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Chaput B, Meresse T, Bekara F, Grolleau JL, Gangloff D, Gandolfi S, Herlin C. Lower limb perforator flaps: Current concept. ANN CHIR PLAST ESTH 2020; 65:496-516. [PMID: 32753250 DOI: 10.1016/j.anplas.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022]
Abstract
Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.
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Affiliation(s)
- B Chaput
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France.
| | - T Meresse
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - F Bekara
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - J L Grolleau
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France
| | - D Gangloff
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - S Gandolfi
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France; Department of Plastic and Hand Surgery, CHU Charles Nicolle, 76000 Rouen, France
| | - C Herlin
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
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Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer. Ann Plast Surg 2019; 84:S34-S39. [PMID: 31800552 DOI: 10.1097/sap.0000000000002188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects. PATIENTS AND METHODS A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction. RESULTS Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm. All flap areas exceeded 80% of the lower abdominal area. Overall, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5-117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7. CONCLUSIONS Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores.
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Lee JS, Eom JR, Lee JW, Choi KY, Chung HY, Cho BC, Yang JD. Safe delayed procedure of nipple reconstruction in poorly circulated nipple. Breast J 2018; 25:129-133. [PMID: 30557907 DOI: 10.1111/tbj.13167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 11/30/2022]
Abstract
Nipple-areolar complex reconstruction represents the final step in breast reconstruction. However, there is no gold standard nipple reconstruction technique that addresses the issue of blood circulation in the flap, which is the most basic complication. Nipple reconstruction was performed in 21 patients. A delayed procedure was performed when a poor outcome was expected due to marginal pinpoint bleeding in the distal tip after flap elevation during nipple reconstruction. The delayed nipple reconstruction can be viewed as a safe and reliable method for improving nipple blood circulation, reducing complications, and enabling long-term nipple projection maintenance in high-risk patients.
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Affiliation(s)
- Joon Seok Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeung Ryeol Eom
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong Woo Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kang Young Choi
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ho Yun Chung
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Chae Cho
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Dug Yang
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
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Li X, Chen M, Jiang Z, Liu Y, Lu L, Gong X. Visualized identification of the maximal surgical delay effect in a rat flap model. Wound Repair Regen 2018; 27:39-48. [PMID: 30338888 DOI: 10.1111/wrr.12680] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 08/23/2018] [Accepted: 10/02/2018] [Indexed: 11/27/2022]
Abstract
Currently, experimental evidence suggests that the surgical delay can increase flap survival area, but its effect may decrease if the optimal delay period is missed. The aim of this study is to establish a sensitive and objective modality based on the visualized and individualized infrared thermography for identifying the maximal surgical delay effect. A rectangular three-angiosome flap was designed on the unilateral dorsum of the rat. Ninety-six rats were randomly divided into six groups according to the various delay time. Both the relative temperature and the relative temperature ratio were measured by the infrared thermography. Arterial density, number of vessels >0.1 mm in diameter, microvessel density, VEGF concentration, and flap viability were measured. Receiving operating characteristic curve with the highest Youden-Index was used to detect and identify an optimal cutoff point of the relative temperature ratio in the maximal surgical delay effect. The criteria for identifying the flap maximum delay effect based on the infrared thermography included the surface of the postdelayed flaps presented white color (higher temperature) instead of the red and white pattern of the normal skin and the optimal cutoff point of the relative temperature ratio was ≥1.17 with a sensitivity of 84.6% and a specificity of 77.3%. Instead, the sensitivity and specificity of the conventional method based on the delay time were 38.5 and 90.9%, respectively. Infrared thermal imaging can accurately identify the maximum delay effect when combined with the relative temperature ratio.
