Posthemithyroidectomy Hypothyroidism: Updated Meta-Analysis of Risk Factors and Rates of Remission.

INTRODUCTION: The aim of this study was to determine the incidence and risk factors for hypothyroidism, both clinical and subclinical, following hemithyroidectomy in preoperatively euthyroid patients, as well as hypothyroidism remission and its time of remission. MATERIALS AND METHODS: A search was performed in Medline (via PubMed), Web of Science, and the Cochrane Library using the keywords "hemithyroidectomy + postoperative + hypothyroidism" and "hemithyroidectomy + hormone supplementation". RESULTS: Fifty-four studies with a total of 9,999 patients were included. After a mean follow-up interval of 48.2 mo, the pooled hypothyroidism rate was 29%. The subclinical hypothyroidism rate was 79% of patients with hypothyroidism (18 studies). Moreover, a meta-analysis of 12 studies indicated a pooled hypothyroidism remission rate after hemithyroidectomy of 42% (95% CI: 24%-60%). Older patient age (MD = -2.54, 95% CI = -3.99, -1.10, P = 0.0006), female gender (OR = 0.69, 95% CI = 0.58, 0.82, P < 0.0001), higher preoperative thyroid-stimulating hormone levels (MD = -0,81, 95% CI = -0.96, -0.66, P < 0.00001), pathological preoperative anti-thyroid peroxidase antibodies (OR = 0.37, 95% CI = 0.24, 0.57, P < 0.00001) and anti-thyroglobulin antibodies (OR = 0.52, 95% CI = 0.36, 0.75, P = 00,005), and right-sided hemithyroidectomy (OR = 0.54, 95% CI = 0.43, 0.68, P < 0.00001) were associated with postoperative hypothyroidism development. In metaregression analysis, Asia presented a significantly higher hypothyroidism rate after hemithyroidectomy (34.6%, 95% CI = 29.3%-9.9%), compared to Europe (22.9%, 95% CI = 16.2%-29.5%, P = 0.037) and Canada (1.8%, 95% CI = -22.6%-26.2%, P = 0.013). CONCLUSIONS: Hypothyroidism is a frequent and significant postoperative sequela of hemithyroidectomy, necessitating individualization of treatment strategy based on the underlying disease as well as the estimated risk of hypothyroidism and its risk factors.

The history of esophageal surgery.

BACKGROUND: Esophageal surgery has always been considered extremely demanding, given the surgical experience and skills required, due to the anatomic location of the esophagus as well as the impact of such extensive operations on patients' homeostasis. The intention of the present study is to review all historical time points of esophageal surgery, from its inception to the modern era of minimally invasive esophageal surgery. METHODS: The first clear description of esophageal surgery is dated back to 1738, in an attempt to remove a foreign body from the thoracic esophagus. However, the high morbidity and mortality rates of esophageal surgical operations led to the invention and application of less invasive surgical procedures. RESULTS: Esophageal surgery has evolved from extensive surgical operations to minimally invasive esophagectomies, aiming exclusively to reduce perioperative morbidity and mortality, while maintaining surgical effectiveness. Despite the fact that benign esophageal pathologies were the main stimulus for this evolution, minimally invasive esophageal surgery is now applied even in patients with esophageal cancer, with outcomes comparable to those of traditional surgical approaches. CONCLUSION: It would be interesting to see how all these new surgical techniques may evolve, altering further the current status of esophageal surgery in the future.

Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence. METHODS: Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses. RESULTS: A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09). CONCLUSION: PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

Hereditary Diffuse Gastric Cancer: A 2022 Update.

Gastric cancer is ranked fifth among the most commonly diagnosed cancers, and is the fourth leading cause of cancer-related deaths worldwide. The majority of gastric cancers are sporadic, while only a small percentage, less than 1%, are hereditary. Hereditary diffuse gastric cancer (HDGC) is a rare malignancy, characterized by early-onset, highly-penetrant autosomal dominant inheritance mainly of the germline alterations in the E-cadherin gene (CDH1) and ß-catenin (CTNNA1). In the present study, we provide an overview on the molecular basis of HDGC and outline the essential elements of genetic counseling and surveillance. We further provide a practical summary of current guidelines on clinical management and treatment of individuals at risk and patients with early disease.

