Ching-Hung Lai

Free medial plantar artery perforator flaps for the resurfacing of thumb defects.

Background:Destruction of the thumb secondary to trauma presents a much more significant influence on daily living than do injuries to the other digits. Various surgical techniques contribute to repair distal defects of the fingers, especially thumb reconstruction. Methods:Seven patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of their thumbs. The flaps can be harvested with or without the main trunk of the medial plantar artery. The perforator of the MPAP flap was anastomosed to a proper digital artery, and the superficial vein of the flap was anastomosed to the dermal vein of the injured finger. These thumbs had no severe length discrepancy or metacarpophalangeal joint injuries. All patients underwent examinations including static 2-point discrimination, moving 2-point discrimination, and Semmes-Weinstein Test Score 6 months after reconstructive surgery. All tests were carried out by the same occupational therapist 6 months after reconstructive surgery. Results:Five male and 2 female patients were selected for free MPAP flap reconstruction from May 2006 to September 2007. The mobility of the fingers was not restricted after surgery. Six flaps survived completely, and 1 flap partially failed because of venous congestion. Sensory restoration was ideal for all 7 MPAP flaps. Conclusion:The MPAP flap is a suitable choice for reconstructing palmar defects of the fingers, with less donor site morbidity. The cushiony character of the MPAP flap is anatomically similar to the pulp tissue of fingers, and sensory restoration is ideal compared with that of other reconstructive methods. Technical difficulty is focused on anastomosis of perforators (diameter ≤0.8 mm).

Medial epicanthoplasty based on anatomic variations

The presence of epicanthal folds is a unique appearance in the eyelids of Asians. Various medial epicanthoplasty techniques have been discussed to achieve a better aesthetic result. Owing to the complexity of the surgery, a design based on anatomic variations of the epicanthal fold is imperative. From September 2006 to November 2010, the author performed medial epicanthoplasty procedures on 86 Asian patients. The whole procedure, including discrepant Z skin incision, myotomy and the plication of the medial canthal ligament (MCL), was performed layer by layer. The inner canthal distance (ICD) was measured and calculated by software ImageJ before and 3 months after surgery. All patients were satisfied with the long-term results and there were no recurrences of the epicanthal fold. The shortening ratios of the ICD ranged from 7.2% to 13.7% (average 10.78%) in the group without the plication of the MCL (57/86). In addition, the ICD shortening ratio ranged from 9.1% to 17.7% (average 15.66%) in the group with the MCL plication (29/86). The technique we described is aimed to correct layered structures including skin, muscle and the MCL of the medial epicanthus. Satisfactory results were ideally achieved with finer scar and natural cosmetic appearance in this series.

Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure

BACKGROUND Bulkiness and unsightly scarring are the major complaints after oral cancer reconstruction with free flap transfer. Some debulking procedures, such as blunt-tipped cannula liposuction or staged excision, can result in some improvement, but these methods do not provide a one-stage procedure for flap thinning and scar revision due to the concern of flap ischemic change. All suction lipectomy methods were applied on flap resurfacing cases; no through-and-through defect case was used. The author used a nonstandard open-tip cannula for liposuction and w-plasty for scar revision in a one-stage operation in oral through-and-through defect cases. This method achieved excellent aesthetic results without complications. MATERIAL AND METHODS From January of 2004 to October of 2006, secondary debulking procedures were performed on 22 patients who had undergone reconstruction with free anterolateral thigh flaps. All flaps were on the cheek for oral cancer through-and-through defect reconstruction. Suction lipectomy with nonstandard open-tip cannula and w-plasty were performed. RESULTS All flaps survived well without any partial skin necrosis. Over 85% of patients were satisfied with the outcome. CONCLUSIONS This method can provide a one-stage debulking procedure for the cheek through-and-through defect after free flap reconstruction, and it achieves good aesthetic outcomes.

A new trend for the treatment of blepharoptosis: Frontalis-Orbicularis Oculi Muscle flap shortening technique

Operation techniques for blepharoptosis have been a great challenge for plastic surgeons. Complications and recurrence in conventional operations of eyelid ptosis cannot be neglected. The finding of the close linkage between the longitudinal-oriented frontalis muscle (FM) and the horizontal-orientated orbicularis oculi (OOM) muscle convinced us of the efficacy to develop the dynamic and powerful Frontalis-Orbicularis Oculi Muscle (FOOM) flap-shortening technique which corrects blepharoptosis with good biomechanics in place of the traditional frontalis muscle sling. From January 2003 to September 2007, the FOOM flap shortening technique was applied on 35 ptotic eyelids of 31 patients, age ranging from 18 year to 77 years. All FOOM flaps were harvested and adjusted depending on the severity of the blepharoptosis. The follow up period ranged from 5 to 55 months. Thirty eyelids had good results, with the degree of ptosis less than 2mm. There were only five recurrent ptotic eyelids due to technical undercorrection. The estimation of resected length is measured when the FOOM flap is fully stretched and the length is approximately 22.0-23.0 mm for mild cases, 23.0-24.0 mm for moderate cases, and 25.0-26.0 mm for severe blepharoptosis. The FOOM flap-shortening technique was developed and corrected blepharoptosis with good results compared to conventional operation techniques. It achieves antagonistic equilibrium with ideal biomechanics by debilitating eye-closing power and enhancing eye-opening power.

Forehead osteoma excision by endoscopic approach.

