Web Creep Research Articles

Release of partial syndactyly using a trident flap without skin grafting.

We reviewed outcomes of a modified trident flap technique in 83 patients for a series of partial syndactyly releases performed by a single operator over 30 years. Only patients with at least 3 years of follow-up (range 3 to 27 years) were included. One-hundred and twenty-seven procedures were performed for 83 patients, and no cases of flap necrosis occurred. Three hands had Grade 1 web creep on Withey's semi-quantitative scoring system, and two had Grade 2 web creep. Revision surgery was required for one minor contracture and one intermediate contracture. Abduction angles of up to 30° were measured for operated adjacent fingers. The mean satisfaction score of the child or parents on the visual analogue scale was 1.1. The trident flap is a safe procedure, with excellent functional and cosmetic outcomes. The residual scarring is limited to the web, and there is no scarring on the dorsum of the hand. Level of evidence: IV.

Simple Syndactyly Release With Dental Roll Dressing

The goal of surgical intervention to repair syndactyly is to improve cosmesis and allow for a fully functional hand with independent finger motion while preventing web creep, angular deformity of the involved digits, soft tissue contracture, or neurovascular injury. Because web creep is one of the most common complications of commissure reconstruction, it is important to create a good dorsal flap with a broad insertion proximal to the commissure. The authors describe a technique in which the placement of a “dental roll” between the newly separated digits helps not only with graft take and to seat the dorsal flap well into the web space, but also to prevent the newly separated digits from touching each other. The use of the dental roll in the web space is novel, can be used in place of standard bolter-type dressings, and, along with the creation of an appropriately sized dorsal commissure flap, has the potential to enhance healing and perhaps prevent web creep.

External fixation: Role in decreasing postoperative complications of complex syndactyly release – A review of 18 patients

BackgroundPrimary and revision surgery for complete complex congenital syndactyly (CCCS) of the hand carries a risk of complications such as web maceration, which can result in flap or graft loss and alter the final appearance. No consensus emerges from the scant published data on postoperative care after CCCS surgery. The objective of this study was to assess the role for temporary external fixation in stabilising the commissure and facilitating surgical wound care. HypothesisUsing external fixation after CCCS release facilitates postoperative wound care and decreases the complication rate. Material and methodsEighteen patients requiring primary CCCS surgery or revision CCCS surgery due to adhesions or web creep were included in a single-centre retrospective study. After release, an external fixator made of Kirschner pins was installed to temporarily immobilise the inter-phalangeal joints. The dressing was changed every 3 days for 3 weeks, and the external fixator was then removed. The parents and nurses completed questionnaires that used 0–10 point scales to assess ease and duration of dressing changes and perceptions and apprehensions experienced by parents and nurses, as well as pain by patients, during dressing changes. ResultsNo patient experienced maceration or failure of a graft or flap. Pin site discharge was noted in 1 patient and resolved fully after pin removal. Pain intensity was estimated at 4.2/10 during the first dressing change and 1.3/10 during the last dressing change. In the parents, apprehension was 9.6/10 and 5.1/10 during the first and last dressing changes, and stress was 8.1/10 and 4.1/10, respectively. Dressing change difficulty was rated 1.1/10 at the first and 0.9/10 at the last dressing change. Dressing change duration decreased from 13 to 10minutes. ConclusionThese encouraging results support temporary commissure stabilisation by an external fixator to decrease postoperative complication rates and facilitate dressing changes after CCCS release. Level of evidenceIV, retrospective observational study.

Évaluation du lambeau palmaire de Blauth lors de la prise en charge des syndactylies congénitales : à propos de 31 commissures

The main purpose of our study was to assess the web creep rate of congenital syndactyly treated with a Blauth palmar commissural flap. Every child with at least one syndactyly, simple or complex, syndromic or not, were included in this study. The main criterion of this study was the web creep rate according to the Withey scale (0 to 4). Scar assessment according to the Vancouver Scar Scale, hair growth and/or dyschromia on the full-thickness graft, digital spacing, flexion deformity, clinodactyly, range of motion of the finger, sensitivity and satisfaction were also assessed. Separation of the webbed fingers was performed in 65 syndactylies between 1993 and 2015. The median age at the time of surgery was 14 months. We reviewed 31 web flaps with a mean follow-up time of 9 years. Fifty eight percent of the webs were grade 0 on the Withey scale, 36% were grade 1, 6% were grade 2. There was no grade 3 or 4. No correlation was found between the age at the time of surgery, gender, web space involved, complexity of the syndactyly, and the web creep. A decrease in range of motion and a flexion deformity of the fingers involved were more frequently found in complex syndactylies. Eighty seven percent of full-thickness grafts presented dyschromia, and 42% abnormal pilosity. Palmar flap as described by Blauth is a safe technique ensuring good functionals outcomes and a low web creep rate for the reconstruction of the web space in congenital syndactyly.