Immunotherapy in Combination with Well-Established Treatment Strategies in Pancreatic Cancer: Current Insights.

Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer and fourth most common cause of death in developed countries. Despite improved survival rates after resection combined with adjuvant chemotherapy or neoadjuvant chemotherapy, recurrence still occurs in a high percentage of patients within the first 2 years after resection. Immunotherapy aims to improve antitumor immune responses and reduce toxicity providing a more specific, targeted therapy compared to chemotherapy and has been proved an efficient therapeutic tool for many solid tumors. In this work, we present the latest advances in PDAC treatment using a combination of immunotherapy with other interventions such as chemotherapy and/or radiation both at neoadjuvant and adjuvant setting. Moreover, we outline the role of the tumor microenvironment as a key barrier to immunotherapy efficacy and examine how immunotherapy biomarkers may be used to detect immunotherapy's response.

The role of miR-101 in esophageal and gastric cancer.

miR-101 is downregulated in various types of cancer, leading to the notion that miR-101 acts as a suppressor in cancer cell progression. The comprehensive mechanisms underlying the effects of miR-101 and the exact role of miR-101 dysregulations in esophagogastric tumors have not been fully elucidated. This review aims to summarize all current knowledge on the association between miR-101 expression and esophagogastric malignancies and to clarify the pathogenetic pathways and the possible prognostic and therapeutic role of miR-101 in those cancer types. miR-101 seems to play crucial role in esophageal and gastric cancer biology and tumorigenesis. It could also be a promising novel diagnostic and therapeutic target, as well as it may serve as a significant predictive biomarker in esophagogastric cancer.

Presentation and surgical management of xanthogranulomatous cholecystitis.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and most of the times requires surgical management. In addition, distinguishing XGC from gallbladder cancer preoperatively is still a challenge. The aim of the present systematic review was to outline the clinical presentation and surgical approach of XGC. DATA SOURCES: The present systematic review was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases from inception until June 2020. RESULTS: The laparoscopic cholecystectomy rate (34%) was almost equal to the open cholecystectomy rate (47%) for XGC. An important conversion rate (35%) was observed as well. The XGC cases treated by surgery were associated with low mortality (0.3%), limited intraoperative blood loss (58-270 mL), low complication rates (2%-6%), along with extended operative time (82.6-120 minutes for laparoscopic and 59.6-240 minutes for open cholecystectomy) and hospital stay (3-9 days after laparoscopic and 8.3-18 days after open cholecystectomy). Intraoperative findings during cholecystectomies for XGC included empyema or Mirizzi syndrome. In addition, complex surgical procedures, like wedge hepatic resections and bile duct excision were required during operations for XGC. CONCLUSIONS: XGC seemed to be a rare, benign inflammatory disease that presents similar features as gallbladder cancer. The mortality and complication rates of XGC were low, despite the complex surgical procedures that might be required in some cases.

An Assessment of Snail-Farm Systems Based on Land Use and Farm Components.

In this study, the structural and management characteristics of snail farms in Greece were analyzed to maximize sustainable food production. Objectives, such as the classification of farming systems and assessing the effects of various annual production parameters, were investigated. Data were collected (2017) via a questionnaire, and sampling was conducted in 29 snail farms dispersed in six different regions (Thrace, Central Macedonia, West Macedonia, Thessaly, Western Greece, and the Attica Islands). Descriptive statistics for continuous variables and frequencies for categorical variables were calculated. The similarity between farms was analyzed using nonmetric multidimensional scaling (nMDS). The average farm operation duration exceeded eight months and the mean annual production was 1597 kg of fresh, live snails. Results recorded five farming systems: elevated sections (7%), net-covered greenhouse (38%), a mixed system with a net-covered greenhouse (10%), open field (38%), and mixed system with an open field (7%). Snail farms differ in the type of substrate, available facilities, and equipment (60% similarity between most of the open field farms). The geographical location of a farms' settlement affects productivity but also influences the duration of operation, especially in open field farms, due to their operation under a wide assortment of climatic types.

