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Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121 Page 5 of 25

Figure 1. Representation of a two-stage reconstruction according to the modified Paneva-Holevich technique. The figure on the left
illustrates the anastomotic loop between the FDS (blue) and FDP (red) at the palm level. The figure on the right shows the new
elongated FDP formed by the union with the FDS. FDS: flexor digitorum superficialis.

size of the silicon rod. Therefore, this technique significantly improves on the previous ones .
[24]
Vascularized flexor tendon transfer
Guimberteau et al. proposed a one-staged reconstructive technique for Boyes’ Grades 3-4-5 . They
[31]
consider the peritendinous connective tissue and the paratenon as a single operative unit with the flexor
tendons. These structures would provide an adequate blood supply and a gliding sheath that ensures the
optimal function of the tendon itself. This technique is based on retrograde flow through the ulnar artery
and involves the use of the FDS of the fourth finger to fill defects between 18-20 cm. Preoperatively, it is
necessary to ensure the effectiveness of the radial artery with Allen's test and a Doppler test. The technique
involves careful dissection of the ulnar artery proximal to Guyon's canal; at that level, the anterolateral
branches of the artery are identified and will vascularize the flap. Although Guimberteau et al. obtained
better results with this technique if compared to more traditional ones, they acknowledged that, considering
its high complexity, it should be limited to a small number of patients and performed by experienced
surgeons. Cavadas et al. reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger
flexors) with vascularized FDS tendon grafts, including 37 pedicled flaps and three free flaps. The authors
[32]
reported a postoperative total active range of motion of 178.05° (SD 50) .
Currently, the available studies concerning this technique are limited, and the indications are not fully
clarified.