Search

Plate-related complications are major long-term complications in mandible reconstruction. There are controversies regarding the use of a reconstruction plate versus miniplates and a bone flap versus a soft tissue flap with a bridging plate. Direct comparisons of a fibula flap and an anterolateral thigh flap, the applicability between a reconstruction plate and miniplate, and the correlation between plate-related complications and quality of life remain unclarified. Therefore, this study aimed to the explore complications of different flaps and plates and how they impact the patients' quality of life.We retrospectively reviewed the medical records of a total of 205 patients aged18 years who underwent segmental mandibulectomy and reconstruction using fibula flap with reconstruction plate (FR; n = 86), fibula flap with miniplate (FM; n = 61), and anterolateral thigh flap with reconstruction plate (AR; n = 58) due to cancer ablation, osteoradionecrosis, or benign tumor excision between August 2010 and December 2019. Data on characteristics, complications, and health-related quality of life were collected and analyzed.The plate-related complication rate was the highest in the AR group (37.9%), then in the FR group (25.6%), and was the lowest in the FM group (13.1%; p = 0.0079). The plate exposure rate was the highest in the AR group (24.1%), then in the FR group (15.7%), and was the lowest in the FM group (4.9%; p = 0.0128). The plate fracture and dislodge rates for the AR group were both higher than those for the FR and FM groups (24.1% versus 9.3% versus 9.8%, respectively; p = 0.023). The AR group had worse complication-free survival (hazard ratio [HR]: 3.61, 95% CI: 1.99-6.56, and p 0.0001) than the FR and FM groups. Osteoradionecrosis (HR: 6.19, 95% CI: 2.11-18.21, and p = 0.0009) and postoperative radiotherapy (HR: 2.87, 95% CI: 1.34-6.12, and p = 0.0402) were both independent adverse factors for complication-free survival, whereas patient treated primarily (HR: 0.35, 95% CI: 0.17-0.73, and p = 0.0048) was an independent protective factor. Plate-related complication negatively impacted the quality of life based on pain scores (β: -0.56, SE: 0.26, and p = 0.034).Using a fibular flap fixed with miniplates and avoiding the use of a reconstruction plate may yield a reduced plate exposure rate and better health-related quality of life, particularly for patients with osteoradionecrosis or those who need postoperative radiotherapy.

Background Comminuted intraarticular fractures of the metacarpophalangeal joint (MPJ) are difficult to treat. We evaluated the clinical outcomes of using a dynamic traction splint to treat comminuted intraarticular fracture of MPJ. Patients and methods We conducted a retrospective chart review on patients with comminuted intraarticular fracture of the MPJ treated with a dynamic traction splint at National Cheng Kung University Hospital between March 2014 and February 2018. The surgical procedures consisted of a transverse Kirschner wire insertion and treatment for concomitant injuries. The patients then received staged regular rehabilitation programs under a hand therapists' supervision for 14 weeks. Active range of motion (ROM) of injured digits, Visual Analog Scale score for pain, and return-to-work status were recorded to evaluate functional outcomes. Results A total of 10 patients were included. All were male patients and aged 8 to 66 years. The most common injury mechanism was motor vehicle accident (70%). The locations of fractures were 1 at the metacarpal head and 9 at the proximal phalangeal bases. Half of the fractures were open. Concomitant injuries were 1 digital nerve severance, 1 extensor tendon rupture, and 3 dorsal skin avulsions. There were no postoperative complications. The active ROM of the MPJ ranged from 40° to 90° with a median ROM of 80°. The Visual Analog Scale score for pain was 0 in 8 patients and 1 in the other 2 patients. All patients returned to their original workplace after rehabilitation. Conclusions Dynamic traction splints and postoperative rehabilitation programs could be an alternative treatment for comminuted intraarticular fracture of the MPJ.

Background Carotid body paragangliomas are rare and therapeutically challenging. Shamblin I or II carotid body paraganglioma can be removed en bloc. This operation is sometimes combined with preoperative transarterial embolization to control bleeding. However, Shamblin III carotid body paraganglioma, which is encased with carotid vessels, is difficult to remove without carotid artery ligation for excision. Sometimes, not all tumor tissues are removed during operation and residual tumor tissues remain. Here, we review a case of Shamblin III carotid body paraganglioma removal without preoperative transarterial embolization or ligation of the carotid artery. We present a successful technique for Shamblin III carotid body paraganglioma resection that reduces bleeding during the operation. Material and methods A 74-year-old male patient who had an enlarged left neck mass for more than 20 years underwent tumor excision. The final pathology was carotid body paraganglioma. During the operation, the tumor was discovered to be encased in the bifurcation of the common carotid artery. We carefully isolated and temporarily clamped the common carotid artery to enable application of the finger dissection method to completely free the tumor from the carotid artery in a safe and bloodless plane. Results Neither intraoperative massive bleeding nor postoperative cranial nerve deficit occurred. Favorable wound status was noted during outpatient department follow-up. Conclusions We describe a successful case of Shamblin III carotid body paraganglioma removal using temporary clamping of the common carotid artery and the finger dissection method.

