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Supplemental Digital Content is available in the text., Background: The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors’ technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure. Methods: Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors’ surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift. Results: Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury. Conclusion: The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The lower eyelid is one of the commonest areas Asian patients present for rejuvenation. The spectrum of patients presenting for treatment ranges from the young to the more mature. Young patients present with "premature" aging due to an anatomical predisposition. These are patients we figuratively call those who "do not age well." Even patients with strong skeletal support manifest aging, in a predictable and progressive manner. Such patients eventually benefit from quality esthetic surgery of the lower eyelid and mid cheek.

Facial thread-lifting (FTL) has gained more popularity, but the incidences of complications following FTL remain controversial. We aimed to perform a meta-analysis and systematic review to estimate the incidences of complications and to compare the short- and long-term satisfaction rates following FTL.We searched PubMed, Web of Science, Embase and Cochrane library for eligible studies. The primary outcome was the incidences of complications following FTL. The secondary outcome was the satisfaction rate immediately and 6-month after FTL. The pooled incidences of complications and 95% confidence intervals were estimated using random-effects models.A total of 26 studies were included in this meta-analysis. Swelling was the most commonly reported complication with a pooled incidence of 35%, followed by skin dimpling (10%), paresthesia (6%), thread visibility/palpability (4%), infection (2%), and thread extrusion (2%). Absorbable threads were associated with a significantly lower risk of paresthesia (3.1% vs. 11.7%) and thread extrusion (1.6% vs. 7.6%) than non-absorbable threads. Patients older than 50 years had a significantly higher risk of dimpling (16% vs. 5.6%) and infection (5.9% vs. 0.7%) than their younger counterparts. In addition, the pooled long-term satisfaction rate was significantly decreased compared to it immediately after FTL (88% vs. 98%).Non-absorbable threads and older age of patients are associated with higher risks of complications. Therefore, we recommend a judicious use of non-absorbable threads and FLT in older patients. Furthermore, it should be discussed with patients preoperatively that the rejuvenation effect of FTL may not maintain in the long-term.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 .

Given the central importance of the "eyes," meaning the periorbital region, to facial appearance, the motivated blepharoplasty patient has the opportunity to improve appearance significantly beyond the minimum of age reversal, to reveal inner beauty or add attractiveness. Bright and beautiful eyes have good three-dimensional contouring. The benefits of a quality eyelid crease enable the surgical focus to be on lid contouring with a reduced requirement for lid skin and fat excision. A durable crease maintains fixation of both the tarsal and infrabrow segments. The softness of youthful eyes can be regained by precise, but cautious, use of lipofilling.

Background The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes. Objectives The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors’ clinical experience and outcomes with this technique are presented. Methods Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance. Results A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%. Conclusions This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients. Level of Evidence: 4

Asian upper blepharoplasty is one of the most commonly requested procedures in Asian patients. Many incisional and suture methods have been described in the literature. While the suture method is advantageous for its simplicity and quick recovery, the incision method is more versatile and able to deliver predictable and reproducible results for Asian patients presenting with a diverse range of anatomy and requests. Accordingly, the incision method remains the preferred approach for many surgeons performing Asian upper blepharoplasty. In this paper, we detail our open incision hinge upper blepharoplasty technique to create dynamic upper eyelid creases in Asian patients. The surgical videos associated with this paper present our surgical technique in detail, highlighting technical refinements and surgical nuances to perform the surgery precisely and predictably. The conceptual core of our approach is the use of a vascularized orbital septum as a flap to create a fibrous extension from the levator aponeurosis to the dermis at the location of eyelid crease. This vascularized flap securely connects the posterior lamella with the anterior lamella to securely form the eyelid crease with eye opening. This most accurately recreates the anatomy that is present in attractive Asian patients with naturally occurring double eyelid and predictably creates a dynamic and crisp upper eyelid crease. LEVEL OF EVIDENCE V: 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 .

Upper eyelid ptosis correction is a complex procedure. The ethnic differences in the Asian upper eyelid anatomy are compounded by the technical challenges of primary and revision ptosis correction. The authors present a technique of upper eyelid ptosis correction that estimates the exact location of suture fixation that uses the musculoaponeurotic junction of the levator as the reference point. The preoperative considerations in determining the fixation point relative to the musculoaponeurotic junction include the following: A, the extent of ptosis correction needed; B, the degree of compensatory brow elevation with eye opening; and C, eye dominance. The benefits of this approach are the shortened operative time because of more precise preoperative planning and greater predictability and reproducibility of the results. The authors have found that this technique produced consistent and superior results for ptosis correction in Asian patients.

