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PubMed2003

Evaluation of long-term stability in second metatarsal reconstruction of the temporomandibular joint.

PURPOSE: Our goal was to evaluate long-term stability and function of 5 condyles reconstructed with vascularized second metatarsal joint grafts. MATERIALS AND METHODS: Four patients were reconstructed with 5 vascularized metatarsal grafts. These reconstructed joints were then followed for an average of 12.5 years. These patients represent the entire series and were all successfully contacted and reevaluated for this article. Measures of opening, deviation, excursion, symmetry, and clinical symptoms relating to the reconstructed joints are evaluated. RESULTS: Mean preoperative interincisal aperture was 12 mm, and postoperative aperture 48.5 mm. Three unilaterally treated patients had lateral excursion with opening. The mean deflection was 4.3 mm toward the operated side. Lateral and protrusive movements were limited in reconstructed joints, but up to 3 mm of protrusion was shown at 12.5 years. Subjectively, all patients rated their function as acceptable and were able to occlude and masticate without difficulty. Symmetry at rest was improved by surgery. CONCLUSIONS: Vascularized metatarsal joints represent a potentially suitable long-term substitute for condylar reconstruction. This limited series shows the technical viability of the procedure. A larger series may be warranted to compare this promising technique with conventional methods of temporomandibular joint reconstruction.

Adolescent↗

PubMed2003

The effect of posterolateral reconstruction on range of motion and muscle strength in total hip arthroplasty.

Posterolateral reconstruction of the posterior capsule, piriformis tendon, and external rotators in total hip arthroplasty improves the stability of the hip joint. This study was performed to evaluate the effect of this reconstruction on range of motion (ROM) and circumferential muscle strength. We selected 58 limbs of 29 patients. Posterolateral reconstruction was performed in 13 patients (reconstruction group). Posterolateral reconstruction was not performed in 16 patients (nonreconstruction group). No significant differences were seen in preoperative and postoperative ROM between the 2 groups. The reconstruction group had significantly higher abduction muscle strength (P<.0001) and external rotation muscle strength (P<.01) than the nonreconstruction group. Posterolateral reconstruction may be effective in promoting the recovery of abduction and external rotator muscle strength, and it can improve joint stability without limiting ROM.

Aged↗

PubMed1999

Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless?

The spontaneous return of sensation in autologously reconstructed breasts, especially in the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, generated the belief that sensory reinnervation by nerve repair of the flap would be superfluous. This study compares the sensation of the following non-reconstructed and reconstructed breasts: (1) non-operated breasts; (2) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap with sensory nerve repair; (3) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap without nerve repair; and (4) flaps of patients reconstructed with the free TRAM flap without nerve repair. Statistically significant lower pressure thresholds were found for DIEP flaps with nerve repair through Semmes-Weinstein testing. More segments of the DIEP flaps with nerve repair reacted to cold, warm and vibratory stimuli compared to flaps without nerve repair. Delayed but satisfactory sensory evoked potential responses were obtained for all reconstructed breasts, but in 46% of TRAM flaps no response could be registered compared with 23% and 0% for DIEP flaps without and with nerve repair, respectively. Questionnaires confirmed the objective data and showed return of erogenous sensation in 30% of the patients with DIEP flaps with nerve repair. Our data reconfirm the possibility of spontaneous return of sensation in pedicled and/or free lower abdominal flaps without nerve repair. Nerve repair in free DIEP flaps nevertheless does restore sensation earlier postoperatively, increases the quality and quantity of sensation in the flap and has a higher chance of providing erogenous sensation. The benefits obtained outweigh the disadvantages of the increased operating time.

Adult↗

PubMed1999

One hundred free DIEP flap breast reconstructions: a personal experience.

The Transverse Rectus Abdominis Myocutaneous (TRAM) flap has been the gold standard for breast reconstruction until recently. Not only autologous but also immediate reconstructions are now preferred to offer the patient a natural and cosmetically acceptable result. This study summarises the prospectively gathered data of 100 free DIEP flaps used for breast reconstruction in 87 patients. Primary reconstructions were done in 35% of the patients. Well-known risk factors for free-flap breast reconstruction were present: smokers 23%, obesity 25%, abdominal scarring 28% and previous radiotherapy 45%. Free DIEP flaps vascularised by a single (52%), two (39%) or three (9%) perforators were preferentially anastomosed to the internal mammary vessels at the level of the third costochondral junction. Of 74 unilateral DIEP flaps, 41 (55%) flaps were well vascularised in zone IV. Two flaps necrosed totally. Partial flap loss and fat necrosis occurred in 7% and 6% of all flaps, respectively. One patient presented with a unilateral abdominal bulge. Mean operating time was 6 h 12 min for unilateral reconstruction and mean hospital stay was 7.9 days. These data indicate that the free DIEP flap is a new but reliable and safe technique for autologous breast reconstruction. This flap offers the patient the same advantages as the TRAM flap and discards the most important disadvantages of the myocutaneous flap by preserving the continuity of the rectus muscle. The donor site morbidity is reduced, a sensate reinnervation is possible, postoperative pain is less, recovery is quicker and hospital stay is reduced. The more complex nature of this type of surgery, leading to increased operating time, is balanced by the permanent and gratifying results achieved.

