracodorsal artery. Even though great progress has occurred in the prevention of postoperative adhesion of extremity injuries, the problem has not been completely solved and is still of special importance in complex injuries. Between March of 1995 and February of 1996, seven patients underwent reconstructive operation as a result of soft-tissue defects of the upper or lower extremities or the scalp. We transferred free adipofascial tissue overlying the serratus anterior muscle in three patients and both serratus anterior muscle and adipofascial tissue in four patients. A free adipofascial flap overlying serratus anterior muscle was transferred when a gliding surface was required, owing to the exposure of tendons and neurovascular structures. The average duration from operation to follow-up examination was 8 months (from 4 to 16 months). The results of the operations were satisfactory in functional and cosmetic aspects. This kind of flap was very effective in reconstruction of soft-tissue defects and gliding surfaces for these reasons: easy dissection, the capability of obtaining a long vascular pedicle, large-sized flap, composite flap including muscle or rib, and the fact that there was no serious functional or cosmetic deficit at the donor site.     

The use of muscle flaps to treat left ventricular assist device infections

Left ventricular assist devices have become an important adjunct in the therapeutic armamentarium for patients with end-stage heart failure. Although they may provide a bridge to transplantation, they are prone to certain problems, expecially infection. Because these are life-sustaining devices, changing the device or simple explantation may be a risky, if not impossible, option. Therefore, we evaluated the effectiveness of a surgical alternative, namely, coverage of infected devices with muscle or myocutaneous flaps. Eighty-two consecutive patients who underwent the insertion of 88 left ventricular assist devices at our institution over a 6.5-year period were evaluated. Follow-up was provided for all patients and ranged from 1 to 7.5 years. The duration of ventricular support ranged from 0 to 434 days. All patients who demonstrated clinical evidence of infection were identified. Overall, 54 patients (66 percent) had infections locally at the device site, at distant sites, or systemically during support. Cultured organisms included gram-positive and -negative bacteria, fungi, and viruses. Of the 56 infections in these 54 patients, 21 (38 percent) were device-related, i.e., in the pocket created by the device, in the device itself, or from the driveline. Thus, 24 percent (21 of 88) of all ventricular support devices inserted demonstrated device infection during use. Therapeutic modalities used to combat device-related infection included both nonsurgical management with antibiotics alone and surgical procedures such as device change or relocation, device explant, and flap coverage. Eight of the 20 patients in whom the 21 device-related infections occurred underwent surgical intervention. Four of these eight patients undenwent local flap coverage of their infected left ventricular assist devices. All four patients also had evidence of systemic infection, or "device endocarditis." Coverage was successfully achieved in all cases with pedicled rectus abdominis flaps. There were no perioperative complications. Two patients later underwent successful transplantation; the other two died from causes unrelated to the flap. In conclusion, the treatment of infected left ventricular assist devices currently includes both nonsurgical and surgical alternatives. Of the latter, muscle flaps should be considered a first-line intervention to assist in eradicating infection by providing well-vascularized tissue. Although there were no perioperative complications, the 50 percent mortality rate is consistent with that reported for patients with "device endocarditis." It may be that flap coverage of infected ventricular assist devices, if instituted at an earlier stage in the therapeutic process, could help prevent systemic infection in these patients and, therefore, improve their overall outcome.     

The serratus anterior subslip: anatomy and implications for facial and hand reanimation

The ideal donor muscle for facial and hand reanimation has yet to be found. Donor muscles commonly used today, such as the gracilis and pectoralis minor, are limited by bulkiness and the number of force vectors they can provide. In the authors' study of 50 fresh cadaver serratus anterior muscles, they further describe neurovascular anatomy of the muscle slip (i.e., the portion of the muscle that inserts on a rib) and subslip (superficial or deep subdivision of the slip after division along a loose areolar plane). All 260 slips could be separated into a deep and a superficial subslip, yielding a total of 520 subslips. A branch of the serratus artery (a terminal branch of the thoracodorsal artery serving the lower five to seven slips of the muscle) and a branch of the long thoracic nerve were identified for each of these. Deep subslips were thinner than superficial subslips, both at the origin of the slip on the rib periosteum (2.4 mm versus 3.0 mm, p < 0.0001) and centrally at the serratus artery (3.3 mm versus 4.0 mm, p < 0.0001). In addition, the subslips of the most inferior slip were thinner than those of more superior slips, both at the origin of the slip (2.3 mm versus 2.8 mm, p < 0.0001) and at the serratus artery (3.0 mm versus 3.8 mm, p < 0.0001). Fine anastomosing vessels were present between the slips and the subslips. The average number of anastomosing vessels present between adjacent slips was 1.7, and 2.1 anastomosing vessels were present between the subslips of a given slip. Given the thinness of these vessels (all less than 0.2 mm) compared with those of the vascular pedicle of the subslip (mean, 0.7 mm; all greater than 0.4 mm), the authors believe these can be safely divided without compromising subslip vascularity. After division of these vessels, a mean length of 9.6 +/- 1.5 cm is available to allow independent orientation of each subslip. When the serratus muscle flap is separated into its component subslips, a maximum of 10 possible force vectors may be transferred on a single vascular pedicle. Subslips are significantly thinner than donor muscles commonly used today. These two advantages offer the potential for significant functional and aesthetic improvement when the serratus anterior muscle flap is used for face and hand reanimation. Mimetic muscles such as the orbicularis oculi and orbicularis oris could possibly be reconstructed in their proper anatomical positions.     

Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction

Limb salvage after extremity tumor ablation may include the use of allograft bone. The primary complication of this method is infection of the allograft, which can lead to limb loss in up to 50 percent of cases. The purpose of this study is to evaluate the efficacy of primary muscle flap coverage in the setting of allograft bone limb salvage surgery. This study is a prospective review of all patients with flap coverage of extremity allografts over the 10-year period 1991 to 2001. There were 20 patients (11 male and nine female patients) with an average age of 28 years (range, 6 to 72 years). Flap coverage was primary in 16 patients and delayed in four. Delayed coverage was performed for failed wounds that did not have a primary soft-tissue flap. Pathologic findings included osteosarcoma in nine patients, Ewing sarcoma in five patients, malignant fibrohistiocytoma in two patients, chondrosarcoma in two patients, synovial sarcoma in one patient, and leiomyosarcoma in one patient. Allograft reconstruction was performed for the upper extremity in 12 patients and for the lower extremity in eight patients. Flap reconstruction was accomplished with 20 pedicle flaps in 17 patients (latissimus dorsi, 12; gastrocnemius, four; soleus, three; and fasciocutaneous flap, one) and four free flaps (rectus abdominis, three; latissimus dorsi, one) in four patients. All pedicled flaps survived. There was one flap failure in the entire series, which was a free rectus abdominis flap. This case resulted in the only limb loss noted. The follow-up period ranged from 1 to 50 months (average, 12.35 months). At the time of final follow-up, three patients were dead of disease and 17 were alive with intact extremities. The overall limb salvage rate in the setting of bone allograft and soft-tissue flap coverage was 95 percent (19 of 20). Reoperation for bone-related complications was required in 50 percent (two of four) of cases receiving delayed flap coverage compared with 19 percent (three of 16) of patients with primary flap coverage (statistically not significant). The results of this study support the use of soft-tissue flap coverage for allograft limb reconstruction. In this series, no limb was lost in the setting of a viable flap. Reoperation was markedly reduced in the setting of primary flap coverage. Pedicled or microvascular transfer of well-vascularized muscle can be used to wrap the allograft and minimize devastating wound complications potentially leading to loss of allograft and limb.     

The supply of blood in the skin territory above the lower part of the serratus anterior muscle

At present, the putative clinical use of the musculocutaneous and ostomusculocutaneous serratus anterior flaps has been compromised by the risk of partial or total necrosis of the skin overlying the lower part of the serratus anterior muscle. Therefore, the aim of this study was to delineate a skin area vascularized by perforant musculocutaneous branches of arteries stemming from the lower segment of the anterior serrated muscle. Black ink was injected in thoracodorsal artery branches for the serratus anterior muscle in 50 human cadavers before the autopsies (the study was approved by the Institutional Review Board). The surface area of the labeled skin was determined and its borders delineated by means of transparent millimeter grid. Planimetry data were subsequently analyzed with the aid of PC computer program. The results show that the calculated mean surface area (143.79 +/- 2.68 x 2.077; range 138.22-149.36 cm2) of the skin vascularized by perforant musculocuaneous branches stemming from the lower segment of the anterior serrated muscle, can serve as a reliable guide for taking serratus anterior flap in any patient. Therefore, appropriately sized musculocutaneous or osteomusculocutaneous serratus anterior flap can be safely and efficiently used in plastic and reconstructive surgery.     

