Fascial anchoring technique in medial thigh lifts

The medical thigh lift has not gained widespread acceptance since its introduction 20 years ago because of problems such as inferior scar migration, labial separation, and early recurrence of ptosis. Anchoring of the inferior skin flap to the tough, inelastic deep layer of the superficial perineal fascia has reduced such complications. Originally described by Colles in 1811, this fascial layer helps define the perineal-thigh crease. Eighteen patients having medial thigh lifts in combination with liposuction were followed for 6 to 24 months. The technique involves initial liposuction followed by resection of a crescent of redundant skin and fat at the superior medial thigh. The inferior skin flap is suspended from Colles' fascia of the perineum with subdermal PDS sutures. No undermining or deepithelialization of flaps is performed. Complications are few, and patient satisfaction is high.     

The lateral arm fascial free flap: its anatomy and use in reconstruction

Free fascial transfer has been used for reconstruction of gliding surfaces of the upper and lower extremities or when thin, pliable coverage is required (hand, heel, nose, and ear). In our experience with the lateral arm fasciocutaneous flap, we have found that the fascia alone is an excellent source of tissue for free flap transfer. A thorough investigation of the microscopic, gross, and radiographic anatomy of the lateral arm fascia was undertaken by the study of 25 fresh cadavers. Vascular pathways were mapped, their locations were analyzed, and then they were correlated with the elevation, design, and transfer of the flap. The lateral arm has a large fascial component located anterior and posterior to the lateral intermuscular septum, which itself lies between the triceps and the brachialis and brachioradialis muscles. It is perfused by the posterior radial collateral artery (PRCA), one of the terminal branches of the profunda brachii. This vessel (PRCA) provides at least four fascial branches from 1 to 15 cm proximal to the lateral epicondyle, the largest of which is located an average of 9.7 cm superior to the lateral epicondyle. Fascia up to 12 x 9 cm may be used with good axial perfusion. The histologic cross sections demonstrate the complex anatomy of the fascia itself, as well as its relation to the nutrient vessels. We have applied the lateral arm fascial flap in five cases of upper extremity reconstruction. We have also found this flap valuable in preservation of underlying anatomic detail for total reconstruction of the ear and nose when local tissue and more conventional flaps were not available.     

Paravascular connective tissue structures of the veins of the pelvic cavity in man

The data on structure of the paravasal connective tissue formations in some parietal pelvic veins, in the utero-vaginal plexus veins, in the fatty tissue space veins of the rectum, of the vesicular and prostatic plexuses are presented, as well as those on connections between the fascial vaginae for the veins in the human subabdominal part of the pelvis and its fascial nodes. Theoretical interpretation of gaping of the pelvic fundal venous vessels is presented. Participation of the paravasal connective tissue formations in organization of the fascial nodes of the human small pelvis is stated.     

Cranial Morphology of a Pantolestid Eutherian Mammal from the Eocene Bridger Formation,Wyoming, USA: Implications for Relationships and Habitat

Pantolestinae is a eutherian subfamily of mammals whose members are known from the middle early Paleocene through at least the beginning of the Oligocene of North America. They are also known from Europe, and possibly Africa. A lack of information on pantolestine skulls has prevented the use of cranial anatomy in evaluation of this group’s enigmatic higher-level phylogenetic relationships. Conversely, postcranial skeletons are well known and locomotor interpretations based on them are robust. The most complete known skull of a pantolestine, Pantolestes longicaudus (YPM 13525), is described here and compared to potential close fossil relatives and extant mammals. Semicircular canal morphology is used to test locomotor hypotheses. YPM 13525 lacks an ossified bulla. It has a mediolaterally broad basioccipital, a large entoglenoid process, and a deeply incised glaserian fissure of the squamosal, caudal and rostral tympanic processes on the petrosal, a foramen for an internal carotid artery (ICA) that entered the tympanic cavity from a posteromedial position, bony tubes enclosing the main stem and transpromontorial branch of the ICA, a large anterior carotid foramen formed within the basisphenoid, evidence of a stapedial artery ramus superior, a groove on the dorsal aspect of the basisphenoid leading to the piriform fenestra possibly for drainage of the cavernous sinus to an extracranial inferior petrosal sinus, a dorsum sellae with well-developed posterior clinoid processes, a foramen rotundum within the alisphenoid, and a sphenorbital fissure between the alisphenoid and orbitosphenoid. Overall, the morphology is not strikingly similar to any potential close relative and the phylogenetic position of Pantolestinae cannot be estimated without cladistic analysis of a character matrix that includes this new morphology and broadly samples extant and extinct eutherian taxa. Semicircular canal morphology differs from that of two likely terrestrial Paleocene mammals, Aphronorus (another pantolestid) and Eoryctes (a palaeoryctid), suggesting a different, possibly semi-aquatic, lifestyle for Pantolestes.     

