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Wang X, He ZP, Sun Y, Li LC, Liu YQ, Yang YR, Qi LN, Yang JH, Shi YT, Qin XZ. More potential uses of specific perforator flaps in the calf - A cadaveric study on the subdermal vascular structure of the lower leg. Ann Anat 2024; 254:152262. [PMID: 38582236 DOI: 10.1016/j.aanat.2024.152262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective. METHODS This study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques. RESULTS The perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network. CONCLUSIONS We observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.
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Affiliation(s)
- Xin Wang
- Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin, China
| | - Zao-Peng He
- Department of hand and foot surgery, The Lecong Hospital of Shunde, Foshan, Guangdong, China
| | - Ye Sun
- Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin, China
| | - Liang-Chang Li
- Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin, China
| | - Yan-Qun Liu
- Department of Orthopaedic, Yanbian University Hospital, Yanji, Jilin, China
| | - Yi-Ran Yang
- Department of Anesthesiology, Medical College of Yanbian University, Yanji, Jilin, China
| | - Ling-Na Qi
- Department of Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin, China
| | - Jing-Han Yang
- Department of Anesthesiology, Medical College of Yanbian University, Yanji, Jilin, China
| | - Yu-Tong Shi
- Department of Clinical Medicine, Medical College of Yanbian University, Yanji, Jilin, China
| | - Xiang-Zheng Qin
- Department of Anatomy, Medical College of Yanbian University, Yanji, Jilin, China.
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Lee G, Kim B, Jeon N, Yoon J, Hong KY, Lim S, Eo S. Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer. Hand (N Y) 2023; 18:272-281. [PMID: 34253087 PMCID: PMC10035084 DOI: 10.1177/15589447211028925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. MATERIALS AND METHODS Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. RESULTS This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. CONCLUSION The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.
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Affiliation(s)
- GiJun Lee
- MS Jaegeon Hospital, DaeGu, South Korea
| | - BumSik Kim
- Dongguk University Ilsan Medical Center, Seoul, South Korea
| | | | - JungSoo Yoon
- Dongguk University Ilsan Medical Center, Seoul, South Korea
| | - Ki Yong Hong
- Dongguk University Ilsan Medical Center, Seoul, South Korea
| | - SooA Lim
- Dongguk University Ilsan Medical Center, Seoul, South Korea
| | - SuRak Eo
- Dongguk University Ilsan Medical Center, Seoul, South Korea
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Kelada MN, Salem RR, Eltohfa YA, Ghozlan NA, Kholosy HM. "Posterior interosseus artery flap for hand reconstruction: anatomical basis and clinical application". BMC Musculoskelet Disord 2022; 23:662. [PMID: 35820834 PMCID: PMC9275144 DOI: 10.1186/s12891-022-05630-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
Summary Flap options for upper limb reconstruction have increased due to better understanding of its vascular anatomy. The posterior interosseus artery flap (PIAF) is used to cover defects of the wrist, hand, proximal thumb, and first web space. This flap has many advantages but requires good knowledge about the anatomy of the posterior interosseus artery (PIOA) and its perforators. Methods Twenty upper extremity cadaveric specimens were injected with red latex, Fine dissection of the PIOA and its perforators took place; the perforators were counted, measured, described and photographed. Twenty patients with dorsal hand defects, had PIAF. Cases have Post-operative care and followed up for 6 months post-operative. Results The PIOA was constant in all cadaveric dissections and gave off 4–8 septocutaneous perforators along its course between the extensor carpi ulnaris (ECU) and extensor digitorum (EDM) muscles. The mean distance of the distal most perforator in the middle third forearm from the ulnar styloid was 10.39 ± 1.54 cm. The anastomosis between the PIOA and the anterior interosseus artery (AIOA) was there in all specimens. Venous congestion occurred in 10% of the cases and was managed conservatively. Necrosis of the distal third of the flap was inevitable in one case; excellent results were obtained in the other cases 90%. Conclusions The posterior interosseus artery flap is an excellent perforator flap for hand reconstruction preserving the ulnar and radial artery; but it has a possible complications such as venous congestion or partial flap necrosis that could be managed conservatively. Level of evidence II.
