History dependence of force production in submaximal stimulated rat medial gastrocnemius muscle

Studies on maximal stimulated muscle have shown that history dependence is an integral part of muscle force production. The purpose of this study was to evaluate the history dependent effects in submaximal stimulated muscle. For this purpose, lengthening and shortening experiments were performed on the medial gastrocnemius muscle of the rat. The length dependence of lengthening induced force enhancement and shortening induced force depression was studied in maximal (80 Hz) and submaximal (30 Hz) stimulated muscles. The most important results of this study are (a) submaximal stimulation reduces the maximal amplitude of the history effects and (b) lengthening induced force enhancement and shortening induced force deficit are affected differently by submaximal stimulation. The implication of these results for the underlying mechanism and functional relevance of the history dependent effects is discussed.     

Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection

To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.     

Nail lengthening and fingertip amputations

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult. In the period between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be used with different flaps for pulp reconstruction.     

Study of human muscle contraction using electrically evoked twitch responses during passive shortening and lengthening movements

Electrically evoked twitch properties of the human plantarflexor muscles were measured with the muscles at a constant length (static) and during passive shortening and lengthening. A Kin-Com dynamometer system was used to passively move the ankle joint at 0.52 rad s-1 (30 degrees s-1), as well as to record the twitch responses which were elicited by supramaximal electric shocks applied over the tibial nerve in the popliteal fossa. In the lengthening and shortening conditions, twitches were evoked by triggering the shocks so that the twitch response occurred at a similar angular position for all three conditions. The lengthening twitch peak torque was about twice as large as that recorded for the shortening condition. There was, however, no statistical difference in the twitch time course in these three testing conditions. This twofold increase in the peak twitch torque during lengthening, compared to shortening, is much greater than the torque increase reported during eccentric, as compared to concentric maximal voluntary contractions. These findings suggest that a deactivation process of the contractile system occurs during muscle shortening, while in contrast, during passive lengthening a potentiation mechanism is acting, and that both these mechanisms are independent of volitional muscle activation. The present study is the first to demonstrate the possibility of electrically evoked contractions of human muscles during passive lengthening and shortening. We believe that the use of such evoked contractions may be promising for the study of contractile behaviour of human skeletal muscles during eccentric and concentric conditions.     

The effects of the nitric oxide donor SIN-1 on ischemia-reperfused cutaneous and myocutaneous flaps

Ischemia-reperfusion injury causes tissue damage that leads to a decrease in bioavailability of nitric oxide. The authors hypothesized that an exogenous supply of nitric oxide will have beneficial effects on survival of skin and skeletal muscle subjected to ischemia-reperfusion injury. By using the nitric oxide donor SIN-1 (3-morpholino-sydnonimine) the effects of direct intraarterial infusion of an exogenous source of nitric oxide in reperfused flaps was studied. Bilateral island buttock skin flaps and latissimus dorsi myocutaneous flaps were elevated in eight pigs, for a total of 32 flaps. Flaps were subjected to 6 hours of ischemia followed by 18 hours of reperfusion. Flaps on one side of each animal were randomized to be treated with the nitric oxide donor (treatment group). The contralateral side was treated with an equivalent volume of saline vehicle (infusion control) SIN-1, or saline was administered as a continuous direct intraarterial infusion at the onset of reperfusion and continued during the observation period. Outcomes measured were tissue neutrophil accumulation by using myeloperoxidase assay and tissue survival (intravenous fluorescein and nitroblue tetrazolium for skin and muscle, respectively). In both skin and myocutaneous flaps, SIN-1 treatment caused a significant improvement in survival and a decrease in neutrophil accumulation. Nitric oxide may play an important role in the pathophysiologic process of ischemia-induced reperfusion injury in skin and skeletal muscle. Nitric oxide donors may be a promising family of therapeutic agents for the prevention of ischemia-induced reperfusion injury in cutaneous and myocutaneous flaps.     

