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INTRODUCTION The medical demand for lymphedema treatment is huge since the disease mechanism remains unclear, and management are difficult. Our purpose was to develop a reliable lymphedema model mimicking the clinical scenario and allows a microsurgical approach. MATERIALS AND METHODS Male Lewis rats weighing 400 to 450 g were used to create lymphedema with groin and popliteal lymph node dissection and creation of 5 mm circumferential skin defect (n = 6). A skin incision was made and closed primarily for control group (n = 5). Evaluation included indocyanine green (ICG) lymphangiography 1 and 2 months postoperatively, volume difference between bilateral hindlimbs measured using micro-CT, and the skin was harvested for histological evaluation 2 months postoperatively. RESULTS Larger volume differences present in the lymphedema group (17.50 ± 7.76 vs. 3.73 ± 2.66%, p

Facial deformity, facial paralysis, and sensory loss are inevitable after some head and neck tumor resection and reconstruction, especially in high stage cancer. To overcome these obstacles, we present a case of T4a gum cancer patient (41-year-old) who received holistic reconstruction of the mandible defect via an osteo-peroneal-artery-perforator combined flap for defect coverage and cross-mental nerve graft for lower lip and chin sensation at the primary stage, followed by ipsilateral facial nerve (lower trunk) innervated gracilis functioning free muscle transplantation for facial reanimation and correction of the sunken face 3 years later. After 4.5 years of follow-up, the patient was satisfied with his appearance, and obtained a spontaneous and symmetrical smile without sensory deficit. This experience showed a possible solution to the reconstruction for complicated head and neck cancer patients.

Reconstruction of defects measuring approximately two-thirds of the lower lip width is traditionally reconstructed utilizing loco-regional flap utilizing lip and cheek tissues. This often results in microstomia and unsatisfactory aesthetic outcome. This may hinder the psychosocial aspect of a recovering cancer survivor. Here we describe a single-stage reconstruction in a 79-year-old male patient who received lower lip resection for squamous cell carcinoma. The reconstruction was accomplished using a facial artery musculomucosal flap together with a free radial forearm flap for vermilion and soft tissue defect reconstruction after lip tumor resection with uneventful postoperative course. The patient remains disease-free after 2-year follow-up and does not require revision surgeries for functional or aesthetic reason. This approach may be considered a good option for reconstruction of missing lip and soft tissue simultaneously when the facial vessels are well-preserved during neck dissection. Aesthetically pleasing and functionally satisfactory outcomes may be produced.

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 January 2006 and December 2012, 167 subjects who underwent marginal mandibulectomy and postoperative radiotherapy with different modalities were enrolled. The association of ORN with mandibular bone measurements and patient variables was analyzed, and a nomogram was established. RESULTS Fifteen (8.98%) of the 167 patients developed ORN during the follow-up period, and ORN was significantly associated with diabetes mellitus (DM), body mass index (BMI), remaining bone height, remaining bone height to original bone height ratio, resected bone height to original bone height ratio, and mandibular dose (P: < 0.001, 0.004, 0.042, 0.018, 0.010, 0.020, respectively). Interestingly, the risk of ORN had no significant difference between conformal and intensity modulation radiation therapy (P = 0.407). Multivariate analysis revealed that DM and resected bone height to original bone height ratio ≥ 50% were independent risk factors for postoperative ORN. A nomogram consisting of BMI, DM, resected bone height to original bone height ratio, mandibulotomy, and mandibular dose for predicting the ORN-free probability was established; and the c-index of the nomogram for ORN status was 0.803. CONCLUSION A nomogram based on the risk factors was plotted to strengthen the prediction of ORN quantitatively. Surgeons should be more discrete regarding the treatment plan for patients with higher probability of ORN. LEVEL OF EVIDENCE 3b Laryngoscope, 130:101-107, 2020.

