Tian-Yeu Cheng

Reconstruction of burn scar of the upper extremities with artificial skin.

The management of upper‐extremity burn contractures is a major challenge for plastic surgeons. After approval by the Food and Drug Administration, artificial skin (Integra) has been available in Taiwan since 1997. From January of 1997 to July of 1999, the authors applied artificial skin to 13 severely burned patients for the reconstruction of their upper extremities, resulting in an increased range of motion in the upper‐extremityjoints and improved skin quality. An additional benefit was the rapid reepithelialization of the donor sites. There were no complications of infection throughout the therapeutic course, and the overall results were satisfactory. During the 2‐year study, scar condition was monitored between 8 and 24 months, and a good appearance and pliable skin were obtained according to the Vancouver Scar Scale. According to this evaluation of Oriental skin turgor, normal pigmentation was restored about 6 months after the resurfacing procedure. For patients with severe burns in whom there is insufficient available skin for a full‐thickness skin graft or another appropriate flap for scar revision, Integra is an alternative. The two major concerns in dealing with artificial skin are (1) a 10‐ to 14‐day waiting period for maturation of the neo‐dermis, necessitating a two‐stage operation, and (2) prevention of infection with antibiotics and meticulous wound care. (Plast. Reconstr. Surg. 108: 378, 2001.)

The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries.

Over the last half century, advances in treatment have changed the principal cause of death in burn patients from burn shock and wound sepsis to pulmonary sepsis, of which inhalation injury has always played a key role in morbidity and mortality. Even though Navar et al., Am. J. Surg. 1985;150:716-720 have noted that patients with inhalation injury had a mean fluid requirement of 5.8 ml/kg/% burn to achieve resuscitation from early burn shock, while patients without inhalation injury required only a mean fluid of 4.0 ml/kg/% burn, to achieve successful resuscitation in inhalation injured patients with minimum but adequate fluid has always been a challenge. To further define the difference of early fluid therapy between inhalation and noninhalation in extensively burned patients, a retrospective analysis was carried out in the Tri-Service General Hospital. Sixty-two flame burned patients (aged from 16 to 81 years-old with a mean age of 33.2+/-15.1 years: with burn size ranging from 30% to 98% TBSA with a mean burn size of 60.5+/-22.7%; 26 with inhalation injury; noninhalation 36) were reviewed during a 5-year period. The Parkland formula is the initial choice of fluid regimen with 4 ml/kg/% burn and the amount of replacement is monitored by urine output and is titrated to maintain urine output between 0.5 and 1.0 ml/kg/h. The mean amounts of fluid requirements of both inhalation and noninhalation burned patients were 3.1 +/- 1.0 and 2.3+/-0.8 ml/kg/% burn respectively (p < 0.05). Our study showed less fluid requirement for both inhalation and noninhalation injured patients in comparison with the Navar study and Parkland predictions in the first 24 h postburn. Furthermore, the inhalation injured patients definitely required volumes of fluid in excess of those required in noninhalation injured cases.

Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb

Finding an appropriate soft-tissue grafting material to close a wound located over the distal phalanx of the thumb, especially the pulp region, can be a difficult task. A sensate first dorsal metacarpal artery flap, mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap, can be useful for this purpose. The pedicle includes the ulnar branch of the first dorsal metacarpal artery, the dorsal veins, and the cutaneous branch of the radial nerve. Although this tiny artery is anatomically variable, safe dissection can be achieved by including the radial shaft periosteum of the secondary metacarpal bone and the ulnar head fascia of the first interosseous muscle. This approach has been used for 8 individuals with extensive pulp defects of the thumb over the past 3 years. Skin defects in all patients were combined with bone, joint, or tendon exposure. All flaps survived completely. This 1-stage procedure is reliable and technically simple. It provides sensate coverage to the pulp of the thumb but also avoids nerve repair or more complicated microsurgery.

Surgical management of axillary bromidrosis--a modified skoog procedure by an axillary bipedicle flap approach.

We developed a modified Skoog procedure to treat axillary bromidrosis and hyperhidrosis that creates a bipedicle flap over the axillary fold with two parallel incisions to achieve a complete excision of the sweat glands. If necessary, the flap can be extended by making another parallel incision for a larger axillary hair-bearing area. Between 1988 and 1992, 110 patients were operated on using this method, but only 92 of the 110 patients, with an average follow-up period of 29.5 months, were available for this follow-up study. In this series, 86.9 percent of patients gave a family history of axillary bromidrosis. This follow-up review demonstrated that 93.5 percent of patients experienced no odor or occasional very mild axillary odor postoperatively. Postoperative scar formation was either nonvisible or excellent in 95.1 percent of patients, and 82.6 percent of patients reported either a hairless axilla or a marked decrease of axillary hair. Most importantly, 92.4 percent of patients reported a marked decrease in axillary sweat. Four axillary fossae developed postoperative subcutaneous hematomas, and six wounds had mild dehiscence. All of the wounds eventually healed satisfactorily after minor procedures. We concluded that for the treatment of extensive axillary apocrine bromidrosis, this new method achieves complete excision of the sweat glands and provides excellent functional and cosmetic results.

The boomerang flap in managing injuries of the dorsum of the distal phalanx.

