Muscle-based Flaps Research Articles

Reconstruction of Oncological Defects in the Pelvic-perineal Region: Report on the Consensus Workshop at the 44th Annual Meeting of the DAM 2023 in Bern, CH

The surgical-oncological treatment of pelvic and perineal malignancies is associated with a high complication rate and morbidity for patients. Modern multimodal treatment modalities, such as neoadjuvant radio-chemotherapy for anal or rectal cancer, increase the long-term survival rate while reducing the risk of local recurrence. Simultaneously, the increasing surgical radicality and higher oncological safety with wide resection margins is inevitably associated with larger and, due to radiation, more complex tissue defects in the perineal and sacral parts of the pelvic floor. Therefore, the plastic-surgical reconstruction of complex pelvic-perineal defects following oncological resection remains challenging. The reconstructive armamentarium, and thus the treatment of such defects, is broad and ranges from local, regional and muscle-based flaps to microvascular and perforator-based procedures. While the use of flaps is associated with a significant, well-documented reduction in postoperative complications compared to primary closure, there is still a lack of reliable data directly comparing the postoperative results of different reconstructive approaches. Additionaly, the current data shows that the quality of life of these patients is rarely recorded in a standardised manner. In a consensus workshop at the 44th annual meeting of the German-speaking Association for Microsurgery on the topic of "Reconstruction of oncological defects in the pelvic-perineal area", the current literature was discussed and recommendations for the reconstruction of complex defects in this area were developed. The aim of this workshop was to identify knowledge gaps and establish an expert consensus to ensure and continuously improve the quality of reconstruction in this challenging area. In addition, the importance of the "patient-reported outcome measures" in pelvic reconstruction was highlighted, and the commitment to its widespread use in the era of value-based healthcare was affirmed.

Comparison of Lymphatic Drainage of the Lower Limbs After Soft Tissue Reconstruction by Microvascular Muscle Flap Versus Fasciocutaneous Flaps.

Complex traumatic injuries of the lower limb are increasingly being salvaged. The common long-term morbidity includes secondary lymphedema. The role of microvascular flaps is often discussed for lymph flow restoration. However, the differential effect of using muscle flap versus fasciocutaneous flap in the lower-limb trauma to avoid secondary lymphedema is not studied. Forty patients who underwent microvascular flap reconstruction were reviewed retrospectively to obtain data regarding clinical demographics and surgical procedure. Assessment for presence of clinical lymphedema was done. The lymphatic drainage in all these patients was assessed by 99mTc lymphoscintigraphy. Of the 40 patients included in the study, group A (n = 23) underwent muscle-based free flap reconstruction, and group B (n = 17) had fasciocutaneous flaps. Clinical lymphedema was present in 21 patients, of which 18 were of group A and 3 of group B. On lymphoscintigraphy, 14 patients had either partial or complete obstruction in the reconstructed lower limb, 11 in group A and 3 in group B. All of them (n = 14) were found to have associated clinical lymphedema. The association of clinical lymphedema (P < 0.001) and obstructive pattern on lymphoscintigraphy (P < 0.05) with muscle flaps was found to be statistically significant. With the advancement in surgery and techniques, not only salvageability but also stable and morbidity free outcomes are the goals. Fasciocutaneous flaps may have better lymphatic outcomes than the muscle-based flaps, and the criteria for lower-limb reconstruction can be reformed to include simultaneous soft tissue and lymphatic reconstruction.

Partial breast reconstruction- a new era of breast reconstruction? Systematic literature review

Background: Partial breast reconstruction has increasing popularity in improving aesthetic outcomes in breast cancer surgery. Over the years there is trend observed in literature in development of oncoplastic techniques where muscle-based (LD) flaps are now replaced by non-muscle perforator flaps (PCWF) and mastectomy is now being reserved to narrow clinical indications. The evidence of oncologic outcomes and complications are still in the process of collection, therefore good quality systemic reviews are of foremost importance.

