Ming-Huei Cheng

• MD, MBA, FACS
• Professor and Chairman at A+ Surgery Clinic

Lymphedema is a chronic, dynamic, and multifaceted disease that is effectively treated by surgery. However, there is a lack of consensus in the field about the ideal technique; is it better to perform one surgery type at a time (the “single‐malt whisky” approach), or combine different procedures in a single surgery (the “cocktail” approach)? Here,...

Negative pressure therapy (NPT) has been shown to facilitate wound healing and promote hair growth in a porcine model. However, there is a paucity of research on the impact of negative pressure on hair growth in murine models. Despite the ability of nude mice to develop hair follicles, the hair they produce is often flawed towing to genetically ind...

Secondary lymphedema is a common condition among cancer survivors, and treatment strategies to prevent or treat lymphedema are in high demand. The development of novel strategies to diagnose or treat lymphedema would benefit from a robust experimental animal model of secondary lymphedema. The purpose of this methods paper is to describe and summari...

Lower extremity lymphedema following perineal resections and particularly pelvic clearance and/or inguinal lymphadenectomies is a debilitating complication of cancer treatment.KeywordsVascularized lymph node transferSubmental lymph nodeLower extremity lymphedemaLymphatic microsurgeryLymphaticovenous anastomosisLiposuction

Background: The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. Methods: Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricula...

Background: The pathophysiology of adipose proliferation or differentiation in extremity lymphedema has not been thoroughly studied. This study investigated the impacts of the lymph harvested from lymphedematous limbs on the adipogenesis of adipose-derived stem cells (ASCs). Methods: ASCs were isolated from the adipose tissue of normal extremiti...

Lower extremity lymphedema can be from either primary or secondary causes. Regardless, surgical management is largely guided by Cheng’s Lymphedema Grading correlated with the Taiwan Lymphoscintigraphy Staging. Lower extremity lymphedema with Cheng’s Lymphedema Grading of Grades II–IV with total obstruction on lymphoscintigraphy is an indication for...

Background: This study investigated the effect of nanofibrillar collagen scaffold (BioBridge) implantation from the affected limb to the unaffected contralateral femoral vein or lymph node in a rat model. Methods: Hind limb lymphedema in Lewis rats was created with lymphadenectomy and inguinal circumcision without radiation. The volumetric diffe...

Background: This study investigated breast cancer-related lymphedema (BCRL) and its correlation with the incidence of cellulitis and mortality in the National Health Insurance (NHI) database in Taiwan. Methods: Between 2004 and 2014, the NHI database of patients with breast cancer who underwent surgical procedures, adjuvant therapies, BCRL, cell...

Background: This study investigated the outcomes of the distal facial vein catheterization (DFVC) to manage venous thrombosis in vascularized submental lymph nodes (VSLN) flap transplantations. Methods: Between March 2017 and December 2020, patients who underwent VSLN flaps were divided into Group I: combined delayed primary retention sutures (D...

The vascularized lymph node transfer in elderly patients was a safe, reliable, and effective procedure with minimal complications. It has significantly decreased the frequency of cellulitis and improved the quality of life without using compression garments postoperatively.

Background: Secondary lymphedema is a debilitating morbidity. This study investigated the outcomes of vascularized lymph node transfer (VLNT) in elderly patients with secondary upper extremity lymphedema. Methods: Between 2008 and 2018, elderly (≥65 years) patients with secondary upper extremity lymphedema who underwent VLNT were retrospectively...

Background: This study investigated the long-term effects of arterial ischemia and venous occlusion on lymph node drainage function in a rat model. Methods: Bilateral groin lymph node flaps of 18 Lewis rats were dissected. The pedicle artery was clamped for 4, 5, and 6 h (A4, A5, and A6 groups), and the vein for 3, 4, and 5 h (V3, V4, and V5 gro...

The vascularized submental lymph node flap is an excellent donor site for vascularized lymph node transfer (VLNT). Iatrogenic donor site lymphedema of the head and face has not been reported, and it has the advantages of greater number of lymph nodes, reliable skin paddle for flap observation, and larger pedicle facial vein for lymphatic drainage f...

