Chih-Cheng Tsai

Endoscopic excision of benign tumors in the forehead and brow.

Twenty-five cases of benign tumor of the forehead and brow were excised successfully with endoscope-assisted surgery. The access incision was selected strategically behind the front hairline. For tumors in the middle of the forehead, the tumor was approached by subgaleal dissection. For those in the brow or temporal area, the dissection plane was just superficial to the deep temporal fascia. Patient age ranged from 3 to 59 years. The mass varied in size from 1.0 × 0.5 to 2.0 × 2.0 cm. There were 18 lipomas, 6 dermoid cysts, and 1 pilomatricoma. There was no residual mass or recurrence 1 to 24 months postoperatively. There was no paresthesia or numbness in the scalp. Patients and their families were greatly satisfied with this operation and the absence of visible scarring.

Early diagnosis of necrotizing fasciitis by utilization of ultrasonography.

Necrotizing fasciitis is a rare and rapid progression soft tissue infection. The only identifiable feature is tissue necrosis along a single fascia plane. Because the skin is initially spared, it is difficult for early recognition prior to extensive tissue destruction. Ultrasonography was used for early diagnosis of this infection in five cases. All 5 patients presented with severe cellulitis. Under the suspicion of necrotizing fasciitis, ultrasonography was performed before surgical debridement. Tissue biopsy was done for histological confirmation of the diagnosis. Three patients were proven to have necrotizing fasciitis and two cellulitis only. The ultrasonographic findings of necrotizing fasciitis included: 1) irregularity of the fascia; 2) abnormal fluid collections along the fascia plane; and 3) diffuse thickening of the fascia when compared with the control site in the normal limb. However, in severe infectious cellulitis, the above mentioned findings were not observed. Our results indicate the usefulness of the ultrasonography for early diagnosis of necrotizing fasciitis.

The use of composite acellular allodermis-ultrathin autograft on joint area in major burn patients--one year follow-up.

Scar contracture is a major long-term sequelae of meshed split-thickness skin grafts in the case of full-thickness burn injuries, and especially in joint areas. Severe contracture around joints may lead to loss of mobility. The thickness of the dermis in the autograft plays a major role in the functional and cosmetic outcomes of the third degree burn. How to replace lost dermis is a major problem in skin restoration following severe burns. The human allograft skin (AlloDerm) is an acellular dermal matrix with normal collagen bundling organization and intact basement membrane complex. We present 12 cases of clinical application of a composite grafting technique in which the allogeneic skin (AlloDerm) provided source of dermis, and an ultrathin autograft (0.004-0.006 inch in thickness) provided epidermis. In these patients, The composite grafts were applied to full-thickness burn wounds over various articular skin surfaces. The average skin graft take rate was 91.5%. These ultrathin autografts allow the donor sites to heal faster. The mean time of donor site reepithelization was 6 days. All patients had a nearly normal range of joint motion (average 95% of normal) after one years follow up. Wound assessment over time has shown supple skin that has been resistant to trauma and infection. The cosmetic results were judged to be fair to good by surgeons and patients after one years follow up.

The reverse lateral arm adipofascial flap for elbow coverage

The reverse lateral arm adipofascial flap covered immediately with a skin graft has been used successfully for reconstruction of a cubital fossa defect (caused by avulsion injury) and an exposed olecranon (resulting from recurrent bursitis) in 2 patients. The flap is nourished by the septal perforators of the posterior radial collateral artery, which in turn obtains its blood supply from the interosseous recurrent artery. The distal vascular pedicle should contain a sufficient amount of subcutaneous fat and its underlying fascia to enhance the arterial input and the venous drainage of the flap. The primary benefit of this technique is that the thickness of the flap can be tailored to fit into the defect, and the donor site can be closed primarily without tension. The advantages include satisfactory cosmetic results, a rapid one-stage procedure, no sacrifice of the main artery or local muscle, and avoidance of any long-term immobilization of the involved elbow joint.

Endoscope-assisted parotidectomy for benign parotid tumors.

&NA; Sixteen cases of parotidectomy of benign tumors were performed by means of a short incision with the assistance of endoscopic surgery. The average length of the preauricular and retromandibular incision was 6.9 cm (range, 6.0‐8.1 cm). This incision provided safe dissection of the facial nerve trunk and exposed a major part of the gland to direct vision. Identification and separation of the facial nerve branches in peripheral glandular tissue was performed by means of endoscopic surgery instead of wide exposure with a long incision. Because endoscopic surgery provided good illumination and magnification on the monitor, the operation could proceed clearly and sharply in a bloodless field. Therefore, the incidence of facial nerve injury and perioperative morbidity was minimized. In this series, tumors were removed completely, without injury to the facial nerve. Patients were also satisfied with the short and inconspicuous postoperative scars. Lin S‐D, Tsai C‐C, Lai C‐S, Lee S‐S, Change K‐P. Endoscope‐assisted parotidectomy for benign parotid tumors. Ann Plast Surg 2000;45:269‐273

