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McClelland B, Novak CB, Hanna S, McCabe SJ. Using Decision Analysis to Understand the Indications for Unilateral Hand Transplantation. Hand (N Y) 2016; 11:450-455. [PMID: 28149213 PMCID: PMC5256653 DOI: 10.1177/1558944715628008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Upper extremity transplantation has been performed to improve quality of life, the benefit which must be traded off for the risk created by life-long immunosuppression. We believe the process of decision analysis is well suited to improve our understanding of these trade-offs. Method: We created a decision tree to include a branch point to illustrate the expected recovery of useful function in the transplant, using the best estimates for utility and probability that exist. Results: Our model revealed that when the probability of achieving a good result, graded as Chen level one or two is greater than 73%, transplantation is preferred over no transplantation. The decision is sensitive to the probability of major complications and the utility of a transplanted limb with minimal function. Conclusions: The results of this analysis show that under some circumstances given a high probability of satisfactory functional recovery, unilateral hand transplantation can be justified.
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Affiliation(s)
| | | | | | - Steven J. McCabe
- University of Toronto, Toronto, ON, Canada,Steven J. McCabe, Hand & Upper Extremity Program, Division of Plastic & Reconstructive Surgery, University of Toronto, 399 Bathurst Street, 2EW-423, Toronto, ON, Canada M5T 2S8.
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Public's Knowledge and Attitudes Toward Vascularized Composite Allotransplantation and Donation. Aesthetic Plast Surg 2016; 40:301-8. [PMID: 26893283 DOI: 10.1007/s00266-016-0623-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/01/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of this survey was to assess the public's knowledge and attitudes toward vascularized composite allotransplantation and donation. METHODS Members of the public (n = 5942) were surveyed using a questionnaire that examined their knowledge and attitudes concerning solid organs (kidney, heart, liver, lung, and pancreas) and vascularized composite tissue (hand/upper extremity, lower extremity, abdominal wall, and face) transplantations and donations. RESULTS Respondents demonstrated greater (all P < 0.05) knowledge and willingness to donate and/or receive solid organs than vascularized composite tissues. Educational level, accurate knowledge, willingness to donate, and willingness to receive were significant (all P < 0.05) determinants of acceptance to donate and/or receive hand/upper extremity, lower extremity, face, and/or abdominal wall. CONCLUSION The public presented less knowledge and willingness to donate and/or receive hand/upper extremity, lower extremity, abdominal wall, and face. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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A methodological analysis of the plastic surgery cost-utility literature using established guidelines. Plast Reconstr Surg 2014; 133:584e-592e. [PMID: 24675210 DOI: 10.1097/prs.0000000000000004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cost-utility studies, common in medicine, are rare within plastic surgery despite their capability of measuring the value of procedures by considering the societal costs of improving quality of life. The objectives of this study were to analyze the design quality of the plastic surgery cost-utility literature and to identify areas of needed improvement for future studies. METHODS A scoring tool was constructed based on the Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. A PubMed search through October of 2012 was conducted for English-language plastic surgery utility studies. Articles were selected using two inclusion criteria and evaluated using the scoring tool. RESULTS A 9-point scoring tool was created, and 37 publications were selected. Their average score was 3 out of 9 points. Thirty studies (81 percent) used population preferences in utility measurements. Fifteen studies (41 percent) measured costs, but only four (11 percent) included indirect costs and only five (14 percent) applied discount rates to calculate the value of treatments over time. Three studies (8 percent) earned zero points. The highest scoring study earned 8 points. CONCLUSIONS The identified studies manifest the potential of cost-utility analyses in plastic surgery. Nonetheless, they are inconsistent in applying established cost-utility guidelines, especially in measuring costs and conducting recommended sensitivity analysis. Following this simple scoring tool can help future studies achieve some necessary improvements.