Upper Gastrointestinal Cancer Management in the COVID-19 Era: Risk of Infection, Adapted Role of Endoscopy, and Potential Treatment Algorithm Alterations.

INTRODUCTION: The safety of upper gastrointestinal cancer patients in the SARS-CoV-2 outbreak is extremely important and most surgeons need to establish a contingency management. AIM: In this study, we present the surgical outlines of patients suffering from upper gastrointestinal cancers. MATERIALS AND METHODS: Data were obtained from PubMed, Cochrane Database of Controlled Trials, and SCOPUS of reports up to September 2020. RESULTS: The COVID-19 outbreak makes surgical procedures extremely difficult to be performed. The most common criteria to prioritize patients for surgical treatment are stage, tumor biology, presence of tumor-related symptoms, the risk of tumor to become non-resectable, and time interval from neoadjuvant therapy. The multidisciplinary teams can help assigning a priority level to each clinical case. CONCLUSION: We have to continue providing treatment to oncologic patients in the face of COVID-19 uncertainty, with higher caution and responsibility in order to develop a safer and more effective personalized treatment plan.

ATSC transplantation contributes to liver regeneration following paracetamol-induced acute liver injury through differentiation into hepatic-like cells.

INTRODUCTION: Drug-induced liver injury (DILI) is a leading cause of acute liver injury (ALI). Acetaminophen (also termed paracetamol), can often be found in drugs that may be abused (i.e., prescription for pain relief). Animal experiments have shown that mesenchymal stem cell transplantation can ameliorate or even reverse hepatic injury. MATERIAL AND METHODS: ALI was induced in Wistar rats using paracetamol. ATSCs were transplanted via the intravenous, portal vein, or intrahepatic route directly onto the liver parenchyma. Histological evaluation was conducted to assess drug-induced injury following transplantation. Fluorescence in situ hybridization (FISH) was used to verify the location of stem cells on the liver parenchyma. The effect of those cells on liver regeneration was tested by immunohistochemistry for hepatic growth factor (HGF). In addition, reverse transcription-quantitative PCR (qRT-PCR) was used to assess hepatic growth factor (HGF), hepatic nuclear factor 4α (HNF4α), cytochrome P450 1A2 (CYP1A2) and α-fetoprotein (AFP) mRNA expression. RESULTS: Immunohistochemical staining for HGF was stronger in the transplanted groups than that in the control group (P<0.001). HNF4α and HGF mRNA levels were increased on day 7 following transplantation (P<0.001 and P=0.009, respectively). CYP1A2 mRNA levels were also increased (P=0.013) in the intravenous groups, while AFP levels were higher in the intrahepatic groups (P=0.006). ATSC transplantation attenuates ALI injury and promotes liver regeneration. Furthermore, expression of specific hepatic enzymes points to ATSC hepatic differentiation. CONCLUSION: The study showed the positive effects of transplanted adipose tissue stem cells (ATSCs) on liver regeneration (LG) through hepatotrophic factors. Furthermore, increased expression of hepatic specific proteins was recorded in ATSC transplanted groups that indicate stem cells differentiation into hepatic cells.

Histone deacetylase inhibitors as a new anticancer option: How far can we go with expectations? delivery systems.

Histone modification that occurs through the process of acetylation plays a key role in the epigenetic regulation of gene expression. The balance between histone deacetylases (HDACs) and histone acetyltransferases controls this process. Histone deacetylase inhibitors (HDACIs) can induce cancer cell cycle arrest, differentiation and cell death, reduce angiogenesis and modulate immune response. Therefore, HDAIs represent a group of enzymes that can be used for the development of pharmaceutical agents against a variety of malignant diseases. The mechanisms of their anticancer effect depend on many factors. HDACIs vorinostat, romidepsin and belinostat have been approved for some T-cell lymphomas and panobinostat for multiple myeloma. Other HDACIs are tested in clinical trials for the treatment of hematological and solid malignancies. The results of such studies are promising but further larger studies are needed.