Background Reconstruction for total laryngopharyngoesophagectomy is accomplished mainly by gastrointestinal transposition but can be complicated by anastomotic tension or associated neck-skin defect. Here, we present the results of total esophageal reconstruction by gastrointestinal transposition alone or with additional free tissue transfer and propose an algorithm accordingly. Methods We reviewed patients who had oncologic total laryngopharyngoesophagectomy between January 2012 and January 2016. Twenty-four men and one woman were included with a mean age of 54 (range, 41-72) years. Patients were grouped by reconstruction into the gastric pull-up (GP, n = 15), colon interposition (CI, n = 2), GP combined with free jejunal flap (GPFJ, n = 6), or GP combined with anterolateral thigh flap (GPALT, n = 2) group to compare clinical outcomes. Results The mean operation time was 1037.3 minutes and was significantly longer in the GPALT group than in the GP group (1235.0 ± 50.0 minutes vs. 929.7 ± 137.7 minutes, p =.009). All flaps survived. After a mean follow-up of 18 months, the overall leakage, stricture, and successful swallowing rates were 44%, 4%, and 76%, respectively. There was no significant difference in the leakage (53.3%, 50.0%, 16.7%, and 50.0%, p =.581), stricture (6.7%, 0%, 0%, and 0%, p = 1.000), or successful swallowing (73.3%, 50.0%, 83.3%, and 100%, p =.783) rates between GP, CI, GPFJ, and GPALT groups, respectively. Conclusions The proposed algorithm that ranks gastric pull-up as a priority and uses additional free tissue transfer to overcome the anastomotic tension or associated neck-skin defect is feasible.

Background Deep burn wounds have a high tendency to form hypertrophic scars. Previously, we found that angiogenin promoted neovascularization during deep burn wound healing. However, the association between angiogenin and scar formation is unclear. Methods We obtained human burn scar tissues from patients who underwent scar surgery and examined the role of angiogenin in scar tissues and determined its effects in scar fibroblasts and on transforming growth factor β1 (TGF-β1) secretion. Results Our results showed an inverse correlation between angiogenin expression and scar severity. Next, we examined the effects of angiogenin in scar fibroblasts. We found that angiogenin was persistently expressed in human scar fibroblasts and that angiogenin expression significantly increased with time in the culture medium of scar fibroblasts. Treatment of scar fibroblasts with recombinant angiogenin significantly decreased their proliferation and TGF-β1 secretion. Moreover, angiogenin inhibited TGF-β1-mediated Smad2 signaling pathway. Conclusion Our data suggest a negative role of angiogenin in fibroblast proliferation via TGF-β1-mediated Smad2 signaling pathway.

BACKGROUND Burn blister fluid contains several angiogenic factors to promote wound neovascularization. In our previous study, we found that deep partial-thickness burn (DPTB) wounds showed higher expression levels of angiogenin to enhance vascularization compared with superficial partial-thickness burn wounds. Neovascularization is a complex process that involves an interaction between circulating angiogenic cells and mediators. We hypothesized that in addition to angiogenic factors burn blisters may contain specific cell types. The aim of the present study was to characterize the specific cells present in burn blisters. METHODS Twenty-four burn blister fluid samples were obtained with informed consent from patients with superficial partial-thickness burn (n = 16) or DPTB (n = 8) wounds. Blister cells were isolated from individual intact blisters and characterized with flow cytometry analysis using CD14, CD34, vascular endothelial growth factor receptor 2, and CD133 markers. CD14 and CD34 blister cells were also isolated using a magnetic-activated cell sorting system to examine their potential for endothelial differentiation. Angiogenin levels in the burn blister fluids were evaluated with enzyme-linked immunosorbent assay. RESULTS CD14 cells were the most highly represented cell type in the burn fluids of both groups, although a significantly greater percentage of CD14 cells were observed in DPTB fluids. CD14 blister cells had a higher potency to differentiate into functional endothelial cells as compared with CD34 cells. The proportion of CD14 cells gradually increased after burn injury. In contrast to CD14 cells, angiogenin showed the highest expression levels at day 1 postburn. With regard to burn wound neovascularization, angiogenin expression was partially correlated with CD14 blister cells in the burn fluids. CONCLUSIONS We provide the first report on the characterization of blister cells in burn fluids. Our data suggest that CD14 blister cells may play a role in burn wound neovascularization. Measurement of CD14 blister cells serves as a possible tool for assessing burn wound status.

