Pao-Yuan Lin

Background: This study tested the hypothesis that hyperbaric oxygen (HBO) therapy enhanced the circulating levels of endothelial progenitor cells (EPCs), soluble angiogenesis factors, and blood flow in ischemic areas in patients with peripheral arterial occlusive disease (PAOD). Methods: In total, 57 consecutive patients with PAOD undergoing the HBO therapy (3 atmospheres (atm) for 2 h each time) were prospectively enrolled into the present study. Venous blood sampling was performed to assess the circulating levels of EPCs and soluble angiogenesis factors prior to and during five sessions of HBO therapy. Additionally, skin perfusion pressure (SPP), an indicator of blood flow in ischemic areas, was measured by moorVMS-PRES. Results: The results demonstrated that the circulating levels of EPCs (cluster of differentiation (CD)34+/CD133+/CD45dim, CD31+/CD133+/CD45dim, CD34+) and soluble angiogenesis factors—vascular endothelial growth factor/stromal cell-derived factor 1/hepatocyte grow...

Extracorporeal shock wave (ECSW) and adipose-derived mesenchymal stem cells (ADMSCs) have been recognized to have capacities of anti-inflammation and angiogenesis. We tested the hypothesis that ECSW and ADMSC therapy could attenuate ischemia-reperfusion- (IR-) induced thigh injury (femoral artery tightened for 6 h then the tightness was relieved) in rats. Adult male SD rats ( = 30) were divided into group 1 (sham-control), group 2 (IR), group 3 (IR + ECSW/120 impulses at 0.12 mJ/mm given at 3 h/24 h/72 h after IR), group 4 (allogenic ADMSC/1.2 × 10 cell intramuscular and 1.2 × 10 cell intravenous injections 3 h after IR procedure), and group 5 (ECSW + ADMSC). At day 7 after the IR procedure, the left quadriceps muscle was harvested for studies. At 18 h after the IR procedure, serum myoglobin/creatine phosphokinase (CPK) levels were highest in group 2, lowest in group 1, and with intermediate values significantly progressively reduced in groups 3 to 5 (all < 0.0001). By day 5 afte...

Although chronic kidney disease (CKD) is known to aggravate cardiovascular disease in the setting of cardiorenal syndrome (CRS), the impact of impaired cardiac function on the progression of CKD has seldom been reported. This study tested the impact of acute myocardial infarction on a rodent CKD model and the therapeutic effect of valsartan in this setting. Adult male Sprague-Dawley rats (n = 50) equally divided into group 1 (sham control), group 2 (CKD induced by 5/6 nephrectomy), group 3 (AMI by ligation of left coronary artery), group 4 (CKD+AMI), group 5 (CKD+AMI+valsartan, orally 10 mg/kg/day). By day 60, kidney injury score, creatinine levels, and ratio of urine to creatinine were highest in group 4 and lowest in group 1, significantly higher in group 4 than those in groups 2 and 5, and significantly higher in group 5 than those in group 2 (all p < 0.001). Protein expressions of inflammation (IL-1β/MMP-9), oxidative stress (NOX-1/NOX-2/oxidized protein, angiotensin-II recep...

This study tested the hypothesis that high-cholesterol diet (HCD)-induced fatty liver disease could be ameliorated by rosuvastatin (Ros) and propylthiouracil (PTU) therapy. Thirty-two Zealand rabbits were equally divided into group 1 (sham-control), group 2 (HCD for 8 weeks), group 3 [HCD-Ros (20 mg/kg/day administration after 4-week HFD for 4 weeks)], group 4 [HCD-PTU (0.1% PTU in drinking water) with treatment course as group 3]. Liver weight, fibrosis, collagen deposition area, and serum levels of AST/ALT were highest in group 2, lowest in group 1, and significantly higher in group 4 than group 3 (all P<0.0001). The levels of inflammatory (TNF-α/NF-κB/IL-1ß/IL-6/MMP-9/VCAM-1/PAI-1/TLR-4, MyD88/IL-12/IFN-γ), oxidative stress (NOX-1/NOX-2/oxidized protein), apoptotic (Bax/cleaved-capase-3/PARP), fibrotic (Smad-3/TGF-ß), and mitochondria-damaged (cytosolic-cytochrome-C) proteins showed an identical pattern, whereas antiapoptotic (Bcl-2), mitochondrial-integrity (mitochondrial-cyt...

