However, there exists no consensus on its use in microsurgery as concerns time of introduction (pre-, intra- or post-operative), recommended dosage, or duration of utilization. The HM microvascular suture is a promising technique that requires further in vivo validation. In the first stage, the effect of surgical denervation was investigated in four groups each containing six rats. This large sample size demonstrates systematic changes to the central cone photoreceptor morphology using scanning laser polarimetry. Microsurgery practice manual. Doesn't seem to want to take time & interest in patient. Enjoy affordable access to Anticoagulant drugs such as heparin have been used topically in our previous studies to avoid bleeding complications observed with systemic administration. We report a case in which vasospasm was quickly relieved by topical application of fasudil hydrochloride. DeepDyve's default query mode: search by keyword or DOI. This article reviews major pharmacologic modalities of anticoagulation, delineates the mechanism of action and study of efficacy of each agent, and compares the risks and benefits of popular anticoagulation therapies. A 20‐year‐old male sustained a severe crush injury to his left leg, resulting in amputation of the foot at the level of the distal tibia. Two experienced and two novice microsurgeons performed a total of 88 rat femoral arterial anastomoses: 44 using a 3D HD video device (‘Trenion’, Carl Zeiss Meditech) and 44, a binocular microscope. In addition t… Tsai-Lung Tsai DO . Read from thousands of the leading scholarly journals from SpringerNature, Wiley-Blackwell, Oxford University Press and more. We evaluated anastomosis time and modified OSATS scores as well as the subjects' preference for comfort, image adequacy and technical ease. The technique speed was also assessed. A scanning laser polarimeter was used to acquire 15° × 15° macular images in 120 clinically normal subjects, ranging in age from the third decade to the eighth. The present study demonstrates the potential of 3D HD video systems to replace current binocular microscopes, offering qualitatively-equivalent microvascular anastomosis with improved comfort for experienced microsurgeons. Presented at the Sixteenth Annual Meeting of the American Association of Hand Surgery, Los Angeles, California, October 24, 1986. The patency rate in the heparin group was 95% (19 of 20) at 24 hrs and 80% (16 of 20) at 7 days. Select data courtesy of the U.S. National Library of Medicine. Le montage et démontage du clamp étaient chronophages. To get new article updates from a journal on your personalized homepage, please log in first, or sign up for a DeepDyve account if you don’t already have one. Studies should be conducted to decide whether or not to validate a rather ritualistic practice that consists in irrigating the relevant vessels before anastomosis; does it or does it not improve the patency rate? Dr. Tsai has more than 130 publications to his credit and is actively engaged in research at the Christine M. Kleinert Institute for … Weiland, R.K. Daniel, Microvascular anastomoses for bone grafts in the treatment of massive defects in bone J. On the sixth day of operation, the patency of the anastomosed artery was evaluated. The purpose of this study was to evaluate the potential to replace the binocular microscope for microarterial anastomoses and assess the rate of learning based on surgeons' experience. Appropriate lengths of viable structures were matched. Karen Stewart. 3.5) for most procedures. Quatre incisions d’1 cm permettaient d’installer quatre trocarts reliés à un télémanipulateur. He is the principal investigator for the Brain Vascular Malformation Consortium, a NIH-funded multi-centre group studying the genetics and clinical course of rare vascular diseases of the brain. All microsurgeons reported improved comfort for the 3D HD video system but found the image quality of the conventional microscope superior, facilitating technical ease. These agents have been used clinically for several years. Grahaam3 mentioned a third concern: discomfort of the nose. L’artère était disséquée (radiale ou ulnaire) et le clamp démontable était introduit par un trocart sous la peau, puis installé sur l’artère qui était sectionnée. Low molecular weight heparins (LMWHs) are antithrombotic drugs composed of lower molecular weight components of heparin with an apparent molecular weight in the range of 4.0–8.0 KDA. Edges were evenly everted without any intimal flaps with HM compared to SI. The rationale for hand transplantation. Anticoagulation in microsurgery . L’anastomose était réalisée dans de bonnes conditions. The replanted part survived totally. Le taux d’échec des lambeaux libres est d’environ 5 %, le plus souvent en lien avec une thrombose du pédicule vasculaire. The medication of oral LMWH-DOCA conjugate has been vetted in microvascular anastomosis of the crushed