1
|
Danielian A, Razfar A, Labib MT, Seth R, Nabili V, Blackwell KE, Kerr RPR. Ultrasonic Shears Decrease Postoperative Hematomas in Head and Neck Microvascular Reconstruction. Otolaryngol Head Neck Surg 2024; 171:395-399. [PMID: 38680041 DOI: 10.1002/ohn.794] [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: 11/11/2023] [Revised: 03/16/2024] [Accepted: 04/06/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To evaluate postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral hospital. METHODS A total of 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates. RESULTS The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870), relative risk = 0.28, P = .0015. Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared to 8 of 1418 (0.56%) in the ultrasonic shears cohort. CONCLUSION Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction.
Collapse
Affiliation(s)
- Arman Danielian
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Ali Razfar
- Facial Plastic Surgery Private Practice, Los Angeles, California, USA
| | - Manwel T Labib
- David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Rahul Seth
- Golden State Plastic Surgery, Walnut Creek, California, USA
| | - Vishad Nabili
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Keith E Blackwell
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| | - Rhorie P R Kerr
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
| |
Collapse
|
2
|
Hathi K, Nam YSJ, Fowler J, Dishan B, Madou E, Sowerby LJ, MacNeil SD, Nichols AC, Strychowsky JE. Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review. Otolaryngol Head Neck Surg 2024. [PMID: 38769856 DOI: 10.1002/ohn.822] [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: 01/31/2024] [Revised: 04/04/2024] [Accepted: 04/27/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology. DATA SOURCES MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022. REVIEW METHODS Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed. RESULTS The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases. CONCLUSION The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.
Collapse
Affiliation(s)
- Kalpesh Hathi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - You Sung Jon Nam
- Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | - James Fowler
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| | - Brad Dishan
- Corporate Academics, Health Sciences Library, London Health Sciences Center, London, Ontario, Canada
| | - Edward Madou
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| | - Leigh J Sowerby
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| | - Anthony C Nichols
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| | - Julie E Strychowsky
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Canada
| |
Collapse
|
3
|
Xie Z, Yan K, Qu Y, Gao S, Lu T, Hu C, Wang S, Shangguan W, Wu G. A Retrospective Study of Transaxillary Endoscopic Breast Augmentation Using Ultrasonic Scalpel or Conventional Electrocautery for Implant Pocket Dissection. Aesthetic Plast Surg 2024; 48:1949-1955. [PMID: 37626139 DOI: 10.1007/s00266-023-03569-8] [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: 06/14/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Ultrasonic scalpel has been reported to be superior to conventional electrocautery in many studies. However, with respect to transaxillary endoscopic breast augmentation, few studies on the effect of ultrasonic scalpel are available in the literature. METHODS The medical records of 173 female patients who underwent breast augmentation via endoscopic transaxillary approach from January 2018 to December 2020 were reviewed retrospectively. The patients were divided into two groups according to the implant pocket dissection instruments. In group A, the implant pockets were dissected with conventional electrocautery (EC group) on 81 patients, and in group B, ultrasonic scalpel (US group) was used for implant pockets on 92 patients. All operations were performed by the same senior plastic surgeon and the same surgical team. The operation time, intraoperative blood loss, postoperative total drainage volume, days of drainage, postoperative surgical site pain and hospital stay time of the two groups were compared and analyzed statistically. RESULTS The average operation time of the US group (83.82 ± 11.57 min) was significantly shorter than that of the EC group (101.40 ± 14.36 min), intraoperative blood loss in the US group was significantly less than that of the EC group (18.67 ± 6.20 ml vs. 21.59 ± 6.44 ml), the mean hospital stay days (2.96 ± 0.69 vs. 4.30 ± 1.11), total drainage volume (122.24 ± 43.81 vs. 232.37 ± 99.15), and duration of drain (2.52 ± 0.54 vs. 3.77 ± 1.10), mean VAS score for surgical site pain on 3 postoperative days (5.08 ± 1.35 vs. 6.51 ± 1.36, 4.08 ± 1.16 vs. 5.40 ± 1.32, 3.04 ± 0.91 vs. 4.06 ± 1.11) were significantly lower in the US group compared to the EC group. CONCLUSIONS The ultrasonic scalpel reduces operative time, intraoperative blood loss, postoperative drainage, postoperative pain, hospital stay time, and incidence of complications. The ultrasonic scalpel is safe and reliable for transaxillary endoscopic breast augmentation. LEVEL OF EVIDENCE IV 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 .
