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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 152-158

Repair of large soft-tissue finger defects with super-thin mobile abdominal flap at thickness of finger skin


Private Aesthetic, Plastic and Reconstructive Surgery Clinic, Bursa, Turkey

Date of Submission24-Jun-2019
Date of Acceptance20-Jul-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Ayhan Okumus
Ilknur Sokak, Bulvar 224 1/B - 10, Ihsaniye, Nilüfer, Bursa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_56_19

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  Abstract 


Background: The repair of soft-tissue defects on fingers usually utilize hand and finger flaps near the defect area. Regional flaps are insufficient for multifinger defects or defects larger than 5 cm, while pedicle flaps produce esthetically and functionally unsatisfactory outcomes due to the thickness of the donor tissue. This study investigates the use of abdominal flaps prepared to match the thickness of finger skin. Material and Methods: A total of 12 fingers (six patients: 3M, 3F, average age: 27), all with soft-tissue defects, that required local flap surgery but for which adjacent local flaps were not sufficient, were included in this study. Random glove-like mobile abdominal flaps prepared from the inguinal region, were applied in similar thinness to the defect skin on all fingers. Results: Cases were followed postoperatively for an average of 7 years. Flap necrosis was not encountered in any patient, and no patients required additional surgery. esthetically and functionally, satisfactory results were obtained by treating large finger defects caused by injuries using this method. Conclusion: We demonstrated that a mobile flap harvested at the thickness of finger skin can be adapted to the finger in such a way that the finger can remain completely outside. This method is favorable and reliable in situations where local flaps are inadequate, such as in the treatment of finger wounds with large defects, multiple finger injuries necessitating circumferential style repairs or where distant and free flaps would lead to esthetic and functional problems.

Keywords: Abdominal flap, circumferential defect, large finger defects, mobile flap, super-thin skin flap


How to cite this article:
Okumus A. Repair of large soft-tissue finger defects with super-thin mobile abdominal flap at thickness of finger skin. Turk J Plast Surg 2020;28:152-8

How to cite this URL:
Okumus A. Repair of large soft-tissue finger defects with super-thin mobile abdominal flap at thickness of finger skin. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 22];28:152-8. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/152/284961




  Introduction Top


Hands, the body parts that interact most frequently with our surroundings, are exposed to more trauma than other parts of the body. Simple burns, small scratches, and light crushes are parts of our daily lives and rarely require treatment. Larger wounds, however, may necessitate medical care at a health-care organization. These wounds vary on the spectrum from a skin cut requiring sutures to a crushed or dismembered hand, from first- to fourth-degree burns, and from a broken phalanx to amputated fingers. Current achievements in microsurgery enable the replanting of many amputations. Treatment of degloved avulsion amputations, third- and fourth-degree burns, or soft-tissue rupture damage, however, is more difficult, especially in cases where structures need to be closed quickly, such as in wounds that expose the bones, joints, nerves, and tendons. These types of defects are addressed with flap surgery.[1],[2],[3],[4],[5],[6],[7],[8]

For defects where a flap is preferred, such as those that cannot be closed with a skin graft, the ideal option is a flap adjacent to the defect on the same hand, where tissues with similar characteristics are available.[1],[2],[3],[6],[8] One- to two-centimeter tip defects on a finger can be covered with a cross-finger or v-y advancement flap, while 3–4 cm defects can be covered with metacarpal artery pedicled flaps. These flaps are only sufficient for covering 3–5 cm defects on one digit or hand area; therefore, alternatives are needed for larger defects.[4],[5],[9],[10],[11] It is not possible to cover circumferential soft-tissue defects involving multiple phalanges or defects which cover the entire extensor or flexor side of the hand with such flaps.[1],[2],[3],[12],[13],[14] When a defect involves several fingers, other options need to be taken into consideration. In such cases of large and deep defects, pedicled forearm flaps, which enable the incorporation of more tissue while still being adjacent to the defect, can be utilized as well as the transfer of free flaps prepared from another body region that can provide tissues of appropriate size and thickness.[9],[10],[11] Priority is given to ensuring flap survival when tissues are transferred as free flaps or reconstructed pedicled forearm flaps. While covering the defect, flaps should not be pulled at the ends, overstretched or compressed as all of these can threaten flap vitality. While a defect is closed using this procedure, the flap must remain alive. As bulky tissue, several operations to refine the flap, make it thinner or revise it are often necessary. Despite revisions, the flap might remain bulky and feel like an attachment when compared to normal finger skin.[15],[16]

The ideal flap on a defect finger must have certain characteristics including adequate coverage of significant structures such as the bones, nerves, veins, and tendons; being thin enough not to restrict finger mobility; sitting on the defect completely, and not compromising the integrity of the finger esthetically. The ideal flap must also have a high possibility of survival; little requirement for further revision; and it must not lead to additional surgical areas (e.g., anastomosis area, donor site) on an already vulnerable and technically damaged hand or digit.[16] This study presents efforts to use a flap that meets these conditions to the maximum possible extent. The flap is a super-thin, mobile, glove-like random flap derived from abdominal skin near the inguinal region.