The engineering of tracheal substitutes is pivotal in improving tracheal reconstruction. In this study, we aimed to investigate the effects of biomechanical stimulation on tissue engineering tracheal cartilage by mimicking the trachea motion through a novel radial stretching bioreactor, which enables to dynamically change the diameter of the hollow...

Background: Breast reconstruction with nipple-sparing mastectomy (NSM) has superior aesthetic outcomes. This study investigated the outcomes of NSM with deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast aesthetics. Methods: All patients who underwent NSM with DIEP flaps were rec...

Tracheal reconstruction remains challenged in clinical. We aimed to fabricate scaffolded cartilage sheets with rigid and elastic supports for tracheal reconstruction. The chondrocyte cell-infiltration activity was examined in the polycaprolactone sheet scaffolds with various thicknesses and pore sizes after seeding cells on the top surface of the s...

Background: Heparin-induced thrombocytopenia and thrombosis (HITT) may result in microsurgical flap failure. This study investigated the outcomes of HITT in primary lymphedema patients who underwent vascularized lymph node transplantations (VLNT). Methods: Between 2012 and 2019, primary lymphedema patients who underwent VLNTs were retrospectivel...

The indications for submental vascularized lymph node flap transfer include Cheng’s Lymphedema Grades 2–4, total obstruction of the lymphatic system in Taiwan Lymphoscintigraphy Staging (TLS) T4–T6, partial obstruction of TLS P1–P3, without patent lymphatic vessels, repeated episodes of cellulitis, and failure to complete decongestive physical ther...

The surgical treatment of lymphedema has evolved tremendously over the past decade. With the advances in microsurgical techniques, new options are available for patients suffering from the physical and emotional sequelae of symptomatic lymphedema. Furthermore, recent strides in new technology, techniques, and improved skill-sets have resulted in an...

Primary extremity lymphedema is a debilitating disease with a reported incidence of 1–3 in every 10,000 births, and it may present with concomitant vascular lesions or retroperitoneal lymphangiomatosis with chylous ascites. The diagnosis of primary extremity lymphedema includes history, physical examination, lymphoscintigraphy, and indocyanine gree...

The surgical and microsurgical treatment of lymphedema is rapidly evolving with new technology of diagnostic devices, new surgical techniques, improved outcome reporting, and descriptions of more effective treatment strategies. Moving forward within the subspecialty, a thorough understanding of previous developmental milestones related to lymphatic...

Surgical treatments for lymphedema may be appropriate when nonsurgical therapy is inadequate in maintaining well-controlled symptoms. To better understand surgical outcomes, a more comprehensive definition of surgical success and cure is a prerequisite. Tracking outcomes post lymphedema surgeries include the limb circumferential or volumetric measu...

For many years, lymphoscintigraphy has been considered the gold standard imaging modality for the diagnosis of extremity lymphedema. The diagnostic utility of lymphoscintigraphy depends upon meticulous technical performance and correct image interpretation. However, there is no standardized lymphoscintigraphy protocol, making comparison among studi...

Dental stem cells can differentiate into different types of cells. Dental pulp stem cells, stem cells from human exfoliated deciduous teeth, periodontal ligament stem cells, stem cells from apical papilla, and dental follicle progenitor cells are five different types of dental stem cells that have been identified during different stages of tooth de...

Demand for gender-affirming phalloplasty continues to grow worldwide, and the extended radial forearm flap phalloplasty remains one of the most commonly performed techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting...

Background: Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. Methods: Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node t...

Background: Advantages of one‐stage implant‐based reconstructions include expedited surgery and recovery. This study aimed to investigate clinical and patient‐ reported outcomes in one‐stage implant‐based breast reconstructions without acellular dermal matrix (ADM). Methods: A prospectively collected database from 2002 to 2018 was retrospectively...

