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The Microsurgery Tranining Card is a useful, practical, economic, easily assembled and used device, and provides a valuable tool for basic microsurgical training, especially for residents and fellows in teaching programs.

Background The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques? Methods We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity. Results We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings. Conclusion Dogma never is a good teacher; it remains elementary that routine “knowledge” is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

This paper presents the management and outcomes for two consecutive operative series of gunshot wounds (GSWs) involving the brachial plexus. The cases were from Louisiana State University Health Sciences Center (LSUHSC) and were obtained by retrospective chart reviews. Series 1 includes patients with injuries managed between 1968 and 1980 and series 2, from 1981 to 1998. Pre- and postoperative motor function was assessed using the LSUHSC grading system. The outcomes for each surgical technique for each series are presented. Fewer cases of brachial plexus elements injured by GSWs in series 2 may be due to decreased firearm-related injuries between 1993-1997, i.e., 39,595 versus 32,436 deaths, respectively. The graft repair increase in series 2 may have been the result of more severe injuries, since documented trends between 1971 and 1997 show the use of larger caliber bullets. This paper shows that with the outlined management and surgical techniques, surgery on certain GSWs of the brachial plexus is worthwhile.

Hippocrates provided the first written description of the peripheral nervous system (PNS), as early as the 4th century B.C., and later Herophilus identified nerves as such, distinguished them from tendons; he also traced nerves to the spinal cord. The traditional Hippocratic teaching of the time, however, doubted that nerve healing occurred. Through the subsequent centuries, several papers were written about the PNS but, without sufficient understanding of anatomy, physiology, and the regenerative capacity of the PNS, it is not difficult to comprehend the frustration that might have been encountered by surgeons in dealing with nerve injuries and their subsequent repair. This was probably the reason why nerve repair was rarely actually undertaken prior to the 19th century. A plethora of studies on the PNS and its regeneration has been reported over the last 150 years and has provided us with current knowledge. It is important, before describing the most recent developments in the area of peripheral nerve regeneration, to briefly outline the major advances over the last century. Currently, the therapeutic approaches taken toward the patient with peripheral nerve injury change continuously. Sophisticated advances in technology, cellular and molecular neurobiology, and electron microscopy will doubtless optimize reconstructive strategies in treating nerve injury. A greater awareness and understanding of the nerve ultrastructure, as well as the underlying mechanisms of the regenerative process and those factors detrimental to nerve regeneration, will assist in the successful repair of nerve injury. This paper reviews the cellular, biochemical, and ultrastructural elements of nerve injury and repair, and the rationale for current reconstructive strategies and techniques.

Background Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces. Methods Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed. Results A total of 22 patients were included with a mean age of 64.3 years (33–86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed. Conclusion Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.

Background Replantation is the ideal treatment in traumatic scalp defects to provide immediate coverage with restoration of hair-bearing skin. However, data are limited to case reports and small case series. Comprehensive analysis of techniques and outcomes is not available. Our aim was to systematically analyze the available literature to better understand management and postoperative outcomes of patients undergoing scalp replantation. Methods A systematic review of the PubMed, Cochrane, and EBSCO databases was performed in October 2019. Search terms included “replantation,” “replant,” “revascularized,” “revascularization,” “avulsion,” and “scalp.” Only papers reporting microvascular replantation of completely avulsed scalps, including case reports, were included. Review articles, non-English language articles, articles discussing nonreplant coverage, incomplete scalp avulsions, and articles discussing delayed scalp replantation were excluded. Data extracted included demographics, percent of scalp affected, mechanism, operative technique, and postoperative outcomes. Statistical analysis was performed using Mann–Whitney U tests, Kruskal–Wallis, and chi-squared tests. Results From a total of 704 initial results, 61 studies were included for analysis comprising 149 scalps. Complete survival was achieved in 54.7%, partial survival in 38.9%, and failure in 6.7%. Total ischemia time greater than 12 hours was associated with complete replant failure. Arterial anastomoses appeared to protect against complete loss. The number of venous repairs, proportion of venous-to-arterial repairs, use of vein grafts, thromboprophylaxis, or intraoperative complications did not affect outcomes. Patients required significant volumes of blood products, which was associated with partial success. Salvage rate after unplanned return to the operating room was 60.0%. Normal hair growth was achieved in all surviving native scalp tissue. Conclusion Scalp replantations, while technically challenging, are the ideal treatment for scalp avulsions. Fortunately, these have high rates of success. And as a focal point of a patient's appearance, this is invaluable in restoration of a sense of normalcy.

