Ming-Ting Chen

Revascularization of digits after thirty-three hours of warm ischemia time: A case report

A case of digits revascularized after 33 hours of warm ischemia time is described. Ischemic changes had occurred already with ultimate loss of the distal segments, but most of the fingers survived to provide the patient with adequate function. Although the commonly accepted limit of warm ischemia time has been reported to be within 6 to 12 hours, revascularization of digits can be attempted in selected cases even after an apparent prolonged warm ischemia time.

Evaluation of survival in digital replantation with thermometric monitoring

Since January 1981, we have used the Exacon thermometer to monitor skin temperature of 180 completely amputated digits during and after replantation surgery. When skin temperature on the first day after surgery was above 32 degrees, 153 of 154 replanted digits survived. In contrast, when skin temperature was 32 degrees or lower, 22 of 26 replanted digits failed. Data were analyzed by the Probit model, which indicated that skin temperature monitoring with 32 degrees as critical temperature is significant at P = 0.01. Also, critical temperature was tested in the range of 31.0 degrees to 33 degrees at intervals of 0.1 degree. We found the probability of predicting the viability for replanted digits is highest when skin temperature is 32 degrees or higher.

A technique for simultaneous replantation of multiple amputated digits at Tamai's Zone V.

A technique for simultaneously replanting multiple digits amputated at Tamais Zone V is described. Since these multiple amputated digits are connected together, they should be replanted as a single unit. The technique includes applying the pneumatic tourniquet first, debridement, bone shortening, and fixation of all the amputated digits, including tendon repairs, application of vascular clamps before releasing the tourniquet, followed by vascular anastomosis in one-by-one fashion for each digit. The disadvantage of this technique is the difficulty in keeping the digit cool. The advantages are it is a less time-consuming operation, there is reduced blood loss and contamination, and there is a better axial arrangement of the bony framework.

Primary Cutaneous Large B-cell Lymphoma of Leg, with Unusual Presentation as a Chronic Ulcer-A Case Report

Background: Primary cutaneous B cell lymphoma (PCBCL) refers to those rare cases of B-cell lymphoma that present in the skin without evidence of extracutaneous disease. In the World Health Organization-European Organization for the Research and Treatment of Cancer (WHO-EORTC) classification, the major subtypes are: primary cutaneous marginal zone B-cell lymphoma (PCMZL), primary cutaneous follicle center lymphoma (PCFCL), and primary cutaneous large B-cell lymphoma of leg (PCLBCL, leg type). PCLBCL, leg type is the most rare and aggressive form of PCBCL. Aim and Objectives: Our purpose is to share our experience of this rare disease and to bring awareness to the possibility of PCLBCL (leg type) presenting with chronic ulcer instead of bluish nodules.Materials and Methods: This case report describes a 33 year-old male with presentation of left medial thigh chronic ulcer and cellulitis for 6 months. Initially, the swollen leg with progressive tenderness and huge ulcerations were observed and had no response to antibiotic treatment. Besides bleeding ulcers, the presence of pinkish skin plaques raised suspicion of malignancy. Pathology revealed diffuse large B-cell lymphoma involving the dermis. Plain chest film, sonography, bone scan and MRI did not show extracutaneous manifestations. Results: After multiagent chemotherapy with eight cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), PCLBCL of leg achieved a complete response and the ulceration healed without skin graft. Follow-up of 8 years showed no tumor relapse.Conclusion: Primary cutaneous large B-cell lymphoma of leg is an extremely rare disorder which requires biopsy of involved skin and thorough study to exclude non-cutaneous disease. As in this case, it mimics chronic ulcer and cellulitis at presentation. It is always crucial to perform biopsy on chronic ulcers. Given the aggressive nature of this disease, early diagnosis and chemotherapy is appropriate treatment modalities. (J Taiwan Soc of Plast Surg 2012;21:242~249)

Alveolar Soft Part Sarcoma: A Case Report, Literature Review, and Differentiation from Vascular Malformation

Background: Alveolar soft part sarcoma (ASPS) is a rare malignant tumor, usually presenting as an indolent slow-growing malignancy with a high incidence of pulmonary metastases early in the disease course. It affects adolescents and young adults, and most frequently occurs in the muscle of the lower extremity. The vascularity of ASPS is typically high, with prominent vessels see within the tumor. It is therefore crucial to differentiate ASPS from a benign vascular lesion. Aim and Objectives: We present this rare case of ASPS and review current literature. Surgeons need to be made aware of the disease to avoid treating it as a benign vascular lesion. Materials and Methods: We present a 15-year-old girl with a growing mass over left thigh since primary school age (preadolescence). Following a series of imaging studies including magnetic resonance imaging and angiography, soft tissue malignancy or vascular lesion was suspected. Abdominal echo, brain magnetic resonance imaging, bone scan and chest computed tomography were also performed. She received surgical excision and specimen was sent for pathological examinations. Patient continues to receive regular out-patients follow-up to date. Results: Alveolar soft part sarcoma was diagnosed pathologically. Multiple small pulmonary metastases were noted on chest computed tomography. After resection of primary tumor, she has received oral thalidomide and endoxan. Follow-up magnetic resonance imaging of left thigh demonstrated no tumor recurrence one year later. Follow-up chest x-ray three years later showed no apparent nodule lesions though CT scan still demonstrated bilateral lung metastases, some remained stationary and some slightly enlarged. Conclusion: Although a rare disease, accurate diagnosis of ASPS needs to be made pathologically. Surgeons need to have a high index of suspicion based on clinical and imaging studies. Adequate surgical resection with adjuvant therapy is essential for disease management in cases with pulmonary metastasis.