Dorsal Hexagon Local Flap Without Skin Graft for Web Reconstruction of Congenital Syndactyly

The ideal web reconstruction for syndactyly requires both satisfactory function and aesthetic appearance. In this study, we report a dorsal hexagon local flap with adequate size and that leaves most of the scars in the interdigital space. Between June 2015 and June 2017, 16 patients (10 males and 6 females) with 22 syndactylies underwent surgical reconstruction using the dorsal hexagon local flap technique. All patients had simple syndactyly. The postoperative evaluation included the quality of scarring, the extent of flexion and extension deformity, web creep, lateral flexion deformity, and rotational deformity of the digit. All flaps survived and there were no postoperative complications. All patients achieved satisfactory interdigital commissure depth. During 12 to 34 months of follow-up, no case of flexion contracture or web creep after reconstruction was noted. The dorsal hexagon local flap is an alternative method for syndactyly reconstruction. Therapeutic IV.

Application of modified pentagonal dorsal finger flap in the congenital syndactyly release

Objective To explore the clinical efficacy of modified pentagonal dorsal finger flap in the congenital syndactyly release. Methods From January 2010 to January 2014, 20 cases of simple cutaneous syndactyly were treated by modified pentagonal dorsal finger flap combined with finger Zigzag flap. The flap coverage scope, the occurrence of infection and necrosis of the skin flap and other early complications were recorded. The web depth and finger extension angle were measured and compared with the healthy side. Finger web creep and finger web scar were scored, and whether reoperation was performed due to the above complications was recorded. Questionnaire was used to evaluate parents' satisfaction. Results Twenty patients were follow-up for 30 to 75 months, with an average of 38 months. No complications such as infection and necrosis of skin flaps occurred after operation. The shape of the web was wide. The web depth of the affected side was (2.37±0.56) cm, and the finger extension angle was (24.50±4.74)°. There was no significant difference between the affected and healthy side. The reoperation rate due to web creep, web contracture and scar flexion contracture was 0. Family members were satisfied with the treatment outcome. Conclusion The modified pentagonal dorsal finger flap combined with finger Zigzag flap can reconstruct web space to the level of proximal interphalangeal joint, reduce the complications such as web creep and scar contracture after operation. Wide web is good for fingers to grasp large objects with high operative safety. Key words: Hand deformities,congenital; Syndactyly; Modified pentagonal dorsal finger flap; Web reconstruction; Web contracture

Interdigitating Rectangular Flaps and Dorsal Pentagonal Island Flap for Syndactyly Release

Interdigitating triangular flaps is the most commonly described technique for syndactyly release. However, triangular flaps may be associated with flap misalignment, flap tip necrosis, and a steep learning curve in design and technique. This study describes a series of syndactyly reconstructions using interdigitating rectangular flaps in both simple and complex syndactyly. A single surgeon's experience of syndactyly reconstruction using interdigitating rectangular flaps was reviewed retrospectively. Patient demographics, associated syndromes, operative technique, complications, and recurrences were analyzed. Ninety-four web spaces in 50 children with 16 simple incomplete, 36 simple complete, 14 complex, 26 complicated, and 2 unclassified syndactylies were reconstructed with interdigitating rectangular flaps. Seventy-eight commissures were reconstructed with a dorsal pentagonal island flap and 16 with a dorsal rhomboid flap. Full-thickness skin grafts were used in 98% of webs. Five major complications required surgical intervention-2 recurrences, 2 web space scarrings, and 1 wound infection. Ten minor complications occurred-skin graft donor site dehiscence (3), partial loss of the skin graft (4), minor distal interphalangeal joint flexion contractures (2), and a case of minor web creep (1). Average follow-up was 13.7 months. All parents were satisfied with the function and appearance of their child's reconstructed digits. Interdigitating rectangular flaps provide an effective technique for release of both simple and complex syndactyly. Advantages include easy learning owing to the relative simplicity of design; intraoperative modification of flap design (cut as you go), and wide flap tips, which prevent flap tip necrosis. Therapeutic IV.

