T. Schoeller

Definite surgical treatment of complicated recurrent pilonidal disease with a modified fasciocutaneous V-Y advancement flap

BACKGROUNDnDifferent methods for managing pilonidal disease have been described in the literature. Recurrence impairs the success of all forms of therapy, but the lowest rates have been reported for reconstructions involving local flaps. Nevertheless, treatment of pilonidal disease with a fasciocutaneous V-Y flap is not a well-established procedure. We have modified the surgical technique and used it selectively for complicated recurrent cases. Our experience with this method is analyzed, and its validity is evaluated.nnnMETHODSnTwenty-four patients with recurrent pilonidal sinus undergoing radical excision and reconstruction with our modified fasciocutaneous V-Y advancement flap between 1986 and 1993 were studied retrospectively.nnnRESULTSnExcept for two minor transient wound dehiscences, in all cases primary healing was achieved. Furthermore, an excellent functional result and acceptable scar pattern were obtained in all twenty-four patients, with a mean follow-up of 4.5 years. Neither evidence of recurrence nor impairment of daily life activity was noted.nnnCONCLUSIONSnTreatment of complicated recurrent pilonidal sinus with the described technique offers a safe but demanding method for definite reconstruction, and we support a more common application.

Masseteric nerve: A possible donor for facial nerve anastomosis?

In the medical treatment of facial nerve paralysis a large number of different techniques have been developed to restore the function of the facial nerve. These include (a) the ipsilateral nerve grafting (e.g., partial hypoglossal‐facial, spinal accessory‐facial, partial glossopharyngeal‐facial), (b) crossfacial nerve grafting and (c) temporal muscle flaps or even free muscle transfers. None of these techniques uses the masseteric nerve as a graft for reconstruction of the facial nerve. This preliminary report deals with the anatomical basis, which could lead to a new technique. The masseteric nerve leaves the infratemporal fossa through the mandibular notch, accompanied by the masseteric artery. At this level the nerve consists in nine of 36 cases studied of only one branch (25.0%), in 17 cases of two branches (47.0%), in nine cases of three (25.0%), and in the remaining case of four branches (2.8%). There are three main reasons for considering the masseteric nerve as a possible donor for at least the orbicular branch of the facial nerve: (1) The approach to the mandibular notch is quite simple; (2) since the nerve consists of two or more branches in 75.0% of the cases, severe dysfunction of the masseter muscle should not occur; (3) if there is complete denervation of the masseter muscle, its function may be taken over by the temporalis muscle. Clin. Anat. 11:396–400, 1998.

Microsurgical repair of the sural nerve after nerve biopsy to avoid associated sensory morbidity: a preliminary report.

OBJECTIVEThe purpose of this article is to report our preliminary results regarding microsurgical repair of the sural nerve after nerve biopsy, in an attempt to reduce the well-described sensory morbidity and neuroma formation. METHODSThree patients with a suspected diagnosis of peripheral neuropathy underwent sural nerve biopsies to establish definitive diagnoses. A 10-mm segment of the sural nerve was resected with local anesthesia. After harvesting of the specimen, the proximal and distal nerve stumps were carefully mobilized and united with epineural suture techniques, under a surgical microscope. Sensory evaluations (assessing the presence of hypesthesia/dysesthesia or pain) of the lateral aspect of the foot, in regions designated Areas 1, 2, and 3, were performed before and 6 and 12 months after the biopsies. A visual analog scale was used for pain estimation. RESULTSThe biopsy material was sufficient for histopathological examinations in all cases, leading to conclusive diagnoses (vasculitis in two cases and amyloidosis in one case). The early post-biopsy hypesthesia, which was present for 4 to 8 weeks, improved to preoperative levels as early as 6 months after the nerve repair. Sensory evaluations performed at 6- and 12-month follow-up times demonstrated that none of the patients complained of pain at the biopsy site or distally in the area innervated by the sural nerve. Ultrasonography performed at the 12-month follow-up examination revealed normal sural nerve morphological features, with no neuroma formation, comparable to findings for the contralateral site. CONCLUSIONMicrosurgical repair of the sural nerve after biopsy can eliminate or reduce sensory disturbances such as paraesthesia, hypesthesia, and dysesthesia distal to the biopsy site, in the distribution of the sensory innervation of the sural nerve, and can prevent painful neuroma formation. To our knowledge, this article is the first in the literature to report on microsurgical repair of the sural nerve after nerve biopsy. Decreased side effects suggest that this technique can become a standard procedure after sural nerve biopsy, which is commonly required to establish the diagnosis of various diseases, such as peripheral nerve pathological conditions, vasculitis, and amyloidosis. More cases should be analyzed, however, to explore the usefulness of the technique and the reliability of sural nerve biopsy samples in attempts to obtain conclusive diagnoses.

