Wen-Her Wang

Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure

BACKGROUND Bulkiness and unsightly scarring are the major complaints after oral cancer reconstruction with free flap transfer. Some debulking procedures, such as blunt-tipped cannula liposuction or staged excision, can result in some improvement, but these methods do not provide a one-stage procedure for flap thinning and scar revision due to the concern of flap ischemic change. All suction lipectomy methods were applied on flap resurfacing cases; no through-and-through defect case was used. The author used a nonstandard open-tip cannula for liposuction and w-plasty for scar revision in a one-stage operation in oral through-and-through defect cases. This method achieved excellent aesthetic results without complications. MATERIAL AND METHODS From January of 2004 to October of 2006, secondary debulking procedures were performed on 22 patients who had undergone reconstruction with free anterolateral thigh flaps. All flaps were on the cheek for oral cancer through-and-through defect reconstruction. Suction lipectomy with nonstandard open-tip cannula and w-plasty were performed. RESULTS All flaps survived well without any partial skin necrosis. Over 85% of patients were satisfied with the outcome. CONCLUSIONS This method can provide a one-stage debulking procedure for the cheek through-and-through defect after free flap reconstruction, and it achieves good aesthetic outcomes.

PERIPHERAL SYMPATHECTOMY FOR RAYNAUD'S PHENOMENON: A SALVAGE PROCEDURE

We retrospectively reviewed the effectiveness of peripheral sympathectomy for severe Raynauds phenomenon. In this study, a total of 14 digits from six patients with chronic digital ischemic change were included. All patients had pain, ulcer, or gangrenous change in the affected digits and were unresponsive to pharmacologic or other nonsurgical therapies. In all cases, angiography showed multifocal arterial lesions, so microvascular reconstruction was unfeasible. Peripheral sympathectomy was performed as a salvage procedure to prevent digit amputation. The results were analyzed according to reduction of pain, healing of ulcers, and prevention of amputation. In 12 of the 14 digits, the ulcers healed and amputation was avoided. In the other two digits, the ulcers improved and progressive gangrene was limited. As a salvage procedure for Raynauds phenomenon recalcitrant to conservative treatment, peripheral sympathectomy improves perfusion to ischemic digits and enables amputation to be avoided.

Management of the primary varicose veins with venous ulceration with assistance of endoscopic surgery

Two hundred sixty-two cases of primary varicose veins in which the lesions extended to the areas of the lower third of the leg and/or the ankle were treated with the assistance of endoscopic surgery. The conditions of varicose veins were classified by the reporting standards in venous disease. The number of cases in lesions of C2, C4, C5, and C6 were 60, 156, 31, and 15, respectively. They were also classified into 4 clinicoanatomic types according to varicositic changes in normal veins. The number of cases in types I, II, III, and IV were 57, 88, 42, and 75, respectively. The incidence of skin changes resulting from varicosity were 100%, 90.5%, 53%, and 50% in types I, II, III, and IV, respectively. The incidence of skin changes in this series was 77.6%. About one fourth of the cases having skin changes progressed to C5 and/or C6 lesions. Early and radical treatment of varicose veins could prevent the occurrence of skin changes and subsequently avoid the incidence of C5 and/or C6 lesions. The mean number of incisions in each limb was 2.9. With good illumination and magnified monitor view, the varicose veins and incompetent perforating veins were radically excised, but the normal veins were preserved. Forty-six cases of C5 and C6 lesions were followed up at least 1 year postoperatively. Four cases were lost from follow-up. In all cases except 1, there has been no recurrence. The conditions of skin changes improved subsequently. The recurrent rate of ulceration was 2.4%. In treatment of primary varicose veins with or without ulceration, surgery with assistance of endoscopic surgery achieved a low recurrence of ulcerations and minimal operative scarring.

Reversed-Flow Superior Thyroid Artery: An Alternative Recipient Vessel in Head and Neck Reconstruction

In neoadjuvant intra‐arterial infusion chemotherapy patients, the common recipient arteries are frequently damaged owing to preoperative chemotherapy‐induced intima injury. When ante‐grade arterial inflow to the free flap is not available, end‐to‐side carotid arterial anastomosis or exploration of another recipient artery may be an appropriate solution. However, reversed arterial flow is an alternative to such a situation. We report a case with squamous cell carcinoma on the right buccal area, which was successfully reconstructed using a free anterolateral thigh flap with reverse superior thyroid arterial inflow. This alternative method might shorten the operation time and also reduce further exploration injury in the operation field.