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Affiliation(s)
- Melad N Kelada
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Alexandria, N.B. 15 Hussein kabadaya street from El Bitash main, El Agamy, Alexandria, Egypt.
| | - Rasha R Salem
- Department of Human Anatomy and Embryology, Faculty of Medicine, University of Alexandria, N.B. 15 Hussein kabadaya street from El Bitash main, El Agamy, Alexandria, Egypt
| | - Youssef A Eltohfa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Naser A Ghozlan
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Hassan M Kholosy
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Costa AL, Colonna MR, Vindigni V, Bassetto F, Tiengo C. REVERSE POSTERIOR INTEROSSEOUS FLAP: DIFFERENT APPROACHES OVER THE YEARS. SYSTEMATIC REVIEW. J Plast Reconstr Aesthet Surg 2022; 75:4023-4041. [DOI: 10.1016/j.bjps.2022.06.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/27/2022]
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Kocman EA, Kavak M, Kaderi S, Karabagli Y. An extended distally based reverse posterior interosseous artery flap reconstruction for the thumb and distal defects of the fingers. Microsurgery 2021; 41:430-437. [PMID: 33877703 DOI: 10.1002/micr.30746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 04/03/2021] [Accepted: 04/09/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND The reverse posterior interosseous artery flap is useful for covering hand defects. However, its major drawback is the short pedicle that limits the reach of the flap up to the metacarpophalangeal level. The authors performed a new modification extending the distal reach of the flap by including the recurrent branch of the posterior interosseous artery and they aimed to present the results of reconstruction with this technique. PATIENTS AND METHODS Seven patients with a mean age of 35.2 years (range 17-64 years) underwent extended RPIAF surgery. Six patients were admitted to the emergency department with isolated hand trauma. One patient was present in elective settings with chronic osteomyelitis and skin loss of the thumb related to previous trauma. The defects were located on the distal metacarpophalangeal level (thumb and other fingers). PIA perforators and the recurrent branch were included into the pedicle (Type A) in five cases, whereas the flap was harvested based solely on the recurrent branch (Type B) in two cases. The type B flaps had longer pedicle lengths due to discarding the forearm skin. The donor sites were covered with skin grafts in six patients. RESULTS The average size of the extended RPIAF was 3 × 3.5 cm to 10 × 6 cm (mean 8.28 × 4.14 cm). All of the flaps completely survived, and no complications were encountered during the postoperative period. Functional recovery of the operated hands were observed during the follow up period 13.5 months (8-24 months). Both the patient and our satisfactory levels were high and all of the patients returned to their works. Quick DASH score was used in the final functional evaluation retrospectively. Due to the pandemic, the evaluation could be made with a telephone. Two patients could not be reached in the evaluation. The mean quick DASH score of five patients was 28.64. CONCLUSION The extended RPIAF is a reliable choice in distally located thumb and finger defects if the recurrent branch of the posterior interosseous artery is included in the pedicle.
