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Aksoyler D, Ercan A, Losco L, Chen SH, Chen HC. Experience in reconstruction of esophagus, epiglottis, and upper trachea due to caustic injuries in pediatric patients and establishment of algorithm. Microsurgery 2021; 42:125-134. [PMID: 34536298 DOI: 10.1002/micr.30805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/08/2021] [Accepted: 08/27/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Unintentional swallowing of corrosive agents cause problems in the pediatric population. Swallowing dysfunction can be seen after injuring the pharynx and/or epiglottis which leads to the obstruction of esophagus. An algorithm was established taking into account the injury to the epiglottis and restoring gastrointestinal continuity with isolated or combine free and or supercharged jejunum flap, or supercharged colon transposition flap. METHODS Seventeen patients between the ages of 3 and 16 (mean age: 7.7) were treated between 1985 and 2019. Three different procedures were performed based on endoscopic findings; for patients with no or minimal damage to epiglottis, pedicled colon transposition was done in 12 cases. For patients with epiglottic scarring or edema, a two-stage reconstruction was performed. In the first stage, free jejunum flap was implemented to the pharynx to facilitate food passage, followed by a pedicled jejunum in two cases, or a pedicled colon transposition in two cases to provide gastrointestinal continuity. For one patient with severe epiglottic scarring, a free jejunal flap was used as a diversion conduit in the first stage, followed by supercharged colon transposition to restore gastrointestinal continuity. RESULTS Supercharged intestinal flaps were harvested with 3-4 cm of extra intestinal tissue than the measured thoracic portion in each individual in order to reach the hypopharyngeal region. The size of the free jejunal flaps were 10 cm. Oral feeding was initiated on the eighth postoperative day. Partial loss of the anterior wall of the jejunal flap was seen in one case, in which a free anterolateral thigh-vastus lateralis musculocutaneous flap was used for reconstruction. The mean follow-up time was 5.1 years and there was no stricture in the final outcome. CONCLUSION A competent epiglottis is essential for proper swallowing reflex. Meticulous microsurgical dissection and performing supercharged intestinal flaps provide a complication-free end result.
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Affiliation(s)
- Dicle Aksoyler
- Department of Plastic Reconstructive and Aesthetic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Alp Ercan
- Department of Plastic Reconstructive and Aesthetic Surgery, Atasehir Memorial Hospital, Istanbul, Turkey
| | - Luigi Losco
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Shih-Heng Chen
- Department of Plastic Reconstructive and Aesthetic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Reconstructive and Aesthetic Surgery, China Medical University Hospital, Taichung, Taiwan
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Vinzenz K, Schaudy C. Osteoplastic surgery of the face – state of the art and future aspects. Eur Surg 2011. [DOI: 10.1007/s10353-011-0040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Motility Differences in Free Colon and Free Jejunum Flaps for Reconstruction of the Cervical Esophagus. Plast Reconstr Surg 2008; 122:1410-1416. [DOI: 10.1097/prs.0b013e31818820f4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Vinzenz K, Holle J, Würinger E. Reconstruction of the maxilla with prefabricated scapular flaps in noma patients. Plast Reconstr Surg 2008; 121:1964-1973. [PMID: 18520882 DOI: 10.1097/prs.0b013e3181706dd6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with a high rate of mortality. When untreated, it results in disfiguring midface defects and severe scarring. Ideal reconstruction of complex maxillofacial defects requires the restitution of bone, dental implants, soft tissue, and the thin and durable lining of the oral and paranasal cavities. Prefabricated composite grafts from the scapula are used to restore the maxilla in patients with this disease. METHODS A new concept of osteosynthesis involving titanium plates connected to dental implants, achieving greater mechanical stability of the reconstructed bony framework, is described. Nine complex midface defects were reconstructed with dermis-prelaminated scapular flaps. A bone flap from the lateral margin of the scapula was taken and osseointegrated implants were inserted. The bone flap was then prelaminated with dermis and covered with a Gore-Tex sheath to prevent adhesion. Two to 3 months later, the composite flap was transferred to the midface. RESULTS Restoration of a maxilla with pneumatized paranasal cavities and a keratinized attached epithelium covering the alveolus and hard palate was successfully performed in all noma patients. The reconstructed "masticatory gingiva" and osseointegrated dental implants enabled patients to exercise oral functions shortly after surgery. CONCLUSION Long-term observation of selected noma patients showed restoration of oral function and stability of the maxilla after several years.
