Chien-Hsing Wang

Subtotal Resection of Gastrocnemius Muscles for Hypertrophic Muscular Calves in Asians

Background: Many Asian women are bothered by plump calves, which they consider to be unsightly. In the past, liposuction was frequently performed to treat oversized legs, but little effect could be obtained if the condition was caused by hypertrophy of calf muscles. Methods: Gastrocnemius muscle resection for hypertrophic muscular calves was performed in 20 patients at Buddhist Tzu Chi General Hospital from May of 2001 through September of 2004. One patient underwent resection of the medial head only, two underwent total resection of both medial and lateral heads, and the other 17 patients underwent subtotal resection with preservation of the proximal 4 to 6 cm of muscle of both heads. Results: The resected gastrocnemius muscle weighed from 250 to 430 g per calf (mean, 343 g). The maximal calf circumference was between 32 and 41 cm (average, 35.2 cm) preoperatively and 26 and 35 cm (average, 30.5 cm) postoperatively. Calf reduction was 3.5 to 7 cm (average, 4.7 cm), or 10.1 to 21.2 percent (average, 13.3 percent). Two patients developed seroma and three developed late hematoma. One patient had dragging of one foot because of incidental severance of the nerve to the soleus muscle that lasted for 6 months, until complete recovery occurred. No patient complained of functional deficits during gait or sports activities after 3 to 6 months. Conclusions: Subtotal resection of both heads of the gastrocnemius muscle can result in satisfactory calf reduction without impairment of leg function and avoid hollow deformity in the popliteal fossa. Five patients still had scar problems during the short-term follow-up period, but all were rather satisfied with their reduced calf sizes.

Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps.

Massive composite defects of the face are difficult to reconstruct. Such defects are usually created after ablation of advanced cancers of the head and neck region. The use of a free fibular osteocutaneous flap for the bone and mucosal lining of the oral cavity and anterolateral thigh flap for the outer cutaneous lining are well established. We present our experience of using these two flaps simultaneously in the reconstruction of such defects and to evaluate the outcome. There were a total of 10 patients in our study. Their average age was 48.8 years. All had squamous cell carcinoma of the oral cavity. Their pathological stages were mostly stage T4 with only one case being T3. Flap survival was 100%. The application of dual free flaps, though technically more demanding, allows good orientation of the flaps. Seven patients maintained a good functional outcome. They were able to eat a soft diet. Their speech was easily comprehensible. The combination of a free anterolateral thigh flap with vascularized fibular osteocutaneous flap can be performed safely with adequate functional outcome. This combination of flaps should be considered for this group of patients.

A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction.

AbstractFree flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps.

AbstractWe describe our experience in expanding the use of pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. A total of 33 patients underwent 34 flaps between March 2003 and January 2012. The defects included 18 ischial, 3 trochanteric, 5 lower abdomen, 2 perineogenital, 1 groin, and 5 knee defects. There were 29 proximal pedicled (2 of which were preexpanded), 3 distal pedicled, and 2 propeller flaps. Complications included 1 total necrosis, 1 partial necrosis, 3 wound dehiscence in recipient site, 1 hematoma, and 1 donor-site dehiscence. The total flap survival rate was 94%. There were no donor-site morbidities except poor cosmesis in the skin-grafted sites. Pedicled anterolateral thigh flap is highly versatile with a wide arc of rotation. A proximal pedicled flap can be used for lower abdomen, perineogenital, ischial, and trochanteric defects and the distal pedicled or a propeller flap for knee and proximal lower leg defects.

A Double-Skin Paddle Radial Forearm Flap for the Reconstruction of Oral Submucous Fibrosis

Objective: Oral submucous fibrosis can result in progressive restriction of mouth opening. Surgical treatment is indicated for severe cases. An innovative technique, a double-skin paddle radial forearm flap, using only one forearm donor site to reconstruct the bilateral buccal defects, is described. Patients and Methods: A total of six patients, having severe oral submucous fibrosis, were treated between July 2002 and August 2004. The surgical procedure consists of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a double-skin paddle radial forearm flap. Results: The preoperative mouth opening was 2 to 5 mm (mean: 3.3 mm). The intraoperative mouth opening ranged from 13 to 20 mm (mean 16.5 mm) after submucous release and ranged from 32 to 42 mm (mean 35.5 mm) after further release via myotomy and coronoidotomy. The proximal flap incorporated one perforator in two patients and two perforators in the remaining 4 patients. The size of the flaps ranged from 8 to 9 cm in length and 2 to 2.5 cm in width. Five flaps survived uneventfully. Arterial thrombosis, developing 24 hours after the operation, was noted in one flap. The flap was successfully salvaged after emergent exploration. Temporomandibular joint subluxation developed in one patient and required surgical reduction. One patient needed flap revision due to bulkiness. The postoperative mouth-opening range was 22 to 37 mm (mean: 30 mm) at an average follow-up period of 19 months. The average increase of the mouth opening was 26.7 mm, compared with the preoperative interincisor distance. Conclusion: Double-skin paddle radial forearm flap allowed simultaneous reconstruction of two separate buccal defects using a single donor site and thus obviates the need for a second free flap.

