Flap selection as a determinant of success in pressure sore coverage.

OBJECTIVE: To establish a treatment algorithm for the long-term surgical management of pressure sores. DESIGN: Retrospective case series. SETTING: University-based teaching hospital. PATIENTS: From March 1979 to July 1995, 280 unselected pressure sore reconstructions (113 ischial, 94 sacral, and 73 trochanteric sores) were performed in 201 patients (130 men and 71 women; age range, 16-90 years; mean, 50 years). Of the patients, 90% had severe spinal cord injuries (paraplegia or quadriplegia). Forty-one percent of the wounds were chronic (present longer than 3 months). MAIN OUTCOME MEASURES: Length of stay, postoperative morbidity and mortality, and flap success (defined as a completely healed wound). RESULTS: Overall, 89% of the flaps healed primarily (ischium, 83% [94/113]; sacrum, 91% [86/94]; trochanter, 93% [68/73]). Three fourths of cases were treated in a single stage (debridement and reconstruction). The inferior gluteus maximus island flap (ischium) (94% [32/ 34]), the V-Y gluteus maximus advancement flap (sacrum) (97% [36/37]), and the tensor fascia lata flap (trochanter) (95% [42/44]) had the highest success rates. Flap success was not significantly affected by the size of the pressure sore or the number of previous flaps used. Postoperative hospital stays averaged 20 days. The overall complication rate was 28%, most commonly from a slight wound edge dehiscence. CONCLUSIONS: Flap selection and the appropriate short- and long-term sequence of flap use significantly improve success rates for pressure sore coverage. Reconstruction can be reliably performed in a single stage with a relatively short hospitalization.

Influence of radiotherapy on microvascular reconstruction in the head and neck region.

Over a 5-year period at the University of California San Francisco, 42 patients who required microvascular reconstruction for abnormalities in the head and neck area were identified. Twenty-four patients (Group I) underwent reconstruction for a variety of neoplastic and non-neoplastic conditions and did not receive radiotherapy. Eighteen patients (Group II) had undergone previous radiotherapy averaging 6,090 rads. The mean ages for Group I and II patients were 40.7 and 55.5 years, respectively. In Group I, 13 muscle, 7 fasciocutaneous, 4 osteocutaneous, and 2 jejunal transfers were performed. In Group II, 11 muscle, 5 fasciocutaneous, 3 osteocutaneous, and 2 jejunal transfers were performed. Flap survival at 3 months was 88% in Group I and 95% in Group II. Wound complication rates were similar in both groups (15% Group I, 19% Group II), as was donor site morbidity (15% Group I, 29% Group II). Operative times (10.9 hours Group I, 10.6 hours Group II) and median postoperative hospitalization (14 days Group I, 16 days Group II) were comparable as well. Four of the five patients in whom the flap procedures failed were subsequently treated by a second microvascular reconstruction. Previous irradiation of the recipient bed did not appear to affect the success of subsequent microvascular reconstruction or the difficulty of such reconstruction as judged by operative time.

The effects of facial nerve ablation on craniofacial skeletal development in neonatal rabbits.

The effects of unilateral facial nerve ablation on craniofacial development in the rabbit were examined. In this experimental model, 10 newborn rabbits 12 days of age underwent unilateral resection and cautery of the facial nerve. They were allowed to grow to skeletal maturity and were sacrificed at 6 months. Analysis of variance was used to compare direct measurements of prepared skulls in the experimental animals with 3 unoperated control litter mates and with 5 litter mates who underwent a sham procedure (exposure of the facial nerve without section). The animals with facial nerve resection demonstrated an average snout deviation toward the side of injury of 8.3 degrees, apparently due to shortening of the maxilla and mandible on the affected side. This study provides new data regarding the role of the functional matrix in the modulation of craniofacial growth and development.

Volumetric quantification of intracranial and ventricular volume following cranial vault remodeling: a preliminary report.

This preliminary study documents preoperative and postoperative changes in cerebral tissue as well as intracranial and ventricular volume in patients who underwent cranial vault remodeling for craniosynostosis. The documentation and calculations were provided from CT data according to a craniofacial protocol. Three-dimensional images were then obtained of the preoperative and postoperative skulls and cerebral tissues. From these data, comparisons of preoperative and postoperative volumes of the cerebral tissue and ventricles could be examined. In one case, a frontal bone advancement combined with anterior cranial vault remodeling was associated with an increase in intracranial volume of 110 cc (8 percent) and a ventricular volume increase of 112 percent. The reported technique should allow more complete evaluation of the preoperative pathology and documentation and prediction of the projected intracranial and ventricular volume changes.