Mathematical principle of planar Z-plasty

To extend the work of precursors attempting to use Z-plasties with angles that have arbitrary degrees and may or may not be equal in size, a comprehensive study was done to clarify and simplify the correlation among the angles, limbs, and diagonals of the geometrical construction of Z-plasties. In geometry, the truth of a proposition must be proved; it is a question to which the answer must be found. By law and formula, a ternary trigonometric equation was derived from a simplified geometric diagram by a trigonometric approach. A procedure declaration accompanies this formula; neither was previously mentioned in the literature.     

Voluntary activation level and muscle fiber recruitment of human quadriceps during lengthening contractions.

Voluntary activation levels during lengthening, isometric, and shortening contractions (angular velocity 60 degrees/s) were investigated by using electrical stimulation of the femoral nerve (triplet, 300 Hz) superimposed on maximal efforts. Recruitment of fiber populations was investigated by using the phosphocreatine-to-creatine ratio (PCr/Cr) of single characterized muscle fibers obtained from needle biopsies at rest and immediately after a series of 10 lengthening, isometric, and shortening contractions (1 s on/1 s off). Maximal voluntary torque was significantly higher during lengthening (270 +/- 55 N.m) compared with shortening contractions (199 +/- 47 N.m, P < 0.05) but was not different from isometric contractions (252 +/- 47 N.m). Isometric torque was higher than torque during shortening (P < 0.05). Voluntary activation level during maximal attempted lengthening contractions (79 +/- 8%) was significantly lower compared with isometric (93 +/- 5%) and shortening contractions (92 +/- 3%, P < 0.05). Mean PCr/Cr values of all fibers from all subjects at rest were 2.5 +/- 0.6, 2.0 +/- 0.7, and 2.0 +/- 0.7, respectively, for type I, IIa, and IIax fibers. After 10 contractions, the mean PCr/Cr values for grouped fiber populations (regardless of fiber type) were all significantly different from rest (1.3 +/- 0.2, 0.7 +/- 0.3, and 0.8 +/- 0.6 for lengthening, isometric, and shortening contractions, respectively; P < 0.05). The cumulative distributions of individual fiber populations after either contraction mode were significantly different from rest (P < 0.05). Curves after lengthening contractions were less shifted compared with curves from isometric and shortening contractions (P < 0.05), with a smaller shift for the type IIax compared with type I fibers in the lengthening contractions. The results indicate a reduced voluntary drive during lengthening contractions. PCr/Cr values of single fibers indicated a hierarchical order of recruitment of all fiber populations during maximal attempted lengthening contractions.     

The Tagliacozzi flap as a method of nasal and palatal reconstruction

A random flap of upper arm skin has been successfully used to reconstruct large nasal (seven patients) and palatal (three patients) defects. This method is an attractive alternative for nasal reconstruction in patients whose foreheads cannot be used. Problems of color match can be managed by subsequent resurfacing of the nose with a single-piece full-thickness graft taken from the supraclavicular area. Pedicle flaps can be transected 9 to 12 days after inset, thus shortening the immobilization period.     

Effects of sodium pentobarbital anesthesia on blood flow in skin, myocutaneous, and fasciocutaneous flaps in swine.

Drug effect on flap blood flow is most commonly determined in anesthetized animals, yet the effect of the anesthetic is often poorly understood. Halothane and nitrous oxide cause profound changes in skin blood flow and thus provide an unsuitable anesthetic technique for use in measuring drug effects on skin and myocutaneous flaps in swine. The goal of this study was to determine the effects of sodium pentobarbital anesthesia on cardiovascular parameters and blood flow in skin, myocutaneous, and fasciocutaneous flaps in pigs. In seven pigs, 7 forelimb skin flaps, 7 forelimb fasciocutaneous flaps, 14 arterial buttock flaps, and 14 latissimus dorsi flaps were created. Blood flow was measured at 2-cm intervals along each flap while the animal was awake and anesthetized. A cardiac depressant effect of pentobarbital was observed, but no change in blood flow could be demonstrated in control skin or control muscle. However, pentobarbital did significantly increase blood flow in all viable portions of arterial and random skin flaps, fasciocutaneous flaps, and the cutaneous segments of the latissimus dorsi flap. These demonstrated effects of pentobarbital should be taken into consideration in designing and analyzing studies of flap blood flow in the acute postoperative phase.     

