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Introduction: obesity is one of the most common diseases worldwide, and the most effective treatment to it is the bariatric surgery. One of the negative impacts of this procedure is the body dysmorphia caused by overhanging skin. In Brazil, the national health system - Sistema Único de Sáude (SUS) - provide body contouring surgery to treat post-bariatric patients, since 2007. This article aims to describe the Brazilian public health approach to post bariatric patients and perform an analyze in the Brazilian health care database., Methods: in Brazilian Health System database, a search for the post-bariatric procedures performed between 2007 to 2021 was done. The variables analyzed were geographic location, year, mean days of hospitalization, death, and mortality rate. Also, we evaluated the number of bariatric procedures done in the same period. Statistical analysis was performed using the Student-t and the chi-square tests and p-value <0.5 was considered significant., Results: a total of 12,717 plastic surgery procedures in post bariatric patients were done, with a national prevalence of 13.8%. Dermolipectomy was the most performed procedure, with 6,719. The years of 2020 and 2021 suffered a decreased of 64.3% and 70.9% in the number of surgeries (p<0,001). Bariatric Procedures had a high rate and a higher percentage of growth comparing to post bariatric surgery (p<0,001), totalizing 93,589 surgeries., Conclusions: Brazil had a significant number of body contouring surgery, however with a low prevalence. Dermoliepctomy was the most common procedure performed. We could notice a significant impact of COVID pandemic in those procedures .

Introduction: nose is the central point of the face and vulnerable to the occurence of non-melanoma skin cancer (NMSC), impacting on appearance. The paramedian forehead flap (PMFF) is considered the best option to treat extensive nasal defects. The objective of this study is to present the experience on PMFF for nasal reconstruction in the treatment of NMSC of a cancer referral center., Methods: retrospective study was carried out through data from medical records of patients who underwent nasal reconstruction with PMFF due to NMSC at the Cancer Institute of the State of São Paulo (ICESP)., Results: 111 patients were identified, mostly ederly, with comorbidities and on initial tumors (T1 and T2). Basal cell carcinoma (BCC) was the predominant histological type. Dorsum and tip were the most affected subunitis. In addition to skin coverage, reconstruction of the lining and structural framework was also performed in half of the cases. Second intention healing was the technique of choice in closing the donor area. Pedicle division ocurred predominantly in the second operation and the median time to complete reconstruction was 6 months. There were low complication rates., Conclusions: the PMFF is safe and effective to treat nose NMSC, even in cases of high complexity. Since the treatment time can be prolonged and impact on quality of life, it is essential to emphasize and discuss this aspect with the patients before surgery.

Introduction: bariatric surgery is the main treatment for cases of severe obesity and body contour surgery to correct body dysmorphia resulting from weight loss. However, these procedures are associated with a significant number of postoperative complications., Objective: this study aims to analyze complications in post-bariatric patients undergoing body contour surgeries and correlating them with the age and BMI of these patients., Methods: the current study is a retrospective study evaluating 180 consecutive patients undergoing body contour surgery after bariatric surgery within a period of three years (2014-2016). Data such as age, gender, Body Mass Index before bariatric and plastic surgeries, type of surgery performed and complications were collected, and correlated the age as well as the BMI of the patients in the pre-bariatric (PB) and pre-plastic (PP) periods with the complications presented., Results: of the 180 patients evaluated, 91.7% were females (n = 165), and the mean age was 46.3 ± 1.7 years. The most performed surgery was abdominoplasty (48.9%), followed by mammaplasty (21.1%). Some complications occurred in 26.1% of the patients with partial dehiscence (40.4%) and seroma (14.9%) being the most frequent. Patients who presented complications had a higher mean age (50.8 years) than those who presented with no complications, and major complications accounted for 2.7% of the sample., Conclusions: a statistically significant number of surgeries progressed without complications and, when they occurred, there were minor complications in most of the sample. Complications were more frequent in older patients with some of them having a BMI over 30 Kg/m2.