Background Asian cleft rhinoplasty is a unique procedure with specific challenges. Objectives This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach. Methods An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated. Results From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low. Conclusions The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients. Level of evidence 4.

Logical correction of aging contour changes of the face is based on understanding its structure and the processes involved in the aging appearance. Aging changes are seen at all tissue levels between the skin and bone although the relative contribution of each component to the overall change of facial appearance has yet to be satisfactorily determined. Significantly, the facial skeleton changes profoundly with aging as a consequence of significant resorption of the bones of dental origin in particular. The resultant loss of skeletal projection gives the visual impression of descent while the reduced ligamentous support leads to laxity of the overlying soft tissues. Understanding the specific changes of the face with aging is fundamental to achieving optimum correction and safe use of injectables for facial rejuvenation.

Introduction The anterolateral thigh flap is one of the commonest soft tissue flap performed today. The rectus femoris is dominantly supplied by the vascular pedicle which takes off from the same source artery that is harvested with the anterolateral thigh flap. Therefore, the blood supply of the rectus femoris may potentially be compromised when harvesting the anterolateral thigh flap. This study revisits the blood supply of the rectus femoris in the light of recent advances in the understanding of the vascular anatomy of the anterolateral thigh. Materials and methods From January 2010 to June 2011, a prospective intraoperative observational study was performed in 50 consecutive anterolateral thigh flaps, noting the dimensions and locations of (1) the descending branch, (2) the presence of the oblique branch of the lateral circumflex femoral artery, and (3) the number and size of the muscle branches supplying the rectus femoris. Temporary selective occlusion with microvascular clamps was performed to evaluate the dominance of the blood supply to the muscle. Flap harvest was then completed as planned. Results The oblique branch was noted to be present in 23 (46%) of 50 patients. Of these, 21 (91%) of 23 of oblique branches supplied a large muscle branch to the rectus femoris. When the descending branch alone was present, occluding the dominant pedicle will usually compromise the blood supply to the muscle. In situations where 2 large muscle branches arise from the descending and oblique branches, occlusion of either pedicle did not affect the circulation of the rectus femoris, demonstrating codominance in this situation. Conclusions The vascularity of the rectus femoris can be classified as either a type A or B. Type A rectus femoris is the classic pattern with a single dominant pedicle from the descending branch. Type B rectus femoris is seen when an oblique branch supplies a codominant pedicle to the muscle. The implication of this anatomy is that in a type B rectus femoris, one of the 2 muscle branches can be safely ligated to increase the pedicle length when harvesting of the anterolateral thigh flap, without compromising the vascularity of the muscle.

This anatomical study was undertaken to define the soft-tissue spaces, retaining ligaments, and their relations in the midcheek.Sixty fresh hemifaces were dissected. The retaining ligaments and facial spaces were defined and their dimensions recorded. The course of the key vessels and branches of the facial and infraorbital nerves were defined and their anatomical relations noted.The preseptal and prezygomatic spaces underlie the lid-cheek and malar segments of the midcheek. A previously undocumented soft-tissue space, the premaxillary space, was found to underlie the nasolabial segment. The retaining ligaments of the midcheek are the tear trough-orbicularis retaining ligament complex in the upper midcheek and the zygomatic and maxillary ligaments in the lower midcheek. The tear trough-orbicularis retaining ligament complex separates the preseptal space above from the prezygomatic and premaxillary spaces below. Facial nerve branches in the midcheek are closely associated with the zygomatic ligaments located outside the lower boundary of the prezygomatic space and are protected so long as the dissection is kept within this space. The infraorbital nerve is protected by the floor of the premaxillary space, formed by the levator labii superioris and, at the inferior boundary of the space, by the close relation with the maxillary ligaments.This study completely defined the spaces and retaining ligaments of the midcheek. Knowledge of this anatomy is key to safe and atraumatic suborbicular dissection for effective midcheek lifts.

The premasseter space is a recognized, sub-superficial musculoaponeurotic system (SMAS) soft-tissue space overlying the lower masseter immediately anterior to the parotid. The performance, safety, and effectiveness of composite face lifts are enhanced when the space is used. This has drawn attention to the need for better understanding of the premasseter anatomy above the space.The anatomy of the upper premasseter region was investigated in 20 fresh cadaver dissections as well as intraoperatively in hundreds of composite face lifts.A small, transverse, rectangular soft-tissue space overlies the upper masseter and was named the middle premasseter space. The space (transverse width, 25 to 28 mm; vertical width, 10 mm) is separated from the originally described (lower) premasseter space by a double membrane. It is a safe space between the upper and lower buccal trunks of the facial nerve, which are immediately outside the space and separated from it by the respective upper and lower boundary membranes. The parotid duct immediately beneath the floor of the space usually underlies the upper boundary membrane.The middle premasseter space is significant, as it is the center of the key anatomy immediately cephalad to the lower premasseter space. When used in composite face lifts, the space provides predictable sub-SMAS dissection between the buccal trunks of the facial nerve to the mobile area beyond the anterior border of the masseter where the SMAS overlies the buccal fat pad.