Free jejunal flap is one of the optimal choices for restoring upper digestive tract. The purpose of this study was to introduce the treatment strategies and to compare the outcomes of free jejunal flap for pharyngoesophageal reconstruction between hypopharyngeal cancer and chemical corrosive injured esophagus. From 2001 to 2012, patients who had been received esophageal reconstruction by free jejunal flap for pharyngoesophageal defect were divided into squamous cell carcinoma (SCC) group and corrosive chemical injury (CCI) group. All data on outcomes and complications including relevant radiographic investigations were collected retrospectively. Sixteen patients were in SCC group and 9 patients in CCI group underwent free jejunal flap reconstruction. Two cases of flap failure were noted in SCC group, and no flap failure in CCI group-the total failure rate was 8% (2/25 patients). In SCC group, 5 of 16 patients (31.3%) developed fistula; however, no fistula in CCI group. One patient in SCC group and 3 patients in CCI group developed esophageal strictures. Other than early stricture (stricture <1 year) which reached significant difference, all of other complications were not statistically significant between two groups. The average follow-up time was 42 months. Postoperative early stricture but lower fistula occurrence is expected in patients with corrosively injured esophagi. This helpful preliminary findings could not only early-check complication, but also better explanation and prepare were taken placed before operation.

This study tested the hypothesis that extracorporeal shock wave (ECSW) treatment can improve ischemia-induced left ventricular (LV) dysfunction in mini-pig with co-existing chronic kidney disease (CKD). LV ischemia in mini-pigs was induced by applying an ameroid constrictor over mid-left anterior descending artery (LAD), while model of CKD was established by right nephrectomy with partial ligation of left renal arterioles 2 weeks before LAD constriction. Thirty mini-pigs were randomly divided into group 1 (sham-control), group 2 (LV-ischemia), group 3 (LV-ischemia + CKD), Group 4 [LV-ischemia + ECSW (applied 1200 shots at 0.1 mJ/m2/equally to 4-ischemic regions by day-90 after LAD constriction], and group 5 (LV-ischemia-CKD + ECSW). By day-180 after CKD induction, echocardiography showed that LV ejection fraction (LVEF) was highest in group 1, lowest in group 3, significantly lower in group 2 than that in groups 4 and 5, and significantly lower in group 5 than that in group 4, where...

We tested the hypothesis that arteriosclerosis-augmented aortic pulse wave velocity (PWV) and -impaired vasorelaxation were attenuated by rosuvastatin (Rosu) and propylthiouracil (PTU) therapy. Thirty-two New Zealand rabbits were equally divided into group 1 (sham-control), group 2 [high-cholesterol-diet (HCD) for 8weeks], group 3 [HCD-Rosu (20mg/kg/day administration after 4-week HFD for 4weeks)], and group 4 [HCD-PTU (0.1% PTU in drinking water), the treatment course as group 3]. KCl-induced vasoconstriction of carotid artery (CA) was significantly higher in group 2 than in other groups (all p<0.01), but showed no differences among groups 1, 3 and 4, whereas acetylcholine-induced vasorelaxation exhibited an opposite pattern of KCl-induced vasoconstriction among the four groups (p<0.001). Basic nitric-oxide release from endothelial cells of CA was highest in group 1, lowest in group 2, but showed no difference between groups 3 and 4 (all p<0.001). PWV value was highest in ...

Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and p...

The choice of optimal flap is still a challenge for patients with resection of head and neck cancer and reconstruction, especially for recurrent cases. In this article, we report the results of the new innovation of free lower medial thigh perforator (LMTP) flap for head and neck reconstruction in a series of patients. Fifteen patients received reconstruction with free LMTP flaps. The defect locations included the buccal area (3 cases), tongue (6 cases), lower/upper gum (5 cases), and soft palate (1 case). The perforators of flap design were detected at the distal third of the line, which was drawn from the midpoint of inguinal ligament to medial upper border of patella. The superficial temporal artery (7 cases), superior thyroid artery (6 cases), and facial artery (2 cases) were dissected as recipient vessels. The flap sizes varied from 12 × 5 cm(2) to 20 × 8 cm(2) . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the...