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Moffett ML, Suarez-Almazor ME. Prospect theory in the valuation of health. Expert Rev Pharmacoecon Outcomes Res 2014; 5:499-505. [DOI: 10.1586/14737167.5.4.499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Barker JH, Allen F, Cunningham M, Basappa PS, Wiggins O, Banis JC, Alloway RR, Steve WE, Frank JM. Risk assessment and management in hand and facial tissue transplantation. Eur J Trauma Emerg Surg 2011; 37:469. [DOI: 10.1007/s00068-011-0131-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 06/16/2011] [Indexed: 12/22/2022]
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Chung KC, Oda T, Saddawi-Konefka D, Shauver MJ. An economic analysis of hand transplantation in the United States. Plast Reconstr Surg 2010; 125:589-598. [PMID: 19910847 PMCID: PMC4387885 DOI: 10.1097/prs.0b013e3181c82eb6] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations. METHODS One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results. RESULTS For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY. CONCLUSIONS Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.
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Affiliation(s)
- Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI
| | - Takashi Oda
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI
| | - Daniel Saddawi-Konefka
- Transitional Year Program, Saint Joseph Mercy Hospital System of Ann Arbor; Ann Arbor, MI
| | - Melissa J. Shauver
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI
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Schuind F, Abramowicz D, Schneeberger S. Hand transplantation: the state-of-the-art. J Hand Surg Eur Vol 2007; 32:2-17. [PMID: 17084950 DOI: 10.1016/j.jhsb.2006.09.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 08/04/2006] [Accepted: 09/04/2006] [Indexed: 02/03/2023]
Abstract
The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient's pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.
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Affiliation(s)
- F Schuind
- Service d'Orthopédie-Traumatologie, Cliniques Universitaires de Bruxelles, Hôpital Erasme, 808 route de Lennik, B-1070, Brussels, Belgium.
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Cugno S, Sprague S, Duku E, Thoma A. Composite tissue allotransplantation of the face: Decision analysis model. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2007; 15:145-52. [PMID: 19554146 PMCID: PMC2687497 DOI: 10.1177/229255030701500304] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Facial composite tissue allotransplantation is a potential reconstructive option for severe facial disfigurement. The purpose of the present investigation was to use decision analysis modelling to ascertain the expected quality-adjusted life years (QALYs) gained with face transplantation (versus remaining in a disfigured state) in an effort to assist surgeons with the decision of whether to adopt this procedure. STUDY DESIGN The probabilities of potential complications associated with facial allotransplantation were identified by a comprehensive review of kidney and hand transplant literature. A decision analysis tree illustrating possible health states for face allotransplantation was then constructed. Utilities were obtained from 30 participants, using the standard gamble and time trade-off measures. The utilities were then translated into QALYs, and the expected QALYs gained with transplantation were computed. RESULTS Severe facial deformity was associated with an average of 7.34 QALYs. Allotransplantation of the face imparted an expected gain in QALYs of between 16.2 and 27.3 years. CONCLUSIONS The current debate within the medical community surrounding facial composite tissue allotransplantation has centred on the issue of inducing a state of immunocompromise in a physically healthy individual for a non-life-saving procedure. However, the latter must be weighed against the potential social and psychological benefits that transplantation would confer. As demonstrated by a gain of 26.9 QALYs, participants' valuation of quality of life is notably greater for face transplantation with its side effects of immunosuppression than for a state of uncompromised physical health with severe facial disfigurement.
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Affiliation(s)
- Sabrina Cugno
- Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Ontario
| | - Sheila Sprague
- Department of Surgery, Division of Plastic and Reconstructive Surgery, St Joseph’s Healthcare, Hamilton, Ontario
| | - Eric Duku
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Achilleas Thoma
- Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Ontario
- Department of Surgery, Division of Plastic and Reconstructive Surgery, St Joseph’s Healthcare, Hamilton, Ontario
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
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Abstract
Now that partial face transplantation has been performed, attention is focused on likely functional, aesthetic and immunological outcomes, and full facial transplantation is the likely next step. Facial transplantation has been the source of ethical debate, a key part of which focuses on valid informed consent. We review the process of informed consent in health settings, assessing how applicable the current standards are for facial transplantation. The factors which need to be assessed during the screening programme are outlined. We conclude that both individual and process factors are important in obtaining consent for radical new procedures, and outline our own gold standard for ensuring informed consent in facial transplantation.
