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Vascular occlusion causing vision loss is a rare yet one of the most devastating complications of facial esthetic fillers. In this article, we present a case of unilateral blindness and superficial skin necrosis in a 31-year-old woman after the injection of hyaluronic acid for esthetic purposes. The delicate ocular fundal findings of ophthalmic artery occlusion were demonstrated by ophthalmoscopy, optical coherence tomography, and fluorescein angiography. Magnetic resonance imaging also showed subsequent ischemic changes in the optic nerve and posterior scleral wall after ophthalmic artery occlusion. Despite management including intraocular pressure-lowering agents, globe massage, and anticoagulation with acetylsalicylic acid and hyperbaric oxygen therapy, her final vision was not restored. Given the lack of effective treatments, this report depicts the comprehensive ocular fundal findings of an ophthalmic artery occlusion after esthetic hyaluronic acid filler injection, and highlights the importance of a preventive approach to avoid such catastrophic complications.

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.

Autologous chondrocytes (C cells) are effective sources of cell therapy for engineering cartilage tissue to repair chondral defects, such as degenerative arthritis. The expansion of cells with C cell characteristics has become a major challenge due to inadequate donor sites and poor proliferation of mature C cells. The perichondrial progenitor cells (P cells) from the cambium layer of the perichondrium possessed significantly higher mesenchymal stem cell markers than C cells. In the transwell co-culture system, P cells increased the passaging capacity of C cells from P6 to P9, and the cell number increased 128 times. This system increased the percentage of Alcian blue-positive C cells from 40% in P6 to 62% in P9, contributing about 198 times more Alcian blue-positive C cells than the control group. C cells co-cultured with P cells also exhibited higher proliferation than C cells cultured with P cell-conditioned medium. Similar results were obtained in nude mice that were subcutaneously implanted with C cells, P cells or a mixture of the two cell types, in which the presence of both cells enhanced neocartilage formation in vivo. In aggregate, P cells enhanced the proliferation of C cells in a dose–dependent manner and prolonged the longevity of mature C cells for clinical applications.

Rete ridges are important to the mechanical function of skin in animals with minimal hair, including humans. As mice do not exhibit rete ridges, the need for a quality animal model is pertinent. Here, we develop a Lanyu pig (Sus scrofa) full-thickness wound model to explore tissue regeneration because the architecture and function are similar to humans and inbred genetic variants are available. Full- and partial-thickness wounds were generated on the dorsum. Full-thickness wounds at post-wound day 57 exhibit severe scar with no signs of wound-induced hair follicle neogenesis. Wound contraction is greater in the anterior/posterior relative to the medial/lateral axis. In wound beds, K14+ cells increased while K10+ , p63+ and PCNA+ cells decreased compared to unwounded tissue. Epithelial β-catenin is unchanged. The wound bed expresses more ColI, less ColIII and no elastin. Rete ridges do not form after full-thickness wounding, but incompletely regenerate after partial-thickness wounding. An alkaline phosphatase (ALP)+ cell population, not associated with hair follicles, is present at the bottom of the rete ridge basal layer in pig and human unwounded skin. These K5+ /K10- /PCNA- /ALP+ epithelial cells are absent after full-thickness wounding but reappear after partial-thickness wounding, before invagination of new rete ridges. In summary, full-thickness wounding on the dorsum of Lanyu pigs results in scar formation and perturbed molecular expression while partial-thickness wounding permits limited rete ridge and papillary dermis regeneration. Future functional studies and further characterization will help contribute knowledge for the regenerative medicine field.

Locked thumb metacarpophalangeal joint caused by entrapment of the sesamoid bone is an uncommon entity. The intact volar plate, strong ligamentous attachment between the sesamoid bone and the joint, and altered axis of inserted muscle all contribute to failure of closed reduction. The patient's history, clinical presentation, and plain radiographic findings are all important clues to diagnosing this rare disease. We describe 2 patients with a similar mechanism of injury, where the sesamoid bones were displaced into the thumb metacarpophalangeal joint causing lock thumb. The anatomy, pathophysiology, and surgical management of the patients are also described and discussed. Both patients were successfully treated with meticulous open reduction.