Adult↗

PubMed1999

Oromandibular reconstruction using a third free flap in sequence in recurrent carcinoma.

Successful results of a second microsurgical reconstructive attempt have been reported previously in recurrent oral carcinoma. However, the feasibility of a third free flap following a third excision has remained to be determined. Six oral carcinoma patients with multiple recurrences, surgical excisions and free flap reconstructions on three separate occasions are presented. Resections had a curative intent in all cases in the first and second ablations and in four of the six cases in the third one. Five radial forearm flaps and one double free flap were used for the first reconstruction. During the second reconstruction two radial forearm, two fibula osteoseptocutaneous, one double free flap and one rectus femoris flap were used to reconstruct the larger defects resulting from excision of the recurrent tumours. However, no vascularised bone transfers were performed following the third excision and soft tissue free flap plus plate option was used for segmental mandibular defects. There was one partial flap loss among 21 free flaps performed. Three patients died within an average of 8 months following the third reconstruction while the others remained alive, surviving an average of 6 months. In conclusion, a third free tissue transfer for reconstruction in multiply recurrent oral carcinoma was found to be feasible, safe and effective. The use of free flaps contributed to the prevention of complications in these difficult cases and enabled the patients to spend the remaining days of their lives outside hospital.

Adult↗

PubMed1998

Rigid fixation in mandibular reconstruction.

A primary goal of mandibular reconstruction is to preserve form and function. Free vascularized bone remains the gold standard for mandibular reconstruction of the anterior defect. While lateral mandibular defects need for vascularized bone remain controversial, free bone flaps provide the most reliable bone stock readily available for dental implantation. Mandibular alignment remains critical for recreating the 3-dimensional relationships of mandibular projection, occlusion, and condylar placement. Depending on the defect, a variety of techniques can be used to maintain mandibular alignment. These include prefabrication of the plate, placement of an internal fixation device, and intermaxillary fixation. Fixation techniques in this day and age generally rely on plates and screws. Miniplates are popular among some reconstructive surgeons while others prefer larger reconstruction plates that can span the entire defect. Bony contouring is critical since keeping bone surfaces in contact allows for improved bone healing. Condylar reconstruction this critical, when the ramus and condylar head are resected, require reconstruction to maintain the entire solid arch. A variety of these techniques are discussed. While the challenge remains reconstituting a solid arch, a variety of techniques can be employed. These techniques including fixation technique, bony contour, mandibular alignment, and condylar reconstruction will be discussed.

Bone Plates↗

PubMed2000

Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance.

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.

Journal Article↗

PubMed2003

[Reconstruction of the urethral plate or ventral penile skin with foreskin or penile skin island flaps].

PURPOSE: Reconstruction of urethral plate with hairless skin. Reconstruction of ventral penile skin in patients with hypospadia. MATERIAL AND METHODS: Utilization of foreskin or a circular penile island flap to form the urethral plate. Second stage urethral reconstruction with buccal mucosa. Resurfacing of the ventral surface of the penis with a foreskin island flap using the buttonhole technique. An innovation in contrast to previously described procedures is the resection of a transversal strip of dorsal penile skin to avoid bulky wedges of skin on the sides of the penis. MATERIAL AND RESULTS: The urethral plate was reconstructed in 2 hypospadia-scripples and in one patient with penoscrotal hypospadia. Urethra reconstruction with buccal mucosa was accomplished without complications in 2 patients in a second stage. Partial necrosis of the most distal port of penile skin was observed as a complication after the first operation in one patient. Functional and cosmetic results were good after treatment with split skin thickness grafts. The penis was straightened in 2 patients with hypospadis sine hypospadis and the urethra reconstructed according to Mathieu in 3 patients with distal urethral defects. The ventral skin defect was covered with an outer leaflet of foreskin island flap using the buttonhole technique. Complications were not observed postoperatively or in later follow-ups. Functional and cosmetic results were good in all patients. CONCLUSION: The foreskin island flap is excellent for reconstruction of missing skin on the ventral shaft of the penis.