Free tissue transfer for lower extremity trauma in the pediatric patient

Aim: The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described. Factors include microsurgeon inexperience, inadequate center resources, and fear of historically described poor surgical outcomes. The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects. Methods: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric (aged 18 and younger) lower extremity following traumatic etiology since 2005. Outcomes included flap failure, return to the operating room, and functional status, where available. Results: Seven studies were deemed appropriate for inclusion, with a total of 243 flaps included. Motor vehicle and motorcycle accidents were greater than 75% of total etiology. Most defects involved the foot or ankle (65.1%). In total, perforator flaps compromised the majority of flaps (54%), with the most common being the anterolateral thigh, the scapular/parascapular, and deep inferior epigastric flaps. Less common perforators included the groin flap, tensor fascia lata, radial forearm, lateral arm, and thoracodorsal perforator flap. Muscle-based flaps were less common (46%), with the latissimus dorsi and rectus muscle flaps composing the majority. The most commonly used recipient vessel was the anterior tibialis (49.5%) and posterior tibialis vessels (45.3%). Most studies performed reconstruction within 7-10 days of presentation. There was a cumulative 6.5% flap failure rate. Conclusion: Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes. Recent trends indicate increasing usage of perforator flaps. This study shows that based on existing data, free flap utilization for pediatric patients is an adequate modality for repair, and may warrant greater consideration moving forward.

The superior lateral genicular artery flap for reconstruction of knee and proximal leg defects

Reconstruction of defects around the knee region requires thin and pliable skin. The superior lateral genicular artery (SLGA) flap provides an excellent alternative to muscle-based flaps. The anatomy and the surgical techniques of the SLGA flap were reviewed and the results of cases using the SLGA flap for coverage of knee and proximal leg defects were analyzed. SLGA flaps were performed in two cases and followed up for at least 6 months. Twelve articles on the use of the SLGA flap were also identified. A review of 39 cases showed that the mean diameter of the perforator supplying the skin of the flap was 1.04 mm, while the mean diameter of the SLGA at its origin was 1.78 mm. The mean length of the pedicle measured from the origin of the popliteal artery was 7.44 cm. The average dimensions of the flap were 14.8×6.6 cm with primary closure of the donor site in 61.5% of cases. Of these cases, 38.5% were due to trauma, 23.1% were post-burn complications, 12.8% were defects after resection of tumors, and 10.3% were for ulcers post-bursectomy. The most common complication was flap tip necrosis. All studies reported favorable outcomes with complete wound healing.

Reinforcement of the abdominal wall with acellular dermal matrix or synthetic mesh after breast reconstruction with the pedicled transverse rectus abdominis musculocutaneous flap. A prospective double-blind randomized study

Introduction The pedicled transverse rectus abdominis musculocutaneous flap (p-TRAM) is a well-established option for autologous breast reconstruction (BR) but donor-site morbidity is still reported. The aim of the present study was to compare donor-site morbidity after reinforcement of the abdominal wall regarding development of bulging or hernia, abdominal muscle strength, complications, and abdominal pain hypothesizing, that reinforcement with acellular dermal matrix (Strattice™) is superior to reinforcement with synthetic mesh (Prolene®). Materials and methods A randomized, prospective, double-blind study was conducted with 29 patients admitted for BR with the p-TRAM flap at Department of Plastic Surgery, AUH, Denmark, 2014–2016. Allocation rate 1:1. Follow-up at 4, 12, and 24 months. Results 24 months postoperatively the computerized tomography verified bulging frequency was 35.7% in the ADM group and 6.7% in the synthetic mesh group (p = 0.11). Two patients (14.3%) in the ADM group and no patients in the synthetic mesh group developed hernia. No significant difference between baseline and 2-year measurement of abdominal muscle strength was observed. Conclusion The present study did not demonstrate any statistically significant differences between treatment groups regarding risk of bulging or hernia, abdominal muscle strength, complications, pain or pain related QoL within two years of follow-up. Although the small sample size sets limitations for drawing wide conclusions the hypothesis that reinforcement with ADM is superior to synthetic mesh cannot be confirmed. Further research into methods for decreasing donor-side morbidity related to the TRAM flap or other rectus abdominis muscle-based flaps is needed.

