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Christensen JM, Ahn L, Meulendijks MZ, Iskhakov D, Wong F, Winograd J, Valerio IL, Cetrulo CL, Helliwell LA, Eberlin KR. Technical Variables in Lower Extremity Free Flap Reconstruction. J Reconstr Microsurg 2024; 40:78-86. [PMID: 37040875 DOI: 10.1055/a-2071-3250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.
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Affiliation(s)
- Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Leah Ahn
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mara Z Meulendijks
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Iskhakov
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frankie Wong
- Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Winograd
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Curtis L Cetrulo
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Wong FK, Christensen JM, Meulendijks MZ, Iskhakov D, Ahn L, Fruge S, Cetrulo CL, Helliwell LA, Winograd JM, Valerio IL, Eberlin KR. Secondary Surgery after Lower Extremity Free Flap Reconstruction. Plast Reconstr Surg 2023; 152:1118-1124. [PMID: 36912738 DOI: 10.1097/prs.0000000000010403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Microsurgical free tissue transfer may be the only reconstructive option for lower extremity limb salvage. However, the functional and aesthetic results following free tissue transfer after initial salvage may be suboptimal, thus requiring secondary operations to facilitate definitive wound healing and/or refinement. METHODS A multi-institutional retrospective cohort study was performed including patients who underwent lower extremity free tissue transfer from January of 2002 to December of 2020. The authors' primary outcome variable was the presence of secondary surgery after free tissue transfer for lower extremity reconstruction. Independent variables (eg, wound cause, flap, donor type, recipient, comorbidities) were collected. Secondary surgery was categorized as (1) procedures for definitive wound closure and (2) refinement procedures. Multivariable logistic regression was performed to determine which variables were independently associated with the outcome. RESULTS A total of 420 free tissue transfers for lower extremity reconstruction were identified. Secondary surgery was performed in over half (57%) of the patients. Presence of diabetes (OR, 2.0; P = 0.01; 95% CI, 1.2 to 3.5) and use of a latissimus dorsi donor (OR, 2.4; P = 0.037; 95% CI, 1.1 to 5.4) were predictors of wound closure procedures. Fasciocutaneous (OR, 3.6; P < 0.001; 95% CI, 1.8 to 7.2) and myocutaneous (OR, 3.0; P = 0.005; 95% CI, 1.5 to 9.9) flaps were predictors of refinement procedures when compared with muscle-only flaps with skin grafts. CONCLUSIONS The majority of lower extremity free tissue reconstructions required secondary procedures to provide definitive wound closure and/or refinement. Overall, this study provides predictors of secondary surgery that will help formulate patients' expectations of lower extremity limb salvage. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Frankie K Wong
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Joani M Christensen
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Mara Z Meulendijks
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - David Iskhakov
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Leah Ahn
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Seth Fruge
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Curtis L Cetrulo
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School
| | - Jonathan M Winograd
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Ian L Valerio
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Kyle R Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School
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Helliwell LA, Hyland CJ, Gonte MR, Malapati SH, Bain PA, Ranganathan K, Pusic AL. Bias in Surgical Residency Evaluations: A Scoping Review. J Surg Educ 2023; 80:922-947. [PMID: 37142488 DOI: 10.1016/j.jsurg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/21/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States. DESIGN A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively. SETTING/PARTICIPANTS English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included. RESULTS The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery. CONCLUSIONS Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.
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Affiliation(s)
| | | | - Madeleine R Gonte
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Wayne State University School of Medicine, Detroit, Michigan
| | | | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, Massachusetts
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Hyland CJ, Xiang DH, Yang AZ, Helliwell LA, Broyles JM. In-person, Hybrid, and Virtual Grand Rounds in Plastic Surgery: Impact and Participant Perceptions. Plast Reconstr Surg Glob Open 2023; 11:e5103. [PMID: 37441112 PMCID: PMC10335825 DOI: 10.1097/gox.0000000000005103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/15/2023] [Indexed: 07/15/2023]
Abstract
Many plastic surgery residency programs adapted to the COVID-19 pandemic by implementing virtual grand rounds. This study aimed to assess the impact of virtual grand rounds and how attendees perceived virtual grand rounds to inform future programmatic planning. Methods This was a quality improvement initiative involving a cross-sectional survey and retrospective review of administrative records for the 2017-2018 (in-person) and 2021-2022 (virtual) academic years for two academic plastic surgery training programs in Boston, MA. Respondents were residents, fellows, and faculty within the two multisite plastic surgery residency training programs. Results There were 39 respondents (51% faculty, 41% residents, and 8% fellows). There was no evidence of different preferences for the format of future grand rounds (P = 0.08), with most preferring hybrid, defined as in person for speakers and others who could attend. Most respondents indicated a more accessible learning environment (86.8%) and lack of in-person interaction (82.1%) as reasons for liking and not liking virtual grand rounds, respectively. Excluding outliers, attendance in 2021-2022 was on average 7.4% points greater than that in 2017-2018 (P < 0.001), or six to seven more individuals at each session. There were significantly more out-of-state speakers in 2021-2022 (84%) as compared to 2017-2018 (28%) (P = 0.0008). Conclusions Virtual grand rounds improved attendance and the geographic diversity of speakers. Attendees preferred a hybrid format for future grand rounds, citing advantages and disadvantages to both in-person and virtual formats.
