Letter to the Editor: Short Report
659
Entrapment of Digital Nerves due to an Embedded Ring: A Case Report Takuya Uemura, MD, PhD1 Kiyohito Takamatsu, MD, PhD2 Mikinori Ikeda, MD1 Hiroaki Nakamura, MD, PhD1 1 Department of Orthopaedic Surgery, Osaka City University Graduate
School of Medicine, Osaka, Japan 2 Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
Mitsuhiro Okada, MD, PhD1
Address for correspondence Takuya Uemura, MD, PhD, Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku, Osaka 545-8585, Japan (e-mail: [email protected]).
Chronic embedded ring injury, which has a very dramatic appearance, is very rare, with only approximately 20 cases previously reported in the English literature.1–10 In most of the reported cases, the ring was simply removed with a ring cutter in the emergency setting, and few surgical interventions were required. There have been only a few reports of sensory disturbance of the finger with an embedded ring.2,4,8 However, the appearances of the digital nerves have never been confirmed with a surgical procedure when the ring was removed. This is the first case report of a chronic embedded ring injury in which severe constriction of the digital nerves by the embedded ring was demonstrated on surgical exploration, and atraumatic neurolysis of the digital nerves was required. A 73-year-old woman presented with an embedded ring in her right ring finger, with swelling and foul discharge after a blow. She had been wearing the ring for more than 20 years, and the ring had been embedded for 10 years. She had previously received psychotherapy and had taken orally antianxiety agents for few years, but she was on no drugs at the time of presentation. The patient reported that she had gained weight from 38 kg early in life to 62 kg recently. On examination, only the dorsal part of the ring could be seen above the skin dorsally, and an intact bridge of skin overlaid the volar aspect of the ring (►Fig. 1). The ring finger was swollen with foul discharge, but the distal circulation was satisfactory. The range of motion was limited to moderate flexion. On neurological examination, although there was no numbness, sensation distal to the buried ring was diminished: Semmes Weinstein monofilament values were 4.56 on the ulnar side and 4.31 on the radial side; static two-point discrimination values were 10 mm on the ulnar side and 8 mm on the radial side. Plain radiographs of the ring finger showed the completely buried ring within the volar soft
tissue, but bone scalloping was not appreciable in the proximal phalanx (►Fig. 2). Surgical exploration was performed under brachial plexus anesthesia to avoid damaging the neurovascular bundles during removal of the ring. A Brunner zigzag incision was made on the volar aspect of the ring finger. The neurovascular bundles, especially the digital nerves, were extremely entrapped between the ring and the proximal phalanx (►Fig. 3), and the flexor digitorum profundus tendon was ruptured. The neurovascular bundles were released carefully, and then the ring was removed safely after opening the stems of the ring without using a ring cutter because of the divided original design of the bottom of the ring (►Fig. 4). The hypertrophic granulation tissue at the entrance wounds was debrided, and the skin was primarily closed. The wound healed uneventfully with oral antibiotic coverage. About 1 year and 7 months after the surgery, the sensory disturbance of the finger improved without numbness; Semmes Weinstein monofilament values were 3.61 on the ulnar side and 2.83 on the radial side, and static two-point discrimination values were 7 mm on the ulnar side and 6 mm on the radial side. Although we recommended additional tendon reconstruction of the flexor digitorum profundus, she refused it and was left with restricted flexion of the distal interphalangeal joint. In the early stage of the embedded ring, the digital skin is still intact, although minor abrasion can occur, and the ring is very tight and barely mobile.6 As the condition progresses, the skin and subcutaneous tissue are eroded with low-grade infection, and then part of the volar skin starts healing. As time goes by, the ring becomes gradually embedded into the finger with only the dorsal surface exposed. In the final stage, the soft tissue, flexor and extensor tendons, digital nerves, and phalangeal bone become involved. Because the digital
received December 13, 2013 accepted December 15, 2013 published online February 19, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370362. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
J Reconstr Microsurg 2014;30:659–662.