The goals of reconstruction in the foot and ankle should be to restore ambulation and enable the patient to use normal footwear. In these wounds, free fasciocutaneous flaps provide pliable protection and gliding of tendons. There can however be problems with contour and bulk. We describe the combined use of liposuction and arthroscopic shaving to achieve effective flap contouring in a single session. We performed the technique in 10 free fasciocutaneous flaps in nine patients. The average interval between the initial reconstructive procedure and flap debulking was 7 months. Complications included two cases of flap superficial epidermal loss and one haematoma. At an average of 8.6 months follow-up, five patients reported that they were very satisfied with the procedure, three were satisfied and one was dissatisfied. Seven of the nine patients were using their original covered footwear at the time of follow-up. In conclusion, the combined use of liposuction and arthroscopic shaving is simple and effective in the contouring of fasciocutaneous flaps leading to good patient satisfaction and enabling the use of normal footwear.

Background The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap. Methods Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks. Results The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases. Conclusion Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications. Clinical question: Therapeutic Level of Evidence: IV

Background The exact anatomical cause of the tear trough remains undefined. This study was performed to identify the anatomical basis for the tear trough deformity. Methods Forty-eight cadaveric hemifaces were dissected. With the skin over the midcheek intact, the tear trough area was approached through the preseptal space above and prezygomatic space below. The origins of the palpebral and orbital parts of the orbicularis oculi (which sandwich the ligament) were released meticulously from the maxilla, and the tear trough ligament was isolated intact and in continuity with the orbicularis retaining ligament. The ligaments were submitted for histologic analysis. Results A true osteocutaneous ligament called the tear trough ligament was consistently found on the maxilla, between the palpebral and orbital parts of the orbicularis oculi, cephalad and caudal to the ligament, respectively. It commences medially, at the level of the insertion of the medial canthal tendon, just inferior to the anterior lacrimal crest, to approximately the medial-pupil line, where it continues laterally as the bilayered orbicularis retaining ligament. Histologic evaluation confirmed the ligamentous nature of the tear trough ligament, with features identical to those of the zygomatic ligament. Conclusions This study clearly demonstrated that the prominence of the tear trough has its anatomical origin in the tear trough ligament. This ligament has not been isolated previously using standard dissection, but using the approach described, the tear trough ligament is clearly seen. The description of this ligament sheds new light on considerations when designing procedures to address the tear trough and the midcheek.

In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results. Level of Evidence IV 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. Electronic supplementary material The online version of this article (doi:10.1007/s00266-012-9904-3) contains supplementary material, which is available to authorized users.

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.

Background: In patients with extensive bone and soft-tissue defects, the inclusion of the hemisoleus muscle with the fibula osteoseptocutaneous flap would provide the needed soft-tissue volume to the flap. This study evaluates the reliability and technical considerations for the inclusion of the hemisoleus with the fibula and skin paddle as a chimeric, peroneal artery-based flap. Methods: The location and size of major arterial branches of the peroneal artery supplying the lateral hemisoleus muscle were investigated in 10 cadaveric injected lower limb specimens. The utility of this design was demonstrated in five clinical cases. Results: The lateral hemisoleus was noted to be consistently supplied by large muscle branches from the peroneal artery, soleus vessels 1 (proximal) and 2 (distal). The mean diameter and distance from the origin of the peroneal artery for soleus vessels 1 and 2 were 1.8 mm and 2.1 cm, and 1.6 mm and 6.3 cm, respectively. The fibula osteoseptocutaneous flap incorporating the hemisoleus muscle was performed in five clinical cases. All were successful. Either soleus vessel 1 or soleus vessel 2 can be used as the pedicle to the muscle, depending on the specific reconstructive requirements for the reach and placement of the hemisoleus. Conclusions: The fibula osteoseptocutaneous flap incorporating the hemisoleus muscle can reliably be raised by preserving constant muscle branches that arise from the peroneal artery to supply the lateral hemisoleus. This flap provides the additional bulk in selected cases, with little additional donor-site morbidity.

