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Ischemic preconditioning of the myocardium with repeated brief periods of ischemia and reperfusion prior to prolonged ischemia significantly reduces subsequent myocardial infarction. Following ischemic preconditioning, two "windows of opportunity" (early and late) exist, during which time prolonged ischemia can occur with reduced infarction size. The early window occurs at approximately 4 hours and the late window at 24 hours following ischemic preconditioning of the myocardium. We investigated if ischemic preconditioning of skeletal muscle prior to flap creation improved subsequent flap survival and perfusion immediately or 24 hours following ischemic preconditioning. Currently, no data exist on the utilization of ischemic preconditioning in this fashion. The animal model used was the latissimus dorsi muscle of adult male Sprague-Dawley rats. Animals were assigned to three groups, and the right or left latissimus dorsi muscle was chosen randomly in each animal. Group 1 (n = 12) was the control group, in which the entire latissimus dorsi muscle was elevated acutely without ischemic preconditioning. Group 2 (n = 8) investigated the effects of ischemic preconditioning in the early window. In this group, the latissimus dorsi muscle was elevated immediately following preconditioning. Group 3 (n = 8) investigated the effects of ischemic preconditioning in the late window, with elevation of the latissimus dorsi muscle 24 hours following ischemic preconditioning. The preconditioning regimen used in groups 2 and 3 was two 30-minute episodes of normothermic global ischemia with intervening 10-minute episodes of reperfusion. Latissimus dorsi muscle ischemia was created by occlusion of the thoracodorsal artery and vein and the intercostal perforators, after isolation of the muscle on these vessels. Muscle perfusion was assessed by a laser-Doppler perfusion imager. One week after flap elevation, muscle necrosis was quantified in all groups by means of computer-assisted digital planimetry. Our results show that ischemic preconditioning resulted in a significant reduction (p < 0.05) in muscle-flap necrosis immediately and 24 hours following ischemic preconditioning. Perfusion changes after flap elevation were similar among the three groups. Ischemic preconditioning of skeletal muscle prior to flap creation significantly reduces subsequent muscle-flap necrosis caused by the ischemia of flap creation immediately and 24 hours following ischemic preconditioning. Further elaboration of the mechanisms of ischemic preconditioning may allow pharmacologic preconditioning to be used in the augmentation of skeletal muscle-flap survival in the clinical setting.

The rectus abdominis musculocutaneous free tissue transfer has become a mainstay of reconstruction for large defects in the head and neck. The length of the deep inferior epigastric vessel is traditionally accepted to be 8 to 10 cm from its origin to its entrance into the rectus muscle. This pedicle is usually not long enough for reconstruction of the upper midface, forehead, and cranial base if vascular anastomosis to the neck vessels is necessary. Vein grafts have been recommended under these circumstances. We have been able to extend the length of the vascular pedicle by intramuscular dissection of the lateral branch of the deep inferior epigastric artery and veins in 26 clinical cases. The dissection is carried along the posterior surface of the muscle, up to the first tendonous inscription. Intraoperative measurements of the pedicle length before (6.9 +/- 1.0 cm) and after (13.7 +/- 2.0 cm) dissection, as well as in 17 fresh cadavers (34 muscles), demonstrate that the pedicle length can be increased safely from 7.8 +/- 0.5 cm to 17.7 +/- 0.52 cm (range, 15.8 to 19.1 cm). This long-pedicled flap has been used successfully in 26 patients for reconstruction of different types of defects in the head and neck, without using vein grafts.

Many large vault or skull base tumours are best treated by wide surgical excision and primary reconstruction using a microvascular free tissue transfer (free flap). We report 23 patients who were reconstructed using free flaps, eight having been previously treated surgically elsewhere and seven of whom had recurrent disease after radiotherapy. There was one flap failure and a local recurrence rate of 16% (3/19). The outcome at a mean follow-up period of 29 months, was 19 patients alive and four deaths.

