Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon.

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion.

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for lower eyelid entropion.

Rib osteochondral graft for scaphoid proximal pole reconstruction.

BACKGROUND: An irreparable scaphoid proximal pole is challenging to treat because of the fragment size and limited blood supply. Salvage surgery, such as partial wrist fusion or proximal row carpectomy, may be performed but is not ideal for young patients. There are few reports of proximal scaphoid reconstruction using rib osteochondral grafts. METHODS: Four patients were treated with rib osteochondral graft for reconstruction of the scaphoid proximal pole. The patients had a mean postoperative follow-up of 24 months. The mean age at the time of surgery was 30 years. Outcome measurements included total active range of wrist motion arc, grip strength, and wrist function score. We also evaluated the progression of osteoarthritis and changes in carpal height. RESULTS: No complications occurred at the donor site. The range of motion improved from 82° to 95° before and after surgery. Grip strength improved from 22 kg to 33 kg before and after surgery. There was a remarkable improvement in the modified wrist function scores of Green and O'Brien from 40 points to 70 points before and after surgery. No progression of arthrosis was seen on the radiographs of all the patients. There was no significant difference in the carpal height ratio before and after surgery. CONCLUSIONS: Proximal scaphoid fractures may require reconstruction of the articular surfaces of the radius, capitate, and lunate. Reconstruction with a rib osteochondral graft is flexible, easy to fabricate, and can reconstruct the three articular surfaces.

Factors associated with elevated blood lactate levels in patients undergoing maintenance hemodialysis.

Factors associated with chronic elevation of the blood lactate levels in patients undergoing chronic maintenance hemodialysis (hereinafter, hemodialysis patients) have not yet been thoroughly investigated. The purpose of the present study was to clarify factors associated with elevated blood lactate levels in hemodialysis patients. We divided the hemodialysis patients into two groups according the blood lactate levels (the high blood lactate group [> 2 mmol/L] and normal blood lactate group), and conducted a retrospective comparison of the following items between the two groups: (1) the creatinine generation rate (%CGR) and the geriatric nutrition risk index (GNRI) as indices of the nutritional status; (2) the left ventricular ejection fraction (LVEF) and E/A, an indicator of diastolic function; (3) the ankle-brachial index (ABI) and transcutaneous partial pressure of oxygen as indices of the adequacy of circulation in the peripheral blood vessels of the lower extremities; (4) the white blood cell count and serum level of C-reactive protein (CRP) before dialysis as markers of an inflammatory state. The mean age and serum CRP level were significantly higher in the high blood lactate group than in the normal blood lactate group. There were no significant differences in the markers of the nutritional status, cardiac function, or adequacy of circulation in the peripheral blood vessels of the lower extremities between the two groups. Advanced age and a state of chronic inflammation appear to be associated with elevated blood lactate levels in patients undergoing chronic maintenance hemodialysis.

Effects of the tip structure of temporary indwelling catheters on blood recirculation at various blood flow rates and diameters of the mock blood vessel.

AIMS: The aim of the present study was to determine the effects of the tip structure of the catheters used for hemodialysis on blood recirculation at varying blood flow rates and diameters of the mock blood vessel in a well-defined in vitro experimental system, focusing on reverse connection mode. METHODS: A mock circulatory circuit was created with silicon tubing (15 or 20 mm), a circulatory pump, connected through the catheter to dialysis circuit and dialyzer attached to dialysis machine. The tip of the inserted catheter was fixed to the center of the silicone tube, and 3 L of pig blood was poured into the blood side of the dialyzer and the recirculation rates were measured at blood flow rates of 100, 150, and 200 mL/min. Five types of commercially available catheters were used: (A) Argyle™, (B) Gentle Cath™ (Hardness gradient type), (C) Gentle Cath™, (D) Niagara™, and (E) Power-Trialysis®. RESULTS: In the case of reverse connection mode, (1) the recirculation rates were lower in the catheter with a relatively large side hole (catheter C, 17%), catheters with a greater distance between the end hole and side hole (catheters C and D, 25%), and catheter with a symmetrical tip structure (catheter E, 10%) as compared with those in catheters A and B (40% and 25%); (2) increase of the blood flow rate in the dialysis machine was associated with a reduced recirculation rate; and (3) a wider inner diameter of the mock blood vessel and faster flow rate in the vessel were associated with a reduced recirculation rate. CONCLUSION: The lowest recirculation was observed with the catheter with symmetrical holes, which produces a helical blood flow line that does not intersect with the blood streamline flowing out to the blood supply hole.

