Microsurgical reconstruction for head and neck in patients with end-stage renal disease undergoing dialysis.

INTRODUCTION: Free flap transfer for head and neck defects has gained worldwide acceptance. Because flap failure is a devastating outcome, studies have attempted to identify risk factors-including renal failure. We sought to determine whether end-stage renal disease (ESRD) patients undergoing dialysis are at increased risk of flap failure following microsurgical head and neck reconstruction. PATIENTS AND METHODS: The study's participants were patients who underwent free flap reconstruction in the head and neck region at Hualien Tzu Chi Hospital between January 2010 and December 2019. We used the National Health Insurance "Specific Diagnosis and Treatment Code" to identify patients undergoing dialysis; these patients comprised the dialysis group, whose members were matched to a non-dialysis group for age and gender. The dependent variables were flap survival rate, take-back rate, and flap failure risk between the dialysis and non-dialysis groups. RESULTS: We included 154 patients in the dialysis (n = 14) and non-dialysis (n = 140) groups. The groups were similar in terms of age and most comorbidities, except diabetes mellitus, hypertension, and coronary artery disease, which were more prevalent in the dialysis group. The dialysis and non-dialysis groups had similar flap survival rates (100% vs. 92.9%; p = .600). Twenty-three patients underwent take-back surgery, most in the non-dialysis group (14.3% vs. 15.0%; p = 1.000). Patients in the dialysis group were more likely to have prolonged intensive care unit stays; however, dialysis alone did not predict flap failure (OR: 0.83; p = .864). CONCLUSION: This study found no significant differences in free flap survival and take-back rates between patients with and without dialysis. Dialysis did not increase the risk of flap failure following microsurgical head and neck reconstruction in this study; however, prospective, randomized controlled trials are needed.

Reconstruction of Plantar Forefoot Area with Lateral Toe Pulp Flap: Case Report and Literature Review.

Reconstruction of the plantar forefoot area is challenging because it performs important functions, including carrying the body weight and balancing the ambulation gait, and lacks similar skin and soft tissues to manage the adjacent region. Herein, we shared our experience of using a lateral toe pulp flap and reviewed the relevant literature on this topic. A 33-year-old man presented with a large granuloma in the left plantar forefoot area after undergoing multiple operations owing to the diagnosis of callus. After tumor excision, the wound exhibited tendon exposure and a large infected dead space in the myofascial layer. After serial debridement with negative pressure wound therapy, the wound, which measured ~3.5 × 2.5 cm2, was reconstructed using a lateral toe pulp flap. The flap was transposed to obliterate the dead space; the remaining skin defect (size: ~2 × 2 cm2) was resurfaced with a full-thickness skin graft, harvested from the left inguinal region, followed by primary closure of the flap donor site. The flap completely survived. The lateral toe pulp flap is an easy, effective, and reliable option for reconstruction of the defects in the plantar forefoot area.

Endoscopic Concurrent Gastrocnemius Muscle Resection and Soleus Muscle Neurectomy for Severe Muscular Calf Hypertrophy.

BACKGROUND: Selective neurectomy or muscle resection techniques for calf reduction conventionally focuses on the gastrocnemius muscle. Nonetheless, the underlying soleus muscle plays an important role in muscular calf hypertrophy. In our experience, the results of calf reduction have been suboptimal in patients with severe muscular calf hypertrophy who had undergone gastrocnemius muscle resection only. This study aimed to describe a new calf reduction method that employs concurrent gastrocnemius muscle resection and soleus muscle neurectomy using an endoscope-assisted single-incision approach in patients with severe muscular calf hypertrophy. METHODS: One hundred thirty-nine patients who underwent simultaneous gastrocnemius muscle resection and soleus muscle neurectomy for severe muscular calf hypertrophy from March 2017 to June 2020 were retrospectively analyzed. RESULTS: After combined gastrocnemius resection (mean weight per calf was 349g) and soleus neurectomy, about 3.8 to 8.2 cm (mean: 6.4 cm) or 12.8% to 24.3% (mean: 16.6%) of the calf was reduced. Three patients each had cellulitis, hematoma, and seroma. Two patients had traction injury to the sural nerve, whereas one patient developed mild depression. One patient developed Achilles tendon rupture at 2 months postoperatively. None of the patients complained of functional impairment with respect to easy fatigability, stability, gait, or sport activities at 6 months postoperatively. CONCLUSIONS: This study is the first to combine gastrocnemius muscle resection with selective soleus muscle neurectomy to achieve the most efficient calf reduction for severe muscular calf hypertrophy.