Dorsal pentagonal island flap to reconstruct post-burn interdigital web.

This study reports the use of a dorsal pentagonal island flap for post-burn webbing contracture, in which the islanded flap is harvested from the burn scar tissue. Fourteen dorsal pentagonal island flaps were harvested in seven patients with post-burn webbing. Each flap was selected by examining the scar tissue donor using a modified Vancouver scar scale. Modification from the basic design was made according to the density of the donor scar tissue and the metacarpophalangeal joint movement. All the flaps survived with normal abduction of the affected fingers. Modification of the flap design needed adjustment by assessing it through flexion and extension of the metacarpophalangeal joints. There was no incidence of web creep after two months to one year of follow-up. Dorsal pentagonal island flap shows promising results as an alternative for reconstructing post-burn webbing.

A Systematic Review and Comparison of Outcomes Following Simple Syndactyly Reconstruction With Skin Grafts or a Dorsal Metacarpal Advancement Flap

Many techniques exist for simple syndactyly reconstruction. The most commonly used techniques involve either skin grafts or a dorsal metacarpal advancement flap. Our aim was to review and compare the outcomes of these 2 techniques systematically. We reviewed articles from PubMed, MEDLINE, EMBASE, and Google Scholar published between January 1966 and January 2016. We identified studies that reported outcomes after reconstruction of simple syndactyly using skin grafts and those using only a dorsal metacarpal advancement flap. Cases of complex syndactyly and those that were not clearly differentiated by technique or type of simple syndactyly were excluded. Outcomes were then stratified by technique and type of syndactyly (complete and incomplete). We identified 693 articles and selected 34 for inclusion. No standardized outcome measure was uniformly applied in the examined studies. Overall, skin grafting procedures were associated with more complications (eg, flap necrosis/graft failure, contracture, web creep, hypertrophic scarring) and a greater need for revision. When stratified by subtype, patients with simple, complete syndactyly who underwent skin grafting had a significantly higher rate of hypertrophic scarring than those who underwent reconstruction with a dorsal metacarpal advancement flap. Simple syndactyly reconstruction with a dorsal metacarpal advancement flap may lead to fewer complications than procedures using skin grafts. However, substantial limitations of currently available evidence do not allow for the recommendation of a specific technique. Future research should use a uniform reporting system for syndactyly classification and complications. Therapeutic IV.

Foot Syndactyly: A Clinical and Demographic Analysis.

BackgroundSyndactyly of the foot is the second most common congenital foot anomaly. In East Asia, however, no large case study has been reported regarding the clinical features of isolated foot syndactyly. In this study, we report a review of 118 patients during the last 25 years.MethodsWe conducted a chart review of patients who underwent surgical correction for foot syndactyly between January 1990 and December 2014. Operations were performed with a dorsal triangular flap and a full-thickness skin graft. The demographics of included patients and their clinical features were evaluated. Surgical outcomes and complications were analyzed.ResultsAmong 118 patients with 194 webs (155 feet), 111 patients showed nonsyndromic cases and 7 patients showed syndromic cases. In 80 unilateral cases (72.1%), the second web was the most frequently involved (37.5%), followed by the fourth (30%), the first (15%), the third (15%), the first and second in combination (1.3%), and the second and third in combination (1.3%). Among 31 bilateral cases, 2 cases were asymmetric. Among the remaining 29 symmetric bilateral cases, the second web was the most frequently involved (45.2%), followed by the first (22.6%), and the fourth (6.5%). No specific postoperative complications were observed, except in the case of 1 patient (0.51%) who required a secondary operation to correct web creep.ConclusionsThis retrospective clinical study of 118 patients with both unilateral and bilateral foot syndactyly revealed that the second web was the most frequently involved. In addition, complete division and tension-free wound closure with a full-thickness skin graft of sufficient size showed good postoperative results.