A new in utero sheep model for unilateral coronal craniosynostosis.

Several animal models have been designed in the past to analyze the pathophysiology and management of craniosynostosis, very few of which were intrauterine. Those that were interuterine had problems with either a short gestation or limited availability that prevented most researchers from using them in treatment analysis. We desired to create a biologically sound intrauterine model of craniosynostosis, using an animal with a long gestation and an early calvarial bone formation, which was easy to manipulate in utero, that could be created by any researcher studying this disorder. Using biologic data available regarding growth factors thought to be involved in bone growth and cranial suture closure, we developed a new in utero fetal lamb model for the study of craniosynostosis. Ten 70-day gestation fetal lambs (term gestation 140 days) received a midline coronal incision to expose both coronal sutures. The entire right coronal suture was then excised along with a 4-mm bony margin. In each animal, the site was packed with 25 mg of demineralized sheep bone powder augmented with 50 microg of bone morphogenetic protein-2 (BMP-2) and 1 microg of poly-transforming growth factor-beta. The scalp was closed, and the sheep were returned to the uterus until either 90 or 140 days of gestation. Complete fusion of the right coronal suture occurred in all fetuses by 90 days gestation. In every animal, right-sided frontal bone flattening and supraorbital rim elevation were evident. Histologic analysis showed bony synostosis at the suture site without evidence of suture regeneration. By 140 days, this isolated suture fusion led to marked craniofacial abnormalities including right supraorbital rim elevation, significant frontal bone flattening, a decrease in the anterior-posterior length of the cranial vault, and flattening of the cranial base. In conclusion, we have developed a new model for the study of the secondary effects induced by the process of cranial suture fusion, which produces abnormalities seen in naturally occurring cases of isolated right coronal suture synostosis. In addition, this model confirms that isolated coronal suture fusion alone can lead to the multiple cranial and facial abnormalities seen with this disorder, even in the absence of associated cranial base suture fusions.

The in utero correction of unilateral coronal craniosynostosis.

We performed the first in utero correction of a unilateral right coronal craniosynostosis using 70-day gestation fetal lambs. The craniosynostosis was created in eight fetuses by excising their right coronal sutures, and then placing demineralized bone powder, transforming growth factor-beta, and bone morphogenetic protein-2 into the defect. Twenty-one days later, after suture fusion had occurred, four of the eight sheep were treated with a 4 mm x 12 mm strip craniectomy to open the entire synostosed right coronal suture. The edges of the excision were wrapped with 100-microm-thick Gore-Tex (W. L. Gore & Associates, Flagstaff, Ariz.) sheets to prevent bony refusion. All eight lambs then progressed to term (140 days). The skulls of four normal, unoperated, term lambs were used as controls. At 140 days, all four treated lambs had a widely patent strip craniectomy site without any evidence of bone regeneration. This in utero correction led to a marked improvement in craniofacial morphology of three of four animals when compared with the uncorrected controls with significant (p < 0.01) correction in orbital position, skull length, and shape of the frontal bone. This was in sharp contrast to the uncorrected animals, which had marked orbital elevation, compression of the anteroposterior length of the cranial vault, frontal bone flattening, and shortening of the cranial base. The fourth corrected animal also showed evidence of improvement but had some abnormal calvarial changes secondary to the development of horns, which displaced the calvaria in a downward vector. We conclude that the in utero correction of craniosynostosis is feasible and provides a significant benefit by decreasing the severity of many of the associated deformities seen with this disorder.

Natural history of fetuses with cleft lip.

The prospect of fetal surgery for cleft lip is predicated on our ability to accurately identify fetuses with clefts and exclude those that have associated anomalies. Prenatal ultrasound is currently the most appropriate means with which to do this. We reviewed the ultrasonographic data from two large perinatal referral institutions to determine the natural history of fetuses with cleft lip who may be candidates for fetal surgery. Forty fetuses had a cleft lip diagnosed prenatally by ultrasound. In this group, severe associated anomalies were common (30 of the 40) and multiple (23 of the 40) in a majority of fetuses. Life-threatening anomalies, such as central nervous system and cardiac anomalies, were the most common defects. As a result, many fetuses were aborted therapeutically or died in the perinatal period. Out of 12 surviving fetuses, only six had isolated clefts, and two surviving fetuses, diagnosed with isolated cleft lip, had no defect identified postnatally. This information has important implications for the perinatal management of fetuses with cleft lip and the potential role of fetal intervention.