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 Major trauma has been one of the leading causes of morbidity, mortality, and functional disability, resulting in substantial societal burden. The aim of this study was to estimate the trends in burden of adult major trauma in Taiwan during 2003–2015. Methods Adult patients with initial encounter of major trauma (injury severity score ≥ 16) were abstracted from the claim data of National Health Insurance (NHI) in Taiwan from January 2003 to December 2015. We explored the trends of incidence and mortality rates over time stratified by age and sex, as well as life expectancy (LE), loss-of-LE, lifetime healthcare expenditure and total loss-of-LE compared with age, sex and calendar-year matched referents simulated from the vital statistics of Taiwan. Results A total of 71,731 cases of adult major trauma, and an estimated loss of 979,676 life-years were found with an increasing trend in cumulative incidence rate (CIR18-84) during 2003–2015. The incidence rates were significantly higher in men than women. For both sexes, the incidence rates for those aged 65 and above were about 2–3 times higher than those of all other age groups. The one-year case fatality rates among the elderly were about 31–61%, higher than all other ages. The lifetime healthcare expenditures per person were 47,616 USD in men and 43,416 USD in women. Conclusion There is a consistently increasing trend in incidence and mortality of major trauma in Taiwan, especially among elderly people. For Taiwan, an aged society beginning since 2018, the challenge should be tackled more effectively in the coming decades.

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:Whether one-vein or two-vein drainage yields better outcomes in anterolateral thigh flap reconstruction after oral cancer ablation is still being debated. Thus, the authors investigated this question.Methods:In this retrospective cohort study, the authors reviewed the charts of 321 patien

To comprehend the merits of a Manual Tactile Test (MTT) in assessing hand sensorimotor functions by exploring the relations among 3 subtests along with the precision pinch performances for patients with peripheral nerve injuries (PNIs); and to understand the accuracy of the MTT by constructing the sensitivity and specificity of the test for patients with PNI.Case-control study.Hospital and local community.Patients with PNI (n=28) were recruited along with age-, sex-, and handedness-matched healthy controls (n=28) (N=56).Not applicable.The Semmes-Weinstein monofilament, moving and static 2-point discrimination, roughness differentiation, stereognosis and barognosis subtests of the MTT, and precision pinch performance were used to examine the sensory and sensorimotor status of the hand.The worst results in all sensibility tests were found for the patients with PNI (P.001) in comparison with the controls. Multiple linear regression analysis showed the MTT was a better indicator for predicting the sensorimotor capacity of hands in the patients with PNI (r(2)=.189, P=.003) than the traditional test (r(2)=.088, P=.051). The results of the receiver operating characteristic curve estimation show that the area under the curve was .968 and .959 for the roughness differentiation and stereognosis subtests, respectively, and .853 for the barognosis subtest, therefore revealing the accuracy of the MTT in assessing sensorimotor status for patients with PNI.This study indicates that the MTT is highly accurate and a significant predictor of sensorimotor performance in hands of patients with PNI. The MTT could therefore help clinicians obtain a better understanding of the sensorimotor and functional status of the hand with nerve injuries.

The estimated prevalence of diabetes is 9.78% in Taiwan. The lifetime risk for patients with diabetes to have foot ulcers might be as high as 25%. About 15% of these patients require major limb amputation because of ischemia and infection. Peripheral artery disease is still a major problem involved in diabetic foot disease and the cause for major amputation despite an increase in the prevalence of revascularization surgery and new revascularization techniques over the past 20 years. We investigated the major limb amputation rates in patients with diabetic foot and critical limb ischemia who had undergone revascularization surgery in our hospital. The records of 42 patients who had undergone revascularization surgery for diabetic foot were retrospectively reviewed. Nineteen patients (45%) required major limb amputation despite revascularization. The affected limbs of only 15 patients (36%) were salvaged. Four patients died soon after surgery because of comorbidities, and another 4 were lost to follow-up. Two patients died from procedure-related sepsis, and overall perioperative mortality was 4.8%. Ten predictive risk factors (duration of diabetes, history of smoking, coronary artery disease, congestive heart failure, cerebral vascular accident, contralateral amputation, end-stage renal disease, fever episode, wound infection severity score, and arterial obstruction level) were included for analysis. Although none was significant, long-duration diabetes (OR: 1.13), end-stage renal disease (OR: 10.02), wound infection (OR: 1.56), and infrapopliteal lesions (OR: 3.00) tended to be unfavorable predictive risk factors of limb amputation. Revascularization surgery is still potentially beneficial for these patients--eg, it decreases the contralateral limb amputation rate by 7.5%--if done early in high-risk patients.

