Reversed gracilis pedicle flap for coverage of a total knee prosthesis

Analysis of Major and Minor Pedicles in Flap Perfusion by Computational Fluid Dynamics

Background

Type 2 muscle flaps are characterized by major and minor pedicles, such that the minor pedicle is unreliable, and the major pedicle is a requirement for the success of the flap. The role of the minor pedicle, beyond the decreased caliber and decreased vascular territory in comparison to the major pedicle, is poorly understood. We sought to model the fluid dynamics of a model flap containing a major and minor pedicle to understand differences between the pedicles and the implications on perfusion.

Methods

We first generated a computer-assisted design model of a type 2 flap with a major and minor pedicle. We then performed computational fluid dynamics to analyze velocities and flow within the pedicles and flap.

Results

In our investigation, we found that the flow velocity within the major pedicle was higher than the minor pedicle, indicative of decreased resistance to flow. Concomitantly, we found decreased pressures within the major pedicle, reflecting decreasing resistance to flow. Interestingly, we found increased kinematic viscosity in flap areas supplied by the minor pedicle, suggesting decreased flow rates and increased resistance.

Conclusions

We identified that the major pedicle has increased flow velocity, decreased resistance, and decreased kinematic viscosity, suggesting its dominance in maintaining flap perfusion. Our study also identifies computational fluid dynamics as a powerful tool in studying flap perfusion dynamics.

Reconstruction of complex knee wounds with a distally based gracilis flap and gastrocnemius myocutaneous flap: A case report

A gastrocnemius muscle flap is a versatile option for covering the proximal one-third of the lower leg and around the knee. On the other hand, it is of limited use in patients with short gastrocnemius muscle or insufficient volume. The authors present a case in which a knee soft tissue defect occurred in a very thin patient and was reconstructed using a gastrocnemius myocutaneous flap and a distally based gracilis flap as a supplementary flap.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature

Background

Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking.

Methods

A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA).

Results

The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different.

Conclusions

Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.

Versatility of Medial Sural Artery Islanded Pedicled Perforator Flap for Resurfacing Areas Around the Knee

ABSTRACT

Soft tissue defects with exposed tendon, bones, and joints around the knee are difficult and challenging to treat because of its location over a joint, requires a stable cover that is supple and stretchable. For any knee defects, the gastrocnemius muscle flap is the first choice for the reconstruction, although it causes less functional deficit; however, because of its less reach, it is difficult to cover the defect in the superolateral aspect of knee joint and anterior to the tibial tuberosity with the other disadvantage being the bulkiness. The medial sural artery perforator flap (MSAPF) provides thin fasciocutaneous tissue similar to the adjacent normal soft tissue in the knee and so, its use leads to an improved reconstruction of contour and eliminating the need of a skin graft over the primary defect. Here, we will be discussing a case series using MSAPF to cover the defects around the knee.

The Versatility of the Pedicled Medial Sural Artery Perforator Flap: From Simple to Its Chimeric Pattern and Clinical Experience with 37 Cases

BACKGROUND

Defects in the knee area, popliteal fossa region, and upper third of the lower extremity can pose a challenge for reconstructive plastic surgeons. The purpose of this article is to report the authors' experience with the use of the pedicled medial sural artery perforator flap in its simple and chimeric form for reconstruction of defects in three different regions: knee, popliteal fossa, and proximal lower leg.

METHODS

From April of 2018 to April of 2019, 37 patients (29 men and eight women) with a mean age of 51 years (range, 18 to 78 years) underwent reconstruction with 37 pedicled medial sural artery perforator flaps. All flaps were harvested as pedicled perforator flaps in conventional or chimeric fashion and were based on one or two perforators. The defect locations included the knee (18 cases), popliteal fossa (seven cases), and proximal lower leg (12 cases). The cause of reconstruction was trauma in 22 patients (59 percent), tumor in 10 patients (27 percent), and donor-site closure of free medial sural artery perforator in five patients (14 percent).

RESULTS

The flap sizes varied from 3.5 × 5 cm to 5 × 10 cm. All but one flap, which showed distal tip necrosis, survived completely after surgery. The donor sites were all closed primarily. Minor complications included flap dehiscence (two cases) and minor wound infection delaying the healing process (four cases). All complications were treated conservatively. Follow-up observations were conducted for 3 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results.

CONCLUSION

The pedicled medial sural artery perforator flap can be considered an optimal method of reconstruction for covering defects not only in the knee area but also in the popliteal fossa and upper lower leg.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Novel Fasciocutaneous Flap Design for Reconstructions in Scarred Tissue: A Case Report

This article aims to introduce a technically easy and reliable flap design for the coverage of soft tissue defects in areas where traditional flap options are limited by trauma or scarring. We applied the boomerang design in cases with defects around the knee and also extrapolated it to other regions like the wrist and sacrum. Patients with soft tissue defects in regions with scarred tissues or limited flap reconstructive options were recruited. The procedures resulted in uneventful recovery and excellent cosmetic outcomes for the patients. The authors of this article recommend the usage of this uncomplicated flap design in areas with otherwise limited flap options due to restricted vascularity or surrounding scar tissue.