Medial Sural Artery Perforator (MSAP) Island Pedicle Flap for Medial Side of Knee Resurfacing under Epidural Anesthesia

Background: Numerous techniques were reported for knee soft tissue defect reconstruction. Regional flap with epidural anesthesia could be considered if patients underlying disease could not bear general anesthesia. Aim and Objectives: Epidural anesthesia instead of general anesthesia reduced high pulmonary morbidity in patients with pulmonary disease. Besides, epidural anesthesia can attenuate the surgical stress response, increase lower extremity blood flow associated with sympathectomy, and improve pain control. Materials and Methods: This 55 year old male has chronic obstruction pulmonary disease (COPD) with the problem of traumatic hemopneumothorax and soft tissue defect over medial side of left knee. Defect was resurfacing by medial sural artery perforator (MSAP) island pedicle flap under epidural anesthesia. Results: The MSAP island pedicle flap provides durable skin and thin soft-tissue coverage with good aesthetic result in four months follow up. Conclusion: The MSAP island pedicle flap could be an alternative choice in regional reconstruction, especially when patients condition is not suitable for general anesthesia.

Management of Primary Varicose Veins with the Assistance of Endoscopic Surgery: Its Role in the Treatment of Venous Ulceration

Purpose: Primary varicose veins have been treated using endoscopic surgery and achieved an encouraging result, with very low incidence of recurrence. In this study, the result of endoscope-assisted operation for primary varicose veins with venous ulceration was evaluated. Materials and Methods: From February 1997 to December 2006, 103 legs in 91 patients of primary varicose veins with skin ulceration (C5 and/or C6 lesions) were treated with the assistance of endoscopic surgery. The mean age of these patients at the time of operation was 58.1 (range 28-87) years. The numbers of C5 and C6 lesions were 55 and 48 respectively. A total of 97 legs in 87 patients received complete follow-up. The follow-up period ranged from 2 to 104 months. The results for the rate of ulcer healing and recurrence were analyzed with the Kaplan-Meier survival analysis. Results: Among the 97 legs receiving complete follow-up, initial ulcer healing was achieved in 95 legs (97.9%), including 50 legs in the C5 group and 45 legs in the C6 group. The mean time for ulcer healing was 11.3 and 15.2 weeks in C5 and C6 groups respectively. The total number of recurrences was 5 and the mean time of recurrence was 35.8 months. The 5-year ulcer recurrence rate was 7.3%. Only two legs in two patients did not heal completely after the operation in this series. This study revealed that there were always clustered varicose veins with variable incompetent perforating vessels running immediately beneath the ulcerated skin and/or at the base of the ulcer. To achieve a complete and non-recurrent ulcer healing, radical excision of these varicose veins was mandatory. Conclusion: In the treatment of primary varicose veins with ulceration, surgery with assistance of the endoscope achieved an excellent ulcer healing rate with low recurrence of ulcerations. Besides, with the advantages of the endoscope providing a magnified monitoring view with good illumination, the relationship between varicose veins and the venous ulcer was also established. This is a good alternative for the treatment of venous ulceration.

Suction Lipectomy with Nonstandard Open-tip Cannula and W-plasty for Flap Contouring Running Head: Liposuction and W-plasty for Flap Debulking

To manage oral defect following ablative cancer surgery the microvascular free tissue transfer is in fashion, and the bulkiness of such flaps usually poses concerns to both patients and surgeons after the operation, therefore, debulking procedures are usually in order. The suction lipectomy is the more common procedure than the other debulking procedures. Standard suction lipectomy procedure is usually using a small blunt-tip cannula, which can not adequately suck out the subdermal fat, due to the flap is relatively dense and compact in consistency. To resolve the inadequacy of this standard suction lipectomy procedure, we introduce the use of nonstandard open-tip cannula. In this study, we generated 204 patients, ranging in age from 35 to 69 years old, who underwent ablative surgery for oral squamous cell carcinoma from January 2001 to January 2005. All 204 patients had through-and-through oral defects and accepted free tissue transfer, however, because of the unsightly bulky appearance, 52 (25%) of them received a combination of both liposuction by open-tipped cannula and scar revision by w-plasty. We reported that the use of nonstandard open-tip cannula 10 mm or 8 mm in diameter for debulking lipectomy produced excellent cosmetic results with our patients in this study. We combined this technique with W-plasty scar revision at the same time. There is no partial or total flap necrosis noted in this one-stage operation and all patients were satisfied with the outcome.