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.

Summary Corticosteroids have been used for treating various musculoskeletal problems for more than five decades. They remain the drug of choice in rheumatology, orthopedics, and other areas. Most local corticosteroid injections are safe; however, complications may occasionally arise. Tendon rupture is uncommon after a local corticosteroid injection. We present two cases and review possible rupture mechanisms. In case 1, the patient presented with a painful swelling on the dorsal side of her right first metacarpophalangeal joint. An orthopedic surgeon prescribed three local corticosteroid injections over 4 weeks, and the patient experienced a sudden loss of extension on the distal phalanx of her thumb 3 weeks after the last injection. Two days later, the proximal phalanx of the thumb lost its extension. Surgical exploration revealed that the extensor-pollicis-longus and extensor-pollicis-brevis tendons were completely severed. Both tendon ends had edematous necrosis with collagen degeneration. In case 2, the patient presented with ruptures of the extensor-pollicis-brevis tendon and the radial collateral ligament of her first metacarpal joint after receiving a local corticosteroid injection. In case 1, functional recovery was achieved by repairing the extensor-pollicis-brevis tendon and by transferring the extensor indicis proprius tendon to the extensor pollicis longus. In case 2, the patient was lost to follow-up and did not undergo surgery. Most physicians overlook local-corticosteroid-injection-induced tendon injuries. We hope that such patients will alert all physicians to the risk of tendon rupture associated with corticosteroid injections.

The evolution of flight in feathered dinosaurs and early birds over millions of years required flight feathers whose architecture features hierarchical branches. While barb-based feather forms were investigated, feather shafts and vanes are understudied. Here, we take a multi-disciplinary approach to study their molecular control and bio-architectural organizations. In rachidial ridges, epidermal progenitors generate cortex and medullary keratinocytes, guided by Bmp and transforming growth factor β (TGF-β) signaling that convert rachides into adaptable bilayer composite beams. In barb ridges, epidermal progenitors generate cylindrical, plate-, or hooklet-shaped barbule cells that form fluffy branches or pennaceous vanes, mediated by asymmetric cell junction and keratin expression. Transcriptome analyses and functional studies show anterior-posterior Wnt2b signaling within the dermal papilla controls barbule cell fates with spatiotemporal collinearity. Quantitative bio-physical analyses of feathers from birds with different flight characteristics and feathers in Burmese amber reveal how multi-dimensional functionality can be achieved and may inspire future composite material designs. VIDEO ABSTRACT.

A variety of digit and limb repair and reconstruction methods have been used in different clinical settings, but regeneration remains an item on every plastic surgeon's “wish list.” Although surgical salvage techniques are continually being improved, unreplantable digits and limbs are still abundant. We comprehensively review the structural and functional salvage methods in clinical practice, from the peeling injuries of small distal fingertips to multisegmented amputated limbs, and the developmental and tissue engineering approaches for regenerating human digits and limbs in the laboratory. Although surgical techniques have forged ahead, there are still situations in which digits and limbs are unreplantable. Advances in the field are delineated, and the regeneration processes of salamander limbs, lizard tails, and mouse digits and each component of tissue engineering approaches for digit‐ and limb‐building are discussed. Although the current technology is promising, there are many challenges in human digit and limb regeneration. We hope this review inspires research on the critical gap between clinical and basic science, and leads to more sophisticated digit and limb loss rescue and regeneration innovations.

