Ming-Chung Yeh

Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site

From August of 1995 through July of 1998, 38 free anterolateral thigh flaps were transferred to reconstruct soft‐tissue defects. The overall success rate was 97 percent. Among 38 anterolateral thigh flaps, four were elevated as cutaneous flaps based on the septocutaneous perforators. The other 34 were harvested as myocutaneous flaps including a cuff of vastus lateralis muscle (15 to 40 cm3), either because of bulk requirements (33 cases) or because of the absence of a septocutaneous perforator (one case). However, vastus lateralis muscle is the largest compartment of the quadriceps, which is the prime extensor of the knee. Losing a portion of the vastus lateralis muscle may affect knee stability. Objective functional assessments of the donor sites were performed at least 6 months postoperatively in 20 patients who had a cuff of vastus lateralis muscle incorporated as part of the myocutaneous flap; assessments were made using a kinetic communicator machine. The isometric power test of the ratios of quadriceps muscle at 30 and 60 degrees of flexion between donor and normal thighs revealed no significant difference (p > 0.05). The isokinetic peak torque ratio of the quadriceps and hamstring muscles, including concentric and eccentric contraction tests, showed no significant difference (p > 0.05), except the concentric contraction test of the quadriceps muscle, which revealed mild weakness of the donor thigh (p < 0.05). In summary, the functional impairment of the donor thighs was minimal after free anterolateral thigh myocutaneous flap transfer. (Plast. Reconstr. Surg. 107: 1766, 2001.)

Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site.

Background: The anterolateral thigh flap is commonly used for reconstruction of various soft-tissue defects. This article presents the authors’ approach to one-stage reconstruction of composite soft-tissue defects using an anterolateral thigh flap with a vascularized fascia lata. Methods: This retrospective review analyzed 973 patients who had undergone anterolateral thigh flap reconstruction for various soft-tissue defects over the past 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite anterolateral thigh flap combined with vascularized fascia lata. The fascia lata component of the flap was used for abdominal wall and fascial defect reconstruction in 12 patients, for lip-cheek defect reconstruction in 15 patients, for reconstruction of composite defects in extremities in nine patients, and for reconstruction of the perineum in one patient. Functional outcomes of donor sites were investigated by using a dynamometer. Results: All flaps except one survived. The overall flap survival rate was 97 percent. Patients achieved satisfactory results without major postoperative complications. The study revealed that vascularized fascia may mimic a fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency in quadriceps femoris muscles contraction in the donor thighs, no difficulties in daily ambulation were reported by the patients. Conclusions: The anterolateral thigh flap with vascularized fascia lata provides a reliable fascial component for single-stage reconstruction of complex soft-tissue defects.

Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation

Single flap for complex hypopharyngoesophageal and anterior neck skin defect reconstruction is still a challenge for reconstructive surgeons. Herein, we present five patients, with advanced hypopharyngeal cancer and anterior neck skin invasion, which received a single anterolateral thigh (ALT) fasciocutaneous flap for composite inner pharyngeal and outer skin defect reconstruction after wide composite resection. Two ALT flaps were divided into two distinct paddles supplied by two or more separate perforators, one part for reconstructing the inner pharyngeal defect and another for neck skin coverage. Three ALT flaps only supplied by one sizable perforator could not be divided and de‐epithelization of mid‐part had to be done to reconstruct both defects with the single flap. The results revealed survival of all flaps. There were no flap loss, fistulas, or bleeding complications. All patients recovered uneventfully and could eat a soft diet to regular diet postoperatively. In conclusion, one‐staged reconstruction of complex pharyngoesophageal and external skin defects after extensive oncological resection is feasible using a single ALT fasciocutaneous free flap.

