New aspects of the topographical anatomy of the mammary gland regarding its neurovascular supply along a regular ligamentous suspension

The exact location of the main nerves and vessels to the breast and the nipple-areola complex has always been obscure. We found that the course of the rich neurovascular supply to the nipple runs along a regularly-located, suspensory apparatus and can therefore be predicted exactly. It consists of a horizontal fibrous septum originating at the pectoral fascia along the 5th rib, merging into vertical ligaments along the sternum medially and along the lateral border of pectoralis minor laterally. Cranially, and in an anterior direction, the vertical ligaments are connected by the superficial fascia. In the current anatomical study, we seek to demonstrate the vascular supply provided by these structures more impressively. For this purpose we dissected the ligamentous suspension after intraarterial injection with colored latex in both breasts of 10 female cadavers. The large vessels, guided by this circle of fibrous attachments could then be seen clearly. In a further 4 female cadavers, a similar procedure was performed after intraarterial injection of surgical ink. This stained the vascular layers even more intensely. This topographical knowledge has clinical relevance. The rich and constant neurovascular supply to the nipple areola complex may be maintained in a new breast-reduction technique, which allows safe postoperative viability and sensibility of the nipple. The clinical results act as a striking evidence of our anatomical findings. Further procedures taking advantage of the easy determination and access to the neurovascular supply may be seen in future.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

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.     

The medial periareolar approach to submuscular augmentation mammaplasty under local anesthesia

The medial approach to submuscular augmentation mammaplasty under local anesthesia begins with a medial periareolar incision around one-half or more of the areola. A subcutaneous tunnel is made toward the medial breast border, avoiding mammary ducts and sensory nerves to the nipple. The breast is reflected laterally, exposing a patch of pectoralis major muscle. A submuscular pocket is then created beneath portions of the pectoralis major, rectus abdominis, external oblique abdominis, and serratus anterior muscles, after which the implant is inserted and the muscle, dermis, and skin are closed sequentially. The periareolar incision allows for favorable scars without compromising the access or exposure necessary for accurate implant placement. Complete muscle coverage of the implant should contribute to a lower rate of capsular contracture. With a medial submuscular approach, nipple sensation is rarely altered, and revisions, if necessary, can be done through the same incision, still under local anesthesia, for increased safety, economy, and convenience. The medial approach to breast augmentation is a highly versatile, safe, and consistent method of achieving excellent results in breast augmentation in terms of scar, symmetry, and softness.     

The innervated anterolateral thigh flap: anatomical study and clinical implications

During the past 20 years, the neural anatomy of many flaps has been investigated, although no extensive studies have been reported yet on the anterolateral thigh flap. The goal of this study was to describe the sensory territories of the nerves supplying the anterolateral thigh flap with dissections on fresh cadavers and with local anesthetic injections in living subjects. The sensate anterolateral thigh flap is typically described as innervated by the lateral cutaneous femoral nerve. Two other well-known nerves, the superior perforator nerve and the median perforator nerve, which enter the flap at its medial border, might have a role in anterolateral thigh flap innervation. Twenty-nine anterolateral thigh flaps were elevated in 15 cadavers, and the lateral cutaneous femoral nerve, the superior perforator nerve, and median perforator nerve were dissected. In the injection study, the lateral cutaneous femoral nerve, superior perforator nerve, and median perforator nerve in 16 thighs of eight subjects were sequentially blocked. The resulting sensory deficit from each injection was mapped on the skin and superimposed on the marked anterolateral thigh flap territory. The study shows that the sensate anterolateral thigh flap is basically innervated by all three nerves. The lateral cutaneous femoral nerve was present in 29 of 29 thighs, whereas the superior perforator nerve was present in 25 of 29 and the median perforator nerve in 24 of 29 thighs. Furthermore, in the proximal half of the flap, the lateral cutaneous femoral nerve lies deep, whereas the superior perforator nerve and median perforator nerve lie more superficially. Whereas the lateral cutaneous femoral nerve innervates the entire flap, the superior perforator nerve innervates 25 percent of the flap and the median perforator nerve innervates 60 percent of the flap. Clinically, a small anterolateral thigh flap (7 x 5 cm) can be raised sparing the lateral cutaneous femoral nerve and using only the selective areas innervated by the superior perforator and median perforator nerves. Alternatively, a large anterolateral thigh flap can be raised with this multiple innervation. This can be helpful if one wants to harvest the flap under local anesthesia. Sensate bilobed flaps can be harvested when dual innervated flaps are required.     

