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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General
| anesthesia_type = General
| airway = Nasal ETT, Oral ETT, consider awake
| airway = Nasal or oral ETT
Consider awake intubation
| lines_access = PIV
| lines_access = PIV
| monitors = Standard, 5-lead ECG
| monitors = Standard
| considerations_preoperative = History of head and neck radiation, extent of tumor and airway history
5-lead ECG
| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated
| considerations_preoperative = Extent of tumor
| considerations_postoperative = Assess degree of airway edema, smooth extubation
Airway history (head and neck radiation)
| considerations_intraoperative = Adequate muscle relaxation
Electrocautery and risk of airway fire
Tracheostomy may be indicated
| considerations_postoperative = Assess degree of airway edema
PONV prophylaxis
Smooth extubation
}}
}}


Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.<ref name=":0">{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}</ref>
'''Glossectomy''' refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, [[obstructive sleep apnea]], and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.<ref name=":0">{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}</ref>


There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible ("lip-split mandibulotomy"), or opening the sublingual or submental compartments for improved visualization of the inferior tongue ("transcervical pull-through"). Neck dissection and reconstruction may be performed for glossectomy procedures.<ref name=":0" />  
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible ("lip-split mandibulotomy"), or opening the sublingual or submental compartments for improved visualization of the inferior tongue ("transcervical pull-through"). Neck dissection and flap reconstruction may be performed for glossectomy procedures.<ref name=":0" />  


== Preoperative management ==
== Preoperative management ==
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|-
|-
|Neurologic
|Neurologic
|
|Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement
|-
|-
|Cardiovascular
|Cardiovascular
|Consider CAD if smoking history
|Consider [[Coronary artery disease|CAD]]/vascular disease/HTN if smoking history
|-
|-
|Respiratory
|Pulmonary
|Mouth opening, tongue fixation / mass obstruction of the airway, presence of trismus. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN
|Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]
|-
|-
|Gastrointestinal
|Gastrointestinal
|Assess for dysphagia/GERD
|Assess for dysphagia/[[Gastroesophageal reflux disease|GERD]]
|-
|-
|Hematologic
|Hematologic
|
|Consider DVT risk if smoking/cancer history
|-
|Renal
|
|-
|Endocrine
|
|-
|-
|Other
|Other
|Consider history of alcohol abuse in head and neck cancers
|Consider history of alcohol abuse in head and neck cancers, assess nutritional status
|}
|}


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=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===


* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway
* Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, equipment for surgical airway<ref name=":2" />
* If oral intubation, reinforced ETT and bite block recommended<ref name=":1" />
* If oral intubation, reinforced ETT and bite block recommended<ref name=":1" />
* Assistance should be immediately available during induction
* Assistance should be immediately available during induction
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=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===


* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}</ref>
* Consider endoscopic or laryngoscopic airway exam to assess tumor extension<ref name=":2">{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}</ref>
* Consider pre-op acetaminophen 500-1000 mg PO
* Consider acetaminophen 500-1000 mg PO as part of multimodal regimen
* Consider aprepitant 40-80 mg for patients with history of severe PONV
* Consider aprepitant 40-80 mg for patients with history of severe PONV
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===


== Intraoperative management ==
== Intraoperative management ==
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* Standard monitors, PIV
* Standard monitors, PIV
* Mouth gags per surgeon
* Mouth gags/lip retractors per surgeon


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===


* Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon<ref name=":1">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams & Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}</ref>
* Standard premedication
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions<ref name=":1">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams & Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}</ref>
* Consider awake fiberoptic if large tumor at the tongue base  
* Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation<ref>{{Cite journal|last=Kheterpal|first=Sachin|last2=Martin|first2=Lizabeth|last3=Shanks|first3=Amy M.|last4=Tremper|first4=Kevin K.|date=2009-04-01|title=Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics|url=https://doi.org/10.1097/ALN.0b013e31819b5b87|journal=Anesthesiology|volume=110|issue=4|pages=891–897|doi=10.1097/ALN.0b013e31819b5b87|issn=0003-3022}}</ref>
** Consider high flow nasal cannula for pre-oxygenation
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference
* Consider awake fiberoptic intubation if large tumor at the tongue base
* If nasal/airway landmarks effaced, consider awake tracheostomy


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===


* Supine, arms tucked
* Supine, arms tucked
* Arm positioning may differ if radial free flap
** Arm positioning may differ if radial free flap
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries<ref name=":1" />
* Table often 180°
* Table often 180°


