Tissue expanded free flaps B. J. Mayou, Ikpar’tmrwt
D. T. Gault
and J. G. Crock
crf‘Plastic Swger?~, St Thomas’ Hospital.
Lortrhtr
SUMMA R I’. Over the last few years there have been various reports of the use of tissue expanders as an adjunct to microvascular free transfer of tissue. This study looks at the effect of expanding the actual flap prior to transfer. Two case reports are given and it is proposed that expanded free flaps are large and thin. They have a capsule which enables them to be safely sutured under tension. They are “delayed ” by the expansion process and the donor deformity is minimal. It is suggested that tissue expansion is a useful technique prior to free flap transfer for the reconstruction of large defects.
.’ Microsurgery. Muscle and musculocutaneous flaps. Tissue expansion. What do they have in common?” wrote an ent.husiastic W. C. Grabb in response to Chedomir Ra.dovan’s article on the temporary tissue expander (Grabb. 1981). Unfortunately. Dr Grabb has not lived to see the amalgamation of these three breakthroughs in plastic and reconstructive surgery. However. his vision is ever maturing in clinical practice today. Tissue expansion was first used clinically by Charles G. Neumann in 1956 during the reconstruction of a partially amputated ear (Neumann. 1957). His idea then lay dormant until Radovan rediscovered the technique in the 1980’s. He used expansion during breast reconstruction (Radovan, 1982). Soon not only was skin being expanded for use as local advancement flaps but also musculocutaneous flaps were being expanded--either before or after transfer on their pedicles (Argenta r’t LII.. 1983; Goldstein. 1984; Elliot c’t ~1.. 1988). Several authors have described the use of tissue expanders to close free flap donor defects (Hallock. 1988). In 1990 Laitung and Batchelor described an expanded scapular Rap for replacing neck skin. The follow,ing reports describe various aspects of transferring expanded tissue as free flaps with particular emphasis on expanded musculocutaneous free flaps.
A 1000 ml expander was inserted under the posteromedial portion of the muscle. The incision was placed on the back parallel to the infero’lateral edge of the muscle. Postoperative pain was quite severe and this was controlled by injecting marcaine into the drain tubes. The effect was dramatic. The expander was inflated (2000 ml) o\‘er the next 9 months. At the time of definitive flap transfer, the flap was raised by extending the initial incision up to the level of the musculotendinous junction in the axilla and down to the posteromedial portion of the muscle. The tissue expander was then removed and, by pinching the redundant tissue, a skin ellipse was planned so as to leave a donor defect which could be closed directly (Fig. 3). The dimensions of this ellipse Iwere approximately 27 x 18 cm. There was good bleeding from the posteromedial portion of the muscle (i.e. that normally supplied by the lumbar perforating vessels). The skin paddle retracted somewhat from the edges of the muscle and there was a well formed capsule on the undersurface of the muscle. The muscle was stretched and thin. being only 3 mm thick in parts, and the overlying subcutaneous tissue was 2 cm thick. The skin graft was removed from the patella and sides of the knee and the femoral artery and vein were exposed in the subsartorial canal. The thoracodorsal vessels were then divided and anastomosed, end to end. to unnamed branches of the femoral vessels. The muscle paddle wrapped around approximately 60 O/O of the circumference of the knee while the skin paddle only wrapped around 45 %. The edges of the muscle were covered above and below with skin Raps from the undamaged skin and on the sides with split skin grafts. The flap was thus blended in well to the defect site. The postoperative recovery was unremarkable. At 2 months the flap had a good contour and was developing protective sensation (Fig. 3A). IJnfortunately she fell on her knee and grazed the flap, but this healed with conservative treatment (Fig. 31~).
