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The medical achievements of Sir William Osler (1849-1919), although numerous and important in his time, contribute less to his continued presence in medical literature. What remains is his literary and historical heritage, which is preserved in numerous essays and addresses. Some of his thoughts, which might be worth reading by today's busy plastic surgeons, were chosen from his writings, and they are presented here.

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Vascular compromise is a relatively frequent complication of breast reconstruction performed with the use of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps. The authors present their experience in delaying TRAM flaps by preelevating the island 7 to 10 days before flap transfer. The skin island is fully incised and raised from the lateral tip to the lateral border of the rectus muscle on one side, and is raised from the tip to the midline on the opposite side. The inferior epigastric pedicle of the rectus muscle remains intact. This method was used in 55 patients. No total flap loss, and only two cases (3.6%) of partial flap necrosis were observed. Preelevating the island is a very simple and effective method of TRAM flap delay, alternative to the ligation of the inferior epigastric pedicle.

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In the Head and Neck Cancer Department of Cancer in Warsaw between August 1997 and September 1998 twenty patients with primary unresectable oral cavity cancer were referred for combined modality treatment with cisplatin based chemotherapy followed by wide resection (in the case of tumor regression) with immediate reconstruction and adjuvant radiotherapy. Tumor regression after chemotherapy was obtained in 15 patients and all of them were referred to surgery; wide resection and reconstruction using pectoralis major (PM) flap. 14 patients completed all treatment protocol, also with adjuvant radiotherapy. Tolerance of treatment was excellent and there was no influence of chemo- and radiotherapy for adaptation of PM flaps. During observation local recurrence was observed in two cases. Twelve patients are alive without evidence of disease. Study is continued.

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Breast reconstruction using a modified latissimus dorsi island flap is presented. The whole muscle is raised on its vascular pedicle, folded beneath the skin island and sutured in layers, thus substituting the volume of an endoprosthesis. The method may give satisfactory results in carefully selected cases (mostly in women with a small contralateral breast). It can also be applied in reconstruction after subcutaneous mastectomy.

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The results of salvage surgery or cryosurgery performed in 62 cases of oral or oropharyngeal cancer, recurring or persisting after radical radiotherapy, were analysed retrospectively. Salvage surgery was performed in 33 cases. The relatively high frequency of postoperative complications observed in years 1973-1984, has declined since 1985, concomitant with the introduction of myocutaneous flaps for reconstruction. Twenty-nine patients who were disqualified from major surgery, were treated by cryosurgery. Using both methods, 3-year overall survival was obtained in 24.1% of cases.

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The lower transverse rectus abdominis myocutaneous (TRAM) flap may give excellent results in breast reconstruction using autogenous tissues alone, however, surgical technique is demanding, and the risk of necrosis owing to vascular failure is high. We observed excellent vascularity of the flap in all 20 cases operated upon so far; in all these cases skin island was surgically delayed for one week before final transfer.

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The use of continuous thoracic epidural anaesthesia allows several oncological and reconstructive operations of the breast to be performed on an outpatient basis. The method is easy and safe in the hands of an experienced anaesthetist, and the recovery is immediate. The potential side effects (transient haemodynamic changes) may result from the sympathetic blockade and can be easily controlled during the operation. The method is not advocated in cases in which substantial blood loss is anticipated.

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Early experience with the modified transverse incision for mastectomy is presented. A 'fish-shaped' incision, by adding two triangles at the lateral tip, decreases the amount of excess skin and prevents the 'dog ear' deformity, makes up the difference in the length of the transverse edges depending on the location of the tumour and provides easy access to the axilla.

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Experience with cheek reconstruction after resection, using a single pectoralis major island flap with its inner surface previously split-skin grafted, is presented. No complications were observed in the initial series of 4 cases. The method appears to be a valuable alternative in selected cases, whenever local tissues cannot be used for reconstruction.

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Four modifications of a classical pectoralis major myocutaneous flap are presented: the extended flap incorporating anterior rectus abdominis sheath, the peninsular flap used whenever the pedicle cannot be tunnelled under cervical skin, the flap with external pedicle for the longest arc of rotation, and the double-face flap for reconstruction of full-thickness cheek defects.

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A fish shaped modification of the classic Stewart transverse incision is described. By adding the two triangular incisions, it corrects the inequality of the wound edges, prevents "dog ear" deformity and facilitates access to the axilla. It is particularly good for obese patients and produces excellent cosmetic results and healing.

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