Surgical anatomy and blood supply of the fascial layers of the temporal region

In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.     

Functional studies on sciatic nerve blood flow in respect to its vascular supply and tonic neural activity.

An introduction of laser flow meters for a continuous measurements of a tissue blood flow has opened new avenues for an accurate assessment blood flow in peripheral nerves. The aim of our study was: 1) to carry out a functional verification of anatomical sources of a sciatic nerve blood supply in the rat; 2) develop a measurement technique to facilitate standardisation of results; 3) to determine the role of nerve fibres tonic activity in the maintenance of a resting blood flow in the sciatic nerve. Based on results of the present study the following conclusions have been drawn out: 1) in order to obtain a real values of the blood flow through the sciatic nerve it is necessary to remove its muscular fascia; 2) an uninjured epineurium plays a crucial role in maintaining the resting blood flow; 3) major blood supply of sciatic nerve comes from inferior gluteal and popliteal arteries; 4) the tonic neural activity plays a role in the maintenance of the resting sciatic nerve blood flow in anaesthetised rats.     

Pudendal and caudal rectal nerve blocks in the horse - An anesthetic procedure for reproductive surgery

The pudendal and caudal rectal nerves in four male and five female adult crossbred horses were anesthetized with a local solution. The injection site was located at the foramen for the caudal gluteal artery and vein in the sacrosciatic ligament. Twenty milliliters of local anesthetic solution were injected via a 15-cm, 18-gauge needle. Quantitative data on anesthesia were determined from these injections. Dye was injected with the anesthetic in four additional horses so that accurate placement of the solution could be determined at postmortem examination. Satisfactory anesthesia of the anus, perineum, and vulva in the mare and of the anus, perineum, glans penis and penile layer of the prepuce in the male was achieved by placement of anesthetic near the foramen for the caudal gluteal vessels in the sacrosciatic ligament. Penile extrusion also occurred.     

Relationship of hypoxia-inducible factor 1α and p21WAF1/CIP1 expression to cell apoptosis and clinical outcome in patients with gastric cancer

Background

This case report highlights two unusual surgical phenomena: lipoma-like well-differentiated liposarcomas and sciatic hernias. It illustrates the need to be aware that hernias may not always simply contain intra-abdominal viscera.

Case presentation

A 36 year old woman presented with an expanding, yet reducible, right gluteal mass, indicative of a sciatic hernia. However, magnetic resonance imaging demonstrated a large intra- and extra-pelvic fatty mass traversing the greater sciatic foramen. The tumour was surgically removed through an abdomino-perineal approach. Subsequent pathological examination revealed an atypical lipomatous tumour (synonym: lipoma-like well-differentiated liposarcoma). The patient remains free from recurrence two years following her surgery.

Conclusion

The presence of a gluteal mass should always suggest the possibility of a sciatic hernia. However, in this case, the hernia consisted of an atypical lipoma spanning the greater sciatic foramen. Although lipoma-like well-differentiated liposarcomas have only a low potential for recurrence, the variable nature of fatty tumours demands that patients require regular clinical and radiological review.     

Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.     

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face.(ABSTRACT TRUNCATED AT 250 WORDS)     

乳突切迹与侧颅底重要结构的解剖学观测及应用

目的：通过测量乳突切迹与侧颅底重要骨性结构的距离,为临床相关应用提供解剖学参考。方法：取成人颅骨标本50例（去颅盖标本8例,整颅42例）100侧,测量乳突切迹及其与侧颅底重要孔、裂和管的距离。结果：左右侧乳突切迹后缘距茎乳孔、颈静脉孔外侧缘、颈动脉管外口后缘、破裂孔、棘孔、卵圆孔距离分别为25.16±3.73cm和25.02±3.58cm、30.92±3.50cm和30.45±3.49cm、38.22±3.57cm和38.14±3.43cm、57.23±3.71cm和57.14±3.44cm、47.94±3.83cm和48.32±3.54cm、53.70±3.98cm和53.55±3.75cm。结论：以乳突切迹后缘做为侧颅底手术的定位标志能够为临床相关应用提供较方便、准确的定位参考。     

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.     

