Bing-Hwei Shen

Necrotizing fasciitis of the head and neck: an analysis of 47 cases.

Necrotizing fasciitis is an overwhelming infection common to the perineum, abdominal wall, and extremities. It is a surgical emergency related to a high mortality rate that is more often seen in elderly and immunocompromised patients. Necrotizing fasciitis occurs uncommonly in the head and neck region. Over a 12‐year period, 47 cases of necrotizing fasciitis of the head and neck region were collected at this hospital. The demographics, predisposing factors, clinical presentation and courses, management, complications, and outcomes were analyzed. The cases were divided into two groups: survivors and nonsurvivors. Statistical comparisons were made of the parameters age, gender, smoking or drinking habit, underlying medical problems, laboratory data, and treatments used. Forty‐two patients (89.4 percent) had associated systemic disease; most of these patients had diabetes (72.3 percent). The clinical manifestations are nonspecific but are often typical for diagnosis. The necessity of computed tomographic scans is not conclusive in this study. Presentation of septic shock (p = 0.004) and association with underlying malignancy (p = 0.03) were the only statistically significant factors that led to a poor prognosis. The cornerstones of proper management include early diagnosis, aggressive surgical debridement, broad‐spectrum antibiotics, and intensive supportive care. (Plast. Reconstr. Surg. 107: 1684, 2001.)

Primary Cutaneous Leiomyosarcoma

Primary cutaneous leiomyosarcomas are rare malignant tumors. They can occur at any age, but most commonly between the fifth and seventh decade of life. Because of the small number of patients treated, treatment recommendations are still evolving. We report the results of a retrospective study of 12 patients treated for leiomyosarcomas through a thirty year period (from 1973 to 2002). Five males and seven females (mean age, 54.4 years; age range, 22-81 years), more than 58% of the patients were at least 50 years old. The tumors presented mainly as solitary lesions and were located on the upper and lower extremities (seven lesions), trunk (three lesions), and the head and neck (two lesions). The main treatment of choice was surgical wide excision. Clinical follow-up revealed local recurrences in four patients after a period ranging from 3 to 72 months after surgical excision. No distant metastases have been observed in our series. We reviewed published articles. The clinical findings, pathologic examinations and treatments were analyzed. We believe primary cutaneous leiomyosarcoma should be considered biologically benign with regard to distant metastases, despite the malignant histologic appearance. Wide local excision is recommended, and it would seem that narrow margins with a tumor-free plane should be sufficient.

The use of “composite dressing” for covering split-thickness skin graft donor sites

To evaluate the effect of a new dressing method for clean wound coverage, two kinds of dressing materials are combined together to cover nine wounds in nine patients. All the wounds are split-thickness skin graft donor sites located in the anterior thighs. The size of the wounds ranges from 6 cm x 4 cm to 10 cm x 8 cm (42 cm(2) on average). A central fenestration is created in the polyurethane film layer for draining the wound discharge, and a piece of 2.5 cm x 2.5 cm carboxymethyl cellulose dressing is fixed on top of the fenestration for protecting the underlying wound. Dry gauze is used to cover the composite dressing, which is replaced daily. The wound condition is checked and recorded everyday until the patient is discharged. Further management and follow-up for the wound is performed at the outpatient department or by telephone. All wounds healed smoothly on the postoperative 6th to 7th day. No wound infection was noted, including one patient who had diabetes mellitus. Five patients responded to follow-up for at least 5 months and no hypertrophy scar formation was noted. From clinical experiences, we know that this new method is practical and cost-effective for covering small-sized, split-thickness skin graft donor-site wounds.

Delayed dilated cardiomyopathy for major burn injuries

PURPOSE The early impact on the heart of severe burns has all been well documented previously. Here, we report on the late effects of burns upon the heart, and dilated cardiomyopathy, such aspects having been little reported previously in the literature. METHODS Over the past 8 years (June 1991 to December 1998), 55 scalded or flame-burnt patients for whom the total burnt body surface area (TBSA) exceeded 50% were treated. Seventeen patients survived and were followed up. The mean age was 44 years. The mean follow-up period was 47.3 months; four patients displayed a previous history of heart disease. We used several parameters to evaluate and follow cardiac status to see the late effect of burns upon the heart. RESULTS Of 17 patients, 3 patients (17.7%) were found to exhibit dilated cardiomyopathies after a mean time of 6 months post-injury. A dramatic recovery from symptoms and roentgenographic findings were observed for all patients following symptomatic treatment. CONCLUSION Here we report three cases of delayed dilated cardiomyopathy, a condition that has been little reported in the past. There may be many causating factors. Several recommendations are described.

Risk Factors of Surgical Intervention in the Management of Venomous Snakebite in Northern Taiwan

Venomous snakebites are not uncommon in Taiwan, and the snake venom causes both systemic and local effects. Petechiae, edema, swelling, ecchymosis, necrosis of the skin and subcutaneous tissue, and necrotizing fasciitis could be seen locally, and surgical intervention may be needed to deal with these problems. However, functional impairment and limb loss were still sometimes inevitable. We retrospectively reviewed medical records of 118 patients bitten by venomous snakes from Jan. 1999 to Dec. 2004, and risk factors of surgical intervention were studied. The relationship of the need of surgical intervention and snake species, clinical grading, symptoms, and other associating factors were analyzed. Surgery was needed in 16 of 118 patients(13.5%)bitten by venomous snakes, 7 by Taiwan cobra, 5 by Taiwan habu, 1 by green habu, 1 by hundred pacer, and 2 by unknown snake. Risk factors of surgical intervention were Taiwan cobra snakebite(7/14)and delayed given of antivenom. Taiwan cobra snakebite was found with higher risk of local necrosis and infection. Therefore, more surgical interventions were needed in this group of patients, and early antivenom given and broad spectrum antibiotics coverage were recommended

Survival of Full-Thickness Skin Graft on the Prelaminated Expanded Polytetrafluoroethylene in Spraque-Dawley Rats

The purpose of this study is to evaluate and compare the survival and deformity of a full-thickness skin graft over the flap prelaminated by Gore-tex (ePTFE, expanded polytetrafluoroethylene, Gore-tex Soft Tissue Patch, Gore & Assoc Inc, Flagstaff, AZ, USA) in Spraque-Dawley (S-D) rats. The materials were implanted subcutaneously for prelamination of a 2-, 4-, and 6- week period. A pedicle flap enveloping the implant was then elevated. After applying Biobrane under the composite flap, the harvested full-thickness skin was grafted onto the composite flap. The survival of the FTSG and deformity of synthetic materials were evaluated at the time of one week after skin graft surgery. In this study, the survival of skin graft in the Gore-tex group was about 32%. Microscopically, the Gore-tex scaffold was integrated by fibroneovascular tissue. Based on the survival rate of the skin graft, this study demonstrates that prelamination with Gore-tex can produce a relatively lower survival rate of in-situ skin graft on composite tissue flap, and less implant expulsion was observed. The Gore-tex scaffold allowed growth of fibroneovascular tissue but showed visible deformity. The secondary deformity of the Gore-tex scaffold and lower survival of skin graft neglected the clinical usage of this synthetic flap.

Outcome Evaluation of Skin-Grafted Free Muscle Flap versus Reverse Sural Fasciocutaneous Flap in Soft Tissue Reconstruction of Weight-Bearing Heel

There were eighteen patients received soft tissue reconstruction of weight-bearing heel at our institution in past 10 years. Eleven patients received skin-grafted free muscle flaps and seven received reverse sural fasciocutaneous flaps. The etiology of the wounds were osteomyelitis (55.6%), necrotizing fasciitis (11.1%), trauma (11.1%) and tumor resection (11.1%). The patients who received free muscle flap surgery were younger (average 45.2 y/o), had much larger wound size (12.4x 6.6cm^2) longer operative time, and less hospital days. The complication rate was comparable between these two modalities. They all achieved a considerable successful rate and limb salvage rate. The muscle flap group presented as higher percentage in resuming walking and working. It also had better functional score but higher chance of chronic ulcer. In consideration of weight-bearing heel reconstruction, the skin-grafted muscle flap seems to be the first choice. In elder patient or patient who is not suitable for long operative time, reverse sural fasciocutaneous flap is probably an alternative with acceptable successful rate but less functional result is expected.

Malignant Salivary Gland Tumors-Ten Years Clinicopathological Experience at VGH-Taipei

Malignant salivary gland tumors are uncommon and demonstrate wide diversity of histopathological types and biological behaviors. We report the experience in the management of patients with malignant salivary gland tumors and review the outcome of treatment in an effort to identify significant factors of survival, local recurrence and distant metastases. The age (p=0.002), stage (p＜0.001), histological grade (p=0.020), resection margin (p=0.036) and the presence of neck metastases, local recurrences and distant metastases (p＜0.001) were significantly associated with poorer survival. Local recurrences was correlated with stage (p＜0.001), histology grade (p=0.042), and resection margin (p=0.026). Distant metastases depended on stage (p=0.006), especially tumor size, and facial palsy (p=0.030). The treatment of salivary gland malignancies remains primarily surgical. However, the benefits of combined modality therapy with regard to overall survival await prospective clinical trials.

Patency and Caliber Change of the Internal Jugular Vein in the Oral Cancer Patients Receiving Cancer Ablation, Modified Radical Neck Dissection and Free Flap Reconstruction

Background The incidence of the internal jugular vein thrombosis (IJVT) after neck dissection had been reported common in reconstruction surgery of oral cavity tumor patients. Development of narrowed but patent vein was regarded as one of the factors leading to thrombus formation after neck dissection; therefore, changes in the caliber of IJV should be assessed before and after operation. Methods From May 2004 to May 2005, we performed a prospective study of 20 patients who received neck dissections that spared IJV and immediate free flap reconstruction for oral cancers. The patency and caliber of the IJV of all patients was evaluated with a CT scan preoperatively and duplex Doppler ultrasound examinations were performed at 1 day, 7days, and 3 months postoperatively. Results No thrombosis of the IJV was noted both in preoperative and postoperative evaluations. All free flap reconstruction was successful. The mean ratio of the post-over the preoperative caliber of the IJVs after 1 day, 7 days and 3 months was 0.706, 0.724, and 0.962, respectively. Conclusions The caliber of the IJV decreased during the early postoperative period; however, it returned to close to normal gradually after 3 months.

Tracheal Stenosis after Inhalation Burn Injury-A Case Report

Tracheal stenosis is most commonly the result of mechanical trauma from endotracheal intubation. Other known causes of acquired tracheal stenosis are external trauma, infection, inflammation and thermal or caustic injuries. Inhalation injury itself has the potential risk of tracheal stenosis. Patient with tracheal stenosis may present with dyspnea, stridor, and even lift-threatening airway obstruction. We report a case of severe tracheal stenosis following an inhalation burn injury. The patient experienced progressively dyspnea and stridor one month after his injury. The CT scan of neck demonstrated severe subglottic and tracheal stenoses. He was successfully treated by the insertion of a tracheal T-tube. The patient has been symptom-free and no restenosis could be detected for the last 30 months.