Yuan-Sheng Tzeng

Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect.

We describe our experience using the proximal pedicled anterolateral thigh (ALT) flap for the reconstruction of trochanteric defects. Seven ALT island flap procedures were performed in 6 patients between September 2006 and May 2007. Four of the 7 patients had trochanteric pressure sores because of paraplegia. In these patients, intramuscular perforators were dissected to raise a fasciocutaneous flap. Three myocutaneous flaps of the vastus lateralis muscle were used to treat osteomyelitis of the trochanter with implant extrusion. The mean follow-up was 7 months (range, 2–12 months), and all flaps survived. Trochanteric coverage with the proximal pedicled ALT flap gave excellent results. We conclude that the ALT flap is a reliable flap for trochanteric coverage.

Herniation of the cervical disk in plastic surgeons.

AbstractHerniations of the cervical disk in plastic surgeons are far more common in practice than the paucity of reported cases would indicate. A likely explanation may be the peculiar, nonergonomic positions that plastic surgeons must hold during surgery while wearing a headlight and loupes. From January 2003 to December 2006, at Tri-Service General Hospital, Taiwan, 4 plastic surgeons experienced herniations of the cervical disk. Magnetic resonance imaging study indicated there was disk herniation or bulging with spinal cord impingement. Two plastic surgeons received cervical diskectomy, corpectomy with strut reconstruction using titanium cages. These 2 surgeons were symptom-free 2 years after their operations. The other 2 plastic surgeons were under conservative physical therapy with persistent symptoms. The clinical evidence indicated that cervical disk herniation is an occupational hazard in plastic surgeons. To prevent prolonged hyperflexion and twisting of the neck, we proposed wearing a cervical brace during surgery for the plastic surgeons at Tri-Service-General Hospital since January 2008. No more plastic surgeons have experienced herniation of the cervical disk since then. The results indicated that wearing a cervical brace may be an effective measure to protect plastic surgeons from cervical disk disease.

Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores

BACKGROUND Despite advances in reconstruction techniques, the treatment of sacral sores remains challenging to plastic surgeons. The superior gluteal artery perforator (SGAP) flap is reliable and preserves the entire contralateral side as a future donor site. The ipsilateral gluteal muscle is preserved, and the inferior gluteal artery flaps are viable. However, dissection of the perforator is tedious and may compromise the perforator vessels. METHODS Between April 2003 and March 2013, we performed two modified flap-harvesting techniques: a rotational and a tunnel method, with only a short pedicle dissection to cover 30 sacral defects. Patient characteristics including sex, age, cause of sacral defect, flap size, perforator number, use and postoperative complications were recorded. RESULTS All flaps survived except two, which developed partial flap necrosis and were finally treated by contralateral V-Y advancement flap coverage. The mean follow-up period was 14.8 months (range, 3-24 months). No flap surgery-related mortality or recurrence of sacral pressure sores or infected pilonidal cysts were noted. CONCLUSIONS Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. The advantages of our modification procedure include shorter operative time, lesser bleeding and lesser pedicle trauma, which make the SGAP flaps an excellent choice for sacral sore coverage.

Reconstruction of perineoscrotal defects in Fournier's gangrene with pedicle anterolateral thigh perforator flap

Fourniers gangrene is an acute and potentially lethal necrotizing fasciitis that involves the scrotum and perineum. This disease can result in the extensive loss of skin and soft tissues of the perineoscrotal area with exposure of the testes. To reconstruct the large defects of scrotal and perineal remains a surgical challenge.

Intraoperative indocyanine green fluorescent angiography-assisted modified superior gluteal artery perforator flap for reconstruction of sacral pressure sores

Pressure sores are often observed in patients who are bedridden. They can be a severe problem not only for patients and their caregivers but also for plastic surgeons. Here, we describe a new method of superior gluteal artery perforator flap harvesting and anchoring with the assistance of intraoperative indocyanine green fluorescent angiography. In this report, we describe the procedure and outcomes for 19 patients with grades III and IV sacral pressure sores who underwent the operation between September 2015 and November 2016. All flaps survived, and two experienced wound‐edge partial dehiscence. With the assistance of this imaging device, we were able to acquire a reliable superior gluteal artery perforator flap and perform modified operations with it that are safe, easy to learn and associated with fewer complications than are traditional.