Balanced auricular reconstruction in dystopic microtia with the presence of the external auditory canal

This article presents a new repositioning method in dystopic microtia (low-set microtia, anteriorly tilted microtia, or both) with the presence of the external auditory canal. In the case of low-set malformations, the dystopic auricular canal complex was freed from adjacent bony structure, shifted upward, and anchored to the thick periosteum of the suprameatal triangle or the adjacent superior portion of the temporal bone with nonabsorbable sutures. When the auricular vestige was large and dystopia was severe, the complex was shifted with attachment of the temporoparietal fascia on its cranial part. Meanwhile, when the auricular vestige was small and dystopia was mild, the complex was shifted without attachment of the temporoparietal fascia. Then, the ear framework fabricated with autogenous costal cartilage was positioned and wrapped with the temporoparietal fascial flap. In the case of anteriorly tilted malformations, the dystopic complex was freed, shifted posteriorly, and anchored to the periosteum of the suprameatal triangle. Preauricular dead space, resulting from shifting the complex, was obliterated with pieces of costal cartilage. Simultaneously, the ear framework was placed and wrapped with the temporoparietal fascial flap. No skin necrosis of the shifted complexes occurred in any of the cases. In one case, the facial nerve was transected during dissection and reanastomosed. Upward repositioning distances in low-set microtias were between 1 and 3.5 cm. Posteriorly repositioning distances in anteriorly tilted microtias were 2 and 3 cm. Thirteen patients with low-set malformations, two patients with anteriorly tilted malformations, and three patients with low-set and anteriorly tilted malformations underwent reconstructive operations. The new repositioning method is relatively simple, safe, and effective.     

The anterior tibial artery flap: anatomic study and clinical application

Satisfactory replacement of skin defects over the lower leg remains a difficult problem. Various forms of coverage, including, local rotation flaps, muscle flaps, and fascial and free flaps, have their specific indications and inherent disadvantages. In this work, a new axial skin flap based on perforating vessels in the territory of the anterior tibial artery is described. A series of 50 lower leg dissections was carried out in 25 fresh cadavers after latex injection into the femoral artery. Detailed studies of the cutaneous distribution of the anterior tibial artery showed that three main arteries perfuse the anterior lateral portion of the lower leg. The superior lateral peroneal artery and the inferior lateral peroneal artery interseptal cutaneous perforators arise at an average of 25.6 and 17.2 cm from the lateral malleolus, respectively. The superior lateral peroneal artery was present in 100 percent of the specimens, whereas the inferior lateral peroneal artery was present in 70 percent of the specimens. In their course, they give several muscular branches to the peroneus longus and brevis prior to perforating the fascia and arborizing in the subcutaneous tissues of the anterolateral portion of the leg. The average external diameter was 1.6 cm for the superior and 1.4 cm for the inferior lateral peroneal artery. The superficial peroneal nerve accessory artery is the third artery which contributes to the skin of the lower leg. It arises from the superior lateral peroneal artery in 30 percent of cases, from the inferior lateral peroneal artery in 40 percent, and from both in 30 percent. The artery runs along with the superficial peroneal nerve and gives several cutaneous perforators along its descending course. Several cutaneous axial flaps can be fashioned around this anatomy. The operative technique along with demonstrative clinical cases is presented followed by pertinent discussion.     

Muscle-splitting approach to superior and inferior gluteal vessels: versatile source of recipient vessels for free-tissue transfer to sacral, gluteal, and ischial regions

The superior gluteal vessel has been reported as a recipient in free-tissue transfer for the coverage of complex soft-tissue defects in the lumbosacral region, where a suitable recipient vessel is difficult to find. The characteristics of proximity, vessel caliber, and constancy make the superior gluteal vessel preferable to previously reported recipient vessels. However, there are technical difficulties in microsurgery (e.g., short pedicle length and deep location) and muscle injury (transection of the muscle) associated with use of the superior gluteal vessel. The purpose of this article is to present a modification of an approach to the gluteal vessel to alleviate technical difficulties and minimize muscle injury. From August of 1997 to January of 1999, six patients received microvascular transfer of the latissimus dorsi muscle or myocutaneous flap to the sacral (4) and ischial (2) regions. The causes of defects were tumor (1), trauma (1), and pressure sores (4). A muscle-splitting approach was used on the superior gluteal vessel and was later applied to the inferior gluteal vessel. The gluteus maximus muscle was split as needed in the direction of its fibers, and the perforators were dissected down to the superior or inferior gluteal artery and vein deep into the muscle. The follow-up period ranged from 6 to 22 months, and all of the flaps survived with complete recovery of the lesion. The major drawbacks of using the superior and inferior gluteal vessels can be overcome with the muscle-splitting approach, which provides increased accessibility and additional length to the vascular pedicle while causing minimal injury to the muscle itself. It also proves to be an easy, safe, and reliable method of dissection. When free-tissue transfer to sacral, gluteal, and ischial regions is indicated, the muscle-splitting approach to the superior and inferior gluteal vessels is a recommended option in the selection of a recipient vessel.     

