Jing-Wei Lee

Distally based anterolateral thigh flap: an anatomic and clinical study.

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 × 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 ± 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.

Mandibular Defect Reconstruction with the Help of Mirror Imaging Coupled with Laser Stereolithographic Modeling Technique

With the advent of microsurgery, composite defect in the mandible can be repaired with various forms of osteocutaneous free flaps. However, it is difficult to accurately reconstruct a large defect in the mandible when not enough mandibular reference blueprints remain. This case report describes a large ameloblastoma at the left lower molar region and ascending ramus of the mandible in a 53-year-old male patient. Before surgery, spiral computed tomography scanning of the whole skull of the patient was performed. Using three-dimensional reconstruction and mirror imaging coupled with laser stereolithographic technique, a complete mandibular biomodel with idealized shape was fabricated. A titanium reconstruction plate was made using the biomodel as a guide. The tumor mass together with the left mandible from the second premolar to the condylar head area was resected en bloc. The large mandibular defect was then reconstructed with the precontoured titanium plate and three segments of vascularized fibular bone graft fixed along the plate. The temporomandibular joint was restored with temporal is muscle as an interpositional disc replacement. The complex defect in the mandible was thus repaired with satisfactory functioning and esthetic result. We suggest that with the help of mirror imaging coupled with laser stereolithographic technique, a precontoured titanium plate can be made for the reconstruction of large mandibular defects.

Treatment of enophthalmos using corrective osteotomy with concomitant cartilage-graft implantation

Post-traumatic enophthalmos is a relatively common problem following orbitozygomatic fractures. Bony-volume expansion and soft-tissue atrophication are considered the main aetiological causes of this condition. Although most surgeons are familiar with the treatment principles in this field, inadequate long-term results are frequently observed. The cardinal reason is due to overt volume deficits, owing to suboptimal reduction and the ever-existing problem of soft-tissue atrophy. As such, it seemed logical that some treatment steps should be incorporated to increase the volume of orbital tissue. However, making fine adjustments to soft-tissue volume and orbital size during the same actual surgery is extremely difficult, if not impossible, which constitutes the biggest challenge in the treatment of enophthalmos. Based on the experiences from the management of seven patients with chronic enophthalmos (Group II), we could ascertain the average amount of the volume supplement required and were motivated to exploit a novel protocol of one-stage treatment for correction of disfiguring enophthalmos. In addition to the standard fracture-reduction methods, we use autologous, diced-cartilage graft to augment the orbital-tissue volume concomitantly for six consecutive patients (Group I) from 2004 to 2008. The actual quantities of inserted cartilage measured from 3.0 to 5.5ml in total. An aesthetically and functionally satisfactory result is attained in every case thus treated, with only one patient exhibiting a minor degree of overcorrection (1mm exorbitism). We thus advocate that this strategy is a viable option for preventing or rectifying late enophthalmos following severe orbitozygomatic fractures.

Structure, properties and animal study of a calcium phosphate/calcium sulfate composite cement.

In-vitro and in-vivo studies have been conducted on an in-house-developed tetracalcium phosphate (TTCP)/dicalcium phosphate anhydrous (DCPA)/calcium sulfate hemihydrate (CSH)-derived composite cement. Unlike most commercial calcium-based cement pastes, the investigated cement paste can be directly injected into water and harden without dispersion. The viability value of cells incubated with a conditioned medium of cement extraction is >90% that of Al2O3 control and >80% that of blank medium. Histological examination reveals excellent bonding between host bone and cement without interposition of fibrous tissues. At 12 weeks-post implantation, significant remodeling activities are found and a new bone network is developed within the femoral defect. The 26-week samples show that the newly formed bone becomes more mature, while the interface between residual cement and the new bone appears less identifiable. Image analysis indicates that the resorption rate of the present cement is much higher than that of TTCP or TTCP/DCPA-derived cement under similar implantation conditions.

Secondary procedures following digital replantation and revascularisation

In this retrospective study, 79 digits of 55 patients received 102 secondary procedures following replantation. We divided the procedures into two groups, occurring before or after 2 months following replantation. The procedures in the early group were mainly for soft tissue coverage (92%), and those in that late group were mainly for tendon (67%) to improve function. Factors associated with higher incidence of early secondary procedures included multiple-finger injury, avulsion or degloving injury and level of injury proximal to zone III in finger replantation (p<0.05). However, younger patients and those with proximal level replantation in fingers had more late secondary procedures (p<0.05). Flexor tenolysis procedure significantly improved the digital function after replantation (p<0.05).