Toluene and xylene are common components of surgical smoke, whereas hippuric acid (HA) and methylhippuric acid (MHA) are the products of toluene and xylene metabolism in humans, respectively. HA and MHA can be used as indicators to evaluate the exposure hazards of toluene and xylene. In this study, we used liquid chromatography tandem mass spectrom...

Objectives The composition and concentration distribution of volatile organic compounds (VOCs) in surgical smoke had seldomly been reported. This study aimed to investigate the profile of VOCs and their concentration in surgical smoke from breast surgery during electrocautery in different tissues, electrosurgical units, and electrocautery powers....

Background: This study compared the outcomes of unilateral microsurgical breast reconstructions using abdomen-based flaps between normal body mass index (BMI; 18.5 < BMI < 24.9 kg/m2) and overweight (25 < BMI < 29.9 kg/m2) patients. Methods: Between March 2000 and December 2015, patients who underwent unilateral breast reconstructions using abdo...

Background This study investigated the morbidity of the marginal mandibular nerve (MMN) post vascularized submental lymph node (VSLN) harvest. Methods The VSLN with sacrifying or preserving the medial platysma was retrospectively classified as group I or II. Midline deviation and horizontal tilt were subjectively evaluated. Horizontal, vertical, a...

Background: The composition and concentration distribution of volatile organic compounds (VOCs) in surgical smoke had seldom reported. This study aimed to investigate the profile of VOCs and their concentration in surgical smoke from breast surgery during electrocautery in different tissues, electrosurgical units, and electrocautery powers. Methods...

Background Primary lymphedema is an anomaly of the regional lymphatic system with long symptom duration or severe lymphatic obstruction. Few microsurgical treatments for primary lymphedema have been reported. This aim of this study was to investigate the outcomes of microsurgical treatments in pediatric primary lymphedema patients. Methods Between...

Background Extremity lymphedema can occur bilaterally with different severities on each side. The aim of this study is to investigate the treatment outcomes of such patients with bilateral extremity lymphedema of different severities.Patients and Methods Between 2013 and 2017, patients with bilateral extremity lymphedema of different severities acc...

Background: The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema. Methods: Thirty-two female patients with unilateral lower extremity lymphe...

Background: The medial sural artery perforator (MSAP) flap is an increasingly versatile and reliable flap for soft tissue reconstruction. This study investigates complication rates and long-term outcomes of the MSAP flap. Methods: A retrospective review was performed on consecutive patients undergoing MSAP flap reconstruction at Chang Gung Memor...

Background: Lymphedema is a disease in which tissue swelling is caused by interstitial fluid retention in subcutaneous tissue. It is caused by a compromised lymphatic system. Lymphoscintigraphy is the current and primary modality used to assess lymphatic system dysfunction. Ultrasound elastography is a complementary tool used for evaluating the ti...

Background: This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer-related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings. Methods: Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo...

Background: Lymphedema surgery was not widely known in Austria before the introduction of lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in 2014. This study shares the experience and process of establishing and institutionalizing lymphedema surgery service in Austria. Methods: The purpose of introducing reconstructive...

Background: Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients...

Background: Vascularized lymph node transfer (VLNT) is an effective surgery for extremity lymphedema. This study evaluated a lymphatic drainage device (LDD) for the drainage of accumulated fluid into the venous system. Methods: Micropore filtering membranes with pore sizes of 5, 0.65, and 0.22 μm polyvinylidene difluoride, and 0.8 μm Nylon Net F...

Background: The aim of this study was to compare non-contrast-enhanced 3D phase contrast magnetic resonance angiography (3D PC-MRA) and conventional intravenous administration of contrast media, i.e., contrast-enhanced MRA (CE-MRA), to evaluate the courses of facial arteries for the preparation of vascularized submental lymph node flap (VSLN flap)...

The hands‐on supermicrosurgery course provided participants a valuable learning experience of in‐depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular,...

Background: Vascularized lymph node transfer (VLNT) has become one of the effective surgical treatments for extremity lymphedema. This study was to evaluate the re-exploration and total complication rates of VLNT for lower extremity lymphedema between two different flap inset techniques. Methods: Sixty-nine patients who underwent 74 submental VL...

