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A nonthermal laser device is approved for noninvasive body circumference reduction and temporary improvement in the appearance of cellulite. Another noninvasive device based on the principle of manual lymph drainage is approved for body circumference reduction and improving the appearance of cellulite. This pilot study evaluated the effectiveness of combining these treatments for reducing body circumference. Healthy men and women (N = 27), 22 to 70 years of age with a body mass index of 25 to 40 kg/m2, inclusive, seeking to improve the appearance of their waist, hips, and upper abdomen, were enrolled. The laser device consists of 6 independent, variable frequency lasers emitting a 532-nm green light with a mean power output of 17 mW (Erchonia Verjú Laser System; Erchonia Corporation, Melbourne, Florida). The lymphatic drainage system is a pressure therapy intended for body contouring and cellulite reduction applications and for reducing edema (Green PRESS 8 Lymphatic Drainage System; Iskra Medical, Podnart, Slovenia). Participants received 12 treatments, one every 3 to 4 days over a 6-week period. Each session included a 30-minute nonthermal laser treatment (15 minutes each to front and back) followed by a 30-minute treatment with the lymphatic drainage system. To evaluate comparability of the combined devices treatment with the nonthermal laser treatment, individual study success for the nonthermal laser alone was a 3.0-inch (7.62 cm) decrease in combined baseline hips, waist, and upper abdomen circumference at the end of the study. A 50% increase in combined hips-waist-upper abdomen circumference measurement following combined treatments was considered a clinically meaningful improvement over the use of nonthermal laser alone. Individual study success was achieved by 17 participants (63.0%), exceeding the preestablished overall study success criteria of 60% in comparison with nonthermal laser treatment alone. The mean (SD) combined body circumference decreased from 112.3 (13.7) inches at baseline to 108.5 (13.8) inches at the end of the study, a mean decrease of 3.9 (2.7) inches ( P < .0001). One-way analysis of variance tests for changes in total body circumference measures at weeks 4, 8, and 12 were significantly less than baseline (for each, P < .01); however, the study failed to achieve a 50% decrease in combined hips-waist-upper abdomen circumference measurement following application of combined treatments versus nonthermal laser alone. Additional treatment with a manual lymphatic drainage system does not improve the effectiveness of a nonthermal 532-nm green laser for reducing hips, waist, and upper abdomen circumference.

The tensor fascia lata (TFL) muscle, together with the overlying skin of the anterolateral thigh, makes a reliable musculocutaneous unit. It can be lengthened safely by taking the fascia lata and the skin of the anterolateral mid and lower thigh to within 8 cm of the knee. The skin of the longer flap is supplied by large perforating musculocutaneous arteries, the terminal branches of the vascular pedicle of the muscle. The shorter flap can easily be transposed over the trochanteric area, while the larger flap will cover not only the trochanter but also the ischial and sacral areas. The flap serves equally well as a transposition, island, or free flap. The anatomical and vascular basis of the flap is presented, together with its application in 21 patients. Possible further applications of the flap, including anterior rotation, are discussed.

A patient who developed clostridial infection of the abdominal wall following laparotomy for small bowel perforation is described. Immediate debridement resulted in the loss of the entire abdominal wall. Dressing of the exposed viscera during the period of stabilization and prior to reconstruction was achieved using amniotic membranes.

THREE times a year on average, we are called upon to treat patients with gunshot injuries to the mid and lower face which involve loss of much facial soft tissue, intra-oral lining and intervening bone; in addition, there are often cornminuted fractures of the bones adjacent to the open wound. Primary treatment has usually consisted only of debridement, stabilisation of the fractures and perhaps dressing the wounds with skin grafts. Later the oral lining and the skin defect have been reconstructed with local tissues and/or skin flaps. Still later, efforts have been made to reconstruct the missing skeleton with bone grafts but exposure of the remaining facial skeleton is difficult and the graft bed is often fibrotic. Although many of these patients have had 30 to 35 operations, the results are disappointing. In searching for a better solution to the problem we considered the case of a sculptor patching a damaged clay model. First he would build an armature into the damaged area and upon this replace the missing clay. Finally a glaze would be applied to protect the reconstruction. By analogy, in a complex facial reconstruction, the armature could be bone grafts to simulate the facial skeleton, the clay could be the vascular omentum and the outer protective layer could be a skin graft. In the rather meagre literature on reconstruction of the maxilla, there is one article of note. Obwegeser (1973) describes an ingenious reconstruction of the maxilla using a lattice of split rib grafts fixed to the remaining stable points. The bone bending forceps of Tessier are essential to bend the ribs to the proper cont0ur.l During the past 3 years, we have used the omentum as a pedicled flap for chest wall reconstruction in 12 patients with radiation necrosis (Jurkiewicz, 1977x as pioneered by Kiricuta (1963) and DuPont and Menard (1972). We had no significant complications and were impressed with the ease with which skin grafts took upon the omentum. More recently, our colleague, Dr P. G. Arnold (Arnold et al., 1976) impressed us with the use of the omentum as a “vascular putty” to cover a Silastic gel prosthesis in reconstructing a breast; even though the reconstruction was covered with a skin graft, the contour of the reconstructed breast more nearly corresponded to that of the normal breast than any other reconstruction we have seen. Alday and Goldsmith (1972) and Das (1976) have defined the vascular anatomy of the omentum and its variations. There are usually 3 main omental vessels which arise from the gastro-epiploic arcade. In 1972, McLean and Buncke first reported the free transfer of the omentum by microvascular anastomosis to repair a scalp defect. The gastro-epiploic vessels are 1.5 to 3.0 mm in diameter and their anastomosis to similar sized vessels is relatively easy. Friendly collaboration and support from surgical colleagues, operating room staff and anaesthetist is essential; in the case to be described the anaesthetic time was 144 hours !

Three flap procedures and reference to a fourth are described for use in the perineal area. These are advocated as they have been uniformly successful. Other plastic procedures are mentioned.

The history and development of the latissimus dorsi myocutaneous flap has been recently reviewed by Schneider et al. (1977) who used it for breast reconstruction. The following case illustrates another use for this remarkably versatile flap.