Replantation of Total Avulsed Scalp With Microsurgery : Experience of Eight Cases and Literature Review

BACKGROUND Reports in the literature about scalp replantation are mostly sporadic; rarely can one find a large series. We present our experience with eight cases of scalp amputation replanted microsurgically. METHODS From 1992 to 2003, eight patients who sustained scalp amputation injuries underwent microsurgical replantation. Age ranged from 3 to 46 years (average, 27.3), and four patients were male. The scalp amputations in the three adult male patients were sustained from cutting incidents by a blade, whereas those in the four female patients were from their long hair getting caught in a roller machine. A 3-year-old boy suffered scalp avulsion from a dog bite. A vein graft was needed in four patients whose scalp injuries resulted either from avulsion or a dog bite, which was not deemed necessary for those sustained by cutting injuries. RESULTS Seven of the eight replantations were successful. The failed replantation in this series was the case where only arterial revascularization was performed, which resulted in venous congestion. Rotation scalp flap was placed to cover the defect. A boy who sustained scalp amputation from a dog bite suffered partial necrosis of the replanted scalp, which was covered with a skin graft. The resulting alopecia area was eventually excised after tissue expansion. CONCLUSION Successful replantations can achieve the best esthetic and functional results compared with other procedures. Scalp amputations sustained from sharp cuts seem to be quite as common as hair traction injuries. Such amputation injuries were more common in male patients with short hair. The manner of injury often will influence planning during replantation. Even if the amputated scalp was crushed or contaminated, such as those sustained from animal bites, replantation should still proceed, unless a greater contraindication exists.

Heterotopic replantation in mutilating hand injury.

To achieve optimal hand function in the reconstruction of a mutilated hand is quite a challenge, and every salvage procedure should be tried, especially for amputated parts that cannot be replanted to their original anatomic sites. Five patients who sustained work-related mutilating hand injuries and who underwent digital heterotopic replantation are reported. Two patients had irreparably crushed, amputated thumbs. One patient (patient 1) received heterotopic replantation of the ring finger to the thumbs position; the other patient (patient 2) received heterotopic replantation of the middle finger to the thumb. Three additional patients received digital heterotopic replantation to enhance hand function. Patient 3 underwent heterotopic replantation of the middle finger to the index fingers position. Patient 4 underwent transplantation of the middle finger to the index fingers position, the ring finger to the middle fingers position, and the little finger to the ring fingers position. In patient 5, the ring finger was transplanted to the index fingers position. In all patients, satisfactory results were achieved in hand function and wound healing. In these patients, the restoration of a functional thumb was the first priority, followed by establishing at least two opposable fingers at the sites where metacarpophalangeal joints were functional.

Epidemiology of Pediatric Burn Injuries in Southern Taiwan

This study comprised of 468 pediatric burn-injury cases. The patients were collected from October 1986 to December 1993 in the Burn Center at Kaohsiung Chang Gung Memorial Hospital. The population of burned children accounted for 31.3% of all 1495 patients admitted during the period. We are interested in backgrounds, causes of burn, extent of injury, place of burn, and activities during the events. The most common causes of injury were scalds (76.5%) in children under the age of 5 years (67.1%). Male was affected predominantly (61.8%). Most of the burn injuries ocurred in the winter months between October and January, and the accidents majorly happened at home (73.9%). The overall mortality was low (1.9%).

Reconstruction of traumatic Stensen duct defect using a vein graft as a conduit: two case reports.

Treatment of Stensen duct defect is still controversial. The authors describe the successful use of a retrograde vein graft as a conduit for traumatic segmental Stensen duct defect reconstruction. One patient sustained facial trauma with severe duct crushing and severance, the other had multiple cutting injuries with segmental duct defect. However, primary repair was impossible. A retrograde vein graft harvested from forearm for Stensen duct defect reconstruction was performed using microsurgical technique. A silicon stent was retained for 8 weeks. The sialographic examination showed good functional results without stricture postoperatively. This could be an option for treating such a complicated defect.