Contour asymmetry of the legs is a major aesthetic concern among Asian women. This study enrolled 60 patients with asymmetric calf hypertrophy, defined as a differential calf circumference exceeding 0.6 cm. Differential selective neurectomy techniques, which depend on the sizes of the small and large calves, were performed exactly via a 1-cm popliteal wound. The pre- and postoperative mean differences between the larger and smaller calf circumferences at the 1-year follow-up consultation were 1.38 +/- 0.65 and 0.42 +/- 0.38 cm, respectively (p0.01). The reduction was significantly greater in the leg that was initially larger. The procedure was effective in reducing circumference discrepancies so that leg contours were more balanced. All the patients were able to ambulate normally within 5 months after the procedure without disability. The authors posit that differential neurectomy is a safe and reliable technique for the correction of asymmetric calf hypertrophy, with minimal morbidities.

Summary Introduction The purpose of this study was to demonstrate the reliability and advantages of the slit arteriotomy for end-to-side arterial anastomosis. Materials and methods Sixty free flaps for reconstruction of the upper and lower extremities were re-vascularised using this technique. Flaps used were: gracilis (20), latissimus dorsi (18), rectus abdominis (6), lateral arm (6), fibula (3), radial forearm (4), scapular (1) and anterolateral thigh (2). Technique: A double microclamp is applied. Using a 30° microknife, a longitudinal slit is made on the recipient vessel. The clamps are then approximated slightly. This slackens the segment bearing the slit and opens up the slit to facilitate placement of sutures. Beginning at the heel, interrupted sutures are placed in such a way as to feed the redundancy of the donor artery wall towards the toe of the anastomosis. A slightly oversized slit is used to stretch the donor vessel, which due to its inherent elastic recoil keeps the anastomosis patent. Once the tourniquet is released, blood flow resumes and the slit forms an elliptical opening. A video is available for viewing at our website: www.microflap.com. Results The arterial patency rate was 98%. The mechanical advantage of the slit arteriotomy construct was demonstrated through computer simulation on a finite-element analysis model. Conclusion The slit arteriotomy is simple, reliable, and can be consistently used in the transfer of free flaps to the extremities. As no portion of the recipient vessel wall is excised, the anastomotic diameter is increased. This promotes blood flow through the anastomosis.

The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospective intraoperative analysis of the vascular anatomy of the lateral thigh that focuses on clinically important variations that impact flap harvest.Eighty-nine consecutive anterolateral thigh flaps were harvested. A detailed intraoperative analysis was performed of the vasculature anatomy and variations of the pedicle encountered during dissection.Fasciocutaneous flaps were harvested in 82 percent (73 of 89) and myocutaneous flaps were harvested in 17 percent of cases (15 of 89). Sizable perforators were absent in 1 percent of the cases (one of 89). A mean of 1.9 sizable cutaneous vessels were identified. Musculocutaneous perforators were noted in 85 percent of cases and septocutaneous vessels were seen in 15 percent. Most septocutaneous vessels were located in the proximal thigh. In the midpoint of the thigh, musculocutaneous perforators predominate. Those located within 1 cm of the septum characteristically have a short, direct intramuscular course. In contrast, those located more laterally and distally in the thigh characteristically have a tortuous intramuscular course. An oblique branch of the lateral circumflex femoral artery was noted to be present in 35 percent of cases (31 of 88), and the dominant perforator supplying the anterolateral thigh was noted to originate from this branch in 14 percent of cases (12 of 88).This study further clarified the vascular pedicle anatomy of the anterolateral thigh. The existence of the oblique branch of the lateral circumflex femoral artery in a proportion of patients and its reliability when used as the flap pedicle were demonstrated.

Suprafascial radial forearm flaps cause far less donor morbidity compared with the conventional method of including the deep fascia. Here we describe our technique of harvesting the flap with a bottom-up approach, which simplifies flap elevation and is safe and expedient. The radial artery pedicle is ligated distally and secured to the flap. Gentle traction on the pedicle presents the inferior surface of the pedicle, facilitating dissection. The superficial layer of the deep fascia is taken with the flap, together with a generous cuff of subcutaneous tissue above the pedicle in which vessels nourishing the flap are located. It is crucial to preserve the conjoin of the deep layer of the deep fascia to the fascia covering the brachioradialis laterally and flexor carpi radialis medially. This fascial layer prevents bow-stringing of the tendons during wrist and finger flexion and allows the use of a full-thickness skin graft to close the donor site. The latter delivers superior cosmetic results than can be achieved with a split-thickness skin graft.