Chronisch rezidivierende, lokal destruierende Silikonome nach Brustaugmentation durch flüssiges Silikonöl

Abstract. At the beginning of the sixties the injection of liquid silicon oil was frequently used for breast augmentation. It was thought to be safe, simple and effective. But as complications such as local silconomas, inflammatory reactions, induration, foreign body extrusion and foreign body migration were published this procedure was not used anymore. We report about a 45-year-old female patient who suffered from late complications, chronic recurrent local destructive siliconomas, which have not been described in the literature yet. Because of the destruction forced by the primary siliconimplant a bilateral subcutaneous mastectomy had to be performed and siliconomas were excised at regions different from the original injection site. Several breast reconstructions have been performed but this tissue has also been destroyed by the recurrent and aggressive siliconomas. As there can be a long period of latency before the aforementioned complications of liquid silicon injections can occur, we recommend careful follow-up for these patients.Zusammenfassung. Anfang der 60 er Jahre war die Augmentation der Brust durch Injektion von flüssigem Silikon eine sicher geglaubte Methode, welche ob des simplen Eingriffs und des raschen Erfolgs allzu oft unkritisch angewandt wurde. Als Komplikationen, welche diese Methode in Verruf brachten, wurden lokale Silikonome, entzündliche Infiltrationen und Indurationen, Fremdkörperextrusionen, sowie Fremdkörpermigrationen beschrieben. In der vorliegenden Arbeit wird über den Jahrzehnte langen Krankheitsverlauf einer 45 jährigen Patientin mit einer in der Literatur noch nicht erwähnten Spätkomplikation, der chronisch rezidivierenden, lokal destruierenden Form eines Silikonoms, berichtet. Die lokal destruierende Wirkung des flüssigen Silikons und der sekundären Silikonome erforderte eine beidseitige subcutane Mastektomie, sowie zahlreiche Silikonomexstirpationen auch außerhalb der ursprünglichen Applikationsstelle. Mehrfache plastisch-chirurgische Brustrekonstruktionen wurden durch den ungewöhnlich aggressiven und rezidivierenden Verlauf der Silikonome zerstört. Aufgrund der möglichen jahrelangen Latenz Silikon-assoziierter Komplikationen empfehlen wir eine konsequente Nachuntersuchung für betroffene Patienten aus den frühen Tagen der flüssigen Silikoninjektion.

Freie Lappenplastiken zur Rekonstruktion komplexer Defekte am Handrücken: Ästhetische und funktionelle Aspekte

BACKGROUNDnComplex and large soft-tissue defects of the dorsum of the hand, which cannot be covered with skin grafts or local flaps have to be reconstructed by means of free tissue transplantation. The purpose of this study was to present our experience with free fasciocutaneous flaps and muscle flaps with split-thickness skin graft for defect coverage of the dorsum of the hand in eight patients.nnnPATIENTS AND METHODnEvaluation of eight patients who underwent coverage of the dorsum of the hand with free flaps during 1997 to 2001 is presented. Other treatment options are discussed.nnnRESULTSnAverage age of the patients was 57 years and average follow-up was 25 months. For defect coverage we used a later alarm flap in four cases, a gracilis muscle flap with split-thickness skin graft in three cases and a latissimus dorsi flap with split-thickness skin graft in one case. In five patients we performed an extensor tendon reconstruction. Three of those cases achieved a good, one a fair and one case had a bad functional result. In one patient we had a partial flap loss. Muscle flaps with skin graft revealed better esthetic results than fasciocutaneous flaps.nnnCONCLUSIONnMicrovascular free-tissue transplantation has expanded our options, giving us the opportunity for more refinement in hand reconstruction and improving the standards for a successful outcome.