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===


* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)<ref name=":2" />
* TIVA with propofol and remifentanil or sufentanil
* Complete muscle relaxation essential
** Opioid infusion useful for smooth extubation<ref name=":2" />
* Complete muscle relaxation essential, may use rocuronium
* Maintaining lower MAP not mandatory but can decrease bleeding
* Maintaining lower MAP not mandatory but can decrease bleeding
* Prophylactic steroids for airway edema
* Prophylactic steroids for airway edema
* PONV prophylaxis with dexamethasone and ondansetron
* PONV prophylaxis with dexamethasone and ondansetron
* Maintain FiO2 <0.3 if lasers are used to prevent airway fire
* Maintain FiO2 <30% to prevent airway fire from electrocautery use
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP<ref name=":1" />
* Goal euvolemia
** Patients may be volume depleted prior to surgery and require fluid boluses
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension<ref name=":1" />
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins <ref>{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}</ref>


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===


* Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs
* Assess degree of upper airway obstruction prior to extubation
* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure)
** Reintubation may be impossible if obstruction occurs
* Extubation after recovery of protective airway reflexes
* Smooth extubation important if skin graft used for closure
* If extubated, may require treatment with humidified oxygen or nebulized bronchodilators
** Graft hematomas are the primary cause of skin graft failure<ref>{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}</ref>
* Extubate after recovery of protective airway reflexes


== Postoperative management ==
== Postoperative management ==
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===


* Inpatient admission depending on size/location, free flap, tracheostomy
* Inpatient admission depending on size/location of resection, free flap, tracheostomy
* Encourage early nutrition, foley removal, mobilization
* Encourage early nutrition, foley removal, mobilization


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* Intraoperative infiltration with local anesthetic
* Intraoperative infiltration with local anesthetic
* Multimodal including non-opioid and bolus/PCA opioid analgesics  
* Multimodal including non-opioid and bolus opioid analgesics
* Consider opioid PCA if subtotal/total glossectomy


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===


* Airway obstruction second to airway edema
* Airway obstruction due to airway edema
* Bleeding
** May require treatment with humidified oxygen or nebulized bronchodilators
* Infection
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)<ref name=":0" />
* Aspiration
* Aspiration
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins <ref>{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}</ref>
* Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue<ref name=":0" />
* Dysphagia
* Bleeding
** Manipulation of mass
** Lingual artery/veins
** Consider external jugular/carotid if neck dissection
* Salivary fistula
* Osteonecrosis if mandibulotomy<ref name=":0" />
* Graft failure


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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!Partial
!Partial
!Subtotal/Total Resection
!Subtotal/Total Resection
|-
|Unique considerations
|
|
|-
|Position
|Supine
|<--
|-
|-
|Surgical time
|Surgical time
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|Postoperative disposition
|Postoperative disposition
|Inpatient depending on degree of resection / neck dissection / flap
|Inpatient depending on degree of resection / neck dissection / flap
|<-- May require prolonged intubation or tracheostomy care
|May require prolonged intubation or tracheostomy care
|-
|Pain management
|Multimodal
|<--
|-
|Potential complications
|Bleeding, infection, aspiration
|<--
|}
|}


Line 161: Line 162:


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />
[[Category:Otolaryngology]]
[[Category:Pharyngeal surgery]]

Latest revision as of 23:49, 4 April 2022

Glossectomy
Anesthesia type

General

Airway

Nasal or oral ETT Consider awake intubation

Lines and access

PIV

Monitors

Standard 5-lead ECG

Primary anesthetic considerations
Preoperative

Extent of tumor Airway history (head and neck radiation)

Intraoperative

Adequate muscle relaxation Electrocautery and risk of airway fire Tracheostomy may be indicated

Postoperative

Assess degree of airway edema PONV prophylaxis Smooth extubation

Article quality
Editor rating
Comprehensive
User likes
1

Glossectomy refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.[1]

There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible ("lip-split mandibulotomy"), or opening the sublingual or submental compartments for improved visualization of the inferior tongue ("transcervical pull-through"). Neck dissection and flap reconstruction may be performed for glossectomy procedures.[1]

Preoperative management

Patient evaluation

System Considerations
Neurologic Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement
Cardiovascular Consider CAD/vascular disease/HTN if smoking history
Pulmonary Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pulmonary hypertension
Gastrointestinal Assess for dysphagia/GERD
Hematologic Consider DVT risk if smoking/cancer history
Other Consider history of alcohol abuse in head and neck cancers, assess nutritional status

Labs and studies

  • Head CT/MRI

Operating room setup

  • Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, equipment for surgical airway[2]
  • If oral intubation, reinforced ETT and bite block recommended[3]
  • Assistance should be immediately available during induction