Introduction Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades. Methods PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test. Results The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p Conclusion Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.

Background Injury or compression of a sensory nerve is an under-reported source of disabling pain in the lower limb. It is known that peripheral nerve microsurgeons can reconstruct and rewire injured nerves to relieve chronic pain but this option remains not completely understood and ignored by most orthopaedic surgeons, neurologists, and pain therapists. In this paper, we describe our experience with knee and ankle peripheral nerve surgery to improve the condition of patients suffering from chronic, posttraumatic lower limb pain. Patients and Methods Between 2015 and 2018, a retrospective investigation was performed including patients who underwent ankle and knee nerve surgery for posttraumatic chronic pain with at least 1 year of follow-up. Previous surgeries or type of trauma, pain location and characteristics, type of operation (reconstruction, decompression, or denervation), and number of nerves operated were listed. Selective neuropathy was confirmed by ultrasound-guided nerve blocks. Outcome was assessed combining the visual analogue scale (VAS) score at rest and during movement, functional indexes, drug use, and ability to work. Results A total of 34 patients (14 knee and 20 ankle) were included in this study. A statistically significant difference (p Conclusion Peripheral nerve microsurgery is a useful and minimally invasive tool to be added in the algorithm of treatment of chronic knee and ankle pain. Physicians should be trained to suspect a neuropathic origin of pain in absence of musculoskeletal signs of pathology, especially following trauma or surgeries.

Aim The author presents a solicited “white paper” outlining her perspective on the role of nerve transfers in the management of nerve injuries. Methods PubMed/MEDLINE and EMBASE databases were evaluated to compare nerve graft and nerve transfer. An evaluation of the scientific literature by review of index articles was also performed to compare the number of overall clinical publications of nerve repair, nerve graft, and nerve transfer. Finally, a survey regarding the prevalence of nerve transfer surgery was administrated to the World Society of Reconstructive Microsurgery (WSRM) results. Results Both nerve graft and transfer can generate functional results and the relative success of graft versus transfer depended on the function to be restored and the specific transfers used. Beginning in the early 1990s, there has been a rapid increase from baseline of nerve transfer publications such that clinical nerve transfer publication now exceeds those of nerve repair or nerve graft. Sixty-two responses were received from WSRM membership. These surgeons reported their frequency of “usually or always using nerve transfers for repairing brachial plexus injuries as 68%, radial nerves as 27%, median as 25%, and ulnar as 33%. They reported using nerve transfers” sometimes for brachial plexus 18%, radial nerve 30%, median nerve 34%, ulnar nerve 35%. Conclusion Taken together this evidence suggests that nerve transfers do offer an alternative technique along with tendon transfers, nerve repair, and nerve grafts.

Background The omental flap has a rich history of use over the last century, and specifically as a free flap in the last four decades. It has a wide variety of applications in reconstructive surgery and has shown itself to be a reliable donor tissue. We seek to review the properties that make the omental free flap a valuable tool in reconstruction, as well as its many surgical applications in all anatomic regions of the body. Methods We conducted a narrative review of the literature on Medline and Google Scholar. We reviewed basic science articles discussing the intrinsic properties of omental tissue, along with clinical papers describing its applications. Results The omental free flap is anatomically suitable for harvest and wound coverage and has molecular properties that promote healing and improve function at recipient sites. It has demonstrated utility in a wide variety of reconstructive procedures spanning the head and neck, extremities, and viscera and for several purposes, including wound coverage, lymphedema treatment, and vascularization. It is also occasionally employed in the thoracic cavity and chest wall, though more often as a pedicled flap. More novel uses include its use for cerebrospinal fluid leaks. Conclusions The omental free flap is a valuable option for reconstructive efforts in nearly all anatomic regions. This is a result of its inherent anatomy and vascularity, and its angiogenic, immunogenic, and lymphatic properties.

