Pao-Yuan Lin

Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute.

Background: Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. Patients and Methods: A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20‐year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. Results: A total of 201 cases required emergent surgical re‐exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re‐exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. Conclusion: Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate.

The outcome of prostaglandin‐E1 and dextran‐40 compared to no antithrombotic therapy in head and neck free tissue transfer: Analysis of 1,351 cases in a single center

Free tissue transfer has become a popular technique for soft tissue defect reconstruction in head and neck cancer ablation. Although high success rates and good reliability of free flaps are proven, microvascular thrombosis is still the most critical issue for microsurgeons. Pharmacological antithrombotic agents are widely used but their efficacy is still debated. In this study, we analyzed whether prostaglandin‐E1 (PGE1) and dextran‐40 can improve the outcomes compared to no antithrombotic therapy at all. We retrospectively reviewed 1,351 free flaps performed for head and neck reconstruction after cancer ablation. Three groups defined were 232 flaps received PGE1, 283 flaps received dextran‐40, and 836 received no antithrombotic therapy. The demographics of these three groups indicated no statistical differences. The results showed that flap survival revealed no significant difference among PGE1, dextran‐40, and control group (P = 0.734). There was a tendency to hematomas in PGE1 group (P = 0.056) when compared with other two groups. Dextran‐40 significantly increased flap failure rate in high‐risk patients with diabetes mellitus (P = 0.006) or hypertension (P = 0.003), when compared with PGE1 and control group. These results revealed antithrombotic therapy with PGE1 and dextran‐40 do not determine a significant improvement in flap survival.

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.

A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction

Background: Perforator‐based fasciocutaneous flaps for reconstructing pressure sores can achieve good functional results with acceptable donor site complications in the short‐term. Recurrence is a difficult issue and a major concern in plastic surgery. In this study, we introduce a reusable perforator‐preserving gluteal artery‐based rotation flap for reconstruction of pressure sores, which can be also elevated from the same incision to accommodate pressure sore recurrence. Methods: The study included 23 men and 13 women with a mean age of 59.3 (range 24–89) years. There were 24 sacral ulcers, 11 ischial ulcers, and one trochanteric ulcer. The defects ranged in size from 4 × 3 to 12 × 10 cm2. Thirty‐six consecutive pressure sore patients underwent gluteal artery‐based rotation flap reconstruction. An inferior gluteal artery‐based rotation fasciocutaneous flap was raised, and the superior gluteal artery perforator was preserved in sacral sores; alternatively, a superior gluteal artery‐based rotation fasciocutaneous flap was elevated, and the inferior gluteal artery perforator was identified and dissected in ischial ulcers. Results: The mean follow‐up was 20.8 (range 0–30) months in this study. Complications included four cases of tip necrosis, three wound dehiscences, two recurrences reusing the same flap for pressure sore reconstruction, one seroma, and one patient who died on the fourth postoperative day. The complication rate was 20.8% for sacral ulcers, 54.5% for ischial wounds, and none for trochanteric ulcer. After secondary repair and reconstruction of the compromised wounds, all of the wounds healed uneventfully. Conclusions: The perforator‐preserving gluteal artery‐based rotation fasciocutaneous flap is a reliable, reusable flap that provides rich vascularity facilitating wound healing and accommodating the difficulties of pressure sore reconstruction.

Reconstruction of the hypopharynx with the anterolateral thigh flap: defect classification, method, tips, and outcomes.

Background: The authors retrospectively reviewed their experience over the past 5 years with reconstructions of hypopharyngeal defects using anterolateral thigh flaps. The purpose of the study was to present a modified classification of defects, the method and tips used, and outcomes and morbidities. Methods: From 2002 to 2007, 55 anterolateral thigh flaps were harvested for reconstruction of hypopharyngeal defects after tumor ablation in 54 patients. Patient age ranged from 38 to 77 years (average, 54 years). In 24 cases, free flaps were used for reconstruction of circumferential defects; in 28 cases, they were used to reconstruct partial defects; and in three cases, they were used to reconstruct circumferential and skin defects. Results: Total flap loss occurred in one patient and partial flap loss occurred in three patients. Strictures occurred in three patients and fistulas occurred in 10. In one case, arterial occlusion was noticed postoperatively. The arterial anastomosis was revised and the flap was salvaged. In another case, venous occlusion was noticed. The vein was reanastomosed with a vein graft and the flap was salvaged. Postoperatively, seven patients tolerated a regular diet. The donor site was skin grafted in five cases, closed with reverse anterolateral thigh in one case and with retrograde V-Y advancement flap in one case, and closed primarily in the rest. There were no donor-site complications. Conclusion: Reconstruction of the hypopharynx with the anterolateral thigh flap offers versatility in the coverage of large and complex defects and is associated with minimal donor-site morbidity.