Variations of the distally based sural artery flap have been used in the literature with varying success rates. This article stresses the axiality of this flap based on the sural nerve and the short saphenous vein. Forty distally based sural artery flaps were used for a variety of defects in the distal leg. In the proximal leg, the groove between the medial and lateral heads of the gastrocnemius muscle was explored to include the subfacial part of the medial sural nerve with the flap. The subfascial part of the nerve can consistently be included with the flap and gives off cutaneous supply to the tip of the flap to increase reliability of the distal part of the flap. The short saphenous vein should be harvested with an additional length to allow for supercharging or intermittent bleeding in the event of flap congestion. With this approach our success rate with this flap was 98%. To maximize the reliability of the distally based sural artery flap, the sural nerve and short saphenous vein must be included with the flap along its entire length.

Advancements in microsurgical techniques as applied to perforator flaps have made harvesting flaps in a free-style manner a practical reality. A hand-held Doppler identifies sizable perforators on which flaps can be based. In free-style free flap harvesting, any region of the body can be chosen as a donor site as long as there is an audible pulsatile Doppler signal. The value of the free-style free flap concept lies in its ability to overcome anatomical variations. The clinical application of raising flaps in a free-style manner has been demonstrated in the thigh where flaps have been raised safety and reliably in spite of the many anatomical uncertainties in this area. Flaps can, thus, be designed and raised in any region of the body to suite the unique requirements of individual cases. However, limitations to the clinical application of the free-style free flap should be noted; the course of the perforator may be unpredictable. Small and long perforators may be difficult to harvest and inset. Furthermore, the skin territory and intra-operative flap thinning should more conservative compared with conventional flaps. These shortcomings can however be overcome by clinical experience and improvement in surgical techniques.

The propeller-type flap design is increasingly used in reconstructive surgery for various regions of the body. To date, determinants of perforator patency when subjected to twisting have not been elucidated. We propose a simulation model to study parameters affecting perforator patency under such conditions. Nonlinear finite element procedure was used to simulate a perforator consisting of an artery and a vein with both ends fixed. A rigid body was attached to the top of the perforator for applying prescribed angular displacement. The effect of the following parameters on the pedicle patency was determined: (1) increasing angle of twist, (2) vessel stiffness, (3) vessel length, (4) diameter, (5) intraluminal pressure, and (6) the presence or absence of blood flow during twisting. Simulation results were reported in effective stress and strain on the twisted pedicle. In the context of perforator patency, effective strain, which is a measure of vessel deformation or collapse, is the more relevant outcome. The vein was more prone to occlusion because of its weaker wall and lower intraluminal pressure. Four factors that affected perforator patency were identified: angle of twist, intraluminal blood pressure, and perforator diameter and length. There was no significant difference whether twisting was performed prior to or after restoration of blood flow (P0.05). Therefore, to optimize condition for maintaining perforator patency, the angle of twist should be kept180 degrees, perioperative blood pressure should be kept stable (avoiding periods of hypotension), and the selected perforator should be approximately 1 mm in diameter and30 mm in length. We found that the propeller flap is a feasible design. This study defined the determinants of perforator patency and will serve as a useful guide when performing such flaps.

Background: Auricular transplants from cadaveric sources may be a viable alternative for difficult auricular reconstruction once immunologic problems are largely solved. The authors report on the neurovascular anatomy and technical details of harvesting the auricle as a single facial subunit. Methods: Nine auricles were studied in latex-injected (n = 5) and fresh cadaveric heads (n = 4). In latex-injected heads, dissection in the neck and auricular region and microdissection within the substance of the auricle were performed under loupe magnification. The arterial network was exposed and measurements were taken, including the size, length, and diameters of vessels. The number of branches supplying the entire auricle was noted. Methylene blue dye was injected into fresh cadaveric heads through the posterior auricular (n = 2) or superficial temporal arteries (n = 2) to assess the territory supplied by each arterial system. Results: Dye injected into the superficial temporal artery stained the upper two-thirds of the anterior and posterior auricular regions; all anterior cartilaginous eminences, except the antitragus, were homogenously stained. Dye injected into the posterior auricular artery stained the lobule, posterior auricular skin, and the depressed anterior auricular regions, including the cavum conchae, scapha, and triangular fossa. Neither the superficial temporal nor the posterior auricular arteries could adequately nourish the entire auricle as single pedicles. The auriculotemporal and great auricular nerves can be included in the transplant for sensation. The temporoparietal scalp can also be reliably included to meet reconstructive requirements. Conclusions: The auricle can be reliably elevated as a transplant when nourished by both the superficial temporal and posterior auricular arterial systems. The external jugular vein and external carotid artery can therefore be used as the vascular pedicle for auricular transplantation.