Retraction Note: Impact of the third wave of the COVID-19 pandemic and interventions to contain the virus on society and patients with kidney disease in Cambodia.

[This retracts the article DOI: 10.1186/s41100-021-00372-6.].

Continuous intradialytic amino acid infusion from the start of dialysis is better to avoid catabolism under the high-volume pre-dilution on-line HDF.

It was reported that amino acid infusion during hemodialysis is useful for improving nutritional status. The optimal administration method of amino acid infusion under the high-volume pre-dilution on-line HDF (HVPO-HDF) was analyzed in this study. Subjects were 10 patients on maintenance dialysis at our clinic. We performed high-volume pre-dilution on-line HDF. We investigated two methods for administration of Neoamiyu® 200-ml total amino acid (TAA) infusion for patients with renal failure: (1) continuous infusion into the dialysis circuit for 4 h from the start of dialysis to its completion (infusion rate 50 ml/h) and (2) continuous infusion started 1 h before completion of dialysis (infusion rate 200 ml/h), and compared pre- and post-dialysis blood concentrations and leakage of TAA, essential amino acids (EAA), and nonessential amino acids (NEAA) between these methods. Pre-dialysis blood concentrations of amino acids showed no difference between both the groups. Post-dialysis blood concentrations of amino acids were higher in all concentrations were significantly higher with continuous infusion starting 1 h before completion of dialysis. Leakage of amino acids showed no difference between both the groups. The continuous intradialytic amino acid infusion from the start of dialysis is better to avoid catabolism under high-volume pre-dilution on-line HDF.

A predictor of a postoperative fistula after double-opposing Z-plasty in bilateral cleft lip and palate patients.

Furlow double-opposing Z-plasty (FDOZ) as primary palatoplasty for the bilateral cleft lip and palate (BCLP) closure often leads to a palatal fistula formation in cases with wide clefts. We examined the utility of the calculated maximum closable cleft width to determine the feasibility of a direct palatal closure without lateral incisions. In this retrospective study, we analyzed consecutive patients with a BCLP who were treated for 5 years from 2009. In sixty-three BCLP patients, the following dimensions were measured preoperatively: an actual distance between maxillary tuberosities (Actual X); actual cleft height, calculated from the line joining the maxillary tuberosities to the cleft edge (Actual Y); and actual cleft width at the hard-soft palate junction (Actual Z) and calculated maximum cleft width requiring a direct closure (CMZ). Six months postoperatively, the relationships between the fistula occurrence and actual Z/CMZ were examined. Median values (interquartile range) of Actual X, Y, and Z and CMZ were 35.0 (33.0-39.0) mm, 7.0 (6.0-8.0) mm, 10.0 (8.0-11.0) mm, and 4.6 (2.7-5.7) mm, respectively. The median age at operation was 8.0 (7.0-17.0) months. Fistulae at the hard-soft palate junction developed postoperatively in three cases with more than a 10-mm cleft width (4.76%). A receiver operating characteristic (ROC) curve analysis indicated that actual Z was a better predictor of a postoperative fistula formation than CMZ. An actual cleft width was a better predictor of the fistula occurrence than a calculated maximum cleft width after FDOZ for a BCLP repair. The low fistula rate of FDOZ suggested that FDOZ could be used to close the palate with less than a 10-mm cleft width.

Effects of Fat Repositioning for Tear Trough Deformity on Eye Movement.