Background: Anatomical variability of perforators of the anterolateral thigh flap has been reported. The authors introduce a classification based on the number, location, and origin of the cutaneous perforators to comprehensively illustrate their vascular patterns in hopes that unfavorable anatomical variations of the anterolateral thigh flap can be overcome in clinical applications. Methods: The authors enrolled and reviewed 110 anterolateral thigh flaps created between September of 2010 and January of 2013 for head and neck reconstruction after cancer ablation. The location of the perforators was defined by Yu's ABC system. Its corresponding origin from the descending or transverse branch of the lateral circumflex femoral artery was clarified by Shieh's vascular anatomical classification for the anterolateral thigh flap. Results: Of the 110 flaps, a single perforator (A or B or C) was observed in 20 flaps (18.2 percent), double perforators (A + B or B + C or A + C) were observed in 59 flaps (53.6 percent), and triple perforators (A + B + C) in 31 flaps (28.2 percent). The origin of perforators was the descending branch in 76 flaps (69.1 percent), the transverse branch in 10 flaps (9.1 percent), and both descending and transverse branches in 24 flaps (21.8 percent). The authors observed 16 vascular patterns. The most common type was double perforators, with perforators B and C originating from the descending branch [n = 40 (36.4 percent)]. Conclusions: The clinical significance of each pattern is delineated, and surgical technical considerations are suggested according to flap requirements and types of vascular anatomy.

Summary Background Malignant fibrous histiocytoma (MFH) is a common soft-tissue sarcoma in adults, which commonly affects the extremities, trunk, head, and neck. Of these regions, the extremities are more often affected. However, only a few studies have specifically investigated the clinical behavior and prognosis of this malignancy, especially in East Asian populations. Aims and objectives We collected data on MFH cases for a period of 10 years and present our experience here in treating patients with extremity MFH. Materials and methods This study was a retrospective analysis of patients with extremity MFH treated in the Department of Plastic Surgery at National Cheng Kung University Hospital between January 2004 and December 2013. Data on patient profiles, surgical resection, radiotherapy, and chemotherapy were all reviewed. The patients were followed up regarding their local recurrences and survivals. Results Thirteen patients (6 men and 7 women) were enrolled in this study. The mean age of the patients was 57.9 years (range, 33–82 years). The sizes of the clinical tumors ranged from 1.7 to 15 cm in a maximal linear dimension (mean, 7.3 cm), and 76.9% of the tumors developed in the lower extremities. The average follow-up time was 63.5 months. One patient received limb amputation, and 12 patients were treated with limb salvage including marginal or wide excisions. Adjuvant radiotherapy was performed in 10 patients whose tumor sizes exceeded 5 cm or who exhibited inadequate excision or recurrence. Chemotherapy was performed in six patients who exhibited a distant metastasis or vessel invasion. The local and distant recurrence rates were 53.8% and 30.8%, respectively. A total of 42.9% of patients with local recurrence developed distant metastases. The surgical margin was the only significant factor of local disease control, and distant metastasis was the only factor relevant to the overall survival (OS). Conclusion An adequate resection margin during treatment for the primary MFH tumor achieves optimal results for local disease control. It influences the OS rate, because local-recurrence-related distant metastasis is significantly associated with high mortality.

As immunotoxicity assessments of newly developed biomaterials are often restricted to use in assessment of local tissue response at the implantation site, they do not always show an immune response acceptable to qualify them for clinical use. We tested a new method to assess systemic toxicity: counting the CD4(+) and CD8(+) cells in the spleen. Three different biomaterials were subcutaneously implanted in three groups of rats for the same time period. After 31 days, their spleens were harvested, and CD4(+) and CD8(+) cells were counted. The mean CD4(+)/CD8(+) cell counts were 24.5 ± 3.6/19.8 ± 4.0 (porous collagen matrix group), 25.5 ± 7.1/21.6 ± 3.8 [synthetic collagen matrix (Duragen®) group] and 28.1 ± 4.1/19.6 ± 3.7 (porcine dermis group). Differences in cell counts were not significant. The immunotoxic response generated against porous collagen matrix was comparable to that produced by a similar biomaterial already used clinically. This is, to the best of our knowledge, the first study on cytotoxic lymphocytes in the spleen to quantify systemic immune response to a biomaterial; however, such studies have been conducted with bacterial and viral antigens, and with vaccines. We believe that the present study provides a viable method for larger studies to confirm our current findings.