Patients and surgical technique

A total of 12 fingers (six patients: three males, three females), all with soft-tissue defects, that required local flap surgery but for which adjacent local flaps were not sufficient, were included in this study. The average age of the patients was 27 years (range 20–38). Four patients had defects on one finger and two had defects on multiple fingers [Table 1]. Four fingers presented with skin amputation indicating avulsion at various areas of the proximal phalanges and were unsuitable for avulsion replantation (nerves and veins were retracted and were damaged, yet still had continuation inside the finger), four fingers presented with skin damage on the entire dorsal side and four presented with the skin, tendon, vein, nerve, and joint defects on the entire volar side including the palm. The average defect size was measured at 3.75 cm × 6.98 cm (range 2 cm × 3 cm–7 cm × 9 cm). Four of the patients reported having their hands trapped in a machine at their worksites, and two were injured as the result of a car accident with a ring-avulsion injury that excoriated the skin [Figure 1], [Figure 2], [Figure 3]. Repair for five patients was completed by closure of the defect with an ultra-thin mobile abdominal flap in the first 6 h after injury, while the sixth patient with a fourth-degree burn was treated with flap defect closure on the 10th-day postinjury.
Table 1: Case series

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Figure 1: Case 1. Avulsion amputation of skin only

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Figure 2: Case 2. Fourth-degree burn on the 2nd through the 5th dorsal digits, dorsal view

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Figure 3: Case 2. Fourth-degree burn on the 2nd through the 5th dorsal digits, ulnar lateral view

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Random glove-like flaps prepared from the inguinal region were applied in similar thickness to the amputated skin on patients with soft-tissue avulsion.

The parameters for which the hand would be the most comfortable were determined before the operation. Close attention was paid in choosing a hairless, loose area as to allow as much finger movement as possible. Flaps for single fingers were designed to cover the whole finger like a glove continuity only on the tip. For coverage of multiple fingers, a flap around 1 cm was applied between the fingers, the fingertips were pulled through the distal side, and the primary donor site was closed [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Figure 4: Case 1. Glove-like flap coverage of thumb avulsion

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Figure 5: Case 2. Planning of the flap

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Figure 6: Case 2. Flap attached to fingers

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Figure 7: Case 2. Closure of primary donor site during the same session

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For single finger repair, flap thickness was designed to be the same as that of the soft tissue adjacent to the avulsion area. The flap was prepared as conformant with the defect size and width was wrapped around the finger and was longitudinally closed on the flexor side, preserving the subdermal plexus [Figure 4].

For repair of multiple fingers, in Case 2, flap thickness was again designed to be the same as that of the defect and a size that a distance of 1 cm could be preserved between fingers. Tunnels were formed into which the fingers could be tucked in. After the fingers were placed inside, fingertips were exposed via a skin incision over the defect margin. The skin in this area was made thinner at the dermal margin and secured to the nail roots. One centimeter of skin was secured between the fingers in such a way as to be bilaterally placed at the margins of the finger defect; preventing skin deficiency on the flap after potential edema or contracture. The primary donor site was then closed, completing the formation of the super-thin mobile flap as discussed in previous literature.[17],[18]

One patient, Case 3, presented with extensive and deep volar injuries on all fingers of left hand and was first treated with tendon prostheses applied in appropriate tonus on the flexor pollicis longus and flexor digitorium profundus (FDP) tendons at the FDP adherence point where they correspond to tendons in the wrist. Finger joint stability was partly ensured upon repair of the joint capsule surroundings with soft tissues. For this patient, vascular-pedicled inguinal flap measuring 9 cm × 18 cm was elevated to cover the large defect palm and silicon prostheses, because defect had a size of 9 cm × 18 cm while palm and silicon prostheses. In contrast to the classic application, however, the flap was designed with the proximal side on the hand and the distal side on digits. It was thus possible to make the flap edge as thin as finger skin and achieve nerve coaptation. The superficial circumflex iliac artery, vein, and lateral cutaneous nerve were incorporated into the flap. The lateral cutaneous nerve was split into two, and end-to-end anastomosis was performed on the median nerve stumps on the radial side and on ulnar nerves on the ulnar side at the wrist. The volar side of the hand was covered with the proximal portion of the flap. The distal area of the flap was refined for thinness in a way such as not to disrupt circulation with the vascular component remaining between the fingers and was applied to the volar side of fingers at the same thickness as the amputated soft tissue.

