Hand Reconstruction Research Articles

Persistent median artery and communicating branch related to the superficial palmar arch

Microvascular surgery, plastic and reconstructive hand surgery, and coronary artery bypass surgery call for a microanatomical study of the branching pattern of the superficial palmar arch (SPA). For the anatomical analysis, we used a group of 20 dissected human hands injected with 4% formaldehyde solution and a 10% mixture of melted gelatin and India ink. The morphometric study was performed on 40 human hands of adult persons injected with methyl-methacrylate fluid into the ulnar and radial arteries simultaneously and afterwards corroded in 40% KOH solution for the preparation of corrosion cast specimens. The mean diameter of the SPA, between the second and third common palmar digital arteries, was 1.86 ± 0.08 mm. We identified the persistent median artery (PMA) in 5% of hands. We distinguished the three main groups of the SPAs according to variations in morphology and branching of the arch: Type 1, the long SPA; Type 2, the middle length SPA; and Type 3, the short SPA found in 27.5% of specimens. The communicating branch (CB), a vessel interconnecting the SPA to the closest branch of the radial artery, is classified into two different morphological groups. The third type of incomplete short arterial arch is the most important of the three groups of SPAs. That short SPA is potentially inadequate for restoring circulation after occlusion or radial artery harvesting for coronary artery bypass.

Efficacy of Bi-lobed Second Dorsal Metacarpal Artery Flap in Pediatric Electric Hand Burns

Background: Bi-lobed second dorsal metacarpal artery (SDMA) flap is a viable option for the reconstruction over electrical burns of hand in the pediatric patients. The purpose of this study is to evaluate of the success rate and donor site range of motion after SDMA flap. Methods: A prospective observational cohort study was undertaken in all patients who underwent reconstruction with SDMA flap at institution from March 2016 to March 2018. Data was collected regarding flap success rate and active motion arcs of metacarpophalangeal joint (MCPJ) and proximal interphalangeal joints (PIPJ) of donor area. Results: Among 32 patients, survival rate of flap is 96.87 percent (n=31) with only partial loss of 3.12 percent (n=1). At mean follow up of 12 months, donor finger movements at MCPJ and PIPJ were almost similar to that on opposite side. Conclusion: Second dorsal metacarpal artery flap is useful and reliable flap in complex reconstruction of burn hands in pediatric group in terms of survival and range of motion. Key words: Second dorsal metacarpal artery flap, Metacarpophalangeal joint, Hand burn, Pediatric

SMR: Spatial-Guided Model-Based Regression for 3D Hand Pose and Mesh Reconstruction

3D hand reconstruction is an important technique for human-computer interaction. Interactive experience depends on the accuracy, efficiency, and robustness of the algorithm. Therefore, in this paper, we first propose a balanced framework called spatial-aware regression (SAR) to achieve precise and fast reconstruction. SAR can bridge convolutional networks and graph-structure networks more effectively than existing frameworks to fully exploit extracted spatial information using a novel spatial-aware initial graph building module. In addition, SAR uses adaptive-GCN to make keypoints interact efficiently and effectively; and regresses 2.5D belief maps to characterize uncertainty. SAR is highly flexible because it can predict an arbitrary number of keypoints and apply pose-guided refinement for coarse to fine regression. To produce more rational results for challenging cases and mitigate 3D label reliance, we also propose a more robust model-based framework called spatial-guided model-based regression (SMR) that is based on SAR. There are two critical designs of SMR: 1) it uses SAR to enhance the features with pose information to help the regression of hand model parameters; and 2) it regresses parameters in a spatially aware manner that is similar to SAR. Experiments demonstrate that the proposed frameworks surpass existing fully-supervised approaches on the FreiHAND, HO-3D, RHD, and STB datasets. Also, the performances of the proposed frameworks under weakly/self-supervised settings outperform other competitors. Meanwhile, the proposed frameworks are accurate and efficient.

Various soft tissue defect reconstructions using anterolateral thigh and vascularized fascia lata composite free flap.