Scedosporium apiospermum is an emerging opportunistic fungus that can cause localized infection in healthy hosts or severe disseminated disease in immunocompromised hosts. Most cases are reported in Western Europe, Australia, and North America. We report a 52-year-old immunocompetent Taiwanese woman who presented with a 6-year history of recurrent asymptomatic papulonodular lesions on her right foot after minor trauma. Deep fungal infection caused by Scedosporium sp. was diagnosed after a skin biopsy with fungal culture of the skin specimen. She underwent two surgical excisions, each followed by a 4-month course of oral itraconazole and intralesional injections of amphotericin B as well, but similar lesions recurred at the same location 1 year later. She had another surgical excision and the pathological findings showed mycetoma. The fungus was identified as S. apiospermum by PCR assay of fungal culture specimen using the internal transcriber spacers (ITS1, similarity 99.4%; ITS2, similarity 100%) and the D1–D2 (similarity 99.0%) regions of the ribosomal operon. After 4 months of oral voriconazole (400 mg/day), no recurrence was noted in the subsequent 2 years.

Summary Synovial sarcomas are highly aggressive soft tissue malignant tumors that occur primarily in young adults. They arise from mesenchymal tissue and typically in or near tendons and tendon sheaths. They can develop at any site but the majority (80–95%) of synovial sarcomas are located in the extremities and mostly at the lower extremities. Groin synovial sarcoma is rare. About 10% of lower limb soft tissue sarcomas have major vessel involvement. In the past, amputation was the standard surgical procedure for lower limb soft tissue sarcoma with major vessels involvement. However, using modern surgical techniques, we can successfully perform a limb-preserving operation with a tumor-free margin. A 17-year-old girl presented with left inguinal synovial sarcoma with femoral artery and vein encasement. The patient received radical tumor resection with major vascular structures. Segmental femoral vessel defects were reconstructed with polytetrafluoroethylene grafts. After revascularization, we designed a pedicled anterolateral thigh fasciocutaneous flap for coverage of the wound and reconstructed vessels simultaneously. The circulation of the lower extremity was good and the girl recovered well after the surgery without morbidity. Synovial sarcoma would potentially be associated with local recurrence and distant metastasis. The presences of bone and neurovascular bundle invasion are adverse predictors of recurrence and mortality. Surgery remains the mainstay of treatment. In the advance of current surgical technique, limb-preserving surgery is possible even for tumor-involved major vessels.

We presented a patient who experienced the anterolateral thigh (ALT) flap failure but the reconstruction was successfully salvaged by harvesting a second ALT flap from the same donor site 2 days after the first reconstruction. A 47-year-old man received cancer ablation for right mouth floor squamous cell carcinoma. The resultant defect was planned to be reconstructed with the ALT flap. During the flap dissection, we identified three proximal cutaneous perforators originating from the transverse branch of the lateral circumflex femoral artery (t-LCFA) and two distal cutaneous perforators originating from the descending branch (d-LCFA). We harvested a skin flap based on the distal two perforators and divided the d-LCFA just distal to the bifurcation of the d-LCFA and the t-LCFA. Unfortunately, the ALT flap showed venous congestion on postoperative day 2 and eventually failed. We harvested a second ALT flap from the same donor site based on the previously preserved perforators. The recovery course was smooth thereafter. We believe that the harvest of a second ALT flap from the same donor site may be an option, to avoid other donor site violation, in some patients who experienced the first flap loss. © 2014 Wiley Periodicals, Inc. Microsurgery 34:409-412, 2014.