Abstract: Congenital Syndactyly Reconstruction of 391 Webspaces

INTRODUCTION: Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly and postoperative function will depend on the preoperative state of the hand in addition to the method of reconstruction selected. We present the 18 year experience of surgical reconstruction of congenital syndactyly in all of its forms at a high throughput children’s hospital. METHODS: All patients who underwent webspace reconstruction for congenital syndactyly by the senior author over an 18 year period were included in this study. Data included demographics, medical history, anatomy and severity of syndactyly, surgical technique, follow up and need for revision. Patients who underwent hand surgery prior to their first clinic visit were excluded from outcomes analysis. Logistic regression was performed to identify factors that were associated with postoperative wound complications and revision. RESULTS: Reconstruction was performed for 182 patients with 391 webspaces; 21 patients were referred from outside surgeons and excluded from outcomes analysis. Twenty-eight patients had complications over 32 webspaces. The most common complications were web creep (n=10), scar contracture (n=6), and flexion contracture (n=5). Dorsal VY advancement flap was the most common method for reconstructing simple incomplete syndactyly and was associated with decreased risk of complication in the 3rd webspace (OR=0.427 p=0.006) while triangular flaps and skin graft was associated with increased complications (OR=2.75, p <0.001). Presence of a complicated hand anomaly did not significantly increase the likelihood of complications (p=0.21). CONCLUSION: Syndactyly is a common congenital hand condition that occurs as both an isolated anomaly and as part of several syndromic diagnoses. We describe the largest retrospective cohort of congenital syndactyly reconstruction to date and discuss important technical and clinical considerations to minimize postoperative complications and revisional surgery.

Congenital Syndactyly Reconstruction of 391 Webspaces: An 18 Year Experience: Level 4 Evidence

There is no financial information to disclose. Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly, and postoperative function will depend on the pre-operative state of the hand in addition to the method of reconstruction selected. All patients who underwent webspace reconstruction for congenital syndactyly by the senior author over an 18 year period were included in this study. Data included demographics, medical history, anatomy and severity of syndactyly, surgical technique, follow-up and need for revision. Patients who underwent hand surgery prior to their first clinic visit were excluded from outcomes analysis. Logistic regression was performed to identify factors that were associated with postoperative wound complications and revision. Reconstruction was performed for 182 patients with 391 webspaces; 21 patients were referred from outside surgeons and excluded from analysis. Twenty-six patients had complications (16%), of which 13 (8%) required revision. The most common complications were web creep (n = 10), scar contracture (n = 6), and flexion contracture (n = 5). Dorsal VY advancement flap was the most common method for reconstructing simple incomplete syndactyly and was associated with decreased risk of complication in the 3rd webspace (OR = 0.427, P = 0.006), while triangular flaps and skin graft were associated with increased complications (OR = 2.75, P < 0.001). Presence of a complicated hand anomaly did not significantly increase the likelihood of complications (P = 0.21). •Syndactyly is a common congenital hand condition that occurs as both an isolated anomaly and as part of several syndromic diagnoses.•We describe the largest retrospective cohort of congenital syndactyly reconstruction to date and discuss important technical and clinical considerations to minimize postoperative complications and revisional surgery.

V-Y and rectangular flap combination for syndactyly repair

Objective: For syndactyly repair, several delicate, well-planned flap combination techniques have been reported. This study presents technique details with functional and aesthetic results of a dorsal rectangular and volar V-Y advancement flap combination for web reconstruction and S incisions for finger separation in patients with syndactyly.Method: Ten patients with 16 syndactyly webs were treated. Patients were examined in terms of function and aesthetic. Evaluation criteria included the Vancouver Scar Scale, range of motion, degree of web creeping, parent’s satisfaction rates, and finger abduction. During the initial period, vascular compromise of fingers, haematoma, infection, seroma, flap necrosis, or graft failures were not noted in any patients. No patients required revision surgery. During the later period, parent satisfaction scores were excellent or good, finger function was complete, and the Vancouver Scar Scale showed that two webs had hyperpigmented areas and two had supple pliability.Conclusion: This simple syndactyly release technique can provide a low rate of web creep, good scar quality, and optimal functional results.

