I- Chen

Robot-assisted free flap reconstruction of oropharyngeal cancer--a preliminary report.

BackgroundThe robotic surgical system provides a clear, magnified, 3-dimensional (3D) view as well as a precise and stable instrumental movement, which minimizes many technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. A preliminary result of transoral robot-assisted free flap reconstruction of oropharyngeal cancer is presented herein. Materials and MethodsBetween May and December 2013, the Da Vinci Surgical System (Da Vinci Si, Intuitive Surgical, Sunnyvale, CA) was used in 5 (4 men and 1 woman) cases of oropharyngeal reconstruction. Robot-assisted reconstruction was performed for inset of the flap and for performing a venous anastomosis of the free radial forearm fasciocutaneous flap. ResultsAll of the reconstructive surgeries were successful without flap failure or take-backs. There were no wound infections or fistulas. ConclusionThe application of a robotic surgical system seems to be a safe option in the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

Management of extremity neurilemmomas: clinical series and literature review.

BackgroundDelicate enucleation of neurilemmoma preserves most of nerve fascicles and causes minimal nerve function impairment. Accurate preoperative diagnosis of neurilemmoma is based on clinical findings and image studies. Materials and MethodsBetween November 2003 and February 2013, operations for the treatment of neurilemmoma were performed on 14 patients (12 men and 2 women) at our institution. The image studies in this series were collected. The tumor mass was approached by splitting the epineurium. In a few cases, enucleation of the neurilemmoma caused some fascicles loss, but reconstruction with sural nerve grafts preserved nerve function. ResultsBefore surgery, 7 patients received computed tomographic scan, 4 patients underwent magnetic resonance imaging, and 3 patients received sonography. Six patients presented with motor or sensory deficits immediately after tumor enucleation. Three patients recovered completely from the neurological defects with or without nerve reconstruction. ConclusionsOur results indicate that neurilemmoma can be removed by delicate enucleation with an acceptable risk of injury to the nerve trunk.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction

Background Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. Materials and Methods A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013–December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. Results This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. Conclusions There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

Preoperative Computed Tomography Angiography for Evaluation of Feasibility of Free Flaps in Difficult Reconstruction of Head and Neck.

BackgroundFree tissue transfer has been advocated for anatomic and functional reconstruction of soft tissue defects after surgical removal of an extensive recurrent tumor and/or arising from previous irradiation in the head and neck. We report a case series of difficult reconstruction in the head and neck in which preoperative computed tomography (CT) angiography was utilized to evaluate the feasibility of free flap reconstruction. The preoperative radiological evaluation was performed to determine the availability of reliable vessels for anastomosis in free flap reconstruction. If none was found, regional pedicle flap or palliative treatment was applied instead. The use of CT angiography allows the clinical surgeon to perform precise surgical planning with greater confidence. This may improve surgical results, thereby potentially reducing perioperative morbidity. MethodsTwenty CT angiograms were obtained from 20 patients. All patients were men with a mean age of 57.2 years (range, 42–72 years) and were scheduled to undergo difficult reconstruction in the head and neck. All patients (20/20 [100%]) suffered from oral squamous cell carcinoma. They had all received extensive operations and radiation therapy. Eighteen patients (18/20 [90%]) had completed a course of perioperative irradiation. The CT angiography reports were used to perform detailed preoperative surgical planning accordingly. The findings of CT angiography were classified into 3 groups: group I: normal CT angiography (patent recipient arteries) (Fig. 3); group II: abnormal CT angiography (recipient vessels were present but stenosis or atherosclerotic lesions were noted) (Fig. 4); group III: abnormal CT angiography with no patent recipient arteries in bilateral sides of the neck (Fig. 5); CT angiography results were correlated to the operative findings. ResultsThe patients were classified into 3 groups based on the angiographic findings. Six patients (6/20 [30%]) were assigned to group I, 8 patients (8/20 [40%]) to group II, and 6 patients (6/20 [30%]) to group III. In groups I and III, all patients (12/12 [100%]) underwent the treatment according to the original preoperative detailed planning. No flap failure was noted in these 2 groups. In group II, 4 patients’ recipient vessels (4/8 [50%]) possessed adequate blood flow intraoperatively; hence, microvascular free flaps were transplanted. Venous congestion in 1 case (1/4 [25%]) was noted. The remaining patients in this group (4/8 [50%]) underwent reconstruction with pedicle flaps rather than free flaps because of the lack of suitable target vessels intraoperatively. All flaps (4/4 [100%]) survived. Among the patients who were treated surgically, intraoperative findings were in accordance with those predicted by CT angiography. The total abnormality rate of CT angiography was 70%. Vascular abnormalities detected as a result of preoperative CT angiography led to changes in the operative plan in 50% (10/20) of the patients. ConclusionsThe use of CT angiography should be considered for difficult microsurgical reconstructions in the head and neck. When an abnormality in vascular anatomy is detected by CT angiography, the surgeon is advised to consider altering the operative plan accordingly. This allows precise operation, thereby maximizing the possibility of an optimal outcome. Changing the operative plan based on results of CT angiography may also help to avoid the difficult situation in which the surgeon finds that there are no suitable recipient vessels for free flap reconstruction during the operation. In addition, CT angiography enables surgeons to conduct the preoperative surgical planning with greater confidence, thereby potentially enhancing the success rate of difficult reconstructions in the head and neck, which in turn would tend to improve the perioperative course for the patient and consequently to improve results by decreasing vascular complication rates.