Coverage of pressure sores with free flaps

AbstractIntroduction. Thencoverage of recurrent pressure sores with unstable scar in thensurrounding tissue is still an unsolved problem in thenliterature. Local and regional transfer of tissue often does notnmeet the requirements of the tissue deficit. Especially innrecurrent pressure sores, the adjacent skin has already beennconsumed due to multiple surgeries. As a good alternative, thenmicrosurgical transfer of flaps offers viable tissue to coverneven large pressure sores.nMethods. We performed antotal of six free flaps in five patients who suffered fromnintractable pressure sores in the hip region. The age of thenpatients was between 41 and 63 years. The defect size variednbetween 6×6 cm and 25×30 cm. Two combined myocutaneousnscapulalatissimus dorsi, two myocutaneous latissimus dorsi, onenanteromedial thigh, and one rectus femoris flap were used toncover the defects.nResults. The averagenfollow-up time was 29 months. Flaps provided stable coverage innfour of five patients at 12-month follow-up. There was onensubtotal flap necrosis that was subsequently treated withnsplit-thickness skin grafting.nConclusion. In thisnseries of five patients with six free flaps, we were able tonshow that the microsurgical transfer of tissue is a valuablenoption in the treatment of difficult pressure sores. Even innolder and debilitated patients, this method is a goodnalternative to conventional local flaps.ZusammenfassungEinleitung. Die Deckungnvon Dekubitalulzera mit instabiler Narbenbildung in der Umgebungnist eine in der Literatur immer wieder abgehandeltenProblemstellung. Die lokale und regionale Übertragung von Gewebenkann beim komplexen Dekubitalulkus nicht immer zu einerndauerhaften Beseitigung des Gewebedefizits führen. Besonders beinAuftreten von Rezidiven besteht die Gefahr, dass dasnErsatzgewebe aus der Umgebung selbst vernarbt oder durchnverschiedenste lokale Gewebeverschiebungen aufgebraucht ist.nEine gute Alternative bietet hierfür die freie Lappenplastik,nbei der selbst größere Druckulzera mit gut durchblutetem Gewebengedeckt werden können.nMethoden. Es wurden annunserer Klinik bei 5 Patienten wegen persistierendem, nichtnheilenden Dekubitalulkus insgesamt 6 mikrochirurgischenLappenplastiken durchgeführt. Das Alter der Patienten lagnzwischen 41 und 63 Jahren. Die zu deckende Defektgröße warnzwischen 6×6 cm und 25×30 cm. Es wurden 2 kombinierte myokutanenSkapula- Latissimus-dorsi-, zwei myokutane Latissimus-dorsi-,nein anteromedialer Oberschenkel- und ein myokutanernRectus-femoris-Lappen zur Defektdeckung verwendet.nErgebnisse. Diendurchschnittliche Nachuntersuchungszeit betrug 29 Monate. Nachn12 Monaten zeigte sich bei 4 von 5 Patienten der transferiertenLappen gut eingeheilt ohne Hinweis auf ein Rezidiv. Bei einemnPatienten kam es zum Lappenverlust, welcher in weiterer Folgenerfolgreich durch eine Spalthauttransplantation behandelt werdennkonnte.nSchlussfolgerung.Wirnkonnten in einer Serie von 5 Patienten mit 6 freiennLappenplastiken zeigen, dass der mikrochirurgischenGewebetransfer bei der Therapie des Dekubitalulkus eine gutenAlternative zu den herkömmlichen lokalen Verfahren darstellt.nAuch bei älteren und polymorbiden Patienten kann diesesnVerfahren durchaus in Erwägung gezogen werden.