The reconstruction of large skeletal defects secondary to osteomyelitis is a challenging problem. This paper reports on the treatment of bone defects caused by osteomyelitis of the radius using an Ilizarov distraction technique and a vascularized fibular graft. A 25-year-old man first presented with a right radial defect caused by osteomyelitis when he was 3 years old. His right forearm was shortened and angulated with a dislocation of the distal radio-ulnar joint. The defect in the radial shaft was noted on a radiograph. The reconstruction of his radial bone defect was performed in three separate operations. A two-stage Ilizarov application was performed. Ten months after this operation, the radial bone defect was reconstructed with a vascularized fibular osteocutaneous graft. The right radius was shortened by 10 mm due to the angulation in the distal fixation of the graft 14 years after surgery. Although limited motions of the right thumb extension and wrist supination were noted, other hand functions were adequately restored. The Ilizarov technique is an effective method for correcting distal radio-ulnar joint dislocations and shortened, angulated ulnar bones. The specific features of the vascularized fibular graft make it suitable for the bone reconstruction of large defects in the radius.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.

Despite recent advances in perforator flap reconstruction, there can be significant variability in vessel size and location. Although pre-operative evaluation may provide valuable information, real-time intraoperative methods have the potential to provide the greatest benefit. Our laboratory has developed the Fluorescence-Assisted Resection and Exploration (FLARE™) near-infrared (NIR) fluorescence imaging system for visualizing, intraoperatively, details of the underlying vasculature. The FLARE™ system uses indocyanine green, a safe and reliable NIR fluorophore already FDA-approved for other indications. The system has been optimized in large animal models for the identification of perforator size, location, and perfusion, and has also been translated to the clinic for use during breast reconstruction after mastectomy. In this paper, we review our pre-clinical and clinical data, as well as literature describing the use of similar NIR fluorescence imaging systems in plastic and reconstructive surgery.

The advent of microsurgery has allowed the replantation of traumatically amputated limbs. Replantation of a severed limb to the contralateral stump in bilateral traumatic amputation, however, is rarer, and criticisms include a prolonged hospital stay and complications. A 54-year-old man was caught in a paper-pulping machine and suffered bilateral lower limb amputation rendering his left lower leg unsalvageable. The right lower leg, after debridement however, was suitable for replantation to the left stump. This replantation was performed successfully. The patient was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. At 11-year follow-up the patient has a preference for his replanted leg in contrast to his contralateral prosthesis and has suffered no long-term complications. In addition, from a psychological perspective, he has experienced restoration of perceived body length with the cross-leg replantation.

Wide resection of a malignant tumor in the parotid gland often results in loss of a long segment of facial nerve, as well as a soft-tissue defect. With conventional nerve grafts, functional recovery of the facial nerve is poor in cases with risk factors that might inhibit nerve regeneration, such as a history of irradiation and a recipient bed scarred from previous operations. For such cases, a vascularized nerve graft is reported to be more effective than a nonvascularized nerve graft. This paper describes the first successful use of a free vascularized lateral femoral cutaneous nerve graft combined with an anterolateral thigh flap to repair the facial nerve and a soft-tissue defect. This method is technically simple, has minimal donor-site morbidity, and typically results in successful nerve recovery.

The authors have robotically harvested the internal mammary vessels to provide the recipient pedicle for free-flap breast reconstruction in 22 consecutive cases. Through minimal-access incisions, the robot facilitated the harvest of a pedicle up to 10 cm in length. The pedicle was brought out through the second intercostal space into the mastectomy wound, allowing the anastomosis to be performed on the skin surface with loupes or microscope. This paper illustrates their experience and offers an innovative approach to free-flap breast reconstruction.

This paper describes the rationale and technique for a combined procedure of transtrochanteric rotational osteotomy and vascularized iliac bone grafting in cases of osteonecrosis of the femoral head with an extensive and widely collapsed necrotic lesion in young patients. The authors performed this combined operation for 12 joints in 12 patients over 14 years from 1984 until 1997. At a mean of 81 months after the operation, in eight patients who had no pain, the average Harris hip score was 90.0 points. Postoperative radiographic evaluation revealed that collapse (more than 2 mm) of the femoral head was prevented in ten patients. Conversion to an endoprosthesis was avoided in all patients except one in this series. The authors recommend this procedure for advanced and extensive osteonecrosis of the femoral head, especially in young patients, to preserve the joint, even though it is a relatively complex procedure.

