Search

Scapulothoracic dissociation, particularly in combination with open fractures of the shoulder girdle, can be associated with significant soft tissue injury and present challenges with coverage and fixation. A single case of an open scapulothoracic dissociation was reviewed. Case presentation, clinical course and initial outcomes are discussed. A 22-year-old patient presented with an open left segmental clavicle fracture, sternoclavicular dislocation and scapulothoracic dissociation after being ejected in a motor vehicle collision. The shoulder girdle was initially stabilized with trans-clavicular trans-manubrial plating followed by staged pedicled rotational rectus abdominis flap. Follow-up at 1 month revealed well healed wounds and 90 degrees of forward flexion. Patients with open fractures and scapulothoracic dissociation can present multiple challenges when considering fixation and soft tissue coverage. A viable option in these patients is a pedicled rotational rectus abdominis flap when more typical coverage options are precluded from associated injuries.

Background The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. Methods A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. Results There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). Conclusions The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Summary Background The vertical rectus abdominis myocutaneous (VRAM) flap is an established technique employed to reconstruct pelvic and perineal defects not amenable to primary closure. The aim of this study was to systematically review the morbidity of VRAM flap reconstruction following exenterative pelvic surgery. Materials and methods A systematic literature search was conducted by using Medline, EMBASE, and Cochrane databases. Abstracts of all studies published from inception to November 2019 were identified. Search terms used included ‘vertical rectus abdominis myocutaneous’, ‘vertical rectus abdominis musculocutaneous’ and ‘VRAM’. Only studies that described outcomes when a VRAM flap was used during exenterative pelvic surgery were included; case reports were excluded. The primary outcome measure was VRAM flap morbidity. Secondary outcome measures included donor site morbidity and hospital length of stay. Results Sixty-five studies with a total of 1827 patients were identified and included. Perineal reconstruction was most commonly performed following abdominal perineal excision of the rectum (APER) (n = 636 and 34.8%). Median patient age at surgery ranged from 38 to 78 years. Mean perineal flap morbidity was 27%, with a complete flap loss rate of 1.8% and a perineal hernia rate of 0.2%. Mean donor site morbidity was 15%, with an abdominal dehiscence rate of 5.5% and an incisional hernia rate of 3.3%. Conclusions While overall morbidity after VRAM flap reconstruction in pelvic visceral surgery is high; the risk of major complications remains low. These data are important when counselling patients for surgery.

Summary Background The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh. Methods This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database. Results Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades. Conclusion All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Penile cancer accounts for 1-10% of men neoplastic diseases and 30-60% of patients have inguinal metastases at the time of diagnosis. Inguinal metastases of penile cancer with femoral vessel involvement could lead to vascular fistula and hemorrhagic shock. We present 3 consecutive patients with inguinal metastases of penile cancer complicated by infection and hemorrhage from femoral vessels invaded by the tumor. Simultaneous extra-anatomical axillo-femoral bypass graft, wide excision of tumor and groin defect reconstruction was used to achieve “tumor-free” oncologic aim and to save the lower limb. We consider the extra-anatomic axillo-femoral bypass associated with wide inguinal tumor excision and defect covering a feasible surgical solution for improving the life quality and extend life expectancy in patients with lymph node metastasis of penile cancer complicated by necrosis, infection and femoral vessel involvement.

Reconstruction of the vagina is usually performed in patients undergoing abdominal-perineal resection or pelvic exenteration for carcinoma of the cervix, vagina, or rectum. Vaginal reconstruction is indicated for both psychological rehabilitation and perineal wound healing. Immediate reconstruction after partial or total vaginal resection facilitates primary healing of the perineal defect, decreases fluid loss from the pelvis, reduces infection rate, prevents herniation of abdominal contents into the perineum, and decreases nutritional demands. Additionally, flap closure provides neovascularization of the remaining pelvic tissue, which is particularly important in successful wound healing for patients who have either had radiation to the area or who are having postoperative radiation therapy. Moreover, even in the sexually inactive patient, this surgery provides patients with faster healing and overall enhanced self-esteem

The rectus abdominis flap is a versatile, workhorse flap. It is ideal for head and neck reconstruction requiring large, soft tissue bulk without bony reconstruction, particularly for defects of the tongue, orbits, maxilla, cheek, posterior mandible, and cranial base. Its ability to be folded upon itself and harvested with multiple skin paddles makes it versatile for complex three-dimensional and multilaminar defects. Its pedicle size and length and consistent vascular anatomy make the flap a reliable choice for head and neck reconstruction. Its indications in head and neck reconstruction and technique in harvest are elaborated in this chapter.