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Affiliation(s)
- Emre A Kocman
- Department of Plastic Reconstructive Aesthetic Surgery, Osmangazi University, Faculty of Medicine, ESKİŞEHİR, Turkey
| | - Mustafa Kavak
- Department of Orthopedics and Traumatology, Osmangazi University, Faculty of Medicine, ESKİŞEHİR, Turkey
| | - Sina Kaderi
- Department of Plastic Reconstructive Aesthetic Surgery, Osmangazi University, Faculty of Medicine, ESKİŞEHİR, Turkey
| | - Yakup Karabagli
- Department of Plastic Reconstructive Aesthetic Surgery, Osmangazi University, Faculty of Medicine, ESKİŞEHİR, Turkey
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Franchi A, Häfeli M, Scaglioni MF, Elliot D, Giesen T. The use of chimeric musculocutaneous posterior interosseous artery flaps for treatment of osteomyelitis and soft tissue defect in hand. Microsurgery 2019; 39:416-422. [PMID: 30779433 DOI: 10.1002/micr.30434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/30/2018] [Accepted: 01/25/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION There is growing evidence of the superior ability of muscular tissue to clear bacterial bone infection. Unfortunately, in the hand, there are almost no small local muscular flaps, and muscular transfers to the hand are mainly microsurgical free transfers. In this report, we present the results of the use of a chimeric posterior interosseous flap including part(s) of the forearm muscles to treat osteomyelitis and soft tissue defect of hand from a series of patients. PATIENTS AND METHODS Four male patients with an average age of 32 years (range 20-46 years), were affected by acute osteomyelitis in hand. Previous fracture fixation with percutaneous K-wires was the cause of bone infection in three case. In one case, the osteomyelitis was a consequence of an open fracture. The bones affected were four metacarpals and one proximal phalanx, all with a minimal cortical defect (from the K-wire) obscuring a larger medullary infection, which required extensive bone and overlying soft tissue debridement, leaving a soft tissue defect to be reconstructed of size ranging from 2 x 4 cm to 5 x 7 cm. The soft tissue defects were due to concomitant superficial infection and consequent debridement. All patients were treated with bone debridement and a chimeric posterior interosseous flap, which included part of the extensor digiti minimi and/or extensor carpi ulnaris to fill the intramedullary canal of the bones. No fixation of bone was necessary. RESULTS The skin paddle of the flaps ranged from 2 x 5 cm to 5 x 6 cm, replicating the defect area, plus a teardrop tail of skin circa 1.5 cm wide and as long as the pedicle of the flap. The muscular components of the flaps used to fill the intramedullary canals ranged from 1 x 1 x 1.5 cm to 1.5 x 1.5 x 4 cm. All flaps survived and osteomyelitis resolved in all cases without major complications. At the final follow-up at 16 months (range 12-26 months), assessment of the hands using TAM, Power Grip and Key Pinch Strength measurements and, where appropriate, Kapandji scores, demonstrated satisfactory hand function. CONCLUSION The chimeric posterior interosseous flap including part of the muscles of the forearm may be a robust solution for augmenting the flap bulk and may be used in cases of severe osteomyelitis of the hand.
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Affiliation(s)
- Alberto Franchi
- Kantonsspital Luzern, Klinik für Hand-und Plastische Chirurgie, Lucerne, Switzerland
| | - Mathias Häfeli
- Kantonsspital Graubünden, Departement Chirurgie, Handchirurgie, Chur, Switzerland
| | - Mario F Scaglioni
- Kantonsspital Luzern, Klinik für Hand-und Plastische Chirurgie, Lucerne, Switzerland
| | - David Elliot
- Broomfield Hospital, St Andrew's Centre for Plastic Surgery and Burns, Chelmsford, Essex, United Kingdom
| | - Thomas Giesen
- Swissparc AG, Hand Surgery Service, Zürich, Switzerland.,Clinica Ars Medica, Centro Manoegomito, Gravesano, Switzerland
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Hamada R, Shinaoka A, Sugiyama N, Watanabe T, Miura Y, Kimata Y. Recurrent branch of anterior interosseous artery perforator-based propeller flap for distal forearm injuries: Report of 2 cases. Microsurgery 2018; 38:917-923. [PMID: 30380173 DOI: 10.1002/micr.30388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/18/2018] [Accepted: 09/21/2018] [Indexed: 11/10/2022]
Abstract
Despite various options for the reconstruction of soft tissue defects in the distal forearm, perforator-based propeller flap is rarely used. Here, we presented 2 cases of distal forearm injuries that were repaired using the recurrent branch of anterior interosseous artery perforator-based propeller flap. Patients in these cases were 57 and 67 years of age. Wounds resulting from farming machine injury and pyogenic extensor tenosynovitis following cat bite wounds were localized to the distal forearm and dorsum of the hand. Defect dimensions were 5 cm × 10 cm and 5 cm × 8 cm. The 12 cm × 7 cm and 21 cm × 4 cm sized recurrent branch of anterior interosseous artery perforator-based propeller flap was designed adjacent to the wounds. In the latter case, the absence of the posterior interosseous artery in the distal forearm was observed. One perforator from the recurrent branch of the anterior interosseous artery emerged through the septum between the extensor digiti minimi and extensor carpi ulnaris 7.5 cm and 6.0 cm proximal to the ulnar head in cases 1 and 2, respectively. Perforators were identified using multidetector computed tomographic angiography and handheld Doppler. Extending to two-thirds or almost the full length of the forearm, the flaps were raised and rotated by 90° and 120° to cover the defect. The donor sites were closed using free skin graft. Both flaps survived. Except for minor wound dehiscence and hemarthrosis, no other postoperative complications occurred. Patients returned to work or daily activities at 3- and 4-month follow-up after surgery.