Collapse
Affiliation(s)
- Zhiyang Xie
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Kaili Yan
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Yuming Qu
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Sheng Gao
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Tong Lu
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Chao Hu
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Shu Wang
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Wensong Shangguan
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China
| | - Guoping Wu
- Department of Plastic Surgery, The Affiliated Friendship Plastic Surgery Hospital of Nanjing Medical University, Nanjing, 210029, Jiangsu province, China.
| |
Collapse
|
4
|
Hofmann M, Haeberlin A, de Brot S, Stahel A, Keppner H, Burger J. Development and evaluation of a titanium-based planar ultrasonic scalpel for precision surgery. ULTRASONICS 2023; 130:106927. [PMID: 36682289 DOI: 10.1016/j.ultras.2023.106927] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/21/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
This paper introduces a titanium-based planar ultrasonic microscalpel. The concept of silicon-based planar ultrasonic transducers has already been proven, but they are not yet suitable for clinical use due to material failure. The main objective of this work was to develop a smaller, lighter, and more cost-effective ultrasonic scalpel that could be used as an alternative or supplementary device to current surgical instruments. Various prototypes were fabricated and characterized, differing in bonding by three epoxy adhesives and two solder pastes as well as three variations in tip design. The instruments were designed to operate in the frequency range of commercial instruments and to generate a longitudinal displacement amplitude. The electro-mechanical characterization through impedance analysis and vibration measurements was complemented by an in vitro cutting trial and an acute in vivo animal experiment in comparison to commercial ultrasonic and electrosurgical devices. The operating frequency was around 40 kHz and 48 kHz depending on whether matched or unmatched operation was used. Unmatched operation turned out to be more suitable, achieving displacement amplitudes of 25.3 μm and associated velocity amplitudes of up to 7.9 m/s at an electrical power of 10.2 W. The cutting ability was demonstrated in vivo by successful dissection even under anticoagulation. The geometry of the instrument tip was found to have a major influence on cutting performance by affecting the resonance behaviour and tissue penetration.
Collapse
Affiliation(s)
- Martin Hofmann
- School of Biomedical and Precision Engineering, University of Bern, 3008 Bern, Switzerland; Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland.
