Chi-Yu Wang

Botryomycosis presenting as nasal cutaneous fistulas caused by Prevotella melaninogenica

Summary Botryomycosis is an uncommon chronic suppurative granulomatous bacterial infection that can affect the skin and viscera. Clinically, lesions typically consist of small tender nodules from which draining sinuses may develop to expel a purulent discharge. Histopathological features include characteristic aggregation of microorganisms (grain) within the inflammatory infiltrate. The commonest causative organisms are Staphylococcus aureus and Pseudomonas aeruginosa, of others. Botryomycosis resulting from Prevotella melaninogenica has not been reported previously. We report the case of a middle‐aged patient with botryomycosis presenting as nasal cutaneous fistulas caused by P. melaninogenica, which was successfully treated with surgical intervention combined with systemic antibiotic treatment.

Intraoperative indocyanine green fluorescent angiography-assisted modified superior gluteal artery perforator flap for reconstruction of sacral pressure sores

Pressure sores are often observed in patients who are bedridden. They can be a severe problem not only for patients and their caregivers but also for plastic surgeons. Here, we describe a new method of superior gluteal artery perforator flap harvesting and anchoring with the assistance of intraoperative indocyanine green fluorescent angiography. In this report, we describe the procedure and outcomes for 19 patients with grades III and IV sacral pressure sores who underwent the operation between September 2015 and November 2016. All flaps survived, and two experienced wound‐edge partial dehiscence. With the assistance of this imaging device, we were able to acquire a reliable superior gluteal artery perforator flap and perform modified operations with it that are safe, easy to learn and associated with fewer complications than are traditional.

Functional results of free tissue transfer for complex heel‐calcaneal defects

Loss of soft tissue in heel‐calcaneal region is frequently caused by trauma, infection, or tumors. Limited availability of similar tissue becomes challenging, therefore, the use of free tissue transfer offers a solution. Our aim is to describe long term functional outcome of different free tissue transfers for these defects.

Use of split-thickness plantar skin grafts in the management of leg and foot skin defects: Systematic review on epidermal grafting

The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split‐thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split‐thickness skin graft (0.014 in. thick) from a non‐weight‐bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.

Successful salvage and reconstruction of a finger threatened by Vibrio vulnificus necrotising fasciitis using fenestrated‐type artificial dermis and three steps of topical negative pressure wound therapy

Vibrio vulnificus can cause severe skin and soft tissue infection (SSTI). The pathogen is an opportunistic marine bacterium that is likely to infect patients with chronic liver disease, patients in an immunocompromised state, and those in end‐stage renal disease. V. vulnificus gains entry through soft tissues by direct penetration of a wound by infected marine organisms, such as raw oysters, shellfish and other seafood, or by exposing a wound to contaminated water. Despite its ease of entry, V. vulnificus necrotising fasciitis with compartment syndrome has rarely been described. We report a case of an elderly patient with end‐stage renal disease undergoing haemodialysis, who developed necrotising fasciitis following infection by V. vulnificus through a puncture injury while cleaning fish. A successful salvage and reconstruction surgery was performed using fenestrated‐type artificial dermis followed by negative pressure wound therapy. This case presents a reasonable treatment option for threatening V. vulnificus necrotising fasciitis with compartment syndrome.

Breast Reconstruction Using Pedicled Latissimus Dorsi Myocutaneous Flaps in Asian Patients With Small Breasts.

Background The use of implants is still the most common procedure for breast reconstruction because they are easy, less painful than tissue transplants, and do not need a donor site. However, it is challenging to find a suitable implant for patients with small breasts, and some women fear foreign bodies and possible complications or reoperations. Autologous breast reconstruction using the pedicled latissimus dorsi (LD) myocutaneous flap without an implant provides a good option for Asian women with small breasts. Materials and Methods Between June 1992 and December 2015, 31 patients underwent breast reconstruction with 33 LD flaps (29 unilateral and 2 bilateral). The skin paddle of the flap was designed with an oblique or transverse pattern depending on the mastectomy defect and the elasticity of skin. The thoracodorsal nerve was divided during flap harvesting to prevent a “twitching breast” postoperatively. Patients refused to have contralateral breast augmentation except for 2 with bilateral simultaneous augmentation after mastectomy bilaterally. Outcome measures were flap survival, shape and contour, symmetry of breast, complication of flap and donor site, patient satisfaction, and any local tumor recurrence or metastasis. Results The mean patient age was 46.7 years (range, 27–72), and the mean body mass index was 22.5 kg/m2 (range, 18.6–30). The mean size of the harvested skin paddle was 11.9 × 5.0 cm (range, 10 × 3 cm to 15 × 9 cm). Mean operative times were 200.8 minutes (range, 112–230 minutes) and 305 minutes (range, 300–310 minutes) for unilateral and bilateral reconstructions, respectively. Pathology reports showed a negative safety margin in all cases. Most cases were of invasive duct carcinoma (58%). All LD flaps survived, and the wounds healed satisfactorily over a mean follow-up of 49.9 months (range, 3–161 months). Donor sites were closed primarily with a hidden linear scar under the dorsal bra strap. Donor site morbidities were mainly seromas (15%), which were treated conservatively in most patients. Conclusions The LD flap produced good autologous tissue for reconstruction, and no implants were needed for Asian women with small breasts. The reconstructed breasts showed good shape, contour, and symmetry. The results of donor site were acceptable and no significant functional loss. There were no major complications, and patient satisfaction was high.

Postmastectomy Breast Reconstruction Combined With Contralateral Breast Augmentation for Taiwanese Women With Small Breasts

Background Although autogenous tissue-based breast reconstruction has been widely used in the past decade, implant-based breast reconstruction is more often used in Taiwan because Asian women are generally slender with small breasts. For patients with very small breasts, it is hard to achieve the goal of reconstructing a similar breast to the contralateral one, even with the smallest size implant available commercially. Therefore, these patients need not only breast reconstruction but also contralateral breast augmentation. Here we report the surgical outcomes and cosmetic results of breast reconstruction using cohesive gel implants combined with simultaneous contralateral breast augmentation. Materials and Methods A retrospective chart review was conducted to identify all patients with AA-sized to B-sized breast cups undergoing expander-implant reconstruction combined with contralateral breast augmentation between 2002 and 2015. Thirty patients were included. For each patient, patient profile (age, body mass index, and initial breast size), type and stage of breast cancer, surgical information (including implant sizes and the type of reconstruction and augmentation), and postoperative subjective pain scales were recorded. Outcomes were analyzed by identifying complications, the need for surgical revision, the presence of local or distant metastases, and patient satisfaction ratings. Results At a mean 2.3-year follow-up (range, 4 months to 12 years), problems occurred in 7 of the 30 patients, with 9 complications in 8 reconstructed breasts and in 1 augmented breast. Complications were mostly capsule contracture. Aesthetic satisfaction was rated as “excellent” or “good” by most of the patients, and only 1 commented “poor” on both overall and reconstructed results because of postoperative radiotherapy-associated skin necrosis. The total mean subjective pain scale was 1.9/10; a higher mean pain scale of 3.08 was noted in those patients undergoing augmentation with no extra incision. Conclusions This is the first report of implant-based breast reconstruction with simultaneous contralateral augmentation in Taiwan, showing its efficacy, safety, and good cosmetic outcomes with relatively low complication and revision rates.