Glomus tumors are rare, usually benign, vascular hamartomas consisting cells resembling the smooth muscle cells of the normal glomus body. They can be solitary or multiple, whereas solitary tumors are majorly located on the digits. Digital glomus tumors most commonly appear in subungual region and show a strong female predominance. There are several classical symptoms, clinical tests, and imaging tools, such as X-ray, magnetic resonance imaging, and ultrasonography, which can provide good accuracy for clinical diagnosis. However, misdiagnosis and delayed diagnosis are still commonly observed because primary physicians are unfamiliar with classical symptoms and clinical tests. Complete surgical excision often can result in complete relief of symptoms. Recurrence is largely caused by incomplete excision, but repeated image study is recommended to rule out new or malignant lesions. This series is a retrospective review of 50 cases with glomus tumors managed at our institute. We aim to review the key aspects of glomus tumor and provide a simple guideline for earlier diagnosis and treatment.

Dermatofibrosarcoma protuberans (DFSP) is a rare soft-tissue neoplasm in children with low-grade malignant potential; metastasis is rare but there is risk of local recurrence after treatment.1 An adequate surgical tumor-free margin is vital for long-term outcome and survival after wide excision or Mohs micrographic surgery.1 However, such surgeries may result in severe functional and cosmetic defects at anatomically critical areas. Neoadjuvant or adjuvant imatinib mesylate therapy may help control tumor progression, but treatment experience in pediatric DFSP is limited to case reports and there is no established treatment protocol. We report a toddler boy with a DFSP near his left eye treated with adjuvant imatinib mesylate after an inadequate postoperative tumor-free margin.

Burn wound healing is a complex and dynamic process that involves the interaction between different cell types and mediators. Neovascularization is an imperative stage of wound healing and consists of not only angiogenesis but also adult vasculogenesis. A superficial partial-thickness burn (SPTB) heals within 2 weeks without scarring. A deep partial-thickness burn (DPTB), conversely, requires 2 weeks or longer to heal and requires an aggressive treatment to prevent hypertrophic scarring. Burn blisters on the skin are a hallmark of not only SPTB but also DPTB; however, the effect of burn blister fluids on the neovascularization in these types of burns has not been fully explored. To verify this effect, the role of different burn fluids and the angiogenic factors that modulate this process are currently under investigation.

Deep partial thickness burn (DPTB) wound fluids have a greater propensity for establishing neovascularization than did superficial partial thickness burn (SPTB) wound fluids in our previous study. To investigate the factors responsible for this activity, cytokine array and enzyme-linked immunosorbent assay were used to perform an expression analysis of angiogenic factors in burn fluid. Although present in approximately equal amounts in both SPTB and DPTB blister fluids from burn patients, angiogenin does appear to be involved in the ability of DPTB blister fluid to promote neovascularization in vitro and in vivo. Angiogenin alone was sufficient to induce endothelial differentiation of circulating angiogenic cells (CAC) without vascular endothelial growth factor A involvement. In addition, angiogenin was positively associated with CAC differentiation in the burn blister fluid. Blocking the effect of angiogenin in burn blister fluids resulted in a significant reduction of endothelial cell proliferation, CAC differentiation, and new blood vessels formation in vivo. Moreover, immunohistochemistry revealed that high angiogenin expression colocalizes with high vascularity in human burn wounds at day 7, further supporting our hypothesis that angiogenin is involved in burn wound neovascularization.

Background Limb amputation is considered one of the most devastating consequences of electrical injury. Any factors that correlate with the degree of muscle damage can be used to predict the necessity of limb amputation. The aim of this study was to determine the factors that can be used to predict limb amputation in high-voltage electrically injured patients. Methods Eighty-two high-voltage electrically injured patients were admitted to our hospital during a 17-year period. A retrospective analysis of the possible related risk factors between amputation and non-amputation patients was performed. Results A total of 68 patients were enrolled for analysis. Thirteen patients underwent limb amputations. Multivariate analysis of the risk factors between amputation and non-amputation groups showed statistical significance for day 1 creatine kinase-isoenzyme MB (CK-MB) level. A serum CK-MB level above 80 ng/ml predicted high risk of limb amputation with high specificity (84%) and sensitivity (77%). Only one patient with a remarkable decrease of creatine kinase (CK) and CK-MB levels after fasciotomy avoided a major limb amputation. Conclusion Our results suggest that CK-MB level is an independent factor for prediction of limb amputation. We suggest that the addition of CK-MB evaluation to clinical symptoms screening may be a valuable method to early detection of muscle damage.