Simultaneous calf reduction and contouring with customized differential subtotal gastrocnemius resection and muscle transposition: Analysis of 200 cases.

BACKGROUND: Oversized muscular calves can cause severe emotional distress. Total, partial, and subtotal resections of the gastrocnemius muscle for calf reduction have been described. However, the amount of muscle resected may be inappropriate, and the resultant leg contour may not be straight or esthetically pleasing enough. OBJECTIVES: This study aimed to describe a technique of customized differential subtotal gastrocnemius resection and muscle transposition. METHODS: A total of 200 patients who underwent customized differential subtotal gastrocnemius resection and muscle transposition for hypertrophic muscular calves from July 2013 to June 2016 were included in the study. RESULTS: A total of 148 patients underwent subtotal resection of both heads, and calf reduction ranged from 3.2 to 7.2 cm (mean 14.8%). Forty-two patients underwent subtotal resection of the medial head alone, and calf reduction ranged from 2.8 to 5.5 cm (mean 9.2%). Ten patients underwent subtotal resection of the lateral head alone, and calf reduction ranged from 1.2 to 2.1 cm (mean 4.6%). The medial gastrocnemius muscle was subtotally resected in 190 (95%) patients. In 130 (65%) patients, the preserved medial gastrocnemius muscle was transposed superomedially to achieve a straighter medial contour. None of the patients complained that their legs were too thin because of over-reduction. Cybex test showed that near-total muscle strength recovery was achieved within 6 months. CONCLUSION: Customized differential subtotal gastrocnemius resection together with muscle transposition resulted in enhanced calf reduction with straighter leg contour, without any impairment of the leg function. This approach may be more appealing to both patients and surgeons.

Single Incision Endoscope-Assisted Gastrocnemius Muscle Resection for Calf Hypertrophy: Analysis of 300 Cases.

BACKGROUND: Muscular calf hypertrophy can cause severe psychological distress. Total or subtotal resection of the gastrocnemius muscle results in significant calf reduction. However, both techniques require a second incision of 5 and 2 cm, respectively, at the posterior mid-calf. The resultant mid-calf scar is more difficult to conceal when wearing short skirts or pants. OBJECTIVES: The authors sought to describe the technique of endoscope-assisted gastrocnemius muscle resection to obviate the need for a mid-calf scar and to review the outcomes of patients who underwent this procedure. METHODS: A retrospective study of 300 patients in a single center in Taiwan who underwent endoscope-assisted subtotal resection of the gastrocnemius muscle for hypertrophic muscular calves, between March 2015 to June 2019, were included in this study. RESULTS: The combined weight of the resected gastrocnemius muscle ranged from 156 to 484 g per calf (mean = 276 g). The mean maximal calf circumference was 36.1 cm preoperatively and 30.9 cm postoperatively. The calf reduction achieved was 3.0 to 8.1 cm (mean = 5.2 cm), or 8.9% to 19.8% (mean = 14.4%). The complications were minor, and the rate was low (2%). As for the popliteal fossa scar, 6 patients underwent further treatment of their hyperpigmented or hypertrophic transverse scar. There were no complaints of impaired leg function regarding gait or sports activities 3 to 6 months postoperatively. CONCLUSIONS: At present, gastrocnemius muscle resection remains unrivaled in its ability to achieve calf reduction. The surgery is now much more appealing to patients as a result of employing the endoscope-assisted technique to obviate the mid-calf scar.