Outcome of Anterolateral Thigh, Radial Forearm and Jejunal Free Tissue Transfer for Circumferential Esophagopharyngeal Reconstruction Ngian Chye Tan, MBBS, FRCSEd; Yen-Chou Chen, MD; Hsiang-Shun Shih, MD; Pao-Yuan Lin, MD; Yur-Ren Kuo, MD, PhD Kaoshiung Chang Gung Memorial Hospital, Taiwan ABSTRACT Background: Circumferential esophagopharyngeal reconstruction is both complex and challenging. There are a multitude of reconstructive techniques being described in literature. In our institute, free tissue transfers can be in the form of visceral flaps, like the free jejunal flap, or fasciocutaneous flaps, like the anterolateral thigh (ALT) flap and radial forearm flap (RFF). The aim of our study was to compare and contrast three different types of free flaps when used for circumferential esophagopharyngeal reconstruction. Materials and Methods: From 2001 to 2009, 128 patients underwent free tissue transfer for esophagopharyngeal defects after cancer resection. Sixty-six patients had pat...

The authors retrospectively reviewed their experience over the past 5 years with reconstructions of hypopharyngeal defects using anterolateral thigh flaps. The purpose of the study was to present a modified classification of defects, the method and tips used, and outcomes and morbidities. From 2002 to 2007, 55 anterolateral thigh flaps were harvested for reconstruction of hypopharyngeal defects after tumor ablation in 54 patients. Patient age ranged from 38 to 77 years (average, 54 years). In 24 cases, free flaps were used for reconstruction of circumferential defects; in 28 cases, they were used to reconstruct partial defects; and in three cases, they were used to reconstruct circumferential and skin defects. Total flap loss occurred in one patient and partial flap loss occurred in three patients. Strictures occurred in three patients and fistulas occurred in 10. In one case, arterial occlusion was noticed postoperatively. The arterial anastomosis was revised and the flap was salvaged. In another case, venous occlusion was noticed. The vein was reanastomosed with a vein graft and the flap was salvaged. Postoperatively, seven patients tolerated a regular diet. The donor site was skin grafted in five cases, closed with reverse anterolateral thigh in one case and with retrograde V-Y advancement flap in one case, and closed primarily in the rest. There were no donor-site complications. Reconstruction of the hypopharynx with the anterolateral thigh flap offers versatility in the coverage of large and complex defects and is associated with minimal donor-site morbidity.

The anterolateral thigh flap is commonly used for reconstruction of various soft-tissue defects. This article presents the authors' approach to one-stage reconstruction of composite soft-tissue defects using an anterolateral thigh flap with a vascularized fascia lata. This retrospective review analyzed 973 patients who had undergone anterolateral thigh flap reconstruction for various soft-tissue defects over the past 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite anterolateral thigh flap combined with vascularized fascia lata. The fascia lata component of the flap was used for abdominal wall and fascial defect reconstruction in 12 patients, for lip-cheek defect reconstruction in 15 patients, for reconstruction of composite defects in extremities in nine patients, and for reconstruction of the perineum in one patient. Functional outcomes of donor sites were investigated by using a dynamometer. All flaps except one survived. The overall flap survival rate was 97 percent. Patients achieved satisfactory results without major postoperative complications. The study revealed that vascularized fascia may mimic a fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency in quadriceps femoris muscles contraction in the donor thighs, no difficulties in daily ambulation were reported by the patients. The anterolateral thigh flap with vascularized fascia lata provides a reliable fascial component for single-stage reconstruction of complex soft-tissue defects.

For buried flaps in the head and neck, direct monitoring of the flap can be extremely difficult. The authors report their experience with 22 patients who underwent pharyngoesophageal reconstruction using an anterolateral thigh (ALT) fasciocutaneous perforator flap with a design that addresses the concerns of buried flap monitoring. This is an observational study of 22 patients, who underwent pharyngoesophageal reconstruction with ALT fasciocutaneous flaps between June 2006 and February 2008. The design of the flap consists of three components: proximal component of flap for pharyngeal reconstruction, mid-component de-epithelized for esophageal-skin flap junction, and distal component either as an external sentinel monitor or for replacing the external neck skin, nourished solely by the suprafascial plexus. The patients' age ranged between 40 and 72 years with a mean age of 55.5 years. The measurements of the skin paddles of the ALT flaps ranged from 10 to 30 cm in length and 6 to 8 cm in width. The flap success rate was 95.5% (21/22). The overall sensitivity and specificity rate of this monitoring method is 100% and 94.7% respectively. There were venous congestions found in four skin paddles. One was demonstrated to be false positive after re-exploration. The other three were true positives and two of these were salvaged successfully. The remaining flap could not be salvaged due to severe deep neck infection. Three patients had a small fistula at the distal end of the esophageal-skin flap junction. All healed spontaneously after conservative treatment. This ALT flap design for pharyngoesophageal defect reconstruction is simple and versatile. The distal skin flap can be utilized as an external sentinel monitor for the buried part of the flap, and for resurfacing of the anterior neck skin if required.