The effect of burn blister fluid in neovascularization during burn wound healing is unknown. Burn blister fluid, containing a large amount of chemokines, is thought to play a role in the early stage of neovascularization. This process includes angiogenesis and vasculogenesis. Because of different healing time of burn wounds, we hypothesized that neovascularization in superficial partial thickness burn (SPTB) and deep partial thickness burn (DPTB) wounds were different. The neovasculogenic effects of two different burn blister fluids were also different. We found Day 7 DPTB wounds had a significant increase in blood vessels compared with SPTB wounds by immunohistochemistry. DPTB blister fluid significantly promoted neovascularization via increasing endothelial cell proliferation, and migration and differentiation of circulating angiogenic cells relative to SPTB blister fluids. In the animal study, DPTB blister fluids markedly promoted new blood vessel formation compared with those from SPTB blister fluids using in vivo Matrigel plug assay. These results suggest that DPTB wounds require more new vessel formation than SPTB. Furthermore, the measurement of angiogenic activities in burn blister fluids serves as a possible tool for assessing burn wound status.

Stenotrophomonas maltophilia has been increasingly reported as a nosocomial opportunistic pathogen in debilitated patients, including burn patients. There is, however, only one published report in English that discusses S. maltophilia bacteremia in burns. We performed a retrospective chart review and statistical analysis of the incidence, the duration of hospital stays before a diagnosis of bacteremia, antimicrobial susceptibility, prognosis, and mortality risk factors in burn patients. From January 1996 to December 2004, 14 episodes of S. maltophilia bacteremia in 13 of 666 patients admitted to the burn center at our hospital were identified. The patients, nine males and four females, ranged in age from 1 to 76 years (mean: 42.9+/-24.4 years). Eleven injuries were from flame burns and two were from scald burns. The mean total burned surface area (TBSA) was 47+/-30.2% and mean prognostic burn index (PBI) was 81.7+/-31.3. The average annual incidence was 2.3 episodes per 1000 admissions, and no outbreak cluster was noticed. The mean hospital stay before bacteremia was 19.8+/-11.9 days. Most isolates were susceptible to ticarcillin-clavulanate (87.5%) and moxalactam (85.7%). The overall mortality was 30.7% (4/13) and correlated significantly with TBSA (P

Thirty-seven consecutive free anterolateral thigh flaps in 36 patients were transferred for reconstruction of head and neck defects following cancer ablation between January of 1997 and June of 1998. The success rate was 97 percent (36 of 37), with one flap lost due to a twisted perforator. The anatomic variations and length of the vascular pedicle were investigated to obtain better knowledge of anatomy and to avoid several surgical pitfalls when it is used for head and neck reconstruction. The cutaneous perforators were always found and presented as musculocutaneous or septocutaneous perforators in this series of 37 anterolateral thigh flaps. They were classified into four types according to the perforator derivation and the direction in which it traversed the vastus lateralis muscle. In type I, vertical musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 56.8 percent of cases (21 of 37), and they were 4.83 +/- 2.04 cm in length. In type II, horizontal musculocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 27.0 percent of cases (10 of 37), and they were 6.77 +/- 3.48 cm in length. In type III, vertical septocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 10.8 percent of cases (4 of 37), and they were 3.60 +/- 1.47 cm in length. In type IV, horizontal septocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 5.4 percent of cases (2 of 37). They were 7.75 +/- 1.06 cm in length. The average length of vascular pedicle was 12.01 +/- 1.50 cm, and the arterial diameter was around 2.0 to 2.5 mm; two accompanying veins varied from 1.8 to 3.0 mm and were suitable for anastomosis with the neck vessels. Reconstruction of one-layer defect, external skin or intraoral lining, was carried out in 18 cases, through-and-through defect in 17 cases, and composite mandibular defect in two cases. With increasing knowledge of anatomy and refinements of surgical technique, the anterolateral thigh flap can be harvested safely to reconstruct complicated defects of head and neck following cancer ablation with only minimal donor-site morbidity.