Entrapment of Digital Nerves due to an Embedded Ring
Uemura et al.
Fig. 1 The appearance of the embedded ring on the ring finger. About two-thirds of the ring is embedded into the soft tissue of the proximal phalanx. The volar skin is intact.
circulation is usually maintained with the slowly progressive nature of this injury, ischemia has never happened even in the advanced stage, and few cases require surgical intervention.2,5,6 Awan et al identified the intact and formed digital arteries and nerves over the embedded ring on surgical exploration.1 In contrast, the neurovascular bundles, especially the digital nerves, were severely constricted between
the ring and the proximal phalangeal bone in the present case. This is the first report confirming entrapment of the digital nerves due to an embedded ring, and it appears that aggressive surgical intervention including atraumatic neurolysis is needed to prevent damage to the digital nerves whenever the ring is removed in severe cases of embedded ring injury. The term “embedded ring syndrome” is recognized and stresses the absolute association noted between the embedded ring injury and mental or cognitive impairment.2,3,5,6 Leung and Ip reported that mental illness, female sex, poor social support, poor mental function, and a timid personality were risk factors for embedded ring injury.6 They also mentioned that most patients refused further reconstruction such as tenolysis and the function of the finger did not improve after removal of the ring, especially in advanced cases, and these might have been related to the patients’ mental
Fig. 2 Plain radiograph of the ring finger. The volar part of the ring is completely buried.
Fig. 3 Intraoperative view of the ring finger showing the entrapment of the neurovascular bundle under the embedded ring (arrow).
Journal of Reconstructive Microsurgery
Vol. 30
No. 9/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
660
Entrapment of Digital Nerves due to an Embedded Ring
Uemura et al.
661
exploration is needed to detect and release entrapment of the digital nerves, preventing damage to the neurovascular bundles. A favorable preoperative psychiatric assessment is also important for a good postoperative result.
References
2
3
Fig. 4 The digital nerves becoming thinner (arrow) after neurolysis and removal of the ring.
condition, poor compliance, and loss to follow-up.6 In this case, the patient was a woman with a history of psychosomatic disorder, and she refused further secondary tendon reconstruction with tendon grafting, did not perform rehabilitation, and was lost to follow-up. These coincide with the features of embedded ring syndrome.2,6 If individuals with psychiatric illness or loss of cognitive function have a tight ring, it should be considered as a risk factor for embedded ring injury, and the ring should be removed before becoming embedded. In severe cases of embedded ring injury, when the ring is removed, surgical
4
5 6
7 8 9 10
vessel over an embedded ring: a case report. Hand Surg 2013; 18(1):125–128 Witt PD. Uncommon features of an uncommon problem: embedded ring syndrome in a child. Plast Reconstr Surg 2007;119(5): 1631–1632 Zeng BW, Guo YJ, Huang CC. Embedded ring injury of the middle finger in an amphetamine abuser. J Chin Med Assoc 2006;69(2): 95–97 Sleilati F, Claude O, Werther JR, Ebelin M, Doursounian L. Chronic finger constriction by completely embedded rings: one ring may hide another. Plast Reconstr Surg 2004;114(6):1674–1676 Deshmukh NV, Stothard JS. The embedded ring injury - case report and review of literature. Hand Surg 2003;8(1):103–105 Leung YF, Ip SP. Chronic erosion injury of a digit by a ring: epidemiology, staging, treatment and prognosis. Br J Plast Surg 2002;55(4):353–355 Bennett KG, Brou JA, Levine NS. Completely embedded ring in the finger of a growing child. Ann Plast Surg 1995;34(1):76–77 Kuschner SH, Gellman H, Hume M. Embedded ring injuries. Clin Orthop Relat Res 1992;(276):192–193 Drake DA, Lewis F, Newmeyer WL, Kilgore ES Jr. An unusual ring injury. J Hand Surg Am 1977;2(2):111–112 Freedman BJ. Ulceration of wedding-ring into phalanx. BMJ 1947; 2(4538):1034
Journal of Reconstructive Microsurgery
Vol. 30
No. 9/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Awan B, Samargandi OA, Aljaaly HA, Makhdom AM. Single patent
Letter to the Editor: Short Report
663
The Bone-In-Fillet Flap: A Spare-Parts Approach to Achieving Simultaneous Bony Pelvic Stabilization and Soft Tissue Reconstruction following External Hemipelvectomy Edward M. Kobraei, MD1
William G. Austen Jr., MD1
1 Division of Plastic and Reconstructive Surgery, Massachusetts
General Hospital, Boston, Massachusetts J Reconstr Microsurg 2014;30:663–666.