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Affiliation(s)
- Xiucun Li
- Department of Hand Surgery, Foot and Ankle Surgery, The Second Hospital of Shandong University, Shandong University, Jinan, Shandong, China.,Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
| | - Miao Chen
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
| | - Zhenmin Jiang
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
| | - Yang Liu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
| | - Laijin Lu
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
| | - Xu Gong
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.,Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, Changchun, Jilin, China
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Delayed procedure in propeller perforator flap: Defining the venous perforasome. J Plast Reconstr Aesthet Surg 2017; 70:286-289. [DOI: 10.1016/j.bjps.2016.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 11/05/2016] [Accepted: 11/18/2016] [Indexed: 11/20/2022]
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Kundu N, Chopra K, Morales R, Djohan R, Chung T, Gastman BR. Superior epigastric artery perforator (SEAP) flap: A novel approach to autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68:519-24. [DOI: 10.1016/j.bjps.2014.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 08/15/2014] [Accepted: 12/07/2014] [Indexed: 11/27/2022]
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Vosburg RW, White MJ, Heckler FR. Supercharging of delayed pedicled transverse rectus abdominis myocutaneous flaps, is it a viable option? Microsurgery 2014; 35:204-6. [DOI: 10.1002/micr.22301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 12/15/2022]
Affiliation(s)
- R. Wesley Vosburg
- Department of Plastics and Reconstructive SurgeryAllegheny General HospitalPittsburgh PA
| | - Michael J. White
- Department of Plastics and Reconstructive SurgeryAllegheny General HospitalPittsburgh PA
| | - Frederick R. Heckler
- Department of Plastics and Reconstructive SurgeryAllegheny General HospitalPittsburgh PA
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Li Y, Xu J, Zhang XZ. Lowering the pivot point of sural neurofasciocutaneous flaps to reconstruct deep electrical burn wounds in the distal foot. Burns 2013; 39:808-13. [DOI: 10.1016/j.burns.2012.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 08/04/2012] [Accepted: 08/15/2012] [Indexed: 11/30/2022]
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Delaying the superficial inferior epigastric artery flap: A solution to the problem of the small calibre of the donor artery. J Plast Reconstr Aesthet Surg 2011; 64:1181-6. [DOI: 10.1016/j.bjps.2011.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/28/2011] [Accepted: 04/10/2011] [Indexed: 11/23/2022]
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Comparison of two different vascular delay methods in a rat cranial epigastric perforator flap model. Ann Plast Surg 2009; 64:89-92. [PMID: 20023457 DOI: 10.1097/sap.0b013e3181951720] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The effectiveness of vascular delay in transverse rectus abdominis muscle flaps has been demonstrated in many studies. In deep inferior epigastric perforator flaps, however, the effectiveness of ligation of deep versus superficial epigastric vessels in producing delay is unclear. Using a rat model, we compared ligation of deep and superficial vessels with each other and with a (nondelayed) control group (n = 10). One vascular delay group (n = 10) had ligation of the contralateral cranial epigastric vessels (homolog to the human deep inferior epigastric vessels); the other (n = 10) had ligation of contralateral superficial inferior epigastric vessels. One week later, cranial epigastric perforator flap elevation was performed. Both vascular techniques were effective in producing delay, and there was no statistically significant difference between the 2 groups. Ligation of superficial inferior epigastric vessels, deep inferior epigastric vessels, or both, at least 1 week prior to the deep inferior epigastric perforator flap elevation may increase the usable skin paddle area in humans.
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Preoperative Angio-CT Preliminary Study of the TRAM Flap After Selective Vascular Delay. Ann Plast Surg 2007; 59:611-6. [DOI: 10.1097/sap.0b013e31803df4d0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.
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Affiliation(s)
- Glyn Jones
- Division of Plastic and Reconstructive Surgery, Emory Crawford Long Hospital, Atlanta, GA 30308, USA.
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Abstract
Adequate delay of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap might not necessarily require interruption of the venous system. The retained ipsilateral deep vein of the dominant pedicle could then be used as a secondary outflow source for potential salvage of a congested flap. A venous "supercharged" rat TRAM flap model has been designed to evaluate the efficacy of this maneuver. Seventy-two female Sprague-Dawley rats (CD) were equally divided into two major groups, differing only in whether a delay by division of the dominant cranial epigastric artery had first been performed. An inferior-based TRAM flap (nondominant) was raised for each rat, with three subsets of 12 rats in each group, ie, with the cranial epigastric vein subsequently divided (group control), retained (supercharged), or retained but the inferior pedicle divided (venous flap). Both supercharged subsets had significantly augmented flap survival when compared with flaps in their group raised without the cranial epigastric vein, whether a delay maneuver had (96 +/- 6% vs 89 +/- 7%; P = 0.012) or not (80 +/- 8% vs 65 +/- 21%; P = 0.034) been performed. Flaps with only a cranial epigastric vein pedicle totally necrosed, implying that the observed enhancement in flap viability was not the result of transformation into a venous flap, but perhaps as a crossover flap where an adjacent venosome was captured. Venous supercharging can be accomplished by inclusion of the ipsilateral dominant deep vein, and should be a consideration in the clinical planning of delay maneuvers and for treatment of the compromised TRAM flap.