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Affiliation(s)
- Anthony Renshaw
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
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Barker JH, Furr A, Cunningham M, Grossi F, Vasilic D, Storey B, Wiggins O, Majzoub R, Vossen M, Brouha P, Maldonado C, Reynolds CC, Francois C, Perez-Abadia G, Frank JM, Kon M, Banis JC. Investigation of Risk Acceptance in Facial Transplantation. Plast Reconstr Surg 2006; 118:663-70. [PMID: 16932174 DOI: 10.1097/01.prs.0000233202.98336.8c] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant. METHODS To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures. RESULTS The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures. CONCLUSIONS This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.
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Affiliation(s)
- John H Barker
- Department of Surgery, University of Louisville, KY 40202, USA.
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Majzoub RK, Cunningham M, Grossi F, Maldonado C, Banis JC, Barker JH. Investigation of risk acceptance in hand transplantation. J Hand Surg Am 2006; 31:295-302. [PMID: 16473694 DOI: 10.1016/j.jhsa.2005.09.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Revised: 09/19/2005] [Accepted: 09/19/2005] [Indexed: 02/02/2023]
Abstract
PURPOSE Twenty-four hands have been transplanted in 18 individuals and clinicians continue to debate whether the risks justify the benefits in these procedures. To assess quantitatively the risks versus benefits in hand transplantation we used a validated instrument (Louisville Instrument for Transplantation) to measure the degree of risk individuals are willing to accept to receive different types of transplantation procedures. METHODS The Louisville Instrument for Transplantation contains 237 standardized questions that incorporate modified standard gamble and time trade-off outcome measures and questions that assess body image perception, depression, self-esteem, optimism, socially desirable responding, and demographics. Respondents were questioned on the extent to which they would trade off specific numbers of life-years or sustain other costs in exchange for receiving 7 different transplantation procedures. For this study we questioned 227 individuals in 4 study populations with differing life experiences: healthy individuals, organ transplant recipients, upper-extremity amputee patients, and lower-extremity amputee patients. RESULTS All populations questioned perceived risk similarly despite their differing life experiences and would accept differing degrees of risk for the different transplantation procedures. Organ transplant recipients were the most risk-tolerant group whereas upper-extremity amputee patients were the most risk adverse, even when considering a single hand transplant. All groups that were questioned would accept a higher degree of risk to receive a double versus a single hand transplant. CONCLUSIONS By questioning individuals who have experienced directly the risks of immunosuppression and those who could benefit from hand transplantation, this study presents an empiric basis for assessing risk versus benefit in this procedure.
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Affiliation(s)
- Ramsey K Majzoub
- Department of Surgery, University of Louisville, Louisville, KY 40202, USA
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Abstract
The practice of medicine takes place in an environment of uncertainty. Expected value decision making, prospect theory, and regret theory are three theories of decision making under uncertainty that may be used to help us learn how patients and physicians make decisions. These theories form the underpinnings of decision analysis and provide the opportunity to introduce the broad discipline of decision science. Because decision analysis and economic analysis are underrepresented in upper extremity surgery, the authors believe these are important areas for future research.
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Affiliation(s)
- John Myers
- Yale University School of Medicine, Department of Epidemiology and Public Health, Division of Biostatistics, New Haven, CT, USA
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Abstract
Transplantation of a vascularized limb or its components is defined as composite tissue allotransplantation, and is one of the newest areas in surgery. To date, 24 hands have been transplanted onto 18 recipients. The initial results have been promising, and hand transplantation may become an important procedure for functional restoration of upper limbs. However, the ethical aspects of using chronic immunosuppression for a condition which is not life threatening have been the subject of debate. In this article, we review the field of composite tissue allotransplantation.
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Affiliation(s)
- Hebe D Kvernmo
- Department of Orthopaedics, Division of Hand and Microsurgery, National Hospital, NO-0027 Oslo, Norway.