External hemipelvectomy (EHP) involves resection of the entire lower extremity and part of the ipsilateral hemipelvis. It is performed once limb-salvaging alternatives have been exhausted for cure or palliation of locally advanced pelvic malignancies among other indications. Successful reports of the procedure date back to Girard in 1895 in France, however, it was associated with mortality rates greater than 55% in the mid-1930s.1 Advances in antisepsis, anesthesia, treatment of shock, and surgical technique reduced operative mortality rates to 14% by the 1950s and more recently to the range of 0 to 7%.1,2 As the mortality of EHP has improved, attention shifted to patient outcomes. Unfortunately, many studies indicate that EHP remains a morbid procedure with poor quality of life and functional outcomes. In a large series of EHP, Apffelstaedt et al reported a greater than 50% complication rate following EHP, with flap necrosis and wound infection the most common complications.3 Functional outcomes included 5% prosthesis use, 9% wheel-chair confinement, 6% bedbound, and 81% using crutches for ambulation, with similar outcomes in other studies.3,4 Other problems significantly impacting quality of life stem from the disruption in pelvic ring stability that occurs with EHP, including difficulties with upright sitting, side-to-side transfers, and poor fitting of lower extremity prostheses.5,6 Management of defects resulting from EHP requires a sophisticated reconstructive strategy and has a direct bearing on patient outcomes. In this report, we describe the Bone-InFillet flap to simultaneously restore pelvic ring stability and provide robust soft tissue cover.
received December 21, 2013 accepted December 31, 2013 published online April 21, 2014
Kevin A. Raskin, MD1
Address for correspondence Edward M. Kobraei, MD, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 1575 Tremont Street, apt. 1103, Boston, MA 02120 (e-mail: [email protected]).
Case Example An otherwise healthy 16-year-old adolescent boy presented to the Massachusetts General Hospital in January 2013 with progressive, recurrent right hip pain of 3 to 4 days duration. A year prior, he underwent surgical excision of an alleged aneurysmal bone cyst in his country of origin. Plain radiographs revealed a large, ill-defined osteolytic lesion of the right iliac fossa and ischium. Magnetic resonance imaging demonstrated a 19 13 13 cm well-defined, multiseptated, and cystic mass centered on the right acetabulum and hip joint (►Fig. 1). Biopsy revealed grade 2 osteosarcoma. After neoadjuvant chemotherapy, EHP was performed. Concurrent with tumor extirpation, a free fillet flap was harvested containing tibia and overlying soft tissue (►Fig. 2). The flap was transferred to the pelvis for microsurgical anastomosis and tibial fixation proximally to the sacrum and distally to the symphysis pubis (►Fig. 3). The external iliac artery and the inferior vena cava were chosen as recipient vessels. The patient did well postoperatively without any complications (►Fig. 4). Beginning at 1-month postoperatively, he was able to transfer independently and could sit upright. There has been no evidence of pelvic visceral herniation, wound complications, or recurrent malignancy.