An energetic l3-year-old school girl was knocked off her horse and run over. She sustained an extensive degloving injury to her left knee. No neurovascular damage was sustained. The defect was initially covered by a meshed split skin graft which took nicely but could not withstand the rigours of school life. Constant traumatic breakdown of the graft over the patella and an awful cosmetic defect severely disrupted her life (Fig. 1). Twelve months after the injury it was decided to use an expanded latissimus dorsi free flap to protect the patella and to improve the appearance of the knee. 413
British Journal of Plastic Surgery
Fig. 1
Fig. 3 Figure I-An extensive degloving injury to the left knee of a 13-year-old school girl. She constantly traumatised the meshed skin graft over the patella. In addition the cosmetic defect was unacceptable. Figure 2-The size of the flap. The flap which was raised following i:issue expansion-as drawn on the left side of the patient postoperatively-was significantly larger than the flap which could have been r aised without expansion-as drawn on the right. Also note the minimum donor defect. Figure WA) The result 4 months postoperatively She sustained a full thickness graze to the flap which healed spontaneously. (B) The area of cross hatching represents skin which has reg; lined protective sensation at 2 months postoperatively.
Tissue Expanded Free Flaps ____-
Fig. 4
Fig. 6 Figure 4 Gross hypertrophic scarring of a burn on the neck. The hum expanded parascapular flap. A flap 19 x 9 cm was harvested and postoperatively. Figure 7-Side view 4 years postoperatively. There is This was carried out w recently that the benciits of the procedure are
A pretty II?-year-old school girl was doing a class experiment with a steam engine when it exploded, severely burning her neck. Initial attempts to treat the burn with split skin grafting were thwarted by gross hypertrophic scarring and some scar contracture (Fig. 3). The injury was a major psychosocial burden on her and hser ‘family and after 2 years (in 1987) it was decide’d to replace the unsightly scar with an expanded parascapular flap. A 1000 ml Icxpander was inserted under the skin of the back through a small midline incision. Care was taken not to encroach on the pedicle-the circumflex
Fig. 5
Fig. 7 had been split skin grafted on three separate oc~:awm~. Figure S-The the donor site was closed directly. Figure 6 ~The result 4 years some loss of the angle of the neck, which was treated by hposuction. not yet evident because of postoperative oedemu.
scapular vessels. The expander was r.hen inflated (1000 ml) over the next 6 weeks. At the second stage operation the flap was raised with the patient lying supine. An ellipse I9 x 9 cm was dissected out (Fig. 5). The lateral portio’n lay over the pedicle, which was in virgin tissue. The bulk of the tlap lay over the expander-medial to the pedicle-and was approximately 1.5 cm thick. The donor site was closed directly and the flap was lailored to fit the recipient defect. In so doing the scar from the first stage procedure was discarded. The patient was rolled over and the neck was prepared. The circumflex scapular vessels were anasto-
British Journal of Plastic Surgery
416
Fig. 8 Figure &The vascular architecture of the latissimus dorsi. The undisturbed muscle (right) contains 7 vascular units which drain into three major named vessels (the thoracodorsal vessels, the posterior intercostal perforating vessels and the lumbar perforating vessels). This is classified as a type C7 muscle (after Crock, 1990). Placement of the tissue expander interrupts the posterior intercostal perforating vessels, effectively delaying the muscle. It then contains 5 units which drain into 2 major named vessels (the thoracodorsal and lumbar perforating vessels). The muscle is then classified as a tvue B5 muscle (after Crock. 1990). The latter arrangement is theoretically more robust for transfer on the thoracodorsal vessels. .L