Background: tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence., Methods: a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018., Results: 245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications., Conclusion: the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

Objective: to evaluate the initial therapeutic experience of transplantation of vascularized lymph nodes in patients with lymphedema of the upper limbs secondary to the treatment of breast cancer, and to verify if the positioning of the transplant influences the surgical result., Methods: we conducted a prospective, comparative test of two therapeutic modalities, with 24 patients with lymphedema of the upper limb after breast cancer treatment, classified as grades 2 and 3, according to the International Lymphedema Society. The two types of procedures performed were: 1) total breast reconstruction with - deep inferior epigastric perforator (DIEP) flap associated with lymph node flap, in patients with no previous breast reconstruction or loss of previous reconstruction (axillary positioning); 2) isolated inguinal lymph node flap performed in patients with completed breast reconstruction or without the desire to perform the breast reconstruction (wrist positioning)., Results: the reduction percentage of the affected limb volume was 20.1% (p=0.0370). The number of infectious episodes (cellulites) also decreased significantly, from 41% in the preoperative period to 12.5% in the postoperative one (p=0.004). There were no differences between the proximal and distal groups., Conclusion: the transplantation of lymph nodes positively affected the postoperative evolution of patients with lymphedema secondary to breast cancer. We observed no differences in relation to flap positioning.

Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs., Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization., Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions., Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Objective: to evaluate the role of age in the risk of postoperative complications in patients submitted to unilateral breast reconstruction after mastectomy, with emphasis on total reconstruction loss., Methods: we conducted a retrospective study of patients submitted to breast reconstruction, whose variables included: oncological and reconstruction data, postoperative complications, including loss of reconstruction and complications of surgical wound. We divided the patients into two groups, according to the classification of the Brazilian National Elderly Policy and the Statute of the Elderly: young (age <60 years) and elderly (60 years or more). We also grouped them according to the World Health Organization classification: young people (age <44 years), middle age (45-59 years); elderly (age 60-89 years) and extreme advanced age (90 years or older). We applied the surgical risk classification of the American Society of Anesthesiologists to investigate the role of the preoperative physical state as a possible predictor of complications., Results: of the 560 patients operated on, 94 (16.8%) were 60 years of age or older. We observed a local complication rate of 49.8%, the majority being self-limited. The incidences of necrosis, infection and dehiscence were 15.5%, 10.9% and 9.3%, respectively. Patients older than 60 years presented a chance of complication 1.606 times greater than the younger ones. Forty-five (8%) patients had loss of the reconstruction; there was no statistically significant difference in the mean age of the patients who presented this result or not (p=0.321)., Conclusion: in selected patients, breast reconstruction can be considered safe; most documented complications were limited and could be treated conservatively.

Objective: to evaluate the primary outcome of local complications and late recurrence in patients with hidradenitis suppurativa undergoing radical resection and specific reconstruction., Methods: we conducted a retrospective analysis of the medical records of patients attended by the Plastic Surgery Service of the Clinics Hospital, Medical School, USP, between 2010 and 2016. We included patients who underwent radical resection of hidradenitis suppurativa in advanced stage and reconstruction through primary closure, grafts or flaps., Results: we analyzed 34 lesions in 19 patients, of which 64.5% had local complications, though with 73.5% efficient healing after 12 weeks postoperatively. We observed late recurrence in 47%, but in isolation, 22.2% of the reconstructions with locoregional flaps had recurrence after one year., Conclusion: extensive and radical resection of the disease associated with locoregional flap coverage (pedicled or perforating) has been shown to be the best management in terms of late results.

Objective: to evaluate a brief hospitalization protocol for the treatment of pressure ulcers, proposed by the Complex Wound Group of Clinical Hospital of University of Sao Paulo Medical School, particularly in regard to selection of patients, hospitalization time, cutaneous covering, complications and sore recurrence., Methods: retrospective cohort of 20 consecutive patients with 25 pressure lesions Grade IV. All patients were ambulatorily prepared and were hospitalized for surgical one time procedure for pressure lesion closing., Results: in total, 27 flaps were performed to close 25 wounds. Three patients showed minor dehiscence (11.1%). There was no recurrence during the post-surgical follow-up period. No patient suffered a new surgery and no flap showed partial or total necrosis. Median time of hospitalization was 3.6 days (2-6 days) and median follow-up was 91 months (2-28 months). All patients maintained their lesions closed, and there was no recurrence during follow-up., Conclusion: the brief hospitalization protocol was considered adequate for the resolution of pressure wounds, showing an average time of hospitalization of 3.6 days and rate of minor surgical wound dehiscence of 11.1%.

Objective: to report the initial experience with Negative-Pressure Wound Therapy with instillation in infected or contaminated complex wounds., Methods: the negative-pressure wound therapy with instillation used was V.A.C. Ulta with Veraflo instillation (Kinetic Concepts, Inc). The mode of operation was continuous with negative pressure set at 125 mmHg for two hours and instillation between the pauses. The instillation time was 20 minutes (contact time of the topical agent with the wound) and the instilled substance was 0.9% normal saline. After adequate preparation of the wound, it was covered with graft or flap., Results: ten patients with complex or contaminated wounds were operated on. The mean number of NPWTi changes was 1.4, the mean number of surgeries was 2.4, the interval until complete wound coverage was 6.3 days, and the interval up to the time of discharge was 11.4 days., Conclusion: the comparison of the negative-pressure wound therapy with instillation with two previous studies (historical control) evidenced a shorter hospitalization time, favoring TPNi. This study had an initial character, making it necessary to conduct a randomized and controlled trial to confirm the efficacy of this therapy and verify its cost-effectiveness.

Objective: to evaluate patient satisfaction and surgical results obtained after mastopexy with breast implant inclusion., Methods: we conducted a prospective study of 20 consecutive female patients with a mean age of 39.9 years, submitted to augmentation mastopexy. We applied semi-directed psychological interviews pre and postoperatively. The answers to the evaluations were tabulated, categorized, and allowed patient satisfaction analysis. We evaluated surgical results through photographic analysis of three independent plastic surgeons, in the pre and postoperative periods, when scores were attributed to the following items: breasts shape, breasts volume, breasts symmetry, nipple-areolar complex position, and scar quality and extent., Results: nineteen patients (95%) referred satisfaction with the surgical results attained (p<0,001). The mean sum of the scores attributed by the three surgeons to each patient varied between 4.7 and 10, with an overall mean of 7.28. The results were considered good or great for 65% of the sample and poor for 8.4%., Conclusion: there was a 95% satisfaction rate among patients with the results obtained through augmentation mastopexy. The photographic analysis of the results obtained a mean score of 7.28, considered as a good result, albeit the weak correlation among evaluators., Objetivo: avaliar a satisfação das pacientes e os resultados cirúrgicos obtidos após a mastopexia com inclusão de implantes mamários., Métodos: estudo prospectivo com 20 pacientes consecutivas do sexo feminino, com média etária de 39,9 anos, que foram submetidas à mastopexia de aumento. Foram aplicadas entrevistas psicológicas semidirigidas nos períodos pré e pós-operatórios e cujas respostas foram tabuladas, divididas em categorias, e possibilitaram a avaliação da satisfação das pacientes. Foi realizada avaliação dos resultados cirúrgicos através da análise fotográfica por três cirurgiões plásticos independentes, nos períodos pré e pós-operatórios, que atribuíram notas aos seguintes itens: forma da mama, volume da mama, simetria entre as mamas, posicionamento do complexo aréolo-papilar e qualidade e extensão das cicatrizes., Resultados: dezenove pacientes (95%) referiram satisfação com o resultado cirúrgico obtido (p<0,001). A média das somatórias das notas atribuídas pelos três cirurgiões, referentes a cada paciente, variou entre 4,7 e 10, sendo a média geral de 7,28. Os resultados foram considerados bons ou ótimos para 65% da amostra e pobres para 8,4%., Conclusão: houve satisfação de 95% das pacientes com os resultados obtidos pela mastopexia de aumento. A análise fotográfica dos resultados obteve nota média de 7,28, caracterizado como bom resultado, apesar da fraca concordância entre os avaliadores.

Objective: To evaluate the use of modified brachioplasty, investigating in late postoperative complications and satisfaction with the outcome, in women previously submitted to bariatric surgery., Methods: The population (N = 18, age 49.2 ± 11.3 years), which had undergone brachioplasty 25.2 ± 11.9 months after the bariatric procedure, was contacted after 31.7 ± 38.8 additional months. Surgical complications and satisfaction with the operation were estimated by interviews, including a questionnaire designed for this purpose., Results: pre-bariatric body mass index (BMI) was 57.1 ± 11.1 kg / m(2), being 28.3 ± 6.0 kg/m(2) before the brachioplasty, without significant changes thereafter. Three minor surgical complications were recorded (3 / 18, 16.7%), namely, temporary paresthesia, seroma and small imperfection of the scar. The satisfaction rate was approximately 90%, with the three most rewarding results for the patients being the ease of dressing (P = 0.01), decreased weight of the arm (P = 0.03) and absence of edema (P = 0.04). There was a negative correlation between severe weight loss and degree of satisfaction, however, no patients regretted the procedure., Conclusion: the modified brachioplasty was successful in cases with severe brachial ptosis with possible extension to the chest. The study confirmed functional and aesthetic benefits, and thanks to the technique applied, most of the complications and disappointments could be avoided.

Objective: Degloving injuries on the lower extremities are often serious injuries. It is difficult to decide on the most appropriate treatment, whether flap repositioning and suturing or converting the avulsed flap to split-thickness skin grafting., Methods: This study assessed patients with degloving injuries in lower extremities, reviewing the epidemiological profile and treatment performed. It is proposed a treatment protocol for management of those lower extremity avulsion injuries., Results: Twenty-one patients were evaluated. The cause of trauma was running over in 11 patients (52.4%) and motorcycle accident in 10 (47.6%). All twenty-one patients had treatment with washing, debridement, resection of avulsed flap and converting the flap to split-thickness graft, in according with the following treatment protocol for management of those lower extremity avulsion injuries that came to our Emergency Unit: Patients were initially classified as unstable or stable (hemodynamically). In the unstable group (two patients),due to the patient condition, flap resection was performed and the skin kept in the tissue bank for later grafting. In the stable group (19 patients), flap viability was assessed using clinical parameters and fluorescein. If deemed viable the flap was sutured to its original position. If deemed unviable (all 19 patients), it was resected and converted to split-thickness skin and mesh grafting with vacuum-assisted device over the graft., Conclusion: In order to avoid flap necrosis and to add a new skin donor area is important to recognize the problem in the Emergency Room and to manage properly those injuries.

Background: To establish a relation between the survival rate of island skin flaps submitted to prolonged ischemia and the effect of streptokinase and allopurinol administered after the ischemic period., Methods: A total of 48 male Winstar rats, each weighing between 300 and 350 grams,were separated into four groups of twelve as follows: control, allopurinol, streptokinase and association of allopurinol and streptokinase, were submitted to an epigastric island flap dissection followed by epigastric vessel bundle clamping. Flaps remained this way for 8 hours in normothermic mixed ischemia. After the ischemic period, clamps were removed and each rat received the therapeutical scheme proposed for the group by intravenous injections. Flap survival analysis was performed on the seventh post operative day. Variance and descriptive analyses (as a percentage of the necrotic area) as well as Dunnett-T3 multiple comparisons among the 4 groups and median tests were carried out., Results: Rats in the control group presented an average of 79.88% of necrosis in the flap total area; those which received allopurinol presented an average of 64.05% of necrosis whereas the group which received streptokinase showed an average of 55.52% of necrosis. With the association of both drugs, rats presented an average of 54.30% of necrosis in the flap total area. By applying Dunnet test and the median test, it could be verified that, in this study the streptokinase group had the lowest necrosis rate., Conclusion: The systemic administration of streptokinase after 8 hours of normothermic global ischemia resulted in an increased survival rate of epigastric island skin flaps in rats, when compared to the administration of allopurinol, association of the two drugs and the control group.

Reduction mammaplasty is nowadays one of the most frequently performed plastic surgeries. The main purpose is the reduction of the volume of breasts, but the resulting scars can jeopardize the result of the operation. The Division of Plastic Surgery follows the modern tendency of reducing the length of the incisions and thus the resulting scars. A technique that incorporates this principle was developed with good results. The technique is simple enough to be used in a training program.

Adequate dose of cyclosporin A shows immunosuppressor effect, and low toxicity. The doses reported previously ranged from 2.5 to 25 mg/kg every 24, 48 hours and even 7 days. Routes for cyclosporin A administration are subcutaneous or intramuscular preferentially. In the present study, cyclosporin A (CSA) single dose subcultaneous was administered to 21 Wistar-Furth rats, adult, males, weighing 350-450g. The animals were divided in 3 groups receiving 2.5 mg/kg (group 1), 5.0 mg/kg (group 2) and 10.0 mg/kg (group 3). Blood samples were collected at 1, 4, 8, 12, 24, 48 and 72 hours after drug collection into plastic tubes containing sodium EDTA. Blood cyclosporin A levels were determined by a commercially available radioimmunoassay kit (Sandoz RIE Kit Basel) after whole hemolysis using liquid nitrogen. Cyclosporin A blood concentrations vs time curve were plotted (log C vs t). Two compartment open model was applied to estimate the kinetic parameters as t(1/2) beta e beta. A model independent calculation was applied to estimate the kinetic parameters as AUCT, CIT and Vd. Initially, parametric and nonparametric tests were applied. Due to the high dispositional variability, nonparametric statistics (Wilcoxon's test) was applied for analysis of results obtained. Based on data obtained in the present study the authors suggest linear pharmacokinetics where Cmax AUCT showed proportional increases with the dose administered, remaining unchanged the Kinetic parameters as t(1/2) B,B, CIT and Vd.

From 1988 up to 1994, 64 patients were submitted to reconstruction of the breast using tissue expanders. A silicone prosthesis was implanted in a second operation. The technique was used both for immediate and delayed breast reconstruction after radical modified mastectomies. Surgical procedures as well as indications, advantages and complications of the technique were discussed. Good results were achieved in 89% of cases. Tissue expander is a valid option for breast reconstruction even though late complications due to the capsular contraction did occur.

The objective of this work was to study the protective effects of the free radical scavenger N2-mercaptopropionylglycine used in a rat model of reperfusion of epigastric island flaps submitted to transient occlusion of their vascular pedicles. In one group the epigastic vein of the flap was occluded for 5 hours. In the second group the epigastric artery was occluded for 21 hours and in the third group both the epigastric vein and artery were occluded for 8 hours. The scavenger or equivalent volume of saline solution was injected 10 minutes before the vascular occlusion and 10 minutes before declamping. The flap viability was assessed on the seventh day after flap reperfusion. In the three types of vascular occlusion a significant, and differential, increase of the areas of flap survival was observed. The protective effect of N2-mercaptopropionylglycine in reperfusion injuries was demonstrated.

Cryptotia is a congenital abnormality represented by the absence of the retroauricular sulcus in its superior portion. As the physiopathology of the problem involves the lack of skin tissue in the superior part of the ear sulcus, Mulliken suggested for the first time in 1988, the use of skin expanders as a method to obtain the extra skin necessary to correct this deformity. We bring forward our experience in the use of skin expanders in the treatment of three patients with cryptotia, bilateral in one of them. The technical aspects of the operations as well as the types of expanders used are described in detail. In all cases the correction of the cartilagenous deformities, freeing of the superior pole of the ear and redefinition of the retroauricular sulcus were performed. There were no significant complications. There was no change of the initial good results after a two years follow-up.

The posterior interosseous vessels give a significant contribution to the fascial plexus which supplies the skin of the forearm. This vascular arrangement forms the basis for an island fasciocutaneous flap which can be based either proximally or distally. Its principal advantage is that it is a thin flap with excellent circulation and that the donor area can be closed primarily. The design and usage of an island fasciocutaneous flap with possibility of expansion is also described.

Plastic surgeons with a certain frequency have to face the problems of increased mammary volume in patients treated for hypomastias, mammary asymmetries or just for replacement of tissues surgically resected. In 28 years of using the Cronin prosthesis some questions appeared about the correct indications of mammary prosthesis. We present 10 patients unsatisfied with the esthetic results of a mammary prosthesis because of ptosis, capsular retraction, asymmetry as well as pain. The treatment consisted of taking away the prosthesis and reconstruction of the breast with local dermo-fat-glandular flaps. We achieved good esthetic results and remission of pain.

Tissue expanders have emerged recently as a new option for the treatment of alopecia. The method consists in expanding the scalp beyond the defective area. In this way, some disadvantages like the alterations in the donor area and low density of hair follicles, that may result from other techniques, are avoided. We present our experience with tissue expanders in the treatment of 32 patients with alopecia. The extent of these areas varied from 30 to 150 cm2, and the causes were: burn sequels in 12 patients; trauma sequels in ten; tumoral resections in ten; giant nevus pilosus in four and baldness (male standard) in two patients. The resection of the area with alopecia and the replacement by normal adjacent tissue was possible without any complications in all cases. However some disadvantages were observed. They included the necessity for a second surgical procedure because of marked deformity of the cephalic segment.

Fifty nine patients with extensive traumatisms of the external ear, including 3 total amputations, 10 partial amputations with maintenance of reduced pedicle and 46 extensive lesions without further vascularization, have been attended in the Emergency Unit of Hospital das Clinicas at University of São Paulo Medical School from 1979 to 1989. Surgical behaviors performed in each case are described and explained in detail. The main purpose of the study was to show the outliving possibilities of the ear even in serious traumas and to emphasize the need of immediate repair of the ear in order to obtain a satisfactory result.

In the first quarter of 1985, the use of the seat belts in every car was compulsory as disposed by law and it was discontinued afterwards. The authors correlate the number and type of facial fractures in patients admitted to the Emergency unit of the Hospital das Clínicas of University of São Paulo Medical School, during the first quarter of 1984, 1985 and 1986. A significant decrease of the number of cases and the severity of the facial fractures during the 1985 period was observed and, more important, a decrease was noted on the proportion of the nasal and fronto-orbital fractures among the overall number of fractures of the face. There was thus a significant relationship between the use of belts and the number and severity of the facial fractures.

The authors have performed in 150 cases the surgical reconstruction of the vagina using the McIndoe's technique. Since 1986 they are using the non-surgical technique devised by Frank in 1940. As a modification of the method, cylindric molds of acrilic with diameters varying between 1.5 and 3.0 cm have been used. Ten cases of congenital absence of the vagina and 12 intersex cases identified as belonging to the female sex, were treated by this progressive dilatation method. The results, were good and no complications occurred. The long-term follow-up has shown a stable and functional vagina. The main advantagens of the method are the simplicity and the low morbidity.

Ten patients had their vulvar and perineal areas reconstructed using musculocutaneous flaps of the gracilis muscle. Seven patients had extensive resections done for skin carcinomas, two due to traumas and one due to a sequel of Fournier's Syndrome. Reconstruction in tumor cases were performed primarily and the other secondarily. The skin island measured 12 x 8 centimeters and the muscle was taken entirely. The results were satisfactory in all cases. The muscle survived completely, but there was partial skin island loss in 8 instances. In 3 of those cases, there was need for a revision of the flap and skin grafting. The authors concluded that there is always a risk to take the skin island together with the gracilis muscle and the use of the isolated muscle with skin grafting should be considered im most cases.