Lower extremity muscle perforator flaps for lower extremity reconstruction

A true muscle perforator flap is distinguished by the requisite intramuscular dissection of its musculocutaneous perforator to capture the same musculocutaneous territory but with total exclusion of the muscle, and thereby results in minimal functional impairment. Adhering to this definition, several lower extremity donor sites now are available, each with specific attributes especially useful for consideration in the treatment of lower extremity defects. In this author's experience over the past two decades, 20 lower extremity muscle perforator flaps using multiple donor sites proved advantageous for lower extremity coverage problems as either a local pedicled flap or as a microsurgical tissue transfer. Significant complications occurred in 30 percent of flaps (six of 20) in that further intervention was required. Venous insufficiency and bulkiness were found to be the major inherent shortcomings. However, giant flaps, lengthy and large-caliber vascular pedicles, and the possibility for combined flaps were important assets. The choice of a lower extremity muscle perforator flap for lower extremity reconstruction limited the surgical intervention and morbidity to a single body region.     

The role of microsurgery in reconstruction of oncologic chest wall defects.

Regional pedicled myocutaneous flaps are usually the best choice for soft-tissue coverage of full-thickness chest wall defects. As defects increase in size, microsurgical techniques are necessary to augment blood flow to pedicled flaps or to provide free flap coverage from distant sites. This study retrospectively reviews all microsurgical procedures performed at one institution for the coverage of full-thickness chest wall defects. Twenty-five cases of full-thickness chest wall reconstruction are reviewed. There were 20 free flaps and five supercharged pedicled flaps. A rectus abdominis myocutaneous flap (free or supercharged) was used in 20 cases, and a filet free flap following forequarter amputation was used in five patients. Large skeletal defects were repaired with a Marlex mesh/methylmethacrylate sandwich prosthesis. There was 100 percent flap survival and one case of minor, partial flap loss. The prosthesis remained effectively covered in all cases. Five patients required ventilatory support for up to 10 days postoperatively. There were three perioperative deaths due to multisystem failure. Microsurgical techniques are extremely useful for reconstruction of complicated, composite chest wall defects. They are indicated when regional pedicled flap options are unavailable or inadequate. These flaps have a 100 percent success rate and uniformly result in stable soft-tissue coverage.     

Management of complex groin wounds: preferred use of the rectus femoris muscle flap

This study reviews our experience with the rectus femoris muscle flap for complex groin wound reconstruction. Over the past 5 years, the rectus femoris has become our routine method of groin wound reconstruction. The rectus femoris is harvested through a midanterior incision extending over the distal two-thirds of the thigh. The muscle is elevated on its pedicle and transposed into the groin wound defect either directly or through an intervening skin bridge. Hospital and outpatient records were reviewed for all patients undergoing groin wound reconstruction with this technique from 1999 through 2003. Thirty-seven rectus femoris muscle flaps were performed in 33 patients. The mean patient age was 65.3 years (range, 25 to 88 years). Thirty groin wounds (81.1 percent) occurred after infrainguinal revascularization, 23 (76.7 percent) of which contained prosthetic material. Five (21.7 percent) of these wounds had their prosthetic material removed at the time of reconstruction. The remaining seven groin wounds (18.9 percent) occurred after femoral vessel cannulation for either cardiac or transplant surgery. There were no intraoperative mortalities and no anastomotic hemorrhages. There were no flap losses. Thirty-five of the 37 treated wounds healed (94.6 percent), 26 primarily (70.3 percent) and nine (24.3 percent) after delayed healing and contracture. Reoperation was performed in one patient for flap readvancement and in three patients for prosthetic graft removal after initial flap reconstruction. Two patients (6.1 percent) died during their hospitalization with persistent open groin wounds after flap reconstruction. All muscle flap donor incisions healed, with only two (5.4 percent) experiencing minimal delayed healing. There were no donor-site wound infections and no donor sites required reoperation. Thirty-three groin wounds (89.2 percent) demonstrated culture-positive microbial infection, 15 (45.5 percent) of which were polymicrobial. The 30-day mortality rate was 15.2 percent and the 6-month mortality rate increased to 27.2 percent, with multisystem organ failure as the most common cause. The rectus femoris muscle flap is an effective and reliable means of complex groin wound reconstruction. The muscle flap is dependable and the donor site is not problematic, even in the presence of peripheral vascular disease. On the basis of our clinical results, we believe that the rectus femoris muscle flap is the flap of choice for groin wound reconstruction.     