mosed end to side into the facial vessels and the flap was fitted precisely. Postoperative recovery was unremarkable. In particular the flap maintained its size. She is now in her fifth postoperative year and has a satisfying cosmetic result (Fig. 6) although there was a minor degree of webbing of the neck (Fig. 7). This was treated recently by liposuction, with no adverse effect on the flap. Despite her tendency to produce hypertrophic scars the suture lines are flat and her neck is smooth. Both she and her family are pleased and have been helped psychologically by the surgery. Discussion These procedures are further refinements of two well known flaps: one was stumbled upon by Tansini (Purpura, 1908) late last century and rediscovered by Olivari (1976) some 80 years later. The other was described by DOS Santos (1980) and others (Mayou et al., 1982). Various features of the application of tissue expansion to these flaps are worthy of report. Firstly, the very placement of the expander is critical. We ensured that the vessels were not impinged upon during expansion and thus remained in virgin territory until the ultimate transfer. The concern is that if the pedicle is encased in scar tissue it may become impossible to dissect. Cherry et al. (1983) showed, in pigs, that expansion has the same effect on skin vascularity as delaying the area. It seems reasonable to extrapolate that, in humans, expansion delays flaps. In the case of the latissimus dorsi flap, the placement of the expander should turn this type C7 muscle into a type BS muscle
(Crock, 1990) which is theoretically more robust (McGraw and Arnold, 1986) (Fig. 8). Secondly, expanded flaps are noticeably thinner than the equivalent standard flaps. The musculocutaneous flap was especially thin. Argenta et al. (1983) also observed marked thinning of the latissimus muscle in their reported cases of local latissimus dorsi flaps which were expanded prior to transfer. In spite of this. the thinned muscle paddle appears to act as a perfect carrier for tissue vasculature but without the bulk of normal musculocutaneous flaps. In addition, having a thin rim of muscle which extends beyond the skin component of the flap helps to blend the flap into the recipient site. This tends to reduce the ‘blobs and globs’ effect which McDowell (1979) campaigned against. We did notice, however, that the subcutaneous tissues were not thinned to the same degree as the muscle. Delayed liposuction would be a useful adjunct to improve refinement of contour of this flap. We also noticed that there was significant postoperative oedema, which settled spontaneously over a period of months. In contrast, the subcutaneous tissue of the expanded parascapular flap was quite thin and in many instances may not need further thinning - although we can see no contraindications to liposuction in appropriate circumstances and in fact used it in the second case to try to improve the neck angle. Thirdly, the dense capsule which formed under the musculocutaneous flap acted as a base with which to anchor the muscle on the stretch. which should help maintain the thinness of the flap. This is yet another feature which makes this flap more amenable to subtle contouring than the standard musculocutaneous flap.
417
Tissue Exoanded Free Flaus Finally, the donor site of expanded flaps can be closed directly. This is functionally and aesthetically much more pleasing than a large split skin graft. Elliot et al. (1988) have already expounded this virtue in their report on expanded local latissimus dorsi flaps. The expanded latissimus dorsi flap is a refinement of a standard “work horse” musculocutaneous flap. This flap is large but the donor site can be closed directly. The muscle paddle is thin but has a fibrous base which can hold stitcl :s under moderate degrees of tension. The subcutaneous tissue is less attenuated but would be amenable to liposuction for fine contouring once the flap has settled. The scapular flap is also well described. When expanded it is a large thin flap which can be used to fill big defects and yet the donor site can be closed directly. The expander should be placed in such a way as to delay and/or enlarge these flaps without interfering with the vascular pedicle to be used for microvascular transfer. This application of tissue expansion appears to be useful in producing large but supple flaps which should have many applications.
Acknowledgements We wish to acknowledge warmly the assistance of Mr P. Kolhe and Dr B. Philp who helped in one of the cases presented here.