ABSTRACT: Fat repositioning is a common surgical technique for treating tear trough deformity. As this technique is mainly performed for cosmetic purposes, its functional outcomes have rarely been evaluated. The purpose of this study was to evaluate the changes in eye movements that occur after fat repositioning for tear trough deformity. The authors performed fat repositioning on 18 eyelids of 9 patients and evaluated their eye movements and binocular vision before surgery and at 1, 3, and 6 months after surgery. Hess screen and Binocular single vision tests were performed during each follow-up examination and the scores were recorded. The authors observed that fat repositioning did not affect binocular vision; however, vertical and horizontal eye movements worsened at 3 months after surgery. Nevertheless, there was no significant difference between the eye movements recorded before surgery and those recorded 6 months after surgery. Regardless of this finding, it should be noted that vertical or horizontal strabismus might occur after fat repositioning for tear trough deformity.

Impact of the third wave of the COVID-19 pandemic and interventions to contain the virus on society and patients with kidney disease in Cambodia.

Cambodia detected its first case of COVID-19 just 3 days before WHO declared that the outbreak constituted as PHEIC. As of February 15, 2021, and after two major outbreaks, only 479 cases had been reported, 396 (83%) of which were imported. This small number of cases was largely thanks to stringent measures and policies put in place by the government to curb the spread. Despite these efforts, a third cluster outbreak was declared on February 20, 2021. It has disrupted all aspects of life in Cambodia. As in many other countries affected by the virus, economic hardship, lockdowns in cities, and food insecurity ensued. Against the backdrop of this widespread impact on the citizens of Cambodia, we conducted this review article to better understand the situation of healthcare workers in nephrology and dialysis patients and the challenge they face in providing and receiving essential medical care. Healthcare providers have continued working to serve their patients despite facing a high risk of catching SARS-CoV-2 and other challenges including difficulties in traveling to work, increased physical and mental burden, and higher stress due to measures taken to minimize the risk of transmission during patients' care. Some healthcare workers have been discriminated against by neighbors. The most difficult mission is when having to deal with families whose loved one is denied access to a hemodialysis session due to suspected COVID-19 while waiting for PCR test results. Hemodialysis patients reported facing economic hardship and increasingly difficult circumstances. When access to food is limited, patients have eaten canned or dried salted food rather than an appropriate hemodialysis diet. Because hemodialysis centers are concentrated in a few cities, access has become even harder during the travel ban. In-center hemodialysis rules are stricter and does not allow family members or escorts to enter the unit. Only a few hemodialysis patients have been vaccinated. Before COVID-19, hemodialysis patients already faced major burdens. The pandemic appears to be decreasing their quality of life and survival even further. Through this study, we have revealed current hardships and the need to improve the situations for both healthcare workers in nephrology and hemodialysis patients in Cambodia.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis.

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus.

ABSTRACT: The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

A New Surgical Method for Medial Ectropion Repair: Fixing the Lower Eyelid Retractor to the Back of the Tarsal Plate.

ABSTRACT: Involutional ectropion is a disease in which the eyelids are everted outwards, and because the eyelids move away from the eyeballs, the ocular surface and conjunctiva are exposed causing inflammation, pain, photophobia, foreign body sensation, epiphora, and blurred vision. It is thought to be caused by horizontal and vertical laxity. Various surgical methods have reportedly been used to correct involutional ectropion. Shortening the lower eyelid retractor (LER) is an indispensable surgical operation for medial ectropion. When the LER is shortened, it is usually fixed to the lower edge of the tarsal plate. Herein we describe a new type of surgery that has now been performed on 6 eyes in 4 patients. The procedure involves separating the conjunctiva from the tarsal plate, inserting the LER between the conjunctiva and the tarsal plate, and then fixing it to the back of the tarsal plate. In all 6 eyes, the lower eyelid now contacts the eyeball, and morphological improvements were achieved. This new surgical method is a useful way to raise the tarsal plate.

Gingival Sulcus Incision for Zygomaticomaxillary Complex Fracture.

The usual surgical approaches for zygomaticomaxillary complex fracture are subciliary incision, transconjunctival incision, eyebrow incision, lateral canthal incision, coronal incision, preauricular incision, and superior gingivobuccal incision. In the intraoral approach, a horizontal mucoperiosteal incision is performed at the superior gingivobuccal region, and sometimes, includes the upper labial frenum. This may cause discomfort in the oral cavity because of postoperative scarring and shortening of the upper labial frenum. To avoid these complications, the authors performed a novel approach using gingival sulcus incision instead of oral mucosal incision to treat 5 zygomatic fractures. The authors evaluated the regression of the gingival interdental papillae, gingival swelling, and gingival perception at 2 weeks, 1 month, 3 months, and 6 months after the operation. The regression of the gingival papillae and gingival swelling disappeared 3 months and 1 month after the operation, respectively. No paresthesia was observed in any of the cases. The gingival sulcus approach can lead to scarless results and contribute considerably to the aesthetic appearance of the oral cavity.

Amino acid losses are lower during pre-dilution on-line HDF than HD of the same Kt/V for urea.

In this study, we investigated differences in amino acid losses between HD and pre-dilution on-line HDF with equal Kt/V for urea to determine which modality removes less amino acids from extravascular pools and ensures better nutrition. The subjects were patients receiving pre-dilution on-line HDF (n = 10) or HD (n = 10) at this hospital. Dialysis time was 4 h for all patients. In patients on HD, the blood flow rate was 200 mL/min and the dialysate flow rate was 463 ± 29.3 mL/min. In patients on pre-dilution on-line HDF, the blood flow rate was 240 ± 20 mL/min, the dialysate flow rate was 565.0 ± 42.5 mL/min, and the substitution flow rate (substitution volume) was 252.8 ± 26.4 mL/min (57.0 ± 6.0 L). Kt/V for urea was comparable between patients on HD and patients on pre-dilution on-line HDF (1.46 ± 0.25 vs. 1.46 ± 0.31). Amino acid loss and clear space were evaluated. Patients on pre-dilution on-line HDF lost significantly less glutamine and arginine (p < 0.01 and p = 0.032) and significantly less nonessential amino acids (NEAAs) than patients on HD (p = 0.013). They also had significantly lower clear space of total amino acids (TAAs), NEAAs, essential amino acids (EAAs), and branched-chain amino acids (BCAAs) than patients on HD (Total AA p = 0.019, NEAA p = 0.018, EAA p = 0.024, BCAA p = 0.042). When Kt/V for urea is equal, pre-dilution on-line HDF ensures better nutrition than does HD.

Restless legs syndrome effectively treated with constant-pressure predilution online hemodiafiltration.

BACKGROUND: We encountered a case of unstable predilution online HDF due to elevated transmembrane pressure (TMP) when performing constant-speed predilution online hemodiafiltration (HDF) as treatment for restless legs syndrome (RLS) in a dialysis patient. We report the effectiveness of incorporating a newly developed constant-pressure predilution online HDF system as a preventive measure against unstable online HDF and frequent adjustment of settings when treating dialysis patients with RLS. CASE PRESENTATION: A 55-year-old man had suffered from RLS and been undergoing constant-speed online HDF with 45 L target predilution and an ABH-21P hemodiafilter. The symptoms of RLS rated 10 on the International Restless Legs Syndrome Rating Scale (IRLS). The α1-microglobulin (α1-MG) removal rate was only 27.8%, so the hemodiafilter was subsequently replaced with a PEPA hemodiafilter. However, episodes of elevated TMP exceeding 250 mmHg occurred frequently after the replacement and were managed by reducing dialysate flow rate. Therefore, we incorporated a constant-pressure predilution online HDF that maintains TMP below 200 mmHg. The amount of replacement was maintained at approximately 43.5 ± 6.98 L and the α1-MG removal rate was 39.5%, with no need to manually reduce the flow rate. The Alb leakage in dialysate waste was 7.9 g. The patient has maintained an IRLS rating of 0 with no RLS symptoms for the past 4 years. CONCLUSIONS: Using the constant-pressure mode enabled achieved the clinical endpoint, namely, resolution of RLS with no need to manually reduce the flow rate.

Evaluation of the eyebrow position after external Müller's muscle tucking: A new technique for ptosis repair.

Eyebrow descent commonly occurs after ptosis repair or blepharoplasty surgery. The procedures used to correct acquired blepharoptosis are primarily classified into four groups. These procedures target the levator aponeurosis, Müller's muscle, both the aponeurosis and Müller's muscle, or the frontalis muscle. In this study, we used a new technique called external Müller's muscle tucking (EMMT) on 51 patients (94 eyelids), which targets the Müller's muscle for involutional blepharoptosis. The patients were assessed by comparative analysis using pre- and post-operative digital photographs. The distances between the medial canthi, in addition to the eyebrow heights at the medial canthus, pupil and lateral canthus, were measured on a computer screen. Eyebrows descended after surgery at the medial canthus in 53 eyelids (56.4%), at the center of the pupil in 55 eyelids (58.5%) and at the lateral canthus in 48 eyelids (51.1%). The mean distances of eyebrow descent in the 94 eyelids were 0.24, 0.51 and 0.32 mm at the medial, center and lateral positions, respectively. The mean preoperative margin reflex distance (MRD) was -0.05 mm, the mean postoperative MRD was 3.79 mm and the mean change in MRD was 3.83 mm. Preoperative MRD and change in MRD were weakly associated with changes in eyebrow position in 94 eyelids. In conclusion, these findings suggest that eyebrow drooping distance is related to the preoperative severity of ptosis.

Evaluation of the eyebrow position after aponeurosis advancement.

Patients often develop eyebrow drooping after blepharoplasty or ptosis repair. After aponeurosis advancement was performed in 53 patients (100 eyelids) with blepharoptosis, the eyebrow heights at the medial canthus, center of the pupil, and lateral canthus were measured using scanned photographs obtained preoperatively and 3 months postoperatively. In the 100 eyelids subjected to aponeurosis advancement, the eyebrow position was lowered at the medial canthus in 81 eyelids (81%), at the center of the pupil in 84 eyelids (84%), and at the lateral canthus in 80 eyelids (80%). The mean distance of eyebrow drooping in the 100 eyelids was 2.80 mm at the medial canthus, 2.87 mm at the center of the pupil, and 2.50 mm at the lateral canthus. The preoperative margin reflex distance (MRD) was significantly associated with the distance of eyebrow drooping at the medial canthus, the center of the pupil, and the lateral canthus in the 100 eyelids, but the postoperative MRD was not significantly associated with these parameters in the 100 eyelids. In conclusion, eyebrow drooping developed after aponeurosis advancement in most cases, and the distance of eyebrow drooping was associated with the severity of blepharoptosis.

Continuous hemofiltration model using porcine blood for comparing filter life.

The purpose of the present study was to establish a continuous hemofiltration model using porcine blood to compare filter life. Continuous hemofiltration (CHF) experiments were performed using an in vitro hemofilter evaluation system utilizing porcine blood containing trisodium citrate in addition to nafamostat mesilate as anticoagulants. The lifetime of the hemofilter was evaluated using the transmembrane pressure and the pressure drop across the hemofilter at varying trisodium citrate concentrations. The porcine blood used in this experiment was considered to be in a slightly hypercoagulable state because of the continuous contact with non-biological materials and calcium inflow from substitution fluid. Blood containing 7 or 8 mM of trisodium citrate and nafamostat mesilate could be effectively used to compare the lifetimes of hemofilters utilized under the same conditions. In this CHF model using porcine blood, the plugging of the hollow fibers occurred shortly after the plugging of the membrane pores. In conclusion, a CHF model using porcine blood can be established by adjusting the concentration of trisodium citrate added to the blood.

Negative Pressure Wound Therapy Followed by Basic Fibroblast Growth Factor Spray as a Recovery Technique in Partial Necrosis of Distally Based Sural Flap for Calcaneal Osteomyelitis: A Case Report.

The distally based sural flap is regarded as the first choice for reconstruction in the distal part of the lower leg because the flap is easy to raise, reliable in its blood supply, and prone to only a few complications. Limited data have investigated the details of treatment in cases of failure of distally based sural flaps. We report a case of calcaneal osteomyelitis in which a successful outcome was finally obtained with a partially necrosed, distally based sural flap using negative pressure wound therapy with basic fibroblast growth factor spray. The 2-year follow-up examination was uneventful. Moreover, the patient was able to walk freely with an ankle-foot orthosis in her house. This technique can be considered as a useful and effective option to recover unfavorable results of distally based sural flaps.