Detailed neurovascular anatomy of the serratus anterior muscle: implications for a functional muscle flap with multiple independent force vectors

A functional muscle free flap with multiple muscle segments that could be oriented independently to produce different force vectors would be beneficial in facial reanimation and upper extremity reconstruction. The serratus anterior muscle has this potential because two or more individual muscle slips can be transferred on a single vascular pedicle. Although serratus anterior muscular anatomy has been studied previously, little attention has been given to the intramuscular anatomy. Muscle slips 5 through 9 (and 10, if present) in 50 specimens from 27 cadavers were studied following intraarterial latex injection. Eight specimens were injected with a radiopaque material (latex/diatrizoate/lead mixture) for x-ray delineation of the intramuscular vascular pattern. Slips 5 through 9 are consistently supplied by a single dominant branch of the thoracodorsal artery and innervated by the long thoracic nerve. Dissection revealed that the long thoracic nerve and its branches invariably follow the artery and divide proximal to the corresponding arterial division. There is a consistent vascular pattern to each muscle slip, in which the serratus artery gives rise to common slip arteries, each of which supplies adjacent muscle slips. The mean length of a muscle slip from its origin on the rib periosteum to the division of the common slip artery is 9.6 cm. These findings imply that the slips may be separated to the level of these common slip arteries, with up to five slips transferred on a single neurovascular pedicle and each slip oriented independently to provide multiple muscle force vectors. With these possibilities, the reconstructive surgeon may be able to restore more natural facial animation and better intrinsic muscle function in the upper extremity.     

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.     

The effectiveness of muscle flaps for the treatment of prosthetic graft sepsis.

The objective of this study was to assess the efficacy and reliability of muscle flaps in the treatment of prosthetic graft sepsis. A retrospective analysis was performed to assess the outcome of all patients with prosthetic graft sepsis who were treated with a muscle flap at Groote Schuur Hospital between January of 1991 and July of 2000. The specific end points studied were flap survival, limb salvage rate, and mortality. A total of 27 muscle flaps were raised to cover 24 sites of graft sepsis in 21 patients. Twenty-five flaps were performed primarily and two secondarily. The mortality rate was zero. Limb salvage was achieved in 15 of 21 patients (71 percent), with no recurrent sepsis after an average follow-up period of 36 months. The groin was the most common site of infection, with an 86 percent incidence. Eighteen sartorius flaps were raised in the groin. Seventeen of the 18 sartorius flaps survived (94 percent), and a 71 percent limb salvage was achieved with no recurrent sepsis after 36 months of follow-up. This series supports the use of muscle flaps for the treatment of prosthetic graft sepsis. The sartorius flap has been shown to be reliable as a flap in the groin, with successful limb salvage in the majority of patients.     

Free-tissue transfer in elderly patients

A retrospective survey was undertaken to evaluate the success of free-tissue transfer (free flap) in the elderly. During a 70-month period, 199 free flaps were performed in 151 patients at the Western Pennsylvania Hospital, 60 of these involving 47 patients over the age of 60. Primary coverage rates differed significantly between the elderly and younger age groups (68.5 versus 85.3 percent, respectively); however, eventual coverage rates (92.6 versus 96.3 percent), minor complication rates (34.0 versus 34.6 percent), mortality rates (2.1 versus 1.0 percent), flap revision rates (32 percent of patients versus 30 percent), and length of postoperative hospitalization (18.7 versus 18.8 days) were not significantly different in the two groups. Among the elderly, significant increases in flap loss rates were noted with the use of end-to-side arterial anastomosis, placement of the anastomosis within a zone of injury, and the use of the gracilis muscle donor site. Our data suggest that the primary cause of free-flap failure is construction of the anastomosis within a zone of injury. Free-tissue transfer is a valuable option in the repair of tissue defects in the elderly and should not be denied as a treatment because of patient age.     

The use of a free flap in homozygous sickle cell disease

This paper describes what is thought to be the first reported use of a free flap in a patient with homozygous sickle cell disease. The utilization of a free flap in homozygous sickle cell disease should be questioned because the obligate period of ischemia to which the flap must be subjected during the transfer from donor to recipient sites might lead to intravascular sickling in the flap and flap failure. Review of the literature suggests that by reducing the level of sickle hemoglobin to the range of 25 to 40 percent, the risk of failure of a free flap is not significantly increased in the homozygous sickle cell patient. Furthermore, there is good evidence to suggest that a well-vascularized muscle flap provides optimal coverage, reversing the pathophysiologic cycle of the sickle cell ulcer. Thus in cases of multiply recurrent sickle cell ulcers in areas devoid of a local well-vascularized muscle flap, a free muscle flap is indicated, may be the procedure of choice, and can be performed successfully. We report a patient with a 4-year history of multiple recurrent sickle cell ulcers of the left ankle treated with a gracilis free flap. This patient has been followed for 2 years and continues to be free of recurrent ulceration.     

Free flap coverage of bilateral frostbite of the feet

The indications, principles of management, and outcomes of free flap transfer for limb salvage in four patients with bilateral frostbite of their feet are presented. A fasciocutaneous flap was used for coverage when the wound involved a single surface of the foot. When multiple surfaces of the foot required free flap coverage, a muscle flap was used because it could more easily improve the shape and contour of the defect. Successful coverage was achieved in all four patients.     