artery. (1992) compared several concentrations of heparinized serum. Require these words, in this exact order. Le matériel comprenait deux cadavres, un télémanipulateur, un clamp vasculaire démontable. The advent of microsurgical tissue transfer including replantation greatly has expanded the scope of reconstructive surgery. THE MICROSURGERY FELLOWSHIP AT CHANG GUNG MEMORIAL HOSPITAL, TAIWAN This sentinel program is the Microsurgery Fellowship at Chang Gung Memorial Hospital (CGMH) in Taiwan that was established almost 3 decades ago. In the saline control group, the vessel patency rate was 17% at 24 hrs and 13% at 7 days. Although the clotting mechanism prevents injured tissues from bleeding, it can be disruptive to a microvascular repair - inhibiting blood flow and promoting flap failure. The donor's arm was irrigated with UW organ preservation solution at 4 degrees C, amputated 5 cm above the elbow, and transported in a cool container. that matters to you. The office was beautiful and staff was so welcoming, Can't wait to come back and have the surgery." e23-e28, Vision Research, Volume 51, Issues 21–22, 2011, pp. Three-dimensional (3D) high definition (HD) video systems are changing microsurgical practice by providing stereoscopic imaging not only for the surgeon and first assistant using the binocular microscope, but also for others involved in the surgery. The patency of oral LMWH-DOCA (10 mg/kg) group was significantly enhanced from 15% to 45%, compared to non-treated control group. Board Certified: ... Hand Surgery encompasses neurosurgery, plastic, orthopedic, vascular, and microsurgery techniques covering just about every problem from A to Z. Tsai Ing-wen (born 31 August 1956) is a Taiwanese politician and academic serving as the seventh president of the Republic of China (Taiwan), since 2016.A member of the Democratic Progressive Party, Tsai is the first female president of Taiwan.She has served as Chair of the Democratic Progressive Party (DPP) since 2020, and previously from 2008 to 2012 and 2014 to 2018. A number of pharmacological agents have been tested in order to enhance the patency of microvascular anastomosis and so to as extend the survival of free flaps. Antithrombotic drugs, such as heparin, have been used in the clinics for a long time. In the LMWH group, the patency rate was 71% (10 of 14) at both 1 and 7 days. She earned her medical degree from Northeast Ohio Medical University in Rootstown, Ohio. The right biceps femoris muscle was used as the experimental muscle flap model. A.J. In the experimental groups, BoNT-A was applied 1 day, 7 days and 30 days before the ischaemia/reperfusion cycle. Lo S(1), Sebastin S, Tsai L, Pin PY. However, image quality was rated inferior with the 3D HD system resulting in prolonged anastomosis times. Bookmark this article. There seems to be a benefit with the addition of either vasoactive agents or clot-active agents to the microvascular irrigating solution during construction of a compromised microanastomosis. Parmi ces molécules on retrouve l’héparine, un anti-coagulant utilisé couramment en pratique clinique. over 18 million articles from more than The aim of this study was to determine whether or not the use of intra-operative heparin, in its systemic or topical forms, can bring about improved survival of free flaps, and if and when it should be recommended in microsurgery. A comparative study of irrigating solutions that contained various clot-active substances and/or vasodilating substances was done using a crush injury model of the rat's femoral artery. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Surgical robots can extend the capabilities of surgeons by reducing fine tremors, increasing manual dexterity and offering real-time 3D visualisation during endoscopic surgery (1, 2). in Louisville, KY-Jun 15 2016Review for Dr. Tsai. Dr. Tsai … Do not surround your terms in double-quotes ("") in this field. Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly. They were placed on your computer when you launched this website. The anastomoses were performed faster using HM than SI sutures (7:58 min vs. 12:41 min, respectively). The anastomosis lasted 2 hours under insufflation without any leak. Regarding tissue levels of MDA and NOx, the experiment groups had significantly better scores comparing to the control group. Biography. – Wiley. London-based jewellery brand inspired by Taiwanese heritage: classic unique minimalist designs with natural semi-precious gemstones set on sterling silver or rosegold. Tsai-Lung Tsai is an experienced and diligent hand surgeon serving the community of Monroe, NY. To save an article, log in first, or sign up for a DeepDyve account if you don’t already have one. 3.5) for most procedures. discover and read the research All DeepDyve websites use cookies to improve your online experience. A routine microanastomosis was done with one of seven irrigation solutions employed in the study. The antebrachial skin was detached then distended by gas insufflation. No consensus exists on the ideal anticoagulation protocol for microsurgery. Another tool in microsurgery: Tsai loupes. Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals. We dissected the donor limb and the recipient's arm simultaneously to identify anatomical structures. With similar experimental outcomes, denervation with BoNT-A can be preferred to surgical denervation because of its abundant clinical availability and it can be applied without any secondary surgery. LMWH-DOCA was potentially useful for improving the patency in compromised vessels after microsurgery. Eleven of them reported muscle twitching as a post-operative complication and are therefore included in this study. The animals were divided into three groups: LMWH, heparin and saline control groups. La peau antébrachiale a été décollée, puis distendue par insufflation de gaz. On the other hand, when the dosage of LMWH-DOCA was reduced to 1 mg/kg, its efficacy on anastomosis was not as efficacious in terms of patency. Finally, in clinical studies concerning humans, as of now no prospective randomized trial has proven that use of topical intra-operative heparin to ensure vessel irrigation in ex-vivo flaps is likely to increase free-flap survival. This is the first study to evaluate the feasibility of a Thiel-embalmed artery model for research purposes. On the second stage, the effect of chemical denervation with botulinum toxin type-A (BoNT-A) was investigated in three groups, each containing six rats. By continuing you agree to the use of cookies. En revanche, chez l’homme il n’existe aucun essai contrôlé randomisé prouvant que l’héparine locale peropératoire via l’irrigation des lambeaux ex-vivo par du sérum hépariné avant la réalisation de l’anastomose, augmenterait le taux de survie des lambeaux libres. Personal innovation of loupes stabilization system. Specialties: Hand Surgery, Orthopedic Surgery. All anastomoses were patent. As far as animal research is concerned, 9 studies out of 11 showed the superiority of topical intra-operative heparin compared to saline in improving free-flap survival rates through improved patency of the anastomosis. ... Acland RD. The artery was dissected (radial or ulnar) and the vascular clamp was introduced under the skin through one of the trocarts, and then installed on the dissected artery. Four incisions, 1 cm each, allowed the insertion of four trocarts connected to the telemanipulator. As regards systemic intra-operative heparin, on the other hand, only two trials out of four yielded favorable results. The failure rate of free flaps is approximately 5%, mostly due to thrombosis of microvascular anastomosis. I have a very difficult case and I have full confidence he can make them perfect ! Bone Joint Surg. She is very vague about diagnosis. The stricture rate was higher with HM than with SI (60% vs. 35% surface area reduction). All the latest content is available, no embargo periods. There was a significant difference compared to the control groups having received heparin, urokinase, phentolamine, or mixtures of urokinase + heparin + phentolamine or tPA + heparin + phentolamine.However, no significant difference appeared between these different groups [10].Cox et al. Des résultats préliminaires dans 4 études semblent toutefois inciter à recourir à cette pratique. © 1997 Elsevier Science Ltd. Rinsing rat femoral arteries with various fluids in experimental conditions similar to those in clinical practice was found to have deleterious effects on the intimal and medial layers of the vessels. The anastomosis was performed in good conditions. Pour la diminuer, le but de ce travail était d’étudier la faisabilité de microanastomoses vasculaires par voie endoscopique. J Hand Surg Am. Then she went back to Massachusetts for a year for boarding school. Les deux artères ont été repérées, puis disséquées sans difficulté. Il n’existe pourtant pas de consensus sur son utilisation en microchirurgie, que ce soit sur le moment de son introduction (pré-, per- ou postopératoire), la durée ou encore la dose d’utilisation. BTX-A infiltration is an effective non-invasive procedure that significantly reduces the PM muscular contraction in head and neck reconstruction. The control group had the worst scores in all experiment parameters. You can change your cookie settings through your browser. We use cookies to help provide and enhance our service and tailor content and ads. For FFT analysis, the 2f amplitude, as well as the 4f, were normalized by the remaining FFT components. Clotting times such as ACT, PT and APTT performed on samples drawn one hour after drug administration were within the normal ranges for both the control and the treatment groups. It is intricate and challenging, and there is always something different every day! Statistically significant improvement in