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Affiliation(s)
- Ryusho Hamada
- Department of Plastic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan.,Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Akira Shinaoka
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan.,Department of Human Morphology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Narushi Sugiyama
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Toshiyuki Watanabe
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Yuki Miura
- Department of Plastic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan.,Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
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Current trends in local flaps of the hand. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Usami S, Okazaki M. Fingertip reconstruction with a posterior interosseous artery perforator flap: A minimally invasive procedure for donor and recipient sites. J Plast Reconstr Aesthet Surg 2017; 70:166-172. [DOI: 10.1016/j.bjps.2016.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/10/2016] [Accepted: 11/30/2016] [Indexed: 11/25/2022]
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Cavadas PC, Thione A, Rubí C. The Simplified Posterior Interosseous Flap. J Hand Surg Am 2016; 41:e303-7. [PMID: 27178875 DOI: 10.1016/j.jhsa.2016.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 10/22/2015] [Accepted: 04/21/2016] [Indexed: 02/02/2023]
Abstract
Several technical modifications have been described to avoid complications and simplify dissection. The authors describe some technical tips that make posterior interosseous flap dissection safer and more straightforward.
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Affiliation(s)
- Pedro C Cavadas
- Reconstructive Surgery Unit, Clinica Cavadas, Hospital de Manises, Valencia, Spain
| | - Alessandro Thione
- Reconstructive Surgery Unit, Clinica Cavadas, Hospital de Manises, Valencia, Spain.
| | - Carlos Rubí
- Reconstructive Surgery Unit, Clinica Cavadas, Hospital de Manises, Valencia, Spain
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Improvement of the Rotation Arch of the Posterior Interosseous Pedicle Flap Preserving Both Reverse Posterior and Anterior Interosseous Vascular Sources. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e794. [PMID: 27536473 PMCID: PMC4977122 DOI: 10.1097/gox.0000000000000760] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/20/2016] [Indexed: 11/26/2022]
Abstract
Purpose: The reverse posterior interosseous artery flap has several advantages, not sacrificing any major blood vessel, but its relatively short pedicle limits the use to cover defects up to the metacarpophalangeal joint. Our purpose is to demonstrate that the ligature of the anterior interosseous artery (AIA), proximal to the communicating branch with the posterior interosseous artery, leads to an improved flap rotation arch, preserving both vascular sources. Methods: Sixteen fresh cadavers with latex perfusion were analyzed before and after our technique of elongation, and the so-obtained measures were standardized in “percentage of elongation of the pedicle.” Eight patient with the loss of substance at the dorsal aspect of the hand have been treated with this technique, and results were evaluated in terms of flap survival and complication rates. Results: The medium length of the pedicle in the normal flap was 10.8 cm, and after the section of the AIA, the medium length of the pedicle was 13.6 cm with a medium increase of 2.8 cm. It means a medium increase of 24% of the length of the pedicle. In all patients treated, full coverage of the defect was obtained, and we did not experience major complications. Conclusions: This anatomical study supported by our clinical experience demonstrates that the use of the variant described above permits to reach more distal part of the hand without being afraid to stretch the pedicle because of the connection with the anastomotic arcades of the AIA at the wrist reducing the risk of ischemia of the flap.
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