Kao-Ping Chang

An alternative dressing for skin graft immobilization: negative pressure dressing

The key difficulty of skin grafting is keeping the graft immobilized on uneven surfaces involved with motion, such as the nuchal area, axilla, web spaces, and the perineal area. This study reports the development of a new idea of negative pressure dressing (NPD) to maintain good immobilization of the skin graft and, at the same time, not cause any significant distress in the patients daily life. Furthermore, the components of this dressing are available in ordinary hospitals. In this report, there are eight cases of skin grafts which were applied by this method, and the average success rate was approximately 97%. Therefore, use of negative pressure dressings to safeguard immobilization of the skin graft is an appropriate alternative method for grafts on uneven or mobile surfaces.

Free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review.

The advent of free tissue transfer has offered several options that allow the restoration of both the structural and functional defects of the scalp and calvaria caused by malignant tumors or sequelae after trauma. This study aims to investigate the free flap options for complicated scalp and calvarial reconstructions.

Endoscopic excision of benign tumors in the forehead and brow.

Twenty-five cases of benign tumor of the forehead and brow were excised successfully with endoscope-assisted surgery. The access incision was selected strategically behind the front hairline. For tumors in the middle of the forehead, the tumor was approached by subgaleal dissection. For those in the brow or temporal area, the dissection plane was just superficial to the deep temporal fascia. Patient age ranged from 3 to 59 years. The mass varied in size from 1.0 × 0.5 to 2.0 × 2.0 cm. There were 18 lipomas, 6 dermoid cysts, and 1 pilomatricoma. There was no residual mass or recurrence 1 to 24 months postoperatively. There was no paresthesia or numbness in the scalp. Patients and their families were greatly satisfied with this operation and the absence of visible scarring.

Surgical treatment of the chronic tophaceous deformity in upper extremities - the shaving technique.

BACKGROUND Tophaceous gout is frequently directly related to the duration and the severity of hyperuricaemia. Conventional surgical debridement of the tophaceous lesions carries the risk of overlying skin necrosis. Life-long urate-lowering drugs have become the mainstay of primary treatment. However, surgical intervention may be necessary when the overlying skin becomes ulcerated and wound infection develops. This has become the impetus for new surgical treatment methods with less potential for morbidity. METHODS From November 2000 to July 2006, 32 patients with chronic tophaceous deposits involving their hands or elbows were treated surgically in our hospital. In this series, a soft tissue shaver device with a mini-incision technique was used to treat upper extremity tophaceous lesions. Multiple 5-mm skin incisions were made to allow direct access to the tophaceous mass. Intra-lesion shaving was done. A tourniquet aided reduction of intraoperative blood loss. Suction and irrigation were performed simultaneously while the shaver system was operating; the chalky deposits of sodium urate were thereby removed efficiently. RESULTS No major complications were noted among these 32 patients. Using this shaver technique, each tophaceous lesion was removed in less than 15 min. Twenty-nine of these operations (80.6%) were performed for patients at the intercritical gout phase. Two patients suffered a recurrent acute attack of gouty arthritis within 12h after the operation. Symptoms were controlled by oral colchicine as well as nonsteroidal anti-inflammatory drugs (NSAID). Swelling at the operative site was usually evident for the first 10 days postoperatively, therefore posture drainage is advised. CONCLUSION The shaver technique provides another option in the surgical treatment of tophaceous lesions. It prevents poor wound healing associated with tendon or joint exposure that often occurs after conventional enucleating procedures. The tophaceous lesions can be treated surgically at the intercritical gout phase. Also, the upper extremity group has a shorter hospitalisation period when compared with our preliminary study involving treatment of tophaceous deposits in the lower extremity. The shaver technique is worthy of consideration in the treatment of upper extremity chronic tophaceous patients.

The soft-tissue shaving procedure for deformity management of chronic tophaceous gout

Gout is a condition characterized by the deposition of monosodium urate crystals in the joints or soft tissue. A gouty tophus occasionally mimics an infectious or neoplastic process. However, the conventional enucleating procedure might cause complications. In severe cases, skin necrosis and tendon or joint exposure can occur after debridements. In this series, the soft-tissue shaver is used for deformity management of the chronic tophaceous patients and the results are encouraging. From November 2000 to August 2002, 17 patients with chronic tophaceous gout were treated by the shaver technique. Suction and irrigation were performed simultaneously while the shaver was operating, and chalky deposits of sodium urate could be removed efficiently. Skin necrosis was minimized by means of proper incision planning. Also, bedside debridements and wound wet dressing were helpful for improving the outcomes. The families and patients were satisfied with the results. In conclusion, severe chronic tophaceous gout can be a surgical challenge. The soft-tissue shaving technique can be useful for cosmetic debulking of large tophi in patients with advanced chronic tophaceous gouty arthritis.