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Affiliation(s)
- Kurt Vinzenz
- Vienna, Austria From the Department of Plastic and Reconstructive Surgery, Wilhelminenspital Vienna, and the Department of Oral and Maxillofacial Surgery, Evangelisches Krankenhaus Vienna
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Swisher SG, Hofstetter WL, Miller MJ. The supercharged microvascular jejunal interposition. Semin Thorac Cardiovasc Surg 2007; 19:56-65. [PMID: 17403459 DOI: 10.1053/j.semtcvs.2006.11.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2006] [Indexed: 12/15/2022]
Abstract
In a distinct subset of patients, traditional gastric conduits are not available as esophageal replacements, due to either intrinsic disease, tumor involvement, or previous surgery. Esophageal reconstruction in this group can prove daunting. Colonic interposition can be considered as an alternative conduit, but the "supercharged" jejunum (SPJ) may also serve as another option for total esophageal reconstruction. With an experienced hospital team familiar with esophageal surgery and microvascular reconstruction, morbidity is acceptable and long-term functional benefits may exist with this conduit. This article will review the indications and potential problems with the SPJ and will try to impart some of the important technical points that have been identified to minimize the risk of this complex but useful esophageal reconstruction.
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Affiliation(s)
- Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Talbot SG, Cordeiro PG. Inverted, stapled J-pouch free jejunal transfer for reconstruction of the pharynx and esophagus. J Surg Oncol 2007; 95:663-9. [PMID: 17458909 DOI: 10.1002/jso.20760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Since the advent of the jejunal free flap in the early 1900s, it has become one of the most effective and widely used methods for reconstruction of circumferential defects of the esophagus, often due to malignant disease. However, as esophageal resections extend further cranially, reconstruction becomes more difficult due to the size discrepancy between the proximal jejunum and the pharygostome. Several authors have described techniques to overcome this problem, although there is, as yet, no consensus on the most effective method. Here we present our experience with an inverted, stapled J-pouch free jejunal transfer, analogous to that used in the ileoanal anastomosis after proctocolectomy for the treatment of ulcerative colitis and familial polyposis coli. In the head and neck, the inverted J-pouch provides several advantages when a resection extends into the pharynx: a closer size match to the large pharyngeal defect, a reservoir to aid swallowing, and increased conduit size proximally to aid gravity-dependent swallowing in the presence of uncoordinated peristalsis and tongue resection. This technique has served as a safe, effective, and rapid operation for this complex reconstructive problem.
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Affiliation(s)
- Simon G Talbot
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Ascioti AJ, Hofstetter WL, Miller MJ, Rice DC, Swisher SG, Vaporciyan AA, Roth JA, Putnam JB, Smythe WR, Feig BW, Mansfield PF, Pisters PWT, Torres MT, Walsh GL. Long-segment, supercharged, pedicled jejunal flap for total esophageal reconstruction. J Thorac Cardiovasc Surg 2005; 130:1391-8. [PMID: 16256794 DOI: 10.1016/j.jtcvs.2005.06.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Revised: 06/20/2005] [Accepted: 06/30/2005] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Many patients with cancer have limited esophageal reconstruction options when the stomach is unavailable as a replacement conduit or when long-segment discontinuity exists. Jejunum has been used as an alternative conduit, both as a pedicled or free flap interposition; however, reports of this are usually limited to short-segment repairs. Microvascular augmentation of a pedicled jejunal flap allows creation of a longer conduit, making it possible to replace the entire esophagus with jejunum. Few reports describe this technique in patients with cancer. We report our initial experience with "supercharged" pedicled jejunum as an alternative conduit for total esophageal reconstruction. METHODS Review of a prospectively collected departmental database was performed to identify those patients who underwent total esophageal reconstruction with supercharged pedicled jejunum. Data regarding their perioperative course and postoperative function were gathered from the prospectively collected clinical data, review of hospital records, and patient interviews. RESULTS Total esophageal reconstruction with supercharged pedicled jejunum was attempted in 26 patients (age range, 37-74 years) between March 2000 and April 2004. Twenty-four of 26 patients were ultimately discharged with an intact supercharged pedicled jejunum flap, for an overall success rate of 92.3%. One patient experienced intraoperative flap loss caused by technical difficulties harvesting the flap and never had the flap interposed. One other flap loss occurred in the early postoperative period in a patient who had multisystem organ failure after a prolonged reconstruction. Cervical anastomotic leaks occurred in 19.2% (5/26) of the patients. Two midconduit leaks occurred that were suspicious for iatrogenic perforation from nasogastric tube placement; one required reoperation. One additional early reoperation was performed for cecal ischemia. There were no mortalities. Functional results were available in 95.4% (21/22) of the patients receiving supercharged pedicled jejunum who survived at least 6 months after reconstruction. At the time of follow-up, 95% (20/21) of the patients were tolerating regular diet, and 76.2% (16/21) did not require any supplemental alimentation. Ninety-five percent (20/21) of the patients were free from reflux symptoms, and 80.9% (17/21) had no dumping symptoms. Only 1 patient required dilation of a midconduit stricture. One patient required late reoperation for conduit redundancy. CONCLUSIONS Supercharged pedicled jejunum is a suitable alternative conduit for total esophageal replacement in patients with cancer with otherwise limited reconstructive options. Functional outcomes are excellent, despite the severity of disease and technical challenges in this patient population.
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Affiliation(s)
- Anthony J Ascioti
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Tex 77030, USA
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Schlenz I, Korak KJ, Kunstfeld R, Vinzenz K, Plenk H, Holle J. The dermis-prelaminated scapula flap for reconstructions of the hard palate and the alveolar ridge: a clinical and histologic evaluation. Plast Reconstr Surg 2001; 108:1519-24; discussion 1525-6. [PMID: 11711921 DOI: 10.1097/00006534-200111000-00012] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ideal reconstructions of complex defects in the midface require the restitution not only of bone and soft tissue, but also of a thin and durable lining of the oral cavity. So far, split-thickness skin grafts, intestinal grafts, and in vitro cultured mucosal grafts have been used for the reconstruction of the oral lining. The use of skin as a substitute for oral mucosa is controversial because contraction, hair growth, maceration, and dysplastic changes can occur. This clinical and histologic study was performed to evaluate the suitability of dermis as a substitute for oral lining. Twelve complex defects of the midface were reconstructed with dermis-prelaminated scapula flaps. A bony flap from the lateral border of the scapula was prepared, and osseointegrated implants were placed. The bone flap was then prelaminated with dermis and covered with a Gore-Tex membrane to prevent adhesions. The composite flap was transferred to the midface 2 to 3 months later. The oral lining of the flap was evaluated clinically and histologically at 2, 4, and 6 weeks and at 3 to 41 months after the reconstruction. In all patients, the reconstructed bone was covered with a thin and lubricated surface without hair growth. None of the patients showed any signs of maceration. Histologically, these findings corresponded to a keratinized stratified squamous epithelium with highly developed connective-tissue papillae. These features closely resemble those of the normal mucosa of the hard palate and the gingiva. Thus, dermis prelamination is an effective method for reconstructing the mucosa of the alveolar ridge and the hard palate.
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Affiliation(s)
- I Schlenz
- Department of Plastic and Reconstructive Surgery, Wilhelminenspital, Vienna, Austria.
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Abstract
The loss or stricture of the esophagus has a tremendous impact on daily life. Before the era of microsurgery, many patients had to rely on tube feeding from jejunostomy following failure of esophageal reconstruction with conventional methods. Since the application of microsurgery, almost all kinds of esophageal defects can be reconstructed successfully with microvascular transfer of jejunum, colon, and skin flaps. Microsurgery is also used to augment the blood supply for the pedicled colon and jejunum flaps. In 97.6% of cases, successful reconstruction has been achieved. The leakage rate and functional results are evaluated for each group. For the pharynx and cervical esophagus, jejunum is the best choice. For replacement of the thoracic esophagus, a pedicled colon flap is the first choice, but it can be supercharged with microvascular anastomoses to the neck vessels if necessary. We conclude that the microsurgical transfer of jejunum, colon, and skin flaps is a useful approach for reconstruction of the esophagus. With proper selection of the organ substitute and correct inset of the flap, it not only provides anatomical replacement, but also a superior functional result. Free jejunum flap transfer requires attention to flap length and duration of ischemia. Free colon flap transfer requires attention to arteriosclerotic changes and the vascular pattern. Free skin flaps require attention to leakage prevention. Semin. Surg. Oncol. 19:235-245, 2000.
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Affiliation(s)
- H C Chen
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
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Wei FC, Carver N, Chen HC, Tsai MH, Wang JY. Free colon transfer for pharyngo-oesophageal reconstruction. BRITISH JOURNAL OF PLASTIC SURGERY 2000; 53:12-6. [PMID: 10657443 DOI: 10.1054/bjps.1999.3251] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This report describes free transfer of transverse colon for reconstruction of the hypopharynx and cervical oesophagus. The transverse colon based on the middle colic vessels was used in three patients following laryngo-pharyngo-oesophagectomy for hypopharyngeal squamous carcinoma. There were no flap failures or intra-abdominal complications. Solid diet was well tolerated. Transverse colon is easy to harvest, has a long vascular pedicle, wide diameter and good ischaemic tolerance. Contrast studies showed it to be a wide bore passive conduit. Compared with currently available options these features may allow better outcome in pharyngo-oesophageal reconstruction and warrant further evaluation.