Vascularized rib for facial reconstruction

The reconstruction of maxillectomy defects is a complex problem encountered in plastic surgery. Defects can range in size and complexity from small defects requiring only soft tissue to complete maxillectomies requiring large tissue bulk, bone, and one or more skin paddles. The most difficult defects involve the skull base and orbit. The reconstructive surgeon is faced with the challenge of isolating the nasopharynx from the dura and globe while simultaneously restoring the bony framework of the maxilla and orbit to support the soft tissue of the cheek. The authors present a series of six reconstructions using a rectus abdominis muscle flap with associated vascularized rib for reconstruction of complex maxillectomy defects. This flap provides large soft-tissue bulk as well as bony support and a long vascular pedicle. A skin island can be taken with the flap, and the donor-site morbidity is comparable to that seen with a vertical rectus abdominis myocutaneous flap. Six flaps were used in five patients over a 20-month period. All patients had stable support of the orbit at follow-up with adequate soft-tissue coverage, and there were no incidences of visual changes.     

The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment.

Preliminary reports have indicated that debridement of the bony sequestrum followed by muscle-flap coverage allows successful treatment of chronic osteomyelitis. To determine the long-term effectiveness of this procedure, 34 consecutive patients with chronic osteomyelitis of the distal lower extremity treated with debridement, a 10- to 14-day course of culture-specific antibiotics, and immediate muscle-flap coverage were evaluated. Patients were treated from 1979 through 1984, and long-term (greater than 5 years) follow-up was available for 27 (79 percent). Twenty-three (85 percent) of these patients underwent microvascular muscle transplantation (gracilis or latissimus dorsi), and four underwent local muscle flaps (gastrocnemius or soleus) for immediate wound coverage. Twenty-four patients (89 percent) healed and were without recurrence over long-term (greater than 5 years, mean 7.4 years) follow-up. Of the three with recurrence, two were cured (greater than 5 years follow-up) after additional muscle-flap procedures. Thus the overall success rate was 96 percent, with a minimum 5-year follow-up. Guidelines for muscle-flap selection and treatment techniques in current use are presented. Debridement and immediate muscle-flap coverage provide effective, single-stage treatment of chronic osteomyelitic wounds and allow antibiotics to be restricted to short-term use. Furthermore, muscle flaps covered with skin grafts provide durable coverage while allowing subsequent ancillary procedures (i.e., bone grafts) to be performed under the flaps.     

Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.     

EMG of serratus anterior and trapezius in the chimpanzee: scapular rotators revisited.

The importance of arm-raising has been a major consideration in the functional interpretation of differences in shoulder morphology among species of nonhuman primates. Among the characters that have been associated with enhancement of the arm-raising mechanism in hominoid primates are the relative enlargement of cranial trapezius and caudal serratus anterior, as the main scapular rotators, as well as changes in scapular morphology associated with their improved leverage for scapular rotation. Yet in an EMG study of cranial trapezius and caudal serratus anterior function in the great apes, Tuttle and Basmajian (Yrbk. Phys. Anthropol. 20:491-497, 1977) found these muscles to be essentially inactive during arm-raising. Although Tuttle and Basmajian suggest that the cranial orientation of the glenoid fossa in apes has reduced the demand for scapular rotation during arm-raising, subsequent EMG studies on other primate species suggest that these muscles do play a significant role in arm motion during active locomotion. This paper presents a reexamination of muscle recruitment patterns for trapezius and caudal serratus anterior in the chimpanzee. All but the lowest parts of caudal serratus anterior were found to be highly active during arm-raising motions, justifying earlier morphological interpretations of differences in caudal serratus anterior development. The lowest digitations of this muscle, while inactive during arm-raising, displayed significant activity during suspensory postures and locomotion, presumably to control the tendency of the scapula to shift cranially relative to the rib cage. Cranial trapezius did not appear to be involved in arm-raising; instead, its recruitment was closely tied to head position.     

Use of the temporalis muscule flap in blanking out orbits.

We report the use of the temporalis muscle as a transposition flap to obliterate the orbit in 5 patients. In 4 of the cases we split the muscle coronally and passed the anterior part through a window in the lateral orbital wall. In two of these patients, skin grafts were put on both sides of the temporalis muscle-fascia flap, to restore nasal lining and to cover the facial surface simultaneously. In the remaining patients, the muscle was split sagittally to provide a large surface for coverage. The temporalis muscle flap is a versatile one for filling orbits after exenteration.