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Boretto JG, Holc F, Victorica PB. The Foot as a Donor Site for Reconstruction in the Hand. Hand Clin 2024; 40:249-258. [PMID: 38553096 DOI: 10.1016/j.hcl.2023.08.009] [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: 04/02/2024]
Abstract
The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.
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Affiliation(s)
- Jorge G Boretto
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires.
| | - Fernando Holc
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires
| | - Pedro Bronenberg Victorica
- Hand and Upper Extremity Surgery Department, Prof. Dr. "Carlos Ottolenghi Institute", Hospital Italiano de Buenos Aires
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Collar J, Smetona J, Zhang J, Deng Y, Clune J. The Aesthetics of Digit Amputation. Hand (N Y) 2023; 18:829-837. [PMID: 35174717 PMCID: PMC10336824 DOI: 10.1177/15589447211065073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The goal of surgery, when treating a patient with a traumatized hand, is to restore function. The importance of the aesthetics on a patient's psychological well-being should also be considered. The biomechanical ideals for creating a useful hand after digit amputation have been defined; however, ideal aesthetic levels for finger amputation have not been elucidated. The purpose of this study was to determine the general population's visual preferences for different levels of digit amputation in the hand. Methods: In all, 310 participants were surveyed to identify preferences of different levels of single digit amputations in dorsal and volar views. A normal hand was digitally manipulated to simulate various levels of digit amputation. The aesthetics of amputation at the distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, metacarpophalangeal (MCP) joint, and ray amputation were compared to one another via rank order. Average rank for each level of amputation for a digit was determined. Results: Amputation at the DIP was favored over all other levels; however, ray amputation was the second most aesthetic, particularly in the middle and ring fingers even when compared to amputation at the PIP level. Conclusion: When presented a choice at which level to perform a completion amputation or a primary amputation of a digit, and functionality at multiple levels of amputation is equivocal, aesthetic outcomes should be considered. Amputation at the DIP joint is preferable, but ray amputation is aesthetically more pleasing than amputation at the PIP or MCP joints in the index, middle, ring, and small fingers.
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Affiliation(s)
- John Collar
- Yale University School of Medicine, Section of Plastic Surgery, New Haven, CT, USA
| | - John Smetona
- Yale University School of Medicine, Section of Plastic Surgery, New Haven, CT, USA
| | - Jingwen Zhang
- Yale University School of Public Health Center for Analytical Science, New Haven, CT, USA
| | - Yanhong Deng
- Yale University School of Public Health Center for Analytical Science, New Haven, CT, USA
| | - James Clune
- Yale University School of Medicine, Section of Plastic Surgery, New Haven, CT, USA
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End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit? PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4535. [PMID: 36203740 PMCID: PMC9529035 DOI: 10.1097/gox.0000000000004535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.
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Güntürk ÖB, Kaplan İ, Yıldırım T, Gürbüz Y, Ademoğlu Y, Ada S. Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot. Injury 2021; 52:3646-3652. [PMID: 33838878 DOI: 10.1016/j.injury.2021.03.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/14/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not. PATIENTS AND METHODS Ninety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively. RESULTS In 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints. CONCLUSION Multiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.
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Affiliation(s)
| | | | | | - Yusuf Gürbüz
- Emot Hospital 1418 sok No14 Kahramanlar. İzmir, Turkey
| | | | - Sait Ada
- Emot Hospital 1418 sok No14 Kahramanlar. İzmir, Turkey
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Abstract
The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.
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Georgescu AV, Battiston B, Matei IR, Soucacos PN, Bumbasirevic M, Toia F, Tos P. Emergency toe-to-hand transfer for post-traumatic finger reconstruction: A multicenter case series. Injury 2019; 50 Suppl 5:S88-S94. [PMID: 31708087 DOI: 10.1016/j.injury.2019.10.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this paper was to evaluate the outcomes of a homogenous series of emergency with a toe-to-hand transfer reconstructions with a different timing: immediate (same surgical step with the debridement), primary (in the first 24 h), early (24-72 h after the debridement) or delayed (72 h-7 days). MATERIALS AND METHODS Between 2001 and 2011, 31 patients received an immediate reconstruction with a toe-to-hand transfer. Data on indications, timing, type of surgery, complications and outcomes (sensory and motor recovery, patient satisfaction) were extrapolated and recorded. RESULTS Most of the procedures in our series (71%) were performed in the first 24 h. Survival rate was 100%. The only complications were 3 venous thrombosis (10%), solved with surgical re-exploration. Only 1 patient required secondary surgery for web deepening. No functional problems were recorded at the donor site. Sensibility recovery was acceptable in all patients; toe mobility was higher for the reconstructed thumb (85%) than for other digits (77%). Patient satisfaction was high with regard to functional results and lower but acceptable with regard to the aesthetic outcome. There was no difference in satisfaction rate of patients treated within 24 h or within 7 days. CONCLUSION No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. Emergency toe transfer for finger reconstruction is a safe procedure and its outcomes are comparable to those reported in the literature for secondary reconstruction. Immediate reconstruction has the advantage of an easier dissection, but early or delayed reconstruction gives more time to discuss with the patient and to plan surgery.