Treatment of Venomous Snakebites in Eastern Taiwan

Background: The incidence of snakebites decreased gradually in recent years due to change of the socioeconomic environment in Taiwan. However, venomous snakebites still can cause severe morbidity and even death occasionally. Aim and Objectives: This report described treatment and result of poisonous snakebites in Eastern Taiwan. We hope to improve management and decrease complications. Materials and Methods: The medical records of the patients admitted to the Buddhist Tzu Chi General Hospital due to venomous snakebites from Jan 2000 to Sep 2004 were retrospectively reviewed. The patients demographic data, species of causative snake, manifestations of envenomation, treatment and clinical course were collected and analyzed. Results: There were 93 cases of snakebites collected. Most of the snakebites (27%) occurred in the fourth decade of age. The species of snakebites included: Taiwan habu bites (29%), Taiwan bamboo viper bites (16%), cobra bites (7.5%) and unknown bites (34%). The most common locations of the bite were in the upper extremity (60%). 24 patients (25.8%) required surgical intervention, including fasciotomy which was performed in 17 patients (18.3%). The average lengths of hospital stay in non-operated group and operated group were 4.2 days and 18.8 days respectively. Acute renal failure developed in three patients, and one of them required temporary hemodialysis. There was only one death in this series. Conclusion: Surgical intervention is indicated in a particular group of patients and different treatment algorithms should be developed according to snake species to decrease the morbidity of venomous snakebites.

Mucosa-related Lymphoid Tissue Lymphoma of the Parotid Gland-Case Report and Literature Review

Background:Mucosa-related lymphoid tissue (MALT) lymphomas are rare low-grade B-cell lymphomas, mostly arising from the gastrointestinal tract. MALT lymphomas arising from the parotid gland are very rare.Aim and objective:We report the rare condition of mucosa-related lymphoid tissue lymphoma arising from the parotid gland and discuss their treatment and outcome.Material and Methods:A 77-year-old man presents with a 10-month history of a slow growing painless tumor at his right periauricular area. It measured 4 x 3 cm in size. There were another two palpable tumors at lower pole of the parotid gland, with the largest one measuring 1.7cm. After excisional biopsy of the minor tumors at the lower pole. The pathology confirmed MALT lymphoma. Superficial parotidectomy with concurrent radiation therapy was done.Results:There was no evidence of local recurrence and distant metastasis on the 11 months follow-up.Conclusion:Mucosa-associated lymphoid tissue lymphoma is rarely arising from the parotid gland. Diagnosis of the disease is very difficult and should be suspected if a patient has significant risk factors. Conservative superficial parotidectomy is recommended both for diagnosis and treatment. Radiation therapy is recommended for limited stages of the disease with systemic chemotherapy advised for advanced stage. Prognosis is favorable with careful post-treatment follow-up.

Radionecrosis of Soft Tissue: Surgical Treatment and Reconstruction

Background: Radiation therapy has been used increasingly in treating certain malignancies or often as a standard treatment combination in head and neck cancer. However, radiation related wounds can at times be devastating and troublesome. Aim and Objectives: In this paper, we reviewed retrospectively our experience in treating these types of wounds. We reviewed their surgical management and the different methods of reconstruction. Materials and Methods: A total of 6 patients were included in the study. All wounds were located at the head and neck region and associated with previous cancer treatment. Radiotherapy is an inclusion criteria. Medical records were retrospectively reviewed. All the clinical details including pre-reconstructive treatment and reconstructive methods were analyzed. Results: All patients received surgical debridement. Post-debridement wound care included both open type and occlusive type (V.A.C.®). Reconstructive methods followed the reconstructive ladder and all patients received flap coverage, whether as a pedicled flap or as a free flap. One patient received free tissue transfer and the rest received pedicled flap for wound coverage. Two patients received pectoralis major musculocutaneous flap (PMMF) and three patients received deltopectoral fasciocutaneous flap (DPFF). All patients recovered well without complications. Conclusion: Radiation injury to the soft tissue is a prolong progressive continuous process of injury which is hard to heal with ordinal procedure. When the radiation dosage was over 6000 cGy the possibility of wound necrosis and ulceration would be seen more often. The incidence might be underestimated due to poor recognition and identification among these patients. Most of the patients with minor necrosis can be treated with conservative methods and hyperbaric oxygen therapy . But those with extensive areas of necrosis with exposure of underlying major vessels or vital structures need to undergo serial debridements until a suitable wound bed without infection is obtained prior to reconstruction. The pedicled flap shown in our series seemed to be an alternative second choice for reconstruction for it does not require microsurgery and has a shorter operative time when compared to free flap transfer.