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone, joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.

Skin injury in the operating room

Skin injury occurring in the operating room may occur as a result of electrical current, thermal injury, chemical irritation and mechanical stress. Between 1 December 1996 and 28 February 1997, 19 cases of skin injury from a total of 3657 operations were noted in our hospital. These injuries tend to be ignored because of their early spontaneous healing. We suggest that medical staff should pay more attention to this complication and prevent it from occurring.

The rationale of mandible reconstruction in advanced oral cancer: alloplastic material versus autogenous vascularized bone graft

Abstract Autogenous vascularized bone grafts in combination with microsurgical techniques have revolutionized mandibular reconstruction in oral cancer surgery. The vascularized bone graft carries its own blood supply, resists infection, and heals rapidly even in the irradiated bed. However, its use in advanced oral cancer patients is controversial due to the gloomy prognosis of these patients. Effective alloplastic materials such as titanium plate or tray for mandibular reconstruction is a reasonable alternative. These can easily be shaped and have sufficient structural rigidity to maintain the mandibular fragments in proper orientation. Likewise, it is a fast and reliable procedure which can obtain good oral function. However, its potential late exposure due to breakdown of overlying skin, especially after radiotherapy, is well documented. This paper discusses our experience to rescue the oral function after alloplastic material failure using the vascularized fibula osteocutaneous flap, in irradiated patients. All fibula osteocutaneous flaps survived. Symmetry and contour of the reconstructed mandible were judged to be good, and patients were able to eat without saliva drooling. Donor-site morbidity was also low. From this clinical study, we believe that in advanced oral cancer, the titanium plate or tray is a useful adjunct for immediate mandibular reconstruction after surgical resection. The vascularized bone graft should be reserved for patients with alloplastic material failure. This rationale can avoid subjecting the patient to an unnecessary extensive mandibular reconstructive procedure.

Treatment of Ingrown Toenails by Electrocautery Matricectomy-Experiences of 130 Cases

Ingrown toenail is a common problem resulting from various etiologies including improperly trimmed nails, hyperhidrosis, infection and poorly fitting shoes. Patients commonly present with wound infection and purulent drainage in the affected nail groove associated with severe pain and thereby difficult in walking. The ideal management for ingrown toenails should include removal of the ”fishhook” nail to allow for relief of symptoms and the destruction of related part of germinal matrix of nail bed to prevent recurrence of the nail spikes. To investigate the outcome of using the method of electrocautery matricectomy to treat ingrown toenails, a retrospective study was launched including 130 cases in the past six years (from Jan 1999 to Dec 2004). The follow-up clinical examinations and the questionnaire survey regarding the recurrence rate, the severity of symptoms, the duration of postoperative pain and the other relevant factors were recorded and analyzed. The advantages of this method used for treatment of ingrown toenails include: (1) the surgical procedure is simple; (2) the normal foot-wearing time is earlier; (3) the recurrence rate is low; (4) the severity of postoperative pain is decreased; and (5) the duration of postoperative pain is short. The results concluded that the electrocautery matricectomy is an effective method for treatment of ingrown toenails, only 2.3% recurrence rate in our series.

Acute Renal Failure Caused by Low-tension Electrical Burn Injury- A Case Report

To our knowledge and clinical experiences, acute renal failure (ARF) is a major complication of electrical injury but it is rarely found after low-tension electrical burn injury. We reported one case, a 29 year-old male, who was an elevator-repairing worker for seven years. This large-scaled elevator was powered by 380 volts direct current. After the incidence, he was saved and removed from the conductor after 20 minutes later. On the scenery, he was found in the status of unconsciousness, drooping and incontinence. He was sent to our emergent department within 10 minutes. When he received 12-leads EKG examination, he returned to alert consciousness spontaneously. The entrances of electrical current were over left palm and distal phalanx of middle finger and the exits located in neck and right dorsal forearm. The severe metabolic acidosis, mild to moderate elevation of blood urea nitrogen (BUN), serum creatinine, myoglobulin and creatine phosphokinase (CPK) were found in the primary biochemical survey. The gross hematuria was noted initially and turned to tea-color urine soon. The non-oligouric ARF combined with acute respiratory distress syndrome and multiple organs dysfunction were found after admission. The continuous veno-venous hemodialysis (CVVHD) was performed for his renal function support. The symptoms were freed after two days hemodialysitic therapy and the renal function tests (BUN and Creatinine) returned to normal limit after six days.

The Boomerang Flap in Digital Reconstruction

The anatomic and clinical bases for the reliable and versatile boomerang flap in reconstruction of complex distal finger injuries are presented. This one-step procedure, utilizing the dorsolateral skin of the proximal phalanx of an adjacent digit as a reverse island flap, has proved valuable in the salvage of severely injured digits. The boomerang flap was applied in ten cases with distal phalanx injuries. Soft tissue defects in all patients were combined with bone, joint, or tendon exposure. The flaps were transferred as a neurovascular flap for sensory resurfacing of the major pulp loss. This flap preserves the proper palmar digital artery to the fingertip and provides an extended and innervated skin paddle to cover finger soft tissue defect as well as to improve flap sensibility in the distal pulp.