Shyue-Yih Horng

Intralesional corticosteroid therapy in proliferating head and neck hemangiomas: A review of 155 cases

PURPOSE The purpose of this paper is to review the effect of intralesional corticosteroid therapy in the treatment of 155 head and neck hemangiomas. METHODS In the past 10 years, we have treated 155 proliferating head and neck hemangiomas with intralesional corticosteroid injections. Three to 6 injections of triamcinolone acetonide (10 mg/mL) in monthly intervals were given. Using slides and chart review, the results were assessed 1 month after completion of the treatment. RESULTS Eighty-five percent of the lesions showed greater than 50% reduction in volume. Varied treatment response was noted in different classes of hemangioma. Eighty percent of the superficial, 75% of the deep, and 60% of the combined hemangiomas show more than 50% reduction in volume. Further growth was not found after treatment. The postinjection complication rate was 6.4% in this series. There were 2 patients with cushingoid appearance, 5 with cutaneous atrophy, and 3 suffered from anaphylactic shock. We found that lesions showing less than 50% reduction in volume were located mostly in the perioral area. CONCLUSIONS Intralesional corticosteroid injections are safe and effective in arresting hemangioma proliferation. Superficial hemangiomas yield the best results.

Nosocomial infection of Aeromonas hydrophila presenting as necrotizing fasciitis.

Aeromonas hydrophila is infrequently reported as a causative organism of necrotizing fasciitis. We report a case of necrotizing fasciitis due to A. hydrophila in a 44-year-old man with Marfan syndrome who underwent valve replacement surgery twice. He was admitted due to a 2-day history of fever. The fever was attributed to hepatitis, and ingestion of herbal medication was suspected to be the cause. The fever relapsed on the 28th day of hospitalization with rapidly progressive erythematous patches on the bilateral lower extremities. Septic shock developed within a few hours, and 2 small diagnostic incisions on the skin lesions suggested necrotizing fasciitis. Surgical exploration further revealed extensive necrosis of the subcutaneous tissue and fascia, but the muscle was spared. Blood cultures and cultures of the debrided tissue all yielded A. hydrophila. Pathological examination showed necrosis and degeneration of the soft tissue. Although appropriately managed with broad-spectrum antibiotics, fasciotomies and debridement, the patients condition deteriorated rapidly and resulted in death 11 hours after the surgery. This case indicates that A. hydrophila can be a causative organism of nosocomial necrotizing fasciitis.

Treatment of high-flow vascular malformations in the head and neck with arterial ligation followed by sclerotherapy

The traditional treatment of high-flow vascular malformations consists of selective embolization, surgical removal, or a combination of both. Recurrence of the lesion and bleeding control are still the main problems, and the result of treatment is sometimes disappointing. We suggest treatment of these lesions with surgical ligation of the distal major feeding arteries followed by intravascular injection of a sclerosing agent (3% tetradecyl sulfate), and surgical excision and reconstruction when indicated. We have found this to be an effective treatment regimen. We present 14 cases of high-flow vascular malformations of the head and neck area treated with this approach, of which 4 cases developed skin necrosis. Three of these 4 cases of skin necrosis were later treated with skin grafting and, in 1 case, an upper arm skin tube flap was used for nasal tip reconstruction. Three cases underwent delayed reconstruction using tissue expanders. From a symptomatic and aesthetic point of view, preliminary satisfactory results were obtained. We feel that this approach is a good option for treating difficult, high-flow vascular malformations.

Surgical Technique Innovation for the Excision of Subungual Glomus Tumors

The authors have indicated no significant interest with commercial supporters.

Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing.

BackgroundOsteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous flap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula flaps in flap survival, bony union, and postoperative complications. Patients and MethodsFrom 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n = 108) or fibula flaps (n = 45). Data collected for analysis included patient demographics, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use. ResultsAll patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac flap group and fibula flap group. In the group with iliac flap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac flap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P < 0.01). In the group with fibula flap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac flap group (P = 0.04). In the iliac flap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P = 0.04 and 0.36, respectively). ConclusionsFor ORN patients, vascularized iliac bone flap provides more reliable results compared to fibula flap. The merits of vascularized iliac flap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.

Microvascular head and neck reconstruction in patients with liver cirrhosis.

The aim of this retrospective case series was to review the safety, complications, and outcomes of free‐tissue transfer in head and neck cancer reconstruction in patients with liver cirrhosis.

Quantitative Relationship Between Vascular Kinking and Twisting

A wide variety of factors causing vascular thrombosis in the microvascular free flap reconstruction have been encountered. The most frequent situation in our experiences has been vascular kinking because of improper positioning. It has been reported that the best way to avoid kinking is to place the vessels at a neutral axis. However, curving the pedicles to match the recipient vessels cannot be avoided, especially in head and neck reconstruction with a large flap and long pedicle. According to our clinical experiences, the curved vascular pedicle needs rotation in its axis from the neutral position to avoid kinking. Furthermore, we noted that the number of loops equals the number of axial rotations of 360°. We propose that these experiences and ideas can have wide applications in various fields of vascular surgery.

