Kwang-Yi Tung

Gluteal perforator flaps for coverage of pressure sores at various locations.

Management of pressure sores is one of the most formidable challenges confronting the reconstructive plastic surgeon. Traditionally, muscle and musculocutaneous flaps were used for the treatment of pressure sores. However, this clinical approach of using the “pressure dispersing” effects of muscle appears to conflict with certain experimental observations. In the 1960s, Kosiak1 and Keane2 demonstrated that muscle is more susceptible to the effects of pressure than either skin or subcutaneous tissue. Keane2 demonstrated that body weight is borne on superficial bony prominences covered only by skin and subcutaneous tissue, thus protecting muscle from the effects of ischemia. In normal weight-bearing positions over bony prominences, muscle is rarely interposed between bone and skin. When muscle and musculocutaneous flaps are used, the use of adjacent flaps is often obviated because of violation of vascular territories. Furthermore, muscle, and its function are sacrificed, which is especially important in ambulatory patients. In the late 1980s, Kroll and Rosenfield3 introduced the concept of perforator flaps. Perforator flaps, supplied by musculocutaneous perforators, obviate the need for muscle or musculocutaneous flaps, thus minimizing donor-site morbidity. These flaps have gained popularity during the past decade with their current application to pressure sore management by the authors. The rationale for the use of fasciocutaneous perforator flaps can be found in some of the earlier literature on flap physiology.1,2 Fasciocutaneous perforator flaps are durable, safe, and reliable; can be elevated in various locations; permit freedom in flap design; and are associated with low donor-site morbidity. The donor site can often be closed directly. Coşkunfırat and Özgentaş are to be congratulated for their impressive experience with 35 gluteal perforator flaps for coverage of 22 sacral, seven ischial, and six trochanteric pressure sores in 32 patients including 18 who were plegic and five who were bedridden. The authors report an excellent survival rate, with only one flap loss, two wound dehiscences treated by secondary closure, and only one recurrence during the 13.6-month follow-up period. These results are quite remarkable because the factors contributing to recurrence following surgery are often beyond the surgeon’s control. Soft-tissue integrity ultimately depends on the patient’s ability to restore blood flow following ischemia and the avoidance of prolonged pressure. Malnutrition, anemia, concomitant medical problems, shear forces, spasm, infection, and patient compliance are the major variables in the equation. Perhaps the most frustrating aspect of pressure sore management is the high incidence of recurrence, which tremendously increases medical costs and patient morbidity. The authors’ results are outstanding, especially when one considers their exceptionally low incidence of recurrence. Although the follow-up period is short, the recurrence rate is nevertheless the lowest of which I am aware for a similar series. In 1956, Conway and Griffith4 reported on 1000 ischial pressure sore patients, consisting predominantly of plegic and bed-dependent patients. Regardless of the type of treatment (surgical or nonsurgical), recurrence rates were 75 to 77 percent. In 1992, Disa et al.5 reported a 61 percent recurrence rate after

Fabrication of Vascularized Bone Grafts of Predetermined Shape with Hydroxyapatite-Collagen Gel Beads and Autogenous Mesenchymal Stem Cell Composites

BACKGROUND Advances in tissue-engineering techniques have enabled new procedures to be developed for bone regeneration. In this study, for engineering of structural tissues with supporting vascular networks, the authors attempted to produce vascularized tissue-engineered bone grafts using cultured mesenchymal stem cells/hydroxyapatite/collagen gel bead composites and vascular bundle implantation. METHODS Twenty-four New Zealand White rabbits underwent implantation of ringed polytetrafluoroethylene vascular grafts (1 x 3 cm) in the medial thigh with the femoral vascular bundle passing through. The polytetrafluoroethylene grafts were left unfilled (group A), filled with hydroxyapatite/collagen gel beads (group B), or filled with mesenchymal stem cells/hydroxyapatite/collagen gel bead composites (group C). At 4, 8, 12, and 16 weeks, the implants were removed and radiographic and histologic examinations were conducted. RESULTS Radiographic analysis revealed that the area of radiopacity within the chamber was highest in group C. The average calcified densities of groups B and C were between 0.99 +/- 0.11 and 1.29 +/- 0.14. Histologically, there was fibroadipose tissue within the chamber in group A. New tissue had grown into the matrix of the chambers of groups B and C, and substitution of the biomaterials was seen. Newly formed fibrovascular networks and osteoids were simultaneously seen. Bone marrow was observed in the vascular graft of group C 6 months after implantation. CONCLUSIONS Tissue-engineered vascularized bone grafts of predetermined shape were created with mesenchymal stem cell/hydroxyapatite/collagen gel bead composites. The results of this study showed that successful in vivo engineering of vascularized tissue-engineered bone grafts is possible.

Combined Free Vascularized Iliac Osteocutaneous Flap and Pedicled Pectoralis Major Myocutaneous Flap for Reconstruction of Anterior Chest Wall Full-Thickness Defect

Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone.

Treatment of intractable enterocutaneous fistula with an island pedicled anterolateral thigh flap in Crohn's disease – case report

Attempts to treat intractable enterocutaneous fistulae secondary to Crohns disease are challenging and have been associated with long delays. An island pedicled anterolateral thigh (ALT) flap has been shown to achieve adequate coverage of abdominal wall reconstruction. In this case, with the assistance of a well-vascularised flap and adequate medical supportive managements, the intractable enterocutaneous fistula was closed; it then healed progressively.

Treatment of posterior thigh radiation ulcer by a simple and easy technique of transferring island pedicled vastus lateralis muscle flap

Radiation injured tissue heals poorly and tension-free reconstruction should be performed at the time of ulcer excision since granulation tissue tends not to arise in irradiated beds. Typically, arterial-based flaps are the preferred means of reconstruction. These flaps fill the defects and their vascularity enhances local blood flow in the compromised wound beds. A 56 y/o male patient who suffered from a recurrent fibrosarcoma over right posterior thigh received wide resection (including sciatic nerve) on May 2003 and Nov 2005. He also received neoadjuvant chemotherapy and radiotherapy. After surgery, poor wound healing was noted inspite of multiple surgeries of secondary wound closure. On January 2007, he was transferred to our department due to a 7 3 cm recurrent radiation ulcer over right posterior thigh (Figure 1A). We performed the reconstruction after wide excision of all necrotic skin and soft tissue. The dissection and harvest of the vastus lateralis muscle flap was done as previous described in the literatures from anterior thigh. The muscle flap was harvested according to the dimensions of the defect and the pedicle was dissected free towards the origin of the lateral circumflex femoral artery (Figure 1B). Then, we created the passageway for the flap. The intermuscular space between the vastus intermedius and vastus medialis muscles was opened and further dissection was made to penetrate through the adductor muscles and to reach the defect. Then the muscle flap was transposed through the passageway to cover the defect (Figure 1C). The donor site was closed primarily and STSG was harvested from the anterior thigh to cover the muscle flap. The wound healed uneventful and no recurrence of the ulcer noted after one year (Figure 2).

One-Stage Reconstruction of Extensor Mechanism with Free Composite Anterolateral Thigh Flap and Vascularized Fascia Lata after Malignant Tumor Resection of Knee

Background: Combined loss of the extensor apparatus with overlying soft tissue at the level of the knee joint is a difficult challenge to the reconstructive surgeon. Traditionally, it can be achieved with staged operations. However, multiple-stage reconstructions are time-consuming and costly, and the results are usually not satisfactory.Objectives: These patients need not only soft-tissue coverage for the defects but also functional recovery of the knee joint. The composite free anterolateral thigh (ALT) flap can provide soft-tissue coverage and vascularized fascia lata for tendon reconstruction.Methods: We report on a patient with a composite skin and knee extensor mechanism defect after an ablative surgery for malignancy treated by an anterolateral thigh (ALT) flap incorporated with vascularized fascia lata for reconstruction of the patellar tendon defect.Results: One year after the operation, there was no extensor lag at the knee, with knee flexion of 95°. This patient is able to walk without support.Conclusions: This one-stage surgical procedure simultaneously provides excellent functional tendon reconstruction and adequate soft-tissue coverage.

Delayed arteriovenous fistulae formation in previous free ALT flap reconstruction of head and neck cancer.

An arteriovenous (AV) fistula is an abnormal channel that blood flows directly from an artery into a vein, bypassing the capillaries. Acquired arteriovenous fistulas can be caused by any injury that damages an artery and a vein that lie side by side. With the advent of microvascular surgery, free flap reconstruction of oral cancer has become the technique of choice with low complication rate. In this report, we describe a rare complication of delayed development of an arteriovenous fistula after free ALT flap reconstruction. A 40-year-old man admitted to our ward due to recurrent left buccal cancer. Reconstruction with a free anterolateral thigh musculocutaneous flap was performed after ablative surgery on March, 2004. The lateral circumflex femoral artery of the flap was end-to-end anastomosed to the contralateral (right side) superior thyroid artery, while the comitant veins were anastomosed to the right external jugular vein and superior thyroid vein. The flap survived uneventfully. One year later, a growing pulsating mass with strong thrill was noted along the pathway of previous pedicle of ALT flap. (Figure 1A) 3D neck CT and carotid angiography showed evidence of a high flow arteriovenous fistula at right neck with one feeding artery from right external carotid artery and drained into internal jugular vein. (Figure 1B) Further surgery with ligation and excision of the fistula was performed on October 2005 (Figure 2). No recurrence of the arteriovenous fistula was noted until post-operative follow up for two years. There are two types of arteriovenous fistula, congenital and acquired. The acquired arteriovenous fistula is usually the result of trauma, such as penetrating and blunt injuries of arteries and veins that lie closely. Surgery is one of the possible reasons to cause an acquired arteriovenos fistula.

Surgical Treatment of Pincer Nail Using Expanded Onycho-cutaneous Flap

Background: Pincer nail was described, first by Cornelius and Shelley in 1968, as the deformity of nail with excessive transverse curvature of nail plate that increased from proximal to distal along the longitudinal axis. It may cause severe pain, inflammation and dissatisfied appearance. Aim and Objectives: The aim of this study is to collect the results of a simple, effective and nail matrix-sparing technique to treat the pincer nail deformity. Materials and Methods: From Jan. 2007 to Dec. 2007, twelve toes in ten patients with the pincer nail deformity were treated by using the technique of expanded onycho-cutaneous flap after burring of dorsal osteophyte of phalangeal bone. By evaluating the shape, relief of pain and inflammatory status, results were graded as excellent, good, fair, or poor. Results: Nine nails (75%) achieved excellent result, one (8.3%) good result, one (8.3%) fair result and one (8.3%) poor result. Conclusion: Satisfied results were achieved in most nails treated by this surgical technique without any severe complications. Onycho-cutaneous flap is easy to perform, with low morbidity and can be a good option for treatment of pincer nail deformity.

SGAP Flap for Reconstruction of Sacral Pressure Sores

From August 2004 to October 2005 we underwent 13 procedures using SGAP(superior gluteal artery perforator)as pedicles by either advancement(8/13)or interpolated(5/13)flaps in reconstruction of twelve sacral ulcers in twelve patients. Three(two interpolated and one advanced flaps)of the thirteen procedures were complicated with venous congestion and hematoma, two were saved by decompression with tunnel widening and flap debulking, however the other one interpolated flap was lost post salvage and the defect needed resurfacing by a V-Y advancement SGAP flap from the opposite side. Ten of the thirteen flaps survived completely without morbidity and only one recurrence noted after an average 10 months follow-up. We found the interpolative moving of flaps and the thickness discrepancy between defects and flaps (the SGAP flaps were usually too bulky for shallow sacral ulcers)may increase the risk for torsion of pedicle and venous congestion that resulted in serious complication even flap loss.

Versatility of the Anterolateral Thigh Perforator Flap

Seven patients underwent soft tissue reconstruction with free anterolateral thigh (ALT) flaps including six fasciocutaneous and one musculocutaneous flap associated with the vastus lateralis (VL). Four patients underwent the reconstruction for coverage of head and neck defects, including two with buccal cancer, one with tongue cancer, and one with extensive facial burn scars. Two patients required lower extremity reconstruction, including one with a chronic diabetic foot ulcer and the other with a crush injury resulting in tendon exposure in the dorsum of the right foot. The seventh patient had chronic sternal osteomyelitis after coronary artery bypass graft. All flaps survived without complications. Three donor sites were closed primarily and the other four larger defects with skin grafts. Morbidity at the donor sites was limited and acceptable after six months of follow up. According to our experience, the anterolateral thigh flap based on perforators of the descending branch of the lateral circumflex fem oral artery is a reliable and versatile flap. It can be used in almost any composite defect without difficulty.