Undifferentiated Adipose Tissue Stem Cell Transplantation Promotes Hepatic Regeneration, Ameliorates Histopathologic Damage of the Liver, and Upregulates the Expression of Liver Regeneration- and Liver-Specific Genes in a Rat Model of Partial Hepatectomy.

OBJECTIVE: Adipose tissue stem cells (ADSCs) present a promising therapeutic method to alleviate liver failure (LF). The purpose of this prospective study was to evaluate the efficacy of undifferentiated ADSC transplantation on liver regeneration and on the expression of liver regeneration- and liver-specific genes, following 60% partial hepatectomy (PHx). METHODS: Sixty female rats were subjected to PHx and were transplanted with 106 or 2 × 106 ADSCs, either into the portal vein (PV) or into the hepatic parenchyma. Animals of the control group were not transplanted and served as controls. Animals were sacrificed on the 4th, the 7th, or the 15th postoperative day (POD). RESULTS: The transplanted ADSCs were successfully engrafted into the liver parenchyma and ameliorated the histopathologic damage on the 7th and 15th POD. All transplanted animals demonstrated a significantly higher liver regeneration rate on the 4th and 7th POD, compared with the control group. The expression of hepatocyte growth factor, α-fetoprotein, tyrosine aminotransferase, hepatocyte nuclear factor 4a, and cytochrome P450 1A2 was significantly upregulated, compared with the control group. CONCLUSIONS: Although undifferentiated, ADSC transplantation significantly enhanced the liver regeneration process. These findings may be proven clinically valuable, especially in cases of acute LF.

Clinicopathological and Molecular Factors, Risk Factors, Treatment Outcomes and Risk of Recurrence in Mesenteric and Retroperitoneal Extragastrointestinal Stromal Tumors.

BACKGROUND/AIM: The objective of the present study was to determine the clinicopathological factors and treatment outcomes of patients suffering from mesenteric or retroperitoneal extragastrointestinal stromal tumors (EGISTs). MATERIALS AND METHODS: A detailed search in PubMed, using the key words "extragastrointestinal stromal tumors" and "EGIST", found eight studies fulfilling the criteria of this study. RESULTS: Thirty-six patients with a mesenteric and 24 patients with a retroperitoneal EGIST were analyzed, with a follow-up period ranging from 2 to 192 months. Retroperitoneal tumors presented as larger tumors than mesenteric ones, with 95% and 93% immunohistochemical positivity for CD117 antigen, respectively. Surgical resection was performed in 91% of cases, with 57% of patients with mesenteric and 70% of patients with retroperitoneal EGISTs being alive at the last follow-up. CONCLUSION: EGISTs most commonly are of considerable size and usually with a high mitotic count, rendering them high-risk tumors. Tumor necrosis, nuclear atypia, tumor histology, and mutations in the tyrosine kinase KIT or platelet-derived growth factor receptor A (PDGFRA) gene, seem to influence tumor behavior.

Towards a tailored lymphadenectomy for gastric cancer based on the correlation between the primary tumor location and the first lymphatic drain basin: Preliminary data.