Reconstruction of the upper leg and knee with a reversed flow saphenous island flap based on the medial inferior genicular artery

Soft-tissue defects around the knees and below-the-knee amputation stumps are difficult to reconstruct. We present an option for reconstruction of these defects. Reversed flow saphenous island flaps, based on the medial inferior genicular artery, were successfully transferred in 6 patients. All wounds healed well postoperatively. The donor defect can be closed directly when the width is less than 7 cm. This is a thin and reliable fasciocutaneous flap that is useful in covering defects around the knee joint, popliteal fossa, upper half of the leg, and below-the-knee amputation stump.

A Clinical Analysis of Necrotizing Fasciitis: A Review of 54 Cases

Necrotizing fasciitis is a severe and sometimes life-threatening soft tissue infection that is characterized by rapidly widespreading necrosis of fascia and subcutaneous tissue. Fifty-four cases of necrotizing fasciitis were reviewed over a 5-year period. Among them, 25 patients (46%) had diabetes mellitus. The majority of the wound bacterial cultures (71%) yielded a mixed growing. There were negative cultures in six patients, and single organism growth in 14 patients (29%). The predominant organisms growth were Streptococci, Staphylococci, and Escherichia coli. The overall mortality rate was 22% (12/54). Death was caused by systemic septic complications in these patients. All 12 mortalities resulted from delayed debridement (averaging 25 days after initial symptoms appeared). Our study indicates that the early recognition and prompt debridement of all necrotic tissue is essential for reducing the mortality rates of this potentially lethal condition.

Endoscope-assisted correction of primary varicose veins

&NA; The purpose of this study is to evaluate the possibilities and results of application of endoscopic surgery in the operation of primary varicose veins. With good illumination and magnified viewing, the varicosities, incompetent perforating veins, and healthy veins were clearly visualized. The incompetent perforating veins were clipped and divided securely. The varicose veins and tributaries were dissected and removed completely after being clipped and divided. The healthy veins were preserved if possible. Primary varicose veins in 43 limbs of 37 patients were operated. The operation was conducted through one access incision in 31 limbs (72%), two incisions in 11 limbs (25%), and three incisions in 1 limb. The mean number of incisions was 1.3 in each limb. Hematoma formation occurred in 1 patient due to the slipping of one clip on the third postoperative day. The other patients had uneventful postoperative courses. All 37 patients were reviewed 4 to 30 months postoperatively. Only one limb had recurrent varices at a new site. Ninety‐seven percent of limbs (42 of 43) had no recurrence of varicose veins. Seventy‐eight percent of patients (29 of 37) were extremely pleased with this operation. Although the other 22% of patients (8 of 37) appreciated this operation, they were not completely satisfied because some preoperative complaints persisted. In this series, the recurrent rate of varicose veins was low (1 in 43 limbs) and postoperative scarring was minimized, in addition to the advantages of endoscopic surgery. These results demonstrate that endoscopic surgery is a worthy alternative procedure for correcting primary varicose veins. Lin S‐D, Tsai C‐C, Lin T‐M, Lee S‐S, Chang K‐P, Lai C‐S. Endoscope‐assisted correction of primary varicose veins. Ann Plast Surg 2000;44: 241‐249

The reverse lateral arm flap, based on the interosseous recurrent artery, for cubital fossa burns

The reverse lateral arm flap based on the interosseous recurrent artery was used successfully to reconstruct cubital fossa defects caused by high voltage electric burn in two cases. The flap is nourished by the septocutaneous perforators of the posterior radial collateral artery which anastomoses around the lateral epicondyle with the interosseous recurrent artery. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, with no necessity of sacrificing a main artery or local muscle, and it requires no immobilisation of the involved joint.

Tarsal tunnel syndrome secondary to neurilemoma--a case report.

Peripheral nerve entrapment syndromes in the foot include those symptom complexes that are primarily neurologic in origin and result from embarrassment to any of the peripheral nerve trunks or branches of the foot. Tarsal tunnel syndrome usually is precipitated by compression of the tibial nerve posterior and distal to the medial malleolus. A neurilemoma is relatively uncommon in the foot. It is usually a solitary tumor that is almost exclusively benign and can be removed without jeopardizing the integrity of the nerve. Diagnosis is based on a thorough history and clinical pictures. Certain diagnostic modalities, ultrasound and MRI, have been employed to aid in diagnosis. Surgical excision of the tumor remains the treatment of choice.