Monitoring acute skin-flap failure

Reliable and repeatable means for the objective postoperative monitoring of skin flaps is a necessity. If a failing free flap can be recognized early, it can be salvaged by revision of the appropriate anastomoses. For the threatened distal portion of a conventional flap, external factors, such as kinking or hematoma, may be corrected or drug therapy instituted. We have analyzed blood from stab wounds in experimental pig flaps for pO2, pCO2, pH, and hematocrit. The results were compared with fluorescein penetration and flap surface temperature. The most significant finding was hematocrit readings of threatened flaps (54 percent) elevated above those of control flaps (35 percent). pH readings in the jeopardized flaps were 0.4 units below control. These two measures proved to be more reliable than intermittent temperature readings. In contrast to the fluorescein test, which can be used only once, stab wound analysis is repeatable at any time in the postoperative period. It can be effectively used to follow dynamic changes within a skin flap.     

Strength training improves the steadiness of slow lengthening contractions performed by old adults.

When old adults participate in a strength-training program with heavy loads, they experience an increase in muscle strength and an improvement in the steadiness of submaximal isometric contractions. The purpose of this study was to determine the effect of light- and heavy-load strength training on the ability of old adults to perform steady submaximal isometric and anisometric contractions. Thirty-two old adults (60-91 yr) participated in a 4-wk training program of a hand muscle. Both the light- and heavy-load groups increased one-repetition maximum and maximal voluntary contraction (MVC) strength and experienced similar improvements in the steadiness of the isometric and shortening and lengthening contractions. The increase in MVC strength was greater for the heavy-load group and could not be explained by changes in muscle activation. Before training, the lengthening contractions were less steady than the shortening contractions with the lightest loads (10% MVC). After training, there was no difference in steadiness between the shortening and lengthening contractions, except with the lightest load. These improvements were associated with a reduced level of muscle activation, especially during the lengthening contractions.     

Pharmacologic action of isoxsuprine in cutaneous and myocutaneous flaps

The therapeutic effects of isoxsuprine on skin capillary blood flow and viability were studied in arterial buttock flaps, latissimus dorsi myocutaneous flaps, and random skin flaps in pigs. It was observed that parenteral isoxsuprine increased capillary blood flow to the skin of arterial buttock flaps and the skin and muscle of latissimus dorsi myocutaneous flaps in a dose-response manner, with a maximum vascular effect observed at 1.0 mg/kg. However, this maximum effective dose of isoxsuprine did not have any significant effect on skin viability in the cutaneous and myocutaneous flaps compared with the control. Examination of the distribution of capillary blood flow within the flaps at varying distances from the pedicle revealed that isoxsuprine did not increase capillary blood flow or perfusion distance in the distal portion of the skin of arterial buttock flaps, latissimus dorsi myocutaneous flaps, and random skin flaps. The increased capillary blood flow as a result of isoxsuprine treatment was limited only to the arterial portion of the arterial buttock flaps and latissimus dorsi flaps. Therefore, it is concluded that isoxsuprine alone is not effective in augmentation of skin viability in cutaneous and myocutaneous flaps. The pharmacologic action of isoxsuprine on the vasculature in the skin and muscle of flaps was also discussed.     

Assessment of skin flaps using optically based methods for measuring blood flow and oxygenation

The objective of this study was to compare two noninvasive techniques, laser Doppler and optical spectroscopy, for monitoring hemodynamic changes in skin flaps. Animal models for assessing these changes in microvascular free flaps and pedicle flaps were investigated. A 2 x 3-cm free flap model based on the epigastric vein-artery pair and a reversed MacFarlane 3 x 10-cm pedicle flap model were used in this study. Animals were divided into four groups, with groups 1 (n = 6) and 2 (n = 4) undergoing epigastric free flap surgery and groups 3 (n = 3) and 4 (n = 10) undergoing pedicle flap surgery. Groups 1 and 4 served as controls for each of the flap models. Groups 2 and 3 served as ischemia-reperfusion models. Optical spectroscopy provides a measure of hemoglobin oxygen saturation and blood volume, and the laser Doppler method measures blood flow. Optical spectroscopy proved to be consistently more reliable in detecting problems with arterial in flow compared with laser Doppler assessments. When spectroscopy was used in an imaging configuration, oxygen saturation images of the entire flap were generated, thus creating a visual picture of global flap health. In both single-point and imaging modes the technique was sensitive to vessel manipulation, with the immediate post operative images providing an accurate prediction of eventual outcome. This series of skin flap studies suggests a potential role for optical spectroscopy and spectroscopic imaging in the clinical assessment of skin flaps.     