Development of mucoperichondrial and mucoperiosteal flaps bilaterally, total removal of the deviated septum, straightening it outside, followed by replacement as a free graft constitute an option in treatment of the severely deviated nose. Positioning and stabilization of the septum in this technique may prove insufficient in the majority of septorhinoplasty patients in whom both nasal bones are also immobilized. Positioning and stabilization can be achieved adequately by the use of the presented technique that involves passing a 3-0 nylon suture to suspend the cartilage replant to a plastic splint applied to the dorsum of the nose, one-third of which is taped over the realigned nasal bones. In the past 5 years, 45 patients have undergone septorhinoplasty using this technique. The minimum follow-up period was 6 months. No patient developed any major complications. Secondary correction was necessary to improve the aesthetic result in only one patient. The results in patients who underwent this surgical procedure suggest that the presented technique provides excellent results in severely deviated noses associated with major deviations of the septum but must be limited only to those whose deformity is so severe that other techniques will be insufficient to obtain the desired result.

A three-square-flap procedure is described for surgical treatment of minor syndactyly. The average follow-up period in 58 cases (48 patients) was 2 years 4 months. In the three-square-flap method, the interdigital space is regarded as a cube and flaps are designed on each surface of the cube (dorsal side, interdigital surface, and volar side); the flap on the dorsal side forms the basal surface of the new interdigital portion. This technique is most suitable for reconstruction of minor three-dimensional contracture syndactyly. This method does not require skin grafting; the design is uncomplicated and easy to understand, and the operative procedure is simple.

The authors present eight cases of reconstruction of the breasts using bilaterally divided TRAM flaps after removing the injected silicone gel and granulomas. In Japan, we have the opportunity to examine many patients who have had foreign substance injections to the breasts for purposes of augmentation however, most of them are now suffering from delayed complications. Until now we have reconstructed breasts such cases by use of silicone bag prostheses after removal of granulomas; however, now it is difficult to obtain silicone prostheses. Thus, we have decided to reconstruct by the use of autogenous cutaneous and adipose tissue flaps as presented by us in this article.

Objective: A modified Abbe flap of the lambda figure type, designed by the author and used before or after secondary cleft lip repair in 146 consecutive cases since 1990 is described., Design: This series consisted of 71 cases with unilateral deformity and 75 cases with bilateral deformity at adolescent or adult ages. The technical details of this method and representative cases with the results are shown. The philtrum is created by incising the two branches of the lambda flap obliquely at 45 degrees to the skin surface in the lower lip, then matching them in the central recipient bed of the deficient upper lip., Results and Conclusions: The resultant upper lip is not only full and slack, but also attractive with an acute cubic contour of the philtrum. Furthermore, the residual scar at the donor site is concealed in the mentolabial fold.

In order to provide vascularised mucosa for reconstruction of intraoral defects after radical tumour resection, 5 distal radial forearm flaps and 1 fibula flap were prelaminated. Prelamination was performed by fixing small, full thickness mucosa pieces onto the fascia and covering the mucosa with an alloplastic sheet as large as the future flap. The alloplastic material was a silicone sheet (n = 2), a Gore-tex sheet (n = 3) or a titanium sheet (n = 1). The mucosa and the alloplastic material were covered by the skin and subcutaneous tissue which had been elevated to expose the fascia. With the silicone and titanium sheets, the mucosa spread on the fascia and the final flaps were thin, pliable, mucus-producing and larger than the original mucosa pieces. With the Gore-tex sheets, extension of the mucosa was prevented by adhesions and the area of mucosa on the final flap was the same size as the original graft. The six prelaminated flaps were harvested after 8-10 weeks. During this time the patients had radiotherapy and chemotherapy. Preserving the skin and subcutaneous tissue reduced donor site morbidity. Six patients had intraoral defects successfully reconstructed with mucus-producing prelaminated flaps.

The methods usually employed for reconstruction of total lower eyelid loss include (1) tarsoconjunctival flaps from the upper eyelid and skin-graft cover and (2) chondromucosal grafts and local skin-flap cover. We report a technique for coverage of these defects with an island flap involving the full thickness of the ipsilateral nasal wall based on the dorsal (external) nasal vessels, terminal branches of the ophthalmic vessels. The advantages of this method are (1) the main components of the eyelid (skin, tarsus, conjunctiva) are reconstructed in a single short operation, even under local anesthesia, (2) there is one donor area that can be closed primarily without significant deformity, (3) the upper lid remains intact, and ectropion is improbable, and (4) the procedure involves a short hospitalization. As disadvantages we might mention bulkiness of the new eyelid and difficult dissection of the (subcutaneous) pedicle.

This paper demonstrates examples of successful reconstruction of partial-thickness eyelid defects using the expanded forehead flap. Two patients are presented: one in whom cicatrical ectropion was present and the other in whom there was an absence of ectropion. In both patients primary grafting was executed just after the injury was sustained. By the time the patients were referred for reconstruction, mismatch in the quality of the skin and scars along the border of the graft left the area of primary repair to be impaired aesthetically as well as functionally. Reconstruction of the upper eyelid using the expanded forehead flap resulted in excellent approximation of the native tissue. Aesthetic as well as functional capacities were considered in this approximation. The advantage of this technique is that it offers a larger amount of tissue without compromising the aesthetic or functional similarity to the native eyelid.

Purpose: To demonstrate favorable long-term visual outcome after ocular reconstruction in an infant with Fraser syndrome and with complete left cryptophthalmos., Methods: Reconstruction of incomplete right cryptophthalmos in our patient was accomplished in a stepwise manner, beginning in the third week of life, by dissecting the eyelids from the cornea, reconstructing the conjunctival fornices with buccal mucosa, and repairing the upper lid coloboma in a flap reconstruction using the inferior eyelid margin., Results: At age 3 years, the patient currently has good movement of the right eyelids when blinking, reasonable right tear function, and a visual acuity in the right eye between 20/200 and 20/360 on forced preferential looking., Conclusion: In selected cases of incomplete cryptophthalmos, oculoplastic and corneal surgery may result in useful vision and in good eyelid movement when blinking.

A technique for digital pad transposition is described and illustrated. This technique has application for use in cases of metacarpal or metatarsal pad neoplasia or severe trauma. The transposed digital pad will provide a weight-bearing surface of heavy, keratinized epidermis in cases where the normal metacarpal or metatarsal footpad has been removed. The use of the technique in four clinical cases of footpad neoplasia also is reported.

Muscle-sparing rectus abdominis muscle harvest has been advocated to preserve abdominal wall integrity and to reduce postoperative complications and functional loss. In previous cases of pregnancy following single and bilateral rectus muscle harvest, muscle-sparing techniques were used to fortify the abdominal wall. We report a case of uncomplicated gestation and delivery following total bilateral rectus muscle harvest. While abdominal wall strength is greatly affected by rectus harvest, the fascial and tendonous components of the abdominal wall contribute substantial static integrity and elasticity. Careful repair of the donor site makes complete rectus muscle harvest an option even for women contemplating pregnancy.

Cigarette smoke, and specifically nicotine, has been shown to reduce skin-flap survival. The purpose of this study was to determine if the preoperative administration of pentoxifylline can counteract the deleterious effects of nicotine on skin-flap survival in the rat. Sixty rats were distributed into four groups (n = 15). The survival of modified McFarlane skin flaps was assessed on postoperative day 7. The administration of nicotine (0.6 mg/kg) for 24 weeks preoperatively produced an average skin-flap survival of 59 percent; this was significantly decreased compared with controls (p < 0.05). When similarly treated animals were given pentoxifylline (20 mg/kg) for 30 days preoperatively, the mean skin-flap survival improved significantly to 80 percent (p < 0.05). Withholding nicotine for 2 weeks preoperatively also was found to significantly improve skin-flap survival to 73 percent (p < 0.05). Blood filterability was measured as an indicator of viscosity. The blood filterability in rats that received nicotine for 24 weeks was significantly decreased compared with controls (p < 0.05). Both the addition of pentoxifylline preoperatively and the withholding of nicotine for 2 weeks preoperatively were found to significantly improve blood filterability compared with rats that received nicotine alone for 24 weeks postoperatively (p < 0.05).

Objective: To compare the cost and functional results of free and pedicled soft tissue reconstruction after posterior oral cavity and oropharyngeal extirpation., Design: Retrospective study of 53 consecutive patients undergoing extirpation with primary soft tissue reconstruction from January 1, 1991, to December 31, 1995. Median follow-up was 298 days., Setting: Academic tertiary care medical center., Intervention: Twenty-four patients underwent reconstruction with a pedicled pectoralis major myocutaneous flap (PMMF); 29 patients, with a fasciocutaneous free flap (FF) (27 radial forearm, 1 lateral arm, and 1 scapular)., Main Outcome Measures: Direct (inpatient hospital resources used and monetary costs) and intangible (post-operative complications and function) costs., Results: Operative time was longer for FF reconstructions (P = .003), but both patient groups had similar intensive care unit and hospital stays. Treatment cost for FF reconstructions was $41,122, compared with $37,160 for PMMF reconstructions (P = .003). This difference was due to increased professional fees for FF reconstruction (P < .001) which was offset by intangible cost differences. The PMMF group tended toward an increased rate of flap-related complications, compared with the FF group. At last follow-up, 4 patients in the FF group (15%) and 3 in the PMMF group (15%) had their tracheotomy. In contrast, 17 (85%) patients in the PMMF group and 11 (39%) patients in the FF group required enteral tube feedings (P = .002). Also, 18 (64%) patients in the FF group were eating at least a soft diet compared with 6 (30%) patients in the PMMF group (P = .02)., Conclusions: Comparison of direct costs reveals only a modest difference in reconstruction costs that is outweighed by the intangible costs of PMMF reconstruction. The functional benefits of FF reconstruction appear to justify its slight increased expense and its use rather than PMMF reconstruction after extirpation in the posterior oral cavity and oropharynx.

Fifty-four dorsal transposition flaps were performed in 38 patients (46 hands) for severe congenital thumb web-space contractures. At an average follow-up interval of 6 years, complications or unsatisfactory results had occurred in 100% of symbrachydactyly patients and in 27% of all other patients. Postoperative first web-space angle was augmented an average of 59 degrees with a distal flap two-point discrimination of 8 mm. Mean postoperative pinch and grip strengths were 58% and 72%, respectively, of the normal contralateral hand. Parental satisfaction with the functional results was high, and the aesthetic results were generally acceptable. With the exception of symbrachydactyly patients, the dorsal transposition flap remains an excellent reconstructive option for severe congenital contractures of the thumb web space.

Background: Full-thickness lateral pharyngeal wall (LPW) defects are difficult to reconstruct, whether the larynx is preserved or removed (extended total laryngectomy). A simple, reliable reconstructive method using local tissue which optimizes wound healing and functional results would allow partial laryngectomy more often, without incurring the cost, donor site morbidity, and increased operative length of regional or free flaps. My objective was to propose use of the longus colli muscle as a reconstructive flap for defects of the LPW., Methods: Results of using the longus colli muscle flap (LCMF) in a series of 16 patients with primary tumors of the pharyngeal wall or pyriform sinus are presented. The majority had surgery and planned postoperative radiotherapy., Results: There were no wound infections or fistulas. One of 2 previously radiated patients had a transient wound-healing problem. Although 88% of the patients were stage III and IV and 50% had T3-4 primary tumors, there were only 2 local failures, for a local control rate of 88%. Corresponding cancer-free survival was 69% (median follow-up of 22 months). Two thirds of the patients took all or some food by mouth, and of the 12 with larynx preserved, 58% were decannulated, and 11 had a good to normal voice., Conclusions: The reliability of wound healing and absence of negative impact on oncologic and functional results validate use of the LCMF as a reconstructive option for defects in the LPW at both the oropharynx and hypopharynx levels.

Any burn injury, even if considered minimal in extent, can still be catastrophic, if hand burns are severe enough to result in deformities that render the individual unable to perform his own personal daily functions. Usually any necessary skin coverage of the hand can be achieved with skin grafts alone; but occasionally, seemingly heroic measures requiring vascularized flaps will be justified to ensure maximum rehabilitation. Previously, available options included proximal-based local flaps, or distant flaps either pedicled while remaining attached to another body region, or transferred immediately by use of microsurgical techniques. Another new concept that may still be somewhat in the investigational stage for burns is the distal-based local flap. These use more traditional proximal skin territories, but with a distal vascular pedicle that can allow such flaps to reach even the fingertips. More expeditious and technically simpler than the transfer of distant flaps, this alternative deserves further consideration in the appropriate circumstances.

Although loss of the sideburn and temporal scalp with subsequent alopecia is relatively frequent as a consequence of traumatic, surgical, and iatrogenic processes, not many techniques of sideburn reconstruction have been reported. We present a two-stage technique to correct the long-sideburns when there is an associated temporal alopecic defect due to trauma or surgery by means of an expanded supra-auricular trapezoidal flap. The method can achieve not only a satisfactory appearance of the sideburn but also a normal capillary line from the occipital to the frontal region.

We compared the secondary ischemic tolerance of 8 x 12 cm surgically denervated pedicled island skin flaps and skin free flaps raised contralaterally on the buttocks of 50 pigs. The pedicled flaps and free flaps were subjected to 2 hours of primary warm global ischemia followed by 12 hours of reperfusion and 0, 2, 4, 6, or 10 hours of secondary warm global ischemia (n = 10 flaps). Skin necrosis was assessed 7 days after secondary ischemia. Pedicled skin flaps tolerated up to 10 hours of secondary ischemia without skin necrosis. However, incidences of skin necrosis (partial and total) in free flaps subjected to 0, 2, 4, 6, or 10 hours of secondary ischemia were 0, 10, 50, 80, and 100 percent, respectively. In a separate experiment, skin blood flow and hematology were studied in contralateral pedicled flaps and free flaps (n = 20) subjected to 4 hours of secondary ischemia. The skin blood flow measured by 15-micron microspheres at 1.5 hours of reperfusion was significantly higher (p < 0.01, n = 20) in pedicled skin flaps than in skin free flaps (1.91 +/- 0.35 versus 0.67 +/- 0.53 ml/min/100 gm). Under an operating microscope, microthrombi were observed near the arterial and/or venous anastomoses in 8 of 20 skin free flaps but none in the pedicled skin flaps. We obtained venous blood samples by cannulation of the major venae comitantes in 12 of the 20 skin free flaps in which there was no thrombosis in the vascular pedicle for hematologic studies. The venous plasma level of thromboxane B2 was significantly higher (p < 0.05) in the skin free flaps than in their contralateral pedicled skin flaps (195 +/- 49 versus 124 +/- 30 pg/ml). In addition, venous hematocrit, hemoglobin concentration, and white blood cell count also were significantly (p < 0.05) higher in skin free flaps compared with their contralateral pedicled skin flaps. Taken together, these observations were interpreted to indicate that buttock skin free flaps in the pig were less tolerant of secondary ischemia compared with their contralateral pedicled skin flaps subjected to the same ischemic protocol, and this reduced ischemic tolerance in skin free flaps was associated with compromised skin blood flow, hemoconcentration, and thrombosis in the vascular pedicle.

Epidemiological analysis indicates that 40% of open fractures occur in the lower limb and that the tibial and femoral diaphyses are most commonly affected. Recent advances in fracture stabilization and soft tissue reconstruction technique have improved the outcome of these fractures.

A new web flap on a subcutaneous tissue pedicle was developed to repair incomplete simple syndactyly. It was isolated from the top skin in syndactyly and transferred down into the depth of the web space to create a web commissure. With use of this technique, aesthetic appearance of the web and well-functioning fingers were gained. Moreover, this technique made full use of the original skin of the syndactyly, and a skin graft was not needed. We report here the operative technique, which presents another alternative for repair of incomplete simple syndactyly.