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, 3008 Bern, Switzerland; Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Simone de Brot
- COMPATH, Institute of Animal Pathology, University of Bern, 3012 Bern, Switzerland
| | - Andreas Stahel
- School of Engineering and Computer Science, Bern University of Applied Sciences, 2501 Biel, Switzerland
| | - Herbert Keppner
- Haute Ecole Arc Ingénierie, University of Applied Sciences Western Switzerland (HES-SO), 2300 La Chaux-de-Fonds, Switzerland
| | - Juergen Burger
- School of Biomedical and Precision Engineering, University of Bern, 3008 Bern, Switzerland; Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| |
Collapse
|
5
|
Kim J, Shin Y, Jeong W. Harmonic scalpels compared with electrocautery in reconstructive flap harvesting: A meta-analysis. Microsurgery 2021; 42:89-96. [PMID: 34652038 DOI: 10.1002/micr.30831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/01/2021] [Accepted: 09/28/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Numerous studies have compared electrical devices used for flap surgery, but the results are inconsistent. This research was performed to evaluate the efficacy of two different types of electric devices: electrocautery and ultrasonic shears. METHODS The PubMed, Embase, and Scopus databases were searched systematically. A total of 505 cases were included in this study, including 209 electrocautery and 296 harmonic scalpel cases. The following information was retrieved from the included studies: the first author of the article, publication year, flap type, flap harvest time, drain volume, bleeding volume and postoperative complications. Hematoma, infection, flap necrosis and wound dehiscence were considered postoperative complications. The Q statistic for heterogeneity and the I2 index were calculated. If I2 < 50%, we used a fixed-effects model; if I2 > 50%, we employed a random-effects model in our meta-analysis. RESULTS A total of eight studies which met the inclusion criteria were included and reviewed systematically for a meta-analysis. The harmonic scalpel yielded a statistically significantly more favorable flap harvest time and drain volume than did electrocautery. The Harmonic scalpel led to a shorter flap harvest time by 26.29 min (95% CI = -39.38 to -13.2; p < .00001) and smaller drain volume by 58.76 ml (95% CI = -105.27 to -12.25; p = .01) on average. However, there were no significant differences in the bleeding volume or incidence rates of infection, flap necrosis and wound dehiscence. CONCLUSION The Harmonic scalpel method yields better outcomes in terms of the flap harvest time and drain volume than does the conventional electrocautery method. Therefore, the Harmonic scalpel is a better option for cauterization and dissection in flap surgery.
Collapse
Affiliation(s)
- Jaehoon Kim
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Youngmin Shin
- Department of Oromaxillofacial Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Woonhyeok Jeong
- Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| |
Collapse
|
6
|
Mayo-Yánez M, Calvo-Henríquez C, Lechien JR, Fakhry N, Ayad T, Chiesa-Estomba CM. Is the ultrasonic scalpel recommended in head and neck surgery during the COVID-19 pandemic? State-of-the-art review. Head Neck 2020; 42:1657-1663. [PMID: 32441394 PMCID: PMC7280627 DOI: 10.1002/hed.26278] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022] Open
Abstract
Background Guidelines for ultrasonic devices use are imperative because infectious aerosols arising from airway procedures were a key etiologic factor in prior coronavirus outbreaks. This manuscript aims to summarize the available recommendations and the most relevant concepts about the use of ultrasonic scalpel during the SARS‐CoV‐2 pandemic. Methods Literature review of manuscripts with patients, animal models, or in vitro studies where the ultrasonic scalpel was used and the plume produced was analyzed in a quantitative and/ or qualitative way. Discussion Activated devices with tissue produce a biphasic bioaerosol composed (size 68.3‐994 nm) of tissue particles, blood, intact and no viable cells, and carcinogenic or irritant hydrocarbons (benzene, ethylbenzene, styrene, toluene, heptene, and methylpropene). Conclusion It is imperative to use an active smoke evacuator, to avoid ultrasonic scalpel use in COVID‐19 positive patients and in upper airway surgery, as well as to follow the protection recommendations of the guidelines for management this type of patients.