Discussion Despite significant reductions in operative mortality, patient quality of life and functional outcomes following EHP remain
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371511. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Richard G. Reish, MD1 Eric C. Liao, MD, PhD1
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
659
Entrapment of Digital Nerves due to an Embedded Ring: A Case Report Takuya Uemura, MD, PhD1 Kiyohito Takamatsu, MD, PhD2 Mikinori Ikeda, MD1 Hiroaki Nakamura, MD, PhD1 1 Department of Orthopaedic Surgery, Osaka City University Graduate
School of Medicine, Osaka, Japan 2 Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
Mitsuhiro Okada, MD, PhD1
Address for correspondence Takuya Uemura, MD, PhD, Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku, Osaka 545-8585, Japan (e-mail: [email protected]).
Chronic embedded ring injury, which has a very dramatic appearance, is very rare, with only approximately 20 cases previously reported in the English literature.1–10 In most of the reported cases, the ring was simply removed with a ring cutter in the emergency setting, and few surgical interventions were required. There have been only a few reports of sensory disturbance of the finger with an embedded ring.2,4,8 However, the appearances of the digital nerves have never been confirmed with a surgical procedure when the ring was removed. This is the first case report of a chronic embedded ring injury in which severe constriction of the digital nerves by the embedded ring was demonstrated on surgical exploration, and atraumatic neurolysis of the digital nerves was required. A 73-year-old woman presented with an embedded ring in her right ring finger, with swelling and foul discharge after a blow. She had been wearing the ring for more than 20 years, and the ring had been embedded for 10 years. She had previously received psychotherapy and had taken orally antianxiety agents for few years, but she was on no drugs at the time of presentation. The patient reported that she had gained weight from 38 kg early in life to 62 kg recently. On examination, only the dorsal part of the ring could be seen above the skin dorsally, and an intact bridge of skin overlaid the volar aspect of the ring (►Fig. 1). The ring finger was swollen with foul discharge, but the distal circulation was satisfactory. The range of motion was limited to moderate flexion. On neurological examination, although there was no numbness, sensation distal to the buried ring was diminished: Semmes Weinstein monofilament values were 4.56 on the ulnar side and 4.31 on the radial side; static two-point discrimination values were 10 mm on the ulnar side and 8 mm on the radial side. Plain radiographs of the ring finger showed the completely buried ring within the volar soft
tissue, but bone scalloping was not appreciable in the proximal phalanx (►Fig. 2). Surgical exploration was performed under brachial plexus anesthesia to avoid damaging the neurovascular bundles during removal of the ring. A Brunner zigzag incision was made on the volar aspect of the ring finger. The neurovascular bundles, especially the digital nerves, were extremely entrapped between the ring and the proximal phalanx (►Fig. 3), and the flexor digitorum profundus tendon was ruptured. The neurovascular bundles were released carefully, and then the ring was removed safely after opening the stems of the ring without using a ring cutter because of the divided original design of the bottom of the ring (►Fig. 4). The hypertrophic granulation tissue at the entrance wounds was debrided, and the skin was primarily closed. The wound healed uneventfully with oral antibiotic coverage. About 1 year and 7 months after the surgery, the sensory disturbance of the finger improved without numbness; Semmes Weinstein monofilament values were 3.61 on the ulnar side and 2.83 on the radial side, and static two-point discrimination values were 7 mm on the ulnar side and 6 mm on the radial side. Although we recommended additional tendon reconstruction of the flexor digitorum profundus, she refused it and was left with restricted flexion of the distal interphalangeal joint. In the early stage of the embedded ring, the digital skin is still intact, although minor abrasion can occur, and the ring is very tight and barely mobile.6 As the condition progresses, the skin and subcutaneous tissue are eroded with low-grade infection, and then part of the volar skin starts healing. As time goes by, the ring becomes gradually embedded into the finger with only the dorsal surface exposed. In the final stage, the soft tissue, flexor and extensor tendons, digital nerves, and phalangeal bone become involved. Because the digital
received December 13, 2013 accepted December 15, 2013 published online February 19, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1370362. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
J Reconstr Microsurg 2014;30:659–662.