Free flap reconstruction of sarcoma defects in the setting of radiation: a ten-year experience

Neoadjuvant treatment and surgical resection for sarcoma patients can often leave devastating wounds necessitating soft-tissue coverage in the form of free flaps. There is still debate as to the optimal flap for reconstruction of defects in irradiated fields. We aim to describe our experiences with free fasciocutaneous and free muscle flaps for sarcoma reconstruction in the setting of radiation therapy. A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to sarcoma resection from January 2010 to June 2019. Patient characteristics, flap viability and post-operative healing outcomes were all recorded and examined. In total, 49 patients who underwent 51 free-flaps were identified. Of these, 30 flaps were fasciocutaneous, while 21 were muscle-based. Most patients received pre-operative radiotherapy (76.5%), although these rates were not different between groups of flap type, and had no significant association with post-operative outcomes. Complication rates (31.3%) and re-operative rates (21.6%) were also comparable between flap types. Diabetes mellitus was significantly associated with delayed wound healing (p < .016), while the presence of peripheral vascular disease had a significant association with post-operative infection (p < .006). This study shows that free fasciocutaneous and free muscle-based flaps are both viable options for soft-tissue reconstruction demanded by sarcoma resection, even in the setting of radiation. Peripheral vascular disease and diabetes mellitus may confer increased wound complications.

Larger free flap size is associated with increased complications in lower extremity trauma reconstruction.

Free flap reconstruction after lower extremity trauma remains challenging with various factors affecting overall success. Increasing defect and flap size have been demonstrated to be a surrogate for overall injury severity and correlated with complications. In addition, larger free flaps that encompass more tissue theoretically possess high metabolic demand, and may be more susceptible to ischemic insult. Therefore, the purpose of our study was to determine how flap size affects microsurgical outcomes in the setting of lower extremity trauma reconstruction. Retrospective review of 806 lower extremity free flap reconstructions performed from 1979 to 2016 among three affiliated hospitals: a private university hospital, Veterans Health Administration Hospital (VA), and a large, public hospital serving as a level 1 trauma center for the city. Soft tissue free flaps used for below the knee reconstructions of traumatic injuries were included. A receiver operating curve (ROC) was generated and Youden index was used to determine the optimal flap size for predicting flap success. Based on this, flaps were divided into those smaller than 250 cm2 and larger than 250 cm2 . Partial flap failure, total flap failure, takebacks, and overall major complications (defined as events involving flap compromise) were compared between these two groups. Multivariate logistic regression was performed to determine whether flap size independently predicts complications and flap failures, controlling for injury-related and operative factors. A total of 393 patients underwent lower extremity free tissue transfer. There were 229 flaps (58.2%) with size <250 cm2 and 164 flaps (41.7%) ≥ 250 cm2 . ROC analysis and Youden index calculation demonstrated 250 cm2 (AUC 0.651) to be the cutoff free flap for predicting increasing flap failure. Compared to flaps with less than 250 cm2 , larger flaps were associated with increased major complications (33.6% vs. 50.0%, p = .001), any flap failure (11.8% vs. 25.0%, p = .001) and partial flap failure (4.8% vs. 14.6%, p = .001). Logistic regression analysis controlling for age, flap type, era of reconstruction, number of venous anastomoses, presence of associated injuries, presence of a bone gap, vessel runoff, and flap size identified increasing flap size to be independently predictive of major complications (p = .05), any flap failure (p = .001), partial flap failure (p < .001), and takebacks (p = .03). Subset analysis by flap type demonstrated that when flap size exceeded 250 cm2 , use of muscle flaps was associated with significantly increased flap failure rates (p = .008) while for smaller flap size, there was no significant difference in complications between muscle and fasciocutaneous flaps. Increasing flap size is independently predictive of flap complications. In particular, a flap size cutoff value of 250 cm2 was associated with significantly increased flap failure and complications particularly among muscle-based flaps. Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring large surface area of soft tissue reconstruction.

Comparison of Fasciocutaneous and Muscle-based Free Flaps for Soft Tissue Reconstruction of the Upper Extremity.

The authors evaluated retrospectively the results of 164 free flaps in 149 patients with upper extremity defects. Chart reviews were performed from April 2000 to June 2014, analyzing flap choices, complication, and success rate assessment for patients >18 years old, with a soft tissue defect of the upper extremity. Chosen flap types were classified as fasciocutaneous (including adipocutaneous) and muscle-based, respectively. We comparatively analyzed total flap loss, flap survival after microsurgical revisions, and susceptibility rates for thromboses rates and partial flap necrosis. Defect size was larger when muscle-based flaps were used (231 ± 38.6 versus 164 ± 13.7 cm2, P < 0.05). Outcome analysis revealed a tendency towards higher arterial thrombosis rates for muscle flaps (10.2% versus 4.3%) and venous thrombosis rates for fasciocutaneous flaps (2% versus 7%). Total flap loss (6.1% versus 7.8%) and flap survival after vascular revisions (75% versus 70.6%) showed comparable rates. Partial flap necrosis was generally higher in muscle-based flaps (22.4% versus 8.6%, P = 0.02) with impact on patients' hospital stay (37.2 ± 4.69 and 27.11 ± 1.62 days, n = 115, P = 0.01), while no differences in partial necrosis rates were noted in flaps larger than 300 cm2 (25% versus 10%, P = 0.55). There was a trend over time towards using fasciocutaneous-based flaps more frequently with a final overall percentage of 83.7% between 2012 and 2014. Microsurgical tissue transfer to the upper extremity is safe and reliable, but flap-type specific procedural and measures should be taken into consideration. Total flap loss as well as flap survival after microsurgical revisions are not altered between these flaps. They differ, however, in their susceptibilities for thromboses rates, partial flap necrosis and thus require individual risk stratification and flap placement.

Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: A matched‐pair analysis

Limb salvage in patients with peripheral vascular disease (PVD) and soft tissue defects often requires both a restoration of blood flow to the lower extremity and soft tissue coverage. Outcomes of free tissue transfer may be affected by vein grafts, which can be used for the placement of an autologous venous bypass or an arteriovenous (AV) loop leading to different hemodynamic situations. The purpose of this study was to investigate whether free flap anastomosis to a bypass or an AV loop can be performed with comparable results. We performed a matched-pair analysis of 22 patients with PVD undergoing free flap reconstructions of the lower extremity with end-to-side anastomosis to an autologous venous bypass (n = 11, 1 female and 10 male patients) or an AV loop (n = 11, 2 female and 9 male patients). Defects caused by trauma, infection, ulcer, or fasciotomy were reconstructed in each group with 5 muscle-based flaps, 3 parascapular flaps, 2 anterolateral thigh (ALT) flaps, and 1 conjoined latissimus dorsi and parascapular flap. Postoperative complications including thromboses, flap failures, wound complications, and hematomas were compared. Postoperative complication rates including 1 venous pedicle thrombosis (9%vs. 0%, P = 1.0), minor (18% vs. 9%, P = 1.0) and major wound complications (45% vs. 27%, P = .69) as well as hematomas (27% vs. 36%, P = 1.0) did not show relevant differences between the groups. Flap failures were absent in both groups. In patients with PVD, autologous venous bypass grafts may be used for end-to-side anastomoses of free flaps, with postoperative outcomes being comparable to AV loop reconstructions.

Flap Reconstruction of Sarcoma Defects in the Setting of Neoadjuvant and Adjuvant Radiation.

Limb-sparing treatment of extremity soft tissue sarcomas requires wide resections and radiation therapy. The resulting complex composite defects necessitate reconstructions using either muscle or fasciocutaneous flaps, often in irradiated wound beds. A retrospective chart review was performed of all limb-sparing soft tissue sarcoma resections requiring immediate flap reconstruction from 2012 through 2016. Forty-four patients with 51 flaps were identified: 25 fasciocutaneous and 26 muscle-based flaps. Mean defect size, radiation treatment, and follow-up length were similar between groups. More often, muscle-based flaps were performed in younger patients and in the lower extremity. Seventeen flaps were exposed to neoadjuvant radiation, 12 to adjuvant radiation, 5 to both, and 17 to no radiation therapy. Regardless of radiation treatment, complication rates were comparable, with 28% in fasciocutaneous and 31% in muscle-based groups (p < 0.775). Muscle-based flaps performed within 6 weeks of undergoing radiotherapy were less likely to result in complications than those performed after greater than 6 weeks (p < 0.048). At time of follow-up, Musculoskeletal Tumor Society scores for fasciocutaneous and muscle-based reconstructions, with or without radiation, showed no significant differences between groups (mean [SD]: 91% [8%] vs. 89% [13%]). The similar complication rates and functional outcomes in this study support the safety and efficacy of both fasciocutaneous flaps and muscle-based flaps in reconstructing limb-sparing sarcoma resection defects, with or without radiotherapy.

Skin Paddles Improve Muscle Flap Salvage Rates After Microvascular Compromise in Lower Extremity Reconstruction.