A New Method for Treatment of Oral Cancer Postoperative Sialorrhea-Dermal Sling Operation

The treatment of oral cancer is mainly of operative resection. Due to huge extent of resection, reconstructive surgery is performed at the same time to cover soft/and or bony defect. The reconstruction method was mainly of pectoralis major myocutaneous pedicle flap, forehead flap, temporalis muscle flap, deltopectoral flap, and trapezius myocutaneous flap in the past. However, due to progress in microsurgical technique, the free flap becomes preferred reconstruction method recently. Although advances in reconstruction surgery, there are still many sequelae to patients who received extensive surgery. These sequelae include poor outer appearance, and functional disturbance as dysphagia, impaired speech and drooling etc. The goal of reconstruction surgery has to consider wound closure, cosmesis, and preservation of function at the same time if possible. The sialorrhea is one of the main post-operative sequelae to the patient. We have described a new ”dermal sling operation” to improve the post-operative sialorrhea. The ”dermal sling operation” uses a strip of de-epithelized tissue containing dermis and a portion of subcutaneous fat from the flap itself to suspend the mouth angle. There were 78 patients suffered from oral cancer underwent wide excision of lesion and free flap reconstruction from December1999 to March 2001. Post-operative sialorrhea was noted in 11 patients. The ”dermal sling operation” was performed to treat the problem in 7 patients. The follow up period ranged from 3months to 19 months with good results.

Treatment and long-term follow-up of oral cancer postoperative sialorrhea with dermal sling operation.

IntroductionReconstruction of a full-thickness defect that includes oral commissure presents a considerable challenge to maxillofacial and plastic surgeons. The goals of reconstruction are both functional and cosmetic. Sialorrhea, or drooling, is a major problem after flap reconstruction and influences the quality of life of the patient. In this article, we report on our experience performing a dermal sling operation to treat postoperative sialorrhea in patients with oral cancer. Materials and MethodsPreoperative and postoperative levels of sialorrhea were evaluated based on the Drooling Severity and Frequency Scale. Dermal sling operations were performed on 27 patients from January 2000 to December 2013. In these patients, 12 cases were reviewed and followed up over 1 year. ResultsOf the 12 patients, 11 were men and one was a woman, with the mean age of 58 years (range, 40–79 years). There were no operative complications. The mean preoperative score was 4.75 (range, 3–7), and the mean postoperative score was 3.83 (range, 2–5). This change was significant (P = 0.005), with valuation with the Wilcoxon signed rank test. The mean time of follow-up was 3.5 years (range, 1.1–7.7 years). ConclusionsThe dermal sling operation is an acceptable treatment for postoperative sialorrhea in patients with commissure-involved oral cancer.

Post-irradiation Sarcoma in Patients with Nasopharyngeal Carcinoma-Experience at National Taiwan University Hospital

Background: Post-irradiation sarcoma (PIS) is a rare disease. However, these tumors are relatively aggressive and often elude early detection and timely treatment. Literature is limited to small series and case reports. Besides, there is a lack of thorough reports regarding post-irradiation sarcoma in East Asia, the high nasopharyngeal cancer (NPC) risk area. Aim and Objectives: This study investigates the clinical pictures, pathological features, treatments, and prognoses of patients with PIS stemming from NPC at National Taiwan University Hospital.Materials and Methods: A retrospective review of charts from the Cancer Registry Department of National Taiwan University Hospital (NTUH) was performed from 1978-2008. A total of 35 patients with post-irradiation sarcomas were noted. 23 PIS victims who had previous NPC within the irradiated field were included and evaluated (16 males and 7 females; mean age at diagnosis: 51.5 years). Possible risk factors were analyzed and survival curve was generated with the Kaplan-Meier method.Results: NPC was the most common index lesion before radiotherapy in our series. The incidence rate of PIS for patients with NPC was 0.43%, similar to other series. The age at the time of radiotherapy ranged from 17 to 53 (mean: 37.4). The latency period from radiation to PIS ranged from 2.9 to 25 years (mean: 14.1). As for risk factors in our series, they did not include gender, age, radiation dosage, NPC stages, or habits. Mass lesions over the head and neck region were the most common symptom of PIS (65.2%). Of these, osteosarcoma was the most prevalent histological type. Their overall 1-, 2-, 5-year survival rates were 60%, 25%, and 20% at respectively. 19 patients had undergone surgical intervention. On average, each patient had 2.1 operations for PIS. Evidence indicates that surgical safety margins assure PIS victims a better prognosis. With the development of reconstruction techniques and free flaps, more aggressive excision and higher survival rates have been obtained.Conclusions: In areas with a high NPC prevalence, it is important to keep in mind PIS during the differential diagnosis of nasopharyngeal cancer patients with a probably local recurrence. Early diagnosis and wide excision with safety margins are keys to a better prognosis. (J Taiwan Soc of Plast Surg 2012;21:188~200)