Free tissue transfer has become a popular technique for soft tissue defect reconstruction in head and neck cancer ablation. Although high success rates and good reliability of free flaps are proven, microvascular thrombosis is still the most critical issue for microsurgeons. Pharmacological antithrombotic agents are widely used but their efficacy is still debated. In this study, we analyzed whether prostaglandin-E1 (PGE1) and dextran-40 can improve the outcomes compared to no antithrombotic therapy at all. We retrospectively reviewed 1,351 free flaps performed for head and neck reconstruction after cancer ablation. Three groups defined were 232 flaps received PGE1, 283 flaps received dextran-40, and 836 received no antithrombotic therapy. The demographics of these three groups indicated no statistical differences. The results showed that flap survival revealed no significant difference among PGE1, dextran-40, and control group (P = 0.734). There was a tendency to hematomas in PGE1 group (P = 0.056) when compared with other two groups. Dextran-40 significantly increased flap failure rate in high-risk patients with diabetes mellitus (P = 0.006) or hypertension (P = 0.003), when compared with PGE1 and control group. These results revealed antithrombotic therapy with PGE1 and dextran-40 do not determine a significant improvement in flap survival.

Salivary contamination of surgical wounds in clean-contaminated head and neck surgery with free flap reconstruction remains a major cause of infection and leads to significant morbidity. This study investigates the correlation between intraoral flora and surgical site infections (SSIs) among high-risk head and neck cancer patients undergoing resection and free flap reconstruction. One hundred twenty-nine patients were identified as being at high risk for infective complications based on cancer stage, tumor size, comorbid factors, and extent of reconstruction. All patients had intraoral swab cultures before surgery. Patients with culture-confirmed SSI after surgery were chosen for analysis, using the κ index and its 95% confidence interval for concordance analysis. All patients received clindamycin and gentamicin for antibiotic prophylaxis for 5 days. Antibiotic susceptibility testing of all isolates was obtained and analyzed. Thirty-seven patients experienced SSI, or an infection rate of 28.3%, occurring at a mean of 9.3 postoperative days. The overall concordance between oral flora and SSI was fair to moderate (κ index of 0.25), but detailed analysis shows a higher concordance for known and opportunistic pathogens, such as Pseudomonas aeruginosa and Enterococcus faecalis, compared to typical oral commensals. Antibiotic susceptibility tests show rapid and significant increases in resistance to clindamycin, indicating a need for a more effective alternative. Predicting pathogens in SSI using preoperative oral swabs did not demonstrate a good concordance in general for patients undergoing clean-contaminated head and neck surgery, although concordance for certain pathogenic species seem to be higher than for typical intraoral commensals. The rapid development of resistance to clindamycin precludes its use as a prophylactic agent.

To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.

Since the first successful salvage of an amputated finger using microsurgical anastomoses in 1965, replan-tation has been widely used in these decades and is now firmly established as a viable treatment option in traumatic limb amputation. The current concepts of replantation surgery for upper limb amputation are discussed in this review article in terms of history of replantation, present indications for the procedure, pre-theater care, technical refinements, postoperative management and functional outcome. In this article , we demonstrated that the advent of microsurgery has led to replantation of almost every amputated part of the upper limb possible. Replantation of digits and the hand can restore not only circulation but also function and cosmetic appearance. However, major amputations remain a challenge and the functional outcome is often disappointing, albeit the success rate of replantation exceeds 80%. Proper patient selection, adequate pre-theater preservation, good operative skill and postoperative care, as well as tight cooperation among the patient, the surgeon, and the rehabilitation therapist will help to achieve a better final functional outcome.