Given their high rate of complications, radical surgical procedures of anorectal and gynecological tumors require a reliable and individualized reconstruction. The latter is influenced by the frequent indication of adjuvant chemo/radiotherapy that they present. We describe the case of a patient with medical history of vulvar carcinoma that required radical surgery and bilateral inguinal lymphadenectomy. Because of the stage of the tumor, the application of postoperative radiotherapy was clinically indicated; however, after surgery, the patient developed bilateral inguinal ulcers that made postoperative radiotherapy application impossible. Using a radical surgical approach in combination with postoperative radiotherapy increases survival in patients with these types of tumors. Therefore, delaying its use because of wound complications or inadequate reconstruction cannot be justified. The pedicled abdominal rectus flap is an excellent option for this purpose in patients with moderate- to large-sized defects.

Summary:. Carbon ion radiotherapy (CIRT) has been used for malignant tumors that are difficult to excise surgically, such as sacral chordoma, and the success of its outcomes is attributable to the high dose concentration and biological effects. CIRT has produced successful clinical outcomes, and it is considered to have fewer adverse effects on surrounding normal tissues; moreover, complications have been rarely reported. We describe a 75-year-old woman with a full-thickness sacral defect, who had received CIRT for sacral chordoma 3 years earlier. Computed tomography showed sacral bone destruction, and a colonoscopy revealed rectal necrosis. Rectectomy in addition to sacral bone resection was necessary, which resulted in a huge sacral defect of slightly anxious viability. We performed reconstruction of the sacral defect by using pedicled vertical rectus abdominis myocutaneous (VRAM) flap, obliterating sacral defects and intrapelvic dead space that occurred after rectectomy. Six months after surgery, the wound had healed well, and no complication was observed. Sacral complications after CIRT may affect surrounding normal tissues such as the rectum, and it would be difficult to reconstruct the resulting complications. The vertical rectus abdominis myocutaneous flap is considered useful for the simultaneous obliteration of sacral defects and intrapelvic dead space after CIRT.

Several techniques for vaginal reconstruction after pelvic exenteration such as myocutaneous and myoperitoneal flaps are available. However, the use of a myofascial flap has not been previously described. Thus, the objective of this article is to present our experience of vaginal reconstruction with rectus abdominis myofascial (RAMF) flap.Between May 2008 and March 2017, 16 patients underwent anterior, posterior, or total pelvic exenteration with RAMF flap vaginal reconstruction. Patient records were systematically reviewed; demographic, clinic and pathologic, operative details, flap-related and non-flap-related complications, and risk factors for wound healing are reported. Quality of life and sexual function were also investigated.Eleven (68.8%) of 16 patients died during the follow-up (29.1 ± 25 months), whereas 5 (31.3%) are still alive. Early complications were reported in 7 patients (43.8%), with 2 (12.5%) flap-related and 5 (31.3%) non-flap-related complications. Similarly, late complications were reported in 5 patients (31.3%), with 2 (12.5%) flap-related and 3 (18.8%) non-flap-related complications. Quality of life measured by SF-36 (Survey Short Form 36) significantly improved at 12-month follow-up in comparison with baseline (physical component summary 31.5 ± 4.8 vs 26.8 ± 2.9; P = 0.027; mental component summary 29.5 ± 6.0 vs 25.9 ± 2.0; P = 0.042).This study demonstrates for the first time that RAMF flap vaginal reconstruction after pelvic exenteration is an efficacious and safe technique. Furthermore, it is associated with a significant improvement of quality of life and sexual function in those women who had sexual intercourse before surgery.