PURPOSE: The contradictory long-term results following D2 lymphadenectomy have revealed the necessity for a more tailored lymphadenectomy in cases of gastric cancer. Among the patients who had undergone a modified D2 lymphadenectomy for gastric cancer, we further analyzed the subgroup in which histologically and immunohistochemically solitary lymph node metastases were detected. Classifying the primary tumors as towards to the lesser and towards to the grater curvature, we propose possible routes of lymphatic spread and possible clinical implications. METHOD: Between January 2007 and December 2016, 212 patients suffering from gastric adenocarcinoma underwent a modified D2 lymphadenectomy. Solitary lymph node metastases were detected by histology in 14 patients (7 skip metastases) and by immunohistochemistry in an additional 10 patients (5 skip micrometastases). RESULTS: The incidence of the histologically detected solitary lymph node metastases was 6.6% for the whole cohort, increasing to 11.3% with the use of immunohistochemistry. The incidence of the histologically detected skip solitary lymph node metastases was 3.3% for the whole cohort, increasing to 5.7% with the use of immunohistochemistry. Tumors of the lower and middle third of the stomach were equally drained both to the level I and II lymph node stations. However, tumors towards the lesser curvature were mainly drained in the level II lymph node stations (12 out of 19; 63%), while tumors towards the greater curvature were all drained in the level I lymph node stations (5 out of 5; 100%). CONCLUSION: Primary gastric tumors towards the lesser curvature should be treated by a modified D2 lymphadenctomy. However, for tumors towards the greater curvature, a D1(+) lymphadenectomy always including the no. 7 & 9 lymph node stations complex, might be enough.

Single stage aesthetic and functional reconstruction of composite facial gunshot wound with a chimeric functioning muscle and fibular osseous flap. Case report and review of the literature.

The current concepts in the aesthetic and functional reconstruction of complex oromandibular defects are presented with a case of a patient with self-inflicted gunshot wound to the face. The patient presented with a 6 cm composite mandibular defect; the buccomandibular and suborbital aesthetic zones of the cheek along with the mucosa lining, and the ipsilateral facial musculature were missing. A rapid prototyping model of the facial skeleton was used to assist in preoperative planning. A single stage reconstruction with two free flaps was planned; a free fibula osseous flap to reconstruct the mandibular defect, and a free chimeric ALT/functioning vastus lateralis muscle. The one skin paddle of the chimeric flap reconstructed the buccomandibular/suborbital zones of the cheek, and the other the lining of the mouth. The functional muscle provided reanimation of the corner of the mouth by coapting the muscle's motor nerve to the ipsilateral marginal mandibular nerve. A good facial contour and reanimation of the mouth with oral continence was achieved, and the patient presented with good social and emotional smile. This first report of combined use of a fibula osseous flap with a chimeric functional ALT/Vastus Lateralis flap suggests that the chimeric flap principle may be used in complex aesthetic and functional challenges of severe facial trauma.

Mesenchymal Stem Cells Transplantation following Partial Hepatectomy: A New Concept to Promote Liver Regeneration-Systematic Review of the Literature Focused on Experimental Studies in Rodent Models.

Mesenchymal stem cells (MSCs) are an attractive source for regenerative medicine because they are easily accessible through minimally invasive methods and have the potential to enhance liver regeneration (LG) and improve liver function, following partial hepatectomy (PH) and acute or chronic liver injury. A systematic review of the literature was conducted for articles published up to September 1st, 2016, using the MEDLINE database. The keywords that were used in various combinations were as follows: "Mesenchymal stem cells", "transplantation", "stem cells", "adipose tissue derived stem cells", "bone marrow-derived stem cells", "partial hepatectomy", "acute liver failure", "chronic liver failure", "liver fibrosis", "liver cirrhosis", "rats", "mice", and "liver regeneration". All introduced keywords were searched for separately in MeSH Database to control relevance and terminological accuracy and validity. A total of 41 articles were identified for potential inclusion and reviewed in detail. After a strict selection process, a total of 28 articles were excluded, leaving 13 articles to form the basis of this systematic review. MSCs transplantation promoted LG and improved liver function. Furthermore, MSCs had the ability to differentiate in hepatocyte-like cells, increase survival, and protect hepatocytes by paracrine mechanisms. MSCs transplantation may provide beneficial effects in the process of LG after PH and acute or chronic liver injury. They may represent a new therapeutic option to treat posthepatectomy acute liver failure.

Morphometric variability of pyramidalis muscle and its clinical significance.