Long-term results of syndactyly correction by the trilobed flap technique focusing on hand function and quality of life

Syndactyly is usually corrected surgically during the first years of life. The trilobed flap, a surgical method that does not require skin grafting, was developed in the 1990s and the short-term results were comparable with previously reported techniques. Here we report on long-term outcomes, focusing on how children perceive their hand function and quality of life when they grow up. A total of 19 patients (29 web spaces) were operated on between 1990 and 2000, and followed-up 16 years later with questionnaires and clinical tests. The patients reported low QuickDASH scores, normal sensibility and dexterity, and minor cold intolerance. Only two reoperations, due to early web creep, were needed. The condition minimally affected the choice of occupations, leisure activities and perceptions of appearance. The trilobed flap technique for release of syndactyly provides a good long-term outcome with good hand function and minimal impact on the quality of life. IV.

Syndactyly Web Space Reconstruction Using the Tapered M-to-V Flap: A Single-Surgeon, 30-Year Experience

To describe the technique and results of the tapered M-to-V flap for syndactyly web space construction. We reviewed a single-surgeon, single-institution experience of all syndactyly reconstructions performed between 1982 and 2013. Demographic data and patient characteristics were recorded. Complications included flap loss, graft loss, web creep, infection, restricted range of motion, and digit deviation. A total of 138 web spaces were reconstructed in 93 patients. There were 89 primary congenital hand and 32 foot syndactylies. Four patients had an acquired simple incomplete syndactyly and 13 patients had secondary reconstructions. The complication rate was 14%. The most common complication was web creep resulting from partial skin graft loss (12 web spaces; 9%). There were no total flap losses. Univariate analysis revealed no factor to be predictive ofan elevated complication rate. Average follow-up was 2.6 years (range, 6 mo to 26 y). The tapered M-to-V flap proved to be a reliable and versatile technique for web space reconstruction, offering several advantages over the standard rectangular flap method of repair, such as ease of intraoperative adjustment, a z-plasty at the palmodigital crease to minimize scar contracture, and better color match. Therapeutic IV.

Dorsal plane-shaped advancement flap for the reconstruction of web space in syndactyly without skin grafting: A preliminary report

Skin grafting for syndactyly repair is time-consuming, and it has the potential risks of scar contracture and web creep. Several techniques have been described for web reconstruction without skin grafts in simple syndactyly. Based on the hexagonal advancement flap, we designed a "plane-shaped" advancement flap on the dorsal hand or foot for a web reconstruction with primary closure. Between June 2010 and August 2013, a "plane-shaped" advancement flap was used for web reconstruction in 24 syndactylies of 20 pediatric patients. The patients' age ranged from 1.5 to 8 years (mean age: 2.5 years). The patients were followed up for 15-48 months (mean: 28 months). The mean operation time was 60 min (range: 50-75 min). All incisions were closed primarily without skin grafting. All the flaps survived completely without early complications such as infection, vascular compromise or delayed healing. The mean hospitalization time was 3.5 days. There was no occurrence of long-term complications including web creep, flexion contractures, angulation deformity, or obvious keloid formation during the 15-48 months follow-up. Cosmetic and functional satisfactory outcomes were achieved in all cases without secondary revision. The dorsal plane-shaped advancement flap without skin graft is a solution for web space reconstruction in simple syndactyly, especially in the foot.

Intérêt d’un substitut dermique en 1 temps (Matriderm©) dans la couverture des pertes de substance de la face latérale des doigts longs lors d’une cure de syndactylie congénitale : à propos de 20 commissures

Surgical treatment of congenital syndactylies is based on the creation of a new commissure - with a commissural flap - and on the management of fingers lateral faces - with mirror zigzag incisions. Lateral skin defects are covered by full-thickness skin graft. Since their discover 30 years ago, dermal substitutes applications have been enlarged. We have wandered if these technique could be interesting for the treatment of these lateral skin defects. We have launched a monocentric and retrospective study with only one surgeon. The assessor and the operator were different. Included patients have a simple or complex congenital syndactyly, complete or not, associated with a syndrome or not. Children with a first web space syndactyly were excluded. Surgical treatment was performed with a dorsal commissural flap, with mirror incisions and with a lateral skin defects coverage by dermal substitute (Matriderm(©)) and split-thickness skin graft taken from the scalp. The initial assessment criterion was the quality of the scare measured by the OSAS score. Web creep (Whitney's scale) and time of surgery were two minor criteria. Twenty commissures (11 children) have been included between 2008 and 2013. Fourteen complex syndactylies were noted. The average aftercare was equal to 2.7 years (0.5-5.5 years). Interventions were performed at the age of 1.8 years (0.5-4 years). Surgical time was equal to 44.6 min (22-95 min). Patients OSAS score was 11.9 (6-18). It was 12.2 (60-20) for complex forms and 11.9 (10-16) for simple forms. Graft weren't hairy. There was no complication on the donor site. Whitney's score was 1.2 (0-3) and three web spaces were reoperated. We think that the use of dermal substitute Matriderm(©) is a new and serious alternative to treat congenital syndactylies. Results have to be confirmed by a new study which would compare this material to full-thickness skin graft, gold standard technique for these skin defects.