Dekubitalulkusdeckung durch mikrochirurgische Lappenplastiken

AbstractIntroduction. Thencoverage of recurrent pressure sores with unstable scar in thensurrounding tissue is still an unsolved problem in thenliterature. Local and regional transfer of tissue often does notnmeet the requirements of the tissue deficit. Especially innrecurrent pressure sores, the adjacent skin has already beennconsumed due to multiple surgeries. As a good alternative, thenmicrosurgical transfer of flaps offers viable tissue to coverneven large pressure sores.nMethods. We performed antotal of six free flaps in five patients who suffered fromnintractable pressure sores in the hip region. The age of thenpatients was between 41 and 63 years. The defect size variednbetween 6×6 cm and 25×30 cm. Two combined myocutaneousnscapulalatissimus dorsi, two myocutaneous latissimus dorsi, onenanteromedial thigh, and one rectus femoris flap were used toncover the defects.nResults. The averagenfollow-up time was 29 months. Flaps provided stable coverage innfour of five patients at 12-month follow-up. There was onensubtotal flap necrosis that was subsequently treated withnsplit-thickness skin grafting.nConclusion. In thisnseries of five patients with six free flaps, we were able tonshow that the microsurgical transfer of tissue is a valuablenoption in the treatment of difficult pressure sores. Even innolder and debilitated patients, this method is a goodnalternative to conventional local flaps.ZusammenfassungEinleitung. Die Deckungnvon Dekubitalulzera mit instabiler Narbenbildung in der Umgebungnist eine in der Literatur immer wieder abgehandeltenProblemstellung. Die lokale und regionale Übertragung von Gewebenkann beim komplexen Dekubitalulkus nicht immer zu einerndauerhaften Beseitigung des Gewebedefizits führen. Besonders beinAuftreten von Rezidiven besteht die Gefahr, dass dasnErsatzgewebe aus der Umgebung selbst vernarbt oder durchnverschiedenste lokale Gewebeverschiebungen aufgebraucht ist.nEine gute Alternative bietet hierfür die freie Lappenplastik,nbei der selbst größere Druckulzera mit gut durchblutetem Gewebengedeckt werden können.nMethoden. Es wurden annunserer Klinik bei 5 Patienten wegen persistierendem, nichtnheilenden Dekubitalulkus insgesamt 6 mikrochirurgischenLappenplastiken durchgeführt. Das Alter der Patienten lagnzwischen 41 und 63 Jahren. Die zu deckende Defektgröße warnzwischen 6×6 cm und 25×30 cm. Es wurden 2 kombinierte myokutanenSkapula- Latissimus-dorsi-, zwei myokutane Latissimus-dorsi-,nein anteromedialer Oberschenkel- und ein myokutanernRectus-femoris-Lappen zur Defektdeckung verwendet.nErgebnisse. Diendurchschnittliche Nachuntersuchungszeit betrug 29 Monate. Nachn12 Monaten zeigte sich bei 4 von 5 Patienten der transferiertenLappen gut eingeheilt ohne Hinweis auf ein Rezidiv. Bei einemnPatienten kam es zum Lappenverlust, welcher in weiterer Folgenerfolgreich durch eine Spalthauttransplantation behandelt werdennkonnte.nSchlussfolgerung.Wirnkonnten in einer Serie von 5 Patienten mit 6 freiennLappenplastiken zeigen, dass der mikrochirurgischenGewebetransfer bei der Therapie des Dekubitalulkus eine gutenAlternative zu den herkömmlichen lokalen Verfahren darstellt.nAuch bei älteren und polymorbiden Patienten kann diesesnVerfahren durchaus in Erwägung gezogen werden.

Ohrmuschelverletzungen : Klassifizierung und Therapiekonzept

ZusammenfassungDie detailgetreue und nach ästhetischen Gesichtspunkten korrekte Versorgung von Ohrmuschelverletzungen bis hin zur Amputation stellt eine anspruchsvolle Aufgabe für den erstbehandelnden Chirurgen dar. Versäumnisse bei Primärbehandlungen führen zu erschwerten Bedingungen bei der Rekonstruktion, die ästhetischen Resultate sind in der Regel dann nicht zufriedenstellend.Vorgestellt und vorgeschlagen wird eine Klassifikation nach Art der Ohrverletzung. Das differenzierte Behandlungskonzept trägt den verschiedenen Belangen Rechnung. Falldarstellungen werden zu verschiedenen Methoden gezeigt und mit der vorhandenen Literatur verglichen und diskutiert.AbstractThe treatment of traumatic defects of the auricle concerning the exact reconstruction of details and aesthetic aspects is exacting for the surgeon. To face the expectations towards best trauma care, the different locations and extent of auricular injuries should be included in the different therapeutic strategies. The insufficient treatment results in mostly difficult secondary conditions.We present a classification for ear traumas, which considers size and location of defects. Depending on this, different techniques and methods of reconstruction are recommended. Advantages and disadvantages are pointed out and discussed with several examples and with the present literature.