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Barker JH, Vossen M, Banis JC. The Technical, Immunological and Ethical Feasibility of Face Transplantation. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1743-9191(06)60016-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Petit F, Minns AB, Dubernard JM, Hettiaratchy S, Lee WPA. Composite tissue allotransplantation and reconstructive surgery: first clinical applications. Ann Surg 2003; 237:19-25. [PMID: 12496526 PMCID: PMC1513974 DOI: 10.1097/00000658-200301000-00004] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the first clinical cases of composite tissue allotransplantation (CTA) for reconstructive surgery and to discuss the outcome of and indications for these procedures in the context of chronic immunosuppression. SUMMARY BACKGROUND DATA The first human hand transplant was performed in 1998. This procedure, as well as other composite tissue transplants, offers the potential for correcting untreatable large tissue defects. However, concerns remain regarding obligatory chronic immunosuppression and long-term functional results. METHODS All the CTAs performed in humans that have been published or documented were reviewed. The preexisting clinical conditions and surgical procedures and the immunosuppressive therapy are described. The functional results and the complications or side effects of the treatment are detailed. RESULTS Vascularized tendons (two cases), vascularized femoral diaphyses (three cases), knees (five cases), hands (four bilateral and seven unilateral cases), larynx (one case), and nonvascularized peripheral nerves (seven cases) have been transplanted in humans in the past decade. Rejection was prevented in most cases without difficulty. Early results are encouraging, particularly for hand and larynx transplants, but will need to be evaluated in the long term and in a larger number of patients. CONCLUSIONS CTA holds great potential for reconstructive surgery but is at present restricted by the risks of chronic immunosuppression and uncertain long-term results.
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Affiliation(s)
- François Petit
- Plastic Surgery Research Laboratory, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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Abstract
The decision to perform a human hand transplant was justified perhaps on less than an ideal scientific basis-only approximately 60 rat limb transplants and 2 primate limb transplants have survived for longer than 200 days and only 8 of 19 pig limb osteomyocutaneous transplants showed no signs of rejection at 90 days. It seems unlikely that the survival of a human hand transplant will be any better than the survival of a kidney transplant, which has a half-life of approximately 7.5 to 9.5 years. Fourteen hand transplants, however, have now been performed in 11 humans with the skin component of 1 remaining viable up to 3 years after surgery. Intermittent episodes of acute rejection seem to have been relatively simple to reverse by temporarily increasing the dose of immunosuppressive agents and steroids. Chronic rejection has occurred in 1 patient, necessitating re-amputation of the transplanted hand. Active range of motion of the digits has been surprisingly better than would have been expected based on previous results of replantation, but return of sensibility has been less than optimal. The immunosuppression has been well tolerated without any major medical problems or life-threatening episodes, but some patients have developed chronic viral and fungal infections and several have developed posttransplant diabetes. Extrapolating from the previous experience of solid-organ transplants, chronic immunosuppression may predispose a hand transplant patient to an 80% chance of developing an infection, a 20% potential risk of developing posttransplant diabetes, and a 4% to 18% potential risk of developing a malignancy. Even though there is universal agreement that composite tissue allograft transplantation will become the ultimate reconstructive option, no one can predict the eventual role of hand transplantation in the future, but perhaps an international database of these hand transplant patients should be established so that independent reviewers can more objectively evaluate their functional outcome, the incidence of chronic rejection, and the risks of long-term immunosuppression.
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Affiliation(s)
- Neil F Jones
- UCLA Hand Center, Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, CA 90095, USA
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Breidenbach WC, Tobin GR, Gorantla VS, Gonzalez RN, Granger DK. A position statement in support of hand transplantation. J Hand Surg Am 2002; 27:760-70. [PMID: 12239664 DOI: 10.1053/jhsu.2002.35306] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The scientific basis for human trials of hand transplantation was both experimental and clinical. Prolonged survival of limb transplants was achieved in small and large animals by using novel immunosuppressive drugs. Further, all tissue components of the hand (skin, muscle, tendon, nerve, bone, and joint) were individually transplanted with success in humans. After appropriate institutional review of the ethics, experimental data, treatment protocol, and informed consent, clinical trials were approved. Thirteen hands have been transplanted onto 10 recipients, with resultant low morbidity and no mortality. With the exception of one recipient who requested amputation after the second year, results of hand transplantation have been highly successful. Functional return mirrored that seen after hand replantation. The limbs were progressively integrated into activities of daily living and professional tasks. The hand and patient survival rate exceeds the initial results of any previously transplanted organ. This success strongly supports continuation of these human trials.
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Affiliation(s)
- Warren C Breidenbach
- Christine M. Kleinert Institute of Hand and Microsurgery, Jewish Hospital, Louisville, KY 40202, USA
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Affiliation(s)
- John H Barker
- Division of Plastic and Reconstructive Surgery, Department of Surgery at the University of Louisville, Medical School, Louisville, KY 40292, USA
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