Background: The rotation fasciocutaneous flap for buttock pressure sore coverage has the distinct advantage of allowing rerotation in the event of ulcer recurrence. The authors describe their approach of preserving and incorporating musculocutaneous perforators into the conventional rotation design. Methods: The skin incision is the same as that for the conventional gluteal rotation flap. The flap is elevated subfascially until one or two large musculocutaneous perforators of the superior or inferior gluteal arteries are encountered. Intramuscular dissection by splitting fibers of the gluteus maximus muscle is then performed to free the perforator down to its emergent point at the level of the piriformis muscle to enable the perforator to pivot freely with the rotation of the skin flap. Further elevation of the flap beyond the location of the perforator is then performed as necessary to enable tension-free rotation of the skin flap into the defect. Muscle to fill dead space when needed is raised as a separate flap. Seven patients underwent closure of buttock pressure sores in the sacral, ischial, and trochanteric areas using this technique. Results: All wounds healed, with no recurrence, at a mean follow-up of 30 months. This technique can be used to cover pressure sores over the sacral, trochanteric, and ischial regions. Conclusions: This modification of the conventional rotation flap affords the flexibility of rerotation in the event of ulcer recurrence while providing the flap with enhanced blood supply. This is an ideal flap for patients in whom the risk of ulcer recurrence is high.

Introduction: Venous congestion is the main cause of failure in the distally based sural artery flap. Herein, we present our technique of phlebotomy to relieve flap congestion. Venous blood is intermittently drained via an exteriorized segment of the short saphenous vein until flap circulation normalizes. Methods and Materials: From 2000 to 2005, 34 distally based sural artery flaps were performed. In all patients, an extra 5 cm of the short saphenous vein was incorporated with the flap during harvest. Fourteen flaps were noted to be congested after inset. In 2 patients, supercharging was performed. In the remaining 12 patients, intermittent phlebotomy was performed through an externalized segment of the short saphenous vein on the operating table and hourly thereafter until venous congestion improved. Results: All flaps survived. The mean duration of phlebotomy was 30 hours, and mean blood loss in the first 24 hours was estimated to be 94 mL. The color of the flap was noted improved gradually over this period as it established a more efficient venous drainage. Conclusion: Our approach of providing an additional venous outlet for congested flaps contributed to the favorable survival rate noted in this series. Intermittent phlebotomy was a simple and effective way to relieve venous congestion during the immediate postoperative period. As oscillating avalvular veins hypertrophied and multiplied during the ensuing 24‐48 hours, venous circulation improved and the short saphenous vein spontaneously stopped draining. Phlebotomy improved flap survival and was a valuable temporizing measure to prevent critical congestion in flaps adapting to a new circulatory pattern.

BACKGROUND Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications. METHODS Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers. RESULTS The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply. CONCLUSION The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations. CLINCIAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Background This article describes a preperiosteal midcheek lift technique performed by means of the midcheek soft-tissue spaces by precise release of the retaining ligaments that separate the spaces. Methods From November of 2009 to June of 2014, 184 patients underwent this procedure. A transcutaneous lower eyelid blepharoplasty incision was used to access the preseptal space. Medially, the orbicularis oculi origins and tear trough ligament are released sharply, connecting the dissection with the premaxillary space. More laterally, the orbicularis retaining ligament is released, connecting the dissection with the prezygomatic space. With this release, the entire midcheek can be effectively lifted. The fat pads were managed by transposition, excision, or with septal resets as indicated. Canthopexy is performed routinely to provide lower eyelid support. Superolateral traction on the orbicularis oculi elevates the entire midcheek, and this was secured to the lateral orbital rim periosteum. In patients with significant volume loss in the midcheek, structural fat grafting is performed. Results All patients demonstrated a significant rejuvenation of the midcheek with elimination of the eye bags and elevation of the lid-cheek junction and the cheek prominence and improvement of the nasolabial folds. The majority of the patients (96 percent) were satisfied with the procedure. Complication rates were low. Ectropion occurred in 1 percent of patients, and lower lid retraction occurred in 1 percent of patients. Conclusion The midcheek lift by means of the facial soft-tissue spaces is safe, effective, and long lasting. As the dissection is atraumatic, recovery is quick and complications are minimized.