Giant congenital melanocytic nevi: the significance of neurocutaneous melanosis in neurologically asymptomatic children.

Patients with a giant congenital melanocytic nevus can develop melanotic tumors characterized by central nervous system involvement, termed leptomeningeal melanocytosis or neurocutaneous melanosis. Although symptomatic neurocutaneous melanosis is rare, we previously reported distinct magnetic resonance (MR) findings of T1 shortening, strongly suggestive of neurocutaneous melanosis, in 30 percent (6 of 20) of children with giant congenital melanocytic nevi who presented initially without neurological symptoms. The purpose of this study was to determine the incidence of neurocutaneous melanosis in high-risk patients and its long-term clinical significance. Magnetic resonance imaging was recommended for all 46 patients with "at-risk" giant congenital melanocytic nevi involving the skin overlying the dorsal spine or scalp. The clinical histories and follow-up of these patients were evaluated by retrospective chart review. Forty-two underwent MR imaging of the brain and 11 underwent additional MR scanning of the spinal cord. Abnormalities were identified in 14 of 43 MR studies, and 23 percent (n = 10) had T1 shortening indicative of melanotic rests within the brain or meninges. None had associated masses or leptomeningeal thickening. The most common areas of involvement in these 10 included the amygdala (n = 8), cerebellum (n = 5), and pons (n = 3). In the group of 11 patients with spinal MR scans, a tethered spinal cord was demonstrated in one. Additional abnormalities were detected by MR scanning, including a middle cranial fossa arachnoid cyst, a Chiari type I malformation, and a crescentic enhancement that subsequently resolved. Clinical follow-up averaging 5 years (range, 2 to 8 years) revealed that only one of the 46 patients evaluated developed neurological symptoms, manifested as developmental delay, hypotonia, and questionable seizures but no other signs of neurocutaneous melanosis. No patient has developed a cutaneous or central nervous system melanoma. Magnetic resonance findings of neurocutaneous melanosis are relatively common, even in asymptomatic children with giant congenital melanocytic nevi. Although these findings suggest an increased lifetime risk of central nervous system melanoma, they do not signify the eventual development of symptomatic neurocutaneous melanosis during childhood.

Bone morphogenetic protein-2 induces scar formation and skin maturation in the second trimester fetus.

Fetal mammals heal skin wounds through the second trimester of development without evidence of scar. We have investigated the role of bone morphogenetic protein 2 (BMP-2), which is a member of the TGF-beta superfamily, in normal skin development and fetal wound healing. We first used RNA in situ hybridization to demonstrate that BMP-2 was expressed at low levels in the developing hair follicles and in the epidermis of normal human fetal skin. We then created an in vivo model to test how exogenous BMP-2 would affect fetal skin development and wound healing. Fifty micrograms of BMP-2 was implanted into the subcutis of five 70-day-old fetal lambs through a full-thickness linear incision. The BMP-2 was placed beneath the right half of the wound, whereas the left half served as an untreated control. In two of the five animals 1 microgram of TGF-beta was placed into the same position in addition to the 50 micrograms of BMP-2. Twenty days later (90 days gestation, term = 140 days) all the fetal wounds were examined for evidence of cellular hyperproliferation and scar formation. BMP-2 induced massive dermal and epidermal growth when compared with controls. This finding was characterized by marked epidermal thickening and keratinization, a dramatic increase in the number of hair follicles, and more than 50 percent thickening of the dermis. The dermal thickening was the result of both increased cellularity and deposition of large irregular collagen bundles. Wounds treated with both BMP-2 and TGF-beta healed also with an adult-like pattern of scar formation. Surprisingly, the wounds with BMP-2 alone healed with an equal pattern of scar, indicating that there was not an additive effect of combining BMP-2 and TGF-beta. We conclude that BMP-2 is a pleomorphic growth factor that induces cellular growth, maturation, and fibroplasia in both the dermis and epidermis. Further analysis of this growth factor in both fetal and adult wound healing may lead to important discoveries regarding the control of scar formation and fibrosis in many adult tissues.

Reanimation of the paralyzed face.

The challenge of reconstruction in the paralyzed face is to provide symmetry both at rest and in active expression. Although functional considerations must take precedence, the patient with unilateral facial palsy faces social stigmata that are exceptionally difficult. The best reconstructions in late paralyses fall far short of natural facial expression. Conley, one of the pioneers in facial nerve rehabilitation, reflected the frustration of dealing with limited techniques: It has been assumed by many surgeons that involuntary emotional communication is through the facial nerve, but this has never been substantiated. Indeed, emotional expression may be beyond our concept of a mere physical tract. It certainly has never been totally restored by any surgical technique that attempts to rehabilitate the face. When injury to the facial nerve is established, early nerve grafting on the ipsilateral side is the best treatment. In acoustic neuroma and other intracranial operations, the only real opportunity for grafting or repair is at the time of the procedure. If the nature of the injury is uncertain, a period of 12 months is allowed to elapse before consideration of intervention, which should be started if there is no return of function at that point. Electromyography may be of assistance in assessing minimal early return; if any early return is noted, further waiting is indicated. If there is no return at 1 year, cranial nerve XII to VII crossover will preserve facial muscle tone and permit a more measured decision-making approach. Patients with multiple cranial nerves involved may be candidates for a partial hypoglossal transfer using a nerve graft, to attempt to preserve swallowing. In selected cases, cross-facial nerve grafting to the preserved facial muscles will give excellent results and obviate the need for local or distant muscle transfers. When treating established paralysis of long duration, cross-facial nerve grafting with microneurovascular muscle transfer is the best option for symmetrical movement of the face. Temporalis and masseter muscle transfers should be reserved for the patient with intercurrent medical disease or the patient who refuses additional operations or operative sites. Static slings and other related procedures should be considered adjunctive but not primary treatment in the vast majority of cases. Although there are limitations in each of the procedures described, close cooperation between the otolaryngologist, the neurosurgeon, and the plastic surgeon can provide many patients with satisfactory rehabilitation from facial paralysis.

Unreamed rod with early wound closure for grade IIIA and IIIB open tibial fractures: analysis of 40 consecutive patients.

This study evaluated 40 patients with grades IIIA and IIIB open tibial fractures from July 1987 to September 1990. Aggressive debridement of all dead tissue and bone, irrigation with > 9 L of fluid, and emergent intramedullary unreamed rodding (mean time from the emergency room to the operating room: 4 hours 20 minutes) was performed in all patients. Surgical debridement was repeated every 48 to 72 hours until the wound could be successfully closed (mean time: 6.2 days). Progressive weight bearing in a short leg cast was allowed depending on the fracture configuration, with full weight bearing usually beginning at 6 weeks. Additional autogenous iliac crest bone grafting was performed at 2 to 4 months if required. There were 14 grade IIIA and 26 grade IIIB open tibial fractures. Thirty-nine of the 40 patients underwent follow-up until union was obtained both clinically and radiographically. One patient was lost to follow-up. Complications included three soft-tissue infections and two late subflap abscesses. There was no evidence of osteomyelitis in any of these cases. Aggressive debridement and early wound closure appear to be the key in the successful use of unreamed interlocking intrameduallary rods for fixation of open tibial fractures.

Immediate flap coverage in the treatment of large surgical defects after tumor resection.

Fifty-one patients with large surgical defects after tumor resection (range of 100 to 1,050 centimeters squared, mean of 259 centimeters squared) were treated with immediate flap coverage. Indications for flaps were exposed vital structures, a wound bed unsuitable for skin grafting or planned postoperative radiation. Patients were divided into three groups based on tumor location--head and neck, trunk and perineum and groin and extremity. Sixty-eight flaps (11 free and 57 pedicled) were used and all wounds ultimately healed. Overall, extensive complications occurred in eight patients, lesser complications in 11 patients and initial flap loss in three patients. While complications delayed healing, all defects were ultimately successfully covered using flaps. Preferred flap choices for each anatomic area are presented. By providing immediate coverage of these massive defects, flaps allow wide tumor resection that improves palliation and chance for cure. Flaps tolerate postoperative radiation well and do not obscure recurrence if careful follow-up examination is given.

A method for repairing zygomatic arch fractures using a hydroxyapatite cement paste (BoneSource).

A new method has been developed for the closed reduction of minimally displaced, noncomminuted zygomatic arch fractures that is minimally invasive and precludes the use of nonresorbable materials such as plates and wires in the repair. Twenty rats received simple, minimally displaced right-sided zygomatic arch fractures under general anesthesia. In 10 animals these fractures were treated with closed reduction through a temporal approach (Gillies method) to reapproximate the fractured segments. In the second group of 10, immediately after the closed fracture reduction, 1 ml of hydroxyapatite cement paste (BoneSource, Leibinger Corp., Dallas, TX) was injected through a 14-gauge needle into and around the fracture site. This paste, which is remodeled into bone over time, hardens into a plaster-like substance within 20 minutes of mixing. The majority of the paste was placed on the medial aspect of the fracture to act as a buttress between the fractured zygoma and the temporalis muscle lying on the greater wing of the sphenoid. This served to support the fracture by "casting" the bone and preventing it from collapsing medially. Nine of the 10 fractures treated with the hydroxyapatite paste healed completely without evidence of zygomatic displacement or malunion. One fracture had mild displacement of the fractured segment but good bone healing between the fractured sides. No adverse effects were noted in the temporalis muscle of these animals, and mastication was normal. Five of the 10 treated with closed reduction alone also had a good result. Of the remaining 5 fractures 2 had a mild to moderate bony deformity as a result of improper alignment during fracture healing. The other 3 did not heal and, therefore, formed a fibrous nonunion at the fracture site. We concluded that closed reduction of simple zygomatic fractures can be performed if the fracture site is held in place with a stabilizing material such as a hydroxyapatite cement paste.

A prospective study of early soft tissue coverage of grade IIIB tibial fractures.

Between 1987 and 1990, 45 consecutive patients with grade III tibial injuries were treated by an established protocol. There were 31 men and 14 women. The average age was 27 years (range, 17-68 years). The average follow-up was 16 months (range, 12-46 months). Early bony fixation consisted of an external fixator in 28 patients and a non-reamed intramedullary nail in 17 patients. No significant difference in complications was noted between the two types of fixation systems. Forty-three percent of the patients underwent early bone grafting. Free muscle flaps were employed in 78% of patients with a 97% success rate. Local muscle flaps were utilized in 22% of patients with an 84% success rate. Local infection occurred in three patients (6%). Osteomyelitis occurred in two patients (4%). Bony union was present in 98% of patients (44 of 45). Limb salvage was 98% (44 of 45). Early bone grafting (< or = 3 months) yielded earlier bony union (average, 40 weeks) than late bone grafting (average, 52 weeks). This study proves the efficacy of an established protocol of early muscle flap coverage in the management of grade IIIB tibial fractures in a consecutive series of patients. Early bone grafting appears to be beneficial to early bony union. The intramedullary rod fixation system offers an acceptable alternative to the external fixator system in severe acute open tibial fractures.

Ischial pressure sore coverage: a rationale for flap selection.

The role of wound debridement and flap coverage in treating pressure sores is clearly established. However, criteria and supportive clinical data for specific flap selection and the sequence of flaps for coverage of the ischium remain ill-defined. From 1979-1995, 114 consecutive patients underwent flap coverage of 139 ischial pressure sores. Preoperative risk factors, prior flap history, defect size, flap success, complication rates, and the length of hospitalization were retrospectively evaluated and compared for 112 flaps in 87 patients. Flap success was defined as a completely healed wound. Average follow-up was 10 months (range: 1 month-9 years). Overall, 83% (93/112) of the flaps healed. In the majority of cases (75%, 84/112), wound debridement and flap reconstruction was achieved in a single stage. However, there were significant differences in the healing rates among the various flaps used. The inferior gluteus maximus island flap and the inferior gluteal thigh flap had the highest success rates, 94% (32/34) and 93% (25/27), respectively, while the V-Y hamstring flap and the tensor fascia lata flap had the poorest healing rates, 58% (7/12) and 50% (6/12), respectively. Flap success was not significantly affected by the age of the patient or the prior number of flaps used and preoperative risk factors were equally distributed across all types of flaps. The overall complication rate was 37% (41/112), most commonly from a slight wound edge dehiscence (n = 16) that healed with local wound care within one month postoperatively. Results of this study show that proper flap selection and the appropriate sequence of flap use significantly improve success rates for ischial pressure sore coverage in both the short- and long-term. Based upon flap reliability (successful healing rates), reusability, and the need to preserve as many future flap options as possible, a rationale for flap selection is presented which can be individualized to any patient.

Rigid internal fixation vs. traditional techniques for the treatment of mandible fractures.

Treatment results were compared between mandibular fractures repaired with vitallium miniplates versus intermaxillary fixation (IMF) and wire osteosynthesis in 79 patients treated over a 4-year period. The postoperative courses of 35 patients treated with 46 plates were compared to those of 44 individuals treated with traditional reduction techniques. The plated group contained nine complications (26%) versus ten (23%) in the non-plated group. This difference was not statistically significant, despite the presence of more severe fractures in the plated group. Major complications (nonunions, malocclusions) were noted in only three (8%) of the plated group; there were six complications (14%) in the non-plated group. We conclude that the plating of mandibular fractures incurs no greater overall risk of complications than traditional methods of fixation, and a lower risk of major complications, and that the advantages of plate fixation, including decreased time of intermaxillary fixation and cost effectiveness, make this the method of choice in complex mandibular fractures, even in a high-risk population.

Computerized tomographic analysis of orbital hypertelorism repair: spatial relationship of the globe and the bony orbit.

Computerized tomographic scans provide a new means of evaluating the spatial and geometric relationships between the movement of the bony orbit and its soft tissue contents (the globe and extraocular muscles) [1, 12]. Preoperative and postoperative computerized tomographic scans were analyzed in four patients to explore these relationships. Measurement of the changes in distance between the globes correlated most closely with the change in the distance between the lateral orbital walls; resection of medial (inter-orbital) bone provides space into which the globe is translocated. The medial rectus muscle may be bowed across the medial wall osteotomy line, creating a functional shortening of the muscle; this finding may explain the esotropia that is commonly seen after this procedure [2, 3]. These observations should have a direct impact on the understanding and planning of orbital hypertelorism correction.

Complex abdominal wall reconstruction: a comparison of flap and mesh closure.

OBJECTIVE: To analyze a series of patients treated for recurrent or chronic abdominal wall hernias and determine a treatment protocol for defect reconstruction. SUMMARY BACKGROUND DATA: Complex or recurrent abdominal wall defects may be the result of a failed prior attempt at closure, trauma, infection, radiation necrosis, or tumor resection. The use of prosthetic mesh as a fascial substitute or reinforcement has been widely reported. In wounds with unstable soft tissue coverage, however, the use of prosthetic mesh poses an increased risk for extrusion or infection, and vascularized autogenous tissue may be required to achieve herniorrhaphy and stable coverage. METHODS: Patients undergoing abdominal wall reconstruction for 106 recurrent or complex defects (104 patients) were retrospectively analyzed. For each patient, hernia etiology, size and location, average time present, technique of reconstruction, and postoperative results, including recurrence and complication rates, were reviewed. Patients were divided into two groups based on defect components: Type I defects with intact or stable skin coverage over hernia defect, and Type II defects with unstable or absent skin coverage over hernia defect. The defects were also assigned to one of the following zones based on primary defect location to assist in the selection and evaluation of their treatment: Zone 1A, upper midline; Zone IB, lower midline; Zone 2, upper quadrant; Zone 3, lower quadrant. RESULTS: A majority of the defects (68%) were incisional hernias. Of 50 Type I defects, 10 (20%) were repaired directly, 28 (56%) were repaired with mesh only, and 12 (24%) required flap reconstruction. For the 56 Type II defects reconstructed, flaps were used in the majority of patients (n = 48; 80%). The overall complication and recurrence rates for the series were 29% and 8%, respectively. CONCLUSIONS: For Type I hernias with stable skin coverage, intraperitoneal placement of Prolene mesh is preferred, and has not been associated with visceral complications or failure of hernia repair. For Type II defects, the use of flaps is advisable, with tensor fascia lata representing the flap of choice, particularly in the lower abdomen. Rectus advancement procedures may be used for well-selected midline defects of either type. The concept of tissue expansion to increase both the fascial dimensions of the flap and zones safely reached by flap transposition is introduced. Overall failure is often is due to primary closure under tension, extraperitoneal placement of mesh, flap use for inappropriate zone, or technical error in flap use. With use of the proposed algorithm based on defect analysis and location, abdominal wall reconstruction has been achieved in 92% of patients with complex abdominal defects.