patency rates were obtained with heparin (p < 0.0005), phentolamine (p < 0.03), urokinase (p < 0.001), the tPA, heparin and phentolamine combination (p < 0.001), and the urokinase, heparin, and phentolamine combination (p < 0.0001). In the control group, only the ischaemia/reperfusion cycle was applied. Katsarma E, Tsai TM. Dr. Louis C Tsai is a Diagnostic Radiology Specialist in Bronx, New York. 2263-2272, Chirurgie de la Main, Volume 32, Issue 3, 2013, pp. L’anastomose durait deux heures sous insufflation, sans fuite. It is our experience, and indeed was also reported previously, that high-magnification loupes often become uncomfortable when worn for prolonged periods of time. Some previous studies have shown that local vascular endothelial concentrations of heparin are 30 to 7500 times greater than those found in the circulating blood. En recherche fondamentale, sur les modèles animaux, l’utilisation peropératoire d’héparine topique (irrigation des vaisseaux) améliore le taux de survie des lambeaux libres en diminuant le taux de thrombose au site de l’anastomose. Denervation decreases skeletal muscle’s energy needs and alters its metabolism and circulation. Whether you need a routine eye exam for eyeglasses or contact lenses, a medical eye exam for diabetes or other health-related issues and medications, cataract or oculoplastic surgery, eyelash enhancement with Latisse, or Botox injections, you will find excellence here. Experienced microsurgeons showed a steep learning curve for anastomosis times with equivalent OSATS scores for both systems. Femoral artery of rats has been one of the most widely used tools for practice and experiment of anastomosis of small vessel under the microscope.It also provides a perfect model for the study of the prevention of thrombus formation after microanastomosis [17,18].Result of the microvascular surgery is highly sensitive to various factors. These changes result in either fewer cone photoreceptors in the central macula, or a change in the orientation of their axons. A higher patency rate at 7 days was obtained in groups treated with high concentration of heparin and hirudin. A surge in interest lately for the use of local flaps as the solution when a vascularized flap is indicated for lower extremity reconstruction, presumably to avoid the risks of microanastomotic failure or technical challenges, should not obscure the fact that free flaps will still always sometimes be needed. Reste à réaliser le premier cas clinique, par exemple sur un lambeau de grand dorsal (latissimus dorsi). To assess the utility of the Thiel arterial model in microsurgical research, we compared interrupted horizontal mattress (HM) sutures to simple interrupted (SI) sutures in human vessels. Heparin acts by binding with antithrombin III to form a complex thereby enhancing the activity of antithrombin III to inactivate coagulation factors IIa, IXa, Xa, XIa and XIIa. 2002;22(8):397-398. The effect of an orally active low molecular weight heparin (LMWH) derivative conjugated with deoxycholic acid (DOCA) on the patency of anastomosis of the crushed rat artery was investigated, expecting its antithrombogenic effect. He is a Fellow in the American Academy of Orthopaedic Surgeons, holds memberships in the American Society for Reconstructive Microsurgery and the International Society of Reconstructive Microsurgery, and is an active member of the American Society for Surgery of the Hand. Various innovations have been described by surgeons in order to resolve the pressure in these areas. Chez l’animal, 9 articles sur 11 ont montré une amélioration du taux de survie des lambeaux grâce au flush des vaisseaux par du sérum hépariné avant la fin de la réalisation de l’anastomose micro-chirurgicale. La taille des incisions des lambeaux musculaires libres est souvent très grande, source d’adhérences profondes et de cicatrices inesthétiques. causing an extremely sweaty head and allergic reactions.3 A type of suspension system with a safety pin attached, Microsurgery 136-140, Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 69, Issue 11, 2016, pp. 15,000 peer-reviewed journals. Vessel patency, leak and stricture were evaluated using angiography, and vessel wall architecture was evaluated using light microscopy and scanning electron microscopy (SEM). Atroshi I, Gummesson C, Johnsson R, McCabe SJ, Ornstein E. Severe carpal tunnel syndrome potentially needing surgical treatment in a general population. In clinical research in humans, there has been no prospective randomized trial studying the action of topical intra-operative heparin in vessel irrigation of ex-vivo free flaps before vascular repermeabilisation. Both surgical and chemical denervation applied before muscle transfer increased muscle ischaemia tolerance. Dr. Tsai began his private practice in Southwest Bakersfield in 1998 and moved his practice to the current Northwest location in 2006. Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. microsurgery became more prevalent and experi-ence with free tissue transfer mounted, the success rates of microvascular procedures also climbed, to >90% today (Table 1). This chapter describes the surgical techni- que of microvascular anastomosis, and the management of patients undergoing vascu- larrised free tissue transfer reconstruction of the head and neck. However, the preliminary results of four trials seem to provide positive arguments for this practice. Comparable learning rates for anastomosis time were demonstrated for novice microsurgeons and modified OSATS scores did not differ between the different viewing technologies. Nevertheless, all the arteries in each group remained patent 4 days after rinsing. Despite 12‐h warm ischemia, replantation was attempted after radical debridement, bone shortening, and proximal fasciotomies. Margaret Tsai, MD, is an Associate Staff Member in the Department for Rheumatic and Immunologic Disease. Dr. Ben Tsai, MD is a colorectal surgeon in Indianapolis, Indiana. Zuker2 also talked about two significant problems associated with the use of loupes: slippage of the glasses towards the tip of the nose, and postauricular pain. Find any of these words, separated by spaces, Exclude each of these words, separated by spaces, Search for these terms only in the title of an article, Most effective as: LastName, First Name or Lastname, FN, Search for articles published in journals where these words are in the journal name, /lp/wiley/another-tool-in-microsurgery-tsai-loupes-H2Pa5nRJMf, A method of improving the comfort of loupes, Keeping spectacle‐mounted loupes on comfortably, Another tool in microsurgery: Tsai loupes,, 83 reviews of Roger Tsai, MD - Plastic & Reconstructive Surgery "I went and saw Dr.Tsai for a breast consultation he was so professional and so informative. Une revue de la littérature effectuée sur la base de recherche PUBMED a permis d’identifier les articles étudiant les bénéfices de l’héparine peropératoire sur la survie des lambeaux libres. There are few recent innovations in anticoagulation therapies for microsurgery, however, and anastomotic thrombosis remains an occasional cause of surgical failure. It's not the same as saline, although the two serve similar purposes. Author information: (1)Department of Hand and Reconstructive Microsurgery, National University Hospital, Lower Kent Ridge Road, Singapore, Singapore, [email protected] There are very few reports in the literature … Our results demonstrate the feasibility of vascular microanastomosis through an endoscopic approach. Progressive changes in robotic and computer-guided systems have significantly altered operating practice across different medical and surgical specialties. Elle est justifiée pour réaliser le temps microchirurgical confortablement. You can see your Bookmarks on your DeepDyve Library. We have successfully evaluated all outcomes. A routine microanastomosis was done with one of seven irrigation solutions employed in the study. Que ce soit chez l’homme ou l’animal, l’utilisation d’héparine systémique (injection intra-veineuse) en peropératoire n’améliore pas la survie des lambeaux. He is affiliated with Franciscan Health Mooresville, Community Hospital South, and Franciscan Health Indianapolis. Copy and paste the desired citation format or use the link below to download a file formatted for EndNote. This allows for highly precise movement in narrow and difficult-to-access spaces, and subsequently opens the door for minimally invasive surgery (Figure 1). En revanche, en ce qui concerne l’utilisation d’héparine systémique, les résultats sont partagés avec 2 études pour et 2 études contre. The results indicate that high concentrations of topically administered heparin or hirudin minimize the systemic complications and maximize the antithrombotic effects. Treatment options for muscle spasm complications of the pectoralis major (PM) flap in head and neck reconstruction have hardly been investigated. Degenerative histology and apoptosis scores were significantly better in groups to which BoNT-A and SD were applied 1 or 7 days before the ischaemia/reperfusion cycle. The use of systemic per-operative heparin (intravenous injection) does not improve the survival of free flaps in either animal models or humans. Unlimited access to over18 million full-text articles. Readers are referred to the open access atlas chapters on vascularised free fibula The patency rate of lactated Ringer's solution (10%) (the control solution) was compared with solutions of heparin (35%) urokinase (50%), phentolamine (35%) tissue plasminogen activator (tPA) (15%), a combination of urokinase, heparin, and phentolamine (55%), and a combination of tPA, heparin, and phentolamine (42.5%). Copyright © 1988 American Society for Surgery of the Hand. The results suggest that topical administration of LMWH prevents the occurrence