Although technical refinements have improved microvascular techniques, the problem of vessel-size discrepancy between donor and recipient vessels is still unsolved and can decrease the success rate of free tissue transfer. In fact, if vessels with incongruent diameters are not adequately anastomosed, the risk of free flap failure is increased. In this paper, the authors present a new type of microvascular anastomosis to overcome the problem of vessel-size discrepancy. Interrupted mattress sutures are placed in end-to-end anastomosis narrowing the wider diameter and compensating for the diameter incongruency. The surgical technique and main clinical applications of the interrupted micro-mattress sutures are described in detail. Indications and advantages are discussed.

A double vascular pedicled free jejunum was transferred in two patients with complete esophageal defect. When the stomach and colon, which are usually employed for esophageal reconstruction, cannot be used due to previous operations or for other reasons, the jejunum is the next alternative. However, pedicled jejunal transposition is limited in length and may not reach a suitable level over the lower cervical esophagus, even if the distal portion is supercharged. Under such circumstances, a long jejunal segment with two vascular pedicles can be transferred as a free flap and used to reconstruct the whole esophagus in one stage. The paper describes two cases and discusses the advantages of double vascular pedicled free jejunum transfer.

Massive resection of soft-tissue sarcoma in the elbow region often results in loss of long segments of the brachial artery and median nerve, as well as a wide soft-tissue defect. With conventional nerve grafts and revascularization of the arm, forearm and hand function is poor because nerves cannot be regenerated over the long nerve gap in the high elbow region. The authors used a long vascularized nerve graft and found it effective for reconstruction of upper arm function. This paper describes the first application of a free vascularized femoral nerve graft and a free anterolateral thigh true perforator flap based on the lateral circumflex femoral system, to repair elbow and forearm function. Long vascularized femoral nerve grafts of over 12 cm can be obtained, and an anterolateral thigh flap can be harvested from the same donor area.

Free tissue transfer is frequently used for reconstruction in the head and neck region. In patients who suffer tissue loss due to a high-energy trauma, the reconstructive surgeon is often faced with a large gap between the defect and the site of anastomosis outside the zone of injury. Utilization of long vein grafts for reestablishment of blood flow to the transferred tissue vessels is a common procedure. Arteriovenous fistula (AVF) formation on the side table is an alternative solution. In this paper, an "extracorporeal loop" (blind loop) technique is presented as an alternative microsurgical method for prelaminated flap transfer to two different traumatic recipient areas in the face (nose and ear).

This paper reports the authors' experience with the use of distally-based forearm flaps as flow-through flaps for revascularization of distal parts of the hand, by simultaneous coverage of traumatic soft-tissue defects. Two clinical cases are presented and the pertinent literature is reviewed.

This paper reports the authors' experience with the use of microvascular flaps, elevated from severely injured fingers to cover soft-tissue defects of other digits. Two clinical cases are presented and pertinent literature is reviewed.

Reconstruction of large external hemipelvectomy oncologic defects of the proximal limb and trunk remains a formidable surgical challenge. Large pelvic defects can result in exposed bones, neurovascular structures, and surgical hardware due to a paucity of soft tissue coverage. When the size of a hemipelvectomy defect precludes coverage by local posterior- or anterior-based hemipelvectomy flaps, the use of other local flaps must be considered before resorting to free tissue transfer. The rectus abdominis myocutaneous pedicled flap is the most commonly used locoregional flap for soft tissue coverage of large hemipelvectomy soft tissue defects. The concept of utilizing parts from otherwise nonsalvageable limb components in reconstruction is well described in the literature and referred to as the "spare parts" concept. Utilization of these distal "spare parts" has the advantage of obtaining sufficient soft tissue coverage while concurrently obviating additional donor-site morbidity. These spare parts can be utilized as either pedicled or free fillet flaps. This paper describes the unique use of in-continuity chimeric pedicled fillet flaps of the lower extremity to reconstruct and stabilize the pelvic ring, to obliterate dead space, and to provide overlying soft tissue coverage.