Dermatofibrosarcoma protuberans in children and adolescents: Clinical presentation, histology, treatment, and review of the literature

PURPOSE Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade malignant tumor. It is characterized by aggressive local infiltration, leading to a propensity for recurrence. In children, DFSP is even less common and likely misdiagnosed or underdiagnosed. This study is a review of DFSP in the pediatric population and aims to identify factors for successful treatment. MATERIALS AND METHODS From July of 1986 to 2011, a total of 159 patients were diagnosed with dermatofibrosarcoma protuberans at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Subject to the age classification of our institution, patients under the age of 18 are defined in the pediatric category, of which159 cases were identified as our research subjects. Detailed data, including demographic data, imaging studies, pathology, treatment methods, and outcomes, of these identified patients were collected, reviewed, and analyzed. RESULTS A total of 13 patients, consisting of six male and seven female patients, were identified based on our criteria. Two had the lesions noticed at birth. Most patients experienced a variable period of quiescence, followed by a rapid growth phase. All 13 patients underwent wide excisions. Post-excision reconstruction included direct closure in three cases, skin grafting in three cases, and local or free flap reconstruction in seven cases. Of 13 patients, four received postoperative radiotherapy. All patients survived without recurrence up to July 2011, with follow-up periods ranging from 20 months to 19 years. CONCLUSION Clinicians should be aware that DFSP is known to occur among children. Owing to its relatively low incidence, its presence may be confused with commoner lesions such as hemangioma, fibroma, or atrophic plaques without nodule. The confusing situation, as a result, frequently leads to delayed diagnosis. Vigilance in its diagnosis allows for treatment at manageable sizes as well as ensures complete excision. Reconstructive options, such as skin grafting, and modalities, such as adjuvant postoperative radiotherapy, are suggested to best complement each other. The former minimizes disfigurement while the latter minimizes recurrences.

Mesenchymal Stem Cells as Immunomodulators in a Vascularized Composite Allotransplantation

Vascularized composite allotransplantations (VCAs) are not routinely performed for tissue reconstruction because of the potentially harmful adverse effects associated with lifelong administration of immunosuppressive agents. Researchers have been eagerly seeking alternative methods that circumvent the long-term use of immunosuppressants. Mesenchymal stem cells (MSCs) show promise as an immunomodulatory therapeutic agent and are currently being tested in preclinical and clinical settings as therapies for autoimmune disorders or transplant rejection. The mechanisms by which MSCs modulate the immune response are still under thorough investigation, but these most likely involve expression of local factors influencing T-cell regulation, modulation of cytokine expression (e.g., IL-10, TGF-β, TNF-α, INF-γ, etc.), and interactions with dendritic or antigen presenting cells. In this paper, we summarize the current understanding of immunomodulation achieved by MSC therapies and introduce a possible outline for future clinical applications in VCA.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps

Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free‐style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital.

Reconstruction of head and neck cancer with double flaps: comparison of single and double recipient vessels.

Patients with advanced head and neck cancers require reconstruction with a double free flap, but in some situations, it is extremely difficult to attain the ideal set of recipient vessels for these patients. The patients were divided into two groups: group 1 had one recipient vessel; group 2 had two recipient vessels. Fifty-five patients were enrolled between 2001 and 2005. Double flaps, including a fibula osteoseptocutaneous flap and an anterolateral thigh flap, were used for the reconstruction. In group 1, the second flap was anastomosed at the distal runoff of the fibular flap. Group 1 contained 39 patients and group 2 had 16 patients. No significant differences in the success rate, operating time, days of hospitalization, or complication rate were noted between groups 1 and 2. Thus using one recipient vessel is our first choice for double free-flap reconstruction for head and neck defects.

An Ideal Method for Pressure Sore Reconstruction: A Freestyle Perforator-based Flap

Background:Pressure sore reconstruction is quite difficult for plastic surgeons because of long-term high recurrence rates. We designed a freestyle perforator-based flap for pressure sore reconstruction considering pressure sore recurrence and further reconstruction. Methods:We used a handheld Doppler device to locate a perforator position just adjacent to the pressure ulcer. In a series of 34 patients, we used 37 perforator-based flaps to reconstruct 25 sacral, 5 ischial, and 4 trochanteric ulcers. Results:Twenty-eight of 37 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, 3 had partial flap necrosis, 3 had wound dehiscence, 1 died 3 days postoperatively, and recurrence developed in 1 patient. Conclusions:We used the freestyle perforator-based fasciocutaneous flap for pressure sore management with good success. These flaps are easy to design and provide good versatility for coverage. Cooperation of surgical skills and good postoperative care also contributed to the lower recurrence rates and satisfactory results.