We describe a modified technique for the salvage of a total knee arthroplasty after disruption of the extensor mechanism. Between January and December 1992, seven patients had reconstruction of the extensor mechanism with use of a medial or an extended medial gastrocnemius flap. Six of the seven patients were followed for a mean of thirty-three months (range, twenty-six to forty-one months) and were evaluated both preoperatively and postoperatively with regard to the knee and functional scores of The Knee Society as well as the range of motion, extensor lag, walking status, and patellar height. The seventh patient was lost to follow-up six months postoperatively and was excluded from the analysis of the results. Preoperatively, the knee and functional scores were 16 +/- 12.3 points and 12 +/- 12.1 points (mean and standard deviation), respectively; the mean range of motion was 70 +/- 44.0 degrees; and the mean extensor lag was 53 +/- 33.4 degrees. Postoperatively, the mean knee and functional scores improved to 82 +/- 12.4 points and 51 +/- 23.0 points, respectively; the mean range of motion improved to 100 +/- 21.8 degrees; and the mean extensor lag decreased to 24 +/- 18.8 degrees. After the procedure, all patients who previously had been dependent on a walker were able to walk about the community with or without a cane, and those who had been dependent on a wheelchair were able to walk with the assistance of a walker. Patellar height was measured according to the method of Insall and Salvati for the four patients who had a patella. Preoperatively, the patellar heights were grossly abnormal; postoperatively, they more closely approached accepted normal values for three of the four patients. Reconstruction of a complicated rupture of the extensor mechanism with use of a medial gastrocnemius transposition flap after total knee arthroplasty is a reliable option for treatment.

A single-stage two-flap method utilizing an anteriorly based subcutaneous pedicled skin flap and a mastoid fascial flap has been applied successfully for reconstruction of lobule-type microtia. This paper presents three modifications of the two-flap method, with which atypical congenital auricular deformities necessitating both framework construction and coverage were reconstructed successfully. In middle and upper auricular deformities such as a concha-type or a scapha-type microtia, a cranially based postauricular skin flap and lower mastoid fascial flap were used. For upper auricular deformities such as microtia representing lop-ear deformity, a narrow cranially based postauricular skin flap (Grotting flap) and upper mastoid fascial flap were used. For lower auricular deformities such as total absence of the earlobe, a cranially based skin flap and lower mastoid fascial flap were utilized. In each deformity the framework was totally or partially constructed with autogenous costal, conchal, or septal cartilage or their combination according to the size or shape of the defect. Fifty-two atypical auricular deformities were corrected with the modified two-flap method and framework construction. The follow-up has ranged from 4 months to 3 years (average 18 months). No major surgical complications occurred in this series. Representative cases reconstructed with each modified method are shown. While the shape of the cartilage framework is sculptured according to the type and degree of deformity in each patient, the modified two-flap method not only adequately covers the cartilage but also preserves the fabricated framework in its natural contour and position in the diverse varieties of atypical congenital auricular deformities.

Massive posttraumatic defects of the foot in 4 patients and a tibial malunion in another were repaired by flow-through anterior (anterolateral and anteromedial) thigh flaps. Posterior tibial vessels were used as the recipient vessel just below the level of the medial malleolus. Soft-tissue defects in foot-injured patients were covered with flow-through anterior thigh flaps interposing the descending branch of the lateral circumflex femoral system between the transected posterior tibial vessels. In another patient, a combined anteromedial thigh flap and vascularized iliac bone cross-leg "chimeric" flap were successfully transferred for the reconstruction of a malunion of a tibial fracture, which had been accompanied by severe vascular damage to the thigh. The utilization of derivative branches from the lateral circumflex femoral system facilitates revascularization of ischemic areas and simultaneous transplantation of multiple components, as well as preserves recipient vessels. Owing to the stable blood supply, these flaps can be readily processed into both deepithelialized and thin flaps.