Adolescent↗

PubMed2004

[Reconstruction of insufficient anterior cruciate ligament].

AIM: Reconstruction of insufficient anterior cruciate ligament (ACL) has become a standard operative procedure. Still, graft choice and fixation technique are discussed controversially. The objective of this study was to ascertain the current treatment of ACL reconstruction in german orthopedic surgery and trauma centers. METHODS: A total of 250 trauma and 220 orthopedic surgery centers were asked for their treatment strategy and postoperative procedure of ACL reconstruction in an anonymous German-wide survey. RESULTS: 230 questionnaires (48.9 %) were returned for evaluation. 90.4 % of the surgeons reconstruct the anterior cruciate ligament. Patellar tendon is used by 73 % of orthopedists and 80.7 % of trauma surgeons. Reconstruction with semitendinosus tendon transplant is performed by 71.6 % of the orthopedists and 41.6 % of trauma surgeons. For tibial fixation the interference screw is as well of the semitendinosus tendon as of the patellar tendon the most common technique. In about 30 % each the femoral fixation results from interference screw and endo-button. CONCLUSION: There is still no generally accepted intra- and postoperative strategy for reconstruction of ACL. Reconstruction with semitendinosus tendon becomes more common.

Analgesics↗

PubMed2006

[Criteria of life quality after reconstructive breast cancer surgery].

PURPOSE: The aim of this study was to evaluate the quality of life of women after a breast cancer surgery. The question was if women which had reconstructive breast cancer surgery experience a higher quality of life than women who, for various distinct reasons, had not undergone reconstruction. PATIENTS AND METHODS: The participants of this study were women who had either received a mastectomy or those who at the same time underwent a breast reconstruction using implants during the time period from 1/1/2000 until 31/10/2003 at the University Hospital for Women of Heidelberg and Mannheim. With the help of three standardised questionnaires, the women could describe their post-surgical physical and psychological condition as well as the perceived quality of life. The study included 33 patients who had received breast implants and 31 patients without reconstruction. RESULTS: Women who had breast cancer surgery with reconstruction through implants had less problems and restrictions concerning their physical condition as well as their functional status. Moreover, compared to those participants with no reconstruction, their cognitive and emotional burdens were not as pronounced and they also they were able to better cope with the disease. Thus, their overall quality of life was superior than that of the other women. CONCLUSION: Breast reconstruction after primary and secondary mastectomy is an important contribution in order to improve the self-esteem and quality of a patient's life. Furthermore, it plays an essential role in coping with the psychological effects of breast cancer.

Adaptation, Psychological↗

PubMed2005

[Cruciate ligament reconstruction in knees with congenital cruciate ligament aplasia].

INTRODUCTION: The absence of the cruciate ligament is a rare pathology which is described as a congenital entity often being bilateral and in combination with other malformations. Patients mostly deny symptoms of instability but demonstrate signs of laxity. There is not a standardized treatment yet. METHODS: We report a case of congenital cruciate ligament aplasia which was treated with an ACL reconstruction. RESULTS: In the described case, the patient had a bad clinical result after ACL reconstruction with a fixed posterior subluxation of the tibia. Resection of the ACL reconstruction and physical therapy led to a better clinical result. DISCUSSION: While some authors report favourable results with cruciate ligament reconstruction, others report good results with a conservative regime of symptomatic treatment. When patients do not complain of instability conservative treatment might be one option, since the knee joint is adjusted to this abnormality. Surgical treatment should be considered when conservative therapy is frustrane. If however reconstructive surgery is done in cruciate ligament aplasia both cruciate ligaments need to be reconstructed. After isolated ACL reconstruction the tibia might be fixed posteriorly, leading to extension problems and severe patellofemoral pain as seen in our case.

Anterior Cruciate Ligament↗

PubMed2005

Reconstruction of the spinal accessory nerve with autograft or neurotube? Two case reports.