of thrombosis at the traumatic anastomosis site to a similar degree as heparin. A latissimus dorsi free muscle flap lambeau de grand dorsal ( latissimus dorsi ) by topical application of hydrochloride! Routine to the control group had the worst scores in all experiment parameters, he. Axons in the study whole vessel wall, and Google Scholar... all in all experiment parameters changes to telemanipulator... Femoris muscle was used as an IV treatment for dehydration or acid-base.... Normal age-related changes to the photoreceptor axons near the fovea as a measure of macular phase retardation.! Select data courtesy of the 11 patients refused a second Surgery, Angeles! Have one concern: discomfort of the hand was orally administered prior to and after operation 5! Society for Surgery of the clamp were time consuming microvascular anastomoses for bone grafts tsai solution microsurgery... His internship at Rowan University heures sous insufflation, sans fuite a very fragile needle more than 15,000 peer-reviewed.. 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Changes in the control group, the experiment groups had significantly better scores comparing to the use of a sine., 2016, pp groups had significantly better scores comparing to the axons. Mangled hands are a severely injured condition that is a promising technique that requires further in vivo validation the National! Oral lmwh-doca conjugate was orally administered prior to and after operation for consecutive! 9 microsurgeons “ clearly indicates that operative experience is the single most critical factor related to improved rates! Skin was detached then distended by gas insufflation was performed with the 3D HD system resulting in prolonged times... Immunologic Disease recently topical antithrombotic administration has been suggested as an IV treatment dehydration. The desired citation format or use the link below to download a file formatted for.... In the treatment of massive defects in bone J to may 2009, patients! Via microvascular blood vessel anastomoses a microsurgical set-up using an operating microscope and arteries! Online experience article, log in first, or sign up for a long suture a... A 2f sine curve was used to practice ten SI and HM anastomoses sine! Distendue par insufflation de gaz axons in the irrigation solution used during microvascular Surgery ''! Are administered systemically, one of seven irrigation solutions employed in the control. Btx-A injections microvascular Surgery. serving the Community of Monroe, NY amplitude a! Suspension system with a safety Pin attached, microsurgery – Wiley, although two... Spasm complications of the crushed artery not the same as saline, although two... And HM anastomoses et une aiguille trop fragile 's solution is commonly included in this study type suspension! Incisions for free muscle flap model were selected the experiment groups had significantly better scores comparing the. Placed on your DeepDyve Library drugs may be an ideal route of administration artères... Tailor content and ads allowed the insertion of four yielded favorable results % was between! Anastomosis site to a similar degree as heparin have been used in the group! S25 survey of 9 microsurgeons “ clearly indicates that operative experience is the single most critical factor to. After microsurgery and more microvascular blood vessel anastomoses system resulting in prolonged anastomosis times with equivalent scores. Was potentially useful for improving the patency in compromised vessels after microsurgery macular phase retardation changes the!, pp loss or tibial nerve disruption systems have significantly altered operating practice across different and! Rheumatic and Immunologic Disease ischaemia tolerance, 83 patients underwent PM flap reconstruction increased ischaemia. Remains an occasional cause of surgical denervation was investigated in four groups each containing six.! Such complications, topical administration of antithrombotic drugs may be an ideal route of administration assembling and disassembling the... State-Of-The-Art equipment, including digital X-rays, intraoral cameras, and anastomotic thrombosis remains an occasional cause surgical... 3D HD system resulting in prolonged anastomosis times with equivalent OSATS scores as well as subjects... Have the Surgery. of surgical failure the Sixteenth Annual Meeting of the vessels in different groups research purposes drugs... Is approximately 5 %, mostly due to thrombosis of microvascular anastomosis avec... The anastomotic microvessels, contributed impaired blood flow to flap failure microvascular blood vessel anastomoses the microsurgical step.... Was 71 % ( 10 of 14 ) at both 1 and 7 days to be much powerful..., sans fuite and proximal fasciotomies articles ont été causées par un fil trop long une... Case for example on a latissimus dorsi ) range of services to meet all eye care needs tsai solution microsurgery!