Forensic Implications of Anatomical Education and Surgical Training With Cadavers

Anatomical education and surgical training with cadavers are usually considered an appropriate method of teaching, above all for all surgeons at various levels. Indeed, in such a way they put into practice and exercise a procedure before performing it live, reducing the learning curve in a safe environment and the risks for the patients. Really, up to now it is not clear if the nonuse of the cadavers for anatomical education and surgical training can have also forensic implications. A substantial literature research was used for this review, based on PubMed and Web of Science database. From this review, it is clear that the cadaveric training could be considered mandatory, both for surgeons and for medical students, leading to a series of questions with forensic implications. Indeed, there are many evidences that a cadaver lab can improve the learning curve of a surgeon, above all in the first part of the curve, in which frequent and severe complications are possible. Consequently, a medical responsibility for residents and surgeons which perform a procedure without adequate training could be advised, but also for hospital, that has to guarantee a sufficient training for its surgeons and other specialists through cadaver labs. Surely, this type of training could help to improve the practical skills of surgeons working in small hospitals, where some procedures are rare. Cadaver studies can permit a better evaluation of safety and efficacy of new surgical devices by surgeons, avoiding using patients as ≪guinea pigs≫. Indeed, a legal responsibility for a surgeon and other specialists could exist in the use of a new device without an apparent regulatory oversight. For a good medical practice, the surgeons should communicate to the patient the unsure procedural risks, making sure the patients' full understanding about the novelty of the procedure and that they have used this technique on few, if any, patients before. Cadaver training could represent a shortcut in the standard training process, increasing both the surgeon learning curve and patient confidence. Forensic clinical anatomy can supervise and support all these aspects of the formation and of the use of cadaver training.

The Medial Sural Artery Perforator Flap: The First Choice for Soft-Tissue Reconstruction About the Knee

BACKGROUND

The gastrocnemius muscle flap may be considered the first choice in many cases of soft-tissue reconstruction about the knee. Limited arc of rotation and reach of the flap as well as unsightly muscle bulk are major disadvantages and were the impetus to look for a local alternative. The aim of this study is to present a consecutive series of patients with a reconstruction about the knee involving the medial sural artery perforator flap (MSAPF).

METHODS

A consecutive series of 17 cases of defect reconstructions about the knee using the MSAPF is described, with an emphasis on early postoperative complications.

RESULTS

No major flap-related complications occurred except 1 case of tip necrosis that healed uneventfully after excision and secondary suture. Two patients with direct donor-site closure had a minor complication that required no revision, and 2 had partial skin-graft loss.

CONCLUSIONS

In summary, use of this pedicled perforator flap represents a reliable technique for soft-tissue reconstruction about the knee with an acceptable complication rate and optimal contour reconstruction without the need for a skin graft and secondary debulking procedures. The range of motion associated with the MSAPF in comparison to the range associated with the gastrocnemius muscle flap is increased so that more proximal and lateral defects can be covered.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Distally Based Sartorius Muscle Flap for a Gustilo Grade-III Open Fracture of the Lateral Femoral Condyle and the Head of the Fibula with a Complex Soft-Tissue Defect: A Case Report and Review of the Literature

CASE

We present a case of lower-limb trauma associated with an extensive soft-tissue defect around the knee joint, which led to the exposure of bone and the metalwork that was used for the management of the associated fractures. Coverage was performed with a distally based sartorius muscle flap in a single-stage procedure, allowing good recovery with a nice aesthetic and functional outcome at the 1-year follow-up. Additionally, we discuss alternative options for the coverage of severe soft-tissue defects based on the clinical context.

CONCLUSION

A distally based sartorius muscle flap may be a suitable alternative for coverage of complex soft-tissue defects around the knee joint.

Radiological anatomy of the perforators of the gluteal region: The "radiosome" based anatomy

BACKGROUND

The superior (SGA) and the inferior gluteal artery (IGA) perforator flaps are widely used in pressure-sore repair and in breast reconstruction. The aim was to exhaustively depict the topographical anatomy of the whole system of perforators in the buttock.

METHODS

Eighty lower-extremity computed tomographic angiography (CTA) of patients (20 males/20 females, mean age 61-years old, range 38-81) were considered. The source artery, location, type, and caliber of gluteal perforators were analyzed. The location of perforators was reproduced using a standardized two-dimensional grid on the coronal plane, centered onto defined bone landmarks. We defined "radiosome" the cutaneous vascular territory of a source artery inferred through the representation of its whole perforator system at the exit point through the deep fascia.