While calcified cephalohematoma is eminently correctable, a clear description of indications for surgery and surgical techniques are currently lacking in the literature. In this paper we propose a simple classification and an algorithm for the management of cephalohematomas. Three patients were treated for large calcified parietal cephalohematomas. Craniectomy and cranioplasty were performed with excellent outcome. Cranioplasty was performed with the cap radial craniectomy technique in two patients and the flip-over bull's-eye technique in one patient. The literature was reviewed on this entity and an algorithm based on the timing of presentation, extent of calcification and type of calcified cephalohematoma is proposed. Aspiration and compressive dressings can be used for early, incompletely calcified cephalohematomas. Calcified cephalohematoma causing significant distortion of the calvarium requires surgical correction and is classified as Types 1 or 2 depending on the contour of the inner lamella. Type 1, with a normal contoured inner lamella, can be corrected by ostectomy of the outer lamella. Type 2 calcified cephalohematoma has a depressed inner lamella. Elevation of the inner lamella is necessary and the cap radial craniectomy technique can be used. We describe a novel technique, the flip-over bull's-eye techniques as an alternative technique for Type 2 lesions in selected patients. In conclusion, calcified cephalohematomas can safely be treated surgically with excellent outcome. It is hoped that this algorithm will serve as a useful and logical guide in decision making for the management of this condition.

Summary Objective Subacute necrotizing fasciitis is a poorly defined clinical entity. Its very existence has been the subject of much controversy. While rarely reported, subacute forms of necrotizing fasciitis have been documented in the literature by many authors. This paper highlights some recently reported cases in the literature that clearly shows that subacute forms of necrotizing fasciitis indeed exist and may in fact be under-reported because of the lack of awareness and a consistent diagnostic criteria. Methods A Medline search was performed with the following keyword; necrotizing fasciitis, subacute, variant and indolent. Results Majority of reported cases did not give sufficient information to satisfy the reviewer that these cases were indeed subacute forms of necrotizing fasciitis. We identified three cases of subacute necrotizing fasciitis that clearly are subacute cases and analysed their clinical presentation. A diagnostic criterion for defining subacute necrotizing fasciitis was proposed based on these cases and the authors' clinical experiences. Conclusion This proposed diagnostic criterion serves to facilitate future reporting and documentation of this condition. The clinical significance and implication of this are discussed.

Necrotizing fasciitis is perhaps the deadliest form of soft-tissue infection, characterized by a fulminant course and a high mortality rate.1 Meleney in 1924 gave the first modern description of this clinical entity when he introduced the term “acute hemolytic streptococcal gangrene.”2 The term necrotizing fasciitis, coined by Wilson in 1952, is perhaps the most accurate term describing the key features of this infectious process.3 Although our understanding of the pathophysiology of necrotizing fasciitis continues to improve, physicians confronted with this clinical entity continue to thread through “Meleney’s minefield,” fraught with dangers of delayed or even missed diagnosis with catastrophic consequences. In this article, we present a case that we recently managed and highlight the deceptively benign initial presentation of necrotizing fasciitis.

A delay in the diagnosis and appropriate treatment of necrotizing fasciitis has clearly been demonstrated to increase mortality. However, paucity of specific cutaneous signs makes early recognition extremely difficult. This review highlights recent developments in the approaches to the diagnosis of necrotizing fasciitis.A clinical staging of necrotizing fasciitis is proposed to better define the progression of the disease. Several clinical subtypes of necrotizing fasciitis have been described recently with hyperacute and sub-acute variants. Imaging techniques, such as magnetic resonance imaging and frozen section biopsies, have been reported to be of value in the early recognition of necrotizing fasciitis. However availability and cost limit the routine use of these tests. Several diagnostic adjuncts that have been developed recently to help in early recognition will be discussed. These include the fasciitis LRINEC (laboratory risk indicator for necrotizing fasciitis) score and transcutaneous tissue oxygen saturation monitoring. Some may have the potential for widespread application in the assessment of severe soft tissue infections.Delayed recognition, with consequent massive soft tissue loss and sepsis, remains a deadly pitfall in the management of necrotizing fasciitis. With a better understanding of the clinical manifestations and the potential use and limitations of various diagnostic adjuncts available for the assessment of equivocal cases of soft tissue infections, it is hoped that a clear and logical approach to the diagnosis of necrotizing fasciitis may be developed.

Infraclavicular subclavian venepuncture in the oedematous burned patient is often difficult because of increased depth of the vein. In addition, proper patient positioning is not easily achieved because of extensive burns, generalised oedema and bulky dressings. To overcome these difficulties, a modified technique of infraclavicular subclavian venepuncture has been developed. The introducer needle is bent to create a mild curvature. It is inserted at a point 1–2 cm inferior to the palpable lower border of the clavicle along the junction of the middle and medial thirds of the bone, advanced along the deep surface of the clavicle and directed at the superior border of the suprasternal notch. This medial point of insertion shortens the distance of access to the subclavian vein. The curve allows the tip to be kept close to the undersurface of the clavicle as the needle is advanced, thereby reducing the risk of injury to deep structures. The advantages of the modified technique are demonstrated in anatomical dissections. This technique is a viable alternative when conventional techniques fail.

Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score.Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140)Two teaching tertiary care hospitals.One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals.None.The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively.The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score ofor = 6 should be carefully evaluated for the presence of necrotizing fasciitis.

entity. Objective. To raise awareness of this rare condition in the interpretation of preoperative magnetic resonance imaging scans and to assess the results of surgical treatment. Background. Symptomatic epidural varices presenting with radiculopathy are extremely rare, and the diagnosis is often missed in the preoperative evaluation. This condition commonly masquerades as a herniated nucleus pulposus. Diagnosis is often only made intraoperatively. Materials and Methods. Case 1 is a 40-year-old man presenting with acute exacerbation of lower back pain associated with radiculopathy down his right lower limb. Magnetic resonance imaging showed a paracentral disc prolapse. At operation, a congested epidural vein impinging on the L5 nerve root was noted with no intervertebral foramens stenosis. Excision of the vein was performed. The second case, a 50-year-old man with previous spinal instrumentation, was admitted for acute onset of radiculopathy down his left lower limb. At operation, an epidural varix compressing on the L4 nerve root was noted. Retrospectively, features of epidural varices were noted in the preoperative magnetic resonance imaging scans. Both patients reported resolution of symptoms after surgery. Results. Excision was done for the first patient, and coagulative ablation was done in the second patient. Both patients had symptomatic relief and neurologic recovery on follow-up. Conclusion. Our experience and the literature demonstrated that a favorable outcome with resolution of neurologic symptoms can often be achieved after excision or ablation of the epidural varices. [Key words: symptomatic epidural varices, radiculopathy, diagnostic magnetic resonance imaging, surgical excision, coagulative ablation, resolution of symptoms] Spine 2003;28:E347–E350

Background: Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency. Methods: The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively. Results: The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4). Conclusions: Early operative debridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Background Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis. Methods A systematic literature search of PubMed was undertaken using the keywords ‘necrotising fasciitis’, ‘necrotising skin infection’, ‘diagnosis’ and ‘outcome’. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included. Results Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44·5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80·8 per cent), pain (79·0 per cent) and erythema (70·7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24·8 per cent of patients). Conclusion A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case.

Closed reduction and splinting are generally recommended in the acute management of nasal fractures. Although open reduction is recommended for more severe nasal fractures, immediate functional and cosmetic open rhinoplasty following nasal fractures has not been described for Asian noses.The authors document their experiences with combining open reduction of acute nasal fractures with simultaneous cosmetic correction of preexisting aesthetic concerns in an Asian population.Twenty-five Asian patients underwent primary functional and cosmetic open rhinoplasty immediately following acute nasal fracture. Grafts consisted of autologous material, including septum, concha, rib, and deep temporal fascia. Prior to opening the nose, anatomical reduction of the bony vault fractures was performed. Spreader grafts were used to stabilize the fractured or dislocated dorsal septum as well as to straighten the nose. Aesthetic refinement of the nose included lengthening, refining the tip, and increasing tip projection and was performed according to the patients' aesthetic desires. Patient satisfaction was subjectively reported on a 1 to 10 scale.Mean follow-up was 17 months (range, 10-24 months). Twenty-three patients rated the results of their procedures as 7 or higher. Functionally, all patients were breathing as well or better postoperatively compared with their preinjury functional state. One patient (4%) underwent a secondary filler procedure for a slight dorsal irregularity.Immediate cosmetic and functional open rhinoplasty is safe, predictable, and effective in Asian patients.4.

A 67-year-old man with squamous cell carcinoma underwent reconstruction with a free anterolateral thigh myocutaneous flap. Unroofing the skin perforators found that the skin perforators originated from the oblique branch of the lateral circumflex femoral artery with no connections with the descending branch. Thus, the flap was harvested based on the oblique branch, leaving the descending branch in situ. Reconstruction was completed uneventfully and he had an excellent outcome at 1-year follow-up. The anterolateral thigh myocutaneous flap was reputed to be a technically easy flap to harvest. The perforators supplying the skin were visualized and a block of muscle incorporating the perforators harvested with the descending branch of the lateral circumflex femoral artery as the pedicle of the flap. However, not infrequently with this approach, the flap thus harvested has a well-perfused muscle component, whereas the skin component was not viable. This situation is explained anatomically by the potential occurrence of an alternative pedicle that supplies the anterolateral thigh flap, called the oblique branch of the lateral circumflex femoral artery. Our case presented here was a "classic" intraoperative finding of this potential trap and the importance of defining the anatomy before committing oneself to the harvest by unroofing all the skin perforators was emphasized.

Introduction Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively. Methods and materials Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a "propeller" distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel. Results Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel. Conclusion The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.