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Aim: To evaluate the functional outcomes of patients who underwent total or nearly total glossectomy for advanced tongue or base of tongue cancer., Material and Methods: We used the radial forearm free flap (RFFF), anterior lateral thigh flap (ALTF) or fibular osteocutaneous flap (FOCF) to reconstruct the oral defect after radical resection in 39 patients undergoing total or nearly total glossectomy with laryngeal preservation., Results: Good functional outcomes, measured by independent feeding, speech and swallowing were achieved in 35, 36 and 35 patients, respectively. The cumulative 4-year survival rates were 63.8% for tongue cancer and 42.9% for base of tongue cancer., Conclusion: Reconstruction with free flaps is a feasible method to restore the functional outcomes in speech and deglutition among patients who undergo total or nearly total glossectomy with laryngeal preservation.

To repair a 10 x 16 cm soft tissue defect of right lower leg that accompanied with occluded anterior and posterior tibial arteries in a 30-year-old man who sustained comminuted type III(B) Gustilo open tibial and fibular fracture, we present a successful reconstruction by using a large distally based sural island flap perfused by the lowermost perforator of the peroneal artery. This flap is a useful alternative for distal extremity reconstruction when anterior and posterior tibial arteries are occluded, as large flaps can be elevated safely based on only one peroneal perforator.

Three patients with compound injuries of the lower extremities were treated with pedicle fibular grafts and a free muscle flap concomitantly. There were 1 female and 2 male patients, all of whom sustained high-energy trauma in a motor vehicle accident. The bone defect of the tibia ranged from 8 to 12 cm. The size of the soft-tissue defect ranged from 24 x 15 cm to 28 x 15 cm. All patients underwent preoperative angiography to ensure the patency of the peroneal artery and to avoid its use by risking viability of the leg. All patients were treated with an antegrade-flow pedicle fibular graft. The fibular graft was inserted as a single strut in 2 patients and as a double-barrel strut in 1 patient. The pedicle of the free muscle flap was anastomosed to the distal runoff of the fibular bone flap. All free muscle flap transfers succeeded without complication. Bone scans performed on postoperative day 7 showed viability of transferred bone. The average time to radiological union was 9 months, and the average time to full weight bearing was 12 months. Screw loosening occurred in 2 patients and osteomyelitis was noted in another patient who was treated successfully with sequestrectomy and antibiotics. Indications for this technique are a large segmental bone defect with a huge soft-tissue defect, and patency of the peroneal artery and at least one other major artery. This method provides the advantages of one-stage reconstruction, avoidance of contralateral donor site morbidity, easy control of infection, and chance for early weight bearing. When selected carefully, this technique can be considered when one wants to avoid a two-stage, two free flap transfer.

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer.

Background: Untidy facial skin defects manifest extensive soft tissue injury and contamination. Since modern surgical principles emphasize immediate wound closure, most surgeons should learn to convert an untidy wound to a tidy one and to reconstruct defects immediately if possible with the use of grafts and flaps. However, in some situations, healing by secondary intention remains advantageous. The purpose of this study is to reevaluate this traditional approach., Methods: Twenty patients with untidy facial skin defects were treated conservatively over a 4-year period. The defects ranged from 2 x 2 cm2 to 6 x 4 cm2 in size. The depths of wounds were classified into partial-thickness in 9 patients, full-thickness in 7 patients, and deep defects in 4 patients. Each patient was instructed on wound care, which included daily cleaning with normal saline, followed by application of hydrocolloid occlusive dressing. Prophylactic antibiotics were not used., Results: The mean follow-up period was 17 months. All wounds healed within 3 to 5 weeks. There was no wound infection. One patient developed a hypertrophic scar over the cheek, and received excision of the scar and resurfacing with full-thickness skin graft. Two patients had residual traumatic tattooing which was resolved by laser therapy. Two patients had hypopigmentation/hyperpigmentation problems. Most patients (18/20) were satisfied with both functional and cosmetic results., Conclusion: Conservative wound care with hydrocolloid occlusive dressing allows good healing by secondary intention for traumatic facial defects in selected patients.