Vibrio Vulnificus Infection: Cases Review of a Medical Center and Consideration for Future Directions

The mortality rates of Vibrio vulnificus infection have remained relatively high, ranging from 25% to 90% and approaching 100% if septic shock occurred, over the past two decades. Well-documented studies have pointed out some guidelines for antibiotic use and surgical intervention but adequate description and method have not been provided yet. Our studies is a retrospective review of fifty cases of Vibrio vulnificus infection. Consumption of raw or undercooked seafood, marine-related occupations and liver disease are risk factors. Vigilance of this fatal infection in high risk groups along with early medical antibiotics, and surgical debridement may reduce the chance of death or amputation.

Abdominal Wall Reconstruction with Pedicled Anterolateral Thigh Fasciocutaneous Flap in Infected Abdominal Mesh-One Case Report

The infection rate following abdominal wall reconstruction by using mesh has been reported to be about 8%-16%. This is a difficult and frustrating problem and may result in mesh exposure, persistent discharging sinus and enterocutaneous fistula. Conservative management is a time-consuming procedure and the patients suffer from an open discharging wound for long time. We performed radical excision of the infected mesh and then reconstructed with the pedicled anterolateral thigh flap as a one-stage procedure. The integrity of the abdominal fascia was restored with fascia lata and at 9 months follow-up, no ventral hernia was observed. Although this is just a single case report, we believe that this technique can decrease the patients suffering and hospital stay, and it deserves further investigation.

The Effect of Adventitia Stripping in Refractory Ischemic Digits

Ischemic disease of digits is a very frustrating and extremely difficult clinical problem. It is often caused by a variety of diseases, such as atherosclerosis, connective tissue disease, trauma and Raynauds disease. Patients with this problem usually suffer from poor tissue perfusion and impaired microcirculation. In clinical, ischemic digits often present with pain, cold intolerance, ulceration and even gangrene change. Many strategies are proposed today to overcome this disease. Behavioral therapies, such as avoidance of cold exposure and smoking are a very important intervention. Pharmacologic therapies, like the administration of calcium channel blocker, PGE1 and other vasodilators have been the most commonly used agents. Sympatholytic drugs have also been added to reduce the sympathetic tone in vascular smooth muscles. In addition, anticoagulants or antiplatelet agents are administered to inhibit thrombus formation in occlusive vascular disease. Although these agents are usually effective, unfortunately, in refractory cases, amputation is unavoidable. Those patients have to suffer the fate of partial or total loss of the digits. This ultimate outcome frequently comes with high morbidity and dysfunctions both in physical and psychological terms. In those cases which are refractory to medical therapy, surgical intervention had been carried out to improve tissue perfusion. Tissue perfusion depends on the integrity of the vasculature and the neurovascular regulatory elements. Historically, microsurgical revascularization and sympathectomy were widely performed to recover adequate blood flow. Microvascular reconstruction with interposition vein grafting can be used to reestablish the vascular structure. However, not all cases with digital ischemia are suitable for this procedure due to the possible occurrence of multifocal stenosis. Sympathectomy can reduce sympathetic tone and thus increase the radius of blood vessel. According to Poiseuilles law, blood flow is directly proportional to the fourth power of the vessels radius. So even a small increase of radius of blood vessel can lead to a very great increase in blood flow. According to Pick and Flatt, sympathetic fibers travel along the epineurium of peripheral nerve, pass to the adventitia, and innervate the smooth muscle of vessels. The removal of adventitia can block the sympathetic tone in the smooth muscle. This procedure may also increase the radius of vessel and reestablish adequate blood flow.