Reconstruction of Diabetic Foot Defects With the Proximal Lateral Leg Perforator Flap.

BACKGROUND: In patients with diabetic foot ulcers requiring flap reconstruction, the choice of local flaps is limited by the lack of adequate tissue available. Free flaps are often bulky, presenting footwear difficulty due to poor contouring. Here, we present our experience of using the proximal lateral leg perforator flap in the reconstruction of thin diabetic foot ulcers. METHODS: This is a retrospective study of 17 patients with diabetic foot ulcers reconstructed with the proximal lateral leg perforator flap during January 2013 and December 2015. RESULTS: Nine patients had varying degrees of peripheral arterial disease. The perforator was located 7 to 14 cm (mean, 9.7 cm) from the fibula head. The pedicle length ranged from 5 to 9 cm (mean, 6.9 cm). The arterial diameter of the pedicle measured 0.8 to 1.9 mm (mean, 1.4 mm). There was 1 total flap failure. One other flap complicated by venous thrombosis was successfully salvaged. All donor sites were closed primarily without morbidities. All the wounds were stable without recurrent ulceration during a mean follow-up time of 12 months. CONCLUSION: The thin, pliable proximal lateral leg perforator flap is an option for the reconstruction of small to moderate diabetic foot defects especially when it is located over the dorsal foot or the ankle. The flap is simple and quick to harvest without sacrificing a major artery. Although it is limited by the short length and the small diameter of the pedicle, for experienced microsurgeons, the success rate is high.

Varicose Vein Treatment by Suction-assisted Shaving Phlebectomy without the Use of Transillumination/Irrigation: A Simple, Quick and Effective Method.

Traditional management of saphenous vein incompetency is using high ligation and stripping with multiple stab incision phlebectomies for the varicose tributaries. A number of minimally invasive options have been described, each with their own advantages and disadvantages. We describe a new technique using suction-assisted shaving phlebectomy without transillumination and irrigation in the management of varicose veins. METHODS: All patients that underwent combined conventional high ligation and stripping for saphenous vein insufficiency and suction-assisted shaving phlebectomy for varicose tributaries between 2011 and 2016 was included. They were evaluated with respect to surgical time, number of incisions, complications, and outcomes. RESULTS: A total of 232 patients with mean age of 49 years old were included. The mean operation time for combined saphenous stripping and suction-assisted shaving phlebectomy was 29.5 minutes and for suction-assisted shaving phlebectomy was 7.4 minutes. The number of incisions excluding the groin incision was 3 incisions in 38 limbs, 2 incisions in 186 limbs, and 1 incision in 33 limbs. Postoperative complications included 2 (0.8%) skin perforation, 1 cellulitis (0.4%), 2 hematoma (0.8%), 3 saphenous neuropathy (1.2%), 4 skin pigmentation (1.6%), 4 skin depression or irregularities (1.6%), and 3 hypertrophic scarring (1.2%). CONCLUSIONS: Suction-assisted shaving phlebectomy has the advantage of decreased operating time, fewer surgical incisions, ad decreased scar formation. There is no need to purchase expensive medical equipment. It is a simple and effective procedure with comparable complication rates. This technique aims to replace traditional ambulatory phlebectomy and transilluminated powered phlebectomy.

A comparison study between endoscope-assisted and the standard approach in the harvesting of the free rectus femoris muscle flap.