Physiologic changes of compound muscle action potentials related to voluntary contraction and muscle length in carpal tunnel syndrome.

The affect of muscle length and voluntary contraction upon compound muscle action potentials (CMAPs) in subjects with carpal tunnel syndrome (CTS) has been evaluated. Twenty-five hands in a CTS patient group and 29 hands in a normal subject control group were studied. The CMAPs from the abductor pollicis brevis induced by median nerve stimulation at the wrist were obtained for five thumb positions: neutral, abduction for shortening with and without contraction, and adduction for lengthening with and without contraction. Upon muscle shortening with relaxation, CMAP duration decreased in both groups, whereas waveform amplitude increased in the control group and showed no significant change in the CTS group. Muscle shortening with contraction afforded decreased CMAP duration and increased CMAP amplitude in both groups. Upon muscle lengthening with relaxation, both groups showed a reduction in CMAP amplitude and an increase in CMAP duration. Upon lengthening with contraction, CMAP duration decreased in the control group; in contrast, the CTS group showed further amplitude reduction and the waveform duration returned to the neutral value. These results demonstrate that, in patients with CTS, physiologic CMAP summations by muscle shortening or contraction may be less effective, whereas decreases in amplitude and increases in duration may be accentuated by lengthening and contraction.     

Ia-afferent input to motoneurons during shortening and lengthening muscle contractions in humans.

The central nervous system employs different strategies to execute specific motor tasks. Because afferent feedback during shortening and lengthening muscle contractions differs, the neural strategy underlying these tasks may be quite distinct. Cortical drive may be adjusted or afferent input regulated. The exact mechanisms are not clear. Here, we examine the control of synaptic transmission across the Ia synapse during shortening and lengthening muscle contractions. Subjects were instructed to maintain isolated activity in a single tibialis anterior (TA) motor unit while muscle length was varied from flexion to extension and back. At a fixed interval after a firing of the active motor unit, a single electrical stimulus was applied to the common peroneal nerve to activate Ia afferents from the TA muscle. We investigated the stimulus-induced change in firing probability of 19 individual low-threshold TA motor units during shortening and lengthening contractions. Any change in firing probability depends on both pre- and postsynaptic mechanisms. In this experiment, motoneuron firing rate was similar during both contraction types. There was no difference in the firing probability between shortening and lengthening contractions (0.23 +/- 0.03 and 0.20 +/- 0.02, respectively). We suggest that there is no contraction type-specific control of Ia input to the motoneurons during shortening and lengthening muscle contractions. Cortical adjustments may have occurred.     

An evaluation of eight methods of using fluorescein to predict the viability of skin flaps in the pig

The brightness of the fluorescence of fluorescein can be increased by the use of special (interference) filters that allow visualization of the dye when much smaller doses have been given. Standard random-pattern skin flaps were made in pigs and low (1 mg/kg) and high (500 mg) doses of fluorescein were given intravenously. The dye distribution in the flaps was evaluated visually, photographically, and with a dermofluorometer. All the methods proved reasonably accurate in predicting survival, although in an occasional flap, readings by all the methods were off by as much as 3.5 cm. The traditional Wood's lamp visualization proved to be as accurate as any of the newer methods. The inaccuracies of the fluorescein test are probably inherent in the method, since it only measures vascularity at the time the dye is given--and blood supply can change. The main advantage of low-dose fluorescein is that it allows repeated injections at reasonably close intervals. For serial observations, the dermofluorometer is unquestionably the best method.     

