Feng-Chou Tsai

Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures.

&NA; Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 × 2 cm to 26 × 5 cm (mean, 19.7 × 3.3 cm). The size of flaps ranged from 11 × 5 cm to 26 × 8 cm (mean, 21.3 × 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split‐thickness skin graft in two cases. At a mean follow‐up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one‐stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor‐site morbidity.

A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap.

Recent advances in concepts of preexpanded free flaps have made it possible to replace larger postburn contracture area. Free anterolateral thigh (ALT) cutaneous perforator flaps are popular due to constant, reliable anatomy and various clinical applications in our department. Combination of preexpansion, perforator-based prefabrication of tissue expansion and a free anterolateral thigh flap is first introduced and developed to resurface the large territory of postburn cervical contracture in a 33-year-old female patient with second to third degree flame burn with a 45% total body surface area (TBSA) involvement. The limited lateral flexion and rotation was noted despite aggressive rehabilitation for 6 months. The 650cm(3) kidney-shaped tissue expander was inserted around the myocutaneous perforator under the fascia via the midlateral thigh incision in first stage. Two months later right lateral neck scar (size=25cm x 13cm) was excised after serial clinic saline injection. The preexpanded free flap (size=29cm x 15cm) combined with z plasty and capsulectomy was harvested and covered in the contracture defect. A flap totally survived. One-staged resurfacing was achieved with immediate postoperative improvement. The hospital stay was 6 days. The donor site was closed primarily. After 6 months follow-up, the functional improvement was assessed as follows: an increase in rotation of 14 degrees (preoperative 74 degrees to postoperative 88 degrees ); and an increase in lateral flexion of 10 degrees (preoperative 30 degrees to postoperative 40 degrees ). The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles.

Use of the free vastus lateralis flap in skull base reconstruction.

&NA; Free flaps in skull base reconstruction are indicated for providing an effective separation of the intracranial cavity from the oronasal space, for eliminating a dead space, and for the treatment of established wound complications such as dural exposures and cerebrospinal fluid leaks. Seven patients with cranial base defects underwent reconstructions using a free vastus lateralis muscle flap. In two cases, a vastus lateralis flap was raised to incorporate the anterolateral thigh skin as a myocutaneous flap. In four cases, a free flap was indicated for reconstruction following tumor ablation, and in three cases, for the resolution of wound or cerebrospinal fluid leak complications following previous cranial base surgery. All flaps were successful, with no partial failures. In those patients undergoing tumor ablative surgery, the cranial cavity was effectively sealed from the oronasal cavity. Patients with established wound complications following previous cranial base surgery had a complete resolution of their symptoms. This report discusses the suitability of the vastus lateralis flap for skull base reconstruction in terms of the availability of adequate muscle volume to fill dead space, vascularized fascia to augment dural repairs, and the freedom to use skin if required for internal lining or external skin cover. This flap also provides an extremely long pedicle, allows simultaneous flap harvest, and has low donor site morbidity. (Plast. Reconstr. Surg. 111: 568, 2003.)

Electric water heaters: a new hazard for pediatric burns

The electric water heater has recently become a popular household appliance replacing the hot water dispensing jug. This device provides hot water and potable cool water directly from the faucets thus removing the need to refill the container or boil water separately in a kettle. Along with the convenience of dispensing hot water immediately has come an increased incidence of pediatric burns. This paper presents a 6-year retrospective study of such pediatric scald burns from 1996 to 2001. Computer database records revealed that the incidence of pediatric scald burns caused by the electric water heater during the past 6 years was 6.4% (66/1028). The age of victims ranged 0-6 years (mean 1.5+/-1.1 years), most of the victims were in the 1-2-year-old group. In most common cases burn location was the trunk. The accidents often occurred during the cold months and in the living room of the house. From this retrospective study, it was seen that the etiology and incidence of scald burns among children have changed as people have modified their household practice for obtaining hot water in our country. This study aims to increase public awareness to the problem and suggest some prevention measures to reduce this type of scald injury.

Double free flaps for reconstruction of postburn anterior cervical contractures—use of perforator flaps from the lateral circumflex femoral system

Anterior cervical contracture causes considerable problems including restricted range of motion and poor appearance. The reconstructive methods (skin grafs, Z-plasties and local flaps, etc.) have different limitations to their clinical application, and even recontracture that needs repeated surgical release [1–3]. Free flaps have the benefits of replacement for contracture scars with soft, pliable tissue [4–6]. This report presents a case of postburn cervical contractures reconstructed with an anterolateral thigh (ALT) and a tensor fascia lata (TFL) cutaneous perforator flap simultaneously. The combined use of these two flaps provides (1) one-stage procedure; (2) a larger skin territory for reconstruction; (3) primary closure of donor sites; (4) soft, pliable and thin tissues for resurfacing burn contractures; and (5) good aesthetic and functional results.