Background Toe-to-thumb transfer is an established procedure for reconstruction of traumatic thumb amputations. The four types of toe-to-thumb transfers are the second toe, the great toe, the wrap-around great toe and the trimmed great toe transfers. The purpose of this study is to conduct a systematic review of the literature to compare outcomes amongst different methods of toe-to-thumb transfers. Methods A literature search using 'toe-to-thumb transfer' combined with 'thumb injury' and 'thumb reconstruction' as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data, (2) report three or more toe-to-thumb transfers for isolated complete traumatic thumb amputation between the metacarpophalangeal joint and the interphalangeal joint (both excluded) and (3) present functional outcome data. Results Twenty-five studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected between the four transfers with regards to survival, arc of motion, total active motion, grip and pinch strength and static two-point discrimination. Conclusions All four types of toe transfer procedures have predictably high survival rates and good patient satisfaction scores. The current data are inadequate to make any comments with regards to donor site morbidity. Till such data are available, an evidence-based recommendation for the superiority of a specific type of toe-to-thumb transfer cannot be made.

Background: Previous neck dissection and irradiation is believed to affect the success of free tissue transfers in head and neck reconstruction , but evidence is scarce and conflicting. This study seeks to evaluate flap success rates in the presence of these two factors. Methods: Over a ten-year period, a total of 853 free flap cases were evaluated. Success rates were compared between a control group with no prior intervention (non-irradiation and neck dissection, NRTND) against three other groups: irradiation only (RT), previous neck dissection only (ND), and both (RTND). The choices of recipient vessel used were also compared. Results: The flap failure rate was 6.3% (4/63) in the RTND group; 4.8% (1/21) in the ND group; 5.2% (6/115) in the RT group; and 2.1% (14/654) in the NRTND group. There was no statistical significance among the four groups (P 5 0.254). Ipsilateral neck vessels (92.7%) were more frequently used in the NRTND group. In contrast, the superficial temporal vessels, contra-lateral neck vessels were more likely to be selected in the groups with irradiation and/or neck dissection. Conclusions: Free tissue transfer in head and neck patients with previous irradiation and neck dis-section is feasible and can be safely done. In addition, superficial temporal vessel could be the first choice in patients with previous radio-therapy and neck dissection. V C 2014 Wiley Periodicals, Inc. Microsurgery 34:602–607, 2014.

Oromandibular reconstruction resulting from resection of benign tumor, malignant cancer, osteomyelitic or osteoradionecrotic mandible remains a challenge for plastic surgeons today. At present, fibula osteocutaneous flap is the perhaps most commonly used technique for oromandibular reconstruction because of its potential for contouring, immediate dental implant placement, and favorable donor site morbidity. In this study, we review the history of oromandibular reconstruction, summarize the characteristics of different osteocutaneous flaps, offer surgical options of different osteocutaneous flaps, and provide reconstructive strategies for different locations of mandibular defects. Furthermore, we give a detailed description of various modifications in oromandibular reconstruction: (1) the myoosseous flap for lateral segmental defect repair may reduce donor site complication; (2) to improve the function of oral commissure in patients with obscure recipient vessels, we modify the fibula osteocutaneous flap with anterolateral thigh flap and combine the tensor fascia lata using one set of recipient vessel for composite oromandibular reconstruction; (3) to decrease the likelihood of neck infection and improve aesthetic result, we add the segmental soleus muscle to the fibula osteocutaneous flap to obliterate and augment submandibular dead space. Lastly, dental rehabilitation considerations associated with mandibular reconstruction have been given to help assist in surgical treatment planning.

Background: The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral thigh (ALT) flap, and the jejunum flap. This study was to objectively compare three different flaps for pharyngeal reconstruction during the past 10 years. Stricture and fistula were assessed using esophagogram and esophago-scopy. Methods: Forty-five patients with pharyngeal reconstructions had esophagram and esophagoscopy done postoperatively to assess for strictures and fistulas. These patients were divided into three groups based on pharyngeal reconstruction by ALT, RFF, and jejunal flaps. From the results of the esophagogram and esophagoscope, the presence of a fistula or stricture was compared and analyzed. Results: There was only one ALT flap failure. The rate of fistula was 33%, 50%, and 30% in the ALT, RFF, and jejunal flap group respectively. The fistula rate revealed no significant difference between ALT, RFF, jejunal flap groups (P 5 0.63). The rate of stricture was 38.1%, 57.1%, and 0% in the ALT, RFA, jejunal flap groups respectively. The stricture rate in jejunal flap group revealed significant decrease (P 5 0.0093). Conclusion: Jejunal flap has a significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps.

