Cheng-Han Hsieh

Salvage of the skin envelope in complex incomplete avulsion injury of thumb with venous arterializaiton: A case report

Treatment of an avulsion or degloving injury of the hand is a difficult but not unusual operation for plastic reconstructive or hand surgeons. The avulsion may be salvaged by arteriovenous shunting technique. We present a patient with incomplete avulsion injury of the distal phalanx of thumb. Arteriovenous shunting was created and the wound reconstructed primarily under venous arterialization. The avulsed skin envelope was survived well and functional status was improved.

Experience of Surgical Treatment for Occipital Migraine in Taiwan.

PurposeRefractory migraine surgery developed since 2003 has excellent results over the past 10 years. According to the pioneer of migraine surgery, Dr. Bahman Guyuron, 5 major surgical classifications of migraines are described in the field of plastic surgery, namely, frontal migraine, temporal migraine, rhinogenic migraine, occipital migraine, and auriculotemporal migraine. In this study, we present the preliminary surgical results of the occipital migraine surgery. Materials and MethodsA total of 22 patients with simple occipital migraines came to our outpatient clinic for help from June 2014 to February 2015. Thirteen cases were excluded owing to ineligibility for operation or other reasons. The patients who concurrently experienced other types of migraines were precluded even if they received combined migraine surgery. Therefore, 9 simple occipital migraine cases were enrolled in this study. Migraine severity was evaluated by uniform questionnaires to identify the source of migraine. Neurolysis was performed under general anesthesia, with the patient in a prone position. Postoperative conditions were evaluated at the second, fourth, sixth, and eighth weeks by posttreatment questionnaires. ResultsOf all the 9 patients, 5 experienced single-sided migraines of greater occipital nerve origin (2 left-sided and 3 right-sided cases). Two patients had bilateral migraines of greater occipital nerve origin, and unilateral right lesser occipital nerve origin was noted in one patient. The last patient had right-sided migraines of greater and lesser occipital nerve origin. As a result in the follow-up, a response rate greater than 90% was documented, and complete resolution was observed in 2 patients. Drug doses were reduced more than 50% in the remaining patients. The overall efficacy of occipital migraine surgery in this study was 88.8% (8/9 cases). ConclusionSome patients with migraine are good candidates for surgical resolution with appropriate and meticulous selection. Similar to what is observed in Western countries, the migraine surgery is promising and could provide a better quality of life to selected refractory migraine patients in Taiwan.

Tumoral Calcinosis-A Case Report of Rare Soft Tissue Calcification

Tumoral calcinosis is rare, of an unknown origin, and usually characterized by hyperphosphatemia, normocalcemia, and focal and multifocal periarticular soft-tissue calcifications. Tumoral calcinosis occurs in superficial soft tissues, most commonly in the hands, feet, and elbow areas. We present a case of tumor calcinosis in a 47-year-old male patient who had the history of diabetes mellitus (DM) for 10 years and DM nephropathy with end-stage renal disease under hemodialysis. He had a mass (5 cm x 6 cm x 9 cm) at his right elbow and no upper limb ROM (range of motion) limitation. There was no pain associated with the mass, but there were some limitations on the patients ability to dress and undress himself because of the huge size of the mass. After detailed examinations and surgical intervention, the clinical and pathologic findings were tumoral calcinosis. We review the literature and discuss this rare disease.

Idiopathic Granulomatous Mastitis-A Problematic Wound in Breast-Case Report

Background:Idiopathic granulomatous mastitis is a rare benign inflammatory breast disease. Like the autoimmune disease, pyoderma gangrenosum, surgical debridement may lead to problematic wound healing unless aggressive mastectomy is performed. However, some immune-suppressive agents may help wound healing.Aim and Objectives:Treatment of idiopathic granulomatous mastitis by both surgical and medical strategies was discussed.Materials and Methods:A 35 year-old female was diagnosed of idiopathic granulomatous mastitis through pathological examination. Excision biopsy was done but inadequate wound healing with local ulceration was observed. Therefore, oral 5mg prednisolone was prescribed for anti-inflammatory therapy.Results:His wound healed appropriately 3 weeks after oral prednisolone. No recurrent episodes were noted during the follow-up period of 12 months.Conclusion:Oral immune-suppressive agents, instead of surgery, may be the first line therapy of idiopathic granulomatous mastitis when breast preservation is concerned. This therapeutic strategy should be provided to the patients with IGM by both plastic and general surgeons.

Necrotizing Fasciitis Originating from Metastatic Colorectal Tumor Invasion-Case Report

Background: Retroperitoneal necrotizing fasciitis is a rare, fulminate disease, and is often fatal. The etiology of retroperitoneal necrotizing fasciitis may be the result of pelvic or perirectal infection, including those of the gynaecologic and obstetric origin, colonic inflammatory disease, or even due to a ruptured appendix. Aim and Objectives: We present two cases with retroperitoneum and lower extremities necrotizing fasciitis and diagnosed as caused by colorectal adenocarcinoma invasion. We aim to discuss the rare etiology, clinical presentation, diagnosis and treatment. Materials and Methods: We present two cases report with initial presentation of retroperitoneal necrotizing fasciitis, and diagnosed as caused by colorectal adenocarcinoma invasion. Due to severe sepsis, the first patient died on day 73 after emergent fasciotomy and debridement. The second patient who received left hemicolectomy, several courses of debridement, and skin graft was discharged in good health after 60 days. Results: In a review of the current literature, only a few reported cases have presented with retroperitoneal necrotizing fasciitis directly caused by the colorectal cancer. Almost all of the patients in the previously published reports expired during the fulminate course of infection. Our second patient was one of the few cases who successful survived after cancer treatment and reconstruction. Conclusion: Extended necrotizing fasciitis including Fourniers gangrene is a potentially lethal infectious disease. Direct tumor invasion is a rare cause, but results in higher mortality from the disease. If we can provide an early diagnosis via tumor markers, image, or biopsy, we may treat the underlying disease, thereby reducing the number of operations and further improving the outcome. We also should keep in mind that extended necrotizing fasciitis of the groin areas, abdominal wall, and perineum may be related to metastatic tumor invasion.

Is Liposuction with Shaving an Effective Treatment for Bromhidrosis

Background: Bromhidrosis is a troublesome problem that includes unpleasant odor and the occasional staining of clothing. Bromhidrosis patients are known to have more apocrine sweat glands than normal adults. Aim and Objectives: This study was conducted to evaluate the effectiveness of treating axillary bromhidrosis by subcutaneous liposuction with shaving according to histological examination of apocrine glands. Materials and Methods: From January of 2007 through December of 2007, 6 patients underwent subcutaneous liposuction with shaving for bromhidrosis. Pre- and post-operative skin samples were collected and histologically examined to evaluate the number of apocrine sweat glands. The wound and odor conditions were followed up clinically. Results: The average number of apocrine glands is obviously decreased from 46.83 to 2.33 after the operation. All six patients were satisfied with the clinical results of the operation. Conclusion: The operation decreased the number of apocrine glands found under histologic examination and the unpleasant odor improved clinically. Our study found subcutaneous liposuction with shaving an effective treatment for bromhidrosis.

Problem Wounds of the Lower Limb: Management with Collagen Sponge Terudermis

Background: Artificial skin or regenerative template is widely used in reconstructive surgery, especially in the management of difficult and complicated wounds. A simple-staged surgery using a dermal substitute and skin graft could provide a viable option in cases where the patient has advanced age, a poor medical status, or cannot tolerate a major reconstruction procedure. Aim and Objectives: We used Terudermis® as our artificial regenerative template in the management of problem wounds and present our experience. Materials and Methods: From April 2005 to February, 2007, eight patients with problem wounds of the lower limbs who failed conservative management were treated by with artificial dermis (Terudermis®, Terumo Corporation, Tokyo, Japan) and further skin graft. Clinical history, defect size, age, interval time between Terudermis® application to skin graft, and the final results were assessed in all patients. Results: All of the exposed areas included poorly perfused tissue, as well as 3 cases of bone exposure and 5 cases of tendon exposure. All 8 patients received staged surgery and skin graft after an average of 38.13 days following Terudermis® application. Complications included 1 total skin graft loss and 2 cases of partial loss of Terudermis®. Conclusion: The surgical technique for application of artificial dermis and its respective postoperative care are easier than other reconstructive procedures. Additionally, fewer days of in-hospital admission are required. According to our experience, a staged surgery using Terudermis® could provide an alternative choice, especially in elderly patients or in those with poor medical status.

Limb Survival Rate after Bypass Surgery for Peripheral Arterial Occlusive Disease

Background: Limb salvage is considered the primary goal of management of peripheral arterial occlusive disease (PAOD), especially in patients with critical limb ischemia. Purpose: This study was undertaken to evaluate the limb survival rate after femoropopliteal bypass (F-P bypass) surgery, and to determine risk factors affecting the outcome of surgery. Materials and Methods: In our hospital, 36 PAOD patients underwent F-P bypass surgery from May 1992 to February 2007. The records of these patients were reviewed. Results: In our patients, age, renal disease, coronary artery disease, hyperlipidemia, and advanced stage of PAOD before surgery were associated with a lower limb survival rate after revascularization procedures. Conclusions: Patients with risk factors, including age, renal disease, coronary artery disease, hyperlipidemia, and advanced stage of PAOD, had lower limb survival and amputation-free limb survival rates after F-P bypass surgery. With regard to the outcomes reported here, vascular surgeons should explain the long-term outcome of revascularization procedures and evaluate the benefits and disadvantages of the surgery in patients with PAOD.

Correction of Inverted Nipples a New Method Using Bilateral Rhomboid Nipple-Areolar Deepithelialized Turn-Over Flaps

Inverted nipple has been recognized for more than 165 years and it has negative aesthetic, hygienic and functional consequences for both genders. An inverted nipple is defined as one located on a plane lower than the areola. Multiple factors may cause inverted nipple. Nipple inversion can be congenital or acquired. According to a recent classification proposed by Han and Hong, this deformity may be divided into three grades depending on severity. Various corrective surgical and non-surgical techniques have been described. We try to cluster these procedures into three groups. The first group provides traction, the second creates a tighter nipple neck, and the third adds bulk to the side of the base of nipple and beneath the nipple. A review of the literature revealed that the idea of ”triangular flap,” first proposed by Elasy in 1976, has been modified by many authors. The ”triangular flap” technique had the advantage of providing both the tighter neck and greater bulk needed to correct grade Ⅱand Ⅲ inverted nipples. We created a new and successful modification of this surgical procedure. From January 2001 to August 2004, a total of 23 grade Ⅲ inverted nipples in 12 patients (11 females and 1 male; mean age, 32 years; range, 20-45) were corrected using this new procedure. The post-operative follow-up period ranged from 6 months to 49 months (average 23.6 months). There were no complications related to the operation. All patients were satisfied with the surgical results (i.e., anatomically correct nipple projection), and nipple projection in all cases was maintained up to the latest follow up. The procedure is simple, reliable, and can be applied to any grade of inverted nipple with excellent results.