Entrapment of Digital Nerves due to an Embedded Ring
Uemura et al.
Fig. 1 The appearance of the embedded ring on the ring finger. About two-thirds of the ring is embedded into the soft tissue of the proximal phalanx. The volar skin is intact.
circulation is usually maintained with the slowly progressive nature of this injury, ischemia has never happened even in the advanced stage, and few cases require surgical intervention.2,5,6 Awan et al identified the intact and formed digital arteries and nerves over the embedded ring on surgical exploration.1 In contrast, the neurovascular bundles, especially the digital nerves, were severely constricted between
the ring and the proximal phalangeal bone in the present case. This is the first report confirming entrapment of the digital nerves due to an embedded ring, and it appears that aggressive surgical intervention including atraumatic neurolysis is needed to prevent damage to the digital nerves whenever the ring is removed in severe cases of embedded ring injury. The term “embedded ring syndrome” is recognized and stresses the absolute association noted between the embedded ring injury and mental or cognitive impairment.2,3,5,6 Leung and Ip reported that mental illness, female sex, poor social support, poor mental function, and a timid personality were risk factors for embedded ring injury.6 They also mentioned that most patients refused further reconstruction such as tenolysis and the function of the finger did not improve after removal of the ring, especially in advanced cases, and these might have been related to the patients’ mental
Fig. 2 Plain radiograph of the ring finger. The volar part of the ring is completely buried.
Fig. 3 Intraoperative view of the ring finger showing the entrapment of the neurovascular bundle under the embedded ring (arrow).
Journal of Reconstructive Microsurgery
Vol. 30
No. 9/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
660
Entrapment of Digital Nerves due to an Embedded Ring
Uemura et al.
661
exploration is needed to detect and release entrapment of the digital nerves, preventing damage to the neurovascular bundles. A favorable preoperative psychiatric assessment is also important for a good postoperative result.
References
2
3
Fig. 4 The digital nerves becoming thinner (arrow) after neurolysis and removal of the ring.
condition, poor compliance, and loss to follow-up.6 In this case, the patient was a woman with a history of psychosomatic disorder, and she refused further secondary tendon reconstruction with tendon grafting, did not perform rehabilitation, and was lost to follow-up. These coincide with the features of embedded ring syndrome.2,6 If individuals with psychiatric illness or loss of cognitive function have a tight ring, it should be considered as a risk factor for embedded ring injury, and the ring should be removed before becoming embedded. In severe cases of embedded ring injury, when the ring is removed, surgical
4
5 6
7 8 9 10
vessel over an embedded ring: a case report. Hand Surg 2013; 18(1):125–128 Witt PD. Uncommon features of an uncommon problem: embedded ring syndrome in a child. Plast Reconstr Surg 2007;119(5): 1631–1632 Zeng BW, Guo YJ, Huang CC. Embedded ring injury of the middle finger in an amphetamine abuser. J Chin Med Assoc 2006;69(2): 95–97 Sleilati F, Claude O, Werther JR, Ebelin M, Doursounian L. Chronic finger constriction by completely embedded rings: one ring may hide another. Plast Reconstr Surg 2004;114(6):1674–1676 Deshmukh NV, Stothard JS. The embedded ring injury - case report and review of literature. Hand Surg 2003;8(1):103–105 Leung YF, Ip SP. Chronic erosion injury of a digit by a ring: epidemiology, staging, treatment and prognosis. Br J Plast Surg 2002;55(4):353–355 Bennett KG, Brou JA, Levine NS. Completely embedded ring in the finger of a growing child. Ann Plast Surg 1995;34(1):76–77 Kuschner SH, Gellman H, Hume M. Embedded ring injuries. Clin Orthop Relat Res 1992;(276):192–193 Drake DA, Lewis F, Newmeyer WL, Kilgore ES Jr. An unusual ring injury. J Hand Surg Am 1977;2(2):111–112 Freedman BJ. Ulceration of wedding-ring into phalanx. BMJ 1947; 2(4538):1034
Journal of Reconstructive Microsurgery
Vol. 30
No. 9/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Awan B, Samargandi OA, Aljaaly HA, Makhdom AM. Single patent
Letter to the Editor: Short Report
663
The Bone-In-Fillet Flap: A Spare-Parts Approach to Achieving Simultaneous Bony Pelvic Stabilization and Soft Tissue Reconstruction following External Hemipelvectomy Edward M. Kobraei, MD1
William G. Austen Jr., MD1
1 Division of Plastic and Reconstructive Surgery, Massachusetts
General Hospital, Boston, Massachusetts J Reconstr Microsurg 2014;30:663–666.