Injury to the spinal accessory nerve is most commonly iatrogenic, but can be related to cervical trauma or resection of tumor. Of the two most recent publications related to injury of the spinal accessory nerve, one describes transfer of the levator scapulae muscle to restore shoulder function, while the other reports on the results of six surgical repairs, three of which used a sural nerve graft to reconstruct a short neural defect. The present report describes the results obtained in two patients when an iatrogenic injury to the XIth nerve was reconstructed at 3 months after the loss of shoulder function. Denervation of the XIth nerve was confirmed by a first EMG at 6 weeks, and a second one at 12 weeks. At surgery, each XIth nerve was found to have an in-continuity neuroma, most probably related to electrocoagulation. Intraoperative electrical stimulation did not pass the region of nerve injury. In the first patient, the XIth nerve was reconstructed with an autograft from the greater auricular nerve. In the second patient, the XIth nerve was reconstructed with a bioabsorbable conduit, the Neurotube. The patient with the Neurotube reconstruction reached M5 trapezius function by 3 months after surgery, and had no nerve graft donor-site morbidity, while the patient with the autograft reached M4 function by 6 months after reconstruction, and has persistent numbness of the ear lobe. This is the first reported case of a cranial motor nerve being reconstructed with a bioabsorbable conduit.

Accessory Nerve↗

PubMed2005

[The use of the platysma myocutaneous flap for reconstruction in the head-neck area -- a retrospective study].

OBJECTIVE: Following extended tumor resections in the head-neck area options immediate defect reconstruction is needed to reduce healing time and improve rehabilitation. Reconstruction of significant areas of mucosal defects is best accomplished by introduction of a pliable regional transplant. The platysma myocutaneous flap has been used for defect reconstruction in head and neck area since more than 20 years. Its popularity is limited. Since 2001 in our department the platysma mucocutaneous flap is used for such reconstructions. We present a retrospective study evaluating our experience with the platysma myocutaneous flap. METHOD: From 2001-2003 25 patients have been subjected to surgical reconstruction applying the platysma mucocutaneous flap. The primary tumor was located in 16 patients (64 %) in the oropharynx, in 5 patients (20 %) in the hypopharynx and in 4 patients (16 %) in the oral cavity. Evaluation was based on medical records including the operative reports. All patients get a follow up in our outpatient clinic. RESULTS: The platysma flap is easy to harvest and has a low general risk level. Complications are minor and may be avoided by exact preoperative planning. Necrosis of the skin-muscle-flap was observed only after resection of the A. carotis externa (two cases). In these 2 cases an operative revision was necessary (stenting of the pharynx or secondary reconstruction by pectoralis major-flap). The resection of the A. facialis (three cases) did not lead to a serious complication. CONCLUSIONS: Considering the exact indication the platysma flap is suitable for reconstruction of surface defects in the pharynx and oral cavity. A special attention is given to the ipsilateral vascular supply and the length of the muscular pedicel. It proved to be a cost effective method due to the less time and personal expenditure.

Adult↗

PubMed2006

Free anterolateral thigh flap for reconstruction of major craniofacial defects.

Free-tissue transfer has revolutionized skull-base surgery by expanding the ability to perform cranial base resection and by improving the quality of reconstruction. The anterolateral thigh flap has come recently into use in the field of head and neck reconstruction. Its role in craniofacial and midface reconstruction has not been specifically defined. This study involved a total of 18 patients who were treated over a 5-year period from 1998 to 2003. Seventeen patients had locally advanced head and neck cancer, requiring craniofacial resection, and one patient had a complicated gun shot wound of the forehead. Thirteen patients were treated at the National Cancer Institute, Cairo University, Egypt, and five patients at the University of Miami, Florida. The patients presented with defects of the anterior skull base (5), lateral skull base (3), scalp and calvarium (3), and the midface (7). The anterolateral thigh flap was used as a myocutaneous flap in 11 cases and as a perforator fasciocutaneous flap in seven cases. Musculocutaneous perforators supplied the majority of flaps (17/18). Total flap survival occurred in 17 cases; one patient developed complete flap necrosis. The most commonly used recipient vessels were the facial vessels and the external jugular vein. Major complications included one case with meningitis; the patient died after failure of treatment. Another patient died 6 weeks postoperatively from pulmonary embolism. One patient developed CSF leak that stopped spontaneously. In addition, two patients developed minor wound dehiscence that healed spontaneously. The donor-site wound healed without problems except in two cases. One patient had an incomplete take of the skin graft; the other developed wound infection and superficial sloughing. Both wounds healed spontaneously. In addition to the feasibility of simultaneous flap harvesting with tumor resection, the flap's advantage in skull base reconstruction is its reliable blood supply, which can provide adequate dural cover and protection of the brain. Its size and moderate thickness are suitable for reconstruction of scalp and calvarial defects. The abundance of reliably vascularized fat in the flap may be an advantage in long-term maintenance of the volume of the flap in midface reconstruction. Similar to other soft tissue flaps, additional skeletal reconstruction may still be required to achieve an optimal functional and aesthetic result.