Cytological and functional characteristics of fascia adipocytes in rats: A unique population of adipocytes

The dermal adipocytes, superficial fascia and subcutaneous adipose tissue (SAT) exist in the interspaces between the dermis and muscular fascia. They are adjacent to each other and traditionally recognized as one SAT. Recently, the dermal adipocyte was redefined as a unique population independent from the SAT. Also, we identified a novel type of adipogenic progenitors in rat superficial fascia. This study aimed to examine cytological and functional characteristics of fascial adipocytes in rats. Superficial fascia had no adipocytes in neonatal rats but gradually appeared numbers of adipocytes in growing rats. Adipogenic progenitors were found to reside in fascia and had strong ability in spontaneous and induced adipogenic differentiation in vitro. Differentiated fascial adipocytes versus subcutaneous or visceral adipocytes expressed increased adipose triglyceride lipase but decreased beta-adrenoreceptor, perilipin-1 and hormone-sensitive lipase (HSL), thus having high basal lipolysis but low lipolysis response to catecholamines. Phosphorylation of perilipin-1 and HSL and translocation of HSL to lipid droplets were attenuated in response to catecholamines rather than post-adrenoreceptoral lipolytic stimulators. The results suggested that superficial fascia was an origin of adipocytes with distinct developmental, cytological and functional characteristics. We proposed that fascial adipocytes could be considered as a unique population of adipocytes in the body. The fascia origin of adipocytes as an adipogenic model might logically explain fat neogenesis occurred at anatomical locations where originally exist no adipose tissues and thereby no adipose-derived stromal precursors. Also, the special histoanatomical relations and overlaps between the dermis, superficial fascia, SAT, and their adipocytes were discussed.     

Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection.

The trochlea and superior oblique muscle tendon separate the medial and central fat compartments in the upper lid. The purpose of this study was to determine anatomical landmarks to predict the location of and avoid injuring the trochlea and superior oblique muscle tendon with orbital fat resection during upper blepharoplasty. The trochlea and superior oblique muscle tendon were identified in 14 cadaver heads. Bony anatomical landmarks were identified to predict the oblique vector along which the trochlea and superior oblique tendon lie. The trochlea was measured in millimeters from the palpable superior orbital foramen. The oblique course of the superior oblique muscle tendon was measured from its medial location in the lateral direction in millimeters from the frontozygomatic suture. These measurements were obtained with 4.0-power loupe magnification. The trochlea was identified 10.0 +/- 0.9 mm inferior to the palpable superior orbital foramen. The superior oblique muscle tendon coursed laterally along an oblique vector to within 1 mm of the frontozygomatic suture for all 14 dissections. The vertical vector of the superior orbital foramen was measured 15.9 +/- 1.1 mm lateral to the medial canthus. The width of the bony orbit measured 42.2 +/- 1.6 mm. In two dissections, the superior orbital foramen could not be palpated, and the latter measurements were used to predict the superior orbital foramen. This anatomical study showed that when performing orbital fat resection with upper blepharoplasty, the trochlea and superior oblique muscle tendon can be identified and avoided with the above-described bony landmarks.     

Vascularized outer-table calvarial bone flaps

Based on an anatomic study of the vascularization of the calvarium in cadavers, a technique for the transfer of vascularized outer-table calvarial bone has been developed. The outer table of the calvarium receives numerous small perforators from its overlying periosteum. The periosteum is continuous with a distinct fascial layer overlying the temporal aponeurosis which we have termed the innominate fascia. Because of a network of anastomosing vessels from proximal branches of the superficial temporal artery and perforating branches of the deep temporal artery, the outer table of the calvarium can be carried on a pedicle which contains the temporal aponeurosis, innominate fascia, and periosteum. Thirty-seven vascularized outer-table calvarial bone flaps have been performed for a variety of craniofacial reconstructive deformities. Remarkable stability and lack of resorption have led the authors to favor this method of reconstruction particularly in poorly vascularized or previously infected recipient beds.     

The value of preoperative Doppler sonography for planning free perforator flaps

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.