The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches

The deep inferior epigastric artery provides the main blood supply to the lower abdominal wall. Microdissection of the artery, its main branches, and the perforator vessels was undertaken in 20 cadavers. The artery was found to be associated with two veins in most of the cases (90 percent). The lateral division of the deep inferior epigastric artery and the perforator vessels it gives are more dominant (80 percent of cases) than the medial perforators (20 percent of cases). The lateral perforators were greater in number (80) and more consistent than those that arose from the medial division (28). The musculocutaneous perforators are the most important perforators supplying the anterior abdominal wall. An average of 5.4 large perforators (>0.5 mm in diameter) were dissected in each case. These perforators are mostly contained in the area lying laterally and below the umbilicus, with an average distance of 4 cm from the umbilicus. The musculocutaneous perforators may have a direct or indirect course. Larger perforators (>0.5 mm in diameter) were found to have a direct course through the subcutaneous fat to the skin. Smaller perforators do not reach the skin but terminate at the level of the deep fat layer by branching after piercing the rectus sheath. The direct perforator vessels with their associated veins (microdissection) keep a consistent diameter before dividing at the subdermal level and end by contributing to the subdermal plexus.     

Reversed forearm island flap supplied by the septocutaneous perforator of the radial artery: anatomical basis and clinical applications

The cutaneous perforators of the radial artery adjacent to the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve were investigated, and the vascular anatomical features of the reversed forearm island flap supplied by those accompanying perforators were documented. Ten fresh cadavers were systemically injected with lead oxide, gelatin, and water. Twenty forearms were then dissected, and an overall map of the cutaneous vasculature and source vessels was constructed. The accompanying arteries were observed to lie along the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve and to nourish the skin through cutaneous branches. Vascular communication among these cutaneous vessels was evaluated, to determine the cutaneous vascular territory of the radial forearm flap. This anatomical information facilitates flap design in the forearm region. Clinical experience regarding the usefulness of the reversed forearm island flap for hand reconstruction for a series of five patients is presented.     

Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques

The preservation of sensitivity within the nipple-areola complex is of paramount importance to patients presenting for reconstructive and aesthetic breast procedures. Previous attempts to measure sensation in the breast before and after surgery have relied primarily on the Semmes-Weinstein monofilament test, which is an imprecise study that measures the logarithm of force necessary to bend a series of six to 20 filaments. Within the last 10 years, various authors have published normative pressure threshold data for the breast that have varied by a magnitude of greater than 10-fold. Recently, precise anatomic studies have been performed that have elucidated the innervation of the nipple-areola complex medially and laterally from cutaneous branches of the intercostal nerves. Despite this knowledge, no quantitative sensibility studies have yet been performed that compare postoperative sensation when medially versus laterally innervated pedicles have been used in reduction mammaplasty. The present study is the first to use computer-assisted neurosensory testing to generate normal breast sensation data and to compare sensory outcomes between the inferior and the medial pedicle techniques of reduction mammaplasty.A total of 34 patients were divided into four groups and underwent breast sensory testing (67 breasts total) using the Pressure-Specified Sensory Device, a computer-assisted force transducer that measures static and moving one and two-point discrimination. Sensation in the nipple and in the four quadrants of the areola was measured. Groups I and II were composed of 17 unoperated controls with breast sizes ranging from 34A to 36C (group I; 18 breasts) and 36DD to 46EE (group II; 16 breasts) who presented to a general plastic surgery clinic. Groups III and IV were composed of 17 patients who underwent either medial or inferior pedicle reduction mammaplasty between July of 1997 and March of 1999. Pressure thresholds in the most sensitive breasts were as low as 0.3 g/mm2, a marked contrast to data from previous studies using Semmes-Weinstein monofilaments documenting the lowest recordable pressure threshold as greater than 2 g/mm2. Several findings from previous studies using Semmes-Weinstein monofilament testing were confirmed in unoperated controls, including an inverse relationship between sensitivity and breast size, superior nipple sensitivity when compared with the areola, and significant interpatient variability with respect to static and moving two-point discrimination among women matched according to age and breast size. When comparing medial with inferior pedicle reduction mammaplasty patients, it was found that despite significantly greater reductions using the medial pedicle technique (mean of 1.7 kg versus 1.1 kg of breast tissue removed), there were no significant differences in postoperative sensory outcomes in the sample size of 17 patients. Furthermore, within each group of patients undergoing either the medial or inferior pedicle technique, the amount of breast tissue removed did not correlate with postoperative sensory outcomes.Computer-assisted quantitative neurosensory testing is a highly accurate technique for measuring sensibility. The use of this technology demonstrates a 10-fold difference in measurable sensory thresholds in normal patients from preexisting data using Semmes-Weinstein monofilaments. Advances in measurement methods have allowed the authors to compare postoperative sensory outcomes reliably using two popular techniques of reduction mammaplasty.     