This experimental study on 24 male rats evaluated the advantages of vascularized vs. nonvascularized temporoparietal free fascia transfer as an improved form of penile tunica albuginea replacement. The paper describes in detail steps in these techniques and offers functional, anatomic, and histologic follow-up after 3 months. All 24 rats developed straight corpora cavernosa in erection. The flap was successful in each case, providing satisfactory morphologic appearance with minimal bulk. The only differences were histologically provided. Secondary degenerative changes were identified in all penises with nonvascularized fascial transfer, and one-third of penises with vascularized temporoparietal fascia free transfer. These results encourage vascularized free-tissue transfer application as an optimal solution in human penile reconstructive surgery.

Vascularized toenail grafts with long vascular pedicles have usually been transferred under general anesthesia. In this paper, a minimally invasive vascularized nail graft with a short pedicle and small cutaneous flap, which was successfully transferred under digital block of the finger and toe, is described.

Findings reported in the literature on the sensation provided by intraorally applied innervated vs. non-innervated radial forearm free flaps differ. In an effort to understand these differences in sensory recovery, the authors carried out sensory evaluations in 12 patients who had undergone radial forearm free flaps. Seven patients had innervated flaps for defects of the tongue and floor of mouth; five had non-innervated flaps to various sites. Flap sensitivity to temperature, light touch, dull touch, and sharpness and two-point discrimination was assessed at the donor site and contralaterally, and at the recipient site and contralateral mirror-image oral mucosa. Patients subjectively rated post-reconstruction sensation and provided quality of life (QOOL) data. The innervated flaps demonstrated better sensory recovery than the non-innervated flaps, although the latter did restore reasonable sensation. This paper describes the results, compares the study to other similar studies, and discusses various factors in the sensory recovery of both innervated and non-innervated intraoral radial forearm free flaps. The authors conclude that, although the trend in this study is toward improved function with the innervated flaps, these flaps do not appear to offer major intraoral functional advantage over the non-innervated flaps, which attain reasonably effective sensory recovery from neural ingrowth, if the lingual nerve is intact.

In this paper the authors describe and illustrate a rare anatomic variation of the ulnar artery, a superficial ulnar artery. The possible embryologic events responsible for this variation are discussed. In addition, they describe the surgical considerations that should be kept in mind when this abnormality is encountered in the clinical setting of free-tissue transfer and vascularized nerve grafting.

Consistently good results following free-tissue transfers require not only basic skills in small vessel anastomosis, but also the implementation of numerous adjunctive measures. The pioneers in microsurgery have shared many of their hard-learned lessons and clinical nuggets through texts, papers, and seminars. This article presents an assemblage of adjunctive measures of proven utility.

Among a variety of approaches used to stimulate nerve regeneration in experimental settings, is the use of a class of proteins designated as nerve growth factors and various other growth factors. Of these, vascular endothelial growth factor (VEGF), has been demonstrated to possess a potential to stimulate nerve regeneration in addition to its angiogenic properties. A number of studies have investigated the role of VEGF in nerve regeneration, demonstrating that it has both neurogenic and mitogenic activity on cells in the peripheral nervous system. It is therefore likely that VEGF is a molecule of major significance for nerve homeostasis, especially during development, and possibly after nerve injury. This paper reviews the mechanisms of VEGF signal transduction in neurogenesis, and focuses on recent studies that have considerably widened the understanding of the way in which VEGF affects peripheral nerve regeneration. By emphasizing the possible therapeutic implication of VEGF in nerve pathology, the authors would like to introduce a new research approach to study the role of VEGF in the nervous system. They believe that in the future, the factor might become a powerful tool in enhancing nerve regeneration in clinical practice.

This paper reports experiences of 67 toe-to-hand transfers. Success was achieved in all cases. Six cases are discussed that deal with the less investigated problem of long finger reconstruction. Amputation injuries of long fingers through the metacarpus are difficult problems. A determining principle of their restoration consists of the creation of adequate toe length for transfer and correction of biomechanic hyperextension. The report also highlights the advantages of metacarpal reconstruction with the "brass-knuckle" procedure, as the best technique for this type of injury. Aesthetic and functional advantages after such long finger reconstruction and psychological recovery of the patient seem worthy of emulation.

This paper presents the fifth reported case of replantation of a traumatically amputated ear and its management. The ear was amputated in an automobile accident and was revascularized microsurgically. Replantation, when possible, offers the ultimate result; however, shortcomings include the length of operation, prolonged hospitalization, and postoperative management of venous congestion.