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Affiliation(s)
- Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, Clinic Hospital of Recovery, University of Medicine ``Iuliu Hatieganu'', Cluj Napoca, Romania
| | - Bruno Battiston
- UOD Reconstructive Microsurgery, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, Clinic Hospital of Recovery, University of Medicine ``Iuliu Hatieganu'', Cluj Napoca, Romania
| | - Panayotis N Soucacos
- "Panayotis N. Soucacos" Orthopaedic Research & Education Center (OREC), National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Marko Bumbasirevic
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; School of Medicine, University of Belgrade, Serbia
| | - Francesca Toia
- UOD Reconstructive Microsurgery, AOU Città della Salute e della Scienza di Torino, Torino, Italy; Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.
| | - Pierluigi Tos
- UOD Reconstructive Microsurgery, AOU Città della Salute e della Scienza di Torino, Torino, Italy
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Abstract
BACKGROUND Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer. METHODS From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps. RESULTS All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively. CONCLUSIONS In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers. CLINICAL QUESTION/LEVEL OF EVIDECE Therapeutic, IV.
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Li M, Huang M, Yang Y, Gu L, Zhang Z, Yang Y. Preliminary Study on Functional and Aesthetic Reconstruction by Using a Small Artery-only Free Medial Flap of the Second Toe for Fingertip Injuries. Clinics (Sao Paulo) 2019; 74:e1226. [PMID: 31644661 PMCID: PMC6792235 DOI: 10.6061/clinics/2019/e1226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study was designed to introduce the feasibility of fingertip reconstruction by using a free medial flap of the second toe without vein anastomosis. METHODS In total, 8 patients with fingertip injuries were treated successfully with this method. Patients who underwent reconstruction from September 2016 to October 2017 in our hospital with an artery-only free medial flap transfer of the second toe for fingertip injuries were included, and patients who underwent additional procedures that may impact the postoperative results and were followed up for less than 6 months were excluded. Clinical trial registration: ChiCTR19000021883. RESULTS According to the Allen classification, five patients had Type 3 injuries, and three patients had Type 4 injuries. One arterial nerve and one digital nerve were repaired at the same time. No additional dissection was performed in either the donor or recipient site of the dorsal or volar vein. Postoperative venous congestion was monitored based on the color, temperature and the degree of tissue oxygen saturation. The flap size ranged from 1.20*1.0 cm2 to 1.80*1.0 cm2. The reconstruction time was 71.86 (SD 14.75) minutes. The two-point discrimination and the monofilament results were satisfying; cold intolerance did not appear in five patients, and the other three patients had cold intolerance with grades of 4, 12 and 26, which were considered satisfactory. Moreover, leech therapy, continuous bleeding and needle sutures were not utilized in any cases. CONCLUSIONS Reconstruction with a small artery-only free medial flap transfer of the second toe led to satisfactory sensory and motor function in the selected patients with fingertip injuries.
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Affiliation(s)
- Muwei Li
- Department of Microsurgery and Hand Surgery, the Long gang Orthopedics Hospital of Shen zhen, Shen zhen, 518116, China
- *Corresponding authors. E-mails: /
| | - Ming Huang
- Zhong shan School of Medicine, Sun Yat-sen University, Guang zhou, 510080, China
- *Corresponding authors. E-mails: /
| | - Yanjun Yang
- Department of Microsurgery and Hand Surgery, the Long gang Orthopedics Hospital of Shen zhen, Shen zhen, 518116, China
| | - Liqiang Gu
- Department of Microsurgery and Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guang zhou, 510080, China
| | - Ziqing Zhang
- Department of Microsurgery and Hand Surgery, the Long gang Orthopedics Hospital of Shen zhen, Shen zhen, 518116, China
- *Corresponding authors. E-mails: /
| | - Yi Yang
- Department of Microsurgery and Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guang zhou, 510080, China
- *Corresponding authors. E-mails: /
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Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand. J Plast Reconstr Aesthet Surg 2017; 70:1708-1714. [DOI: 10.1016/j.bjps.2017.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/20/2017] [Accepted: 07/26/2017] [Indexed: 11/20/2022]
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10
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Del Piñal F, Urrutia E, Klich M. Severe Crush Injury to the Forearm and Hand: The Role of Microsurgery. Clin Plast Surg 2017; 44:233-255. [PMID: 28340660 DOI: 10.1016/j.cps.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The main goals of treating severe crush injuries are debriding away devitalized tissue and filling any resultant dead space with vascularized tissue. In the authors' experience, the most ideal methods for soft tissue coverage in treating crush injuries are the iliac flap, the adipofascial lateral arm flap, and the gracilis flap. Accompanying bone defects respond very well to free corticoperiosteal flaps. Digital defects often require the use of complete or subtotal toe transfer to avoid amputation and restore function to the hand.