Six cases of frontal osteoma had been operated with assistance of endoscopic surgery. Patient age ranged from 34 to 59 years. The diameter of the masses varies from 8 to 14 mm. The access incision was hidden behind the frontal hairline and the dissection plane went in the subperiosteal layer. The injury of the nerve branch and vessel can be easily avoided and endorsed by manipulating the endoscope. The average length of the procedure was 59.5 minutes. There is no complication such as scalp sensation impairment or hematoma over the forehead or scalp area. The elimination of the forehead osteoma can be executed at the forehead area scarlessly by the assistance of the endoscopic-assisted surgery.

Alternative reconstruction of donor defect of free radial forearm flap in head and neck cancer

Abstract We report our method of restoration of the radial artery in the use of the anterolateral thigh (ALT) flap to overcome the important drawback of sacrificing the radial artery in cases of free radial forearm flap (FRFF), which is indicated for reconstruction of the tongue and other intraoral defects. There were 12 patients in our series, but only seven completed their postoperative evaluations. We harvested FRFF and ALT flaps simultaneously. The former was used for palatal or lip reconstruction and the latter was anastomosed as a flow-through flap to salvage the radial artery. All major donor site problems of the FRFF were solved by coverage by the ALT flap, except for abnormal sensation on the radial side of the donor hand. The FRFF is a proper choice for small tongue or lip defects. When it is chosen for its unique merits, the ALT flap can also serve as an alternative in reconstructing the donor site with least morbidity, including the restoration of patency to the radial artery.

Downregulation of Janus kinase 3 expression by small interfering RNA in rat composite tissue allotransplantation.

RNA interference (RNAi) has recently emerged as an efficient method to silence gene expression in mammalian cells by transfection of small interfering RNAs (siRNAs). The Janus kinase 3 (JAK3) is also pertinent to the development of a new immuno-suppressant. This study aimed to inhibit JAK3 expression using RNAi to determine allograft tolerance. To silence JAK3 expression, one dsRNA was tested to incorporate the JAK3 mRNA sequence. The expression vector containing the pre-mRNA expression cassette was transfected into rat basophilic leukemia cell line, RBL-2H3, for RNAi analysis (in vitro). The alloskin and composite tissue allograft were then transplanted to recipients using RNAi protocol to determine the allograft tolerance (in vivo). The results showed effective in vitro and in vivo downregulation of JAK3 expression by RNAi. Moreover, the histology of alloskin graft and composite tissue allograft (in vivo) under the siRNA showed more prominently diminished inflammatory infiltration than the control group. This is the first time in the literature that the suppressive effect of JAK3 silenced by siRNA has been tested both in vitro and in vivo, and shows that siRNA is capable of specific and functional silencing in allograft rejection.

Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap.

Abstract The pectoralis major myocutaneous pedicled flap (PMMPF) – the “workhorse” for head and neck reconstruction – is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.

Free Medial Plantar Artery Perforator (MPAP) Flap for the Resurfacing of Finger Defect-Report of Two Cases

Background: Finger destruction secondary to trauma represents a much more significant influence on the activity of daily living. Various surgical techniques contribute to cover the distal defect of the finger. Aim and Objectives: We would like to introduce a find-designed perforator skin flap to reconstruct the finger defects. Material and Method: Two patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of fingers. The flaps were harvested without interrupting the circulation of the medial plantar artery. The flap perforator was anastomosed to proper digital artery and the superficial vein of the MPAP flap was anastomosed to dermal vein of the injured finger which had no severe length discrepancy or metacarpophalangeal joint injury. Results: One male and one female patient were arranged for free MPAP flap reconstruction in March and August 2007. The mobility of the fingers was not restricted after surgery. One flap survived completely with no vascular compromise. Another flap encountered venous congestion and only partially failed (30% loss) after salvage. Conclusion: The MPAP flap is a suitable choice to reconstruct defect of the finger with less donor site morbidity. The cushiony characteristic of the MPAP flap is anatomically similar to the pulp tissue of fingers. Technical difficulty is focused on anastomosis of perforators (diameter≦ 0.8mm) and limited access of concomitant vein. With the many advantages of the MPAP flap, it is worthy of application to more reconstruction needs, particularly for finger defects.

Viper Russelli Formosensis Bite Induced Acute Renal Failure-A Case Report Aand Review of Literatures

Snakebite is sometimes a cause of acute renal failure (ARF), especially from Viper species. The incidence of Viper bite is the lowest among the six poisoned snakes in Taiwan. Furthermore, there is a high incidence of oliguric ARF after a viper bite in Taiwan. We would like to report a 62 year-old male presented with oliguric ARF following Daboia russelli formosensis (Viper russelli formosensis) bite. Investigation at the time of the patients arrival revealed hematuria, proteinuria, and prolonged coagulation parameters. Abnormal creatinin level was noted and rapidly increased to 2.5 mg/dL in 4 hours after admission. The patient got improved after antivenom infusion and th e oliguric ARF was corrected after hemodialysis and other supportive treatment. However, the cause of oliguric ARF after Daboia russelli formosensis bite could be a direct nephrotoxicity of systemic envenomation without DIC. Direct venom nephrotoxicity caused by venom of D. r. formosensis corresponds to the specific pathophysiological features of PLA2, which was different in degree and distinguished from those of other Asian countries. Suggestion has been made to pay more care to those snakebite victims when confirmed or even suspected from Viper species. Serum creatinin level is sufficient to detect ARF within one day in our case and related review in Taiwan.