The preliminary outcome of syndactyly management in children with a new external separation device.

To introduce a new external fixation device for the management of syndactyly in children. To evaluate its preliminary clinical result. From January 2011 to June 2012, 12 cases with cutaneous syndactyly of the middle/ring finger were managed with a new external fixator designed by our department. There were eight cases on the right side and four on the left side. The web space and soft tissue were stretched gradually using the new device. A Z-plasty of syndactylies was performed when the web space has reached the width that we required. The results were evaluated according to the clinical appearance and function of the fingers. Twelve cases had been followed up, with an average time of 16 months (range, 12-27 months). The web space and soft tissue in all the cases were stretched successfully using the new device. Skin grafting was not necessary in the reconstruction of syndactyly. In the last follow-up, the Vancouver Score averaged 0.6 (range, 0-2). Three cases had grade 1 web creep, whereas the other nine cases had grade 0 web creep. The total active motion averaged 130.4° for all affected fingers: 130.8° for the middle and 130.0° for the ring finger. Stiffness in the PIP joint preoperatively in two cases did not improve postoperatively. In 12 affected middle fingers, three cases had a supination deformity averaging 10.6° (range, 5°-15°) and one case had a pronation deformity of 5°. In 12 affected ring fingers, one case had a supination deformity of 18° and two cases had a pronation deformity averaging 7.5° (range, 5°-10°). The middle finger was not pronated in any patient. Among all the ring fingers, two had radial deviation of 8°and 25° and 1 had ulnar deviation of 10°. The surgeon-provided visual analog scale score for esthetics averaged 1.8 (range, 0-5). The parent-provided visual analog scale score was 2.7 (range, 1-5) for pain, 1.3 (range, 0-5) for appearance, and 1.3 (range, 0-5) for function. Displacement of the nail bed during distraction was found in two cases, which was resolved by the Winograd technique in the second surgery of syndactyly release. The clinical appearance and function were excellent. When we use the new external fixation device in the management of syndactyly, we can achieve a satisfactory outcome with little scar of the fingers. There was no need for skin grafting. However, the long-term result should be studied further.

Hyaluronic acid scaffold for skin defects in congenital syndactyly release surgery: a novel technique based on the regenerative model

Syndactyly release may require skin grafting to fill the skin defects, which might lead to complications or poor cosmetic outcomes. A simple graftless technique for syndactyly release with a hyaluronic acid (HA) scaffold used to cover the bare areas is described. Between 2008 and 2011, release of 26 webs in 23 patients was performed. All skin defects were covered with Hyalomatrix(®) PA. One patient was excluded due to early post-operative infection that required HA scaffold removal before its integration. Web creep, secondary deformities, scar quality, and patient and parental satisfaction were assessed. Mean follow-up of the group of 22 patients was 24 months. There were no secondary deformities and minimal degree of web creep. All patients had close to normal pigmentation and good pliability at the sites of scaffold application. The results confirm the use of a HA scaffold as a promising alternative to skin grafting in syndactyly release surgery.

Results of syndactyly release using a modification of the Flatt technique

The results of 144 congenital syndactyly releases over a 12-year period by a single surgeon using a modified Flatt technique (dorsal hourglass flap, interdigitating zigzag flaps, and full-thickness skin grafts) are analyzed considering the association of skin grafts and web creep. The mean follow-up was 5 years. There were seven cases of graft failure, only one of which developed web creep. Web creep occurred in 4.2% of web releases. The results suggest that avoiding longitudinal straight-line scars across the web space may be an important factor in avoiding web creep when performing the modified Flatt technique described.