Background: Free tissue transfers performed in patients with hematological diseases represent significant challenges for micro-surgeons. There are rare literatures that address the outcome in these patients. Therefore, we collected our database, analyzed the outcome, reliability , and related-management of microsurgical technique in the patients with hematological diseases. Methods: A retrospective chart review of 20 patients with hematological disorders who received free tissue transfers during 20-years period in a single microsurgical center was done. Eleven patients who received head and neck reconstruction were found to have hyperfibrinogenemia. Seven patients with reactive thrombocytosis after trauma, and two patients with leukemia had soft tissue defects in the upper and lower extremities. Twenty-six flaps were used for free tissue transfers. Intra-operatively all patients received intravenous 5,000 Ud of heparin post immediate reper-fusion. Anti-coagulant medication such as Dextran-40 or prostaglandin-E1 (PGE1) was given postoperatively. Results: Twenty-three of the 26 free flaps survived without vascular compromise. Intra-operatively all patients received intravenous 5,000 Ud of heparin post immediate reperfusion, and anti-coagulant medication such as Dextran-40 or prostaglandin-E1 was given to the patients postoperatively. The three failed cases were found in patients with hyperfibrinogenemia and needed further reconstruction with another flap. The overall success rate was 88.5% (23/26). Conclusions: Hematologic disorder is not a predicted factor of free flap failure. The key factors for success flap survival in patients with hematologic disorders include preoperative knowledge of the medical condition and monitoring potential post-operative complications, aggressive hematologist consultations, and meticulous non-traumatic surgical anastomosis.

Minimally invasive surgery without endoscopic assistance for gracilis muscle flap harvest is extensively used at the authors' institution. However, the proximal incision is still visible. The purpose of this study was to place the proximal incision in the groin area, to improve the cosmetic result at the donor site. In the reported series, nine male and three female patients were evaluated, with patient ages ranging from 31 to 75 years. Ten patients had lower extremity reconstruction, one had a forearm defect, and the other, a head and neck defect. The proximal incision was 5 to 6 cm in length in the groin area. The distal incision was 1.5 cm in length around the knee. After adequate exploration and dissection of the major pedicle of the gracilis muscle flap, which was located at 7 to 8 cm below the groin crease under direct vision, a standard long blunt dissector was used to separate the gracilis muscle. The average incision was about 7 cm in length, and the harvesting time was 55 min. All the free muscle transfers were successful and without major complications. The proximal incision was almost invisible after 3 months. Two patients developed partial loss of the skin graft, requiring further skin grafting. Compared with the conventional technique, this method proved to be advantageous in its easier performance, shorter incision, fewer morbidities, and better appearance at the donor site.

Background: Pressure sore reconstruction is quite difficult for plastic surgeons because of long-term high recurrence rates. We designed a freestyle perforator-based flap for pressure sore reconstruction considering pressure sore recurrence and further reconstruction. Methods: We used a handheld Doppler device to locate a perforator position just adjacent to the pressure ulcer. In a series of 34 patients, we used 37 perforator-based flaps to reconstruct 25 sacral, 5 ischial, and 4 trochanteric ulcers. Results: Twenty-eight of 37 flaps healed uneventfully without complication. One patient had a flap that totally necrosed, 3 had partial flap necrosis, 3 had wound dehiscence, 1 died 3 days postoperatively, and recurrence developed in 1 patient. Conclusions: We used the freestyle perforator-based fasciocutaneous flap for pressure sore management with good success. These flaps are easy to design and provide good versatility for coverage. Cooperation of surgical skills and good postoperative care also contributed to the lower recurrence rates and satisfactory results.

Purpose: The purpose of this study is to present our experience with patients who underwent traumatic ear amputation. Methods: Between January 1988 and April 2002, 10 patients sustained ear amputations. Of these, six patients underwent microvascular replantation (arterial anastomosis only and arterial and venous anastomosis in three patients each), and replantation was attempted in one patient. However, no suitable vessel could be found for the anastomosis, and the amputated ear was treated as a composite graft and buried in a retroauricular pocket. Staged costal cartilage reconstruction was performed in three patients who lost the ear replant after trauma (two patients) or due to infection (one patient). Results: The ear replant survived and showed good cosmetic results in the three patients who underwent arterial and venous anastomoses. The patients who had artery anastomosis only required intrareplant heparin injection (chemical leech) to resolve venous congestion and sustained partial loss of the replanted ear. Secondary procedures were necessary to repair the reconstructions, including an advancement, temporoparietal fascia, or retroauricular flap. Those who underwent staged ear reconstruction had late ear deformities. Conclusion: Microvascular replantation is the best method for reattaching an amputated ear, giving excellent esthetic results. If only arterial anastomosis is performed, a chemical leech is an option for decompressing the venous congestion. In those patients without a suitable vessel for microanastomosis, nonmicrosurgical methods are suggested, such as a temporoparietal fascia flap, retroauricular pocket procedure, or staged-costal cartilage reconstruction , depending on the ear defect.