BACKGROUND: Endoscopic harvesting of muscle flaps is well described for gracilis, latissimus dorsi, gastrocnemius, and pectoralis major amongst others. So far there has been no description of endoscopic harvesting of the rectus femoris muscle as a free flap. The purpose of this study was to compare the perioperative outcomes of harvesting the free rectus femoris muscle flap endoscopically as compared to the standard approach. METHODS: Fifty patients with lower limb defects reconstructed with free rectus femoris muscle flap between January 2014 and December 2016 were included in this study. Their ages ranged from 37 years old to 92 years old. The flaps were harvested with both the standard and endoscopical method. Comparative data between the two methods collected included: age, gender, comorbid illnesses, flap size, defect size, reconstruction time, and flap survival rate RESULTS: Twenty patients underwent flap harvesting endoscopically and 30 were harvested with the standard technique. Their mean ages were 67 ± 9.4 and 65 ± 14 years old respectively (P = .47). The defect size was 96 ± 60 cm2 versus 81 ± 74 cm2 (P = .45). The flap size was 72 ± 34 cm2 in the endoscopic group and 60 ± 42 cm2 in the standard group (P = .52). The mean total reconstruction time in the endoscopic group was 228 ± 48 minutes and 216 ± 64 minutes in the standard group (P = .50). There was no significant difference between flap survival (P = N/A), complication rates (P = .33), and length of admission (P = .84) in the two groups. CONCLUSION: Endoscope-assisted harvesting of a free rectus femoris muscle flap is a feasible option and permits a small scar at the donor site.

Lateral Toe Pulp Flap Used in Reconstruction of Distal Dorsal Toe Defect: Case Report and Review of the Literature.

BACKGROUND: When the distal dorsal part of the great toe is injured, especially with exposure of a tendon, bone, or joint, applying a free or local flap is difficult because of the lack of locally available tissue for reconstruction. Management of the distal dorsal part of a great toe soft tissue defect can be challenging for plastic surgeons. PATIENT AND METHOD: An 18-year-old woman presented with an injury to the dorsal aspect of her right great toe caused by a cobra bite. After fasciotomy, the wound showed exposure of the extensor hallucis longus tendon. After demarcation and infection control, the wound was reconstructed using a lateral toe pulp flap of approximately 3.5 × 1.0 cm. The flap was transposed to the defect, and the donor site was closed primarily. Toe pulp flaps are mainly used to reconstruct finger pulp defects and are useful because they provide a glabrous skin flap suitable for resurfacing fingertip injuries. A lateral toe pulp flap uses a homodigital adjacent skin flap, which is transposed to cover the soft tissue defect. Using a quick and straightforward procedure, we designed this flap to reconstruct a distal dorsal defect of the great toe, with minimal morbidity at the donor site. RESULTS: The flap initially showed mild congestion but survived completely. CONCLUSIONS: Applying a lateral toe pulp flap is a quick, simple, and reliable 1-stage procedure. It may be an effective option in reconstructing distal dorsal defects of the great toe.

Simple Skin-Stretching Device in Assisted Tension-Free Wound Closure.

BACKGROUND: Numerous conventional wound reconstruction methods, such as wound undermining with direct suture, skin graft, and flap surgery, can be used to treat large wounds. The adequate undermining of the skin flaps of a wound is a commonly used technique for achieving the closure of large tension wounds; however, the use of tension to approximate and suture the skin flaps can cause ischemic marginal necrosis. The purpose of this study is to use elastic rubber bands to relieve the tension of direct wound closure for simultaneously minimizing the risks of wound dehiscence and wound edge ischemia that lead to necrosis. MATERIALS AND METHODS: This retrospective study was conducted to evaluate our clinical experiences with 22 large wounds, which involved performing primary closures under a considerable amount of tension by using elastic rubber bands in a skin-stretching technique after a wide undermining procedure. Assessment of the results entailed complete wound healing and related complications. RESULTS: All 22 wounds in our study showed fair to good results except for one. The mean success rate was approximately 95.45%. CONCLUSIONS: The simple skin-stretching design enabled tension-free skin closure, which pulled the bilateral undermining skin flaps as bilateral fasciocutaneous advancement flaps. The skin-stretching technique was generally successful.

A comparison between combined open bypass revascularization and free tissue transfer versus endovascular revascularization and free tissue transfer for lower limb preservation.