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Affiliation(s)
- Francisco Del Piñal
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain.
| | - Esteban Urrutia
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain; Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Maciej Klich
- Instituto de Cirugía Plástica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montañesa, Madrid/Santander, Spain; Department of Traumatology and Orthopedics, Clinical Hospital, Warsaw, Otwock, Poland
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Sabapathy SR, Bhardwaj P. Setting the Goals in the Management of Mutilated Injuries of the Hand-Impressions Based on the Ganga Hospital Experience. Hand Clin 2016; 32:435-441. [PMID: 27712746 DOI: 10.1016/j.hcl.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mutilated injuries need to be treated aggressively and appropriately to avoid amputation or severe disability in the individual. Assessment of the management of these injuries on a global level reveals that there is a gap between the need and availability of the skilled manpower to manage these injuries. There is also a gap in the utilization of the available services. These gaps need to be covered or narrowed as far as possible. Although some measures need policy changes and improvement of health care delivery infrastructure, simpler measures taken at the final health care delivery level can significantly improve the final outcome.
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Affiliation(s)
- S Raja Sabapathy
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India.
| | - Praveen Bhardwaj
- Hand & Wrist Surgery and Reconstructive Microsurgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India
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Abstract
The thumb should be preserved at all costs, and major efforts to preserve it are justified. If nothing can be done (or desperate measures fail), classic procedures or a toe-to-hand are indicated. This article will not only discuss some tips to succeed in extreme acute scenarios, but will also consider the indications of other alternatives in the acute or subacute setting.
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Affiliation(s)
- Francisco Del Piñal
- Instituto de Cirugía Plástica y de la Mano, Hospital La Luz, Madrid, Spain; Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa, Santander, Spain.
| | - Davide Pennazzato
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Esteban Urrutia
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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Diaz-Abele J, Hayakawa T, Buchel E, Brooks D, Buntic R, Safa B, Islur A. Anastomosis to the common and proper digital vessels in free flap soft tissue reconstruction of the hand. Microsurgery 2016; 38:21-25. [PMID: 27392815 DOI: 10.1002/micr.30066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/04/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study seeks to demonstrate the safety of anastomosing free flaps to the common or proper digital artery, and to the volar or dorsal digital vein in soft tissue reconstruction of the hand; as well, as to discuss the advantages of this technique. METHODS Retrospective review of all patients who underwent free flap reconstruction of the hand in two institutions over a period of 5 years. RESULTS A total of 29 free flaps (9 great toe pulp, 7 anterolateral thigh, 6 second toe pulp, 4 radial artery perforator, 2 partial medial rectus, 1 lateral arm) in 28 patients met our inclusion criteria. All recipient vessels were the proper or common digital artery and the volar or dorsal digital vein. There was one case of venous congestion that resolved with leeching. There was no partial or total loss of any of the flaps. CONCLUSION Anastomosing soft tissue free flaps to the common or proper digital artery, and the volar or dorsal digital vein is a safe and effective approach with numerous advantages that should be considered in the reconstruction of soft tissue defects of the hand. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:21-25, 2018.
