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Heredero S, Falguera MI, Gómez V, Sanjuan-Sanjuan A. Customized Soft Tissue Free Flaps in Head and Neck Reconstruction. Oral Maxillofac Surg Clin North Am 2024; 36:545-555. [PMID: 39155167 DOI: 10.1016/j.coms.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
The integration of imaging technologies such as computed tomography angiography and color Doppler ultrasonography are transforming soft tissue free flap reconstruction. The search for thinner and more refined flaps has expanded indications for flaps harvested from donor sites that were not commonly used in head and neck reconstruction. This article explores how these tools and techniques facilitate precise flap selection, thickness, and design customization based on detailed patient preoperative perforator anatomy and vascular configuration mapping. Optimizing outcomes with tailored flap designs improves surgical accuracy and patient-specific results in soft tissue reconstruction.
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Affiliation(s)
- Susana Heredero
- Department of Maxillofacial Surgery, Hospital Universitario Reina Sofía, Avd. Menéndez Pidal s/n, Córdoba 14004, Spain; Unidad de Cirugía Reconstructiva Avanzada, Hospital Cruz Roja, Paseo de la Victoria s/n, Córdoba 14004, Spain.
| | - Maria Isabel Falguera
- Unidad de Cirugía Reconstructiva Avanzada, Hospital Cruz Roja, Paseo de la Victoria s/n, Córdoba 14004, Spain
| | - Vicenç Gómez
- Department of Maxillofacial Surgery, Hospital Universitario Vall d'Hebron, Pg. Vall d'Hebron 119, Barcelona 08035, Spain
| | - Alba Sanjuan-Sanjuan
- Oral and Maxillofacial Surgery, Charleston Area Medical Center, Charleston, WV 24314, USA
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Matsutani H, Shiraishi T, Kita Y, Fujimoto AH, Takushima A. Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV. J Plast Reconstr Aesthet Surg 2024; 96:168-174. [PMID: 39094371 DOI: 10.1016/j.bjps.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/13/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND When performing breast reconstruction using a deep inferior epigastric artery (DIEA) perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of DIEA, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical applications in breast reconstruction. METHODS This retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. RESULTS PMB was present in approximately 85% of the cases, arising near the lateral border of the rectus abdominis, branching caudomedially in more than half of the cases, and perforating 2.3 cm laterally and 8.8 cm caudally, on average, from the umbilicus. The average perfusion area of zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. CONCLUSIONS The use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.
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Affiliation(s)
- Hitomi Matsutani
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan.
| | - Tomohiro Shiraishi
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Yukihiro Kita
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Avelino Hiroshi Fujimoto
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
| | - Akihiko Takushima
- Department of Plastic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo 181-8611, Japan
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Izadpanah A, Jansen DA, Chaffin AE, Alt EU, Izadpanah R. Nontopical Nitrates in Flap Perfusion and Delay Phenomenon. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5918. [PMID: 38911578 PMCID: PMC11191001 DOI: 10.1097/gox.0000000000005918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/30/2024] [Indexed: 06/25/2024]
Abstract
Background Topical nitrates have demonstrated efficacy in improving flap perfusion. However, evidence for nontopical nitrates in modulation of flap perfusion dynamics has yet to be consolidated. Here, we review evidence regarding the use of intravascular, sublingual, and oral nitrates in modulating flap perfusion. Methods We performed a review of the literature for evidence linking nontopical nitrates and flap perfusion, and included clinical studies, animal studies, and in vitro studies. Results Evidence suggests that intravascular, sublingual, and oral nitrates exert vasodilatory properties, which may be harnessed for identification of perforators and improved flap perfusion. We also found evidence suggesting nitrates may facilitate ischemic preconditioning while reducing ischemia-reperfusion injury. Conclusions Nitrates delivered intravascularly, sublingually, or orally may increase flap perfusion and serve as a method for ischemic preconditioning, particularly in the intraoperative setting.
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Affiliation(s)
- Amin Izadpanah
- From the Applied Stem Cell Laboratory, Department of Medicine, Heart and Vascular Institute, Tulane University Health Science Center, New Orleans, La
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, La
| | - David A. Jansen
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, La
| | - Abigail E. Chaffin
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, La
| | - Eckhard U. Alt
- From the Applied Stem Cell Laboratory, Department of Medicine, Heart and Vascular Institute, Tulane University Health Science Center, New Orleans, La
| | - Reza Izadpanah
- From the Applied Stem Cell Laboratory, Department of Medicine, Heart and Vascular Institute, Tulane University Health Science Center, New Orleans, La
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, La
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Lu G, Su Y, Jiang Y, Yang L, Wang Y, Shi G, Zhang F, Duan X, Hu H. Improving the visualisation of perforator arteries for anterolateral thigh flaps harvest in CT angiography via sublingual glyceryl trinitrate. Clin Radiol 2023; 78:e791-e797. [PMID: 37574403 DOI: 10.1016/j.crad.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 08/15/2023]
Abstract
AIM To investigate the improvement of image quality and visualisation of the anterolateral thigh (ALT) flap perforators on computed tomography angiography (CTA) after administration of sublingual glyceryl trinitrate (GTN). MATERIALS AND METHODS Sixty patients with oral lesions received thigh CTA examinations were divided randomly into two groups after administration of sublingual GTN (GTN group) or without administration of sublingual GTN (non-GTN group). Two radiologists calculated the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and assessed the image quality of each vessel. Besides, the grade of thigh artery, the lumen diameter of deep femoral artery, lateral circumflex femoral artery (LCFA), the descending branch of LCFA and its proximal and distal perforators, and the number and type of visible perforators were evaluated quantitatively. RESULTS The SNR and CNR were not significantly different between the two groups (p>0.05). The image quality of CTA in the GTN group was significantly better than that in the non-GTN group (p<0.01). The lumen diameters of the deep femoral artery, LCFA, the descending branch of LCFA and its perforators were significantly larger in the GTN group than those in the non-GTN group (p<0.01). Compared with the non-GTN group, the number of visible perforators and the number of visible septocutaneous perforators were significantly more in the GTN group, and the qualitative grade of visible perforators was significantly higher (p<0.001). CONCLUSIONS The administration of sublingual GTN in preoperative thigh CTA can improve the image quality and visualisation of perforator vessels, thus could help surgeons to select the optimum ALT flaps.