Cupping: from a biomechanical perspective

The effectiveness of the cupping technique, a treatment modality in Traditional Chinese Medicine, in stimulating acupuncture points for pain relief was examined in this paper from a biomechanical perspective. Parametric studies including the effects of vacuum pressure, loading rate, friction coefficient at the cup-skin interface, and size and shape of the cup were carried out using a model based on the finite-element method. The anatomical structures of skin, fat, and muscle were modelled. All the soft-tissue layers were assumed to be nonlinearly elastic and viscoelastic. The rim of the cup was also modelled to study the interaction between cup and skin; the cup rim was assumed to be rigid. The simulation results showed that the stresses in the soft tissue were increased for increasing applied vacuum pressures and that the effects of cupping were mostly limited to the region enclosed by the cup. The simulations also indicated that the magnitude of the applied vacuum may have had direct implications for the severity of bruising of the skin following cupping treatment. Most significantly, the simulation results contradicted the established practice of cup size selection according to the depth of the disorder. Experimental verification of the proposed multi-layered finite-element model is presented. The nature of the bruising inherent to the cupping treatment is also explained by the proposed model.     

Microsurgical reconstruction of the esophagus using supercharged pedicled jejunum flaps: special indications and pitfalls

This report outlines a microsurgical technique for total esophageal reconstruction in situations in which conventional methods using stomach or colon are not available. Eleven patients with corrosive injury and one patient following tumor resection underwent total esophageal reconstruction in a two-stage procedure. In the first stage, skin flaps or free jejunal transfers were used for the cervical reconstruction. In the second stage, supercharged pedicled jejunum flaps placed subcutaneously were used for thoracic esophageal replacement. The study included one male and 10 female patients, with a mean age of 38.4 years. The mean follow-up period was 78.9 months. All patients had one or more complications that required revisional surgery. Pedicled myocutaneous flaps were used to close fistulas or chronic wounds in four patients. The cervical skin tube in two patients and the jejunum in another two patients required shortening because of redundancy. Four patients had dysphagia caused by neck contractures, which were released. Two patients developed pharyngoesophageal strictures that required further free skin flaps for release. Two patients had reflux because of blind pouches arising from the original esophagus and required thoracotomy for removal. At long-term follow-up, all patients are fully rehabilitated and have resumed an oral diet with significant weight gain. Compared with lifelong jejunostomy feeding and its associated psychosocial disadvantages, the authors' experience demonstrates that the application of microsurgical techniques to fully reconstruct the esophagus is of considerable benefit to this difficult patient group.     

Biomechanical and viscoelastic properties of skin,SMAS, and composite flaps as they pertain to rhytidectomy