All fingers were checked to ensure passive mobility inside the flap and within the range allowed by the flap. During the early postoperative period, all patients were made to move their fingers inside the flap, and it was also suggested and checked that they could move up to half of their normal joint movements upon and after discharge.

Patients on whom flap surgery was performed on a single finger were discharged on the same day, while Case 2 was discharged the day after the operation and Case 3 was discharged 2 days after the procedure. All patients were placed on amoxicillin + sulbactam 1000 mg, naproxen sodium 75 mg, and acetylsalicylic acid 100 mg.

Protocol for each patient comprised 1 week of antibiotic and anti-inflammatory treatment, 3 weeks of smoking prohibition, and local dressing. Despite the thinness of the flaps, no patients developed skin necrosis, infection, or damage to the sutures.

Flaps were removed from all patients after 3 weeks [Figure 8] and [Figure 9]. When removing the flap, the abdominal connection to the skin was clamped and flap vitality was checked. No problems were observed, and all flaps were removed at the end of the 3rd week. In Case 2, the fingers were separated from each other at the same time as flap removal [Figure 10] and [Figure 11]. Following flap removal, active and passive joint movements of patients were followed for another 15 days. No wound recovery problems, circulation problems, or partial necrosis were encountered during this period. Patients were then directed to start physiotherapy after the 15th day.
Figure 8: Case 1. Flap appearances at the 3rd-week postoperation, before separation. View of the thumb as covered by flap

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Figure 9: Case 2. Third week. Before flap removal

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Figure 10: Case 2. Radial view after flap removal

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Figure 11: Case 2. View from top after flap removal

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The patient on whom tendon prostheses were used underwent another operation 2 weeks after the flap removal where tendon prostheses were replaced with tendon grafts derived from proximal stumps of the FDS and indicis proprium tendons. Finger flaps were also separated from each other and made independent at that time. The digits and hand were stabilized in a functional position for 4 weeks. No infection, skin necrosis, or tendon rupture was encountered during this period. The patient was directed to physiotherapy upon complete passive finger movement at the end of the 4th week.


  Results Top


Cases were followed postoperatively for an average of 7 years (range: 6 months–13 years). Flap necrosis was not encountered in any patient, and no patients required additional flap or graft application or flap thinning. No donor-site complications such as damage to sutures, infection, or additional surgery requirements occurred. All patients regained protective tactile sense, with results higher than normal at the two-point discrimination test [Table 1]. Sensory tests were performed between 6 months and 2 years, depending on the size of the defect. All patients received physiotherapy for 3–6 months after the operation. Case 3, a more complex injury, dropped out of physiotherapy and treatment of their own accord. This patient did show partial flexion contractures. Functional results close to normal measures were obtained in all other patients [Table 1] and [Figure 12], [Figure 13], [Figure 14], [Figure 15].
Figure 12: Case 1. Comparison of thumb with other hand

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Figure 13: Case 2. Comparison of the fingers with the other hand

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Figure 14: Case 2. Full flexion

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Figure 15: Case 2. Full extension

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Following flap coverage, fingernail formation and growth were present on all patients with a skin defect that included the fingernail area, although these were not full-sized and appeared abnormal [Figure 12] and [Figure 13].


  Discussion Top


Hand injuries caused by motor vehicle accidents, or heavy industry machinery, severe burns, and high-speed appliances can result in significant damage, and leaving structures such as the veins, nerves, tendons, and bones exposed. These defects require prompt closure with flaps in such a way as to minimally disrupt digit functionality. The most suitable alternative for this purpose is a previously defined local flap near the defect area.[1],[2],[3],[5],[6],[7],[8] However, for defects too large to cover with such flaps or for those in locations where these flaps cannot reach, free-flap alternatives must be considered.[10],[11] Most of these flaps, however, are far from ideal as donor skin is rarely as thin as finger skin, and often requires multiple revisions. Adequate thinness has been attempted with skin grafts of fascia flaps, but it was found to be extremely difficult to locate a free cutaneous flap at the thickness of the finger skin. This method requires microsurgery, however, when multiple fingers are injured, flap adaptation is difficult to achieve, while flap vitality and graft survival are problematic.[16],[19],[20] For defects related to deep burns, infection, or skin loss only, repair may be possible with grafts following vacuum granulation, but subcutaneous structures can become damaged as granulation can take a long time. Moreover, contracture development risk is higher after skin graft than after repair with flaps.[17],[21]

