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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

The lower eyelid and midcheek are among the commonest areas of the face causing concern in patients who present for facial 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, resulting in weak structural support for the overlying soft tissues. These are patients we figuratively call those who “don’t 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 midcheek. Recent advances in understanding of surgical anatomy, specifically the detailed description of the midcheek soft tissue spaces and the key retaining ligaments of the midcheek, has enabled the development of dissection techniques that are atraumatic and effective in achieving good surgical correction, while minimizing the downtime of surgery. This anatomy, which is unchanging regardless of the technique used by the surgeon, is the foundation for understanding the effect of surgery in the midcheek and is explained in detail in this chapter. Nonsurgical and surgical approaches to rejuvenation are discussed. The subciliary and transconjunctival approaches to the midcheek are discussed in detail. Correct patient selection for the specific approaches is the key to patient and surgeon gratification.

Facial aging is a consequence of the face’s unique adaptions for the mobility needed for facial expression. This chapter describes the soft tissue construct of the face as being in five concentric layers. Movement originates in the middle layer, which for the most part is muscular and closely bound to the overlying dermis. Stability is provided in key immobile areas around the orbital and oral cavities, by a system of facial retaining ligaments. The ligaments effectively bind the layers by attaching the dermis to the skeleton. While facial movement occurs primarily over the bony cavities, it also occurs adjacent to them in a series of soft tissue glide plane spaces. These sub-SMAS facial soft tissue spaces are located between the ligaments. Being areas that facilitate mobility, they are also areas of inherent weakness. This is where aging originates anatomically. The 3-dimensional course of the facial nerve after it exits the stylomastoid foramen and travels towards the muscles of facial expressions is related predictably and consistently with this five-layered anatomy, being initially deep to the deep fascia (layer 5) as it exits the parotid gland, transitions through layer 4 to innervate the muscle of facial expressions in layer 3. Understanding the transition of the facial nerve from deep to superficial is important as the are the locations where the nerves are susceptible to injury during sub-SMAS facelift procedures.

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.

Introduction The anteromedial thigh flap (AMT) lies adjacent to the anterolateral thigh flap (ALT) area and can be used as a backup whenever the ALT is not feasible. Literature published on the AMT flap is limited, and the vascular anatomy of the AMT flap is not well understood. Clarification of the vascular anatomy will be useful for safe and efficient planning and raising of the AMT flap. Method Fourteen cadaveric lower limbs were injected with latex dye and dissected to study the skin perforators larger than 0.5 mm in the anterolateral and anteromedial thigh. We demonstrate the application of the AMT flap in a clinical case where a combined ALT and AMT flap was used to reconstruct a tongue and floor of mouth defect post cancer resection. Results Perforators that supplied the rectus femoris muscle and the overlying skin were present in all specimens and 12/14 (85.7%) specimens had rectus femoris branches (RFBs) originating from the descending branch of the lateral circumflex iliac artery. In total, 82.4% of AMT perforators are musculocutaneous (14/17 specimens), and they pierce the muscular fascia along a line drawn from the mid-inguinal point to the superomedial pole of the patella. The perforators congregate at the one-quarter mark and the midpoint of this line. This line is useful for the preoperative planning of the AMT flap. Conclusion The anatomy of the RFB, which is critical in the blood supply of the AMT flap, is constant and predictable. The location of the perforators is predictable, which aids preoperative planning.

What's in a name? That which we call a rose by any other name would smell as sweet. William Shakespeare As the title suggests, this contribution by Dr Pessa1 differs from the usual focused plastic surgery articles in this journal. It is closer to a thesis, being several papers in one on related aspects of this anatomy, to which the reader will likely return. Unfortunately, as is the anatomy, the paper is not easy to understand and I regret this brief Commentary cannot do justice to many aspects worthy of comment. It is the culmination of Dr Pessa's anatomical contributions to plastic surgery over more than 20 years that have followed a continuous theme, being largely based on dye injection studies.2,3 The earlier studies focused on the superficial anatomy, whereas the recent progression into unfamiliar territory of the deeper facial anatomy has been more difficult for plastic surgeons to follow.4 The difficulty is defined in the opening paragraph “the sub-divisions of these layers, the terminology that defines them, and their boundaries have remained a source of controversy throughout medical history.”1 Some good clinical correlations and excellent dissections are included to explain the messages. Having spent considerable time studying the illustrations and their legends on several occasions. I concur with the overall message, despite some disappointing errors of detail in the text. So the focus is to understand the relationship between the superficial and deeper facial anatomy. A sound understanding of basic anatomical principles provides the framework on which to understand the detail described. The cheek is not homogenous, but consists of several functionally, and therefore structurally, different regions. In simplest terms the cheek can be considered as having a central part, the cheek proper, and a peripheral part that can be likened to a …

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.

Background: 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. Objectives: 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. Methods: 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. Results: 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. Conclusions: Immediate cosmetic and functional open rhinoplasty is safe, predictable, and effective in Asian patients. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

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.

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.

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

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.

We present a massive 25 cm x 20 cm chest wall defect resulting from resection of recurrent cystosarcoma phyllodes of the breast along with six ribs exposing pleura. The chest wall was reconstructed with a Prolene mesh–methylmethacrylate cement sandwich while soft tissue reconstruction was carried out using a combined free anterolateral–anteromedial thigh musculocutaneous flap with two separate pedicles, anastomosed to the thoracodorsal and thoracoacromial vessels respectively. We explain our rationale for and the advantages of combining the musculocutaneous anterolateral thigh flap with the anteromedial-rectus femoris thigh flap.

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.

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.