The Reconstruction of Cheek Defect Using Tissue Expansion and Design of Flap Setting

Reconstruction of large cheek defects using tissue expansion is a good option for surgeons. The aim of this design is to fully utilize the expanded flap and to conceal the scar in an inconspicuous area on the face. The authors developed a new flap design after tissue expansion which can be expanded more distally to cover the cheek defect. With the proper design of the expanded tissue, one can make full utilization of the flap to cover and reach a wider and more distal defect. The key of the design is to make a proper back cut and to rotate 180 degree upward so that the flap can stretch upward to fully cover the defect. (As described in Fig. 1). Eight patients with cheek defects were reconstructed using the new designed flap. The etiologies of the defects include vascular malformation, hairy nevus, scar contracture, and skin cancer excision. Good coverage with minimal scarring for cheek reconstructions were achieved in all eight patients. There were no flap loss or major complications, and all minor problems were treated by minimal procedures without long term sequelae. The reconstruction of cheek defect using tissue expansion can provide good quality of expanded tissue and obviate donor side morbidity.

Correction of Inverted Nipple Using Crossed X-wing Dermal Flaps

Nipple inversion can cause aesthetic, functional and psychological problems, especially for affected woman. Many patients are distressed by nipple appearance and have problems of breastfeeding. Irritation and inflammation are not uncommon by inverted nipple. They were divided into three groups by the system of grading. The grade was made by preoperative evaluation of severity of inversion and was conformed by the surgical finding. Many techniques have been introduced for correction of this anomaly by many authors, such as purse string suture technique, nipple piercing or dermal flap. We develop a new method as a modified dermal flap for correction of nipple inversion with ”X-wing dermal flap” to achieve a sure and long-lasting result. Between May 2006 and August 2006, total 23 nipples of 13 patients received this method to correct Grade Ⅱ to Ⅲ nipple inversion. Male (N=1) and female (N=12) are included in this study. The X-wing dermal flap method provides an easy and reliable procedure with minimal complication, fast recovery and good result for both patient and surgeon.

Anaphylactic Reaction of Triamcinolone Intra-lesional Injection during Treatment of Strawberry Hemangioma

Triamcinolone acetonide suspension is a long acting corticosteroid product for intra-lesional injection of hemangiomas in our series. There were very few cases reported about triamcinolone induced anaphylactic reaction previously. From April 2001 to April 2005, there are 277 hemangioma patients who received intra-lesional triamcinolone injection in our series. 7 of them suffered from anaphylactic reaction immediately after the treatment. They were recovered smoothly after resuscitation with intramuscular epinephrine injection and oxygen supply. We presented these seven patients about their signs and symptoms of anaphylaxis, treatment protocols, and their following alternative treatment of hemangiomas, and we also reviewed the proposed mechanisms of corticosteroid-associated hypersensitivity reactions in this study.

A Prospective Study of the Effect of Botulinum Toxin A on Masseteric Muscle Hypertrophy-Preliminary Report

This is a prospective study of effect of botulinum toxin A (BOTOX) on masseteric muscle hypertrophy. Six patients (Four bilateral and two unilateral masseteric muscle hypertrophy) were evaluated. Each patient was recorded using subjective and objective scoring system one month, two months, and three months after injection of botulinum toxin A. All six patients showed remarkable improvement of facial contour for the first three months after treatment. There was no complaining of any side effect after the treatment except for one patient who experienced mild weakness on chewing for the first two weeks. This study shows that botulinum toxin A is a safe and effective method in treating masseteric muscle hypertrophy.

Breast Reconstruction after Mastectomy with DIEP Flap

The transverse rectus abdominis musculocutaneous (TRAM) flap has become the procedure of choice for autologous breast reconstruction after mastectomy in the past decade. Despite the numerous advantages of the free TRAM flap, abdominal wall complications are the major concerns for plastic surgeons performing breast reconstruction with TRAM flaps. Since the report of successful breast reconstruction with the free deep inferior epigastric perforator (DIEP) flap by Allen and Treece in 1994, there has been increasing use of the free DIEP flap for breast reconstruction in recent years. The reported results of the free DIEP flaps were comparable to those of the free TRAM flaps, though there might be slightly increases of rates of partial flap loss and fat necrosis. However, the abdominal wall complications could be eliminated. After the experiences of breast reconstructions with free TRAM flaps, we chose the free DIEP flap as our procedure for the breast reconstruction after mastectomy for recent 10 cases. There was no total or partial flap loss. The results were cosmetically acceptable, though the dissections of perforators were tedious. We believe the free DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity.