Kuei-Chang Hsu

Reliability of anatomical landmarks for skin perforators of the thoracodorsal artery perforator flap.

Background: The thoracodorsal artery perforator flap was first introduced in 1995. Many authors focused on using anatomical landmarks to identify skin perforators and on thinning procedures for a skin paddle. In this study, we used the superthin free thoracodorsal artery perforator flap for resurfacing shallow defects of the extremities in 10 patients. Methods: Two anatomical landmarks previously presented by other authors were used for the guidance of flap elevation. The first landmark represented the site of the proximal skin perforator originating from the descending branch of the thoracodorsal artery, and the second landmark marked the site of the thoracodorsal neurovascular hilum. Ten flaps were performed, and all skin perforators originated from the descending branch of the thoracodorsal artery. The skin paddle carried only skin and the superficial adipose layer, and the largest skin paddle was 23 × 9 cm. Results: All defects were resurfaced with smooth contour, except for one flap in which the authors encountered flap tip superficial necrosis. The operative findings did not coincide with the first anatomical landmark in five patients. Likewise, these findings were not consistent with the second landmark in eight patients. In four patients, the thoracodorsal neurovascular hilum was located at the same level of the scapular tip or even above it. These unwanted anatomical variations increased the difficulty of exploration for skin perforators. Conclusions: The thoracodorsal artery perforator flap is a feasible choice for shallow defects in superthin form. Using a color Doppler device to identify the skin perforators preoperatively is highly suggested to prevent unexpected anatomical variations.

Different types of suprafascial courses in thoracodorsal artery skin perforators.

Background: The thoracodorsal artery perforator flap is a versatile flap for resurfacing soft-tissue defects. However, it is too bulky for resurfacing shallow defects. The authors used preoperative color Doppler sonography to identify the suprafascial courses of skin perforators to facilitate the design and thinning procedures of thoracodorsal artery perforator flaps. Methods: Thin thoracodorsal artery perforator flaps were designed in 29 patients. Preoperative color Doppler sonography was used to identify the penetrating points and suprafascial courses of skin perforators. According to the different orientations of suprafascial courses, skin perforators could be classified into three types. The designs and thinning procedures of flaps relied on the findings of preoperative color Doppler sonography. Results: Fifty-eight ideal perforators were marked on the 29 patients. Intraoperative dissections proved that 55 perforators were thoracodorsal artery skin perforators, and three perforators were intercostal artery perforators. In one patient, no skin perforator derived from the descending branch of the thoracodorsal artery was found during intraoperative dissection (3.4 percent). Suprafascial courses could be demonstrated by preoperative color Doppler sonography in 54 of the 55 thoracodorsal artery skin perforators. Nineteen were type 1 perforators (35.2 percent), 26 were type 2 perforators (48.1 percent), and nine were type 3 perforators (16.7 percent). Complications were encountered in six patients (20.7 percent), all of whom recovered well. Conclusions: The suprafascial courses of skin perforators facilitate the design and thinning procedures of thoracodorsal artery perforator flaps. They improve the survivability of flaps and make thinning procedures more secure and efficient.

Sensate thoracodorsal artery perforator flap: a focus on its preoperative design and harvesting technique.

Background: Free sensate thoracodorsal artery perforator flaps that include the posterior divisions of the lateral cutaneous branches of the intercostal nerves have been described. The authors used preoperative color Doppler sonography to identify the nerves and demonstrate its clinical value. Methods: Fourteen free sensate thoracodorsal artery perforator flaps were collected. Preoperative color Doppler sonography was used to identify the locations of thoracodorsal artery perforators and the courses of the posterior divisions of the lateral cutaneous branches of the intercostal neurovascular bundles. These posterior divisions were preserved on flaps and classified into three types. Type A and B nerves sprouted cutaneous perforating fascicles over the lateral region of the latissimus dorsi muscle. Type C nerves went through the region without any dominant perforating fascicle. Results: Twenty-one nerves were mapped, and 24 were found during surgery. The sensitivity of preoperative color Doppler sonography was 87.5 percent. Of the 24 nerves, nine were type A (37.5 percent), 12 were type B (50 percent), and three were type C (12.5 percent). Ten of the 14 patients (sensate group) showed better tactile recovery at both the center and the periphery of flap than the other 10 patients who underwent reconstruction with nonsensate flaps. Conclusions: Preoperative color Doppler sonography is an indispensable tool for sensate thoracodorsal artery perforator flaps in locating the perforators and mapping the posterior divisions of the lateral cutaneous branches of the intercostal nerves. The information can be used to design and harvest sensate thoracodorsal artery perforator flaps, which are associated with earlier and better tactile recovery.

Contributing Factors for Complications and Outcomes in Patients With Snakebite: Experience in a Medical Center in Southern Taiwan

Objectives Snakebite usually results in various complications, such as significant soft tissue damage, infection, hematological, and neurological deficit. Surgical intervention, usually, is indicated in patients with tissue necrosis, infection, and compartment syndrome. To identify the contributing factors for complications and outcomes in different patients with snakebite so that outcomes can be evaluated and treatment of such patients can be initiated at the earliest. Methods Information was collected regarding age, sex, underlying disease, species of snake, and the course of treatment of the victims of snakebite who visited the emergency department of a medical center in southern Taiwan between 2004 and 2014. The data obtained were analyzed using SPSS 20.0. Results The bites from Taiwan cobra (Naja naja atra) significantly resulted in more complications than those from other snakes and required surgical intervention. The use of antivenin and antibiotics, immediate presentation to the hospital, and the location of the bite also were significant contributing factors. Conclusions Taiwan cobra significantly results in higher possibility of prolonged hospitalization, operation, tissue necrosis, infection, and necrotizing fasciitis. Location of the bite, immediate presentation to the hospital, and use of antivenin and antibiotics affect the outcome of snakebite. Knowledge of these factors will help in a better management of patients with snakebite.

High risk of rhabdomyolysis and acute kidney injury after traumatic limb compartment syndrome.

PurposeRhabdomyolysis often occurs after traumatic compartment syndrome, and high morbidity and mortality have been reported with the acute kidney injury that develops subsequently. We focused on the risk factors for rhabdomyolysis and acute kidney injury in patients with traumatic compartment syndrome. We also analyzed the relation between renal function and rhabdomyolysis in these patients. Materials and MethodsA retrospective chart review was conducted from January 2006 to March 2012. Inpatients with traumatic compartment syndrome were included. We evaluated patients’ demographics, history of illicit drugs use or alcohol consumption, mechanism of injury, symptoms, serum creatine kinase levels, and kidney function. ResultsA total of 52 patients with a mean age of 40.9 years were included; 23 patients had rhabdomyolysis (44.2%), of which 9 patients developed acute kidney injury (39.1%). Significant predictive factors for rhabdomyolysis were history of illicit drugs or alcohol use (P = 0.039; odds ratio, 5.91) and ischemic injury (P = 0.005). We found a moderate correlation between serum creatine kinase levels and serum creatinine levels (R = 0.57; P < 0.0001). The correlation coefficient (R) between serum creatine kinase levels and the estimated creatinine clearance rate was −0.45. Rhabdomyolysis was a predisposing factor for acute kidney injury (P = 0.011; odds ratio, 8.68). Four patients with rhabdomyolysis required a short period of renal replacement therapy. ConclusionA high percentage of patients with traumatic compartment syndrome developed rhabdomyolysis (44.2%). Patients with rhabdomyolysis had a higher possibility of developing acute kidney injury (39.1%), and rhabdomyolysis was correlated to renal function. Early diagnosis, frequent monitoring, and aggressive treatment are suggested once compartment syndrome is suspected. The overall prognosis is good with early diagnosis and proper treatment.

Spontaneous Extensor Tendon Rupture in the Rheumatoid Wrist: Risk Factors and Preventive Role of Extended Tenosynovectomy.

ObjectiveSpontaneous extensor tendon rupture is often seen in rheumatoid arthritis (RA) patients, but the risk factors are not clearly defined. We therefore collected the data of RA patients with previous extensor tendon rupture and those with tenosynovitis and analyzed the relationship between extended tenosynovectomy and spontaneous extensor tendon rupture. MethodsWe retrospectively reviewed 17 spontaneous extensor tendon rupture episodes in 15 RA patients and 14 tenosynovitis episodes that required tenosynovectomy in 12 RA patients from 1997 to 2013. Correlations between the incidence of tendon rupture, X-ray findings, and clinical findings in the affected wrists before tendon rupture were analyzed statistically using the test for proportion. ResultsThe following parameters were significantly correlated with spontaneous extensor tendon rupture: disease duration longer than 8 years, persistent tenosynovitis longer than 1 year duration, and Larsen grade greater than 4 (P = 0.02, 0.03, and 0.01, respectively). Dislocation of the distal end of the ulna, carpal collapse, and the scallop sign on X-ray contributed to a higher spontaneous extensor tendon rupture rate among RA patients (P = 0.01, 0.05, and 0.03, respectively). Extended tenosynovectomy was performed on 14 wrists in 12 RA patients with persistent tenosynovitis longer than 6 months, and Larsen grade did not deteriorate in this group compared with those who did not undergo the surgery. No spontaneous extensor tendon rupture occurred following the surgery. ConclusionsRisk factors of spontaneous extensor tendon rupture included disease duration longer than 8 years, persistent tenosynovitis longer than 1 year, and wrist Larsen grade greater than 4. Dislocation of the distal end of the ulna, carpal collapse, and the scallop sign on X-ray indicated a higher probability of extensor tendon rupture. Rheumatologists should consult with hand surgeons promptly to preserve hand function before tendon rupture. Prophylactic extended tenosynovectomy surgery to prevent more severe damage of extensor tendon should be recommended in patients who had the above risk factors.

The Factors of Postoperative Tumor Recurrence and Associated Strategies for Diagnosis and Treatment in Kimura Disease-A Study of 19 Cases and Review of Literatures

Background: Kimura disease is a rare and benign inflammatory lesion which mainly involves the head and neck region of middle-aged Asian males. The tendency to recur remains the leading problem in current treatments. However, the information about the factors of the postoperative tumor recurrence is few in the literatures while the treatment options based on those factors are even fewer. Aims and objectives: To define the factors related to the postoperative tumor recurrence of Kimura disease, and establish the strategy of diagnosis and treatment. Materials and methods: Nineteen patients with Kimura disease were enrolled between January 2000 and January 2012. The relationship between postoperative tumor recurrence and the parameters of disease (age, gender, locations, tumor size, serum eosinophil levels, nephropathy, lymphadenopathy, onset of disease to surgical treatment) were analyzed by logistic regression, linear regression and Fishers exact test.Results: The tumor size (＞6cm in diameter) and serum eosinophil level (≧48%) are two factors related to the increase of postoperative tumor recurrence in Kimura disease (p=0.039 and p=0.038, respectively). A linear relation between the eosinophil level and the tumor size is found (p＜0.001). Younger patients (≦30 years) have higher incidence to develop multifocal lesions (p=0.017). Conclusions: The tumor size and the serum eosinophil level are significantly related to the increase of postoperative tumor recurrence in Kimura disease. Younger patients less than 30 years are prone to develop multifocal lesions. A flowchart according to our findings is presented to improve the diagnosis and management of Kimura disease. (J Taiwan Soc of Plast Surg 2012;21:180~187)

Fibroma of Tendon Sheath in the Hand-Experience of 12 Cases at Kaohsiung Veterans General Hospital

Background:Fibroma of tendon sheath is a rare benign tumor and tends to involve upper extremities, especially in the hand. To our knowledge, treatment with marginal excision biopsy was always thought to be curative with low tumor recurrent rate. More specially, large tumor size fibroma of tendon sheath in the hand was especially rare and seen in case reports only.Aim and Objectives:We try to find out the characteristic of fibroma of tendon sheath in the hand at Kaohsiung Veterans General Hospital (KSVGH) and shared a rare case presented with large tumor size in our series (case 1).Materials and Methods:From January 1991 to March 2007, 12 cases with fibroma of tendon sheath in the hand at KSVGH were collected with a retrospective method. The data of patients collected included gender, age, symptoms, trauma history, outpatient or admission division treatment, location of tumor, preoperative image study, treatment modalities, gross appearance, tumor size, follow-up period, and recurrence.Results:Among these 12 cases, 11 cases underwent marginal excision biopsy at our outpatient division and only 1 case admitted for marginal excision biopsy due to large tumor size with possibility of malignancy. 5 cases received pre-operative image study and the other 7 cases didn’t receive any pre-operative image study. No patient was found to have tumor recurrence or surgical complication during postoperative follow-up. The ratio of male to female is 2 to 1 with male predominant tendency. The average age is 45 years old (M: 46 and F: 44). The tumor distributed over digit in 6 cases, palm in 3 cases, wrist in 2 cases, interdigital web in 1 case. No predilection of right or left hand was found. The average tumor size was 1.5 cm in greatest dimension. One case with large tumor size: 5.4 x 3.8 x 2.6 cm was noted.Conclusion:We found that in most cases (91.7%) presented with small tumor size and the marginal excision biopsy can be completed at outpatient division. In one rare case (8.3%), due to large tumor size and possibility of malignancy, admission surgery may be needed. No tumor recurrence was found in our 9 available follow-up cases. The tumor is characterized with male predominant and digit is the most popular site. Fibroma of tendon sheath was rarely associated with bone erosion, which was common in giant cell tumor of tendon sheath. Preoperative image study is highly suggested, especially in those with large tumor, not only to differentiate fibroma of tendon sheath (FTS) with giant cell tumor of tendon sheath (GCTTS) but also to prevent intraoperative neurovascular and adjacent structures damages. (J Taiwan Soc of Plast Surg 2011; 20: 274∼287)

Oromandibular Reconstruction with a Single Double-Paddle Fibular Osteomyocutaneous Flap for an Advanced Double Oral Cancer

Background: Reconstruction of the composite defects after advanced oral cancer surgery is a real task for most plastic surgeons. Controversy still exists about the optimal method for such anatomic defects. Aim and Objectives: We report our experience of using a single free double-paddle fibular osteomyocutaneous flap to simultaneously reconstruct gingiva, tongue, and mandible defects following wide excision for double oral cancer. Materials and Methods: A 51-year-old man had been diagnosed for a double oral cancer with right mandible and left tongue invasion. Wide resection of the tumors resulted in defects over left side of tongue, right lower gingiva, and nearly total loss of right hemi-mandible. We designed a single free double-paddle fibular osteomyocutaneous flap to reconstruct these defects without other additional flap. Result: The patient had well postoperative recovery and gained exciting functional and cosmetic outcomes. Conclusion: Double-paddle fibular flap composed of two separate cutaneous paddles, muscle and bone is an ideal option for oromandibular reconstruction with low donor site morbidity, and results in good postoperative functional and cosmetic outcome.

First Branchial Cleft Cyst in a Child

In pediatric group, periauricular cysts occur commonly. They can exhibit as auriculobracnchial cysts, fistula or abscess clinically. Among them, origin from first branchial cleft cysts is rare and account for 1% of all branchial anomalies. They are ready to be identified in well-experience otologists or pediatric surgeons. Occasionally, plastic surgeons may meet the cases that will be mistaken as epidermoid cysts. Here, we address one to remind the situation. A 4-year-old girl was referred from local otologist to our clinic division due to persistent right posterior auricular swelling and drainage for years. No positive family or medical history was revealed except a small cyst found after her birth. Discharge became dominant in recent weeks. Over local clinic, no associated inner or middle ear anomaly was detected on examination so that surgical interventions were tried for times, which was not successfully. So, we arranged excision of first branchial cleft cyst and pathologic result confirmed the diagnosis. One and half year later, antecedent upper airway infection occurred and local condition relapsed. Image was checked and it confirmed the recurrence over previous wound site but more deepen-located. Surgical excision was performed again smoothly. Branchial anomalies are important lesions in different diagnosis of head and neck masses in children. During embryogenesis, incomplete closure of branchial cleft and pouch or failure of obliteration of cervical sinus attributes formation. Work classified first branchial anomalies into two groups by anatomy and location. Diagnosis of branchial cleft cyst will depends on clinical signs and highly suggestive the lesion location. Sometimes, the laboratory studies can be used to exclude neoplasm and infectious diseases. MRI image is important in diagnosis, which can show the extent of the lesion and its relationship to adjacent vital structures. Surgical excisions are mainstreams of therapy whether Type Ⅰ or Type Ⅱ after otologic survey. For a plastic surgeon, branchial anomalies may be a challenge disease. After otological survey and exclude some associated systemic anomalies, we will preserve vital structures and make adequate excision. Its important and can ensure pleasing outcome.