Since the first report of successful microsurgical ear replantation in 1980, there have been 12 other cases reported in the English literature. As the number of trained microsurgeons increases, the opportunity to treat the amputated ear with microsurgical techniques should become more common. The reported cases have involved a variety of different mechanisms of injury and methods of treatment. There have been three techniques used to revascularize the amputated ear successfully: primary vascular repair, vein grafting, and use of the superficial temporal vessels as a pedicled vascular leash. Through our own experience and a review of the literature, we have been able to identify certain clinical characteristics that help dictate which technique to use. We report four cases of successful ear replantation, review the various techniques that have been used successfully, and provide treatment recommendations for future consideration.

The use of a rotation pedicled flap, entitled the 'Singapore Swing', comprising temporalis fascia and mastoid periosteum, is presented as a new method of promoting healing in 'open' mastoid surgery for chronic ear discharge. Cadaver studies show that the main blood supply of the flap is derived from a branch of the postauricular artery which enters the pedicle near the mastoid tip. A review of the first 14 operations showed complete healing with dry ears and intact tympanic membranes in all instances, three cases requiring secondary grafting of residual perforations. We consider the results sufficiently encouraging to merit an extended trial of the technique.

Posterior pharyngeal will tumours are infrequent neoplasms with a very poor prognosis. The 5 year survival rate range from 3% to 32%. Most authors agree that the treatment of choice is surgery with post-operative radiotherapy. The results of treatment of 36 patients (tumour excision plus bilateral neck dissection and post-operative radiotherapy) in which the posterior pharyngeal wall defect was closed with a platysma myocutaneous flap were compared with other forms of repair (13 patients). The 5 year survival rate was 17.2% in the whole group. Laryngeal voice was achieved in 79% of patients having a platysma flap reconstruction. The platysma myocutaneous flap is very satisfactory for the repair of the posterior pharyngeal wall as it is easy to perform, it is oncologically safe and its functional results match well with other forms of reconstruction, with the advantage of laryngeal preservation.

In cases in which filtration surgery such as trabeculectomy is necessary, a flat anterior chamber postoperatively due to overfiltration may cause severe problems in the control of intraocular pressure. Once a broad synechia has formed between the iris and the corneal endothelium, this type of refractory, surgically induced angle closure can be difficult to manage. This article details a case of refractory angle-closure glaucoma secondary to a flat anterior chamber following trabeculectomy. Multiple surgical treatments were performed to control intraocular pressure and to reconstruct the anterior segment of the eye.

A recent series of 25 patients who underwent reconstruction of Gustilo IIIB lower extremity wounds with rectus abdominis muscle transplants is presented. Complications include one flap loss and one donor site skin incision dehiscence. At follow-up, a majority of patients were ambulatory and a third employed in some fashion. Comparison with a historical group of patients demonstrates continued improvement in surgical results.

The description of blood supply to the skin through the superficial perineural vascular network has led to the concept of neurocutaneous flaps. Based on preexisting anatomic studies, the clinical use of large reversed-flow neurocutaneous saphenous island flaps is described. This flap is based on the arterial axis associated with the saphenous nerve and the greater saphenous vein in the lower leg. The donor area can be closed by soleus muscle advancement over the tibia and skin grafting. Five successful cases are reported with a low complication rate.

Injuries caused by sparklers are a particular hazard for young children. Case reports highlight the potential severity of such injuries and recommendations are made with regard to prevention.

A turnover contralateral cephalic alar cartilage flap is suggested for the correction of cleft nose alar deformity. The cartilage flap from the normal side wraps around the deficient medial crus and acting as a pulley reposition and augments the affected alar cartilage. The satisfactory and long-lasting results obtained in our small series seem to justify this approach for improving cleft nasal deformities, and we think it should be available in our surgical armamentarium.