External hemipelvectomy (EHP) involves resection of the entire lower extremity and part of the ipsilateral hemipelvis. It is performed once limb-salvaging alternatives have been exhausted for cure or palliation of locally advanced pelvic malignancies among other indications. Successful reports of the procedure date back to Girard in 1895 in France, however, it was associated with mortality rates greater than 55% in the mid-1930s.1 Advances in antisepsis, anesthesia, treatment of shock, and surgical technique reduced operative mortality rates to 14% by the 1950s and more recently to the range of 0 to 7%.1,2 As the mortality of EHP has improved, attention shifted to patient outcomes. Unfortunately, many studies indicate that EHP remains a morbid procedure with poor quality of life and functional outcomes. In a large series of EHP, Apffelstaedt et al reported a greater than 50% complication rate following EHP, with flap necrosis and wound infection the most common complications.3 Functional outcomes included 5% prosthesis use, 9% wheel-chair confinement, 6% bedbound, and 81% using crutches for ambulation, with similar outcomes in other studies.3,4 Other problems significantly impacting quality of life stem from the disruption in pelvic ring stability that occurs with EHP, including difficulties with upright sitting, side-to-side transfers, and poor fitting of lower extremity prostheses.5,6 Management of defects resulting from EHP requires a sophisticated reconstructive strategy and has a direct bearing on patient outcomes. In this report, we describe the Bone-InFillet flap to simultaneously restore pelvic ring stability and provide robust soft tissue cover.
received December 21, 2013 accepted December 31, 2013 published online April 21, 2014
Kevin A. Raskin, MD1
Address for correspondence Edward M. Kobraei, MD, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 1575 Tremont Street, apt. 1103, Boston, MA 02120 (e-mail: [email protected]).
Case Example An otherwise healthy 16-year-old adolescent boy presented to the Massachusetts General Hospital in January 2013 with progressive, recurrent right hip pain of 3 to 4 days duration. A year prior, he underwent surgical excision of an alleged aneurysmal bone cyst in his country of origin. Plain radiographs revealed a large, ill-defined osteolytic lesion of the right iliac fossa and ischium. Magnetic resonance imaging demonstrated a 19 13 13 cm well-defined, multiseptated, and cystic mass centered on the right acetabulum and hip joint (►Fig. 1). Biopsy revealed grade 2 osteosarcoma. After neoadjuvant chemotherapy, EHP was performed. Concurrent with tumor extirpation, a free fillet flap was harvested containing tibia and overlying soft tissue (►Fig. 2). The flap was transferred to the pelvis for microsurgical anastomosis and tibial fixation proximally to the sacrum and distally to the symphysis pubis (►Fig. 3). The external iliac artery and the inferior vena cava were chosen as recipient vessels. The patient did well postoperatively without any complications (►Fig. 4). Beginning at 1-month postoperatively, he was able to transfer independently and could sit upright. There has been no evidence of pelvic visceral herniation, wound complications, or recurrent malignancy.
Discussion Despite significant reductions in operative mortality, patient quality of life and functional outcomes following EHP remain
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371511. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Richard G. Reish, MD1 Eric C. Liao, MD, PhD1
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