The First Hand Allotransplantation in Taiwan: A Report at 9 Months

PurposeHand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. Materials and MethodsOn September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. ResultsThe initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. ConclusionsHand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

Cup-sealer Injuries on Pediatric Hands: Clinical Experiences and Literature Review

Background:Due to the increasing popularity of ”bubble-tea” as a pastime drink, the use of the automatic cup-sealer machine has become a necessary tool to do business in Taiwan. Unfortunately, having a cup of cold drink sealed and handed to the customer quickly does come with costs when negligence occurs. Children, especially younger ones, can sustain serious injuries to their hands with the cup-sealer machine when unattended. A literatures review and case reports regarding the mechanism of injury and clinical course will be presented.Aim and objectives:To share our clinical results and protocols regarding treatments of unique cup-sealer injuries based on different regions of the hand.Materials and Methods:A retrospective review of medical charts of children injured by the cup-sealer machine and treated at Kaohsiung Chang-Gung Memorial Hospital was conducted. All patients were brought to our hospital for first aid without other associated trauma. Our treatment strategies were based on the location and depth of the injured hand. Full thickness skin graft was the first choice for superficial burns over the dorsal hand or fingers and deep burns with tendon or joint exposure were treated with free or local flaps with tendon reconstruction to obtain the best functional outcome. Digital replantations were performed for all finger amputations.Results:A total of 7 cases occurred between June 2004 and December 2010, which included 6 boys and 1 girl, with an average age of 3 years (range, 1.3 to 9 years). Thermal crush injuries inflicted by cup-sealer machine were located on the right hands of 4 patients and the left hands of 3 patients. Two cases with a total of 4 amputated fingers underwent emergent digital replantation, 1 case was skin grafted, 1 case was reconstructed with local reversed dorsal digital and metacarpal island flap, 1 case received a pedicled groin flap and fascia graft for extensor tendon repair, and 2 cases with dorsal hand defects were reconstructed with free anterolateral thigh fasciocutaneous flaps with fascia lata graft. All flaps survived except for 1 case where partial flap loss was noted in the local reversed dorsal digital and metacarpal island flap. All finger replantations were successful. There were no associated surgical or anaesthesia complication.Conclusion:Pediatric hand injury, especially those caused by a cup-sealer machine, can be devastating to a young child with long-term effects on their body image and social difficulties once they reach school age. Pediatric hand injuries should be treated aggressively in all cases. Early reconstruction and rehabilitation is the mainstay for achieving satisfactory functional restoration. However, prevention is the key for avoiding future incidents.

Primary and Secondary Subdermal Pocket Procedure Used in Digital Replantation with Venous Congestion

Background: The major challenge faced by reconstructive microsurgeons for salvaging digital amputations, especially at the level of fingertip, was the lack of available vein. The search for an ideal solution for no suitable vein at the time of replantation remained despite numerous proposal in the literature. Aim and Objective: The aim of this study is to compare the primary use of subdermal pocket procedure at the time of replantation for venous outflow, and as a secondary procedure for the salvage of postoperative venous congestion after replantation. Materials and Methods: From 1999 to 2008, a total of 17 amputations (16 complete digital amputations; 1 near-complete amputation) from 16 patients (9 male; 7 female) were collected, which included 7 guillotine and 10 crushed digital amputations. Their age ranged from 23 to 58 years old, averaging 36.8 years old. All patients were divided into 2 groups based on the timing of subdermal pocket procedure. Results: The first group (Group Ⅰ) has received digital artery revascularization and immediate subdermal pocket procedure as a mean of venous drainage. It was consisted of 11 digital amputations. The mean subdermal pocketing period was 9.1 days, and the success rate was 11 of 11 fingers (100%). The second group (Group Ⅱ) received secondary subdermal pocket procedure as a salvage procedure when postoperative venous congestion became apparent after replantation. This group consisted of 6 amputated digits from a total of 5 patients. The mean time lapse between replantation and the delayed subdermal pocket procedure was 39.0 hours. The average pocketing period was 6.8 days, and the success rate was 4 of 6 fingers (66.7%). Conslusion: The immediate use of subdermal pocket procedure after digital replantation when no vein was available has a greater survival rate as compared to the delay use of subdermal pocket procedure after postoperative venous congestion has occurred. It was recommended to performed primary subdermal pocket procedure to increase the survival rate of finger replantation.