Collapse
Affiliation(s)
- Miguel Mayo-Yánez
- Otorhinolaryngology-Head and Neck Surgery Department, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Galicia, Spain.,Clinical Research in Medicine, International Center for Doctorate and Advanced Studies (CIEDUS), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Galicia, Spain
| | - Christian Calvo-Henríquez
- Clinical Research in Medicine, International Center for Doctorate and Advanced Studies (CIEDUS), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Galicia, Spain.,Otorhinolaryngology-Head and Neck Surgery Department, Complexo Hospitalario Universitario Santiago de Compostela (CHUS), Santiago de Compostela, Galicia, Spain
| | - Jérôme R Lechien
- Human Anatomy & Experimental Oncology Department, Faculty of Medicine UMONS Research Institute for Health Sciences and Technology , University of Mons (UMons), Mons, Belgium.,Otorhinolaryngology and Head and Neck Surgery Department, CHU de Bruxelles, CHU Saint-Pierre, School of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Fakhry
- Otolaryngology-Head and Neck Surgery Department, Universitary Hospital of la Conception Marseille, France
| | - Tareck Ayad
- Division of Otolaryngology-Head & Neck Surgery , Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Carlos M Chiesa-Estomba
- Otorhinolaryngology-Head and Neck Surgery Department, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| |
Collapse
|
7
|
Fibula Free Flap Elevation without Tourniquet: Are Harmonic Scalpel Shears Useful? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2409. [PMID: 31942388 PMCID: PMC6908411 DOI: 10.1097/gox.0000000000002409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
8
|
Schneider D, Goppold K, Kaemmerer PW, Schoen G, Woehlke M, Bschorer R. Use of ultrasonic scalpel and monopolar electrocautery for skin incisions in neck dissection: a prospective randomized trial. Oral Maxillofac Surg 2018; 22:169-175. [PMID: 29492789 DOI: 10.1007/s10006-018-0686-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Ultrasonic scalpel (UC) and monopolar electrocautery (ME) are standard equipment for soft tissue surgery. The aim of the present study was to compare intraoperative and postoperative patterns of patients using either UC or ME for skin incisions in neck dissection. MATERIAL AND METHODS In a prospective randomized study of 30 patients, the thermal effects of UC (n = 15) and ME (n = 15) were examined using real-time infrared thermographic imaging. Additionally, tissue damage was evaluated histopathologically. The other measured variables were operation and bleeding time, postoperative pain score (only neck incision area), in-patient time, and complications. RESULTS UC significantly reduces the thermal effects, compared to ME (p < 0.001). The mean depth of tissue damage (i.e., necrosis) was 272.7 μm for UC and 284.7 μm for ME with no significant difference (p = 0.285). From the third postoperative day, patients treated using UC had noticeably less pain in the neck incision area (t3 p = 0.010; t4 p < 0.001; t5 p < 0.005). Cutting time was reduced for ME by 36.1 s (p < 0.001) and the bleeding time was decreased by 40.9 s for UC (p < 0.001). The total preparation time was the same (p = 0.402). When comparing in-patient time (p = 0.723), as well as complications, no significant differences were seen. CONCLUSION UC results in less postoperative pain and less bleeding in the neck incision area. Accordingly, UC is superior to ME for skin incisions in neck dissection.
Collapse
Affiliation(s)
- Daniel Schneider
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany.
| | - Kai Goppold
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany
| | - Peer W Kaemmerer
- Department of Oral and Maxillofacial Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Woehlke
- Institute of Pathology, Helios Kliniken Schwerin, Schwerin, Germany
| | - Reinhard Bschorer
- Department of Oral and Maxillofacial Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393-397, 19049, Schwerin, Germany
| |
Collapse
|
9
|
Free Flap Elevation Times in Head and Neck Reconstruction Using the Harmonic Scalpel Shears. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e718. [PMID: 27579242 PMCID: PMC4995721 DOI: 10.1097/gox.0000000000000740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/01/2016] [Indexed: 11/26/2022]
Abstract
Free tissue transfer has become the mainstay of head and neck cancer (HNC) reconstructive surgery. The objective of the study is to examine the efficacy of the Harmonic Scalpel (HS) Shears on free flap elevation time and complication rates after HNC reconstruction compared with traditional electrocautery. A retrospective review of 215 HNC patients undergoing surgical ablation and free flap reconstruction from January 2010 to April 2013 at the University of Alberta Hospital was undertaken. All patients requiring free flap reconstruction with radial forearm free flap or fibula free flap were included. Overall, there was no significant difference demonstrated between the HS and electrocautery groups for free flap elevation time for RFFFs (P = 0.563) or FFFs (P = 0.087). No differences were observed in donor-site complications. The HS is a reliable, safe, and alternative method of free flap elevation in HNC reconstructive surgery.
Collapse
|