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).

Endoscope-assisted parotidectomy for benign parotid tumors.

&NA; Sixteen cases of parotidectomy of benign tumors were performed by means of a short incision with the assistance of endoscopic surgery. The average length of the preauricular and retromandibular incision was 6.9 cm (range, 6.0‐8.1 cm). This incision provided safe dissection of the facial nerve trunk and exposed a major part of the gland to direct vision. Identification and separation of the facial nerve branches in peripheral glandular tissue was performed by means of endoscopic surgery instead of wide exposure with a long incision. Because endoscopic surgery provided good illumination and magnification on the monitor, the operation could proceed clearly and sharply in a bloodless field. Therefore, the incidence of facial nerve injury and perioperative morbidity was minimized. In this series, tumors were removed completely, without injury to the facial nerve. Patients were also satisfied with the short and inconspicuous postoperative scars. Lin S‐D, Tsai C‐C, Lai C‐S, Lee S‐S, Change K‐P. Endoscope‐assisted parotidectomy for benign parotid tumors. Ann Plast Surg 2000;45:269‐273

MANAGEMENT OF POISONOUS SNAKE BITES IN SOUTHERN TAIWAN

Snake bite envenomation is not uncommon in Taiwan. This study focuses on the pattern of poisonous snake bites and their management in southern Taiwan over a 5‐year period. The case histories of 37 patients with poisonous snake bites admitted to the Kaohsiung Medical University Hospital between June 2001 and July 2005 were analyzed retrospectively. Three patients, bitten by unknown species of venomous snakes, were excluded from this study. The frequency of snake bites from each species of snake, the local and systemic manifestations of snake bite, treatment of complications and final outcomes were analyzed. Of the remaining 34 patients, 11 (32.4%) were bitten by bamboo vipers, 10 (29.4%) by Russells pit vipers, 8 (23.5%) by Taiwan cobras and 5 (14.7%) by Taiwan Habu. The majority of snake bites (28) occurred between May and November. Those affected were mainly outdoor hikers (14) and workers (9). The antivenin requirements for treatment in the emergency room were in accordance with standard procedures. No mortality was noted among those envenomed by poisonous snakes. Although poisonous snake bite is not a common life‐threatening emergency in the study area, we observed both an environmental risk and a seasonal incidence of snake bite. Keeping the varied clinical manifestations of snake bite in mind is important for effective management. Ready availability and appropriate use of antivenin, close monitoring of patients, institution of ventilatory support and early referral to a larger hospital when required, all help reduce mortality.

Clinical Experience of a Microvascular Venous Coupler Device in Free Tissue Transfers

Most free flap failures result from technical problems in performing vascular anastomoses, such as endothelial intima lacerations, distortion of the vessels, and unequal intersuture distances. These incorrect practices can lead to thrombosis formation and, ultimately, flap failure. Solving this problem is a challenging issue for all micro‐reconstructive surgeons. In the last decade, a vascular anastomotic coupler instrument was developed and reported on. We review our recent experiences of free tissue transfer using this vascular coupler device, and discuss how venous problems can be overcome with its aid. We believe the excellent patency rate of the coupler may minimize the well‐described problems of venous thrombosis in the challenging field of free tissue reconstructions.

Autologous fat grafting alleviates burn-induced neuropathic pain in rats.

Background: The management of neuropathic pain after burn injury is a critical clinical issue. Autologous fat grafting has been shown to alleviate neuropathic pain in certain cases, but has not been shown to alleviate the pain associated with burn-induced scars. The authors assessed the effectiveness of autologous fat grafting for the management of pain in burn-induced scars. Methods: One paw of the experimental rats received a third-degree burn using a heated metal block. Neuropathic pain in the affected paw was assessed based on behavioral responses to thermal and mechanical stimuli. A graft (0.4 ml of autologous fat or a sham graft) was administered by injection to the burn scar and sham-burned paw. The animals were killed 4 weeks after the fat graft treatments; Masson trichrome stain of hind-paw skin and expression of phosphorylated p38 and OX42 in the dorsal horns of the spinal cords were examined. Result: The third-degree burns were completely healed at 4 weeks. Burn-induced scarring caused mechanical allodynia and increased the expression of phosphorylated p38 and OX42 in spinal cord dorsal horn microglial cells. Autologous fat grafting significantly alleviated mechanical allodynia (p < 0.05), and immunohistochemistry showed that the expression of phosphorylated p38 and OX42 was significantly lower in spinal cord dorsal horn microglial cells 4 weeks after fat grafting (p < 0.05). Conclusions: Autologous fat grafting is used daily in clinical practice. It is an effective treatment for the relief of burn-induced mechanical allodynia in rats. Further investigation of the clinical use of autologous fat grafting in burn patients is warranted.