Postoperative chylous ascites is a rare but highly morbid complication following thoracic or abdominal surgeries. Treatment options vary according to different clinical scenarios and facility equipment, but there is no standard guideline. We report a case of 46-year-old patient with chylous ascites after left laparoscopic adrenalectomy for metastatic lung cancer. The conservative treatments failed, included diet control, somatostatin provided and intranodal lymphangiography with lipiodol injection. Laparotomy was performed to explore the lymphatic vessel in the retroperitoneal area where a major and several small leaking holes were identified along the thoracic duct. The left gonadal vein was explored and transposed toward the lymphatic vessel. The lymphaticovenous anastomosis (LVA) was done using side (major leaking hole) to end (gonadal vein) fashion. The chylous leakage dropped from 2000 to 200 mL per day gradually within 10 days after LVA, and the patient was discharged uneventfully 30 days after the LVA surgery. He was followed at our clinic during the first postoperative 10 months without recurrent chylous ascites. This case demonstrates that microsurgical intervention with LVA to physiologically drain the chyle can be an optimal treatment for chylous ascites. A literature review was also conducted, and strategic management is proposed.

BACKGROUND The aim of this study is to evaluate osteonecrosis of the jaw (ONJ) with the extent of marginal mandibulectomy. METHODS Between January 2006 and December 2012, 3087 patients undergoing ablative resection were consecutively enrolled. Among them, 345 cases undergoing marginal mandibulectomy were retrospectively reviewed. RESULTS The occurrence of ONJ was 5.51% and associated with body mass index, overall stage, diabetes, concomitant mandibulotomy, and radiotherapy (P = 0.023, 0.033, 0.009, 0.016, and 0.006, respectively). As for bone parameters based on radiological measurements after marginal mandibulectomy, resected bone height, remaining bone height to original bone height ratio, and resected bone height to original bone height ratio were associated with ONJ. In multivariate logistic analyses, concomitant mandibulotomy, radiotherapy, diabetes, resected bone height of >14.5 mm, resected bone height to original bone height ratio of >49.5%, and remaining bone height to original bone height ratio of

Background Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap. Methods A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups. Results A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04). Conclusion The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

Background The profunda feomris artery perforator (PAP) flap was recently revisited and gains popularity as an alternative method of autologous breast reconstruction. The purpose of this article is to demonstrate that PAP flap can be used reliably for reconstruction of various soft tissue defects. Methods A total of 55 free PAP flaps and 16 pedicle PAP flaps were transferred in 63 patients. Each case was reviewed to verify a PAP flap was performed identifying defect location, flap size, flap design, and postoperative complications. Results Seven flaps in five patients underwent breast reconstructions, 48 patients underwent head and neck reconstructions using free PAP flaps. The mean perforator number was 1.9, and the average pedicles length was 9.7 cm. The majority of perforators were musculocutaneous, and the others were septocutaneous. The mean ischemia time was 121.4 min. Minor complications included wound poor healing, flap partial necrosis, and pedicle vessels problems. Sixteen pedicle PAP flaps were transferred in 10 patients for vulvar reconstruction. Minor complications included urinary tract infection, poor wound healing, wound infection, hematoma. Conclusions The anatomy and number of perforators of PAP flap are reliable with adequate pedicle length. This flap can be an excellent option for reconstruction of most soft tissue defects. J. Surg. Oncol. 2016;114:193–201. © 2016 Wiley Periodicals, Inc.

Purpose Exploration of the internal mammary vessels during microsurgical reconstruction presents an ideal opportunity for identifying and sampling the internal mammary lymph node (IMLN) basin. Methods A retrospective review of patients undergoing microsurgical breast reconstruction using the internal mammary vessels as recipient vessels was conducted from March 2000 to December 2014. Patient demographics, tumor characteristics, preoperative lymph node mapping, reconstructive timing, and outcomes were studied. Results A total of 524 microsurgical breast reconstructions in 516 patients were performed using the internal mammary vessels. IMLNs were sampled in 53 immediate and 42 delayed breast reconstructions. Eight (seven in the immediate and one in the delayed group) of the sampled nodes were positive for cancer metastasis, for an incidence of 8.4% in identified lymph nodes. All patients with metastatic IMLNs subsequently received local-regional radiation and chemotherapy. All patients were alive, and six were disease-free at the conclusion of the study period, which had an average follow up of 67.3 months. Conclusion Incidentally encountered IMLNs during microsurgical breast reconstruction are frequently positive. With negligible downside and the possibility to provide additional information for treatment, the procedure should be encouraged. J. Surg. Oncol. 2016;114:133-139. © 2016 Wiley Periodicals, Inc.