Patients with advanced head and neck cancers require reconstruction with a double free flap, but in some situations, it is extremely difficult to attain the ideal set of recipient vessels for these patients. The patients were divided into two groups: group 1 had one recipient vessel; group 2 had two recipient vessels. Fifty-five patients were enrolled between 2001 and 2005. Double flaps, including a fibula osteoseptocutaneous flap and an anterolateral thigh flap, were used for the reconstruction. In group 1, the second flap was anastomosed at the distal runoff of the fibular flap. Group 1 contained 39 patients and group 2 had 16 patients. No significant differences in the success rate, operating time, days of hospitalization, or complication rate were noted between groups 1 and 2. Thus using one recipient vessel is our first choice for double free-flap reconstruction for head and neck defects.

Background: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. Postoperative complications can be a significant setback for patients undergoing breast reconstruction. In this study, the results of different reconstruc-tive modalities are recorded and their complications are discussed for further preoperative counseling. Materials and Methods: Ninety patients who had undergone breast reconstruction at our institution in the past 5 years were reviewed. Clinical encounters for all reconstruction modalities, namely implant-based, autologous tissue, and combined reconstructions, were assessed. We evaluated several clinical variables, such as type of operation, timing of reconstruction, and early and late complications. Results: Patients were aged 28e61 years, with a mean age of 44.8 years. The body mass index (BMI) ranged from 16.9 to 31.1 kg/m 2 , with an average of 22.87 kg/m 2. The follow-up duration ranged from 5.6 to 85.9 months, with a mean of 38.3. Thirty-eight, 46, and 6 patients received implant-based reconstruction, autologous reconstruction, and combined reconstruction, respectively. The most common complication recorded in the implant-based group was hema-toma (7.9%), whereas re-exploration (6.5%) and abdominal hernia (6.5%) were the most common complications in the autologous tissue reconstruction group. The average age and BMI of the patients who experienced complications were 46.4 years and 22.5 kg/m 2 , respectively, whereas the average age and BMI for the patients without complications were 44 years and 23 kg/m 2 , respectively. Complications were most common in patients who underwent adjuvant irradiation and pedicle flap reconstruction (100%). Please cite this article in press as: Tsai Y-J, et al., Breast reconstruction modality and outcomes after mastectomy, Formosan Journal of Surgery (2015), http://dx. Conclusions: In this small-scale study, we found that an implant-based reconstruction was more frequently performed on older patients. Because of the relatively small average body size and low BMIs of Asian people, obesity is not considered to affect the postoperative complication rate. In addition, postreconstructive irradiation is unlikely to produce additional complications because the patients underwent pedicle flap reconstruction.

In this study, we introduced scalp reconstruction using free anterolateral thigh (ALT) flaps and evaluated postoperative outcomes in nine patients between March 2000 and April 2012. Five patients had problems of exposed prosthesis, three required reconstruction after resec-tion of scalp tumor and one patient presented with third degree flame burns of the scalp. All flaps survived without re-exploration, except three flaps with tip necrosis requiring secondary procedures of debridement and small Z-plasty reconstructions. The superficial temporal artery and its concomitant vein were used as recipient vessels, apart from two cases where previous surgery and flame burns excluded these choices, for which facial arteries and veins were used instead. Primary closure of the donor-site was possible in six cases; with skin grafting performed for the other three patients. All donor sites healed without complications. The ALT flap offers the advantage of customiz-able size, option of fascia lata as vascularized dural replacement, and minimal flap atrophy typical of muscle flaps. Indications include very large defects, defects with exposed prosthesis, or defects with bone or dural loss. Our experience lends credible support to the use of cus-tomized free ALT flaps to achieve functional and cosmetically superior result for the reconstruction of large scalp defects, especially with bone exposure. V