Choke vessels dilate and contract to regulate blood flow between adjacent arterial angiosomes. In skin flap surgery, when arterial inflow to an angiosome is ligated, choke vessels allow blood supply from an adjacent angiosome. In muscle flap surgery, the vascular anatomy is analogous to skin flaps; however, while it is established that the choke vessels will fully dilate irreversibly after two to three days, no study has yet analyzed the acute changes in each vascular region immediately following ligation of one pedicle.To establish whether the choke vessels open or close immediately following ligation of a pedicle, and how this change affects blood flow in the adjacent proximal and distal vascular regions.Radioactive and fluorescent microspheres in a pig model were used to study the regional intramuscular blood flow in each anatomical zone of a rectus abdominis flap. Blood flow measurements for each zone were calculated relative to the entire muscle at preligation, ligation and various times (15 min to 90 min) postligation.There was no statistically significant difference in blood flow across choke zones as a result of ligation. This signifies that the choke vessels do not significantly dilate to produce a statistically significant measureable change in blood flow.Given these results and previous literature findings, the anatomical presence of choke vessels in a muscle is the strongest determining factor for acute flap viability in surgery.Les vaisseaux anastomotiques se dilatent et se contractent pour réguler le débit sanguin entre les angiosomes artériels adjacents. Dans le cadre d’une chirurgie par lambeau cutané, lors de la ligature du débit artériel vers un angiosome, les vaisseaux anastomotiques assurent un débit sanguin en provenance d’un angiosome adjacent. L’anatomie vasculaire est alors analogue aux lambeaux cutanés. Cependant, bien qu’il soit établi que les vaisseaux anastomotiques se dilatent pleinement et de manière irréversible au bout de deux ou trois jours, aucune étude n’a encore analysé les changements aigus de chaque région vasculaire immédiatement après la ligature d’un pédicule.Établir si les vaisseaux anastomotiques s’ouvrent ou se ferment immédiatement après la ligature d’un pédicule et examiner l’effet de ce changement sur le débit sanguin des régions proximales et distales adjacentes.Les chercheurs ont utilisé les microsphères radioactives et fluorescentes d’un porc pour étudier le débit sanguin intramusculaire régional de chaque zone anatomique d’un lambeau du grand droit. Ils ont mesuré le débit sanguin de chaque zone par rapport au muscle entier avant la ligature, au moment de la ligature et à divers moments (de 15 à 90 minutes) après la ligature.Il n’y avait pas de différence statistiquement significative du débit sanguin dans les diverses zones anastomotiques après une ligature. Ainsi, les vaisseaux anastomotiques ne se dilatent pas au point de produire un changement du débit sanguin pouvant être mesuré de manière statistiquement significative.Compte tenu de ces résultats et des conclusions de publications scientifiques, la présence anatomique de vaisseaux anastomotiques dans un muscle est le principal déterminant de viabilité aiguë d’un lambeau lors d’une chirurgie.

Perineal wound complications after abdomino-perineal rectal resection are frequent and clinically relevant for their impact on the length of hospitalization, costs, patients' quality of life and oncologic results. With the diffusion of the preoperative radiotherapy and the gradual shift to the extra-elevator technique, the perineal morbidity rate has increased. Many series describing different techniques of primary closure of the perineal defect have been published, but high-quality clinical studies, indicating which is the best option, are missing. A biologic mesh, associated if possible to an omentoplasty, seems to be sufficient to close the perineal defect after extra-elevator abdomino-perineal rectal resection. However, when the proctectomy is associated to the resection of other organs, as for example vagina or sacrum, resulting in an ample perineal defect, the vertical rectus abdominis flap seems to be the best option. If the perineal defect is smaller, the gracilis or gluteus flaps could be other valid alternatives.

The rectus abdominis flap offers a number of advantages over other flaps used in head and neck reconstruction. The flap can be harvested by a separate team and can be tailored to include skin, muscle, and fat. In addition, the available vascular pedicle is long and its large caliber provides an appropriate size match with recipient neck vessels. Central to reconstructive success is defining an arterial and venous pedicle that provides balanced perfusion to all components of the flap. Anomalous vascular anatomy presents principal challenges in reestablishing free flap perfusion. We present a case of double, right deep inferior epigastric arteries encountered during vertical rectus abdominis myocutaneous flap reconstruction of the tongue and floor of the mouth and discuss the clinical outcomes of this reconstruction.

Bien que le traitement du carcinome epidermoide de l’anus soit medical (radiochimiotherapie), l’amputation abdominoperineale (AAP) reste la seule alternative therapeutique si la radiotherapie est contre-indiquee ou en cas d’echec du traitement medical. La chirurgie de rattrapage des carcinomes epidermoides de l’anus est une chirurgie mutilante avec sacrifice du sphincter anal et confection d’une colostomie iliaque definitive. L’exerese en marge saine, qui constitue le principe fondamental de cette chirurgie, se traduit par une resection large du perinee dans un terrain irradie. Par consequent, la chirurgie du carcinome epidermoide est grevee d’une morbidite postoperatoire elevee en particulier en termes de cicatrisation perineale. Des techniques de reconstruction par lambeaux myocutanes ont ete developpees et ont permis de reduire cette morbidite. Dans un but d’eviction de la colostomie iliaque definitive, des techniques de colostomie perineale ont egalement ete decrites. Ces techniques de reconstruction perineale ont ete utilisees pour les adenocarcinomes du bas rectum avec des resultats satisfaisants sur le plan oncologique et fonctionnel. Cependant, il existe encore peu de donnees sur les colostomies perineales publiees. Leur faisabilite dans le cadre des carcinomes epidermoides de l’anus est limitee par l’etendue de la perte de substance perineale.