Free tissue transfer after lower extremity trauma is associated with notoriously high complication rates. Theoretically, the inclusion of a cutaneous paddle on muscle free flaps may improve clinical flap monitoring. The effect of skin paddle presence on muscle free flap salvage outcomes after take-back was examined. Retrospective query of our institutional free-flap registry (1979-2016) identified 362 muscle-based flaps performed for soft tissue coverage after below-knee trauma. Primary outcome measures were perioperative complications, specifically take-back indications, timing, and flap salvage rates. Univariate and multivariate regression analyses were performed where appropriate. The most common flaps were latissimus dorsi (166; 45.9%), rectus abdominis (123; 34%), and gracilis (42; 11.6%) with 90 flaps (24.9%) including skin paddles. Take-backs for vascular compromise occurred in 44 flaps (12.2%), of which 39% contained a skin paddle while 61% did not. Overall salvage rate was 20.5%, with 31.8% partial failures and 47.7% total flap losses. Muscle flaps with skin paddles were more likely to return to the operating room within 48 hours postoperatively than those without (57.1% vs 18.2%, P = 0.036). After take-back, significantly more muscle flaps with skin paddles were salvaged compared with muscle flaps without paddles (35.7% vs 4.5%, P = 0.024). Similarly, more muscle-only flaps after take-back failed compared with their counterparts with skin paddles (95.5% vs 65.3%, P = 0.024). Muscle flaps with a cutaneous paddle were associated with earlier return to the operating room and more successful flap salvage after take-back compared with muscle-only flaps. These findings suggest that skin paddle presence may improve clinical flap monitoring and promote recognition and treatment of microvascular compromise in lower extremity reconstruction.

Perforator Flaps in Head and Neck Reconstruction

Free tissue transfer has revolutionized the management of complex head and neck defects. Perforator flaps represent the most recent advance in the development of free flap surgery. These flaps are based on perforating vessels and can be harvested without significant damage to associated muscles, thereby reducing the postoperative morbidity associated with muscle-based flaps. Elevation of perforator flaps requires meticulous technique and can be more challenging than raising muscle-based flaps. Use of a Doppler device enables reliable identification of the perforating vessels and aids in the design of free-style free flaps, where the flaps are designed purely according to the perforator located. The major advantage of free-style free flaps is that an unlimited number of flaps can potentially be designed on much shorter pedicles. The anterolateral thigh flap is the most commonly used perforator flap in head and neck reconstruction. Its use is described in detail, as is use of other less common perforator flaps. This article also describes head and neck reconstruction in a region-specific manner and gives a short-list of suitable flaps based on the location of the defect.

Immediate Reconstruction of Oncologic Hemipelvectomy Defects

Soft tissue and bony tumors of the pelvis are rare, but when they occur, treatment presents both an oncologic surgical and a reconstructive challenge. After reconstruction, soft tissue defects can be large and there is usually exposed bone and/or joint. A retroperitoneal abdominal wall defect may also be present. Flap mobilization is generally necessary to eliminate dead space and cover the exposed bone, viscera, and/or prosthetic orthopedic material. We performed immediate reconstruction on 11 patients after radical pelvic resections for tumor. Eleven cases of radical pelvic resection and immediate reconstruction were identified during the period from 1992 to 2002 at University Hospital, Newark, New Jersey. All patients were treated by both the orthopedic oncology and plastic surgery teams. A retrospective review of office charts and hospital records was performed. Data were gathered regarding the following: tumor type and oncologic history, extent of resection, reconstructive modality, complications, and outcome. All patients underwent radical resection of pelvic masses depending on the tumor type and location. Tumor types included chondrosarcoma (6), Paget osteosarcoma (1), giant cell tumor (1), metastatic uterine carcinoma (2), and invasive squamous cell carcinoma arising in a chronic decubitus ulcer (1). The reconstructive procedures performed were the following: rectus abdominus flaps (6), gluteus maximus musculocutaneous flaps (3), and thigh fillet flaps (2). The retroperitoneal defects were repaired with primary tissue approximation of the surrounding available musculature. Additionally, Gore-Tex mesh was used in 2 cases, tensor fascia lata was used in 2 cases, and acellular dermal matrix in 1 case. Blood loss for the combined procedures ranged from 400 mL to 1400 mL. The follow-up period in this series ranged from 24 to 114 months. Complications included skin flap loss with subsequent infection (1), local cellulitis controlled with antibiotics (1), regional recurrence (2). The postoperative course was uneventful for the remainder of the cases. Soft tissue reconstructions after extensive pelvic resections always present as complex reconstructive problems. Reconstruction is dictated by the size of the defects and by tissue availability. The extent and type of resections vary according to tumor size and location. In our experience, local pedicled muscle-based flaps, if available, usually provide adequate tissue mass to eliminate dead space, cover the extent of the wound, and close the retroperitoneal defect. Microvascular tissue transfer is always an option but was reserved in our series for cases with no suitable local alternative.