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Affiliation(s)
- Kazufumi Sano
- Department of Plastic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
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Venous Interruption Is Unnecessary to Achieve an Adequate Delay in the Rat TRAM Flap Model. Plast Reconstr Surg 2003. [DOI: 10.1097/00006534-200301000-00051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Distally-based neurocutaneous flaps have been used successfully for reconstruction of the lower extremity for some decades. The reconstruction of deep wounds exposing tendons, bones and/or vessels in electrical burns requires flap coverage. It is known that there is often some sub-clinical vascular damage in electrical burn injury. Therefore, an important part of the procedure is modification to improve flap viability during the reconstruction of electrical burn wounds. In this paper, we report our experience with the use of distally-based sural and saphenous neurocutaneous flaps for coverage of defects in the lower leg and foot in 14 electrical burn patients. In 12 patients, the flaps survived completely, in two patients the flaps underwent partial necrosis. In these cases, the width of the pedicle of the neurocutaneous flap was increased from 3.5 to 5cm and the neurovenous pedicle was decreased to give a delay effect several days before the flap harvesting. We believe that these modifications positively effect the viability of the flap and should be used to improve neurocutaneous flap circulation in high risk patients.
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Affiliation(s)
- Serkan Yildirim
- Department of Plastic and Reconstructive Surgery, Kartal Dr. Lütfü Kirdar Education and Research Hospital, Göztepe, Istanbul, Turkey.
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Sano K, Hallock GG, Rice DC. The relative importance of the deep and superficial vascular systems for delay of the transverse rectus abdominis musculocutaneous flap as demonstrated in a rat model. Plast Reconstr Surg 2002; 109:1052-7; discussion 1058-9. [PMID: 11884834 DOI: 10.1097/00006534-200203000-00041] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The use of some form of delay maneuver for "high-risk" patients before transfer of the superior pedicled lower transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction has augmented the rate of success in both the experimental and clinical arenas. A common method of vascular delay has been the bilateral division of both the superficial inferior epigastric and deep inferior epigastric vessels. Whether all of these must be divided to adequately effect the delay is unknown. For that matter, the relative importance of the superficial versus the deep vascular systems is unclear. To investigate this uncertainty, a delay was attempted in 61 Sprague-Dawley rats by division of either the superficial inferior epigastric or deep cranial epigastric vessels (the latter is the homologue to the human deep inferior epigastric) in unilateral or bilateral fashion. Division of the contralateral superficial inferior epigastric vessel resulted in significantly greater TRAM flap survival than either ipsilateral or bilateral superficial inferior epigastric vessel division (p = 0.0034 or p = 0.0093, respectively). Division of the ipsilateral or bilateral deep cranial epigastric vessel resulted in significantly greater flap survival than just contralateral deep cranial epigastric vessel division (p = 0.0034 or p = 0.006, respectively). No significant difference was observed between the group having contralateral superficial inferior epigastric or groups with ipsilateral deep cranial epigastric division, implying that either alone would be efficacious to achieve the desired delay effect. This would allow the other vascular system to be retained intact for later potential salvage maneuvers as needed.
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Affiliation(s)
- Kazufumi Sano
- Department of Plastic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan
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Restifo RJ, Ahmed SS, Rosser J, Zahir K, Zink J, Lalikos JA, Thomson JG. TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure. Plast Reconstr Surg 1998; 101:1503-11. [PMID: 9583479 DOI: 10.1097/00006534-199805000-00012] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.
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Affiliation(s)
- R J Restifo
- Yale University School of Medicine, Section of Plastic Surgery, New Haven, Conn 06520-8041, USA
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