Modified technique for nipple-areolar reconstruction: a case series

SUMMARY: Thousands of women undergo postmastectomy breast reconstruction each year. Part of the reconstruction of an aesthetically pleasing breast is a high-quality nipple-areolar reconstruction. The goals for this reconstruction include appropriate nipple projection, areolar color, and areolar texture. Presented in this article is a novel technique that achieves these goals without the need for harvesting a distant skin graft. The nipple-areolar reconstruction is performed under local anesthesia. A skate flap is designed to achieve the nipple reconstruction. The skate flap donor sites are closed primarily, and the outline of the areola is then defined with a round template. The skin is then incised at the border of the areola, and a full-thickness graft is elevated to the base of the reconstructed nipple. After hemostasis is achieved, the skin graft is placed back down in its original position and a bolster dressing is applied. Tattooing is performed 4 months postoperatively to achieve a color match. Twenty-four consecutive patients underwent 31 nipple-areolar reconstructions using this novel technique. All patients achieved excellent results without complications. One patient did experience a partial skate flap loss; however, the wound healed secondarily without the need for revision. The technique described herein can achieve the goals of nipple-areolar reconstruction, including appropriate nipple projection, areolar color, and areolar texture, without the need for a distant skin graft.     

Refinement of the central pedicle breast reduction by application of the ligamentous suspension

In a previous article, the location of the neurovascular structures inside the breast were exactly determined using a suspension apparatus, and how to access these structures was described. The horizontal septum originates at the level of the fifth rib and curves upward into vertically oriented medial and lateral ligaments, thereby guiding the main vessels and nerves to the nipple and areola. This topographical definition is relevant to increase the precision of resection in breast reductions. In further anatomic dissections of 20 female breasts, it was found that the horizontal septum constantly divides the breast into regular sections and, consequently, it can be used as a guide to achieve symmetry in breast reductions with a central pedicle. Using it provides a more predictable and reliable method of maintaining sensation and viability within the nipple-areola complex and attaining symmetry in both breasts. Because no dermal pedicle is necessary, the size of the resulting scar can be reduced. The suspending function of the ligaments provides improved ability to shape the breast. Using this understanding of the ligamentous suspension of the breast, it has been possible to perform safe breast resections with a central pedicle, irrespective of the amount of resection and risk factors. This new approach has been used on 42 patients.     

The nerve supply to the clavicular part of the pectoralis major muscle: an anatomical study and clinical application of the function-preserving pectoralis major island flap

The purpose of this study was to investigate the nerve supply to the clavicular part of the pectoralis major muscle so that the innervation to this part can be maintained in the muscle-preserving pectoralis major island-flap transfer. Although methods have been described that include a limited portion of the muscle while leaving the upper parts undisturbed with an intact motor innervation, reports on anatomical studies of this nerve supply are brief. The distal distribution of the nerves, the spatial relationship to the main vascular pedicle, and the ways to preserve them during surgical procedures remain unclear. Surgically relevant features of the clavicular part of the pectoralis major muscle were studied by dissection. The nerve supply to this part was examined on 11 sides of eight formalin-fixed cadavers. Two fresh cadavers were used for dissection, intraarterial polymer injection, and application of a nerve-preserving surgical technique. In all subjects, a separate nerve innervated the clavicular and upper medial sternocostal portions of the pectoralis major muscle. This nerve arises craniomedial to the main vascular pedicle of the flap and divides into several branches. These branches run in a fascia on the deep surface of the pectoralis major muscle, superficial to the origin and distal course of the vascular pedicle. Most branches to the clavicular part end medial to the coracoid process. The course of the branches to the upper sternocostal part is more medial. Based on their anatomical findings, the authors propose a surgical technique for transfer of the pectoralis major island flap to the head and neck area through a tunnel in the deltopectoral groove, lateral to the origin of the vascular pedicle. Head and neck reconstruction was performed using this technique. The presented method is a muscle-preserving procedure that maintains maximal donor-site function and morphology.     

Subcutaneous mastectomy. The excess skin problem.