Previous studies have focused on biomechanical and viscoelastic properties of the superficial musculoaponeurotic system (SMAS) flap and the skin flap lifted in traditional rhytidectomy procedures. The authors compared these two layers with the composite rhytidectomy flap to explain their clinical observations that the composite dissection allows greater tension and lateral pull to be placed on the facial and cervical flaps, with less long-term stress-relaxation and tissue creep. Eight fresh cadavers were dissected by elevating flaps on one side of the face and neck as skin and SMAS flaps and on the other side as a standard composite rhytidectomy flap. The tissue samples were tested for breaking strength, tissue tearing force, stress-relaxation, and tissue creep. For breaking strength, uniform samples were pulled at a rate of 1 inch per minute, and the stress required to rupture the tissues was measured. Tissue tearing force was measured by attaching a 3-0 suture to the tissues and pulling at the same rate as that used for breaking strength. The force required to tear the suture out of the tissues was then measured. Stress-relaxation was assessed by tensing the uniformly sized strips of tissue to 80 percent of their breaking strength, and the amount of tissue relaxation was measured at 1-minute intervals for a total of 5 minutes. This measurement is expressed as the percentage of tissue relaxation per minute. Tissue creep was assessed by using a 3-0 suture and calibrated pressure gauge attached to the facial flaps. The constant tension applied to the flaps was 80 percent of the tissue tearing force. The distance crept was measured in millimeters after 2 and 3 minutes of constant tension. Breaking strength measurements demonstrated significantly greater breaking strength of skin and composite flaps as compared with SMAS flaps (p < 0.05). No significant difference was noted between skin and composite flaps. However, tissue tearing force demonstrated that the composite flaps were able to withstand a significantly greater force as compared with both skin and SMAS flaps (p < 0.05). Stress-relaxation analysis revealed the skin flaps to have the highest degree of stress-relaxation over each of five 1-minute intervals. In contrast, the SMAS and composite flaps demonstrated a significantly lower degree of stress-relaxation over the five 1-minute intervals (p < 0.05). There was no difference noted between the SMAS flaps and composite flaps with regard to stress-relaxation. Tissue creep correlated with the stress-relaxation data. The skin flaps demonstrated the greatest degree of tissue creep, which was significantly greater than that noted for the SMAS flaps or composite flaps (p < 0.05). Comparison of facial flaps with cervical flaps revealed that cervical skin, SMAS, and composite flaps tolerated significantly greater tissue tearing forces and demonstrated significantly greater tissue creep as compared with facial skin, SMAS, and composite flaps (p < 0.05). These biomechanical studies on facial and cervical rhytidectomy flaps indicate that the skin and composite flaps are substantially stronger than the SMAS flap, allowing significantly greater tension to be applied for repositioning of the flap and surrounding subcutaneous tissues. The authors confirmed that the SMAS layer exhibits significantly less stress-relaxation and creep as compared with the skin flap, a property that has led aesthetic surgeons to incorporate the SMAS into the face lift procedure. On the basis of the authors' findings in this study, it seems that that composite flap, although composed of both the skin and SMAS, acquires the viscoelastic properties of the SMAS layer, demonstrating significantly less stress-relaxation and tissue creep as compared with the skin flap. This finding may play a role in maintaining long-term results after rhytidectomy. In addition, it is noteworthy that the cervical flaps, despite their increased strength, demonstrate significantly greater tissue creep as compared with facial flaps, suggesting earlier relaxation of the neck as compared with the face after rhytidectomy.     

The role of serum imbibition for skin grafts

Numerous studies of grafted skin suggest that full-thickness skin grafts are nourished by exudate from the recipient bed called a serum imbibition. However, whether serum imbibition by itself is sufficient for nourishment of skin grafts has not been shown definitely and directly. To clarify the role of serum imbibition, we performed a comparative study between 20 skin grafts and 20 musculocutaneous flaps. The nourishment of the cell in the skin graft is by serum imbibition. That in musculocutaneous flaps is mainly derived from blood supply. We evaluated the nourishment by means of the unique characteristics of the cell cycle. Once cells are put into a synthetic phase, they cannot reverse or stop the progress of the cell cycle. To take advantage of this characteristic of the cell cycle, prewounding methods (40 flaps were lifted once and put back to the original sites prior to the evaluation) were intended for the cells in pre-elevated skin to turn into a proliferating phase. Cells were examined by antibody against proliferating cell nuclear antigen immunohistologically, to determine whether they had turned into the proliferating phase or not. After 3 days, all flaps were reelevated; half (20 flaps) had their muscle layer and the neurovascular bundle removed to make a full-thickness skin graft. The rest (20 flaps) were only lifted. They were sutured back to the original sites. Ten skin grafts and musculocutaneous flaps each were harvested at 3 hours (1st day) and at 11 days (11th day) after the second operation. Bromodeoxyuridine, which is a thymidine analog and is taken into the cells in the synthetic phase, was introduced intraperitoneally 2 hours before the harvest. All flaps and grafts were evaluated histologically and immunohistologically. Proliferating cell nuclear antigen analysis showed that the prewounding method induced the cells of skin grafts and musculocutaneous flaps to proliferate before the implantation. Regarding the bromodeoxyuridine uptake, no significant differences could be seen between skin grafts and musculocutaneous flaps irrespective of their different nourishment. No structural changes, such as degenerative or necrotic, could be seen at the hair follicle and other glands even at the 11th day. Almost all of the layers of skin grafts survived as long as they were checked by light microscopy (hematoxylin and eosin stain). No differences could be seen between musculocutaneous flaps and skin grafts or between the 1st and 11th days in this study. We concluded that serum imbibition is sufficient for nourishment of skin grafts, just as blood supply is sufficient for nourishment of musculocutaneous flaps.