Abdominal flaps and inguinal flaps have been used to repair hand defects for many years. However, conventional abdominal and inguinal flaps are inadequate for fingers, requiring additional surgeries afterward to refine the flap for thinness or release the fingers as in syndactyly.[22] Use of an abdominal glove flap to repair defects on the hand dorsum was first defined by O'Connor[23] and later modified by Urushidate et al.[17] Hyakusoku and Gao[24] explained super-thin flap concept for the first time in 1994. Gousheh et al.[18] successfully repaired a contracted and hypertrophic burn scar on the hand dorsum with a super-thin abdominal flap in 2008 and Wang et al.[25] used a preexpanded, prefabricated abdominal super-thin flap as a perforator for total hand resurfacing in 2017. These flaps were nourished by the subdermal plexus, and no partial or complete loss occurred. Many studies indicate that super-thin random flaps can be elevated in larger sizes and with less loss than super-thin conventional flaps.[26],[27]

Super-thin abdominal mobile-glove flaps are easy to prepare, apply, and care. Since the skin is secured to the finger skin at the defect margins while placing the fingers inside the flap, fingers can later be conveniently released as in syndactyly release during the same session as flap removal [Figure 11]. These flaps also contain enough skin to straighten contractures on the webs or the flap area. To avoid skin shortage during flap removal, fingers can be placed distally, and the flap can be sutured to the fingers at the defect edges during the course of adaptation of fingers to the abdominal flap. Thin abdominal flaps produce satisfactory results both functionally and esthetically without the need for additional surgical intervention. Of the patients included in this study, only the one with severe tissue loss on the volar hand and digits faced functional problems after the procedure. Moreover, these problems were not associated with skin, but underlying injuries to the joint and tendons. In all other patients, no difficulties were encountered in extension or flexion movement. Since glove-like thin flaps can wrap around the finger circularly instead of a single region, they can be reliably used not only to cover open wounds related to burn or infection but also on traumatic soft-tissue amputations or injuries that create large skin tissue defects. This method was also successfully implemented in this study on patients with damage such as circular avulsion skin amputation, volar severe combined tissue defect, and deep burn. Functionally and esthetically, satisfactory results were produced along with complete coverage of their defects.

Even though flaps similar to the one used by Urushidate et al.[17] were implemented for this study, fingers were not left inside the abdomen and the flap donor site was closed at the time of the procedure. This reduced the risk of infection and complication rates related to wound recovery while minimizing the marks and other visual problems at the donor site. Since fingers were outside the abdomen and circularly free, they were exercised with partially active movements during the recovery period, thus reducing functional problems and shortening the subsequent physiotherapy period. Urushidate et al. treated patients with burn damage to the hand and digits with the elevation of large flaps. In that study, flaps were not used on patients with severe soft-tissue defects or additional injuries or defects on one finger and also were not tested for injury to significant structures such as the bones, nerves, veins, or tendons. Our study included patients with burn injuries as well as those with avulsion amputation, crushing amputation, and heavy industry injuries; use of flaps on finger defects was emphasized, and positive results were produced in all patients.


  Conclusion Top


We demonstrated that a mobile flap harvested at the thickness of finger skin can be adapted to the finger in such a way that the finger can remain completely outside. We also suggest that this method is favorable and reliable in situ ations where local flaps are inadequate, such as in the treatment of finger wounds with large defects, multiple finger injuries necessitating circumferential style repairs or where distant and free flaps would lead to esthetic and functional problems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Gregory H, Pelzer M, Gazyakan E, Sauerbier M, Germann G, Heitmann C, et al. Experiences with the distally based dorsal metacarpal artery (DMCA) flap and its variants in 41 cases. Handchir Mikrochir Plast Chir 2006;38:75-81.  Back to cited text no. 1
    
2.
Omokawa S, Tanaka Y, Ryu J, Kish VL. The anatomical basis for reverse first to fifth dorsal metacarpal arterial flaps. J Hand Surg Br 2005;30:40-4.  Back to cited text no. 2
    