In-Vitro and In-Vivo Evaluation of a New Ti-15Mo-1Bi Alloy

The newly developed Ti-15Mo-1Bi alloy not only possesses all the desirable mechanical properties inherent to beta-Ti Mo alloys, but may even enjoy better clinical applicability with the addition of bismuth element, which has long been administered as antibacterial and antitumor medicines. A significantly higher viability of 3T3 cells was demonstrated when they were grown on Ti-15Mo-1Bi alloy than on Ti-15Mo and Ti-6Al-4V. Cells incubated in the medium conditioned by Bi powder at 37 degrees C for 96 h exhibited viability similar to that in the blank group and higher than that in the Ni conditioned group. In vivo experiments using 6 mm x 2 mm metal pin implanted into the epicondyle of rabbit femur revealed superior potential of new bone growth and better persistence of the deposited bony tissue with the Ti-15Mo-1Bi alloy in contrast to that with Ti-6Al-4V. The difference is evident at 12th week and become even more prominent after 26 weeks, with the new bone area measuring 249% of that around Ti-6Al-4V alloy. In summary, Ti-15Mo-1Bi alloys show no cytotoxicity in the in-vitro test and demonstrates superior ability to retain bone in the in-vivo implantation experiment as compared with Ti-6Al-4V alloys.

Distraction lengthening of a replanted digit.

The Ilizarov technique was used to lengthen a replanted middle finger on a musicians left hand. Bone consolidation was achieved in 6 months without the need for a bone graft. The elongated digit has good sensibility, appropriate stability, and sufficient length, which were essential for a good performance in her profession. The unique indication to apply the callus distraction technique in such a special condition was described, and the relative merits of other treatment alternatives were discussed.

One versus Two Venous Anastomoses in Anterolateral Thigh Flap Reconstruction after Oral Cancer Ablation.

Background: Whether one-vein or two-vein drainage yields better outcomes in anterolateral thigh flap reconstruction after oral cancer ablation is still being debated. Thus, the authors investigated this question. Methods: In this retrospective cohort study, the authors reviewed the charts of 321 patients with oral cancer who, between August of 2010 and July of 2014, had undergone ablative surgery and then immediate reconstruction with the anterolateral thigh flap. Patients who underwent simultaneous reconstruction with additional free flaps were excluded. The patients were subgrouped into newly diagnosed (n = 221) and previously treated (n = 100) groups and then subgrouped into one-vein and two-vein groups. Results: Overall, operative time was significantly longer (366.8 ± 112.7 minutes versus 336.3 ± 99.7 minutes; p = 0.009) and hospitalization was significantly shorter (22.0 ± 13.3 days versus 24.5 ± 13.8 days; p = 0.027) in the two-vein group. In the newly diagnosed two-vein group, operative time was also significantly longer (355.5 ± 91.7 minutes versus 319.9 ± 95.9 minutes; p = 0.008), anterolateral thigh flap take-backs for vascular compromise (3.2 percent versus 10.9 percent; p = 0.041) and venous congestion (1.1 percent versus 7.8 percent; p = 0.027) were fewer, and flap survival was greater (100 percent versus 95.3 percent; p = 0.041). Differences between the one-vein and two-vein previously treated subgroups were not significant. Conclusion: In newly diagnosed patients undergoing anterolateral thigh flap reconstruction after oral cancer ablation, better outcomes are achieved with two venous anastomoses rather than one. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Using a cross-cheek anterolateral thigh flap for simultaneous correction of trismus and oral cancer

Oral cancers in association with trismus are commonly seen in clinical practice. Such a situation deserves special attention as it may complicate the tumour-ablative surgery and interfere with postoperative cancer surveillance. It follows that the simultaneous tackling of oral cancer and trismus should be pursued at any rate. In this presentation, a novel surgical approach using a cross-cheek anterolateral thigh (ALT) flap is introduced. With the special design in length, shape and orientation, this flap is capable of closing a wider defect area, sometimes extending across two functional regions (viz., posterior palate and trigonal area) without resort to two free flaps. As such, complex defects resulting from trismus release and tumour ablation can be readily repaired in a single stage. The advantages of such a technique include abundance in soft-tissue resources, proper flap quality and thickness, reliable blood supply, long and sizeable pedicle, ease in flap inset, need for only one recipient rather than two and the eradication of large area of mucosa that is predisposed to malignant transformation. The favourable outcome implicates that this innovative design could be a viable option in the management of such a clinical problem.

Nasolacrimal duct reconstruction with nasal mucoperiosteal flap

Surgical repair of lacrimal drainage apparatus may be quite difficult in patients with maxillofacial injuries involving extensive structural damage. When the primary tear tract has become nonamendable or inaccessible, it would then be necessary to set up an alternate draining route for tear passage. Conjunctivorhinostomy with a Jones tube is an effective diversionary treatment method, and yet this procedure might be plagued with problems related to alloplastic device usage. Autologous tissue is therefore best suited for nasolacrimal conduit restoration. A superiorly based mucoperiosteal flap, 11 to 13 mm in width and 20 to 25 mm in vertical length, is mobilized from lateral nasal wall and fashioned into a tubelike conduit. This construct is then turned superior-laterally and connected to the conjunctival sac. The fistula tract thus formed has a sufficiently large caliber and is lined entirely with normal mucosal epithelium. Such a feature may exert a favorable influence upon the long-term patency of the tear passage. This approach is applied successfully in 3 consecutive patients of lacrimal system obstruction, one of whom even had experienced 2 failed attempts of Jones tube insertion beforehand. The tactics and experiences in managing these 3 cases form the basis of this report.