Although being a safe and standardised procedure, free-flap reconstruction can be harmful if unpredictable situations occur intraoperatively. The case presented reveals a situation in which an unscheduled interdisciplinary approach allowed to complete our reconstructive aim. An extensive defect at the thigh was planned for reconstruction by means of a free rectus abdominis flap. As the distant part of the flap showed a compromised perfusion during operation and had to be partially discarded, our colleagues from the vascular surgery department created an arterio-venous loop for anastomosis. This allowed a more distant positioning of the flap and ensured a complete defect reconstruction.

Healing tissues by first intention after abdominoperineal resection (APR) for rectal cancer (RC) is difficult to achieve due to the large tissue deficit and the anatomical and functional complexity of the pelvic region. APR in RC removes a much tissue that connects the abdominal cavity with the exterior of the body, with the risk of severe complications. APR must therefore be well planned out in a synchronous approach by an expert multidisciplinary team.

Purpose: In this study we compared the morbidity of breast-conserving surgery with mastectomy and immediate autologous reconstruction. To examine the restriction in movement and muscle strength after pedicled flap breast reconstruction, the patients underwent tests of function. Material and Methods: We followed up 144 patients with breast cancer in the period 2002 - 2004. Sixty-seven of them underwent breast-conserving surgery and 77 had mastectomy with immediate autologous reconstruction. To assess the impact of the muscular defect after pedicled flap reconstruction we performed functional tests of the donor area. Results: We were able to show that latissimus dorsi flap and transversus rectus abdominis flap are secure surgical procedures. We had no flap loss. There was only a slight restriction in movement in the donor area in 15% of the patients. There were no restrictions with regard to everyday life. Conclusion: Pedicled flap techniques are secure procedures for breast reconstruction (no flap loss) with low morbidity and do not affect patients in their everyday life. Microvascular flaps have to be measured against this standard.

Orbital exenteration is a devastating procedure because of the social impact and psychological stress put upon the patient. Besides cancer ablative surgery, reconstruction after removal of the tumor constitutes a major problem and the final aesthetic result is quite important. Both obliteration of the orbital cavity and continuation of the epithelial lining are required. Free rectus abdominis muscle and musculocutaneous flaps are versatile flaps which both enable filling the cavity and reconstituting the skin defect with a cutaneous portion or with a skin graft. Both free rectus abdominis muscle and musculocutaneous flaps were used for reconstruction of orbital exenteration defects in 19 patients. All suffered partial maxillectomy as well. The flaps provided satisfactory aesthetic results in all patients.

Introduction A persistent sinus is an annoying complication following proctectomy. We examined the experience of a single colorectal surgeon in treating this condition using pedicled flaps. Methods Case note review of all patients undergoing gracilis muscle transposition, Rectus abdominis muscle flap or omental flap for persistent perineal sinus. Results Seventeen patients were identified: seven had gracilis muscle transposition, eight had omental transposition and two had a rectus abdominis flap. 13/17 patients who underwent a flap had a persistent sinus following proctectomy for Inflammatory bowel disease. Four patients who had a gracilis muscle transposition achieved healing. Seven out of eight patients had good results with omental transposition. One patient did well after a rectus abdominis flap. Conclusions A gracilis transposition is a relatively simple operation with minimal morbidity useful for superficial sinuses not requiring a muscle bulk. A rectus abdominis flap is a more complex specialized procedure with better results especially in dealing with larger cavities but it may compromise future stoma sites. Omentoplasty has excellent results, but is only available in some patients.

Reconstructive surgery of the soft tissue of the head and neck is a challenge for the surgeon owing to the three-dimensional nature of the face and its tissues.