The anterolateral thigh flap (ALT) is versatile for soft-tissue reconstruction of various body defects because of its thick and vascularized fascia component. We present our clinical experience with the functional one-stage reconstruction of complicated soft-tissue defects using ALTs with vascularized fascia lata (FL). Between April 2018 and February 2022, we transferred ALTs with FL components for various soft-tissue defects in 15 patients. The FL component was used for reconstruction of hand & forearm tendon, medial and lateral patellar synovial membrane, plantar aponeurosis, abdominal wall, dura and Achilles tendon. Functional outcomes were evaluated in each patient. Partial flap necrosis occurred in 2 patients and were treated successfully with minimal surgical debridement and dressing. The vascularized fascia could replace a tendon and fascial component and all the patients achieved satisfactory results without major postoperative complications. Anterolateral thigh flaps with vascularized FL provide reliable fascial and tendon components for single-stage reconstruction of complex soft tissue defects.

Using Free Chimeric Anterolateral Thigh Flap For Reconstruction Of Composite Dorsal Hand Defect

Simultaneous repair of the extensor tendons and soft tissues in hand injuries remains challenging. The free chimeric anterolateral thigh (ALT) flap with fascia lata (FL) flap represents an alternative for hand reconstruction. This report describes the reconstruction of the extensor tendon and skin defects using free chimeric ALT flaps with FL. Eight patients (one female and seven male) underwent reconstruction of complex hand defects with free chimeric ALT and FL flaps. The defects were caused by crushing injuries, burns, snakebite scars, and animal bite wounds. The average skin defect was 116 cm2. Perforators were selected for the skin paddle and the FL flap. The thinning procedure was performed microsurgically. The skin paddle size ranged from 12 to 23cm in length and 6 to 11cm in width, and the FL flaps ranged from 3×5 to 12×5cm. The mean pedicle length was 7.88cm. Nine extensor tendons were repaired with FL flaps. The flap thickness after thinning was only 3-6mm. The donor site was closed primarily in six patients, and skin grafts were used in two cases. All flaps survived without complications. The follow-up period lasted from 17 to 80 months. Range of motion was achieved with satisfaction. The chimeric-thinned ALT and FL flap is a valuable material, and it should be considered a reconstructive option for hand soft tissue and extensor tendon reconstruction. This technique allows us to achieve a good appearance and extensor function without donor-site morbidity.

Advances in Soft Tissue Injuries Associated with Open Fractures.

Management of soft tissue injury is a key component in the overall treatment of upper extremity fractures. Hand surgeons must rely on their armamentarium for treating soft tissue deficits for functional outcomes. Understanding the role of fracture fixation and wound adjuncts, including negative pressure wound therapy and dermal regenerative templates, is the keys to success. In addition, detailed knowledge of local and free tissue options is essential for hand reconstruction.

Reconstruction of soft tissue defects of hand: A systematic approach.

A thorough insight into the management of hand injuries can shape the approach of a surgeon in order to achieve optimal outcomes for the patients. The aim of this study was to share our experience in reconstruction of the hand and establishing an algorithm for classification and treatment of hand injuries. This is a descriptive cross sectional study and was conducted from January 2020 to August 2022 at Burns and Plastic Surgery center, Peshawar. Data was collected from medical records about the patient demographics, mechanism of injury and type of procedures done. Defect size was classified into small (<5cm), medium (5cm to 10 cm) and large (>10cm). The defect site and size was cross tabulated against the method of soft tissue reconstruction in order to make the algorithm for reconstruction of hand injuries. Data was analyzed using SPSS. The study population included 41 (75.9%) male and 13 (24.1%) female patients, mean age 31.56±14.1. Machine injuries (33.3%) and electric burns (24.1%) were the most common cause of hand soft tissue defects. The most commonly performed flap was Posterior introsseous artery (PIA) flap, followed by First dorsal metacarpal artery (FDMA) flap. Flap necrosis was observed in three cases (5.6%). This treatment algorithm for coverage of soft tissue defects in hand injuries will help with the decision making process of hand reconstruction and has didactic value for novice surgeons. It will also form the foundation for further work on this aspect of hand injuries.

Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome.

In the past decade, vascularized composite allotransplantation (VCA) has become clinical reality for reconstruction after face and hand trauma. It offers patients the unique opportunity to regain form and function in a way that had only been achieved with traditional reconstruction or with the use of prostheses. On the other hand, prostheses for facial and hand reconstruction have continued to evolve over the years and, in many cases, represent the primary option for patients after hand and face trauma. We compared the cost, associated complications, and long-term outcomes of VCA with prostheses for reconstruction of the face and hand/upper extremity. Ultimately, VCA and prostheses represent 2 different reconstructive options with distinct benefit profiles and associated limitations and should ideally not be perceived as competing choices. Our work adds a valuable component to the general framework guiding the decision to offer VCA or prostheses for reconstruction after face and upper extremity trauma.

Salvage and Reconstruction of the Mangled Hand: A Case Study Utilizing a Multi-Composite Tissue Product Reconstructive Approach

Objective: To evaluate the efficacy of a novel reconstructive approach utilizing Multiple Composite Tissue Products (MCTPs) in severe hand injuries with risk of amputation. Methods: A comprehensive, single MCTP operation was performed at a single institution involving three tissue products to salvage the nerves, tendons, bone, and skin. This patient case study exemplifies the successful reconstruction of a mangled hand. Results: The application of three tissue products resulted in securing the integrity of the mangled hand’s structures and preservation of basic hand and wrist function, obviating the need for amputation. The patient regained significant restoration substantiating the safety and efficacy of this approach for structural, functional, and cosmetic outcomes. Discussion: Preoperative assessment and multi-disciplinary coordination of care was imperative in optimizing the successful outcomes. The patient’s medical history was complicated by diabetes mellitus, neuropathy, and osteonecrosis. Intensive postoperative rehabilitation, including Passive and Active Range of Motion (PROM, AROM), contributed to recovery and outcomes. Significance: The MCTP reconstructive approach is a promising avenue for optimizing tissue viability to recover from mangled hand injuries. The amelioration of adhesion formation directs proper tissue recovery which conserves tissue that might otherwise necessitate further excision, and possibly amputation. Per patient centered outcomes, this strategy mitigated extensive pain and minimized scarring, which enhanced the cosmetic appeal of reconstructing the mangled hand. These findings underscore the reconstructive potential of a MCTP approach in complex hand salvage, contributing to the recovery of function and cosmetic appeal. Future research should aim to validate similar findings of this case study strategy in a larger cohort.

75 Intraoperative Use of Infrared Thermal Imaging Camera – a Clinical Aid for Pedicled Flaps in Hand Reconstruction

Abstract Introduction Venous insufficiency remains one of the commonest causes for flap failure. Forward-looking infrared (FLIR) thermography measures infrared emissions from dissipated heat and converts temperature values into an image. This has various advantages to the current use of indocyanine green (ICG) angiography to assess flap perfusion. Case A man in his mid-30s was involved in a road traffic accident and sustained extensive injuries to his right hand. These included multiple metacarpal fractures, degloving of the proximal aspect of the entire thumb and significant skin loss on the volar distal forearm. After several washouts and tissue debridement, a pedicled chest wall flap was performed. Five weeks later the chest wall flap was divided using an infrared thermal imaging camera (FLIR E5) intraoperatively as a clinical aid to assess perfusion. This detected a small area of venous congestion which was not detectable by clinical assessment. Discussion There are drawbacks to the current intraoperative use of ICG angiography to assess flap perfusion. These include hot flushes and skin rashes, and the technique requires an intraoperative injection, extensive equipment involving a screen and a specialised camera. In comparison FLIR cameras are handheld, easy to use and involves a one-off cost of purchasing the camera that is relatively inexpensive compared to ICG angiography. Conclusions Thermal imaging techniques such as FLIR provides an alternative intraoperative option for patients who are unable to have ICG, for centres that do not have access to ICG and for surgeons looking for more convenient alternatives.