Ninety-seven children with distal hypospadias were treated surgically using perimeatal-based flap urethroplasty (Mathieu procedure) in a two and a half years period. A review of the medical records revealed two distinct groups of patients according to the suturing type and suture material. In the first group of 36 patients (group I), neourethra was constructed using 6/0 polyglactine (Vicryl) in a single layer, full-thickness, uninterrupted fashion. Skin flaps were approximated using interrupted simple 5/0 polyglactine (Vicryl) sutures. In the second group of 61 patients (group II), 7/0 polydioxanone (PDS) was used in the urethral anastomosis performed in a subcuticular, uninterrupted fashion. The skin flaps were closed using interrupted simple 5/0 rapidly absorbable polyglactine (Rapid Vicryl) sutures. Patients were followed-up from 6 to 12 months. Urethral or meatal stenosis was not observed in any patient. There was no infectious complication. Urethrocutaneous fistula rate was significantly higher in group I (16.6%) compared to group II (4.9%) (p < 0.01). Complication rate following hypospadias repair can be reduced by the use of a subcutaneous suture technique utilizing polydioxanone suture material in urethroplasties.

The pronator quadratus can be prelevated as an island flap and used for coverage of neuromas at the wrist level. We have applied it with success in 4 patients.

Posterior soft-tissue defects of the elbow are difficult to reconstruct by conventional techniques such as closure by approximation or skin graft. An ideal technique should be an easy and reliable one-stage procedure that provides predictable surgical results with regard to elbow function and cosmesis. This report details our experience in 7 patients who underwent a one-stage procedure for coverage of the posterior elbow employing the reverse pedicled lateral arm flap. All flaps survived and all patients were able to resume full range of motion of the elbow joint at the 6-month follow-up. Complications included forearm paraesthesia in 3 patients and conspicuous scarring in a young female patient. We emphasize two valuable refinements in surgical technique including measuring posterior elbow defect in full flexion and postoperative elbow extension splinting. In trauma-related defects of the posterior elbow, a preoperative angiogram is important before raising this flap.

Simultaneous reconstruction of a traumatic defect of the trapeziometacarpal joint and the first metacarpal with a composite dorsalis pedis flap is described. The transplant, consisting of the second metatarsal and the second metatarsophalangeal joint, was reversed at the defect site for the metatarsophalangeal joint to become a new trapeziometacarpal joint. A long vascular pedicle was necessary for direct micro-vascular anastomoses to the radial vessels at the wrist. This transfer can be expected to be effective in reconstructing composite hand defects involving the trapeziometacarpal joint and the entire first metacarpal bone.

The UltraPulse carbon dioxide laser with CPG scanner was utilized to deepithelialize dermal pedicles in breast reduction inferior pedicle flaps. Clinical advantages include lack of bleeding, markedly shortened time of dissection, and excellent wound healing. Histologic studies confirm that the laser removes epidermis and papillary dermis but leaves undamaged the superficial vascular plexus and reticular dermis.

Infrequently, prior reports have described the use of the ipsilateral proximal fibula to replace an absent distal fibula caused by either trauma, infection, or resection for tumor. This is a 27-year follow-up of a 12-year-old patient who lost the distal 7.5 cm of her fibula secondary to trauma. The soft tissue defect was replaced early by an abdominal flap and the bone defect was eventually replaced with 7.5 cm of proximal fibula. The lateral ankle ligaments were reconstructed with the peroneus brevis, and the ankle joint has remained stable. Although traumatic arthrosis has progressed slowly, the patient at age 39 has a relatively painless, mobile ankle joint.

Management of very distal finger amputations is still controversial. Successful replantation results in an almost normal finger but is not without problems, such as technical difficulty, risk of failure and cost. "Reposition-flap" repair is a simpler procedure: it consists of distal bone and nail bed "graft-reposition" and pulp reconstruction by a flap. We compare ten successful replantations and six reposition-flap reconstructions. Replantation has several advantages over reposition-flap repair in terms of less finger shortening, longitudinal nail curvature, absence of PIP flexion contracture and shorter time off work. The results of reposition-flap repair are less satisfactory, but it is nevertheless a useful alternative when replantation is impossible or has failed.