The etiology of herpetic lesions on burn wounds generally is believed to be a reactivation of previous infection or possible exposure to the pathogens under an immunocompromised status. However, this scenario rarely happens in a non-immunocompromised infant with low burned body surface area (

Background: Wide excision or Mohs surgery is the standard treatment of skin squamous cell carcinoma (SCC). Superficial SCC or tumor smaller than 1 cm has been treated successfully with open spray cryosurgery. Larger tumor may not be as effective because tissue destruction is usually superficial. Intralesional cryosurgery (IC) may provide a deeper and better cell killing effect in larger tumors. We investigated the safety and efficacy of treating nodular SCC in 4 patients with IC. Methods: Four patients with nodular SCC/keratoacanthoma (tumor size, 1–2.5 cm, average 1.48 cm) on the face and extremity were treated with IC. An 18-ga needle was connected to a cryogun and inserted into the center of the tumor after local anesthesia. The tumors were treated with 2 freeze–thaw cycles with a 5- to 10-mm free margin. Additional IC or open spray cryosurgery was applied if residual tumor was noted during monthly follow-up. Results: No patient required analgesics or experienced wound infection after the procedures. After IC, all tumors reduced 40% to 75% in size within 1 week. Two patients received 1 additional spray cryosurgery. Complete remission was noted in all tumors (100%) in 2 months. No recurrence was noted during follow-up (average 5.1 years). All patients were satisfied with the results. Conclusion: Our observation suggests that IC can be simple and effective alternative treatment for SCC patients whose condition is not suitable for or who refused operation.

Summary A 40-year-old male motorcyclist suffered a near-total amputation of his right foot. His limb was successfully salvaged with the aid of a cross-leg vascular shunt. Temporary arterial flow from the contralateral limb was transmitted via a pressure monitor tube to perfuse the avulsed part. This allowed the surgeon to carry out unhurried wound debridement, dissection of vital structures and skeletal fixation. The cannulation port was placed well distal to the proposed definitive anastomosis, to reduce damage to the endothelium. This procedure could be a valuable adjunct in major limb replantation, particularly in cases of prolonged ischaemia.

A 3-year-old boy was brought to our hospital with 62% TBSA burn injury by boiled water. He received modern burn therapy, including early debridment and skin grafts. The patient discharged 70 days after being burned. Unfortunately, he sustained an acute right-sided hemiparesis 7 days after discharge. Magnetic resonance imaging revealed left middle cerebral artery territory infarction, and a magnetic resonance angiogram showed nonvisualization of left distal intra-cranial carotid artery and proximal middle cerebral artery. Thickened walls of these arteries indicated acute dissection. The patient received a follow-up magnetic resonance angiogram study 10 years later to check cerebral vascular lesions that may not have been apparent on the original image studies. It showed only persistently thickened left distal intra-cranial carotid artery and middle cerebral artery walls, indicative of old dissection. Therefore, carotid artery dissection must be considered as one cause of acute stroke in pediatric burn patient, even in the recovery phase of burn injury.

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.

We appreciate the comments of Dr. Badoiu and Dr. Caramitru about our study [Hsueh Y-Y, Chen C-L, Pan S-C. Analysis of factors influencing limb amputation in high-voltage electrically injured patients. Burns 2011;37(June (4)):673‐7]. We agree with their experience in that clinical symptoms are of utmost importance in detection of the muscular lesions and determination of amputation. It has been a widely accepted principle that early surgical intervention should be done in patients with obvious compartment or muscle necrosis. However, atypical compartment syndrome usually occurs in a very different clinical setting and is difficult to discern in the early stage. Aggressive surgical debridement (escharotomy, fasciotomy, fasciectomy) every day during the first 3‐4 days after electrocution may help release compartment pressure and prevent further muscle damage caused by ischemia. But the inhomogeneous injury pattern of muscle necrosis caused by electroporation may hamper adequate debridement. That is why selective decompression should be performed at 3‐5 days after injury [1]. The contribution of CK-MB in the early stage of electric injury is an interesting finding in our study. The dramatic decrease of CK-MB level following decompression may indicate the injured limb is salvageable. We also agree with the point that we should be alert in electrically injured patients with high CK-MB levels, whereas an appropriate cutoff level to alert us to pay attention to the muscle condition remains a concern. CK-MB, having statistical evidence and result, will no doubt assist in assessing the possibility of limb amputation. Its importance can not be overlooked in early stage of electric injury. However, a large prospective study should be performed to determine the real value. Further, the pathophysiology of muscle damage between