Defektdeckung durch freie Lappenplastiken am Fußrücken

BACKGROUNDnLarge complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.nnnPATIENTS AND METHODSnEvaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.nnnRESULTSnOn average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.nnnCONCLUSIONnFree muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.ZusammenfassungHintergrundAusgedehnte und komplexe Defekte am Fußrücken mit freiliegenden Strukturen wie Sehnen, Gelenken, Knochen, Nerven oder Gefäßen müssen mit gut durchblutetem Gewebe gedeckt werden.Patienten und MethodeBei 19 Patienten mit einem Durchschnittsalter von 38 Jahren wurden zur Defektdeckung 10xa0M.-gracilis-Lappenplastiken, 4xa0M.-latissimus-dorsi-Lappenplastiken, 2xa0Leisten-Lappenplastiken, eine anterolaterale Oberschenkel-Lappenplastik, eine anteromediale Oberschenkel-Lappenplastik und eine laterale Oberarm-Lappenplastik verwendet. Die ästhetischen Ergebnisse wurden hinsichtlich Hauttextur, Pigmentation, Dicke der Lappenplastik in Bezug zum umliegenden Hautniveau und Narbenbildung beurteilt. Zur Evaluation des funktionellen Ergebnisses wurde das Stanmore-System verwendet.ErgebnisseDer durchschnittliche Nachuntersuchungszeitraum betrug 29 Monate. Es kam zu keinem Lappenverlust. Eine Lappentrimmung wurde bei 6xa0Patienten durchgeführt. Die ästhetischen Ergebnisse waren bei der Defektdeckung mit Muskel-Lappenplastiken mit Hauttransplantaten besser als bei fasziokutanen Lappen. Laut Stanmore-Bewertungsschema erreichten 6xa0Patienten ein ausgezeichnetes, 5 ein gutes und 8 ein nicht zufriedenstellendes funktionelles Ergebnis.FazitMuskel-Lappenplastiken mit Hauttransplantaten, insbesondere die M.-gracilis-Lappenplastik, sind den fasziokutanen und Perforans-Lappenplastiken hinsichtlich Ästhetik und Hebedefektmorbidität überlegen.AbstractBackgroundLarge complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.Patients and methodsEvaluation of 19 patients with an average age of 38xa0years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.ResultsOn average, patients were followed up for 29xa0months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.ConclusionFree muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.

Closure of defects on the dorsum of the foot with free flaps. Functional and aesthetic aspects

BACKGROUNDnLarge complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.nnnPATIENTS AND METHODSnEvaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.nnnRESULTSnOn average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.nnnCONCLUSIONnFree muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.ZusammenfassungHintergrundAusgedehnte und komplexe Defekte am Fußrücken mit freiliegenden Strukturen wie Sehnen, Gelenken, Knochen, Nerven oder Gefäßen müssen mit gut durchblutetem Gewebe gedeckt werden.Patienten und MethodeBei 19 Patienten mit einem Durchschnittsalter von 38 Jahren wurden zur Defektdeckung 10xa0M.-gracilis-Lappenplastiken, 4xa0M.-latissimus-dorsi-Lappenplastiken, 2xa0Leisten-Lappenplastiken, eine anterolaterale Oberschenkel-Lappenplastik, eine anteromediale Oberschenkel-Lappenplastik und eine laterale Oberarm-Lappenplastik verwendet. Die ästhetischen Ergebnisse wurden hinsichtlich Hauttextur, Pigmentation, Dicke der Lappenplastik in Bezug zum umliegenden Hautniveau und Narbenbildung beurteilt. Zur Evaluation des funktionellen Ergebnisses wurde das Stanmore-System verwendet.ErgebnisseDer durchschnittliche Nachuntersuchungszeitraum betrug 29 Monate. Es kam zu keinem Lappenverlust. Eine Lappentrimmung wurde bei 6xa0Patienten durchgeführt. Die ästhetischen Ergebnisse waren bei der Defektdeckung mit Muskel-Lappenplastiken mit Hauttransplantaten besser als bei fasziokutanen Lappen. Laut Stanmore-Bewertungsschema erreichten 6xa0Patienten ein ausgezeichnetes, 5 ein gutes und 8 ein nicht zufriedenstellendes funktionelles Ergebnis.FazitMuskel-Lappenplastiken mit Hauttransplantaten, insbesondere die M.-gracilis-Lappenplastik, sind den fasziokutanen und Perforans-Lappenplastiken hinsichtlich Ästhetik und Hebedefektmorbidität überlegen.AbstractBackgroundLarge complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.Patients and methodsEvaluation of 19 patients with an average age of 38xa0years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.ResultsOn average, patients were followed up for 29xa0months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.ConclusionFree muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity.