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Chrelias T, Berkane Y, Rousson E, Uygun K, Meunier B, Kartheuser A, Watier E, Duisit J, Bertheuil N. Gluteal Propeller Perforator Flaps: A Paradigm Shift in Abdominoperineal Amputation Reconstruction. J Clin Med 2023; 12:4014. [PMID: 37373707 DOI: 10.3390/jcm12124014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Abdominoperineal amputation (AAP) is a gold standard procedure treating advanced abdominal and pelvic cancers. The defect resulting from this extensive surgery must be reconstructed to avoid complications, such as infection, dehiscence, delayed healing, or even death. Several approaches can be chosen depending on the patient. Muscle-based reconstructions are a reliable solution but are responsible for additional morbidity for these fragile patients. We present and discuss our experience in AAP reconstruction using gluteal-artery-based propeller perforator flaps (G-PPF) in a case series. Between January 2017 and March 2021, 20 patients received G-PPF reconstruction in two centers. Either superior gluteal artery (SGAP)- or inferior artery (IGAP)-based perforator flaps were performed depending on the best configuration. Preoperative, intraoperative, and postoperative data were collected. A total of 23 G-PPF were performed-12 SGAP and 11 IGAP flaps. Final defect coverage was achieved in 100% of cases. Eleven patients experienced at least one complication (55%), amongst whom six patients (30%) had delayed healing, and three patients (15%) had at least one flap complication. One patient underwent a new surgery at 4 months for a perineal abscess under the flap, and three patients died from disease recurrence. Gluteal-artery-based propeller perforator flaps are an effective and modern surgical procedure for AAP reconstruction. Their mechanic properties, in addition to their low morbidity, make them an optimal technique for this purpose; however, technical skills are needed, and closer surveillance with patient compliance is critical to ensure success. G-PPF should be widely used in specialized centers and considered a modern alternative to muscle-based reconstructions.
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Affiliation(s)
- Theodoros Chrelias
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Yanis Berkane
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- MICMAC, UMR INSERM U1236, Rennes University Hospital, 35033 Rennes, France
| | - Etienne Rousson
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Korkut Uygun
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bernard Meunier
- Department of Hepatobiliary and Digestive Surgery, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Alex Kartheuser
- Colorectal Surgery Unit, Department of Surgery, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Eric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
| | - Jérôme Duisit
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Department of Plastic and Reconstructive Surgery, Hôpitaux IRIS Sud, 1050 Brussels, Belgium
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, South Hospital, CHU Rennes, University of Rennes 1, 35700 Rennes, France
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Shriners Children's Boston, Harvard Medical School, Boston, MA 02115, USA
- MICMAC, UMR INSERM U1236, Rennes University Hospital, 35033 Rennes, France
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Bertheuil N, Leclere FM, Bekara F, Watier E, Flécher E, Duisit J. Superior epigastric artery perforator flap for reconstruction of deep sternal wound infection. Microsurgery 2021; 41:405-411. [PMID: 33844355 DOI: 10.1002/micr.30743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/08/2021] [Accepted: 03/16/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The treatment of deep wound sternal infection requires loco-regional pedicled flaps, usually with muscular flaps. Perforator propeller flaps represent the ultimate progress in the history of reconstructive surgery. We report here our experience with the superior epigastric artery perforator (SEAP) flaps to repair sternal defect. PATIENTS AND METHODS Six patients presenting deep sternal wounds infection were treated with SEAP propeller flap, between March 2015 and June 2017. The mean age was 71.5 (range 53-83) years. The mean length and width of the defect were 16.2 × 7 cm (ranging 8-20 × 4-10). An elliptical skin flap pedicled on the SEAP was harvested in the inframammary fold and rotated up to 90° to cover the defect. RESULTS All SEAP flaps achieved a successful entire coverage of the defect. The mean size of the skin paddle of the flap was 20.2 × 7.3 cm (ranging 14-27 × 6-9). All flaps were able to provide a complete sternal wound cover. Venous congestion was present in five cases and adequately treated by leech therapy; necrosis was distal in one case, and interesting the entire superficial flap in two cases but with deep tissues remaining viable and able to cover the mediastinum: an infected flap required revision. Satisfyingly, at 2-years postoperative follow-up all-patients were alive with a successful mediastinal cover. CONCLUSIONS The SEAP Perforator propeller flap is an alternative to muscle flaps to achieve treatment of deep and large sternal wound infection.
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Affiliation(s)
- Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, Rennes, France.,INSERM U1236, University of Rennes 1, Rennes, France.,SITI Laboratory, Etablissement Français du Sang Bretagne, Rennes University Hospital, Rennes, France
| | - Franck-Marie Leclere
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU of Poitiers, Poitiers, France
| | - Farid Bekara
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU of Montpellier, Montpellier, France
| | - Eric Watier
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, Rennes, France
| | - Erwan Flécher
- Department of cardiac and thoracic surgery, CHU of Rennes, Rennes, France
| | - Jérôme Duisit
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3327. [PMID: 33564571 PMCID: PMC7858245 DOI: 10.1097/gox.0000000000003327] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
Venous congestion is a frequent problem in flap surgery. Other than surgical revision, there are a multitude of procedures in the literature to tackle this problem, but their effectiveness is not clear. Through a systematic review, we aimed to identify and evaluate the different interventions available for managing flap venous congestion. Methods The MEDLINE, PubMed central, Embase, and Cochrane databases were searched. The study selection process was adapted from the PRISMA statement. All English and French original articles describing or comparing a method for managing flap venous congestion were included. For each article, a level of evidence was assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we specifically analyzed the effectiveness of postoperative non-surgical methods. No formal analysis was performed. Results Through literature searches carried out in various databases, we identified 224 articles. Finally, 72 articles were included. The majority of these studies had a low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10 postoperative) were found. Concerning non-surgical methods, the most represented were leeches, local subcutaneous injection of heparin with scarification, venocutaneous catheterization, negative pressure therapy, and hyperbaric oxygen therapy. Conclusions Risks of venous congestion of flaps must always be present in a surgeon's mind, at every stage of flap surgery. Apart from studies on the use of leeches, which have a significant follow-up and large enough patient numbers to support their efficacy, the low-level evidence associated with studies of other methods of venous congestion management does not allow us to draw a scientifically valid conclusion about their effectiveness.
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Chaput B, Meresse T, Bekara F, Grolleau JL, Gangloff D, Gandolfi S, Herlin C. Lower limb perforator flaps: Current concept. ANN CHIR PLAST ESTH 2020; 65:496-516. [PMID: 32753250 DOI: 10.1016/j.anplas.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022]
Abstract
Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.
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Affiliation(s)
- B Chaput
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France.
| | - T Meresse
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - F Bekara
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - J L Grolleau
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France
| | - D Gangloff
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
| | - S Gandolfi
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, 31000 Toulouse, France; Department of Plastic and Hand Surgery, CHU Charles Nicolle, 76000 Rouen, France
| | - C Herlin
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, 34000 Montpellier, France
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Use of the Propeller Lumbar Perforator Flap: A Series of 32 Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2522. [PMID: 32095384 PMCID: PMC7015594 DOI: 10.1097/gox.0000000000002522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 09/11/2019] [Indexed: 11/25/2022]
Abstract
Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility. Methods Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps. Results We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8-26) × 6.5 cm (range 5-10), and average arc of rotation was 131.3 degrees (range 70-180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1-18). Conclusions In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.
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Management of Pilonidal Sinus Disease with the Aesthetically Shaped Parasacral Perforator Flap: Multicenter Evaluation of 228 Patients. Plast Reconstr Surg 2019; 144:971-980. [PMID: 31568314 DOI: 10.1097/prs.0000000000006087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of pilonidal sinus disease is still not standardized. Currently, the two main procedures are a lay-open excision procedure with secondary healing or coverage with local flaps. The authors present their experience with a one-stage excision-coverage with an innovative parasacral artery perforator flap propeller designed to respect the aesthetic unity of the buttocks. METHODS Study patients were managed with this procedure in the Toulouse, Montpellier, and Rennes university hospitals between 2012 and 2018. Data were collected on clinical and surgical details, immediate and late postoperative complications, and long-term recurrence. Aesthetic satisfaction was evaluated with a self-evaluation questionnaire. RESULTS The authors operated on 228 consecutive patients for pilonidal sinus disease with an aesthetically shaped parasacral artery perforator flap. The median patient age was 23.5 years, the median operative time was 46 minutes, the median flap length was 9.3 cm (range, 6.5 to 14 cm), and the median flap width was 4.1 cm (range, 4 to 6.5 cm). There were five distal necroses but no complete flap necrosis. There were six postoperative hematomas, 11 infections, and 18 wound dehiscences. The median follow-up period was 27.9 months. Median hospital length of stay was 4.2 days. Three recurrences of pilonidal sinus disease and six instances of hidradenitis suppurativa were detected. Approximately 82 percent of the women and more than 85 percent of the men were "satisfied" or "very satisfied" with the aesthetic outcome, without significant differences between the sexes (p = 0.901). CONCLUSIONS The aesthetically shaped parasacral artery perforator flap combines very satisfactory results regarding recurrence and postoperative recovery with cosmetic outcome. This procedure is technically more demanding than other flap procedures, although it is accessible to numerous surgeons as the first-line treatment for pilonidal sinus disease after initial learning. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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de Bonnecaze G, Chaput B. An innovative reconstruction procedure of total nasal resurfacing with a bipedicled propeller perforator flap. Head Neck 2019; 41:3049-3055. [PMID: 31038813 DOI: 10.1002/hed.25790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/10/2019] [Accepted: 04/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A forehead frontal flap is the treatment of choice for complex nasal defects. However, in patients with contra indications for such frontal flaps, few alternatives are available. METHODS We developed a three-stage, nasal reconstruction procedure using a bipedicled, propeller perforator flap based on the modiolus perforators. Here, we describe the flap, the harvesting thereof, and the 6-month outcomes after placement. RESULTS The flap did not exhibit any sign of necrosis or congestion. Six months after reconstruction, the patient had not suffered any esthetic or functional sequela. CONCLUSION Although the indications for our new flap are less numerous than those for a frontal flap, our flap is a useful alternative when frontal flap placement is not feasible (or the patient refuses such a flap) and when placement of a free flap is too risky.
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Affiliation(s)
| | - Benoit Chaput
- Plastic and Reconstructive Surgery Department, University Hospital of Toulouse, Toulouse, France
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Bonte A, Bertheuil N, Menez T, Grolleau JL, Herlin C, Chaput B. Distally Based Medial Plantar Flap: A Classification of the Surgical Techniques. J Foot Ankle Surg 2019; 57:1230-1237. [PMID: 29937338 DOI: 10.1053/j.jfas.2018.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 02/03/2023]
Abstract
The proximally based medial plantar flap is considered to be the reference standard for heel reconstruction. Although less well-studied, a distally based medial plantar flap is a suitable alternative when used to cover a distal foot defect, especially of the hallux, first metatarsal, or metatarsophalangeal joint. Our objective was to provide a complete description and propose a classification of the different surgical procedures used to harvest this flap. A review of the data reported in the MEDLINE database until May 2017 concerning the distally based medial plantar flap was performed. We have illustrated the different surgical procedures through a case series. Three approaches or "types" of flap have been described, and we have proposed a classification for reconstructive surgeons. In type 1, the plantar pedicle is ligatured before division into the medial and lateral plantar artery. In type 2, the medial plantar pedicle is cut proximally just after division. In type 3, the flap is harvested to include the fasciocutaneous perforator vessels, as an advancement flap or a propeller perforator flap. A distally based medial plantar flap affords adequate and reliable coverage of the weightbearing zone. Because the donor site drawbacks are minimal, this flap is a useful option for distal foot reconstruction, and reconstructive surgeons should remember this flap. The type 1 flap appears to be associated with a minimal risk of flap necrosis, even in those with diabetes or arteriopathy, and can cover even the most distal defect.
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Affiliation(s)
- Amandine Bonte
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Lille University Hospital, Lille, France
| | - Nicolas Bertheuil
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud, University of Rennes 1, Rennes, France
| | - Tiphaine Menez
- Surgeon, Department of Plastic, Reconstructive and Aesthetic Surgery, Bordeaux University Hospital, Bordeaux France
| | - Jean-Louis Grolleau
- Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil University Hospital, Toulouse, France
| | - Christian Herlin
- Professor, Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Benoit Chaput
- Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil University Hospital, Toulouse, France.
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Luca‐Pozner V, Boissiere F, Rodriguez T, Karra A, Herlin C, Chaput B. Complex abdominopelvic reconstruction by combined tensor fascia latae and superficial circumflex iliac artery perforator flaps. Microsurgery 2018; 40:25-31. [DOI: 10.1002/micr.30391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/24/2018] [Accepted: 08/28/2018] [Indexed: 11/10/2022]
Affiliation(s)
- V Luca‐Pozner
- Department of Plastic and Reconstructive Surgery, Burns and Wound Healing UnitsCHRU Lapeyronie Montpellier France
| | - F Boissiere
- Department of Plastic and Reconstructive Surgery, Burns and Wound Healing UnitsCHRU Lapeyronie Montpellier France
| | - T Rodriguez
- Department of Orthopedic and Trauma Surgery, Upper Limb and Spine Surgery UnitCHU Lapeyronie Montpellier France
| | - A Karra
- Department of Plastic and Reconstructive Surgery, Burns and Wound Healing UnitsCHRU Lapeyronie Montpellier France
| | - C Herlin
- Department of Plastic and Reconstructive Surgery, Burns and Wound Healing UnitsCHRU Lapeyronie Montpellier France
| | - B Chaput
- Department of Plastic, Reconstructive, Aesthetic Surgery and BurnsCHRU Rangueil Toulouse France
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Chaput B, Bertheuil N, Grolleau JL, Bekara F, Carloni R, Laloze J, Herlin C. Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: A prospective study. Microsurgery 2017; 38:177-184. [DOI: 10.1002/micr.30162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Benoit Chaput
- Department of Plastic and Reconstructive Surgery; Rangueil University Hospital; Toulouse France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery; Hospital Sud, University of Rennes 1; Rennes France
| | - Jean-Louis Grolleau
- Department of Plastic and Reconstructive Surgery; Rangueil University Hospital; Toulouse France
| | - Farid Bekara
- Department of Plastic and Reconstructive Surgery; Lapeyronie University Hospital; Montpellier France
| | - Raphael Carloni
- Department of Plastic and Hand Surgery; CHU Charles Nicolle; Rouen France
| | - Jerome Laloze
- Department of Plastic and Reconstructive Surgery; Rangueil University Hospital; Toulouse France
| | - Christian Herlin
- Department of Plastic and Reconstructive Surgery; Lapeyronie University Hospital; Montpellier France
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Delayed procedure in propeller perforator flap: Defining the venous perforasome. J Plast Reconstr Aesthet Surg 2017; 70:286-289. [DOI: 10.1016/j.bjps.2016.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 11/05/2016] [Accepted: 11/18/2016] [Indexed: 11/20/2022]
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