Adolescent↗

PubMed1999

Mandibular reconstruction with the free vascularized fibular flap: utility of three-dimensional computerized tomography.

Oncologic management in the mandibular area leaves important osseous defects, that require reconstructive procedures with vascularized osseous tissues. Mandibular reconstructions with free vascularized fibular flaps have well-defined indications and some advantages over various other types of vascularized osseous grafts, because the fibular graft permits the reconstruction of large mandibular defects. This study demonstrates the usefulness of three-dimensional (3D) tomography as a tool to determine the size of the defect, and with angiotomography, to define the anatomic pattern of the vascular pedicle. Five patients with varying mandibular tumors and osseous defects were evaluated with 3D tomography in the pre- and postoperative periods. Two patients were immediately reconstructed with vascularized fibular flaps. 3D preoperative tomography showed the dimensions of the tumor, the dimensions of the mandibular resection, and the graft vascular pattern. Three patients were secondarily reconstructed, two of them with partial mandibular defects, and one patient with total mandibular reconstruction. In the preoperative period, 3D tomography was used to determine the dimensions of the mandibular defect, as well as the area of the osteotomies. The technology permits an exact knowledge of the dimension of mandibular defects, allowing better planning of reconstructive procedures.

Adolescent↗

PubMed1995

Free latissimus dorsi flap for reconstruction of the anterior base of the skull.

Defects resulting after resection of malignant tumors of the paranasal sinuses involving the anterior base of the skull need an adequate closure. In addition to such avital tissue as fascia lata, fat, or ceramics, in recent years we used free muscle flaps from the latissimus dorsi for reconstruction. We performed this reconstructive method in seven patients after radical tumor ##. The operation was performed in cooperation with the neurosurgeon. In three cases a transfrontal in combination with a transfacial approach was used and in four cases only a transfacial approach was chosen. The flap was tailored as a pure muscle transplant if only the base of the skull had to be repaired and the surgical cavity had to be obhiterated. In three cases a skin paddle was left on the muscle to perform a closure of the orbit and the hard palate. In four patients we performed primary reconstruction, in three cases secondary reconstruction, which was necessary because cerebrospinal fluid (CSF) leakage occurred after primary reconstruction with avital tissue in addition to insufficient pericranial flap. None of the patients with primary reconstruction developed CSF leakage. There was no free flap failure. The aim of this reconstruction is a safe closure of skull base defects to prevent infection, meningitis, brain abscess, and brain herniation.

Journal Article↗

PubMed2002

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.

BACKGROUND: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated. METHODS: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization. RESULTS: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively). CONCLUSIONS: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.

Activities of Daily Living↗

PubMed2003

Outflow reconstruction in right hepatic live donor liver transplantation.

BACKGROUND: Inconstant venous anatomy increases the risk of outflow complications in right hepatic live donor liver transplantation (RH-LDT), but no consensus has emerged guiding optimal reconstruction for venous outflow. METHODS: We retrospectively analyzed surgical venous reconstruction using a flexible approach to anterior accessory veins in 48 RH-LDTs performed between April, 1998 and July, 2002. RESULTS: Actuarial recipient graft and patient survival was 79% and 85%, respectively. Single hepatic venous anastomosis was performed in 74% of the patients. Twelve patients underwent reconstruction of 20 accessory veins, including 7 posterior segment veins and 13 anterior segment veins. Anterior vein reconstruction techniques included end-to-end anastomosis to the middle hepatic vein, interposition conduit, venoplasty, or a combination of techniques. Documented complications related to the venous anastomosis occurred in only 1 patient (2%), with no patient having a documented venous thrombosis of either the main RHV or a reconstructed accessory vein. There were no differences in outcome based on single versus multiple venous reconstruction. Anteromedial congestion was noted in 3 patients in the absence of anatomic venous anastomotic complication, but the clinical significance of this finding is unclear. CONCLUSIONS: Despite variations in segmental venous drainage and a propensity for anteromedial congestion in right hepatic grafts, RH-LDT can be performed without outflow obstruction with close attention to a wide RHV anastomosis. In addition, anterior accessory vein reconstruction can be reserved for grafts of marginal size or quality where early postoperative venous congestion may impair early graft function. Routine extended hepatectomy incorporating the MHV with the graft is unnecessary.

Actuarial Analysis↗