3.
Battiston B, Artiaco S, Antonini A, Camilleri V, Tos P. Dorsal metacarpal artery perforator-based propeller flap for complex defect of the dorsal aspect in the index finger. J Hand Surg Eur Vol 2009;34:807-9.  Back to cited text no. 3
    
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[PUBMED]  [Full text]  
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Beldame J, Havet E, Auquit-Auckbur I, Lefebvre B, Mure JP, Duparc F, et al. Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers. Surg Radiol Anat 2008;30:429-35.  Back to cited text no. 7
    
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Liu DX, Wang H, Li XD, Du SX. Three kinds of forearm flaps for hand skin defects: Experience of 65 cases. Arch Orthop Trauma Surg 2011;131:675-80.  Back to cited text no. 10
    
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Soutar DS, Tanner NS. The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 1984;37:18-26.  Back to cited text no. 11
    
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Clodius L, Smahel J. The reverse dermal-flat flap: An alternative cross-leg flap. Case report. Plast Reconstr Surg 1973;52:85-7.  Back to cited text no. 12
    
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Atasoy E, O'Neill W. Local flap coverage about the hand. Atlas Hand Clin 1998;3:179-234.  Back to cited text no. 13
    
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Atasoy E. Reversed cross finger subcutaneous tissue flap. In: Strauch B, Vasconez LO, Grabb WC, Hall-Findlay EJ, editors. Grabb's Encyclopedia of Flaps. 1st ed., Vol. 2. Boston: Little Brown; 1990. p. 932-5.  Back to cited text no. 14
    
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Kostakoǧlu N, Keçik A. Upper limb reconstruction with reverse flaps: A review of 52 patients with emphasis on flap selection. Ann Plast Surg 1997;39:381-9.  Back to cited text no. 15
    
16.
Henry M. Degloving combined with structural trauma at the digital level: Functional coverage with fascial free flaps. J Reconstr Microsurg 2007;23:59-62.  Back to cited text no. 16
    
17.
Urushidate S, Yotsuyanagi T, Yamauchi M, Mikami M, Ezoe K, Saito T, et al. Modified thin abdominal wall flap (glove flap) for the treatment of acute burns to the hands and fingers. J Plast Reconstr Aesthet Surg 2010;63:693-9.  Back to cited text no. 17
    
18.
Gousheh J, Arasteh E, Mafi P. Super-thin abdominal skin pedicle flap for the reconstruction of hypertrophic and contracted dorsal hand burn scars. Burns 2008;34:400-5  Back to cited text no. 18
    
19.
Chen HC, el-Gammal TA. The lateral arm fascial free flap for resurfacing of the hand and fingers. Plast Reconstr Surg 1997;99:454-9.  Back to cited text no. 19
    
20.
Karamürsel S, Baǧdatlý D, Markal N, Demir Z, Celebioǧlu S. Versatility of the lateral arm free flap in various anatomic defect reconstructions. J Reconstr Microsurg 2005;21:107-12.  Back to cited text no. 20
    
21.
Roberts DJ, Zygun DA, Grendar J, Ball CG, Robertson HL, Ouellet JF, et al. Negative-pressure wound therapy for critically ill adults with open abdominal wounds: A systematic review. J Trauma Acute Care Surg 2012;73:629-39.  Back to cited text no. 21
    
22.
Matsui J, Piper S, Boyer MI. Nonmicrosurgical options for soft tissue reconstruction of the hand. Curr Rev Musculoskelet Med 2014;7:68-75.  Back to cited text no. 22
    
23.
O'Connor GB. Glove flap method of dorsal hand repair. Am J Surg 1936;32:445-7.  Back to cited text no. 23
    
24.
Hyakusoku H, Gao JH. The “super-thin” flap. Br J Plast Surg 1994;47:457-64.  Back to cited text no. 24
    
25.
Kleinman WB, Dustman JA. Preservation of function following complete degloving injuries to the hand: Use of simultaneous groin flap, random abdominal flap, and partial-thickness skin graft. J Hand Surg Am 1981;6:82-9.  Back to cited text no. 25
    
26.
Prakash V. The pedicled super-thin flap for resurfacing defects due to burn. Burns 2009;35:460-1.  Back to cited text no. 26
    
27.
Wang C, Zhang J, Yang S, Song P, Yang L, Pu LL, et al. Pre-expanded and prefabricated abdominal superthin skin perforator flap for total hand resurfacing. Clin Plast Surg 2017;44:171-7.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
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