Crock, J. G. (1990). The venous architecture of muscles in man. M.D. Thesis, University of Melbourne p. 135. DOS Santos, L. F. (1980).Retalho escapular : urn novo retalho livre microcirurgico. Rev&a Brasileira de Cirurgia, 70, 133. Elliot, D., Lewis-Smith, P. A. and Piggot, T. A. (1988). The expanded latissimus dorsi flap. British Journal of Plastic Surgery, 41. 3 19. Goldstein, M. H. (1984). A tissue expanding vermilion myocutaneous flap for lip repair. Plastic and Reconstructive Surgery. 73, 768. Grabb, W. C. (1982). Discussion on breast reconstruction after mastectomy using the temporary expander by Chedomir Radovan. Plastic and Reconstructive Surgery. 69. 207. Hallock, G. G. (1988). Free flap donor site refinement using tissue expansion. Annals of Plastic Surgery, 20, 566. Laitung, J. K. G. and Batchelor, A. G. (1990). Successful preexpansion of a free scapular flap. Annals of PIustic Surgery, 25, 205. McCraw, J. B. and Arnold, P. G. (1986). McGraw and Amolds atlas of muscle and musculocutaneous paps. Norfolk. Virginia. Hampton Press Publishing Company, Inc., p. 662. McDowell, F. (1979). Editorial. Logs vs. harpsichords, blobby flaps vs finished results. Plastic and Reconstructke Surgery, 64, 249. Mayou, B. J., Whitby, D. and Jones, B. M. (I982). The scapular Rap-an anatomical and clinical study. British Journal of Plastic Surgery, 35. 8. Neumann, C. G. (1957). The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plastic and Reconstructive Surgery, 19, 124. Olivari, N. (1976). The latissimus dorsi flap. British Journal of Plastic Surger.v, 29, 126. Purpura, F. (1908). Tansini method for the cure of cancer of the breast. The Lancet. I, 634. Radovan, C. (1982). Breast reconstruction after mastectomy using the temporary expander. Plastic and Reconstructive Surger?, 69. 195.
The Authors References Argenta, L. C., Marks, M. W. and Grabb, W. C. (1983). Selective use of serial expansion in breast reconstruction. Annals qf Plastic Surgery. 11, 188. Cherry, G. W., A&ad, E., Pasyk, K., McClatchey, K. and Rohrich, R. J. (1983). Increased survival and vascularity of randompattern skin flaps elevated in controlled, expanded skin. Plastic and Reconstructive Surgey. 72. 680.
B. J. Mayou, FRCS, Consultant Plastic Surgeon D. T. Gaul& FRCS, formerly Senior Registrar in Plastic Surgery J. G. Crock, MD, Dip Anat, Lecturer in Plastic Surgery, Department of Plastic Surgery, St Thomas’ Hospital. London SEI 7EH. Requests
for reprints
to Mr B. J. Mayou.
Paper received 9 October 1991. Accepted 4 February 1992. after revision.
BPS15
D. T. Gault
and J. G. Crock
crf‘Plastic Swger?~, St Thomas’ Hospital.
Lortrhtr
SUMMA R I’. Over the last few years there have been various reports of the use of tissue expanders as an adjunct to microvascular free transfer of tissue. This study looks at the effect of expanding the actual flap prior to transfer. Two case reports are given and it is proposed that expanded free flaps are large and thin. They have a capsule which enables them to be safely sutured under tension. They are “delayed ” by the expansion process and the donor deformity is minimal. It is suggested that tissue expansion is a useful technique prior to free flap transfer for the reconstruction of large defects.
.’ Microsurgery. Muscle and musculocutaneous flaps. Tissue expansion. What do they have in common?” wrote an ent.husiastic W. C. Grabb in response to Chedomir Ra.dovan’s article on the temporary tissue expander (Grabb. 1981). Unfortunately. Dr Grabb has not lived to see the amalgamation of these three breakthroughs in plastic and reconstructive surgery. However. his vision is ever maturing in clinical practice today. Tissue expansion was first used clinically by Charles G. Neumann in 1956 during the reconstruction of a partially amputated ear (Neumann. 1957). His idea then lay dormant until Radovan rediscovered the technique in the 1980’s. He used expansion during breast reconstruction (Radovan, 1982). Soon not only was skin being expanded for use as local advancement flaps but also musculocutaneous flaps were being expanded--either before or after transfer on their pedicles (Argenta r’t LII.. 1983; Goldstein. 1984; Elliot c’t ~1.. 1988). Several authors have described the use of tissue expanders to close free flap donor defects (Hallock. 1988). In 1990 Laitung and Batchelor described an expanded scapular Rap for replacing neck skin. The follow,ing reports describe various aspects of transferring expanded tissue as free flaps with particular emphasis on expanded musculocutaneous free flaps.