RESULTS

A mean number of 25.6 ± 5.7 perforators in the gluteal region was observed, distributed as follows: 11.6 ± 4.8(45.2%) from SGA; 7.9 ± 4.5(30.8%) from IGA; 1.5 ± 0.8(5.8%) from fifth lumbar artery; 1.2 ± 0.8(4.7%) from internal pudendal artery; 1.2 ± 1(4.8%) from lateral circumflex femoral artery; 0.3 ± 0.7(1.2%) from circumflex iliac superficial artery. At least one large (internal diameter > 1 mm) SGA septocutaneous perforator was present in 77.5% of patients.

CONCLUSIONS

The gluteal region is vascularized by perforators of multiple source arteries. Septocutaneous perforators of SGA and IGA were planned along a curve drawn from the posterior-superior border of the iliac crest to the greater trochanter. The lumbar artery perforators are clustered over the apex of the iliac crest; the internal pudendal artery perforators are clustered medially to the ischiatic tuberosity. Contributions can also come from the sacral and superficial circumflex iliac arteries.

The "nugget design": A modified segmental gracilis free flap for small-sized defect reconstruction on the lower extremity

BACKGROUND

Little attention has been given to the segmental free gracilis muscle flap supplied by secondary proximal pedicles. We introduce a technical refinement for small-sized three-dimensional defect reconstruction on the foot.

METHODS

Between November 2013 and August 2016, three patients with a mean age of 66 years (range 47-70 years) were included. A segmental gracilis free flap supplied by the most proximal secondary pedicle was harvested according to a modified "nugget design" to treat small-sized defects on the lower extremity requiring dead space reconstruction. Minor and major complications, sensitivity with Semmes-Weinstein monofilament test, soft tissue stability and patient satisfaction at final follow-up were recorded.

RESULTS

In one case, a segmental gracilis muscle was used for dorsal foot reconstruction after debridement of metatarsal phalanx I with osteomyelitis. In two cases, the segmental gracilis free muscle was harvested for defect reconstruction on the right plantar foot after excision of a melanoma. The first patient required revision after partial failure of the initial segmental gracilis free muscle flap. Overall, good results in foot function and a high degree of patient satisfaction was achieved (Likert scale 9.7, range 9-10) after a mean follow-up of 13 months (range 3-24 months).

CONCLUSIONS

Taken from the very proximal dorsal part of the gracilis muscle supplied by the most proximal secondary pedicle and leaving the vast majority of the muscle intact preserves the option to harvest a normal gracilis flap. This technique is especially suitable for small, three-dimensional defects on the lower extremity.

Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty

Background

In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA.

Methods

A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis.

Results

A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported.

Conclusions

Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

Soft Tissue Reconstruction and Flap Coverage for Revision Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations.

METHODS

Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis.

RESULTS

Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer.

CONCLUSION

Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

The distally pedicled gracilis flap for salvage of complex knee wounds

INTRODUCTION

Soft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit.

METHODS

Nine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23-83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed.

RESULTS

Eight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°).

CONCLUSION

The distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap. Evidence Level IV.

Saving grace: distally pedicled gracilis muscular flap in lower limb salvage

During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.

Reverse gracilis muscle flap: an alternative means of skin coverage for recurrent infection after TKA

PURPOSE

Poor wound-healing and skin necrosis are serious but not unusual complications after total knee arthroplasty, and when skin or soft tissue necrosis occurs, reconstructions in the knee area need thin, pliable, tough skin flaps.

METHODS

A 62-year-old man, who previously underwent multiple TKR operations due to recurrent infection, was transferred from another hospital after a gastrocnemius muscle rotation flap failed. We decided to treat the affected area with a reverse gracilis muscle flap. After confirming that the secondary pedicle was intact by Doppler sonography, muscle dissection was extended to the entry of the secondary pedicle. The proximal tendon of the gracilis muscle was transected, and the muscle was rotated 180° and placed at the recipient site.

RESULTS

The aim is to report a case of reconstruction at the anterior knee using a reverse gracilis muscle flap that achieved an excellent final clinical result.

CONCLUSION

This case suggests that the indications for a reverse gracilis muscle flap could be broadened when other flaps are not available for knee prosthesis coverage.

Surgical technique: vastus medialis and vastus lateralis as flap transfer for knee extensor mechanism deficiency

BACKGROUND

Loss of the quadriceps tendon, patella, and patellar tendon leaves a major anterior defect that is difficult to close and compromises knee extension strength. Gastrocnemius muscle transfer does not sufficiently cover such major defects. This paper describes a new surgical technique that addresses these defects and the results of eight cases of revision TKA managed with this new technique.

DESCRIPTION OF TECHNIQUE

The new procedure transfers the vastus medialis or the vastus lateralis and their tibial attachments or both muscles and their distal expansions combined with gastrocnemius and soleus flaps to cover major deficiencies in the anterior knee. Nine cadaver knee specimens were dissected to determine the effect of the transfer on nerve and blood supply of the muscles.

METHODS

Eight patients underwent the new procedure between 2005 and 2009. Four knees had vastus medialis transfer, two vastus medialis and vastus lateralis transfer, two vastus medialis and medial gastrocnemius transfer, and two medial gastrocnemius and medial ½ of the soleus muscle transfer. Minimum followup was 15 months (mean, 43 months; range, 15-74 months). Patients were evaluated for anterior knee pain, quality of knee closure, ROM, extensor lag, walking ability, use of assistive devices, and ability to climb stairs with the operated extremity.

RESULTS

All patients achieved closure of the knee without synovial leaks by 10 days postoperatively. Mean flexion contracture at last followup was 3° (range, 0°-7°). Mean extension lag was 22° (range, 5°-65°). Extension lag was less in those knees that included gastrocnemius or soleus muscle transfer. None of the flaps developed necrosis.

CONCLUSIONS

The vastus medialis and vastus lateralis muscles provide adequate coverage for anterior soft tissue deficits of the knee.

Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis?

PURPOSE

The aim of our review paper is to present a possible algorithm of treatment of knee periprosthetic soft tissue defects, relative to their extent and depth. Different management of exposed total joints is also proposed, depending on the presence or loss of deep infection and on the timing of infection itself.

METHODS

In accordance with literature and the experience of senior knee surgeon, the incidence and risk factors, and possible treatment options of wound complications following total knee arthroplasty have been throughly analyzed.

RESULTS

There is much controversy regarding the optimal management of wound necrosis around a total knee. Local wound care, debridement, and fasciocutaneous, muscle and perforator flaps have been differently used. Muscle coverage remains the standard to which all other flaps should be compared, especially in infected wounds. Perforator flaps have recently represented a true revolution in the soft tissue reconstruction around the knee, with peculiar advantages due to their low donor morbidity and long pedicles.

CONCLUSION

When wound complications occur, prompt management is mandatory. An algorithm for treatment of wound defects is presented, available for both primary and revision knee replacement.

Knee Region Coverage with Reversed Gracilis Pedicle Flap (GReSP Flap)

Introduction

To treat severe soft-tissue complications of total knee arthroplasty, we used an extended reversed gracilis flap based on secondary pedicles (the GReSP flap).

Step 1 Prepare Wound Bed

Locate the gracilis and pedicles, then debride the wound bed.

Step 2 Expose Gracilis Muscle

Expose the superficial aspect of the muscle, while protecting the saphenous vein and nerve.

Step 3 Check Muscle Perfusion

Temporarily clamp the main vascular pedicle to ensure blood supply when perfused only by the secondary pedicles.

Step 4 Mobilize Muscle Flap

Transect the proximal tendon of the gracilis muscle to provide maximal length for the muscle flap and ligate the main vascular and nerve pedicles.

Step 5 Cover with Skin Graft

Suture the flap in place and cover with skin graft.

Step 6 Postoperative Care

Immobilize the knee for two weeks; follow with rehabilitation to restore range of motion.

Results & Preop/Postop Images

We treated three patients who had an infection at the site of a total knee arthroplasty and exposure of the implant.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Body parts removed during surgery: a useful training source

Current undergraduate medical curricula provides relatively little time for cadaver dissection. The Department of Human Anatomy and Physiology at the University of Padova has organized a pilot project with the University Hospital for the donation of body parts that are surgically removed for therapeutic purposes and destined under Italian law for destruction. The aim of the project is to improve residents' practical training skills. A survey over the last two years has shown that about 60 body parts were available each year. These included 13 upper limbs or their parts (i.e., forearm with hand, hand, and fingers) and 47 lower limbs or their parts (i.e., legs with feet, feet, or toes). The residents explained the aim of the project to potential donors, and, if patients were willing to donate, their informed consent was obtained. The residents were present in the operating theater during the surgical procedure. In the post-operative phase, the same residents performed dissections on the body part(s), following a teaching schedule prepared by a clinical anatomist, who also assisted residents during their studies. Residents also acted as tutors for undergraduate medical students who attended these dissections. The underlying pathology for which the body part was removed was examined, and surgical procedures were practiced on the body part itself. Our project provided an opportunity for a close relationship between anatomists and surgeons, reinforcing core knowledge of anatomy by appreciation of its clinical importance. The active involvement of residents as learners and as teachers in the various steps of this project improved their knowledge of surgical techniques and helped to establish a sense of ethical responsibility and respect for the human body. This approach involves study of anatomical structures from new perspectives and leads to improved surgical practice.