Spindle Cell Hemangioma-A Case Report and Literature Review

Background: Spindle cell hemangioma is a rare vascular lesion. The histopathologic findings of it resemble Kaposis sarcoma and hemangioma features. The recurrent rate after excision is up to 50%. Thus, spindle cell hemangioma was recognized as a ”low-grade angiosarcoma” in the past. Aim and Objectives:We report a case which brings attention to surgeons of the need to recognize spindle cell hemangioma because of the previous misunderstanding. We described the histopathologic finding and compared it with Kaposis sarcoma. We remind surgeons to avoid unnecessary treatments in the recurrent or multiple spindle cell hemangioma. Materials and Methods:A 48-year-old male noted multiple skin lesions over the right medial foot for several years. The largest lesion is a purplish nodule about 2 x 1.3 cm^2. A wide excision with 5 mm safe margin of this lesion was done in May 2010. The wound was closed directly. Results:The pathologic diagnosis is spindle cell hemangioma. The wound over the right foot healed well. There is no recurrence after the 11 months follow up.Conclusion:Clinically, spindle cell hemangioma is presented as multiple nodules involving the skin and subcutaneous tissue in the distal extremities. The main differential diagnosis of the spindle cell hemangioma is Kaposis sarcoma. An adequate treatment is by using the wide local excision. Radiation therapy should be avoided due to the potentiality of malignant change. Accurate diagnosis is critical in deciding what the most appropriate therapy is for the patients.

Digit Transposition in Reconstruction of Asymmetric Radial Polydactyly-Report of Three Cases

Background: Asymmetric type polydactyly usually cannot be easily classified or reconstructed. Ordinary reconstruction procedures may not satisfactorily preserve the joint stability, musculoskeletal function and thumb appearance. Aim and objectives: Here, we describe a digit transposition procedure used in three cases with unusual asymmetric polydactyly and discuss the indications and results of digit transposition.Materials and Methods:Three children (two boys and one girl) received digit transposition due to asymmetric type radial polydactyly. The mean age at reconstruction was 3.6 years (range, 3-4 years). The follow-up period ranged from one to five years. Results: All thumbs had a stable MCP joint and preserved musculoskeletal function for pinch. Besides, cosmetic outcomes were achieved. Conclusion: Digit transposition provides a stable joint, a functional thumb and cosmetic appearance for reconstruction of asymmetric radial polydactyly.

Extensor Tendon Rupture in Rheumatoid Arthritis-Surgical Strategies and Results

Background: Rupture of extensor tendons in rheumatoid arthritic hands results in extension lag of fingers and weakens grip power that affects the function of the involved hands. Surgical reconstruction of ruptured tendons should be aimed at both restoration of tendon motion and treatment local causative factors. Aim and Objectives: This study reports the results of surgical repair of extensor tendon rupture in rheumatoid hands using tendon graft, tendon transfer or combination of both techniques. The importance of treating wrist pathologies that cause tendon rupture is also emphasized. Patients and Methods: From October 2001 to May 2008, 15 rheumatoid arthritis patients presenting with spontaneous rupture of extensor tendons of the hands were referred from rheumatologist for surgical reconstruction. A total of 52 ruptured extensor tendons underwent surgical intervention in 17 hands of these 15 patients. The surgical techniques for repair of ruptured extensor tendons were categorized into three groups as tendon graft, tendon transfer, or a combination of both procedures. The range of motion at metacarpophalangeal (MCP) joints of involved fingers were recorded preoperatively and postoperatively. The results were graded by average net gain in range of motion of MCP joints at the end of follow-up. An average net gain of more than 30 degrees in MCP range of motion is classified as excellent result. A good indicates gain between 10 and 30 degrees. While a fair result is defined as less than 10 degrees in gain, a poor result indicates no improvement or even worse. Results: In the three groups of surgical interventions, there are 4 excellent and 3 good results in 9 primary tendon graft procedures, one excellent and 3 good results in 6 primary tendon transfer procedures, and one good result in 2 combined tendon graft and transfer procedures, five reconstruction procedures in the whole series were graded with fair to poor results due to re-rupture of tendon, adhesion, and failed medical control of rheumatoid disease. The extension lag at the MCP joint decreased from a preoperative mean of 54 degrees (range, 35 degrees-80 degrees) to a postoperative mean of 19.5 degrees (range, 5 degrees-65 degrees) in primary tendon graft procedures. The extension lag at the MCP joint decreased from a preoperative mean of 40.2 degrees (range, 0 degree-80 degrees) to a postoperative mean of 8.8 degrees (range, 0 degree-25 degrees) in primary tendon transfer procedures. The extension lag at the MCP joint decreased from a preoperative mean of 51.6 degrees (range, 40 degrees-68 degrees) to a postoperative mean of 37 degrees (range, 15 degrees-60 degrees) in combined tendon graft and transfer procedures. Also, a gross perforation on the dorsal capsule of the distal radioulnar joint (DRUJ) that causes attrition of the extensor tendons over the eroded bony surface was observed in all cases underwent simultaneous tendon reconstruction and wrist synovectomy procedures. 16 of 17 primary tendon reconstruction procedures were combined with dorsal wrist and DRUJ synovectomy, ulnar head debridement procedures, and capsule repair with retinacular flap. Conclusion: Extensor tendon reconstruction in the hand with tendon graft or tendon transfer provides a functional benefit for rheumatoid patients. Surgical intervention is aimed not only at restoring extensor function but also eradicating local causative factors and preventing further damage of tendon.