Patient preparation and premedication

  • Consider endoscopic or laryngoscopic airway exam to assess tumor extension[2]
  • Consider acetaminophen 500-1000 mg PO as part of multimodal regimen
  • Consider aprepitant 40-80 mg for patients with history of severe PONV

Intraoperative management

Monitoring and access

  • Standard monitors, PIV
  • Mouth gags/lip retractors per surgeon

Induction and airway management

  • Standard premedication
  • Administration of antisialogogue (glycopyrrolate) may improve operating conditions[3]
  • Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation[4]
    • Consider high flow nasal cannula for pre-oxygenation
  • Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference
  • Consider awake fiberoptic intubation if large tumor at the tongue base
  • If nasal/airway landmarks effaced, consider awake tracheostomy

Positioning

  • Supine, arms tucked
    • Arm positioning may differ if radial free flap
  • If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries[3]
  • Table often 180°

Maintenance and surgical considerations

  • TIVA with propofol and remifentanil or sufentanil
    • Opioid infusion useful for smooth extubation[2]
  • Complete muscle relaxation essential, may use rocuronium
  • Maintaining lower MAP not mandatory but can decrease bleeding
  • Prophylactic steroids for airway edema
  • PONV prophylaxis with dexamethasone and ondansetron
  • Maintain FiO2 <30% to prevent airway fire from electrocautery use
  • Goal euvolemia
    • Patients may be volume depleted prior to surgery and require fluid boluses
  • Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension[3]
  • If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins [5]

Emergence

  • Assess degree of upper airway obstruction prior to extubation
    • Reintubation may be impossible if obstruction occurs
  • Smooth extubation important if skin graft used for closure
    • Graft hematomas are the primary cause of skin graft failure[6]
  • Extubate after recovery of protective airway reflexes

Postoperative management

Disposition

  • Inpatient admission depending on size/location of resection, free flap, tracheostomy
  • Encourage early nutrition, foley removal, mobilization

Pain management

  • Intraoperative infiltration with local anesthetic
  • Multimodal including non-opioid and bolus opioid analgesics
  • Consider opioid PCA if subtotal/total glossectomy

Potential complications

  • Airway obstruction due to airway edema
    • May require treatment with humidified oxygen or nebulized bronchodilators
  • Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)[1]
  • Aspiration
  • Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue[1]
  • Dysphagia
  • Bleeding
    • Manipulation of mass
    • Lingual artery/veins
    • Consider external jugular/carotid if neck dissection
  • Salivary fistula
  • Osteonecrosis if mandibulotomy[1]
  • Graft failure

Procedure variants

Partial Subtotal/Total Resection
Surgical time 1-3 hr 3-8 hr
EBL 50-150 mL 100-300 mL
Postoperative disposition Inpatient depending on degree of resection / neck dissection / flap May require prolonged intubation or tracheostomy care

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Bigcas, Jo-Lawrence M.; Okuyemi, Oluwafunmilola T. (2022), "Glossectomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32809471, retrieved 2022-02-17
  2. ↑ 2.0 2.1 2.2 Nekhendzy, V; Biro, P (2018). Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition. Philadelphia: Elsevier Saunders. pp. 668–91. ISBN 978-0-323-42881-1. OCLC 983210379.
  3. ↑ 3.0 3.1 3.2 3.3 Jaffe, Richard (2019). Anesthesiologist's Manual of Surgical Procedures. Lippincott Williams & Wilkins (LWW). pp. 233–235. ISBN 978-1-49-637125-6.
  4. ↑ Kheterpal, Sachin; Martin, Lizabeth; Shanks, Amy M.; Tremper, Kevin K. (2009-04-01). "Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics". Anesthesiology. 110 (4): 891–897. doi:10.1097/ALN.0b013e31819b5b87. ISSN 0003-3022. no-break space character in |first4= at position 6 (help); no-break space character in |first3= at position 4 (help)
  5. ↑ Feldman, MA; Patel, A (2010). Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition. Philadelphia: Elsevier. pp. 2357–88.
  6. ↑ Llanos, Sergio; Danilla, Stefan; Barraza, Cristina; Armijo, Eugenia; Pi??eros, Jose L.; Quintas, Maria; Searle, Susana; Calderon, Wilfredo (2006-11). "Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial". Annals of Surgery. 244 (5): 700–705. doi:10.1097/01.sla.0000217745.56657.e5. ISSN 0003-4932. PMC 1856589. PMID 17060762. Check date values in: |date= (help)CS1 maint: PMC format (link)

Top contributors: Helen Heymann, Olivia Sutton and Chris Rishel

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