Meng-Si Wu

The proximal lateral lower leg perforator flap revisited: Anatomical study and clinical applications

The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically.

A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction.

AbstractFree flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps.

AbstractWe describe our experience in expanding the use of pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. A total of 33 patients underwent 34 flaps between March 2003 and January 2012. The defects included 18 ischial, 3 trochanteric, 5 lower abdomen, 2 perineogenital, 1 groin, and 5 knee defects. There were 29 proximal pedicled (2 of which were preexpanded), 3 distal pedicled, and 2 propeller flaps. Complications included 1 total necrosis, 1 partial necrosis, 3 wound dehiscence in recipient site, 1 hematoma, and 1 donor-site dehiscence. The total flap survival rate was 94%. There were no donor-site morbidities except poor cosmesis in the skin-grafted sites. Pedicled anterolateral thigh flap is highly versatile with a wide arc of rotation. A proximal pedicled flap can be used for lower abdomen, perineogenital, ischial, and trochanteric defects and the distal pedicled or a propeller flap for knee and proximal lower leg defects.

Treatment of Venomous Snakebites in Eastern Taiwan

Background: The incidence of snakebites decreased gradually in recent years due to change of the socioeconomic environment in Taiwan. However, venomous snakebites still can cause severe morbidity and even death occasionally. Aim and Objectives: This report described treatment and result of poisonous snakebites in Eastern Taiwan. We hope to improve management and decrease complications. Materials and Methods: The medical records of the patients admitted to the Buddhist Tzu Chi General Hospital due to venomous snakebites from Jan 2000 to Sep 2004 were retrospectively reviewed. The patients demographic data, species of causative snake, manifestations of envenomation, treatment and clinical course were collected and analyzed. Results: There were 93 cases of snakebites collected. Most of the snakebites (27%) occurred in the fourth decade of age. The species of snakebites included: Taiwan habu bites (29%), Taiwan bamboo viper bites (16%), cobra bites (7.5%) and unknown bites (34%). The most common locations of the bite were in the upper extremity (60%). 24 patients (25.8%) required surgical intervention, including fasciotomy which was performed in 17 patients (18.3%). The average lengths of hospital stay in non-operated group and operated group were 4.2 days and 18.8 days respectively. Acute renal failure developed in three patients, and one of them required temporary hemodialysis. There was only one death in this series. Conclusion: Surgical intervention is indicated in a particular group of patients and different treatment algorithms should be developed according to snake species to decrease the morbidity of venomous snakebites.

Simple skin-stretching device in assisted tension-free wound closure

Background Numerous conventional wound reconstruction methods, such as wound undermining with direct suture, skin graft, and flap surgery, can be used to treat large wounds. The adequate undermining of the skin flaps of a wound is a commonly used technique for achieving the closure of large tension wounds; however, the use of tension to approximate and suture the skin flaps can cause ischemic marginal necrosis. The purpose of this study is to use elastic rubber bands to relieve the tension of direct wound closure for simultaneously minimizing the risks of wound dehiscence and wound edge ischemia that lead to necrosis. Materials and Methods This retrospective study was conducted to evaluate our clinical experiences with 22 large wounds, which involved performing primary closures under a considerable amount of tension by using elastic rubber bands in a skin-stretching technique after a wide undermining procedure. Assessment of the results entailed complete wound healing and related complications. Results All 22 wounds in our study showed fair to good results except for one. The mean success rate was approximately 95.45%. Conclusions The simple skin-stretching design enabled tension-free skin closure, which pulled the bilateral undermining skin flaps as bilateral fasciocutaneous advancement flaps. The skin-stretching technique was generally successful.

Mucosa-related Lymphoid Tissue Lymphoma of the Parotid Gland-Case Report and Literature Review

Background:Mucosa-related lymphoid tissue (MALT) lymphomas are rare low-grade B-cell lymphomas, mostly arising from the gastrointestinal tract. MALT lymphomas arising from the parotid gland are very rare.Aim and objective:We report the rare condition of mucosa-related lymphoid tissue lymphoma arising from the parotid gland and discuss their treatment and outcome.Material and Methods:A 77-year-old man presents with a 10-month history of a slow growing painless tumor at his right periauricular area. It measured 4 x 3 cm in size. There were another two palpable tumors at lower pole of the parotid gland, with the largest one measuring 1.7cm. After excisional biopsy of the minor tumors at the lower pole. The pathology confirmed MALT lymphoma. Superficial parotidectomy with concurrent radiation therapy was done.Results:There was no evidence of local recurrence and distant metastasis on the 11 months follow-up.Conclusion:Mucosa-associated lymphoid tissue lymphoma is rarely arising from the parotid gland. Diagnosis of the disease is very difficult and should be suspected if a patient has significant risk factors. Conservative superficial parotidectomy is recommended both for diagnosis and treatment. Radiation therapy is recommended for limited stages of the disease with systemic chemotherapy advised for advanced stage. Prognosis is favorable with careful post-treatment follow-up.

Anatomical Analysis of the Vascular Distribution in the Pectoralis Major Myocutaneous Flap Using Latex Injection

Background:Although the free flap has become the first choice in recent head and neck reconstruction, the pectoralis major (PM) myocutaneous flap still plays an important role, especially in salvage operations. However, unstable blood circulation of skin paddle with a higher partial necrosis rate has previously been reported.Aim and Objectives:In this current study, we tried to clarify the blood supply of the pectoralis major myocutaneous flap and to determine whether it can be harvested as a pedicled perforator flap.Materials and Methods:The 6 sides of 3 fresh frozen cadavers were examined in this study. The pectoral branch of the thoracoacromial artery was dissected out and injected with colored latex. In the first step, the pectoralis major muscle was elevated from the thoracic cage and the characteristics of the encountered muscular perforators were recorded. Following that, the skin flap was separated from the underlying muscle and the cutaneous perforating branches were also documented.Results:The circulation of the pectoralis major muscle has two main territories. It receives blood supply from pectoral branch of the thoracoacromial artery in the cranial portion and from multiple perforating intercostal branches in the caudal portion. These two territories are linked by choke vessels mainly at the level of fourth costal cartilage. The perfusion of the distal flap is maintained by muscle body containing these choke vessels. However, the number of perforating branches to the skin paddle is much smaller than that to the pectoralis major muscle and their locations vary individually, so the perfusion of the skin is unreliable in the absence of these perforators.Conclusion:The blood circulation of the skin paddle of the pectoralis major myocutaneous flap is unstable because of variation in the number and location of perforating vessels present and also the relative paucity of the cutaneous perforating branches. When designing a skin island, especially a small one, great efforts must be made to include either the third perforating branch of the internal mammary artery or the major intercostal perforating branches to improve blood flow. Hand-held Doppler may be helpful in localization of these vessels. (J Taiwan Soc of Plast Surg 2011; 20: 266~273)