Summary Isolated vulvar reconstruction using profunda artery-based perforator flaps have good functional as well as quality of life restoration. Surgical techniques, complications, and final evaluation using questionnaires are presented. Background Vulvar reconstruction remains a great challenge to reconstructive surgeons. A local fasciocutaneous flap from the medial thigh is a good option with multiple choices of the donor arteries. Here, we extended the clinical application of a profunda perforator artery (PAP) flap with the design of an island pedicle flap. Methods From 2012 to 2015, 12 female patients with vulvar cancer received tumor ablation and immediate reconstruction using a PAP flap. The flaps (n = 19) were divided into V-Y advancement perforator flap (group I, n = 4) and island pedicle perforator flap (group II, n = 15). All of the demographic data were collected and analyzed. Results All of the flaps were transferred successfully, and all of the donor sites were closed without morbidities. Group II was superior to group I because of the smaller required flap size (P = 0.004), the smaller defect size/flap size ratio (P = 0.001), and a lower rate of post-op debridement (P = 0.037). The other parameters were not statistically significant. Conclusions PAP flap is a good choice for vulvar reconstruction. We preferred an island pedicle setting for its thin and pliable fasciocutaneous component and robust flap circulation. The favorable functional and aesthetic results can be achieved with limited donor site morbidities. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

Background Frontonasal fistulas can lead to life-threatening intracranial infections. Our refinement of the myocutaneous anterolateral thigh (ALT) flap for treating these fistulas is described. Methods A retrospective review of the microsurgical treatment of frontonasal fistulas is presented. Demographics, etiologies, outcomes, and complications were evaluated. Results Ten myocutaneous ALT flaps were used to reconstruct frontonasal fistula. The mean follow-up was 35 ± 2.5 months. Nine fistulas were secondary to oncologic resections, and one was due to a traumatic origin. Complications included a recurrent abscess in 1 case (10%); there were no cases of cerebrospinal fluid (CSF) leak or flap loss. Preoperative intracranial infections were present in 7 cases, with 6 successfully resolving their infection after surgical intervention and flap obliteration of their fistulas. Conclusion Refinements in the myocutaneous ALT flap design have been illustrated to provide robust dead-space obliteration with vascularized muscle and reliable simultaneous scalp coverage in the treatment of frontonasal fistulas. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Lymphedema is a common morbid after cancer treatment. The disease characterizes with progressive inflammatory process that result in irreversible fibrosis. Its chronology and progressive disease character often impacts the quality of life of cancer survivors. The pathophysiology of lymphedema remains unclear and the disease remains non-curable. In this article, we reviewed available studies of lymphedema and concluded possible treatment strategies for lymphedema. J. Surg. Oncol. 2017;115:96-98. © 2016 Wiley Periodicals, Inc.

Objectives/Hypothesis Elevated inflammatory biomarkers such as C-reactive protein (CRP) and the recently identified neutrophil/lymphocyte ratio (NLR) were demonstrated to be associated with prognosis in human cancers. The aim of our present study is to analyze the relationship of preoperative levels of CRP and NLR with clinicopathological factors and prognosis in oral squamous cell carcinoma (OSCC) patients. Study Design Retrospective study. Methods This study was performed on 226 OSCC patients between July 2007 and April 2012. Their serum CRP levels and NLR were measured preoperatively. Results CRP level ≥ 5.0 mg/L was significantly associated with NLR ≥ 2.44 (linear regression, P

Objectives/Hypothesis: This study was designed to investigate the anatomical features and applications of the ulnar forearm flap in head and neck reconstructive surgery. Study Design: A prospective study was designed to include 50 ulnar forearm free flap transplants in 50 patients. Patient defects requiring reconstructive surgery involved the buccal mucosa, tongue, floor of the mouth, upper or lower gums, lips, soft palate, and scalp. Twenty ulnar forearm flaps were analyzed along the entire ulnar artery to determine the anatomy and distribution of the ulnar artery septocutaneous perforators. Results: All 50 flaps were successfully transplanted into their respective sites. The mean diameters of the ulnar artery and vein were 2.3 ± 0.6 mm and 1.7 ± 0.6 mm, respectively. Arterial and venous size mismatch was experienced in 12 and 33 flaps, respectively. The mean number of sizable perforators was 4.3 ± 1.2, and most of the first perforators were located within 5 cm of the proximal wrist crease. None of the patients experienced long-term complications concerning the ulnar nerve. Conclusions: The ulnar forearm flap is a reliably consistent source of free flap transfer because it harbors constant septocutaneous perforators and produces minimal donor site morbidities for head and neck reconstructive surgery. Laryngoscope, 2012

This prospective study was designed to compare the accuracy rate between remote smartphone photographic assessments and in-person examinations for free flap monitoring. One hundred and three consecutive free flaps were monitored with in-person examinations and assessed remotely by three surgeons (Team A) via photographs transmitted over smartphone. Four other surgeons used the traditional in-person examinations as Team B. The response time to re-exploration was defined as the interval between when a flap was evaluated as compromised by the nurse/house officer and when the decision was made for re-exploration. The accuracy rate was 98.7% and 94.2% for in-person and smartphone photographic assessments, respectively. The response time of 8 ± 3 min in Team A was statistically shorter than the 180 ± 104 min in Team B (P = 0.01 by the Mann-Whitney test). The remote smartphone photography assessment has a comparable accuracy rate and shorter response time compared with in-person examination for free flap monitoring.

Objectives/Hypothesis: Previous studies have demonstrated a relationship between elevated serum squamous cell carcinoma (SCC) antigen (SCC-Ag) levels and shorter survival in cancer patients. Few studies, however, have investigated the role of serum SCC-Ag levels in oral SCC (OSCC). This study was conducted to analyze the relationship between preoperative SCC-Ag levels, clinicopathologic factors, and prognosis in OSCC patients. Study Design: Retrospective case-control study. Methods: Seventy-nine OSCC patients from Chang Gung Memorial Hospital were retrospectively recruited between April 2008 and March 2010. Serum SCC-Ag levels were measured preoperatively. Results: An SCC-Ag level of ≥2.0 ng/mL was significantly associated with the pathologic tumor status (P 10 mm vs. ≤10 mm, P < .001). It was not significantly associated with histologic differentiation (P = 1.000). A univariate analysis revealed that positivity for SCC-Ag was associated with disease-free survival (DFS) (P = .034) and overall survival (OS) (P < .001). In SCC-Ag-positive patients, the distant metastatic rate was higher than in the SCC-Ag-negative patients (P = .053). Conclusions: This study demonstrated that preoperative SCC-Ag is a good marker of pathologic lymph node metastasis, an advanced tumor stage, and a higher rate of distant metastasis. The preoperative SCC-Ag level is a potential prognostic indicator in DFS and OS, but studies with a longer follow-up period are needed to confirm these results.

Biomaterials that support adipogenesis could contribute to tissue engineering therapies to be used as alternatives to traditional methods of tissue reconstruction and regeneration. We have recently shown that hydrogels comprised of urea soluble proteins and polysaccharides extracted from adipose tissue promote preadipocyte differentiation in vitro and adipogenesis in vivo. However, it is not clear if these findings result from the adipose tissue source of the extracts or if the technique isolates adipogenic factors from other tissues. The present study investigates whether the application of this technique to dermis samples would provide adipogenic hydrogels. Extracts from dermis assembled into hydrogels by either temperature or pH mechanisms. Both formulations supported preadipocyte differentiation in vitro and vascularized adipose formation in vivo. The temperature formulation of the gels induced more rapid adipose formation than the pH formulation in vivo. Interestingly, in comparison to our previous studies the dermis derived hydrogels had comparable adipogenic properties to adipose gels in vivo but not in vitro. Further study of these materials could lead to insight of the role of specific matrix properties on adipogenesis.