Ted T. Huang

Ten Years Of Experience In Managing Patients With Burn Contractures Of Axilla, Elbow, Wrist, And Knee Joints

Hypertrophy and contracture of scars are common sequelae seen in patients with severe burns. These changes may impair the movement of various joints. The surgical restoration of deformed joints can be difficult. Although the use of splints and continuous pressure across these joints has been effective in minimizing these problems,1,2 the true efficacy of this regimen in preventing joint dysfunction remains undefined. After we had noticed that the faithful use of splints in patients with neck burns decreased the incidence of neck contracture from 37 percent to 9 percent,3 we reviewed the records of 830 patients treated at our hospitals during a 10-year period to evaluate the efficacy of splints and pressure upon burn scars across the major body joints. An analysis of 625 patients who had sustained burns across the axillae, elbows, wrists, or knee joints indicates that the use of splints and pressure across these joints will not only greatly decrease the incidence of contractures but will also reduce the frequency and need for release operations. However, these appliances must be used for at least 6 months (longer, if possible), if substantial benefits are to be obtained.

Reconstruction of a large abdominal wall defect using combined free tensor fasciae latae musculocutaneous flap and anterolateral thigh flap.

A large abdominal wall defect was reconstructed with the use of a flap combining the tensor fasciae latae musculocutaneous flap and the anterolateral thigh flap in four individuals who had undergone extensive abdominal wall resection because of cancer. The flap was harvested as a single combined composite flap and was transferred to the recipient site by means of microvascular surgery. Morbidity was minimal and the outcome was satisfactory in all instances.

Treatment of burn alopecia with tissue expanders in children.

During the past 18 months, 60 tissue expanders were utilized in the reconstruction of 42 children with burn alopecia of the scalp not amenable to a single excision and primary closure at the Shriners Burns Institute in Galveston, Texas. The children were grouped according to the degree of alopecia. All patients with defects of 15 percent or less of the total hair-bearing scalp were able to obtain complete closure of their defects with two operations, i.e., one to place the expander and the second to remove the expander and advance the flaps. Some patients with defects up to 40 percent were closed with serial expansion. Patients with even larger defects had a significant reduction in the percentage of alopecia and benefited from re-creation of anterior hairlines. We have encountered a postoperative complication rate of 10 percent. When compared to previous methods of treating burn alopecia, tissue expansion allows a more rapid closure, fewer operations and coincident anesthetics, and decreased total length of hospitalization.

A circumareolar approach in surgical management of gynecomastia.

Gynecomastia is a common deformity encountered among male patients. Surgery is primarily aimed at reducing the size of the breast mound and therefore should be considered aesthetic in nature. In an attempt to minimize the problems of hematoma formation, nipple necrosis, and unsightly scarring around the upper torso after the surgery, we have had the opportunity to utilize a circumareolar approach for breast tissue removal in 33 breasts (24 patients). This method, when compared with other techniques, has the advantage of leaving minimal scarring around the areolar margin while obliterating the dead space by imbricating the tissue stalk to minimize hematoma formation.

Outpatient breast surgery under intercostal block anesthesia

During the past 3 years, we have performed various breast operations in 320 patients under local anesthesia, using intercostal nerve block. The amount of local anesthetic solution required has been about 20 ml 1% lidocaine for blocking both sides, and an additional 24 ml of 0.5% lidocaine during the surgery. This dosage is well within safe limits. We have found that various breast operations, ranging from augmentation mammaplasty to a staged reconstruction after mastectomy, can be done with this method of anesthesia. The complications attributable to the nerve block were nil in our series.

Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.

For the past 20 years, the gender treatment team formed under the auspices of the University of Texas Medical Branch Hospitals has treated 121 male individuals with gender identification disorders. The age of this group ranged between 18 and 71 years, with an average of 32.3 years. While all of them were seen regularly for 6 months after surgery, only 68 were followed for a year or longer. The regimen of surgical treatment that consisted of procedures of bilateral orchiectomy, penectomy with relocation of the urethral meatus, labial reconstruction, and neovaginoplasty was used for all patients. The castration procedure used between 1972 and 1977 included removal of both the testes and the spermatic cord. The corpora cavernosa were transected at the pubic symphysis. For vaginal reconstruction, a partial-thickness skin graft was used frequently, in conjunction with a skin flap fashioned from the penile skin, to line the neovaginal vault. Modifications and changes in technique were, however, introduced in 1978. Skin flaps mobilized from the inguinoperineal area instead of a partial-thickness skin graft were used to line the vaginal cavity. A proximal segment of the corpora cavernosa was retained to reconstruct a clitoris. In addition, the spermatic cord was incorporated into the reconstruction of labia majpra. These technical modifications substantially reduced the incidence of vaginal stenosis and improved the external appearance of the genitalia. The experience accumulated from managing this group of patients forms the basis of this report. (Plast. Reconstr. Surg. 96: 921, 1995.)

Reduction of lower palpebral bulge by plicating attenuated orbital septa : a technical modification in cosmetic blepharoplasty

Bulging of the lower eyelid is regarded as a sign of aging. “Herniation” of the periorbital fat pads is traditionally regarded as the factor responsible for the change. Excision of fat pads, therefore, has been the mainstay of treatment in reducing the palpebral bulge in cosmetic blepharoplasty. The surgical excision of “excess” and “herniated” fat pads, however, causes problems such as lid ecchymosis, chemosis, lid contour irregularity, ectropion, and retrobulbar hematoma formation. The author proposes that the loss of fat pad support caused by the attenuation of the orbital septa, not herniation of the excess fat pads, is the major factor responsible for the bulge. The author further proposes that the functional integrity of the orbital septum can be restored by plicating the attenuated orbital septa with 5-0 absorbable sutures. This technique of invaginating the protruded fat pad was performed in 138 individuals (276 lower eyelids). The operation was technically simple, and the approach was “tissue friendly.” The results obtained, with the exception of a mild degree of puffiness encountered soon after the surgery, were satisfactory. Morbidity was minimal.

Deltopectoral skin flap as a free skin flap revisited: further refinement in flap design, fabrication, and clinical usage.

The deltopectoral skin flap is an axial flap; therefore, it can be fashioned as a free skin flap. Although color and texture of the skin are well suited for facial resurfacing, the structural features of inconsistent thickness of the skin, a short vascular pedicle, a minute caliber of the nutrient vessel, and donor site morbidity often preclude the use of this flap for this purpose. The deltopectoral skin flap fabricated as a free skin flap transferred by means of a microsurgical technique was used in 27 patients between 1985 and 1998 at our hospital. The anterior perforating branches of the internal mammary vessels were the primary nutrient vessels of the flap in seven instances. The external caliber of this artery varied between 0.6 mm and 1.2 mm, with an average size of 0.9 mm. The size of the accompanying vein varied between 1.5 mm and 3.2 mm, with an average of 2.3 mm. Coaptation of these vessels with those in the recipient site was technically difficult. Thrombosis occurred at the anastomotic site in three patients, requiring reoperation. Two flaps were saved. The flap failure was drastically reduced in the remaining 20 patients by including a segment of the internal mammary vessel when fabricating the vascular pedicle. The size of the internal mammary arterial segment averaged 2.1 mm, and the average size of the accompanying vein was 2.9 mm. The problem of a bulky flap was managed by surgical defatting/thinning of the flap at the time of flap fabrication and transfer. A V‐to‐Y skin flap advancement technique of wound closure was used in eight individuals. The flap donor‐site morbidities were minimized with this method of wound closure. (Plast. Reconstr. Surg. 107: 1134, 2001.)

A histological study of the lower tarsus and the significance in the surgical management of a involutional (senile) entropion

The dimension of the lower tarsus diminishes with aging. Changes in the number and size of the meibomian glands and in the character of intermingling fibroconnective tissues are thought to be responsible. Furthermore, such alterations of the structural integrity play an important role in the pathogenesis of entropion encountered commonly m the elderly. We have advocated the use of an autogenous cartilage graft harvested from the ear to correct the deformity, especially in instances where the conventional methods of correction have failed.

Breast and subscapular pain following submuscular placement of breast prostheses.

The technique of placing the breast prosthesis beneath the pectoralis major and the serratus anterior muscles appears to minimize the incidence of the firm breast following breast reconstruction commonly seen with other techniques. However, in 8 of 146 individuals I have noted a problem with pain in the lateral aspect of the breast mound and the subscapular area, along with a depressed deformity superomedially and an unsightly bulge inferolaterally and/or laterally. Surgical exploration of the breast mound showed no abnormalities within the submuscular compartment. However, in all instances, the serratus anterior muscles were found to be detached from the ribcage all the way to the point beyond the posterior axillary line. While continuous pressure exerted on the serratus muscles by the implant appears to play an important role in the pathogenesis of this clinical entity, the onset of problems was usually delayed. Removal of the implants or repair of the cavity defects is necessary for patients who have developed this problem.