BACKGROUND: Extensive defects of the lower limb as a result of diabetes and peripheral vascular disease require multidisciplinary treatment. Numerous studies with regards combining vascular bypass surgery and free tissue reconstruction of the lower limb had been published. However the trend has evolved toward a combination of endovascular revascularization and free flap reconstruction. The aim of this study was to compare the safety and efficacy of this combination of treatment to the traditional combination of bypass surgery and free tissue reconstruction. METHODS: All patients who had undergone vascular bypass surgery and free tissue reconstruction of the lower limb as well as those who had undergone endovascular angioplasty with free tissue transfer for lower limb preservation, over a 10-year period was included in this study. RESULTS: A total of 46 patients that underwent limb preservation were included in this study, 22 patients underwent open bypass revascularization and free flap transfer and 24 patients underwent endovascular revascularization and free tissue transfer. There were no differences between the two methods with regards to age, sex, defect size, TransAtlantic InterSociety Consensus level, Wagner classification, length of hospitalization, limb preservation rate, total flap necrosis rate, and partial flap necrosis rate. More importantly, there was no significant difference in the limb preservation rate (P = 0.14). CONCLUSION: In this study we found that the safety and the success rate of lower limb preservation using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer.

The proximal lateral lower leg perforator flap revisited: anatomical study and clinical applications.

BACKGROUND: The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. METHODS: The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozen cadaveric lower limbs. This was analyzed together with 22 clinical cases. RESULTS: Cadaveric dissection showed that there were 1-2 perforators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% musculocutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, the foot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 ± 0.8 mm. Vascular pedicle length ranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 ± 0.3 mm. One flap failure was seen due to arterial thrombosis. The overall flap survival rate was 95%. CONCLUSIONS: The proximal lateral lower leg flap has the advantages of being thin and pliable, quick to harvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in the majority of cases.

Application of proximal lateral leg perforator flaps for head and neck reconstructions.

OBJECTIVE: Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. STUDY DESIGN: Case series and chart review. SETTING: Tertiary care teaching hospital. SUBJECTS AND METHODS: Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. RESULTS: The flap size ranged from 4 × 4 cm to 11 × 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. CONCLUSION: This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects.

Endovascular revascularization and free tissue transfer for lower limb salvage.

Combined bypass surgery with free flap reconstruction is an established method for lower limb salvage. But the success of the combination of endovascular revascularization together with free tissue transfer has so far not been well established. A retrospective review of all patients who had undergone endovascular revascularization and reconstructed with free tissue transfer for lower limb salvage at Tzu Chi Dalin General Hospital between 2008 and 2012 was performed. A total of 26 legs underwent limb salvage in 24 patients. There were 10 male and 14 female patients. Their average age was 71.4 years. The average time interval between endovascular intervention and free tissue transfer was 8 days. There was 100% flap survival but partial flap necrosis was seen in three patients. A high rate of wound infection was seen in eight patients, all requiring further debridement. The total limb salvage rate at 1-year follow-up was 96% and 92% at the 2-year follow-up. In conclusion, the success rate of lower limb salvage using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer. It is associated with a high flap success rate and a high limb salvage rate. It provides physicians with a further treatment option in the management of ischemic lower limbs with extended tissue loss.

A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction.

Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps.

We describe our experience in expanding the use of pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. A total of 33 patients underwent 34 flaps between March 2003 and January 2012. The defects included 18 ischial, 3 trochanteric, 5 lower abdomen, 2 perineogenital, 1 groin, and 5 knee defects. There were 29 proximal pedicled (2 of which were preexpanded), 3 distal pedicled, and 2 propeller flaps. Complications included 1 total necrosis, 1 partial necrosis, 3 wound dehiscence in recipient site, 1 hematoma, and 1 donor-site dehiscence. The total flap survival rate was 94%. There were no donor-site morbidities except poor cosmesis in the skin-grafted sites. Pedicled anterolateral thigh flap is highly versatile with a wide arc of rotation. A proximal pedicled flap can be used for lower abdomen, perineogenital, ischial, and trochanteric defects and the distal pedicled or a propeller flap for knee and proximal lower leg defects.

Human adipose-derived stem cells for the treatment of intracerebral hemorrhage in rats via femoral intravenous injection.