Nasalis myocutaneous island pedicle flap with bilevel undermining for repair of lateral nasal defects.

The superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining is a recently described bipedicled flap used for repair of nasal tip and supratip defects. This flap was used for the repair of small to medium-size defects of the nasal tip and supratip regions. To describe a single-pedicled modification of this flap for the reconstruction of lateral nasal defects at or above the alar groove. With the use of diagrams and fresh cadaver dissection, we demonstrate the method of preparing, raising, and placement of this new flap. We further elucidate in an illustrative way the efficacy of bilevel undermining as it is used for achieving greater flap mobility. Finally, we show representative cases with pre- and postoperative results. We describe the senior author's 4-year experience in the development of this flap. The nasalis myocutaneous island pedicle flap with bilevel undermining, a new method for repair of lateral nasal defects at or above the alar groove, yields excellent functional and cosmetic results. Bilevel undermining is a new and valuable method of achieving greater tissue mobility in muscle-based flaps.

Superiorly based nasalis myocutaneous island pedicle flap with bilevel undermining for nasal tip and supratip reconstruction.

Superiorly based flaps with bilevel undermining for the reconstruction of nasal tip and supratip defects have not been utilized to this point for reconstruction of this cosmetic subunit. The purpose of this presentation is to describe a new flap for the reconstruction of nasal tip and supratip defects and to introduce a new method of undermining-bilevel undermining-in the raising of these flaps. In this presentation we demonstrate (diagrammatically and with fresh cadaver dissection) the methods of preparing, raising, and preforming this new flap. We further introduce and describe the concept of bilevel undermining. We describe the first author's 4-year experience in the development of this flap. We show clinical representative cases with pre- and postoperative results. Superiorly based myocutaneous island pedicle flaps with bilevel undermining, a new method of nasal tip and supratip reconstruction, yields excellent functional and cosmetic results. Bilevel undermining is a new and valuable method of achieving greater tissue mobility in muscle-based flaps.

Soft tissue reconstruction following hemipelvectomy

Background: Resection of primary and metastatic pelvic bone disease may result in large soft tissue deficits. Guidelines for soft tissue reconstruction following pelvic bone resection were evaluated in a retrospective study. Methods: Over a 5-year period 21 patients (31%) required soft tissue reconstruction following pelvic bone resection. Data on these patients were retrieved from case records. Results: Twelve patients underwent immediate, planned reconstruction, 1 a two-stage reconstruction, and 8 patients required a delayed procedure for complications after bone resection and primary closure. Soft tissue reconstruction was usually accomplished with muscle-based flaps; (25 flaps in 20 patients: 20 pedicled, 5 free), or with skin grafts alone (1 patient). Specific postreconstruction complications occurred in 9 patients, 5 in flaps based on the ipsilateral rectus muscle. Conclusion: Flap closure is indicated to achieve primary closure and eliminate deadspace. The ipsilateral rectus muscle should be used with caution and contralateral-based rectus flaps considered. Indications for free flaps include the size and location of the defect and availability of tissue from an amputated limb.

Laser de‐epithelialization of muscle‐based flaps

The LaryngoscopeVolume 100, Issue 6 p. 661-662 Article Laser de-epithelialization of muscle-based flaps Yosef P. Krespi MD, Corresponding Author Yosef P. Krespi MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynDepartment of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at Brooklyn, 340 Henry St., Brooklyn, NY 11201.Search for more papers by this authorMichael H. Weiss MD, Michael H. Weiss MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynSearch for more papers by this authorPramod Bhatia MD, Pramod Bhatia MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynSearch for more papers by this author Yosef P. Krespi MD, Corresponding Author Yosef P. Krespi MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynDepartment of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at Brooklyn, 340 Henry St., Brooklyn, NY 11201.Search for more papers by this authorMichael H. Weiss MD, Michael H. Weiss MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynSearch for more papers by this authorPramod Bhatia MD, Pramod Bhatia MD Department of Otolaryngology, Long Island College Hospital, State University of New York, Health Sciences Center at BrooklynSearch for more papers by this author First published: June 1990 https://doi.org/10.1288/00005537-199006000-00022AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume100, Issue6June 1990Pages 661-662 RelatedInformation