Subcantaneous mastectomy through a lateral approach, with preservation of the nipple and areola on a dermal pedicle, removing the excess skin at the time of aubautaneous mastectomy, is a safe procedure which results in esthetically acceptable breasts. The surgical approach greatly facilitates the removal of the entire glandular portion of the breast. The need for a second surgical procedure is eliminated. Lateral biopsy scars can be reinforced by the dermal sling support, thereby decreasing the chances of exposure of the implant. The implant is also successfully and easily held in position by the use of the dermal-fat sling support. The nipple and areola survive quite well on the dermal pedicle, with preservation of contractility and sensation, as well as of blood supply.     

Relevance of the lesser occipital nerve in facial rejuvenation surgery

Nerve injuries are possible during facial rejuvenation surgery. The great auricular nerve has been studied; however, little is known about the lesser occipital nerve and its relevance in facial rejuvenation surgery. To understand the importance of the lesser occipital nerve in a face lift procedure, the specific anatomy of the nerve was studied in the laboratory in 19 hemifaces, with additional nerve observations in the operating room. The course of the lesser occipital nerve, its branches, and the relationship with the surrounding structures were evaluated and recorded. The great auricular nerve was also dissected to compare the two nerve territories. In the majority of the dissections, the lesser occipital nerve supplied the superior ear and the mastoid area, whereas the great auricular nerve innervated the inferior ear and a portion of the preauricular area. The nerves, however, were variable in size and distribution. Five lesser occipital nerves provided the dominant supply to the ear, compensating for a small great auricular nerve contribution. Therefore, injury to the lesser occipital nerve can result in a major sensory deficit of the ear. We also found the lesser occipital nerve to have a subcutaneous course at a proximal and variable level. These nerve branches can be superficial, and therefore postauricular flap dissection can injure the nerve if the flap is dissected at the fascial level. We therefore suggest that the dissection be at a more superficial level to avoid nerve injury. And finally, if SMAS/platysma suspension sutures are placed, we suggest these be done in a vertical-oblique direction along the course of the lesser occipital nerve, because this should minimize the possibility of trapping terminal branches.     

Improving safety and aesthetic results in inverted T scar breast reduction

Breast reduction using an inverted T scar skin design and a variety of glandular pedicle types is widely practiced and is the standard by which more recent limited scar techniques are judged. The inverted T procedures are attractive because they are predictable and versatile and permit great control over both the extent of reduction and the breast-shaping process. Despite these advantages, common criticisms of inverted T scar techniques include breast shape abnormalities, areolar malposition, hypertrophic scars, and poor long-term projection. Preoperative markings influence both safety and aesthetics. A method of skin marking that is based on a displacement method to determine vertical limb splay angle is described. This design concept must be modified to address certain variants, such as macromastia presenting with normal nipple position or large-diameter areolae, moderately severe macromastia, and macromastia involving radiated breasts. Safety in breast reduction is improved by paying attention to patient positioning issues, using techniques that minimize blood loss, raising flaps of appropriate thickness in the correct plane, and performing resection by observing the principles that reduce the risk of compromise of nipple and areolar circulation. Aesthetic results are improved by analyzing vertical breast meridian lengths during final breast shaping, modifying areolar shape as necessary, and carefully tailoring the medial inframammary crease. The latter is also important for minimizing the potential for scar hypertrophy. The principles presented have been refined during the course of a 12-year experience with several hundred breast reduction procedures. They contribute to improved results in inverted T scar breast reduction when practiced consistently.     

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 vascular territories of the superior epigastric and the deep inferior epigastric systems

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.     

Anatomic study of the vasculature of the submental artery flap

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.     

Two new cutaneous free flaps: the medial and lateral thigh flaps

Two new cutaneous free-flap donor areas are described on the medial and lateral sides of the thigh. The medial thigh flap is supplied by an unnamed artery from the superficial femoral artery and is drained by the accompanying venae comitantes. Its nerve supply is from the medial femoral cutaneous nerve. The lateral thigh flap has its vascular pedicle from the third perforating artery of the profunda femoral artery and its accompanying vein. The lateral femoral cutaneous nerve provides sensation over the area. These flaps provide a large surface area of both skin and subcutaneous tissue without the usual bulk of subcutaneous fat and muscle. Their desirable features include long vascular pedicles with large vessel diameters and potential of being neurovascular flaps with specific sensory nerve supply and predictable anatomy. The principal disadvantage is that the donor site may leave a slight contour defect with primary closure or require grafting when a large flap is taken. We predict that these flaps will become important donor sites for reconstructive problems requiring resurfacing of cutaneous defects in various anatomic areas.