Background: Retroperitoneal lymphangiomatosis (RL) is a rare form of primary lymphedema featuring aberrant retroperitoneal lymphatic proliferation. It causes recurrent cellulitis, repeated interventions, and poor life quality. This study aimed to investigate proper diagnositc criteria and surgical outcomes for RL with extremity lymphedema. Method...

Background: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. Methods: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inf...

The anterolateral thigh (ALT) flap is one of the most versatile and reliable of the thigh-based free flaps. The ALT flap is indicated for reconstruction of a diverse range of defects of various surface area and depths; it can be used as a “ultra-thin” flap for resurfacing, rolled up for filling in dead space, or taken with muscle to obliterate spac...

The second edition of Operative Plastic Surgery is a fully updated, comprehensive text that discusses the most common plastic surgery procedures in great detail. It covers the classic techniques in plastic surgery, as well as the most recent technical advances while maintaining a systematic approach to patient care within each chapter. Traversing t...

Background: Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema. Methods: Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retros...

Appropriate diagnosis, staging and a further selection of the best treatment are fundamental for the management of patients with extremity lymphedema. Several clinical and imaging tools have been described for these purposes. Lymphoscintigraphy is still considered the gold standard imaging modality for diagnosing lymphedema. However, protocol varia...

Objectives: This study aimed to identify the cognitive factors associated with the professional healthcare advice (PHCA) seeking behavior in breast cancer-related lymphedema (BCRL). Methods: From January 2018 to December 2018, patients with BCRL were prospectively enrolled for a cross-sectional survey of lymphedema-related perceived risks, lymph...

Introduction Patients with pre‐existing lymphedema who undergo total knee arthroplasty (TKA) for osteoarthritis (OA) are at high risk for periprosthetic joint infection. This complication usually requires removal of the implant. This study aimed to investigate whether surgical treatment of lymphedema reduces the rate of prosthesis removal in such p...

Purpose The differentiation of arterial versus venous occlusion in free tissue transfers has rarely been described. This study investigated changes in blood flow caused by arterial and venous occlusion and the potential for laser Doppler flowmetry to distinguish between these 2 conditions for better clinical assessment and management of free tissue...

Background Reported ischemia time of vascularized lymph nodes was 5 hours. This study investigated the effects of arterial ischemia and venous occlusion on vascularized lymph node function in rats. Methods Bilateral pedicled groin lymph node flaps were raised in 27 Lewis rats. Femoral artery and vein were separated and clamped for 1, 3, 4, or 5 ho...

Background: Cell-seeded biomaterial scaffolds have been proposed as a future option for reconstruction of bone tissue. The ability to generate larger, functional volumes of bone has been a challenge that may be addressed through the use of perfusion bioreactors. In this study, the authors investigated use of a tubular perfusion bioreactor system f...

Background: Lymphovenous anastomosis (LVA) is technically challenging and could be successfully performed with advanced operating microscope, super-microsurgical instruments, and indocyanine green (ICG) lymphography. This study was to compare the outcomes between side-to-end and end-to-end LVA configurations for unilateral extremity lymphedema. M...

Objective There is no useful tool to clinically predict the occurrence of osteoradionecrosis (ORN) of the mandible quantitatively. The aim was to investigate the risk factors, including different modalities of radiotherapy, for developing mandibular ORN in patients undergoing marginal mandibulectomy and postoperative radiotherapy. Methods Between...

Background:. Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer–related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patien...

Background:. Circumferential difference of lymphedematous limbs at designated anatomic distances has been the primary mode for measuring lymphedematous extremities. Computed tomography (CT) imaging produces accurate, consistent, hygienic volume measurements and a direct limb representation. This study compares these 2 main modalities and assesses t...

The mandible is an essential element of the form and function of the face. Without a normal mandible, normal speech, mastication, deglutition, and, perhaps most importantly, social interaction are all partially if not completely impeded. It is therefore not an overstatement to say that a functional and esthetic reconstruction of the mandible follow...

Cancer surgery is the most common reason for buccal and tongue reconstruction. Considering the reconstruction result and postoperative treatment, especially the requirement of radiotherapy, microsurgery with free flap transfer is now being the one with most optimal result. It has now been the gold standard in head and neck reconstructions, and many...

Successful reconstruction of the maxilla or midface requires a thorough understanding of the anatomy, defect dimensions, and flap options. Several classifications of maxillectomy defects exist, with Cordeiro’s and Bronn’s being commonly uses. With the advances of reconstructive techniques, free tissue transfer become more widely used and is able to...

Background: Primary lymphedema is a debilitating disease. This study was to investigate the outcomes between vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) for treating primary lymphedema. Methods: Between January 2010 and December 2016, 17 patients with mean age of 31.5 ± 15.5 (ranged, 2-57) years diagnosed with 19 p...

Background:. The vascularized groin and submental lymph node (VGLN and VSLN) flaps are valuable options in the treatment of lymphedema. This study was to compare outcomes between VGLN and VSLN transfers for breast cancer–related lymphedema. Methods:. Between January 2008 and December 2016, VGLN and VSLN transfers for upper limb lymphedema were comp...

Purpose: Breast conservation therapy (BCT) is widely accepted for breast cancer treatment. Nipple-sparing mastectomy has been newly developed to preserve the nipple-areolar complex and enhance aesthetic results. The purpose of this study was to evaluate the oncological safety and results of nipple-sparing mastectomy (NSM) after previous BCT. Meth...

Backgroud The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions. Methods Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and conc...

Background: Nipple‐sparing mastectomy poses challenges in providing esthetically‐pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple‐sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites. Methods: Between 2010 and 2016, 79 patients who und...

Purpose To evaluate the feasibility of cutaneous and subcutaneous limb tissue elasticity measurement in participants with limb lymphedema by using acoustic radiation force impulse (ARFI) elastography. Materials and Methods From July 2015 to June 2017, ARFI elastography was performed in 64 participants with lymphedema (seven men and 57 women; age ra...

Objective: The aim was to validate the new Taiwan Lymphoscintigraphy Staging, correlate it with Cheng Lymphedema Grading (CLG) and evaluate the treatment outcomes of unilateral extremity lymphedema. Background: No consensus has been reached for diagnosis and staging for patients with lymphedema among medical specialties. Methods: We included 2...

Background: Vascularized lymph node transfer (VLNT) has shown promising results in the treatment of lower limb lymphedema, but little is known about the number of lymph nodes needed for the transfer to achieve optimal results. This study investigated the correlation between number of transferred lymph nodes in submental VLNT and outcomes regarding...

Background The inframammary fold (IMF) approach for augmentation mammaplasty is less popular in Asia. The incision was modified to lateral IMF(L-IMF) for easy access and better outcome. The aim of this study was to evaluate if L-IMF approach is feasible in Asian women. Methods Between 2002 and 2016, 53 patients with 96 augmentation mammaplasties w...

Tissue engineering has the potential to overcome the limitations of tracheal reconstruction. To tissue-engineer a tracheal cartilage, auricular chondrocytes were encapsulated in a photocurable poly(ethylene glycol)/poly(ε-caprolactone) (PEG/PCL) hydrogel. Chondrogenic genes, including Sox9, Acan and Col2a1, were up-regulated in auricular chondrocyt...

Periosteal osteogenic capacity can be exploited to enhance bone formation in the fields of tissue engineering and regenerative medicine. Despite this importance, there have been no studies examining the composition, structure and osteogenic capacity of periostea from different bone sources. In this study, structure and osteogenic factor content wer...

Background: Vascularized lymph node transfer is a promising surgical treatment for lymphedema. This study investigates the effect of ischemia on the lymphatic drainage efficiency of vascularized lymph node flaps and the critical ischemia time of lymph nodes. Methods: Twenty-four lymph nodes containing groin flaps in twelve Sprague-Dawley rats we...

Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly pe...

As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection...