[Show abstract][Hide abstract] ABSTRACT: Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator 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. We present our experience of using parasacral perforator flaps in reconstructing sacral defects.
Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator flap. The patients' sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded.
There were 19 parasacral perforator flaps in this series. All flaps survived uneventfully except for 1 parasacral perforator flap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall flap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2-24 months). The average length of hospital stay was 20.7 days (range, 9-48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period.
Perforator-based flaps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator flaps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator flap as a good choice for reconstructing sacral defects.
No preview · Article · Jul 2015 · Annals of plastic surgery
[Show abstract][Hide abstract] ABSTRACT: Breast deformities after augmentation with injectable materials carried out by uncertified medical personnel present challenging problems. Materials include liquid silicone, paraffin, polyacrylamide hydrogels, and unknown gels. They usually cause granulomatous reactions, erythema, pain, and even skin necrosis. Tender masses that cannot be differentiated from breast cancers are the major concern. This retrospective study presents the authors' experience in managing 10 symptomatic injected breasts in five patients during the past 8 years. Subcutaneous mastectomies were carried out using periareolar, inverted "T", or inframammary approaches combined with breast reconstruction using bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flaps. All flaps survived well and gave a satisfactory cosmetic appearance. There was no major complication or late occurrence of breast cancers over the following 8 years. Injectable materials used for breast augmentation should be prohibited until more scientific data are available about the long-term effect of these materials in breast tissues. Once the injected breasts become symptomatic, subcutaneous mastectomy and reconstruction with bilateral pedicled TRAM flaps is a reasonable option for the patient.
[Show abstract][Hide abstract] ABSTRACT: Fournier's gangrene is an acute and potentially lethal necrotising fasciitis that involves the scrotum and perineum. This disease can result in the loss of skin and soft tissue. To repair the scrotal and perineal defects remains a surgical challenge.
Between January 2000 and December 2008, 50 patients were admitted to our hospital with a diagnosis of Fournier's gangrene. We retrospectively reviewed 31 of the 44 surviving patients, who needed reconstructive procedures for coverage of scrotal and perineal soft-tissue defects. The choice of reconstructive procedure was based on the size, location, severity of the defects and the availability of local tissue. The patients' age, predisposing factors, defect size and location, reconstructive procedures and outcomes were reviewed.
The mean age of the patients was 53.6 years (range, 20-84 years). The average size of the skin defect was 86 cm(2). A total of 12 patients were treated by scrotal advancement flap coverage, nine by split-thickness skin graft, five by pudendal thigh flap, two by gracilis myocutaneous flap, one by gracilis muscle flap plus split-thickness skin graft and three by pedicle anterolateral thigh flap. The overall surgical complication rate was 16%.
Early debridement and wound coverage in Fournier's gangrene are mandatory to allow patients to return to normal life. We set up a valuable reconstructive algorithm based on the characteristics of the defects and our 9 years of experience, which adds to the versatility of the armamentarium of the reconstructive surgeon.
No preview · Article · Apr 2011 · Journal of Plastic Reconstructive & Aesthetic Surgery
[Show abstract][Hide abstract] ABSTRACT: Microvascular free flap transplantation is the current most common choice for reconstruction of difficult through-and-through buccal defect after cancer extirpation. The chimeric anterolateral thigh (ALT) flap is an ideal flap to cover this full thickness defect, but variation in the location of perforators is a major concern. Herein, we introduce computed tomographic angiography (CTA)-guided mathematical perforators mapping for chimeric ALT flap design and harvest.
Between September 2008 and March 2009, nine patients with head and neck tumour underwent preoperative CTA perforator mapping before free ALT flap reconstruction of full thickness buccal defects. The perforators were marked on a 64-section multi-detector CT image for each patient, and the actual perforator locations were correlated with the intra-operative dissection. The donor limb of choice, either right or left, was also selected based on the dominant vascularity. Flap success rates, any associated morbidity and complications were recorded.
A total of 23 perforators were identified on CTA image preoperatively. Twenty-two of these perforators were chosen for chimeric flap design, and all were located as the CTA predicted, with the rate of utilization being 95.7% (22/23). There were two post-operative complications, including one partial flap necrosis and one microstomia. All of the ALT flaps survived, and there was no donor site morbidity.
Preoperative CTA allows accurate perforator mapping and evaluation of the dominant vascularity. It helps the surgeon to get an ideal designing of the chimeric ALT flap with two skin paddles based on individual perforators, but only one vascular anastomosis in reconstruction of full thickness buccal defects.
No preview · Article · Mar 2011 · ANZ Journal of Surgery
[Show abstract][Hide abstract] ABSTRACT: Anterolateral thigh flap (ALT) is an useful flap for head and neck reconstruction, but the variable perforators may limit its applications. Our goal was to clarify the benefits of preoperative CT angiography (CTA) in mapping of free ALT perforators for reconstruction of cheek through-and-through defects.
We retrospectively reviewed 32 patients undergoing reconstruction of through-and-through cheek defects with a free ALT flap between February 2005 and July 2009. These patients were divided into two groups. Group I (N=17): the ALT flap was designed based on the traditional handheld Doppler probe. Group II (N=15): preoperative imaging with CTA was used to map the perforator's number, size and variations. Surgical results were evaluated for both major and minor complications, as with the operation time, length of hospital stay and donor-site morbidity.
Overall flap survival was 96.88% (31 of 32 flaps). The use of preoperative CTA was associated with a significant reduction in major surgical complications, length of surgery and the need for a secondary debulking procedure (p<0.05). There was no difference in minor complication and donor-site morbidity.
The use of CTA for preoperative navigation of ALT flap for cheek reconstruction is associated with improved operative outcomes. Detailed data from images allow the surgeon to interpret any anatomical variations, choosing the exact suitable thigh, facilitate flap design, and greatly reduce major postoperative complications.
No preview · Article · Feb 2011 · Journal of cranio-maxillo-facial surgery: official publication of the European Association for Cranio-Maxillo-Facial Surgery
[Show abstract][Hide abstract] ABSTRACT: Composite grafting is used to treat nonreplantable fingertip amputations. This procedure has a high success rate and good results in treating fingertip amputations in children, but a lower success rate in adults.
From July 2007 to December 2008, 27 patients with 31 injured fingertips were admitted because of traumatic fingertip amputation at the emergency department of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. All 31 injured fingers had a nonreplantable distal amputated fingertip and underwent composite grafting. We refined the surgical technique by excising the bony segment, defatting, deepithelialization, tie-over suturing, and finger splinting to increase the graft survival. The patients' age, mechanism of damage, lesion size, surgical result, and postoperative complications were recorded.
The mean age of the patients was 40.5 years (range, 20-65 years). The average lesion size was 2.4 cm. Twenty-one fingers (67.7%) had been injured by crushing injury and the other 10 fingers (32.3%) by cutting injury. The overall graft survival rate was 93.5% (29 of 31). The average 2-point discrimination was 6.3 mm in the sixth month after the operation. The esthetic outcome evaluated by self-report questionnaire was 93.1% satisfied, and 86.2% of the patients could use their injured finger normally in daily work.
This easily performed and one-stage surgical procedure provided a reliable method for treating microsurgically nonreplantable fingertip amputations caused by hand trauma. The high overall success rate, satisfactory esthetic outcome, and good functional preservation helped patients return quickly to their daily life.
No preview · Article · Jan 2011 · The Journal of trauma
[Show abstract][Hide abstract] ABSTRACT: To provide an alternative choice for covering trochanteric pressure sores, we report on a modified pedicle anterolateral thigh (ALT) myocutaneous flap based on the descending branch of the lateral circumflex femoral artery.
From August 2007 to January 2010, 20 consecutive patients (10 men and 10 women) underwent 21 pedicled ALT myocutaneous flaps for reconstruction of trochanteric pressure sores. The flap was designed and elevated, resembling the ALT perforator flap including part of the vastus lateralis muscle but without skeletonisation of the perforators.
The mean age of patients was 79.4 years (range: 46-103). The mean follow-up period was 13.9 months (range: 3-32). The flaps were 8-21 cm long and 5-11 cm wide. All flaps healed without major complications. All donor sites were closed primarily without skin grafting and showed good aesthetic results. No recurrence was observed.
This modified design of pedicled ALT myocutaneous flap without skeletonisation of perforators is a reliable and easily harvested flap for reconstruction of trochanteric pressure sores with limited morbidity.
No preview · Article · Sep 2010 · Journal of Plastic Reconstructive & Aesthetic Surgery
[Show abstract][Hide abstract] ABSTRACT: Fournier gangrene is an acute and potentially fatal infection of the scrotum, perineum, and abdominal wall. It is characterized by necrotizing fasciitis with loss of subcutaneous tissue and skin. The aim of this study was to analyze the prognosis and treatment effectiveness of this fulminant infectious disease. Forty-one patients were admitted to our hospital with the diagnosis of Fournier gangrene between January 1998 and December 2006. The patients' age, sex, predisposing factors, duration of symptoms and hospital stay, time to operation, size of the skin defect, bacteria isolated, treatment modalities, and outcomes were reviewed. The data were analyzed by chi2 analysis and Student t test. A P-value <0.05 was considered significant. The mean age of the patients was 57.2 years. The most common predisposing factor was diabetes mellitus in 21 patients (51.2%), followed by cirrhosis of the liver, uremia, alcoholism, and underlying malignancy. The most common symptoms were fever (87.8%) and pain or swelling over the genital region (85.4%). The initial treatment included extensive debridement and open drainage. Time to operation ranged from 1 to 10 days. Reconstructive surgery was performed for 22 patients. The mortality rate was 19.5%. Delayed debridement was a significant factor affecting the survival rate. Our study is a retrospective study of patients with Fournier gangrene undergoing debridement and reconstructive procedure. Because of the fulminant course of Fournier gangrene, it may be difficult to design a prospective study. Fournier gangrene is a severe infectious disease with a high mortality rate. Early and aggressive debridement is a significant prognostic factor in the management of Fournier gangrene. Several reconstructive modalities are useful to correct the tissue defect. Early debridement and reconstructive surgery for wound coverage improve the quality of life.
No preview · Article · Jun 2010 · Annals of plastic surgery
[Show abstract][Hide abstract] ABSTRACT: PURPOSE
to determine the diagnostic value of 64-MDCT angiography for pre-operative assessment of anterolateral thigh (ALT) perforator flaps.
METHOD AND MATERIALS
Thirty-one patients (two women and 29 men; mean age: 51.9±10.4 years) underwent head and neck reconstruction surgery using ALT flap were included. All patients underwent pre-operative CT angiography (CTA) for both thighs using a 64-MDCT scanner. Cutaneous reference lines were made from anterior superior iliac spine (ASIS) to superolateral border of patella prior to examinations. Axial images and three-dimensional volume-rendering imaging were reviewed to determine the origin, course, and cutaneous location of each perforator of ALT. The ALT flaps with satisfactory perforators were subsequently harvested, which served as reference standard. The size of each harvested perforator was categorized as small (less than 0.5mm), medium (0.5-1.0mm) and large (more than 1mm). In the first 15 patients, two radiologists reviewed the images independently to evaluate the inter-observer variation with respect to the presence, origin and course of ALT perforators.
A total of 75 perforators were obtained at surgery. Among them, CTA accurately detected 62 (82.7%) perforators. The detection rate was 75% (12/16) in small, 80% (32/40) in medium, and 94.7% (18/19) in large perforators. CTA accurately predicted the origin from transverse or descending branches of lateral circumflex femoral artery in 61 (98.4%) of 62 perforators. The musculocutaneous or septocutaneous courses were accurately predicted in 48 (77.4 %) of 62 perforators. The mean distance between predicted and final cutaneous locations of perforators were 0.83±0.70cm in the axis parallel to the cutaneous reference lines, and 1.01±1.09cm in the axis perpendicular to the lines. Analysis for inter-observer variation showed almost perfect agreement with respect to the presence (Kappa value=0.838) and the origin (Kappa value=0.92) of perforators. Substantial agreement was observed with respect to the course of perforators (Kappa value=0.768).
CTA is a useful technique for pre-operative planning of ALT perforator flaps.
CT angiography of anterolateral thigh perforators prior to surgery may reduce donor site morbidity by accurately predicting the location, origin and course of perforators.