A 1000 ml expander was inserted under the posteromedial portion of the muscle. The incision was placed on the back parallel to the infero’lateral edge of the muscle. Postoperative pain was quite severe and this was controlled by injecting marcaine into the drain tubes. The effect was dramatic. The expander was inflated (2000 ml) o\‘er the next 9 months. At the time of definitive flap transfer, the flap was raised by extending the initial incision up to the level of the musculotendinous junction in the axilla and down to the posteromedial portion of the muscle. The tissue expander was then removed and, by pinching the redundant tissue, a skin ellipse was planned so as to leave a donor defect which could be closed directly (Fig. 3). The dimensions of this ellipse Iwere approximately 27 x 18 cm. There was good bleeding from the posteromedial portion of the muscle (i.e. that normally supplied by the lumbar perforating vessels). The skin paddle retracted somewhat from the edges of the muscle and there was a well formed capsule on the undersurface of the muscle. The muscle was stretched and thin. being only 3 mm thick in parts, and the overlying subcutaneous tissue was 2 cm thick. The skin graft was removed from the patella and sides of the knee and the femoral artery and vein were exposed in the subsartorial canal. The thoracodorsal vessels were then divided and anastomosed, end to end. to unnamed branches of the femoral vessels. The muscle paddle wrapped around approximately 60 O/O of the circumference of the knee while the skin paddle only wrapped around 45 %. The edges of the muscle were covered above and below with skin Raps from the undamaged skin and on the sides with split skin grafts. The flap was thus blended in well to the defect site. The postoperative recovery was unremarkable. At 2 months the flap had a good contour and was developing protective sensation (Fig. 3A). IJnfortunately she fell on her knee and grazed the flap, but this healed with conservative treatment (Fig. 31~).
An energetic l3-year-old school girl was knocked off her horse and run over. She sustained an extensive degloving injury to her left knee. No neurovascular damage was sustained. The defect was initially covered by a meshed split skin graft which took nicely but could not withstand the rigours of school life. Constant traumatic breakdown of the graft over the patella and an awful cosmetic defect severely disrupted her life (Fig. 1). Twelve months after the injury it was decided to use an expanded latissimus dorsi free flap to protect the patella and to improve the appearance of the knee. 413
British Journal of Plastic Surgery
Fig. 1
Fig. 3 Figure I-An extensive degloving injury to the left knee of a 13-year-old school girl. She constantly traumatised the meshed skin graft over the patella. In addition the cosmetic defect was unacceptable. Figure 2-The size of the flap. The flap which was raised following i:issue expansion-as drawn on the left side of the patient postoperatively-was significantly larger than the flap which could have been r aised without expansion-as drawn on the right. Also note the minimum donor defect. Figure WA) The result 4 months postoperatively She sustained a full thickness graze to the flap which healed spontaneously. (B) The area of cross hatching represents skin which has reg; lined protective sensation at 2 months postoperatively.
Tissue Expanded Free Flaps ____-
Fig. 4
Fig. 6 Figure 4 Gross hypertrophic scarring of a burn on the neck. The hum expanded parascapular flap. A flap 19 x 9 cm was harvested and postoperatively. Figure 7-Side view 4 years postoperatively. There is This was carried out w recently that the benciits of the procedure are
A pretty II?-year-old school girl was doing a class experiment with a steam engine when it exploded, severely burning her neck. Initial attempts to treat the burn with split skin grafting were thwarted by gross hypertrophic scarring and some scar contracture (Fig. 3). The injury was a major psychosocial burden on her and hser ‘family and after 2 years (in 1987) it was decide’d to replace the unsightly scar with an expanded parascapular flap. A 1000 ml Icxpander was inserted under the skin of the back through a small midline incision. Care was taken not to encroach on the pedicle-the circumflex
Fig. 5
Fig. 7 had been split skin grafted on three separate oc~:awm~. Figure S-The the donor site was closed directly. Figure 6 ~The result 4 years some loss of the angle of the neck, which was treated by hposuction. not yet evident because of postoperative oedemu.
scapular vessels. The expander was r.hen inflated (1000 ml) over the next 6 weeks. At the second stage operation the flap was raised with the patient lying supine. An ellipse I9 x 9 cm was dissected out (Fig. 5). The lateral portio’n lay over the pedicle, which was in virgin tissue. The bulk of the tlap lay over the expander-medial to the pedicle-and was approximately 1.5 cm thick. The donor site was closed directly and the flap was lailored to fit the recipient defect. In so doing the scar from the first stage procedure was discarded. The patient was rolled over and the neck was prepared. The circumflex scapular vessels were anasto-
British Journal of Plastic Surgery
416
Fig. 8 Figure &The vascular architecture of the latissimus dorsi. The undisturbed muscle (right) contains 7 vascular units which drain into three major named vessels (the thoracodorsal vessels, the posterior intercostal perforating vessels and the lumbar perforating vessels). This is classified as a type C7 muscle (after Crock, 1990). Placement of the tissue expander interrupts the posterior intercostal perforating vessels, effectively delaying the muscle. It then contains 5 units which drain into 2 major named vessels (the thoracodorsal and lumbar perforating vessels). The muscle is then classified as a tvue B5 muscle (after Crock. 1990). The latter arrangement is theoretically more robust for transfer on the thoracodorsal vessels. .L
mosed end to side into the facial vessels and the flap was fitted precisely. Postoperative recovery was unremarkable. In particular the flap maintained its size. She is now in her fifth postoperative year and has a satisfying cosmetic result (Fig. 6) although there was a minor degree of webbing of the neck (Fig. 7). This was treated recently by liposuction, with no adverse effect on the flap. Despite her tendency to produce hypertrophic scars the suture lines are flat and her neck is smooth. Both she and her family are pleased and have been helped psychologically by the surgery. Discussion These procedures are further refinements of two well known flaps: one was stumbled upon by Tansini (Purpura, 1908) late last century and rediscovered by Olivari (1976) some 80 years later. The other was described by DOS Santos (1980) and others (Mayou et al., 1982). Various features of the application of tissue expansion to these flaps are worthy of report. Firstly, the very placement of the expander is critical. We ensured that the vessels were not impinged upon during expansion and thus remained in virgin territory until the ultimate transfer. The concern is that if the pedicle is encased in scar tissue it may become impossible to dissect. Cherry et al. (1983) showed, in pigs, that expansion has the same effect on skin vascularity as delaying the area. It seems reasonable to extrapolate that, in humans, expansion delays flaps. In the case of the latissimus dorsi flap, the placement of the expander should turn this type C7 muscle into a type BS muscle
(Crock, 1990) which is theoretically more robust (McGraw and Arnold, 1986) (Fig. 8). Secondly, expanded flaps are noticeably thinner than the equivalent standard flaps. The musculocutaneous flap was especially thin. Argenta et al. (1983) also observed marked thinning of the latissimus muscle in their reported cases of local latissimus dorsi flaps which were expanded prior to transfer. In spite of this. the thinned muscle paddle appears to act as a perfect carrier for tissue vasculature but without the bulk of normal musculocutaneous flaps. In addition, having a thin rim of muscle which extends beyond the skin component of the flap helps to blend the flap into the recipient site. This tends to reduce the ‘blobs and globs’ effect which McDowell (1979) campaigned against. We did notice, however, that the subcutaneous tissues were not thinned to the same degree as the muscle. Delayed liposuction would be a useful adjunct to improve refinement of contour of this flap. We also noticed that there was significant postoperative oedema, which settled spontaneously over a period of months. In contrast, the subcutaneous tissue of the expanded parascapular flap was quite thin and in many instances may not need further thinning - although we can see no contraindications to liposuction in appropriate circumstances and in fact used it in the second case to try to improve the neck angle. Thirdly, the dense capsule which formed under the musculocutaneous flap acted as a base with which to anchor the muscle on the stretch. which should help maintain the thinness of the flap. This is yet another feature which makes this flap more amenable to subtle contouring than the standard musculocutaneous flap.
