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The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction--the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.

The development of squamous cell carcinoma in pressure sores is a rare event, considering the high incidence of pressure sores within the elderly and paraplegic populations. The clinical courses of 10 patients with pressure sore carcinoma have been reviewed. The presence of a velvety, cauliflower-like growth on the surface of a long-standing pressure sore should alert the surgeon to the possibility of malignant degeneration. Most of these tumors are well-differentiated squamous cell carcinomas. Of the 10 patients, 8 (80%) died from massive local recurrence or distant metastases an average of 17 months after resection and flap closure despite having apparently localized disease. One patient was disease free when lost to follow-up at 2 years, and 1 patient is without evidence of recurrence or metastases 3 months postoperatively. Altered immunocompetence may play a role in the rapid progression and high mortality associated with this tumor after surgical manipulation.

We discuss our successful management of complex groin wounds caused by shotgun blasts at relatively short range. A straightforward approach to the problem of reconstructing the large soft-tissue defect and providing protection for the femoral artery reconstituted by Gore-Tex graft is described. We emphasize the fundamental principles of management of civilian trauma and illustrate that a Gore-Tex graft need not be covered immediately if there is any possibility that debridement is incomplete. The inferiorly based rectus abdominis flap is recommended as an excellent choice for coverage of the typical shotgun blast groin wound, making it possible to salvage the involved lower extremity in these severe injuries.

Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.

Three cases of hand injury caused by meat grinders are presented. All 3 injuries involved the dominant hand and resulted in varying degrees of deformity. Two of the 3 patients arrived in the emergency room with the injured hand still firmly wedged in the meat grinder. Although these injuries continue to prove very mutilating, maximum restoration of the injured hand can be accomplished by careful extrication, followed by preservation and reconstruction of all viable tissues. Perioperative antibiotics and wound irrigation with antibiotic solution are recommended. Microsurgical technique can be of value in treating selected patients.

An inferiorly based rectus abdominis musculocutaneous flap was used to close a large ischiosacral pressure sore refractory to the usual methods of closure in a paraplegic patient. The functions of the rectus abdominis muscle to initiate vertebral flexion from a supine position and aid in respiration, urination, defecation, and vomiting may play a proportionately greater role in the paraplegic patient. Although our patient did not experience any noticeable clinical deficits, this donor site is theoretically less functionally expendable in the paraplegic patient.