Background and Purpose: The goal of this study was to examine the reliability and validity of measurements obtained with the Alberta Infant Motor Scale (AIMS) for evaluation of preterm infants in Taiwan., Subjects: Two independent groups of preterm infants were used to investigate the reliability (n=45) and validity (n=41) for the AIMS., Methods: In the reliability study, the AIMS was administered to the infants by a physical therapist, and infant performance was videotaped. The performance was then rescored by the same therapist and by 2 other therapists to examine the intrarater and interrater reliability. In the validity study, the AIMS and the Bayley Motor Scale were administered to the infants at 6 and 12 months of age to examine criterion-related validity., Results: Intraclass correlation coefficients (ICCs) for intrarater and interrater reliability of measurements obtained with the AIMS were high (ICC=.97-.99). The AIMS scores correlated with the Bayley Motor Scale scores at 6 and 12 months (r=.78 and.90), although the AIMS scores at 6 months were only moderately predictive of the motor function at 12 months (r=.56)., Conclusion and Discussion: The results suggest that measurements obtained with the AIMS have acceptable reliability and concurrent validity but limited predictive value for evaluating preterm Taiwanese infants.

Background and Purpose: The location of several sensory systems in the head implies that maintenance of head stability may be a potentially important part of locomotor activity. A limited amount of research, however, has been conducted to measure stability or to compare head stability among different groups. The purpose of this study was to determine whether a method for measuring head stability during walking could differentiate among 3 groups: (1) children with cerebral palsy, (2) children without neurological impairment, and (3) adults without neurological impairment., Subjects: Eight adults without known neurological impairment, 6 children without known neurological impairment, and 6 children with cerebral palsy and mild spastic hemiplegia were compared., Methods: Subjects walked on a treadmill at their preferred speed at a number of frequencies. Head stability was characterized by fluctuations in period and amplitude of head motion in the sagittal plane across walking cycles., Results: Mean period fluctuation was lower for the adults than for the children, and it was lower for the children without neurological impairments than for the children with cerebral palsy., Conclusion and Discussion: The method can be used to differentiate head stability among different groups during functional activities.

The authors describe their additional experience with the distally based sural island flap for reconstruction of the whole foot, including the forefoot area in 8 patients. The flap is vascularized by the lowermost perforating branches of the peroneal artery. The skin flap can be elevated, based on the lesser saphenous vein and its accompanying arteries, in all parts of the sural region. This modification allows a farther reach of the flap for coverage of the distal foot and sole. All flaps, innervated by the lateral sural cutaneous nerves, were able to provide protective sensation in the distal soles. In 7 patients the flaps survived completely, and only 1 patient had partial necrosis of the flap. The advantage of this flap is its constant and reliable blood supply without sacrifice of the major artery. Elevation of the flap is simple and rapid. This flap is a versatile alternative that should be considered prior to a free flap transfer.

The authors report 2 patients with a massive bony defect of the tibia due to chronic osteomyelitis. They reconstructed the defect using a free vascularized fibular osteocutaneous flap. Unfortunately, venous insufficiency was diagnosed 24 hours postoperatively. The previous anastomosed veins were promptly explored. The peroneal veins of the vascularized fibular bone graft were noted to be full of thrombi. After thrombectomy, the vessels became very fragile and broke down easily. It was impossible to achieve normal antegrade venous outflow from the previous vein of the donor graft; however, they found that distal runoff of the peroneal vein achieved a reverse venous outflow from the donor graft. The great saphenous vein was dissected and reanastomosed to achieve adequate venous drainage. This procedure may offer an alternative treatment for a flap with venous insufficiency.

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.

Postoperative management procedures after microsurgery are well-established. Usually, maintaining an adequate plasma volume will lower blood viscosity and will provide an adequate arterial inflow to keep the replantation or the flap viable in routine microsurgical procedures. But if the patient's underlying condition is neglected, disasterous complications may occur. The authors report two cases with severe postoperative complications after microsurgery. One patient was a 38-year-old male who suffered from diabetic foot ulcer and received a free muscle flap transfer. He developed acute pulmonary edema at day 6 postoperatively. The other patient was a 20-year-old pregnant woman at 31 weeks gestation who developed pulmonary edema on the POD 4 following microsurgical replantation of the thumb and index finger of her left hand. The complications were believed to be caused by fluid overload and neglect of the patients' underlying conditions. Knowledge of possible precipitating factors and careful monitoring of fluid should avoid acute pulmonary edema after microsurgery under certain unusual conditions.

Between 1989 and 1994, 42 patients with circumferential skin avulsion of lower extremities were treated with full-thickness skin graft from defatted avulsed flap. Among them, 39 patients were run over by rubber tires during car accidents; the remaining 3 patients were victims of industrial accidents by roller machines. The full-thickness skin grafts were prepared from the avulsed skin flap in attachment to avoid junctional hypertrophic scarring. They were then secured with multiple skin staples to their anatomical position to improve skin graft take. Initial take of graft averaged 91 percent (ranged from 75 percent to 100 percent). Twelve patients underwent secondary overgrafting after tangential excision of non-viable skin graft. Follow-up averaging 2.6 years revealed stable wounds in most of the patients. Ten patients experienced occasional breakdown of skin graft in the patella and popliteal fossa, which was treated conservatively. Except for five who had deformed contours of the leg due to muscle transfers, the patients were satisfied with the cosmetic appearance of their legs. Compared with conventional methods, this approach provided better appearance and less contracture.

Twelve patients with circumferentially degloved hands were treated with full-thickness skin grafts harvested from defatted avulsed flaps. All injuries were industrial accidents caused by various roller machines, not crush injuries. Of these 12 patients, 9 patients were degloved from the wrist level and 3 patients were degloved from the forearm. There were 11 distally based skin flaps and one flap was completely detached. Four patients were avulsed distally to the mid palm, with volar neurovascular bundles damaged at the "fenestrae" of the palm, which resulted in devascularization of the involved fingers. Among them, distal fingers were successfully revascularized by microsurgical techniques in 3 patients. The full-thickness skin grafts were prepared from the attached, avulsed skin flap to avoid junctional hypertrophic scarring. The graft was then secured to its anatomic position with multiple skin staples to improve skin graft take. Initial take of the graft averaged 93% (range, 85%-100%). Compared with conventional methods, this approach provides a higher rate of skin take and better cosmetic and functional results.

Between 1989 and 1994, 28 patients who had plantar avulsion injuries were treated. Patient ages averaged 30 years (range 7 to 62 years). Length of follow-up averaged 20 months. Five patients (18 percent) were classified as having suprafascial avulsions, where the shearing plane was limited to the superficial subcutaneous layer, leaving the deeper subcutaneous fat. Twenty-three patients (82 percent) were classified as having subfascial avulsions, where the stripping force extended deep into the plantar aponeurosis. For the suprafascial avulsions, defatting these flaps and replacing them with full-thickness skin grafts was the treatment of choice. For the subfascial group, the avulsions with proximally based flaps (4 patients) that were well nourished by mediolaterally orientated neurovascular bundles could be treated by sewing the avulsed flaps tension-free back to their former positions. For the subfascial group with distally based flaps (19 patients), the avulsed flaps were supplied by anteroposteriorly orientated vascular plexuses that were compromised. Primary revascularization of the soft tissue should be considered whenever possible. Among them, 10 patients attempted microvascular salvage. Only 3 patients succeeded with revascularization. In the remaining 16 patients, the avulsed flaps went on to partial or complete necrosis, and these required secondary reconstruction with free muscle flaps for heel defects.

In six complex lower extremity defects, we have been able to reconstruct combined bone and soft-tissue defects with primary free-muscle transfer, followed by secondary free vascularized bone transfer. Indications for this technique are long segmental bone defects of the tibia associated with large soft-tissue defects, which are not suitable for one-stage composite bone and soft tissue transfer. In the first stage of reconstruction, a well-vascularized muscle flap is used to obliterate the soft-tissue defect to prevent infection. At the second stage, a fibula osteocutaneous flap from the contralateral leg is used to complete the reconstruction. The vascular pedicle of the first muscle flap surrounded by fibrofatty cuff, serves as the recipient vessels free of scar at the time of the second vascularized bone transfer. This method provides great advantages in two-stage free-flap reconstruction of complicated cases in which localization of suitable recipient vessel is technically difficult.

The distally based sural island flap is vascularized by the cutaneous perforating branches of the peroneal artery. Three variants of this flap were used for reconstruction of 19 patients with defects in the ankle and in both dorsal and plantar surfaces of the foot. Four adipofascial sural flaps were used to cover the exposed Achilles tendons. Twelve fasciocutaneous sural flaps were used to resurface defects in the ankle region as well as in the non-weight-bearing area of the heel. Another four sural flaps, innervated by the lateral sural cutaneous nerve, were used to resurface the weight-bearing areas of the heel. The advantage of this flap is a constant and reliable blood supply without sacrifice of major arteries or sensory nerves. It also has the potential for reinnervation and can be performed in a single stage without microsurgery.

Previous work demonstrated that adults naturally adopt a walking frequency to optimize physiological cost, symmetry, and stability. Furthermore, the optimal frequency is predictable using the force-driven harmonic oscillator (FDHO) model. However, no studies have established the developmental processes of optimization in children. Thus, the purposes of this study were to examine the predictability of the preferred stride frequency (PSF) and optimization features of 3- to 12-yr-old children using the FDHO model. Forty-five children and nine adults were measured for anthropometric data to calculate the predicted frequency. They later walked at three frequencies (PSF, PSF +25%, and PSF -25%) at a constant speed on a treadmill. The results indicated that the FDHO model was accurate in predicting the preferred frequency of children (prediction error < 0.07 s). We identified three stages of learning in the development of optimization: an early manifestation of sensitivity to resonant frequency, the subsequent development of ability to modulate walking frequency, and the final establishment of an adult optimization form at age seven. Our findings suggest that walking development may be determined by the dynamic cooperation of physiological, neural, and musculoskeletal systems with respect to the environmental context.

Techniques for aesthetic refinement are as important as those for functional improvement in toe-to-hand transfer. The appearance of the thumb reconstructed using various types of great toe transfer can be improved by reduction of the soft tissue, bone, interphalangeal joint, and nail and by secondary pulp reduction and contouring procedures. Finger and thumb reconstructions using lesser toes can be improved aesthetically by minimal inclusion of adipofibrous tissue under the plantar skin flap especially at the metatarsophalangeal joint region, thus decreasing the anterior-posterior bulkiness. Tight extensor repair, temporary K-pin fixation of the proximal and distal interphalangeal joint in extension, followed by prolonged use of a nighttime extension splint and secondary pulp reduction help to avoid the claw and drumstick appearances of the transferred lesser toe. Adequate soft-tissue coverage, cruciate skin incisions, extensive mobilization, and thinning and trimming of the skin flaps of the digital amputation stump lead to a smooth junction between the amputated digit and the transferred toe. In the distal digital reconstruction, skeletonization of medial and lateral neurovascular bundles of the harvested toe helps primary closure of the digital wound, thus avoiding the unsightly skin graft on the sides of the reconstructed digit. Regarding the donor foot, preservation of the proximal 0.5 to 1 cm of the proximal phalangeal stump of the great toe maintains the span of the foot, thus improving donor site appearance. In single lesser toe or combined second and third toe transfer, the proximal phalanx should not be preserved but an optimal web space should be reconstructed. Primary closure without skin graft is essential for aesthetic appearance of the donor foot.

Children voluntarily adopt a frequency and movement pattern for walking. The force-driven harmonic oscillator (FDHO) model was used in this study for accurate prediction of the preferred walking frequency of nondisabled children and children with spastic hemiplegic cerebral palsy. Four potential optimality criteria with which the preferred walking pattern was forced to comply were examined: minimization of physiological costs, maximization of mechanical energy conservation, minimization of asymmetry in lower limb movements and minimization of variability of interlimb and intralimb coordination. Age and gender-matched nondisabled children (n = 6) and children with spastic hemiplegic cerebral palsy (n = 6) were tested under six frequency conditions of walking at a constant speed on a treadmill. For the nondisabled children, the results indicated that their preferred walking frequency could be accurately predicted by the FDHO model. They freely adopted a walking pattern that minimized physiological costs, asymmetry, and variability of inter- and intralimb coordination. For the children with spastic hemiplegic cerebral palsy, the prediction of preferred overground walking frequency required that the FDHO model be modified to account for muscle mass and leg length discrepancies between limbs and increased stiffness. Most of the children achieved the same optimality goals as the nondisabled when walking at the preferred frequency. However, the children were found to use different mechanisms to attain these goals: for example, a steeper increase observed in physiological cost at higher frequencies; a lowered center of gravity of the body, which allowed for angular symmetry; and greater variability of between-joint coordination in the nonaffected limb and less variability in the affected limb.

Seven patients with extensive loss of soft tissue, extensor tendon, and exposure of bone and joint of dorsum of hand and foot were treated with free composite flaps from the groin area. To retard the adhesion by scarring, membrane interposition between tendon and bone was recommended. The groin flap, based on superficial circumflex iliac vessels, was combined with a well-vascularized external oblique aponeurosis. The groin skin flap provided skin coverage, and the aponeurosis was used simultaneously to create a gliding surface for reconstructed tendons in a single one-stage procedure. All composite free-tissue transfers were successful. The advantages of this technique are: (1) a single, one-stage procedure; (2) fewer adhesions of reconstructed tendons, and no need of secondary tenolysis; and (3) good cosmesis and minimal morbidity at donor site.

One rectus abdominis muscle flap, when based on superior and inferior pedicles, can be transferred simultaneously as two free-muscle flaps in two different configurations during the same operation. The two free flaps based on either pedicle are safe, reliable, and extremely well vascularized. Excellent functional and cosmetic results have been achieved in five patients with minimal donor-site morbidity. It has been our flap of choice for reconstructing the moderate- to large-sized defects at two separate sites of the upper and lower extremities.

The possibility that preferred modes of locomotion emerge from dynamical and optimality constraints and the energetic and dynamical constraints on preferred and predicted walking frequency are explored in this article. Participants were required to walk on a treadmill at their preferred frequency, at a frequency predicted as the resonance of a hybrid pendulum-spring model of the legs, and at frequencies +/-15%, +/-25%, +/-35% of the predicted frequency. Walking at the preferred and predicted frequencies resulted in minimal metabolic costs and maximal stability of the head and joint actions. Mechanical energy conservation was constant across conditions. The head was more stable than the joints. The joints appeared to be in service of the head in maintaining a stable trajectory. The major findings of this study suggest a complementary relationship between energetic (physiological) and stability constraints in the adoption of a preferred frequency of walking. Multiple subsystems may be involved in constraining observed macroscopic behavior in intact biological systems. The approach and results of the study imply that a useful tack in understanding how dynamical control structures arise is to study the potential criteria that serve to act as constraints on skilled movement patterns in unimpaired and impaired populations.

An adipofascial turnover flap is described. This vascularized flap is technically simple to perform and provides excellent cosmetic results for patients with a very large tumor undergoing superficial parotidectomy. The flap also acts as a barrier for regenerating nerves, preventing the development of gustatory sweating.

A challenge to the microsurgeon is perfecting the technique of replantation of small pieces of facial tissue, mainly because of the extremely small size of the arteries as well as a lack of suitable veins for drainage. In the past 4 years, we have had seven cases of facial amputations, which included one scalp, two nasal tips, two ears, one lower lip, and one eyebrow. All of these patients were replanted/revascularized by microvascular anastomosis. Only two of the cases had suitable veins for anastomosis. Alternative techniques used for improving venous outflow were arterio-venous fistula, chemical leeches, and pin pricks. Four of the cases were completely successful, two cases had partial loss of the replant, and one case failed due to absence of venous drainage. In facial amputation, an aggressive microsurgical attempt will result in more tissue surviving and a better cosmetic outcome than in any other reconstructive procedures.

Avulsion trauma to the dorsum of the foot is usually combined with skin and tendon loss. Five patients with such composite tissue loss were treated with composite free groin flaps including the external oblique aponeurosis based on the superficial circumflex iliac vessels. The groin flaps resurfaced the skin defect and the vascularized fascia was used to replace the absent extensor tendons in a single-stage reconstruction. All the composite free tissue transfers were successful. When compared with conventional treatments, the advantages of this technique are one-stage reconstruction, faster wound healing, and fewer adhesions of the reconstructed tendons.

To achieve better functional results following mutilating multidigital trauma, every effort should be made to maximize the ultimate function of the hand, and the plan of replantation should be guided accordingly. All usable parts should be salvaged from the amputated nonreplantable areas. A patient is reported in whom two fingers taken from the nonreplantable midpalm were used to reconstruct the thumb and ring fingers, ultimately improving the overall quality of the patient's life.

We present and discuss the clinical and biochemical findings of three siblings with cerebrotendinous xanthomatosis, which has not been previously reported in Taiwan. Clinical features consisted of tendinous xanthomas, cataracts, mental defects, pyramidal signs, cerebellar ataxia, peripheral neuropathy and renal stones. Biochemical findings included normal serum cholesterol levels, high serum cholestanol levels and elevated serum cholestanol to cholesterol ratios. The serum levels of cholesterol precursor (lathosterol) and plant sterols (campesterol, sitosterol) were also elevated.

A successful case of lower lip vermilion replantation is presented where there was lack of a suitable vein for drainage after arterial flow was re-established. The venous stasis was overcome by the "chemical leech," intra-replant subcutaneous heparin injection at intervals 9 days postoperatively. The result is excellent both aesthetically and functionally.