The Superficial Circumflex Iliac Artery Perforator Flap for Devastating Hand Injuries in the Obese.

Blast injuries to the hand, such as those from fireworks, are debilitating and life altering. Often, because of the nature of the injury, there is a need for soft tissue and skin coverage. However, in the increasingly obese American population, free flaps often are too bulky for functional hand coverage. In this study, we present a series of 7 patients who underwent the superficial circumflex iliac artery perforator (SCIP) flap for upper extremity reconstruction with improvement in cosmesis, including a primarily repaired donor site, as well as an overwhelmingly high return to work with minimal revision surgery necessary. All patients who underwent a SCIP for hand injuries from a blast were included. Flaps were harvested based on previously described methods. A single attending surgeon performed all surgeries. All patients were followed for at least 6 months. Preoperative and postoperative characteristics were described. A total of 7 patients were included in this study. Ages ranged from 16 to 58 years and body mass index from 19 to 48 kg/m2. More than half of the patients had a body mass index greater than 30 kg/m2. All donor sites were primarily closed. Five patients returned to their preinjury work. Three patients had neurotized flaps with return of protective sensation. Three patients required revision surgery; all 3 had liposuction, and 1 had additional flap advancement surgery. The SCIP flap is a versatile flap that can be used in hand reconstruction in blast injuries with good functional outcome and improved cosmesis compared with other perforator flaps for the upper extremity.

Outcomes of Apert Syndrome Hand Reconstruction With Tilapia Skin: A Prospective Study.

Tilapia skin has already been used in various medical scenarios, but there are no studies showing the use of tilapia skin for hand reconstruction in Apert syndrome. The objective of this study is to determine whether the use of tilapia skin during graft bed preparation for children with Apert syndrome can shorten wound reepithelialization intervals, reduce the number of dressing changes, and decrease patient discomfort. This is a prospective study on consecutive patients with Apert syndrome who underwent hand reconstruction at our Hospital. Patients were divided into 2 groups: (1) a control group consisting of patients who underwent conventional digit separation hand reconstruction surgery (2) an experimental group consisting of patients who underwent similar digit separation hand reconstruction surgery that commenced with the placement of a thin layer of tilapia skin at the raw commissures during a first operation, which was subsequently replaced by an autologous skin graft during a second operation staged 10 days postoperatively. Pain assessment was performed using the Visual Analog Scale. The number of dressing changes was also assessed. A T test compared the total number of dressings changes and pain data. Experimental group patients (n = 8) required an average of 9.4 days of daily dressing changes, and control group patients (n = 5) required an average of 20.8 days of daily dressing changes ( P < 0.05) and tended to experience significantly less pain when compared with patients in the control group ( P = 0.079). Tilapia skin can shorten wound reepithelialization intervals by reducing the total number of dressing changes.

Consistent 3D Hand Reconstruction in Video via Self-Supervised Learning.

We present a method for reconstructing accurate and consistent 3D hands from a monocular video. We observe that the detected 2D hand keypoints and the image texture provide important cues about the geometry and texture of the 3D hand, which can reduce or even eliminate the requirement on 3D hand annotation. Accordingly, in this work, we propose S2HAND, a self-supervised 3D hand reconstruction model, that can jointly estimate pose, shape, texture, and the camera viewpoint from a single RGB input through the supervision of easily accessible 2D detected keypoints. We leverage the continuous hand motion information contained in the unlabeled video data and explore S2HAND(V), which uses a set of weights shared S2HAND to process each frame and exploits additional motion, texture, and shape consistency constrains to obtain more accurate hand poses, and more consistent shapes and textures. Experiments on benchmark datasets demonstrate that our self-supervised method produces comparable hand reconstruction performance compared with the recent full-supervised methods in single-frame as input setup, and notably improves the reconstruction accuracy and consistency when using the video training data.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Abstract Background One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

Stature Estimation among Iraqis based on Anthropometrics of the Hands using Multivariable Regression