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Affiliation(s)
| | - T Hayakawa
- University of Manitoba, Winnipeg, MB, Canada
| | - E Buchel
- University of Manitoba, Winnipeg, MB, Canada
| | - D Brooks
- The Buncke Clinic, San Francisco, CA
| | - R Buntic
- The Buncke Clinic, San Francisco, CA
| | - B Safa
- The Buncke Clinic, San Francisco, CA
| | - A Islur
- University of Manitoba, Winnipeg, MB, Canada
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Song D, Li J, Li K, Liu J, Xu J. Modified Innervated Radial Collateral Artery Perforator Flap for Repairing Digital Defects. Indian J Surg 2015; 77:1032-7. [DOI: 10.1007/s12262-014-1117-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/26/2014] [Indexed: 11/24/2022] Open
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Song D, Deng X, Chen Y, Xie S, Zhou X. Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction. Arch Orthop Trauma Surg 2015; 135:1623-31. [PMID: 26377731 DOI: 10.1007/s00402-015-2324-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiangwu Deng
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Yanmin Chen
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Songlin Xie
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China. .,Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China.
| | - Xiao Zhou
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.
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16
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Henry M. Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss. J Hand Microsurg 2015; 7:306-13. [PMID: 26578834 DOI: 10.1007/s12593-015-0207-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, Houston, TX 77004 USA
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17
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Camporro D, González I, Martín C. Isolated second toe transfer after total amputation of the left fifth finger in a professional guitar player. J Hand Surg Eur Vol 2014; 39:1003-4. [PMID: 24127464 DOI: 10.1177/1753193413508689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- D Camporro
- Hospital Universitario Central de Asturias, Department of Plastic and Reconstructive Surgery, Department of Physical Medicine and Rehabilitation, Oviedo, Spain
| | - I González
- Hospital Universitario Central de Asturias, Department of Plastic and Reconstructive Surgery, Department of Physical Medicine and Rehabilitation, Oviedo, Spain
| | - C Martín
- Hospital Universitario Central de Asturias, Department of Plastic and Reconstructive Surgery, Department of Physical Medicine and Rehabilitation, Oviedo, Spain
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Del Piñal F, Moraleda E, de Piero GH, Ruas JS, Galindo C. Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer. J Hand Surg Am 2014; 39:29-36. [PMID: 24369940 DOI: 10.1016/j.jhsa.2013.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/23/2013] [Accepted: 10/25/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers. METHODS Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case). RESULTS All transferred flaps survived. At a minimum follow-up of 1 year (range, 1-14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases. CONCLUSIONS In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Francisco Del Piñal
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain.
| | - Eduardo Moraleda
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Guillermo H de Piero
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Jaime S Ruas
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
| | - Carlos Galindo
- Instituto de Cirugía Plástica y de la Mano, Private Practice and Hospital Mutua Montañesa, Santander, Spain
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Abstract
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
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Affiliation(s)
- Scott M Tintle
- University of Pennsylvania, Philadelphia, PA, United States
| | - L Scott Levin
- University of Pennsylvania, Philadelphia, PA, United States.
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del Piñal F, García-Bernal FJ, Thams C, Studer A, Regalado J. Informe sobre el trasplante de 250 dedos del pie a la mano consecutivos. Indicaciones, resultados, fracasos y nuevas aplicaciones. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.03.012] [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] Open
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del Piñal F, García-Bernal FJ, Thams C, Studer A, Regalado J. Report on 250 consecutive toe to finger transplants. Indications, results, failures, and new applications. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/s1988-8856(11)70316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Abstract
Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. It can be used to correct almost any thumb defect. However, for optimal functional and esthetic results, proper initial care, preoperative planning, proper selection of suitable techniques, adjunct or secondary procedures and proper, postoperative rehabilitation are important.
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Posterior interosseous free flap for finger re-surfacing. J Plast Reconstr Aesthet Surg 2009; 63:832-7. [PMID: 19369132 DOI: 10.1016/j.bjps.2009.01.071] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 01/29/2009] [Accepted: 01/31/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The authors present their clinical experience and surgical methods of soft-tissue coverage for the finger using a posterior interosseous free flap. METHODS Twelve posterior interosseous free flaps, including two dual-paddle flaps, were performed in 12 patients. Indications included: 1) patients with soft-tissue coverage of the dorsum of the finger (n=4), pulp (n=1), fingertip and pulp (n=5), 2) patients subsequent to release of finger and palm contracture (n=1) and 3) patients subsequent to finger separation (n=1). The posterior interosseous vessels were ligated below the level at which the motor branch to the extensor carpi ulnaris crossed the vessel superficially. The recipient vessels were the proper digital artery and palmar subcutaneous vein (n=10), deep branch of the ulnar palm artery (n=1), superficial branch of the radial palm artery (n=1) and the vena comitante. The cosmetic appearance of the donor and recipient sites, static two-point discrimination and active total range of motion of the operated finger were evaluated in a follow-up visit. RESULTS All flaps survived completely and all donor sites were closed directly, leaving a linear scar. De-fatting of the flap was carried out in one case in the late postoperative period; all other patients achieved a cosmetically acceptable result. Static two-point discrimination scores averaged 11 mm (range: 8-15 mm). Postoperatively, seven patients maintained normal flexion and extension of the joint. Two patients who had experienced a fracture and flexor injury recovered near-normal flexion and extension after flexor release; the other patients only recovered partially due to severe preoperative joint stiffness. Preoperatively, the active total range of motion of the operated fingers averaged 187 (range: 20-260). The average active total range of motion of the operated fingers at the last follow-up was 210 (range: 60-260). There was a significant difference between the preoperative and follow-up values (p=0.042). CONCLUSIONS The posterior interosseous free flap may become one valuable option for finger re-surfacing. Avoiding the sacrifice of a main artery of the hand and shorter pedicle can reduce the morbidity and operative time associated with this procedure. In addition, separate regions can be reconstructed with a dual-paddle flap.
