Hsiang-Shun Shih

Prolongation of composite tissue allotransplant survival by treatment with bone marrow mesenchymal stem cells is correlated with T-cell regulation in a swine hind-limb model.

Background: Recently published reports indicate that treatment with mesenchymal stem cells combined with bone marrow transplantation could prolong survival after composite tissue allotransplantation. This study investigated whether bone marrow mesenchymal stem cells combined with irradiation and short-term immunosuppressant therapy, but without bone marrow transplantation, could prolong composite tissue allotransplantation survival. Correlation with regulatory T-cell populations was also evaluated in a swine hind-limb model. Methods: Heterotopic hind-limb transplantation was performed in outbred miniature swine. Group I (n = 4) was the untreated control. Group II (n = 3) received mesenchymal stem cells alone (on days –1, 3, 7, 14, and 21). Group III (n = 5) received cyclosporine A (on days 0 through 28). Group IV (n = 3) received irradiation (on day –1), mesenchymal stem cells (on days 1, 7, 14, and 21), and cyclosporine A (on days 0 to 28). Swine viability and signs of allograft rejection were monitored postoperatively. Histopathologic changes in allografts were examined. The expression and localization of CD4+/CD25+ and CD4+/FoxP3+ T cells were assessed using flow cytometry and immunohistochemistry. Results: Treatment with mesenchymal stem cells along with irradiation and cyclosporine A resulted in significant increases in allograft survival as compared with other groups (>120 days; p = 0.018). Histologic examination revealed the lowest degree of rejection in grafted skin and interstitial muscle layers in the mesenchymal stem cell/irradiation/cyclosporine A group. Flow cytometric analysis revealed a significant increase in the percentage of CD4+/CD25+ and CD4+/FoxP3+ T cells in both the blood and graft in the mesenchymal stem cell/irradiation/cyclosporine A group. Conclusion: These results suggest that prolonged survival after composite tissue allotransplantation induced by treatment with mesenchymal stem cells combined with irradiation/cyclosporine A is correlated with regulatory T cells.

Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site.

Background: The anterolateral thigh flap is commonly used for reconstruction of various soft-tissue defects. This article presents the authors’ approach to one-stage reconstruction of composite soft-tissue defects using an anterolateral thigh flap with a vascularized fascia lata. Methods: This retrospective review analyzed 973 patients who had undergone anterolateral thigh flap reconstruction for various soft-tissue defects over the past 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite anterolateral thigh flap combined with vascularized fascia lata. The fascia lata component of the flap was used for abdominal wall and fascial defect reconstruction in 12 patients, for lip-cheek defect reconstruction in 15 patients, for reconstruction of composite defects in extremities in nine patients, and for reconstruction of the perineum in one patient. Functional outcomes of donor sites were investigated by using a dynamometer. Results: All flaps except one survived. The overall flap survival rate was 97 percent. Patients achieved satisfactory results without major postoperative complications. The study revealed that vascularized fascia may mimic a fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency in quadriceps femoris muscles contraction in the donor thighs, no difficulties in daily ambulation were reported by the patients. Conclusions: The anterolateral thigh flap with vascularized fascia lata provides a reliable fascial component for single-stage reconstruction of complex soft-tissue defects.

Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation

Single flap for complex hypopharyngoesophageal and anterior neck skin defect reconstruction is still a challenge for reconstructive surgeons. Herein, we present five patients, with advanced hypopharyngeal cancer and anterior neck skin invasion, which received a single anterolateral thigh (ALT) fasciocutaneous flap for composite inner pharyngeal and outer skin defect reconstruction after wide composite resection. Two ALT flaps were divided into two distinct paddles supplied by two or more separate perforators, one part for reconstructing the inner pharyngeal defect and another for neck skin coverage. Three ALT flaps only supplied by one sizable perforator could not be divided and de‐epithelization of mid‐part had to be done to reconstruct both defects with the single flap. The results revealed survival of all flaps. There were no flap loss, fistulas, or bleeding complications. All patients recovered uneventfully and could eat a soft diet to regular diet postoperatively. In conclusion, one‐staged reconstruction of complex pharyngoesophageal and external skin defects after extensive oncological resection is feasible using a single ALT fasciocutaneous free flap.

Free fibula osteocutaneous flap with soleus muscle as a chimeric flap for reconstructing mandibular segmental defect after oral cancer ablation.

In some cases, the fibula osteocutaneous flap may not provide sufficient soft tissue for obliterating dead space after tumor ablation. This report describes a modified fibula osteocutaneous flap using a portion of soleus muscle to reduce postoperative complications. This study analyzed 20 patients who underwent ablative oral cancer surgery with mandibular segmental defect between September 2005 and June 2007. Of total, 17 cases were mandible complex defects and 3 were composite defects. Of total, 18 were men and 2 were women, respectively. Age range was 30 to74 years, and mean age was 53 years. The procedure entailed harvest of chimeric fibula flap with skin paddle and bone segment composed of a sheet of soleus muscle (7 × 4 to 12 × 5 cm in size) originating from the perforator branch of the peroneal artery. The soleus muscle was used to obliterate the dead space of the mouth floor and cheek-neck area. All flaps survived except 1 failure due to venous insufficiency. The submandibular and chin area exhibited mild swelling at the submandibular area early postoperatively. Patients had achieved satisfactory contour without donor site morbidity at a mean 12-months of follow-up. Complications included 2 flaps requiring reoperation due to the flap pedicle compromised. One flap was successfully salvaged but the other failed. Two cases of orocutaneous fistula-induced infection recovered after conservative treatment. Donor site assessment revealed a satisfactory outcome without major donor site morbidity. This refinement in mandibular reconstructive surgery substantially reduces postoperative complications.