In this study, a simple modification of the C-V flap technique designed to maintain the neo-nipple projection performed as the last stage of breast reconstruction is described. The technique was used in seventeen patients who were treated with breast reconstruction using the transverse rectus abdominis flap. Except for one patient with a 2.3 mm decrease in nipple projection, the projection of all neo-nipples was preserved at the end of the mean follow-up period of 19.4 months. According to the results of our study, modifying the C-V flap technique by adding rolled triangular dermal-fat flaps improves the long-term maintenance of neo-nipple projection.

The progress in the last 25 years, utilizing the patient’s own tissue for reconstruction, has been amazing. Starting with the landmark procedure of the transverse rectus abdominis flap by Carl Hartrampf, autologous reconstruction has become much more reliable. The aesthetic outcomes have improved as well. This chapter discusses the various types of flaps which are currently employed and their advantages and disadvantages.

The rectus abdominis muscle is well known to be segmented by tendinous intersections into a certain number of serially arranged compartments. The tendinous intersections are present only on the anterior aspect and fused with anterior sheat of the muscle. Since the rectus abdominis is used as a graft, there are lots of studies in the literature about the rectus abdo- minis muscle and its intersections. In the dissection of a 64-year-old man at the Department of Anatomy of Ege University Medicine Faculty, an anatomical form of the rectus abdominis muscle not described in the available literature was encoun- tered. Both rectus muscles, right and left, were symmetrical but there were not any tendinous intersections on them. The total length of the muscle was 30 cm for both sides. The width at the umbilical level was 5.7 cm on the right side and 5.4 cm on the left side. The thickness of the muscle at the umbilical level was 0.5 cm for both sides. This previously unreported variation is very interesting for clinical approaches since the transverse rectus abdominis flap is an important reconstructive tool, particularly in reconstruction of the breast following mastectomy.

An inferior rectus abdominis flap was transferred in an 83-year-old female patient with a cervical esophageal carcinoma. This flap can be a good option for pharyngoesophageal reconstruction when it is desirable to avoid laparotomy and to shorten the operating time in an elderly or high-risk patient.

Total loss of both lips is fortunately rare as reconstruction of such defects poses an enormous challenge. We present a case of concomitant loss of both lips as a result of fulminant pneumococcal septicemia, which was reconstructed with a free vertical rectus abdominis myocutaneous flap due to lack of traditional donor sites.

The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79 %) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The authors report 8 cases of coverage of the inguinal and perineal areas with the inferiorly based rectus abdominis myocutaneous flap. This flap seems to be the technique of choice for coverage of such defects. The design of the flap can be explained by the low venous pressure zone concept.

Deep inferior epigastric (DIE) vessels, important to vascular apastomosis of an inferior rectus abdominis free flap, were studied clinicoanatomically. This study included morphologic and morphometric examinations of the DIE artery and vein. Bifurcations of the DIE vessels, venous valves, the inner diameters of the DIE vessels, and their lengths were recorded. The following results were obtained:1. Morphologic examination: 1) In the artery, single type (no bifurcation of the DIE artery observed) accounted for 72%. 2) In the vein, single type (no bifurcation of the DIE vein observed) accounted for 2%, distal type (two companion veins of the DIE vein come together to form one trunk before joining the external iliac vein) 33%, medial type (two companion veins of the DIE vein come together just at the point of joining the external iliac vein) 14%, and direct type (two companion veins of the DIE vein join the external iliac vein independently) 2%. 3) The DIE artery anastomosed with the superior epigastric artery in the upper abdomen. 4) Numerous surface branches of DIE arteries were evident in the paraumbilicas region. 5) Most venous valves were bicuspid. 6) Most venous valves were at the bifurcation in the distal type.2. Morphometric examination: 1) The mean inner diameter of the DIE artery 5 mm distal from the DIE artery junction was 1.9±0.5 mm. 2) The mean inner diameters of the DIE veins 5 mm distal from the external iliac veins were 1.7±1.1 mm in the medial type, 2.5±1.5 mm in the distal type, 2.1±1.1 mm in the direct type, and 2.6 mm in the single type. 3) The maximum mean length of artery that could be used as a vascular pedicle was 12.3±2.5 cm.

The serratus anterior muscle was used as a free tissue transfer to reconstruct complex craniofacial defects in 5 patients. Serratus anterior muscle alone and serratus anterior muscle with rib were the transfers made. All flaps survived and scapular winging did not occur. The serratus anterior muscle has several advantages for the reconstruction of medium-sized craniofacial defects. Because of its position, a two-team approach is possible. It has a consistent pedicle anatomy and low donor site morbidity. It has a large caliber vessel and a long pedicle. When compared with the commonly employed rectus abdominis flap for moderate-sized defects, the serratus muscle offers greater versatility in design and has the option of incorporating bone and innervated muscle without increasing significant donor site morbidity.