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Affiliation(s)
- F C Wei
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Medical College, Taipei, Taiwan
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Wei FC, Lutz BS, Chen HC, Tsai MH, Lin PY. Free transverse colon transplantation for functional reconstruction of intra-oral lining: a clinical and histologic study. Plast Reconstr Surg 1998; 102:2346-51. [PMID: 9858168 DOI: 10.1097/00006534-199812000-00011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A variety of free-tissue transplantations are available for oropharyngeal (lining) reconstruction. The most commonly used flap, the radial forearm flap, is relatively thin, adaptable, and reliable but does not provide lubrication. In this study, the potential of the transverse colon to provide a lubricating tissue for replacement of oral lining was investigated. Eleven patients requiring replacement of oral lining received transverse colon flap transplantation between November of 1993 and December of 1995. There was one complete flap loss and one partial loss. Flap size used for reconstruction averaged 40.4 cm2, and average vessel length and diameter were 7 cm and 2.0 mm, respectively. In a follow-up period from 15 to 48 months, all colon flaps proved to be durable with continuous lubrication function. Histologic assessment of the transplanted colon flaps at various postoperative times showed an adequate amount of mucus-secreting goblet cells even after irradiation. There was no donor-site morbidity. The main disadvantage seemed a tendency to transplant too much tissue, which resulted in formation of redundant pockets affecting food handling. Thus, 8 out of 10 patients with flap survival required one to three debulking procedures. Given an accurate estimation of the area of mucosa defect and adequate trimming of the colon flaps, the transverse colon flap offers a good alternative for reconstruction of the oral lining, especially when lubrication is desirable in cases with large defects and preoperative or postoperative irradiation, or in case a radial forearm flap is not available.
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Affiliation(s)
- F C Wei
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
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Yoshida T, Shimizu S, Sakai N, Mochimatsu I, Enomoto H, Nakano A. Expansion of the oral end of free revascularised jejunum with a jejunal patch flap rotated like a folding fan. BRITISH JOURNAL OF PLASTIC SURGERY 1998; 51:103-8. [PMID: 9659111 DOI: 10.1054/bjps.1997.0183] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We have devised a new expansion process for the reconstruction of the cervical oesophagus with free revascularised jejunum in cases of hypopharyngeal cancer. The jejunal island flap is divided into three subislands and the major island of the caudal end is split partially at its oral end. The middle island is split, trimmed triangularly, and inserted into opened major island to expand the diameter of the oral end of the conduit for the cervical oesophagus and to make it funnel-shaped. The smallest island on the oral side is used as a circulation monitor for the transferred jejunum. Because the jejunal island patch is rotated around the root of mesentery like a folding fan and joined to the major island, there is neither shortening of the pedicle nor distortion. This method allows expansion of the oral end by up to 180% to facilitate end to end anastomosis in proximal pharyngeal defects.
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Affiliation(s)
- T Yoshida
- Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Japan
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Smith RW, Martin G, Davies DM. Morphological and morphometric changes in revascularised bowel grafts reconstructing the cervical oesophagus. BRITISH JOURNAL OF PLASTIC SURGERY 1989; 42:199-206. [PMID: 2702369 DOI: 10.1016/0007-1226(89)90204-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Revascularised grafts of jejunum and colon have been used to reconstruct the cervical oesophagus in dogs. The grafts were examined at 2 months to assess their morphological and morphometric behaviour in their new position in the oesophagus. The colonic grafts appeared to adapt completely, while the jejunal ones manifest persisting mucosal changes attributable to their new environment.
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Affiliation(s)
- R W Smith
- Royal Postgraduate Medical School, Hammersmith Hospital, London
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Smith RW, Batten J, Davies DM. The functional recovery of revascularised colon and jejunum replacing the cervical oesophagus. SCANDINAVIAN JOURNAL OF PLASTIC AND RECONSTRUCTIVE SURGERY AND HAND SURGERY 1988; 22:117-20. [PMID: 2847309 DOI: 10.3109/02844318809072381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
An experimental animal model was set up to study the comparative behaviour of revascularised transplants of colon and jejunum used to reconstruct the cervical oesophagus. Age, sex and size matched greyhound dogs were used in the study. An investigation of the physiological behaviour of the graft mucosa was carried out at 8 weeks using the mucosal specific activity of the enzyme Na+K+ATPase. The findings demonstrate a clear depression in the functional behaviour of the jejunal graft mucosa, while the colonic graft mucosa remained biochemically unchanged. The significance of these findings is discussed, and the conclusion drawn that they support the hypothesis that colon makes a more stable and functionally superior free graft than jejunum when replacement of the cervical oesophagus is required.
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Affiliation(s)
- R W Smith
- West of Scotland Plastic and Oral Surgery Unit, Canniesburn Hospital, Bearsden, Glasgow
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