Reconstruction of the skin defect of the knee using a reverse anterolateral thigh island flap: cases report.

A reverse anterolateral thigh island flap with the dimensions of 6 × 3, 15 × 6, and 26 × 8 cm, respectively, was elevated in 3 patients to repair the skin defects in the knee resulting from crush injuries. The pedicle of the flap was isolated in a retrograde fashion along the descending branch of the lateral circumflex femoral artery to obtain sufficient length until the pivot point was reached. The distal point of the defect to which the flap could reach for the reconstruction was 12 cm below the knee. All flaps survived, but skin necrosis occurred in the margins of those 2 large flaps. With a wide arc of rotation and sufficient skin paddle, the reverse anterolateral thigh island flap based on reverse flow is a good option for repairing skin defect around the knee; however, a staged or delayed operation might be considered in elevating a large flap.

Interdigitation of the distal anastomosis between tubed fasciocutaneous flap and cervical esophagus for stricture prevention.

Distal end circular stricture is a major complication following circumferential pharyngoesophageal reconstruction with tubed fasciocutaneous free flaps. To reduce the stricture rates, we have incorporated spatulation with interdigitation at the distal anastomosis site. This study investigated whether this procedure could decrease the stricture rate.

A "green" approach to secondary reconstruction: the concept of the recycle flap and a classification.

Background: Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option. Methods: Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years). Results: Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps. Conclusions: There are a number of ways to safely “recycle” the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Stair-step flap for secondary lower lip revision after lip and cheek composite defects reconstruction.

Free flap reconstruction is a common procedure for through‐and‐through lip and cheek complex defects after cancer ablation. However, oral incompetence with unacceptable bulky flap appearance invariably occurs and needs a secondary revisionary procedure. The purpose of this article was to present our method to improve the oral competence and cosmetic appearance by the stair‐step technique of flap revision.

Heterotopic Procedures in Mutilating Hand Injuries: A Synopsis of Essential Reconstructive Tools.

Background: In the complex and challenging treatment of a mutilating hand injury, any available resources need to be primarily recruited. Besides direct digital replantation, the tissue of the nonreplantable “spare parts” could often be “recycled,” and also some replantable or injured structures could be “redistributed” in a more functional individualized pattern, irrespective of their initial origin. Methods: Ten patients, six male and four female, were treated for multidigital mutilating injury with various “heterotopic” procedures. Immediate digital heterotopic replantations were performed in seven patients. In one case, the bone and skin of a nonreplantable digital part were used as grafts in the reconstruction of a metacarpal bone and the overlying skin defect. A neurovascular fillet flap from a nonreplantable finger for the reconstruction of the webspace and a pollicization of an injured index were undertaken in two further cases. Another patient underwent pedicled transfer of the proximal interphalangeal joint and metacarpal bone of an impaired index to the middle finger. Results: Sensate prehensile function was restored in 100 percent of the cases, and the ability for tripod pinch and more subtle tasks was restored in 90 percent. The minimum of two long fingers and a thumb was restored in every case, and the patients judged the appearance of their hands as “acceptable.” Conclusion: In the reconstruction of a mutilating hand injury, besides and beyond the straightforward microsurgery, the various heterotopic procedures are essential reconstructive tools that can enhance the versatility of the hand surgeon when pursuing a better outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Local 'free-style' perforator flaps in head and neck reconstruction: an update and a useful classification.

Background: Any standard skin flap of the body including a detectable or identified perforator at its axis can be safely designed and harvested in a free-style fashion. Methods: Fifty-six local free-style perforator flaps in the head and neck region, 33 primary and 23 recycle flaps, were performed in 53 patients. The authors introduced the term “recycle” to describe a perforator flap harvested within the borders of a previously transferred flap. A Doppler device was routinely used preoperatively for locating perforators in the area adjacent to a given defect. The final flap design and degree of mobilization were decided intraoperatively, depending on the location of the most suitable perforator and the ability to achieve primary closure of the donor site. Based on clinical experience, the authors suggest a useful classification of local free-style perforator flaps. Results: All primary and 20 of 23 recycle free-style perforator flaps survived completely, providing tension-free coverage and a pleasing final contour for patients. In the remaining three recycle cases, the skeletonization of the pedicle resulted in pedicle damage, because of surrounding postradiotherapy scarring and flap failure. All donor sites except one were closed primarily, and all of them healed without any complications. Conclusions: The free-style concept has significantly increased the potential and versatility of the standard local and recycled head and neck flap alternatives for moderate to large defects, providing a more robust, custom-made, tissue-sparing, and cosmetically superior outcome in a one-stage procedure, with minimal donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.