A Free Ultrathin Latissimus Dorsi Perforator Flap (LDPF) for Reconstruction of Soft Tissue Defect in the Hand

A free ultrathin latissimus dorsi perforator flap (LDPF) was first used to reconstruct the soft tissue defect in the hand at Chang Gung Memorial Hospital in Taiwan. A 60 year-old male patient with soft tissue defect over dorsum of right hand underwent microsurgical LDPF reconstruction. The size of this flap was 24×9 cm. The flap survived well. The hospital stay was 12 days. The donor site was closed primarily. At a mean follow-up of 4 months, no complication and donor site morbidity were found. LDPFs have the following advantages: (1) constant anatomy and thin thickness feature (2) the diameter of the pedicle compatible with that of the recipient vessels of the hands, (3) good color and aesthetic match to hand, (4) low donor site morbidity than conventional latissimus dorsi flaps, (5) achieving protective sensation without nerve anastomosis, (6) scar of donor site hidden in the clothes and, (7) two teams work well simultaneously. We conclude that LDPFs provide another option of free thin flaps for reconstruction of soft tissue defect in the hand.

Doughnut Excision for Difficult Scar Revision

A newly designed doughnut excision technique difficult scar revision was proved to be suitable and effective for those moderate-sized scar in pen- joint or high skin tension regions. In the initial stage, the eccentric scar tissue is excised, leaving some residual scar tissue in the central area. In the final stage, the residual scar is completely removed if necessary. The procedure has been utilized for fifteen cases and the results revealed the following advantages as compared to conventional fusiform excision method: 1) a shorter final scar length; 2) an avoidance of linear scarring and, therefore applicability to joint surface; 3) a shorter total treatment period because of more scar tissue removal in initial stage; 4) a more desirable, smooth final appearance, even if the final central scar is not removed, because of the non-linear scar.

Reconstruction of Post-burn Nail Fold Deformity with V-Y Advancement Flap

Post-burn scar contracture involving the dorsum of digits may cause eponychial retraction, proximal nail exposure, pain and impairment of distal phalangeal function. Longitudinal ridges, cracked surface and even fragile nail subjected to repeated breakdowns are common clinical presentations. From 1997 to 2000, there were 36 digits of 9 patients with significant post-burn nail fold deformities that required release of the contracture and nail bed reconstructions with V-Y advancement flaps. After follow up for more than 6 months, 31 digits of 7 patients had both good aesthetic and functional results of nail root reconstruction; the ridges on these nails also subsided. The satisfactory rate was 86%. Incomplete recovery, however, was found in 5 nails of 2 patients. These two patients had initial V-Y advancement performed on 7 digits each. For reconstructions of nail fold deformities secondary to burn injuries, contracture release combined with V-Y flap advancement provided a worthy alternative without sacrificing tissues from another donor site.

Burn Injuries during Pregnancy Case Studies and Literatures Review

Major burns during pregnancy present a significant challenge to burn care units, who must consider both fetal and maternal salvage and management. A 21 weeks pregnant woman suffered from second to third degree flame burns, covering 42% total body surface area (TBSA), specifically the face, trunk and upper extremity. The woman also had inhalation injuries. Burn wound debridement was preformed and tocolytics was given to control uterine contractions at the burn center of Chang Gung Memorial Hospital. The condition of the patient deteriorated further following treatment, with burn wound infection, sepsis and preterm labor all developing. The fetus was lost and the mother died on the 14 and 2lth days post-admission, respectively. This investigation inspired us to report this patient and reviewed the literatures over the recent last 20 years. Timely intervention and comprehensive evaluation should be applied in treating severely burned pregnant women. Termination of the pregnancy or supportive treatment without tocolytics agent may be preferable to aggressive tocolysis for these patients.

The Method of A Free Chimeric Anterolateral Thigh Flap (CALT) for Reconstruction of A Through and Through Defect of Buccal Cancer with Oral Commissure Involvement

Reconstruction of the through and through buccal cancer defect is difficult because of the three-dimensional loss of tissue. The various kinds of reconstruction including pedicled flaps can solve a limited number of problems, but still leave an aesthestic disability. Therefore there are a lot of advantages of free flaps, especially chimeric anterolateral thigh (ALT) flaps. In this paper, we describe the anatomy of the cutaneous perforators of the ALT flap, and the technical refinement to harvest CALT flaps, as well as the reconstruction of the mouth angle for through and through defects in the head and neck regions in detail. The size of through and through defect with oral commissure involvement was 5×14 cm^2 in this case. The size of flap larger than the defect was 6×16cm^2. The flap was separated to 6×10cm^2 proximally, and 6×6cm^2 distally for the cheek defect and the intra-oral lining according to the position of perforators. The recipient artery and vein was superior thyroid artery and a branch of internal jugular vein respectively. The vastus lateralis muscle and fascia was used for the restoration of cheek volume and mouth angle sling. The flap survived well postoperatively. In the clinical follow-up, the patient obtained adequate oral continence, deglutition and resumed a solid diet. The aesthetic result was acceptable after 6 months.