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Affiliation(s)
- Colby J. Hyland
- From the Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - David H. Xiang
- From the Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Alan Z. Yang
- From the Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Lydia A. Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Justin M. Broyles
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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Abstract
BACKGROUND Plastic surgeons have been early adopters of social media, and the efficacy and ethics of this practice have been studied. In addition, plastic and reconstructive surgery (PRS) training programs have begun using social media to connect with the public, including prospective PRS applicants. The ability of social media to attract prospective residency applicants is unknown. This study aims to examine the influence of social media on prospective residency applicants and their perception of a plastic surgery program. METHODS In the academic years 2018 and 2019, we conducted an anonymous, voluntary survey among applicants applying to both the integrated and independent Harvard PRS residency programs. The survey collected data regarding demographics, social media usage, online information gathering, and PRS programs' social media influence on applicants' perception/rank position of programs. RESULTS One hundred nine surveys were completed (23%). Ninety-seven percent of respondents reported searching online for information about residency programs. Twenty percent of respondents noted that a residency program's social media platform "influenced their perception of a program or intended rank position of a program" and 72% of those respondents indicated a positive effect on their perception of a program and its rank list position. At least 15% of respondents were concerned that engaging with a program's social media account would attract attention to their own social media accounts. CONCLUSIONS Applicants routinely rely on online resources to gather information regarding prospective residency programs. Fear of attracting attention to their own personal social media pages may limit applicants' engagement with PRS programs on social media. However, residency programs can still utilize social media to deliver important messages, especially as social media usage continues to grow.
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Affiliation(s)
- Timothy J Irwin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA
| | - Johanna N Riesel
- Department of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ricardo Ortiz
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital
| | - Samuel J Lin
- Beth Israel Deaconess Medical Center, Division of Plastic and Reconstructive Surgery, Boston, MA
| | - Kyle R Eberlin
- From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA
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Serebrakian AT, Amador RO, Christensen JM, Pickrell BB, Irwin TJ, Karinja SJ, Broyles JM, Liao EC, Eberlin KR, Helliwell LA. Webinar during COVID-19 Improves Knowledge of Changes to the Plastic Surgery Residency Application Process. Plast Reconstr Surg Glob Open 2020; 8:e3247. [PMID: 33173711 PMCID: PMC7647617 DOI: 10.1097/gox.0000000000003247] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 12/04/2022]
Abstract
BACKGROUND The COVID-19 pandemic has significantly impacted residency application process for all specialties, including plastic surgery residency. Almost all plastic surgery residency programs have suspended visiting sub-internship rotations. This study quantifies the impact of a webinar through an analysis of poll questions and a post-webinar survey sent to all registered participants. METHODS A dedicated webinar was organized and held by the Harvard Plastic Surgery Residency Training Program. All attendees were asked several poll questions during the webinar. The 192 participants were also sent a post-webinar survey. RESULTS The response rate was 68.2% (n = 131). Respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with before the webinar (P < 0.001). Respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (P = 0.009). In addition, respondents who had not taken time off for research or for other endeavors during or after medical school were less confident about their chances to match at the start of the webinar (P = 0.034). CONCLUSIONS An online webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery. Residency programs should consider webinars as a method to inform and assist medical students during the upcoming application season.
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Affiliation(s)
- Arman T. Serebrakian
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Ricardo O. Amador
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Joani M. Christensen
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Brent B. Pickrell
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Timothy J. Irwin
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Sarah J. Karinja
- From the Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Mass
| | - Justin M. Broyles
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Eric C. Liao
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Kyle R. Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Lydia A. Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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Özkan S, Westenberg RF, Helliwell LA, Mudgal CS. Distal Radius Fractures: Evaluation of Closed Reduction and Percutaneous Kirschner Wire Pinning. J Hand Microsurg 2018; 10:134-138. [PMID: 30483019 DOI: 10.1055/s-0038-1648334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/02/2018] [Indexed: 10/14/2022] Open
Abstract
Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.
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Affiliation(s)
- Sezai Özkan
- Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Department of Trauma Surgery, VU University Medical Center, VU University, Amsterdam, The Netherlands
| | - Ritsaart F Westenberg
- Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Lydia A Helliwell
- Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Chaitanya S Mudgal
- Hand and Upper Extremity Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Abstract
Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.
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Affiliation(s)
- Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Matthias B Donelan
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Plastic and Reconstructive Surgery, Shriner's Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA
| | - Kyle R Eberlin
- Plastic and Reconstructive Surgery, Shriner's Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA; MGH Hand Surgery Fellowship, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Caterson SA, Carty MJ, Helliwell LA, Hergrueter CA, Pribaz JJ, Sinha I. Evolving options for breast reconstruction. Curr Probl Surg 2015; 52:192-224. [DOI: 10.1067/j.cpsurg.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/08/2015] [Indexed: 01/11/2023]
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