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Reingrittha P, Kittipibul K, Kulkittaya S, Jitprapaikulsarn S. U-Turn Design Metatarsal Artery Flap: Reliable Solution in Distal Forefoot Defect. Ann Plast Surg 2024; 93:94-99. [PMID: 38864419 DOI: 10.1097/sap.0000000000004012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND In distal forefoot defect, finding wound closure is challenging because of the distal site and small blood vessels involved. One possible resolution is the utilization of a metatarsal artery flap in a 'U-turn' design. This method offers several advantages, including its long length and a viable option for distal forefoot defect. METHODS Thirty-six patients with forefoot injuries from metatarsophalangeal (MTP) joint to distal interphalangeal (DIP) joint due to trauma were consecutively recruited and completed the study. Outcomes were analyzed descriptively, and risk prediction modeling for edge necrosis was performed. RESULTS The mean ± SD follow-up time was 27.3 months ±1.9. The median (IQR) MTP-to-DIP joint wound width and length were 1.8 (1.4, 3.0) and 3.2 cm (2.9, 6.2), respectively. The median (IQR) width, length, and width-to-length ratio flap dimensions were 3.6 (2.8, 6.0), 4.7 cm (4.3, 9.3), and 1.5 (1.2, 1.7), respectively. The mean ± SD operative time was 32.9 min ± 5.7. The median (IQR) intraoperative blood loss was 5.0 mL (4.0, 5.0). The mean ± SD hospital length of stay postoperatively was 4.0 days ±1.0. The mean ± SD Foot and Ankle Outcome Score and Foot Function Index were 64.1 ± 2.5 and 7.8% ± 3.3, respectively. All patients had good or excellent aesthetic satisfaction. Spontaneously resolving edge necrosis occurred in 13.9%. The mean ± SD time-to-start-ambulation was 1.7 weeks ±0.5. At the 2-year follow-up visit, all patients had reduced U-turn flap pivot point redundancy without shoe size impact, needing reoperation, or donor site morbidity. Edge necrosis was significantly associated with length-to-width ratio ( P = 0.014) but not with Foot and Ankle Outcome Score or Foot Function Index. CONCLUSIONS Metatarsal artery flap of U-turn design was reliable and was associated with a short recovery time, alternative resolution for forefoot area due to short operation time, minimal blood loss, short hospital length of stay, and excellent availability.
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Khan W, Loh CYY, Gkorgkolis V, El-Muttardi N. Dorsal Metatarsal Artery Perforator (DMtAP) flap Reconstruction of the Foot - A Review. JPRAS Open 2020; 26:37-42. [PMID: 33102674 PMCID: PMC7575647 DOI: 10.1016/j.jpra.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/09/2020] [Indexed: 11/29/2022] Open
Abstract
The dorsal metatarsal artery perforator (DMtAP) flap is a relatively new flap in the reconstructive armamentarium. Our understanding has only recently increased with data from cadaveric dissections, which have increased our understanding of the DMtAP system of the forefoot. Sporadic reports in the literature have been published regarding its various uses for defects around the forefoot. This review aims to summarize the reports and results thus far in the literature and bring together the anatomical evidence of DMtAPs in the forefoot. We also demonstrate our experience in raising a DMtAP flap and its potential use for reconstruction of the forefoot after skin cancer surgery. This is a versatile and reliable flap.
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Affiliation(s)
- Waseem Khan
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford, Essex, United Kingdom, CM1 7ET
| | - Charles Yuen Yung Loh
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford, Essex, United Kingdom, CM1 7ET
| | - Vasileios Gkorgkolis
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford, Essex, United Kingdom, CM1 7ET
| | - Naguib El-Muttardi
- St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Court Road, Chelmsford, Essex, United Kingdom, CM1 7ET
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Innocenti M, Dell'Acqua I, Famiglietti M, Vignini L, Menichini G, Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases. Injury 2019; 50 Suppl 5:S11-S16. [PMID: 31706586 DOI: 10.1016/j.injury.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.
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Affiliation(s)
- Marco Innocenti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
| | - Irene Dell'Acqua
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Matteo Famiglietti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Livia Vignini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Giulio Menichini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Serena Ghezzi
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
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Bonte A, Bertheuil N, Menez T, Grolleau JL, Herlin C, Chaput B. Distally Based Medial Plantar Flap: A Classification of the Surgical Techniques. J Foot Ankle Surg 2019; 57:1230-1237. [PMID: 29937338 DOI: 10.1053/j.jfas.2018.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 02/03/2023]
Abstract
The proximally based medial plantar flap is considered to be the reference standard for heel reconstruction. Although less well-studied, a distally based medial plantar flap is a suitable alternative when used to cover a distal foot defect, especially of the hallux, first metatarsal, or metatarsophalangeal joint. Our objective was to provide a complete description and propose a classification of the different surgical procedures used to harvest this flap. A review of the data reported in the MEDLINE database until May 2017 concerning the distally based medial plantar flap was performed. We have illustrated the different surgical procedures through a case series. Three approaches or "types" of flap have been described, and we have proposed a classification for reconstructive surgeons. In type 1, the plantar pedicle is ligatured before division into the medial and lateral plantar artery. In type 2, the medial plantar pedicle is cut proximally just after division. In type 3, the flap is harvested to include the fasciocutaneous perforator vessels, as an advancement flap or a propeller perforator flap. A distally based medial plantar flap affords adequate and reliable coverage of the weightbearing zone. Because the donor site drawbacks are minimal, this flap is a useful option for distal foot reconstruction, and reconstructive surgeons should remember this flap. The type 1 flap appears to be associated with a minimal risk of flap necrosis, even in those with diabetes or arteriopathy, and can cover even the most distal defect.
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Affiliation(s)
- Amandine Bonte
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Lille University Hospital, Lille, France
| | - Nicolas Bertheuil
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, Rennes, France
| | - Tiphaine Menez
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Bordeaux University Hospital, Bordeaux France
| | - Jean-Louis Grolleau
- Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil University Hospital, Toulouse, France
| | - Christian Herlin
- Professor, Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Benoit Chaput
- Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil University Hospital, Toulouse, France.
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Huang L, Pafitanis G, Song D, Hu D, Niu P, Hong X, Qi R, Wei X, Zheng H. Anatomical Basis of the Intermediate Dorsal Pedal Neurocutaneous Perforator Pedicled Propeller Flap: A Cadaveric Dissection. Clin Anat 2018; 31:1077-1084. [PMID: 30318766 DOI: 10.1002/ca.23229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/30/2018] [Accepted: 06/09/2018] [Indexed: 11/09/2022]
Abstract
Soft tissue defects of the forefoot represent a challenging surgical modality to reconstructive microsurgeons. This study describes the anatomical basis and design of the perforator-based intermediate dorsal pedal neurocutaneous vascular flap. Thirty fresh human lower limb specimens were injected with red latex and used for dissection of the dorsal vascular and neural anatomy of the foot. The direction and distribution of the intermediate dorsal cutaneous nerve and the vascular anatomy of the third dorsal artery of the plantar arch, along with the intermediate dorsal neurocutaneous nutrient vessels, were mapped. A simulated flap elevation procedure was performed on one fresh cadaver specimen. A clinical series of five cases is presented to demonstrate the feasibility of using the perforator-based intermediate dorsal pedal neurocutaneous vascular flap to reconstruct soft-tissue defects of the forefoot. The intermediate dorsal cutaneous nerve usually originates from the lateral branch of the superficial peroneal nerve. Crossing the surface of the cruciate ligament, it descends distally to the proximal part of the fourth intermetatarsal space and divides into the third and fourth dorsal metatarsal branches. The intermediate dorsal cutaneous neural nutrient vessels, which are multi-segmental and polyphyletic, offer innervation to the skin paddle of the flap elevated on the basis of the third dorsal perforator of the plantar arch. This perforator occupies a relatively constant position in the proximal part of the intermetatarsal space. It sends multiple tiny branches toward the intermediate dorsal cutaneous neural or paraneural nutrient vessel chain. In terms of clinical application, all flaps survived completely; one patient had partial loss of the skin graft. The design and anatomical basis of the intermediate dorsal pedal neurocutaneous vascular flap based on the third dorsal perforator of the plantar arch is a reliable reconstructive option for reconstructing small soft tissue defects in the forefoot. Clin. Anat. 31:1077-1084, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Lei Huang
- Bengbu Medical College Fuzhou General Teaching Hospital (Fuzhou General Hospital of PLA) Orthopedics Institute, Fuzhou, China
| | - Georgios Pafitanis
- Academic Plastic Surgery Group, Queen Mary University of London, United Kingdom
| | - Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410000, China
| | - Deqing Hu
- Department of Orthopedics, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Peng Niu
- Department of Orthopedic Institute, Fuzhou General Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Xu Hong
- Department of Orthopedic Institute, Fuzhou General Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Ruilin Qi
- Department of Orthopedic Institute, Fuzhou General Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Xudong Wei
- Department of Orthopedic Institute, Fuzhou General Hospital of PLA, Fujian Medical University, Fuzhou, China
| | - Heping Zheng
- Bengbu Medical College Fuzhou General Teaching Hospital (Fuzhou General Hospital of PLA) Orthopedics Institute, Fuzhou, China.,Department of Orthopedic Institute, Fuzhou General Hospital of PLA, Fujian Medical University, Fuzhou, China
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The Concepts of Propeller, Perforator, Keystone, and Other Local Flaps and Their Role in the Evolution of Reconstruction. Plast Reconstr Surg 2016; 138:710e-729e. [DOI: 10.1097/prs.0000000000002610] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery 2016; 38:109-119. [PMID: 27018650 DOI: 10.1002/micr.30047] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" METHODS This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2 index were computed. RESULTS We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). CONCLUSION In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.