The rectus abdominis flap has been widely utilised but a disadvantage is that the flap is rather thick. We have succeeded in preparing a stable thin flap in obese patients. This has been achieved through prefabrication by the subcutaneous insertion of a silicone sheet adjacent to a conventional deep inferior epigastric flap.

Treatment of empyema after pneumonectomy is challenging. We treated 4 patients with postpneumonectomy empyema using a free rectus abdominis myocutaneous flap together with a pedicled pectoralis major muscle flap. The pectoralis major flap was used to fill the apical portion of the cavity, while the rectus abdominis flap was used to fill the caudal portion and occlude any bronchial fistula present. All empyemas were treated successfully without recurrence. This method has the advantage of filling apical and caudal parts of the space at once, making effective use of the combined volume of the two flaps.

The distally based rectus abdominis myocutaneous flap is an important adjunct to radical pelvic surgery. It can be used to fashion a functional neovagina or to create a patch to cover perineal defects created by exenterative surgery. This report reviews the technical aspects of the creation of this flap and our experience with 22 patients who have undergone this procedure. The flap has been found to be technically easy to create. It is reliable with little tissue loss, and donor site complications are acceptable. Healing is aided by filling the pelvic dead space, thereby decreasing bowel complications, and by bringing a new blood supply into the operative site which has often been heavily irradiated. Operative time is minimized since the procedure requires only unilateral mobilization. Subsequent abdominal surgery has been performed without fascial complications.

We described our experience with a recurrent case of buccal cancer in which reconstruction was performed with a skin-grafted rectus abdominis flap. The patient was a 61-year-old woman. She had been undergone tumor excision and reconstruction with a D-P flap at 54 years of age (histopathological diagnosis, acinic cell carcinoma). Recurrence occurred 7 years later. We planned to excise the tumor and perform reconstruction with a rectus abdominis flap. A rectus abdominis flap was prepared before tumor excision, at the same time, free skin was grafted to the raw surface of the flap. Three weeks later, the tumor was excised, and reconstruction was performed. The rectus abdominis flap covered with skin was positioned so that the skin side of the flap formed the cheek and the graft side formed the oral wall. Fat reduction of the flap was performed 18 days later. The flap was successfully transplanted without any necrosis. The outcome was excellent because the flap resembled the natural curve of the cheek. This method is useful for secondary reconstruction and for reconstruction after excision of benign tumors or slowly progressing cancers, such as salivary grand carcinomas.

Recently, microvascular tissue transplantation has come to be generally used for oral and maxillofacial reconstruction. The present status of clinical use of microvascular tissue transplantation for maxillofacial lesions was investigated at 335 oral and maxillofacial surgery centers in Japan. The number of reported was cases 687. Among these, 497 (72.4%) received forearm flap transplantation. A rectus abdominis flap was employed in 104 cases (15.2%). The total survival rate of all transplants was 89.1%

Background. Many reconstructive procedures for large vulvoperineal defects have been described. The present report describes the use of the rectus femoris myocutaneous flap, which has not previously been described for this purpose. Case. A 52-year-old woman suffered a local recurrence of a Bartholin's gland carcinoma after anterior exenteration and pubectomy. A palliative resection was performed which resulted in a large vulvoperineal defect with transpelvic herniation of the peritoneal contents. This was immediately reconstructed with a rectus femoris myocutaneous flap. Her postoperative course and healing were uneventful. Conclusion. This technique is an alternative method for vulvar reconstruction. It is especially useful for large defects when a gracilis or rectus abdominis flap is not available.

We present a case with vertical rectus abdominis myocutaneous free flap in which deep inferior epigastric perforators does not nourish skin paddle of the flap. The skin paddle of musclocutaneous flaps is nourished by musculocutaneous perforators originating from the main vascular system of the muscle. The skin paddle of rectus abdominis flap is also supplied by musculocutaneous perforators of deep inferior epigastric artery (1). Cutaneous perforators end directly within the skin. Their origin may be either from the source artery or from the subcutaneous or fascial brances (2).

This is the first report of a case of aesthetic calf augmentation with microvascular transferred autologous material. The technique regarding to calf augmentation using silicon prostheses is described and the advantages and disadvantages of this method are discussed. This should incite discussion on the use of free-flap technique in aesthetic operations.