417
Tissue Exoanded Free Flaus Finally, the donor site of expanded flaps can be closed directly. This is functionally and aesthetically much more pleasing than a large split skin graft. Elliot et al. (1988) have already expounded this virtue in their report on expanded local latissimus dorsi flaps. The expanded latissimus dorsi flap is a refinement of a standard “work horse” musculocutaneous flap. This flap is large but the donor site can be closed directly. The muscle paddle is thin but has a fibrous base which can hold stitcl :s under moderate degrees of tension. The subcutaneous tissue is less attenuated but would be amenable to liposuction for fine contouring once the flap has settled. The scapular flap is also well described. When expanded it is a large thin flap which can be used to fill big defects and yet the donor site can be closed directly. The expander should be placed in such a way as to delay and/or enlarge these flaps without interfering with the vascular pedicle to be used for microvascular transfer. This application of tissue expansion appears to be useful in producing large but supple flaps which should have many applications.
Acknowledgements We wish to acknowledge warmly the assistance of Mr P. Kolhe and Dr B. Philp who helped in one of the cases presented here.
Crock, J. G. (1990). The venous architecture of muscles in man. M.D. Thesis, University of Melbourne p. 135. DOS Santos, L. F. (1980).Retalho escapular : urn novo retalho livre microcirurgico. Rev&a Brasileira de Cirurgia, 70, 133. Elliot, D., Lewis-Smith, P. A. and Piggot, T. A. (1988). The expanded latissimus dorsi flap. British Journal of Plastic Surgery, 41. 3 19. Goldstein, M. H. (1984). A tissue expanding vermilion myocutaneous flap for lip repair. Plastic and Reconstructive Surgery. 73, 768. Grabb, W. C. (1982). Discussion on breast reconstruction after mastectomy using the temporary expander by Chedomir Radovan. Plastic and Reconstructive Surgery. 69. 207. Hallock, G. G. (1988). Free flap donor site refinement using tissue expansion. Annals of Plastic Surgery, 20, 566. Laitung, J. K. G. and Batchelor, A. G. (1990). Successful preexpansion of a free scapular flap. Annals of PIustic Surgery, 25, 205. McCraw, J. B. and Arnold, P. G. (1986). McGraw and Amolds atlas of muscle and musculocutaneous paps. Norfolk. Virginia. Hampton Press Publishing Company, Inc., p. 662. McDowell, F. (1979). Editorial. Logs vs. harpsichords, blobby flaps vs finished results. Plastic and Reconstructke Surgery, 64, 249. Mayou, B. J., Whitby, D. and Jones, B. M. (I982). The scapular Rap-an anatomical and clinical study. British Journal of Plastic Surgery, 35. 8. Neumann, C. G. (1957). The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plastic and Reconstructive Surgery, 19, 124. Olivari, N. (1976). The latissimus dorsi flap. British Journal of Plastic Surger.v, 29, 126. Purpura, F. (1908). Tansini method for the cure of cancer of the breast. The Lancet. I, 634. Radovan, C. (1982). Breast reconstruction after mastectomy using the temporary expander. Plastic and Reconstructive Surger?, 69. 195.
The Authors References Argenta, L. C., Marks, M. W. and Grabb, W. C. (1983). Selective use of serial expansion in breast reconstruction. Annals qf Plastic Surgery. 11, 188. Cherry, G. W., A&ad, E., Pasyk, K., McClatchey, K. and Rohrich, R. J. (1983). Increased survival and vascularity of randompattern skin flaps elevated in controlled, expanded skin. Plastic and Reconstructive Surgey. 72. 680.
B. J. Mayou, FRCS, Consultant Plastic Surgeon D. T. Gaul& FRCS, formerly Senior Registrar in Plastic Surgery J. G. Crock, MD, Dip Anat, Lecturer in Plastic Surgery, Department of Plastic Surgery, St Thomas’ Hospital. London SEI 7EH. Requests
for reprints
to Mr B. J. Mayou.
Paper received 9 October 1991. Accepted 4 February 1992. after revision.
BPS15