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Affiliation(s)
- Farid Bekara
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Christian Herlin
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Serge Somda
- Biostatistic Unit, Institut Universitaire du Cancer Toulouse, Toulouse, France
| | - Antoine de Runz
- Department of Plastic and Reconstructive Surgery, Nancy University Hospital, Nancy, France
| | - Jean Louis Grolleau
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
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Lee G, Jeong E. Coverage of defect over toes after failure of microsurgical replantation with medial sural artery perforator flap: A case report. Microsurgery 2015; 36:161-4. [PMID: 25867277 DOI: 10.1002/micr.22415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 03/18/2015] [Accepted: 03/25/2015] [Indexed: 11/11/2022]
Abstract
In this report, we present a case of toe reconstruction with a medial sural artery perforator free flap after failure of replantation. A 35-year-old male suffered a crush injury from a heavy object falling over the left 1st, 2nd, and 3rd toes and underwent microsurgical replantation of the toes at an outside facility. Over the next 2 weeks, ischemic necrosis of all the toes developed. This condition was very frustrating for the patient who had very high expectations of preserving the toes, and also for the surgeon to determine the optimal method to reconstruct the distal foot and toes. After debridement of non-viable tissues, the defect over the toes was resurfaced using a medial sural artery perforator free flap and full thickness skin graft. Subsequently, several minor operations, including interdigitation, excision of neuromas, and defatting procedure were performed to complete his reconstruction. Eighteen months later, the patient had very aesthetically pleasing and fully functional toes. A medial sural artery perforator free flap may be used to repair the soft tissue defect on the toes after failed replantation, and provides sufficient skin.
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Affiliation(s)
- Gordon Lee
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Euicheol Jeong
- Department of Plastic Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
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Scaglioni MF, Kuo YR, Chen YC. Reconstruction of distal hand and foot defects with the free proximal peroneal artery perforator flap. Microsurgery 2014; 36:183-90. [DOI: 10.1002/micr.22364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 11/24/2014] [Accepted: 12/01/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Mario F. Scaglioni
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Yur-Ren Kuo
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
| | - Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; Kaohsiung Taiwan
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Zang M, Yu S, Xu L, Zhao Z, Ding Q, Guo L, Liu Y. Freestyle perforator-based propeller flap of medial arm for medial elbow reconstruction. Microsurgery 2014; 35:411-4. [PMID: 25417774 DOI: 10.1002/micr.22358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 11/08/2014] [Accepted: 11/10/2014] [Indexed: 11/09/2022]
Abstract
Elbow reconstruction is challenging for reconstructive surgeons. The purpose of this report is to present the results of the use of freestyle perforator-based propeller flap designed from the medial arm region for elbow reconstruction. The defects following soft tissue sarcoma resection at the medial and posterior elbow were repaired in two patients. The dimensions of the defects were 11 × 7 cm(2) and 10 × 7 cm(2). Two perforators were identified in each case using Doppler ultrasound probe in the medial arm, adjacent to the defect. The perforator with visible pulsation was chosen as the pedicle vessel, which was 12-cm and 7-cm proximal to the medial epicondyle. An elliptical flap, extending almost the full length of arm, was raised and rotated 180° to repair medial elbow defects. The sizes of the flaps were 17 × 8 cm(2) and 11 × 7 cm(2). The donor sites were closed directly. Both flaps survived; temporary venous congestion occurred in one case. There were no other postoperative complications. These cases illustrated that the medial arm flap might be used for reconstruction of medial elbow defects with this freestyle perforator-based propeller flap design.
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Affiliation(s)
- Mengqing Zang
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China
| | - Shengji Yu
- Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Libin Xu
- Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhenguo Zhao
- Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Ding
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China
| | - Lingling Guo
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China
| | - Yuanbo Liu
- Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China
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