Micrografting in Major Burn Treatment-Experience of Taichung Veteran General Hospital

Background: The most difficult problem in major burn treatment is the lack of an autograft donor site. In 1958, Meek devised a technique that used widely expanded postage stamp autografts. Kreis modified Meeks technique in 1993 and called it ”micrograft”. Since then, the micrograft technique has been commonly used for patients with major burns. Aim and Objective: Generally, the scarring from micrografting is severer than that from traditional meshed graft. However, discussion in this concept is few in the past. In this study, we reviewed 10 cases of patients with major burn wounds and compared the quality of the scars from the two grafting techniques used. Materials and Methods: From Sept. 1999 to Sept. 2006, 10 patients received micrografting treatment in 15 separate operations in Taichung Veteran General Hospital. The mean age of these patients was 30.1 years (range: 19-47 years). The mean burn area was 67.8% TBSA (range: 24-90% TBSA). The expansion rate varied from 1:4 to 1:9. The mean follow up time was 25 months (range: 5-65 months). Results: To increase the graft survival rate and control infection in all our patients, we used three procedures: 1) expanded pre-folded gauzes were punctured several times before application, 2) the external dressing was changed on the first post-operation day, and 3) silver sulfadiazine was applied daily from the 7th post-operation day. In the 15 micrografting treatments, the mean area grafted per procedure was 1799±747.4 cm^2 (range 847-3810 cm^2). The mean graft survival rate was 82.6%. The mean number of dampened cork plates used was 16, and the mean cost of cork plates per operation was NT

Reconstruction of Traumatic Ear Loss with Prefabricated Radial Forearm Flap: A Case Report

32000. In the follow up periods, the mean Vancouver Scar Scale was 5.27±1.9 (range 3-8). The mean score of scar pain was 0.63±2.1. We also evaluated the scarring from the traditional meshed skin grafts at the same time in four patients. The mean Vancouver Scar Scale was 7±1.6 from meshed skin graft and 7±1.4 from micrograft. The mean pain score was 3.25±2.4 from meshed skin graft and 0 from micrograft. Conclusion: In the same patient with same condition of burn wounds, there was no obvious difference in scar severity between the micrograft and meshed graft.

Surgical Correction of Syndactyl Deformities of Hand and Feet in Epidermolysis Bullosa-A Case Report

Background: Reconstruction of total ear loss is a challenging task for most plastic surgeons due to the three-dimensional caritilage structure and thin intact skin coverage. In 2006, Chiang reported a method combining tissue expansion and prefabrication of forearm flap for a microtia patient with scarred temporal area and the result is excellent. We used similar method to reconstruction a patient with left ear traumatic loss. Aim and objectives: Many methods have been proposed for reconstruction of traumatic ear loss which depend on regional skin, temporopariental fascia and vessel condition. Due to severe injury of temporopariental fascia and superficial temporal artery, regional flap, ipslateral temporopariental fascia flap or contralateral temporopariental fascia free flap is not indicated in our case. Materials and Methods: We used combining tissue expander on forearm and prefabrication of radial forearm flap with sculptured cartilage ear framework, then later free transferred to reconstruct a patient with left ear traumatic loss. Reults: The patient had a satisfactory asthetic result at follow up 2 years later. Conclusion: This flap should be considered for post-traumatic ear reconstruction, where healthy regional skin, fascia and superficial temporal artery are not available.