Chin-Chiang Yang

The reverse digital artery flap for fingertip reconstruction

Reverse digital artery flaps were performed successfully to resurface the major fingertip defect in 10 patients and the volar defect of the middle phalanx in 1. This thin flap with its long vascular pedicle containing a digital artery and its perivascular cuff tissue has a wide arc of transposition. It can be used to reconstruct the defect located from the proximal phalanx to the fingertip of all fingers. No loss of the flap in this series was noted. The procedure is a time-saving, one-stage operation. Patients who received this procedure had no uncomfortable immobilization of the hand or long hospitalization. It also causes no disfigurement and no functional loss of the involved digit. Our clinical experience showed favorable results.

The adipofascial turn-over flap for complicated dorsal skin defects of the hand and finger

Six cases of complicated dorsal skin defects of hands and two in fingers were successfully resurfaced with local adipofascial turn-over flaps. Flaps with a base-to-length ratio of 1:1.0 to 1:1.5 survived completely. The width of the attached base was 1.0 to 1.5 cm in hands and 0.5 cm in fingers.

Adipofascial turn-over flap for reconstruction of the dorsum of the foot

Local adipofascial turn-over flaps with skin grafts were successfully used to reconstruct complicated skin defects over the dorsum of the foot in 7 patients. The blood supply of the flap comes from perforators in the base and from the surrounding subcutaneous and fascial plexuses. A new concept of base-to-flap area ratio is proposed to predict the survival of the turn-over flaps in addition to the conventional base-to-length ratio. This appears to be a valuable technique for difficult wounds of the dorsum of the foot.

Limb salvage of infected diabetic foot ulcers with microsurgical free-muscle transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.

The adipofascial turnover flap for elbow coverage.

Closure of soft tissue defects in the vicinity of the elbow with exposed bone or joint remains a difficult problem. Local adipofascial turnover flaps covered by a skin graft were successfully used to reconstruct two elbow defects. The flaps base was placed 1.5 to 2.0 cm from the wound edge. The flap-to-base area ratio, which is an important index of flap survival, in addition to the traditional length-to-width ratio were 3.25 and 3.3, respectively. The undermined skin of the flap donor site was preserved rather than discarded as in the conventional deepithelialized turnover flap. The primary benefits of this flap are that it is an easy and rapid one-stage procedure, it requires limited immobilization of the involved joint, and it leaves an inconspicuous donor site scar. The motion of the elbow joint was not impeded because the adiposal component of the flap faced the exposed vital structures. The padding is not thick, but is sufficient to cover and protect the elbow. The flap is especially indicated for small- to medium-sized, complicated elbow wounds.

Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap

Two cases with extensive plantar avulsion injuries had their heel defects resurfaced initially with full thickness skin grafts. Two months later, reinnervation presented in areas of grafted skin innervated by medial and lateral plantar nerves. No reinnervation was found in the plantar heel region originally innervated by the medial calcaneal nerve. Heel ulceration in the non-sensate, grafted skin occurred in the first case. Reinnervated, skin-grafted flexor digitorum brevis muscle flaps were then used for reconstructing the non-sensate plantar heels. There was no breakdown of skin during the follow-up period of 8 months and 6 months respectively. This method provides sensate and durable cover for extensive plantar heel defects.

Amnion overlay meshed skin autograft.

Meshed skin autografts are conventionally dressed with fine petrolatum gauzes. Pain and haemorrhage are a frequent sequel to changing dressings in the early days after grafting. We have explored the use of amnion to overlay the meshed autograft (3:1) in addition to the fine petrolatum gauze. Eleven patients with 24 burn wounds were treated. The amnion provided good protection to the underlying meshed autograft and the neoepithelium. It did not block the re-epithelialization and may have promoted the healing process. Most of the grafts had healed completely by 7 days after application. Pain and haemorrhage were markedly reduced. The non-antigenic nature, adherent quality and inexpensive cost makes amnion a promising biological dressing for meshed autografts.

Immediate reconstruction of the penis with an iliac flap

Immediate reconstruction of the penis can save time and significantly reduce postoperative psychological morbidity. A patient suffered a cancerous lesion in his glans penis. After total amputation, an iliac flap based on the superficial circumflex iliac artery was used to reconstruct the penis. The subcutaneous tissue around the vascular pedicle was carefully preserved for enhancing the venous drainage of the new penis. A self-sculptured silicone implant was inserted later to increase the penile rigidity. The advantages of this technique include ready availability, easy mobilisation, hairlessness, elimination of multi-staged procedures, and saving time. The patient is pleased with the operative results.

Surgical treatment of facial siliconoma involving the temporal area

Complications of liquid silicone injections into the human body include foreign-body reactions, nodule formation, ulcerations, chronic cellulitis, and distant migration of the material. These complications have been described elsewhere.1–16 Surgical treatment of facial deformity caused by the silicone nodules is seldom reported. Because the frontal nerve courses through the temporal area, surgeons usually hesitate to remove the siliconoma present in this area for fear of injury to the nerve. Patients not only suffer from physical deformity but also have psychological embarrassment with withdrawal behaviors. Informed consent of sacrifice of both frontal nerves was obtained from the patients. Radical resection of the temporal siliconoma combined with adjuvant face lift or liposuction with traditional tip-opened cannula was performed on seven cases. The results were quite satisfactory and the patients felt very happy.

Surgical treatment of the penoscrotal Paget's disease

Data from six cases of penoscrotal Pagets disease were collected. Erythematous, indurated, and pruritic skin lesions that failed to respond to the topical therapy were the main complaints. Symptoms had been observed for three to seven years before correct diagnosis. Extensive diagnostic studies revealed negative findings of subjacent adenocarcinoma, but 1 patient had concurrent skin cancer of nasal ala. In treating penoscrotal Pagets disease, our policy is to (1) resect 3 cm or more skin beyond the margin of the cutaneous lesion, (2) resect deeply to the subcutaneous fat, (3) use intraoperative frozen sections to confirm the free margin and (4) reconstruct the wound with the local iliac flap. No local recurrence was noted during the follow-up period of two to seven years. The iliac flap is thin and pliable; it precluded scar contracture and painful penile erection, which are the common sequelae of free skin graft in the penoscrotal area. Patients enjoyed normal sexual activity after surgery.