PURPOSE: The goal of the study is to analyze the morphometric diversity of the pyramidalis muscle (PM) and to evaluate how it is affected by gender and side of occurrence. MATERIALS AND METHODS: Ninety-six (50 male and 46 female) formalin-embalmed Greek cadavers were dissected. RESULTS: The PM was present in 93.8 %, usually bilaterally (79.2 %) than unilaterally (14.6 %) (p = 0.003) and more frequently in females (91.3 %) than in males (68 %) (p = 0.0001). Side symmetry was detected. The mean length of PM in males and females was 8.37 ± 2.80 and 6.18 ± 1.64 cm on the right and 7.50 ± 2.66 and 6.56 ± 1.68 cm on the left side. Male predominance existed on the right and left-sided PM lengths (p = 0.0001 and p = 0.054). The mean width of the right-sided PMs in males and females was 1.61 ± 0.55 and 1.50 ± 0.44 cm and the left-sided 1.56 ± 0.53 and 1.55 ± 0.38 cm without gender dimorphism. The positive correlation between the PM length and width indicates a symmetrical muscle augmentation on the two dimensions. CONCLUSIONS: The study demonstrates that the PM is almost constant in Greeks. Among populations the muscle morphometric variability, its clinical significance and its variable uses will help surgeons when intervening in the lower abdominal wall.

Role of Stem Cells Transplantation in Tissue Regeneration After Acute or Chronic Acetaminophen Induced Liver Injury.

PURPOSE: Acetaminophen-induced liver injury (APAP) is recognized as a frequent etiologic factor responsible for hepatic damage in the developed world. Management remains still elusive as treatment options are limited and their results are inconclusive. Consequently new strategies are explored at the experimental level. Mesenchymal stem cells (MSCs) present a promising modality as they can promote liver regeneration (LG) and compensate acute liver injury (ALI). MATERIALS AND METHODS: Our research was focused on articles related to drug-induced liver injury, mechanisms of liver regeneration (LG) after Acute Liver Injury (ALI) and recent experimental protocols of Mesenchymal Stem Cells (MSCs) transplantation after chemical insult. All these studies are cited on Pubmed and MedLine. RESULTS: This review has three distinct sections. First recent developments in ALI pathogenesis are presented. The second section covers cellular pathways and histological findings relevant to liver regeneration. The final chapter analyzes MSCs transplantation protocols after ALI and interrelation between liver regeneration and hepatic differentiation of MSCs. CONCLUSION: Adipose tissue stem cells (ADSCs) and (MSCs) transplantation represents a promising modality in severe ALI management although many aspects remain to be clarified.

The use of the ALT Flap and Lateral Femoral Cutaneous Nerve for the Reconstruction of Carpal Soft Tissue and Ulnar Nerve Defects: a Case Report.

The anterolateral thigh (ALT) flap has become one of the workhorse flaps, with indications including diverse reconstructive problems. The lateral thigh area is also a useful donor site for nerve grafts. The lateral femoral cutaneous (LFC) nerve can be dissected along with the ALT flap for a substantial length, depending on the requirements of the recipient site. The LFC nerve can be used as a vascularized or non-vascularized nerve graft. The technique offers advantages and it can find clinical applications, satisfying the functional and aesthetic reconstructive requirements of a complex defect. We report the case of a patient who presented with traumatic soft tissue defect of the volar aspect of the wrist and ulnar nerve defect as a complication of a fracture of distal radius. An ALT flap was used to reconstruct the soft tissue defect. The ulnar nerve was resected due to necrosis and the gap was repaired with non-vascularized grafts of the anterior branch of the LFC nerve. The soft tissues were resurfaced successfully without complications. Functional recovery was good for the superficial branch of the ulnar nerve, whereas it was variable for the deep branch of the ulnar nerve. The anterolateral thigh area offers significant advantages as donor site in the reconstruction of complex soft tissue defects being a large source of vascularized skin, fat, fascia, muscle and nerve. This availability allows for single donor site dissection, minimizing the operating time and the associated morbidity.