Background: Estimating stature is of exceptional value in personal identification and the forensic sciences. At the same time, the literature lacks standardized methods for height estimation. Objectives: To estimate the stature of Iraqi individuals based on the morphometric parameters of both hands. Methods: 101 students recruited from Al-Rafidain University College collected data concerning ethnicity, gender, weight, and height and measured fourteen morphometric parameters for each hand, including the hand length (RHL; LHL), palm length (RPL; LPL), hand breadth (RHB; LHB), maximum handbreadth (RHB; LHB), and the length of each finger (RD1,2,3,4,5; LD1,2,3,4,5). A multivariable linear regression is used to predict stature based on the former variables. Results: The sample included males (48.5%) and females (51.5%) aged 18–23 years of Arabic (95%) and Kurdish (5%) ethnicity. The average weight (65.68±1.32) and height (169.52±1.13) were calculated. Regression analysis (accuracy=74.8%, p&lt;0.001) and the male cohort (65%, p&lt;0.001) possessed higher statistical accuracy than females (47.2%, p&lt;0.001). Stature estimation within the total sample and males assumed similarities concerning parameters allocated to both hands that principally included the length of the right hand, right middle finger, left palm, and left little finger. In contrast, females' stature estimation corresponded to morphometric parameters strictly related to the left hand, including the length of the hand, palm, ring finger, and little finger. The results also aligned with the neural network analyses and qualitative data from ChatGPT version 3.5. Conclusion: Multivariable predictive models that are crucial in personal identification for forensic purposes were predicted, such as catastrophic scenarios due to disfiguring accidents, organized crime, and mass graves that frequently occurred in Iraq during the past two decades. Our results could also interest reconstructive hand surgery experts.

Plastic-Reconstructive Hand Surgery: a Multidisciplinary Procedure

The present study aims to provide a detailed and accurate summary of reconstructive aesthetic hand surgery in medical terms. This specialized surgical intervention comprehensively addresses the functional and aesthetic alterations affecting the hand, through complex and personalized techniques.Aesthetic reconstructive hand surgery is indicated in a variety of clinical situations, including hand trauma, congenital malformations, degenerative diseases, soft tissue defects, tumors and post-surgical reconstruction. Each case requires a thorough and personalized evaluation to determine the most appropriate surgical approach and to achieve satisfactory results.The anatomical complexity of the hand, consisting of bones, joints, tendons, muscles, nerves and blood vessels, requires in-depth knowledge on the part of the surgeon. The multidisciplinary approach, in collaboration with specialists in plastic surgery, orthopedic surgery, occupational therapy, physiotherapy and rehabilitative medicine, is crucial to the success of the intervention.Aesthetic reconstructive hand surgery seeks to restore hand function, improve aesthetic appearance and ultimately improve patients' quality of life. The focus is on repair and reconstruction of affected tissues, correction of deformities, stabilization of joints, revision of scars, and optimization of hand shape and contour

Hand Reconstruction with Little's Flap, Cross finger Flap and V-Y Flap. A case report

Hand Reconstruction with Little's Flap, Cross finger Flap and V-Y Flap. A case report

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

BackgroundPropeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction. MethodsA comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected. ResultsOut of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%. ConclusionPPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

3D hand reconstruction with both shape and appearance from an RGB image

Modeling 3D hands with geometry details and appearance can increase perceptual immersion and realism in many applications. However, traditional 3D representations such as meshes and voxel grids can not represent high-quality hand shapes with their property of the discrete surface and fixed topology. To address these problems, we introduce implicit function for more detailed shape reconstruction, and design a Structure-aware Signed Distance Function (S-SDF) to reconstruct hand shape in arbitrary resolution. In this way, our method not only focuses on independent fingers but also keeps the relationship between fingers. Such implicit function of 3D representation associated with part semantics and structure of the hand is central to generating realistic hand shapes of diverse variations. Meanwhile, in order to avoid time-consuming and laborious 3D annotating of texture, we present a self-supervised appearance synthesis approach. Extensive experiments on widely used datasets demonstrate that the proposed method reconstructs more realistic hands compared with previous methods.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes.

Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates. Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05. The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group. Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.