Chih-Hung Lin

Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation.

Lower-extremity injury may present as a composite soft-tissue and bone defect, resulting directly from trauma or subsequent debridements. These composite defects often require vascularized osteocutaneous flaps for an effective, staged reconstruction. Among various donor sites, the vascularized fibular flap is generally considered the best option because of its inherent advantages. However, when the fibular flap is not available, iliac and rib flaps become the alternative choices. The purpose of this retrospective study was to compare the functional results of the alternatively chosen bone flaps (iliac and rib flaps) with those of the fibular flaps.

Traction avulsion amputation of the major upper limb: a proposed new classification, guidelines for acute management, and strategies for secondary reconstruction.

&NA; Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft‐tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system. (Plast. Reconstr. Surg. 108: 1624, 2001.)

Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects.

Even a small defect in the lower leg and foot with exposure of bones or tendons can result in an intractable wound, which may require a microsurgical tissue transfer. With the concept of the perforator flap, a pedicled peroneal artery perforator flap can be used for coverage of this difficult region. Between August 2001 and August 2008, 18 pedicled peroneal artery perforator flaps were performed in 18 patients. The fasciocutaneous flaps were employed to cover defects in the pretibial area (n=6), Achilles tendon and/or hindfoot (n=7) and lateral malleolar area (n=5). The pedicled peroneal artery perforator flaps are classified into five types: propeller flap (n=11), peninsular flap (n=4), advancement flap (n=2), proximally based island flap (n=1) and distally based island flap (n=0). The size of the flaps ranged from 7.5×3 cm(2) to 20×8 cm(2). The selected perforator depended on the defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postoperative venous congestion was encountered in four propeller flaps and one proximally based island flap. Venous congestion subsided within days without complications, except one which needed further reconstruction with skin grafts. In conclusion, the peroneal artery perforators are predictable and reliable for the design of a perforated-based flap. Elevation of the flap can be performed easily in the supine or prone position, depending on the defect location. Different designs of this perforator-based flap can repair a variety of leg and foot defects.

Safety and reliability of microsurgical free tissue transfers in paediatric head and neck reconstruction--a report of 72 cases.

Although many large series of free tissue transfers for head and neck reconstruction have been reported in adults, there are few studies in paediatric patients. Seventy-three free tissue transfers for reconstruction of various defects of the head and neck were performed in 72 paediatric patients between January 1990 and September 2002, at our centre. The average age at the time of reconstruction was 11.8 years (range: 2 to 17 years). Thirty-eight patients were girls and 34 were boys. There were 19 tumour resection defects, 18 congenital oro-nasal fistula defects (cleft palate), 11 posttraumatic defects, nine corrosive pharyngo-oesophageal injuries, eight burn contractures, six hemifacial atrophies and microsomia, and one facial paralysis. Thirty-nine fasciocutaneous flaps, 16 osteoseptocutaneous flaps, 10 muscle or myocutaneous flaps, and eight jejunal flaps were transferred. The mean operative time was 8 h 20 min. All flaps survived, except one partial necrosis, with 98.6% success rate. Five patients (6.8%) required re-exploration. There were two venous and three arterial thromboses. All five flaps were successfully salvaged. The average hospital stay was 18 days. This study confirmed free tissue transfer as a safe, reliable, cost- and time-effective method for the reconstruction of various head and neck defects in children.

Conventional versus endoscopic free gracilis muscle harvest.

Compared with conventional techniques, the endoscopically assisted harvest of free tissue has advantages such as minimal interference with cosmesis and reduced donor‐site morbidity. However, the procedure also requires training and has an extensive learning period. In this series of 22 patients, the initial gracilis muscle flaps were harvested using a conventional method; the subsequent flaps were harvested with the aid of endoscopic instrumentation. Endoscopically assisted gracilis muscle harvest in 16 patients was compared with open method harvest in six patients. The endoscopically assisted group had an average incision length of 6.5 cm; that of the conventional group was 15.5 cm. There was one reexploration in the endoscopically assisted group, but all flaps were transferred successfully. Using this minimally invasive technique of vascular and muscular dissection, assisted by endoscopic instruments designed for distal muscle dissection and transection, the gracilis muscles can be harvested within 40 minutes. We consider endoscopically assisted harvest of free gracilis muscle to be safe, relatively simple, and cost‐effective. (Plast. Reconstr. Surg. 105: 89, 2000.)

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint.

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

Assessment of fibula osteoseptocutaneous flap donor-site morbidity using balance and gait test.

To assess the functional deficits in gait and balance after fibular osteoseptocutaneous flap harvest, a case–control study in a hospital‐based biomechanical laboratory was conducted. Eleven patients receiving fibula osteoseptocutaneous flaps were enrolled as study group and 10 age‐matched and healthy subjects as a control group. The average postoperative period at the time of evaluation was 27.4 months (range: 10 to 68 months) and the average age at the time of evaluation was 52.1 years (range: 38 to 76 years). The balance test by Smart Balance Master and gait analysis were used for objective assessment of the donor leg function postoperatively. No statistical differences were observed in the kinetic and kinematic variables of gait analysis except double support time in both the groups. There were also no significant differences in simple static balance test (eyes open, eyes closed, swaying vision, eyes open with swaying surface, and sway‐referenced vision and support). Significant differences were observed in more difficult task (eye closed with swaying support) and in the use of ankle strategy for maintaining maximum balance. In the dynamic balance test only specificity of the forward left direction determined significant difference in reaction time of movement control of gravity. The results of ankle strategy usage and dynamic balance indicated deficits of ankle muscle torque. Necessary postoperative physical training is required for ankle muscle torque and vestibular sense.

Selection of recipient vessel in traumatic lower extremity.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.

Replantation of a Degloved Hand With Added Arteriovenous Anastomoses: Report of Two Cases

Revascularization of the degloved skin is generally accepted as the best option for the management of totally degloved hands. Nevertheless, the selection of vessels for anastomoses is usually difficult in this situation, and insufficient perfusion of the degloved hand skin is common after arterial repair. We present 2 cases of patients who sustained totally degloved hand injuries. Favorable outcomes of replantation were achieved with added arteriovenous anastomoses between the dorsal veins of the degloved hand skin and the digital arteries.

Salvage of a complicated penis replantation using bipedicled scrotal flap following a prolonged ischaemia time

Microsurgical replantation is the standard method to treat penile amputation. The loss of variable area of skin is a common complication following penile replantation due to prolonged ischaemia time, postoperative venous congestion, oedema and wound infection. There is limited literature available on the management of complications following replantation. A skin graft is commonly used to resurface the denuded areas after skin necrosis. However, this simple and rapid approach has some inherent disadvantages, including paresthesia, contracture, mismatched skin colour and disfiguring donor site. In this report, we present the salvage of a replanted penis by a bipedicled scrotal flap in which the skin fragment was necrosed due to prolonged ischaemia time. Cosmetic and functional outcomes in the 1-year follow-up period were satisfactory.