Anatomical Analysis of the Vascular Distribution in the Pectoralis Major Myocutaneous Flap Using Latex Injection

Background:Although the free flap has become the first choice in recent head and neck reconstruction, the pectoralis major (PM) myocutaneous flap still plays an important role, especially in salvage operations. However, unstable blood circulation of skin paddle with a higher partial necrosis rate has previously been reported.Aim and Objectives:In this current study, we tried to clarify the blood supply of the pectoralis major myocutaneous flap and to determine whether it can be harvested as a pedicled perforator flap.Materials and Methods:The 6 sides of 3 fresh frozen cadavers were examined in this study. The pectoral branch of the thoracoacromial artery was dissected out and injected with colored latex. In the first step, the pectoralis major muscle was elevated from the thoracic cage and the characteristics of the encountered muscular perforators were recorded. Following that, the skin flap was separated from the underlying muscle and the cutaneous perforating branches were also documented.Results:The circulation of the pectoralis major muscle has two main territories. It receives blood supply from pectoral branch of the thoracoacromial artery in the cranial portion and from multiple perforating intercostal branches in the caudal portion. These two territories are linked by choke vessels mainly at the level of fourth costal cartilage. The perfusion of the distal flap is maintained by muscle body containing these choke vessels. However, the number of perforating branches to the skin paddle is much smaller than that to the pectoralis major muscle and their locations vary individually, so the perfusion of the skin is unreliable in the absence of these perforators.Conclusion:The blood circulation of the skin paddle of the pectoralis major myocutaneous flap is unstable because of variation in the number and location of perforating vessels present and also the relative paucity of the cutaneous perforating branches. When designing a skin island, especially a small one, great efforts must be made to include either the third perforating branch of the internal mammary artery or the major intercostal perforating branches to improve blood flow. Hand-held Doppler may be helpful in localization of these vessels. (J Taiwan Soc of Plast Surg 2011; 20: 266~273)

Free Flap Reconstruction for Diabetic Foot Lesions

Background: Diabetic foot lesions are often complicated by angiopathy and neuropathy. If a deep ulcer or osteomyelitis is present, there is often exposure of the underlying bone or tendon after aggressive debridement. Owing to recent advancements in microsurgery, such lesions can now be managed successfully with free flap reconstruction. Aim and Objectives: This study was aimed to evaluate the outcome of diabetic foot salvage using free flap reconstruction. Materials and Methods: Between January 2003 and June 2009, patients with diabetic foot and managed with free flap reconstruction in Buddhist Tzu-Chi General Hospital were reviewed. The flap types, success rate and complication rate were analyzed. Results: Forty-six patients (28 males and 18 females) with diabetic foot were reconstructed with a total of 48 free flaps. The mean age was 52.4 years (range from 27 to 79). The different kinds of free flaps that were used were: 25 vastus lateralis flaps, 10 anterolateral thigh flaps, 8 radial forearm flaps, 2 rectus abdominis flaps, 1 rectus femoris flap, 1 gracilis flap and 1 lateral leg flap. The complication rate was 41.7%. This included: total flap loss (1), partial flap loss (2), wound infection (9), loss of split thickness skin graft (4), venous thrombosis (2), hematoma (1) and pedicle bleeding (1). The infection rate was higher in the free muscle flap group (25%) than in the myocutaneous flap group (0%) or the fasciocutaneous flap group (11.8%). There were no perioperative mortalities. The mean follow-up was 15.0 months (range from 1 to 59). The limb salvage rate was 97.8%. Conclusion: In selected cases, diabetic foot lesions can be managed successfully with free flap reconstruction. There is a good outcome with an acceptable complication rate.