Is monitor flap monitoring

Reconstruction of through and through buccal defects after ablation of head and neck cancer is a challenge for the plastic surgeons that requires three-dimensional restoration of the missing tissue. The chimeric anterolateral thigh (ALT) flap first developed by Hallock in 1991 is a combined composite free flap using the lateral circumflex femoral system that has separate skin paddles with different perforators physically attached to the same mother vascular source. The features of this flap made it possible to repair the oral mucosal lining and cheek skin simultaneously with one anastomosis of pedicle. Free flap success is enhanced by the rapid identification and salvage of failing flaps. Constant monitoring of such flaps in free tissue transfer is very crucial to flap survival and salvage. Abnormal appearance of the monitoring component may suggest a compromised flap and this demands emergency pedicle exploration. On the other hand, good viability seen on the monitoring component gives strong indication of a successful free tissue transfer. Many techniques have been developed including implanting devices to monitor the flap, and new imaging techniques to check the flap’s viability. Monitoring-muscle flap or externalizing a component of the flap for monitoring has been used with good benefits. The main disadvantage for these techniques was increased donor site morbidity or the involvement of another donor site for the harvest of skin grafts. The chimeric flaps reported to provide a useful method of external monitoring is reliable, easy to perform, easily interpreted by the nursing staff, and needs no special equipment and provides very sensitive monitoring of a buried flap. However, is monitor flap is really monitoring? We reported a 53-year-old male, a victim of head and neck squamous cell carcinoma, received tumor ablation and simultaneous free flap reconstruction. After ablative excision, an ALT flap with vastus lateralis (VL) muscle was harvested in a chimeric fashion based on a common source vessel-descending branch of the circumflex femoral vessels to reconstruct the resultant two widely separated defects: the first was the tongue-oral cavity and the second the extensive skin and soft tissue defect at the right cheek. The skin paddle was splitted in two skin islands during flap inset. The distal skin island (11 3 8.5 cm) based on the distal perforator was used to reconstruct the cheek defect and the proximal one (10 3 8 cm) based on the proximal perforator to cover the tongue-oral base defect (Fig. 1A). The VL muscle was placed at the right side of maxillary sinus to fill the dead space. Before ligation of the pedicle, both skin and muscle portions had robust blood supply. After microanastomosis to the recipient vessels (superior thyroid artery and external jugular vein), both portions of this chimeric flap regained reperfusion well. However, only the proximal skin island remained revascularized rather than the distal one that reconstructed the right cheek defect after 1 day have passed (Figs. 1B and 1C). At that time, primary thrombosis at the anastomotic site was ruled out by immediately rechecking the flap at the operation room. Under the impression of pedicle injury, we immediately replaced the failing external skin flap using the pedicled pectoris major muscle flap (Fig. 1D). Postoperative course was uneventful and the patient was discharged from the hospital 10 days later. *Correspondence to: Yuan-Sheng Tzeng, M.D., Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei, 11490, Taiwan. E-mail: aarondakimo@yahoo.com.tw Received 24 May 2013; Revised 2 July 2013; Accepted 19 July 2013 Published online 3 September 2013 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22173

The Abdominohypogastric Flap as a Salvage Flap for Composite Wound Coverage of the Forearm and Elbow

Extensive trauma to the upper limb resulting in complex bony fractures and soft-tissue loss usually necessitates extensive free-flap reconstruction to achieve one-stage wound coverage and a satisfactory contour. However, trauma may induce thrombosis of recipient vessels, which may result in failure of the free flap. A groin flap can be used as a salvage flap; the use of groin flaps is usually restricted to soft-tissue coverage of the hand and distal forearm. In this report, we describe an abdominohypogastric flap that was used as a salvage flap for proximal forearm and elbow coverage in two patients in whom free-flap reconstruction was unsuccessful.

Modification of Superior Gluteal Artery Perforator Flap for Reconstruction of Sacral Sores

Background: Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The superior gluteal artery perforator (SGAP) flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. However, the dissection of the perforator is tedious and carries a risk of compromising the perforator vessels. Methods: We modified the harvesting technique into two flap designs: a rotational and a tunnel method with only a short pedicle dissection to cover 12 sacral sores. Results: All flaps survived except one, which had flap tip necrosis and was treated by secondary closure. Conclusion: The advantages of this modification include a faster operation, less bleeding, and less trauma of the pedicle, which make the SGAP flaps an excellent choice for sacral pressure sore coverage.

Use of split-thickness plantar skin grafts in the management of leg and foot skin defects: Systematic review on epidermal grafting

The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split‐thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split‐thickness skin graft (0.014 in. thick) from a non‐weight‐bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.

Breast Reconstruction Using Pedicled Latissimus Dorsi Myocutaneous Flaps in Asian Patients With Small Breasts.

Background The use of implants is still the most common procedure for breast reconstruction because they are easy, less painful than tissue transplants, and do not need a donor site. However, it is challenging to find a suitable implant for patients with small breasts, and some women fear foreign bodies and possible complications or reoperations. Autologous breast reconstruction using the pedicled latissimus dorsi (LD) myocutaneous flap without an implant provides a good option for Asian women with small breasts. Materials and Methods Between June 1992 and December 2015, 31 patients underwent breast reconstruction with 33 LD flaps (29 unilateral and 2 bilateral). The skin paddle of the flap was designed with an oblique or transverse pattern depending on the mastectomy defect and the elasticity of skin. The thoracodorsal nerve was divided during flap harvesting to prevent a “twitching breast” postoperatively. Patients refused to have contralateral breast augmentation except for 2 with bilateral simultaneous augmentation after mastectomy bilaterally. Outcome measures were flap survival, shape and contour, symmetry of breast, complication of flap and donor site, patient satisfaction, and any local tumor recurrence or metastasis. Results The mean patient age was 46.7 years (range, 27–72), and the mean body mass index was 22.5 kg/m2 (range, 18.6–30). The mean size of the harvested skin paddle was 11.9 × 5.0 cm (range, 10 × 3 cm to 15 × 9 cm). Mean operative times were 200.8 minutes (range, 112–230 minutes) and 305 minutes (range, 300–310 minutes) for unilateral and bilateral reconstructions, respectively. Pathology reports showed a negative safety margin in all cases. Most cases were of invasive duct carcinoma (58%). All LD flaps survived, and the wounds healed satisfactorily over a mean follow-up of 49.9 months (range, 3–161 months). Donor sites were closed primarily with a hidden linear scar under the dorsal bra strap. Donor site morbidities were mainly seromas (15%), which were treated conservatively in most patients. Conclusions The LD flap produced good autologous tissue for reconstruction, and no implants were needed for Asian women with small breasts. The reconstructed breasts showed good shape, contour, and symmetry. The results of donor site were acceptable and no significant functional loss. There were no major complications, and patient satisfaction was high.