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Affiliation(s)
- G Lu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Jiang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - L Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - Y Wang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - G Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - F Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China
| | - X Duan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - H Hu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangdong, China.
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Yang L, Yan Z, Lu G, Jiang Y, Wang Y, Shi G, Chen L, Hu H, Duan X. Nitroglycerin improves the visibility of fibula-free flap perforators on computed tomography angiography in patients with oral or maxillofacial lesion. Eur J Radiol 2023; 164:110877. [PMID: 37187079 DOI: 10.1016/j.ejrad.2023.110877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE To investigate the improvement of image quality and visualization of fibula-free flap (FFF) perforators on computed tomography angiography (CTA) after administration of sublingual nitroglycerin (NTG) tablets. METHODS A total of 60 patients with oral or maxillofacial lesions before CTA of the lower extremity were randomly divided into two groups (NTG group and non-NTG group). The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), overall image quality and grading of vessels were evaluated and compared. The lumen diameters of the major arteries and the proximal and distal peroneal perforators were measured. The number of visible perforators in muscular clearance and muscular layer was also counted and compared between the two groups. RESULTS The CNR of posterior tibial artery and overall image quality of CTA images in the NTG group was significantly higher than that in the non-NTG group (p < 0.05), although the SNR and CNR of other arteries did not show significant differences (p > 0.05). The lumen diameters of the peroneal artery and its perforators, anterior tibial artery, and posterior tibial artery were significantly larger in the NTG group (p < 0.001), while no significant difference prevailed in the diameter of the popliteal artery between the two groups (p = 0.298). Compared with the non-NTG group, a significant increase in the number of visible perforators was noted in the NTG group (p < 0.001). CONCLUSIONS The administration of sublingual NTG in CTA of the lower extremity can improve the image quality and visualization of perforators, which aids to surgeons select the optimum FFF.
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Affiliation(s)
- Lingjie Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Zhuoheng Yan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Guoxiong Lu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Yusong Jiang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Yu Wang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Guangzi Shi
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lina Chen
- CHN DI CT Collaboration, Siemens Healthcare Ltd, No.399 West Haiyang Road, Shanghai 200126, China
| | - Huijun Hu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China
| | - Xiaohui Duan
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107 Yanjiang Road West, Guangzhou 510120, Guangdong, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
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Yu XX, Yang SF, Ji CS, Qiu SQ, Qi YD, Wang XM. A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap. Insights Imaging 2022; 13:190. [PMID: 36512153 DOI: 10.1186/s13244-022-01318-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anterolateral thigh perforator (ALTP) flap is considered a versatile flap for soft tissue reconstruction. Computed tomography angiography (CTA) is used for mapping perforator in abdominal-based reconstruction; however, it is less commonly used in ALTP due to its poor imaging efficacy. In this study, we introduced a novel CTA technique for preoperative localization and design of ALTP flap and evaluated its value in directing surgical reconstruction. RESULTS Thirty-five patients with soft tissue defects were consecutively enrolled. Modified CTA procedures, such as sharp convolution kernel, ADMIRE iterative reconstruction, 80 kV tube voltage, high flow contrast agent and cinematic rendering image reconstruction, were used to map ALTPs. A total of 287 perforators (including 884 sub-branches) were determined, with a mean of 5 perforators per thigh (range 2-11). The ALTPs were mainly concentrated in the "hot zone" (42%, 121/287) or the distal zone (41%, 118/287). Most perforators originated from the descending branch of the lateral circumflex femoral artery (76%, 219/287). Three perforator types, namely musculocutaneous (62%, 177/287), septocutaneous (33%, 96/287), and mixed pattern (5%, 14/287), were identified. The median pedicle length measured by two methods was 4.1 cm (range 0.7-20.3 cm) and 17.0 cm (range 4.7-33.9 cm), respectively, and the median diameter of the skin flap nourished by one perforator was 3.4 cm (IQR 2.1-5.7 cm). Twenty-eight ALTP flaps were obtained with the guidance of CTA, and 26 flaps survived after follow-up. CONCLUSIONS The proposed CTA mapping technique is a useful tool for preoperative localization and design of ALTP flap.
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Affiliation(s)
- Xin-Xin Yu
- Department of Radiology, Shandong Provincial Hospital, Shandong University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Shi-Feng Yang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Cong-Shan Ji
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Shen-Qiang Qiu
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Yao-Dong Qi
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
| | - Xi-Ming Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324, Jingwu Road, Jinan, 250021, Shandong, China.
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Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps. Plast Reconstr Surg 2022; 149:750-760. [PMID: 35080525 DOI: 10.1097/prs.0000000000008873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Cohen OD, Abdou SA, Nolan IT, Saadeh PB. Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications. J Reconstr Microsurg 2020; 36:616-624. [PMID: 32643763 DOI: 10.1055/s-0040-1713668] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. PATIENTS AND METHODS Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. RESULTS A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. CONCLUSION ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.
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Affiliation(s)
- Oriana D Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Salma A Abdou
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Pierre B Saadeh
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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