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del Piñal F, Innocenti M. Evolving concepts in the management of the bone gap in the upper limb. Long and small defects. J Plast Reconstr Aesthet Surg 2007; 60:776-92. [PMID: 17452133 DOI: 10.1016/j.bjps.2007.03.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Accepted: 03/07/2007] [Indexed: 11/18/2022]
Abstract
Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.
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Affiliation(s)
- Francisco del Piñal
- Unit of Hand-Wrist and Plastic Surgery, Hospital Mutua Montañesa, Instituto de Cirugía Plástica y de la Mano, Santander, Spain.
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del Piñal F, García-Bernal FJ, Regalado J, Studer A, Cagigal L, Ayala H. The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects. J Hand Surg Am 2007; 32:209-17. [PMID: 17275596 DOI: 10.1016/j.jhsa.2006.11.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Revised: 11/14/2006] [Accepted: 11/14/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. METHODS From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. RESULTS All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. CONCLUSIONS The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Francisco del Piñal
- Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa, Santander, Spain.
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del Piñal F, García-Bernal F, Delgado J, Sanmartín M, Regalado J, Santamaría C. Metacarpal Hand Reconstruction by Combined Second and Third Toe Transfer. Rev Esp Cir Ortop Traumatol (Engl Ed) 2007. [DOI: 10.1016/s1988-8856(07)70004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Atzei A, Pignatti M, Udali G, Cugola L, Maranzano M. The distal lateral arm flap for resurfacing of extensive defects of the digits. Microsurgery 2007; 27:8-16. [PMID: 17205572 DOI: 10.1002/micr.20308] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The distal lateral arm flap (DLAF) was used to reconstruct six extensive defects of the digits: 2 degloving injuries of the thumb and 4 major skin losses of the fingers. Two adjacent fingers were involved in 1 patient. Flap size ranged from 3 x 7 cm to 9 x 14 cm. Four flaps were reinnervated using the posterior cutaneous nerve of the forearm. All flaps survived, though 1 showed marginal necrosis. Average follow-up was 53.4 months. Thumb opposition scored 5 according to Kapandji; finger ROM averaged 50.75%; pinch strength 72.5%. Protective sensation with touch localization was restored. Patient satisfaction for resurfaced digits averaged 8.9 on a 10-points visual analogic scale. All donor sites resulted in a painless scar with good patient satisfaction. The DLAF offers a thin, pliable skin ideal for digit reconstruction, with low rate of donor site morbidity and can be considered when toe-to-hand flap transfer is not advisable or refused by the patient.
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Affiliation(s)
- Andrea Atzei
- Hand Surgery Unit, Policlinico G.B. Rossi, Azienda Ospedaliera-Universitaria, Piazzale L.A. Scuro 10, 37100 Verona, Italy.
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del Piñal F, García-Bernal FJ, Delgado J, Regalado J, Sanmartín M, García-Fernández D. Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique. J Hand Surg Am 2005; 30:111-9. [PMID: 15680565 DOI: 10.1016/j.jhsa.2004.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2004] [Accepted: 09/22/2004] [Indexed: 02/02/2023]
Abstract
Reconstruction of combined finger and soft-tissue defects poses a technical surgical challenge. We present our experience with a hybrid flap: the dorsalis pedis fasciosubcutaneous-toe free flap. In a single stage, this flap solves the problem of medium-sized defects associated with digit losses in the hand. Donor-site morbidity has been minimal.
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Affiliation(s)
- Francisco del Piñal
- Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa and Clínica Mompía Santander, Calderón de la Barca 16-entlo, E-39002 Santander, Spain
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