Human adipose-derived stem cells (huADSC) were generated from fat tissue of a 65-year-old male donor. Flow cytometry and reverse transcription polymerase chain reaction (RT-PCR) analyses indicated that the huADSC express neural cell proteins (MAP2, GFAP, nestin and ß-III tubulin), neurotrophic growth factors (BDNF and GDNF), and the chemotactic factor CXCR4 and its corresponding ligand CXCL12. In addition, huADSC expressed the characteristic mesenchymal stem cell (MSC) markers CD29, CD44, CD73, CD90, CD105 and HLA class I. The huADSC were employed, via a right femoral vein injection, to treat rats inflicted with experimental intracerebral hemorrhage (ICH). Behavioral measurement on the experimental animals, seven days after the huADSC therapy, showed a significant functional improvement in the rats with stem cell therapy in comparison with rats of the control group without the stem cell therapy. The injected huADSC were detectable in the brains of the huADSC treated rats as determined by histochemistry analysis, suggesting a role of the infused huADSC in facilitating functional recovery of the experimental animals with ICH induced stroke.

Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps.

Massive composite defects of the face are difficult to reconstruct. Such defects are usually created after ablation of advanced cancers of the head and neck region. The use of a free fibular osteocutaneous flap for the bone and mucosal lining of the oral cavity and anterolateral thigh flap for the outer cutaneous lining are well established. We present our experience of using these two flaps simultaneously in the reconstruction of such defects and to evaluate the outcome. There were a total of 10 patients in our study. Their average age was 48.8 years. All had squamous cell carcinoma of the oral cavity. Their pathological stages were mostly stage T4 with only one case being T3. Flap survival was 100%. The application of dual free flaps, though technically more demanding, allows good orientation of the flaps. Seven patients maintained a good functional outcome. They were able to eat a soft diet. Their speech was easily comprehensible. The combination of a free anterolateral thigh flap with vascularized fibular osteocutaneous flap can be performed safely with adequate functional outcome. This combination of flaps should be considered for this group of patients.

A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores.

We describe island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transfer through a subcutaneous tunnel, the flap is transferred directly through the upper thigh to the ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treated between May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateral thigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty in transferring the flap to reach the ischial defect in any patient. The length of the pedicle ranged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which was located at the distal third of the thigh. We conclude this flap can be added to the repertoire for the treatment of recurrent, difficult ischial pressure sores.

Subtotal resection of gastrocnemius muscles for hypertrophic muscular calves in Asians.

BACKGROUND: Many Asian women are bothered by plump calves, which they consider to be unsightly. In the past, liposuction was frequently performed to treat oversized legs, but little effect could be obtained if the condition was caused by hypertrophy of calf muscles. METHODS: Gastrocnemius muscle resection for hypertrophic muscular calves was performed in 20 patients at Buddhist Tzu Chi General Hospital from May of 2001 through September of 2004. One patient underwent resection of the medial head only, two underwent total resection of both medial and lateral heads, and the other 17 patients underwent subtotal resection with preservation of the proximal 4 to 6 cm of muscle of both heads. RESULTS: The resected gastrocnemius muscle weighed from 250 to 430 g per calf (mean, 343 g). The maximal calf circumference was between 32 and 41 cm (average, 35.2 cm) preoperatively and 26 and 35 cm (average, 30.5 cm) postoperatively. Calf reduction was 3.5 to 7 cm (average, 4.7 cm), or 10.1 to 21.2 percent (average, 13.3 percent). Two patients developed seroma and three developed late hematoma. One patient had dragging of one foot because of incidental severance of the nerve to the soleus muscle that lasted for 6 months, until complete recovery occurred. No patient complained of functional deficits during gait or sports activities after 3 to 6 months. CONCLUSIONS: Subtotal resection of both heads of the gastrocnemius muscle can result in satisfactory calf reduction without impairment of leg function and avoid hollow deformity in the popliteal fossa. Five patients still had scar problems during the short-term follow-up period, but all were rather satisfied with their reduced calf sizes.