Importance: To develop a practical program in the early phase after nerve repair for more rapid return of function. Objective: To investigate the effects of touch-observation and task-based mirror therapy on the sensorimotor outcomes of patients with nerve repair. Design: An assessor-blinded study with a randomized controlled design. Setting: University hospital. Participants: We recruited 12 patients with median or ulnar nerve repair between the level of midpalm and elbow referred by the plastic surgeons. Intervention: The patients were randomized into touch-observation and task-based mirror therapy or control groups, and both groups received training for 12 wk. Outcomes and Measures: The Semmes–Weinstein monofilament (SWM) test, two-point discrimination test, Purdue Pegboard Test (PPT), Minnesota Manual Dexterity Test (MMDT), and pinch-holding-up activity test were assessed at pretreatment, immediately after treatment, and 12 wk after the last treatment. Results: The experimental group showed greater improvements in the results of the pinch-holding-up activity test and the PPT Unilateral Pin Insertion, Bilateral Pin Insertion, and Assembly subtests. However, change on the SWM test revealed no significant difference between the two groups. Conclusions and Relevance: Touch-observation and task-based mirror therapy is an effective but low-cost treatment protocol to optimize sensorimotor control and functional capability of the upper limb in patients with peripheral nerve injury.

Keloids are pathological scars characterized by excessive extracellular matrix production that are prone to form in body sites with increased skin tension. Caveolin-1 (CAV1), the principal coat protein of caveolae, has been associated with the regulation of cell mechanics, including cell softening and loss of stiffness sensing ability in NIH3T3 fibroblasts. Although CAV1 is present in low amounts in keloid fibroblasts (KFs), the causal association between CAV1 downregulation and its aberrant responses to mechanical stimuli remain unclear. In this study, atomic force microscopy showed that KFs were softer than normal fibroblasts with a loss of stiffness sensing. The decrease of CAV1 contributed to the hyperactivation of fibrogenesis-associated RUNX2, a transcription factor germane to osteogenesis/chondrogenesis, and increased migratory ability in KFs. Treatment of KFs with trichostatin A (TSA), which increased the acetylation level of histone H3, increased CAV1 and decreased RUNX2 and fibronectin. TSA treatment also resulted in cell stiffening and decreased migratory ability in KFs. Collectively, these results suggest a novel role for CAV1 downregulation in linking the aberrant responsiveness to mechanical stimulation and extracellular matrix accumulation with the progression of keloids, findings that may lead to new developments in the prevention and treatment of keloid scarring.

Background Although clinical assessment remains the gold standard for monitoring the circulation of free flaps, several adjunct techniques promote timely salvage by detecting circulation compromise early. The objective of this systematic review was to evaluate the efficacy of an implantable Doppler probe for postoperatively monitoring free flaps. Materials and methods English-language articles evaluating the efficacy of implantable Doppler probes compared with clinical assessment for postoperatively monitoring free flaps were analyzed. The outcome measures were total flap failure rates, salvage rates, sensitivity, false-positive rates, and positive likelihood ratios. Results Of the 504 citations identified, 6 comparative studies were included for meta-analysis. An implantable Doppler probe significantly lowered the flap failure rate (risk ratio: 0.40; 95% confidence interval: 0.21-0.75) and raised the successful salvage rate (risk ratio: 1.73; 95% confidence interval: 1.16-2.59). Pooled sensitivity was higher (1.00 vs 0.98), the positive likelihood ratio was lower (72.16 vs 220.48), and the false-positive rate was higher (0.01 vs 0) in the implantable Doppler probe group than in the clinical assessment group. Conclusion An implantable Doppler probe is significantly more efficacious than clinical assessment for postoperatively monitoring free flaps.

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 There have been no rigorous studies exploring whether the severity of hand injury can predict health-related quality of life (HRQoL). The purpose of our study is to examine the relationship between the initial anatomic severity of hand injuries (evaluated by the Hand Injury Severity Scoring [HISS] system) and HRQoL in patients with hand injuries. METHODS Patients with hand injuries hospitalized for surgery between 2004 and 2008 were recruited and HISS scores were calculated by a hand surgeon. One hundred seventy-three patients were interviewed for demographic information and HRQoL status. The physical and mental component summaries of HRQoL were compared with the initial HISS scores by multiple regression models. RESULTS The greater the HISS score, the lower the score of the physical component of HRQoL. Trend tests showed a significant correlation between the physical component of HRQoL in the dominant hand injured group (p = 0.04), but not in the nondominant hand injured group (p = 0.49). With regard to age, trend tests showed a significant correlation between the physical component of HRQoL in older patients (p < 0.01) but not in younger patients (p = 0.40). For all outcomes of mental component scores, we found no significant relationship with HISS severity in neither main effects nor stratified analyses. CONCLUSIONS HISS is able to predict the physical HRQoL with useful levels of accuracy. It is strongly recommended that surgical therapy departments provide more detailed physiotherapy programs for the high-risk groups, such as dominant hand injury and age of ≥40, to improve their physical HRQoL.

