Complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge for the plastic surgeon. In many cases, these wounds are best addressed with a free tissue transfer. Although this group has performed more than 400 free flaps to the leg during the past 6 years, free tissue transfer can be an arduous operation that requires a team approach and substantial donor site morbidity for the patient. In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. Caveats for successful performance of the reverse sural artery flap include Doppler evidence of patent peroneal perforators, placement of a lazy T-shape skin paddle over the distal gastrocnemius muscle bellies, inclusion of the lesser saphenous vein to augment venous drainage, and, lastly, careful dissection to provide a wide adipofascial pedicle.

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.

Since plastic surgery evolved as a specialty in the early part of this century, the integument of the anterior abdominal wall has been one of the premier sources of tissue for local and distant flap transfer. It enjoys a robust blood supply, scars are easily concealed, the anatomy is familiar to most surgeons, and there is an abundance of skin and subcutaneous tissue, especially in the parous woman. Perhaps the most coveted expanse of skin and fat is that area below the umbilicus because in most cases the donor defect can be closed by an abdominoplasty procedure, leaving only a suprapubic transverse scar.It is not surprising therefore that for decades attention has focused on the lower abdomen as a potential donor site for reconstruction of the breast following mastectomy. Initially flap transfers were performed as multistaged, tube pedicle procedures, but the pendulum of surgical preference has since swung towards one-stage operations. The first of these was a brief encounter by microsurgeons in which the lower abdominal integument was transferred to the breast as a free flap, designed to be based on the deep inferior epigastric (DIE) vesse1s.l Soon after, proponents of the pedicled musculocutaneous flap advocated a "burrowing" approach from above and Hartrampf, Scheflan, and Black2 introduced the lower transverse rectus abdominis musculocutaneous (TRAM) flap. More recently, the lower abdomen has been reappraised by microsurgeons. Hester et aL3 have transferred this skin paddle based on the superficial inferior epigastric (SIE) system, and Shaw4 has produced a large series of free flap reconstructions of the breast, returning once again to the DIE vessels to nourish the tissue.Unfortunately, none of these operations has proved to be a panacea for all occasions. Free flap operations provide tissue with a good blood supply, but then the surgeon is confronted with anastomotic problems: the SIE vessels are small and the pedicle is short. The DIE vessels are longer and Downloaded by: National University of Singapore. Copyrighted material.