Hand strength is a key component in human hand function, especially to those with strength-required jobs. To evaluate post-injury hand strength, this study was conducted to assess the predictability of hand injury severity scoring (HISS) system to hand strength after a period of recovery.In this retrospective study, 80 traumatic hand-injured subjects were recruited. Hand strength tests measured by dynamometers were performed by subjects in ways of palmar pinch, lateral pinch and cylindrical grip. The logistic regression models were used to evaluate the risk of poor hand strength among the severities represented by HISS scores.A positive correlation exists between the differences of the strength of two hands, and the severity shown by HISS system in the poorer half of subjects. The risk to be in poorer half of palmar pinch subtest is significant in moderate subgroup of HISS severity. The risk to be in poorer half of cylindrical grip subtest is significant in major subgroup of HISS severity. The risk to be in poorer half of palmar pinch and cylindrical grip subtests is significant in skeletal component of HISS system.HISS is a descriptive severity scoring system to hand injury and also a useful instrument to predict functional outcome. This study revealed the HISS system may predict post-injury hand strength after recovery.

The outcome measures for patients following peripheral nerve repairs commonly include muscle strength and sensory assessments. However, no significant discussion exists on the impact of nerve injury on sensorimotor control. The objective of this longitudinal study was to explore the effects of nerve regeneration on the control of pinch force in executing functional tasks. Seven patients with digital or median nerve repairs were assessed by a custom-designed pinch device and conventional sensory tools at monthly intervals following nerve repair. These tools measured sensibility, maximum pinch strength, and anticipated pinch force adjustments to movement-induced load fluctuations in a pinch-holding-up activity (PHUA). Six force-related and temporal parameters for sensory measurement were used to determine improvements in pinch performance over time following sensory recovery. The results revealed significant differences in the parameters of peak pinch force, baseline pinch force, force ratio, and the percentage of maximal pinch force output at different points in the course of nerve regeneration. A strong relationship was also found between kinetic data from the PHUA test and the traditional sensibility tests for the nerve repair patients in the present study.

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.

We report a case of successful simultaneous reconstruction of pelvic and perineal defects using bilateral pedicled gracilis and inferiorly based rectus abdominis muscle flaps after en-bloc excision of the tumour and abdominoperineal resection of locally advanced invasive perineal mucinous adenocarcinoma originating from a chronic anal fistula.

Digital nerve defects can result from neglected nerve injuries. The standard method of reconstruction is nerve grafting, but donor-site morbidity encourages searching for alternative graft materials, including vein conduit grafts. From 1995–2005, three patients with neglected digital nerve injuries received vein conduit grafting for digital nerve reconstruction in our hospital. The interval between the injury and the reconstructive procedure ranged from 17 days to 2 years, and the length of the defects ranged from 0.8 to 2.5 cm. All the vein grafts were harvested from the distal forearm. Patient 1 had a moving and a static two-point discrimination (M2PD and S2PD) of 3 and 4 mm, respectively, at a 12-year follow-up. Patient 2 had an M2PD of 5 mm and S2PD of 6 mm at an 11-year follow-up, and the patient 3 had both an M2PD and S2PD of 4 mm at a near 3-year follow-up. They all achieved useful sensory function (S3 and S3+) by modified Highet and Sander criteria. Although previous studies showed secondary repair using vein grafts yielded worse sensory recovery than that of primary repair, in our cases, secondary digital nerve reconstruction with vein conduit grafts gives excellent results at the long-term sensory evaluation, two of them with more than 10 years' follow-up. To the best of our knowledge, this might be the longest follow-up after secondary digital nerve reconstruction using a vein conduit graft. It bears the advantages of readily accessible, no donor-site morbidity, and compatible in size with digital nerves. © 2008 Wiley-Liss, Inc. Microsurgery, 2008.