The First Hand Allotransplantation in Taiwan: A Report at 9 Months.

PURPOSE: Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. MATERIALS AND METHODS: On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. RESULTS: The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. CONCLUSIONS: Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.

A free vascularized tibia-fibular composite graft for the traumatic femoral bony defect of a 6-year-old boy with 10-year follow up: a case report.

INTRODUCTION: Free vascularized fibular grafts have been widely used for the reconstruction of long bone defects. However, the use of a vascularized tibial graft is precluded by its weight-bearing function and unacceptable donor site morbidity. CASE PRESENTATION: We present a rare case of using a vascularized tibia-fibular composite graft taken from a 6-year-old Chinese boy's ipsilateral lower leg to reconstruct a large bony defect of his traumatic femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up. He was able to participate in outdoor activities such as basketball while wearing his prosthesis. CONCLUSIONS: The 10-year follow up demonstrates the feasibility of this salvage procedure for a floating knee injury with neurovascular compromise.

Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation.

Single flap for complex hypopharyngoesophageal and anterior neck skin defect reconstruction is still a challenge for reconstructive surgeons. Herein, we present five patients, with advanced hypopharyngeal cancer and anterior neck skin invasion, which received a single anterolateral thigh (ALT) fasciocutaneous flap for composite inner pharyngeal and outer skin defect reconstruction after wide composite resection. Two ALT flaps were divided into two distinct paddles supplied by two or more separate perforators, one part for reconstructing the inner pharyngeal defect and another for neck skin coverage. Three ALT flaps only supplied by one sizable perforator could not be divided and de-epithelization of mid-part had to be done to reconstruct both defects with the single flap. The results revealed survival of all flaps. There were no flap loss, fistulas, or bleeding complications. All patients recovered uneventfully and could eat a soft diet to regular diet postoperatively. In conclusion, one-staged reconstruction of complex pharyngoesophageal and external skin defects after extensive oncological resection is feasible using a single ALT fasciocutaneous free flap.

Povidone-iodine-related burn under the tourniquet of a child--a case report and literature review.

Chemical burn under pneumatic tourniquet caused by povidone-iodine is an iatrogenic injury and is rarely reported in the literature. It is even rarer in paediatric cases. We report a case of 2-year-old female patient who underwent excision and reconstruction of bilateral radial polydactylies. She was found with chemical burns over posterior aspect of both arms later. These wounds healed secondarily within 4 weeks. This morbidity is relatively under-recognised. Special attention should be paid to paediatric patients, whose skins are more delicate and vulnerable.

CASE REPORT Type II Metacarpal Hands: Reconstruction Planning Revisited.

OBJECTIVE: Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgical planning. Effective transplantation involves 3 main considerations: residual hand function, functional needs and desires of the patient, and optimal surgical management to maximize outcome and minimize patient morbidity. METHODS: The following is a clinical example of the metacarpal hand in which the patient underwent initial reconstruction at an outside hospital and was referred to our institution. This demonstrates how the initial planning and surgical management could have been further optimized to minimize functional deficits and donor-site morbidities as well as reduce the number of subsequent revisional surgeries and rehabilitation time. RESULTS: Several important points in metacarpal hand reconstruction are described given specific level of amputation and residual function after the injury-the timing and sequence of operative strategy depending on the type of injury, the selection of donor-site digit transfers, and the overall treatment strategies for thumb and finger reconstruction. CONCLUSION: It is important to follow proper treatment algorithms in order to determine appropriate timing and sequence of toe-to-digit transfers, multi-stage versus 1-stage, as well as define the reconstructive goal to achieve a tripod pinch for a unilateral or a dominant hand injury or a pulp-to-pulp opposition for nondominant injury in bilateral cases. If adequate planning is performed, unnecessary and additional surgical procedures as well as increased patient suffering and prolonged rehabilitation time can be prevented or optimized.

Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site.

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

Replantation of total avulsed scalp with microsurgery: experience of eight cases and literature review.

BACKGROUND: Reports in the literature about scalp replantation are mostly sporadic; rarely can one find a large series. We present our experience with eight cases of scalp amputation replanted microsurgically. METHODS: From 1992 to 2003, eight patients who sustained scalp amputation injuries underwent microsurgical replantation. Age ranged from 3 to 46 years (average, 27.3), and four patients were male. The scalp amputations in the three adult male patients were sustained from cutting incidents by a blade, whereas those in the four female patients were from their long hair getting caught in a roller machine. A 3-year-old boy suffered scalp avulsion from a dog bite. A vein graft was needed in four patients whose scalp injuries resulted either from avulsion or a dog bite, which was not deemed necessary for those sustained by cutting injuries. RESULTS: Seven of the eight replantations were successful. The failed replantation in this series was the case where only arterial revascularization was performed, which resulted in venous congestion. Rotation scalp flap was placed to cover the defect. A boy who sustained scalp amputation from a dog bite suffered partial necrosis of the replanted scalp, which was covered with a skin graft. The resulting alopecia area was eventually excised after tissue expansion. CONCLUSION: Successful replantations can achieve the best esthetic and functional results compared with other procedures. Scalp amputations sustained from sharp cuts seem to be quite as common as hair traction injuries. Such amputation injuries were more common in male patients with short hair. The manner of injury often will influence planning during replantation. Even if the amputated scalp was crushed or contaminated, such as those sustained from animal bites, replantation should still proceed, unless a greater contraindication exists.

Myxoid liposarcoma with cartilaginous differentiation: identification of the same type II TLS-CHOP fusion gene transcript in both lipogenic and chondroid components.

Heterologous differentiation in adipocytic tumors is a rare phenomenon. Only 4 cases of myxoid liposarcoma (MLS) with cartilaginous differentiation were thus far reported without confirmatory molecular assays. We describe a primary MLS with chondroid differentiation that affected the left thigh of a 47-year-old man. Histologically, multiple sharply demarcated chondroid nodules were embedded among the classic MLS area. By reverse transcription-polymerase chain reaction, the identical type II TLS-CHOP fusion gene transcripts were detected in both the liposarcomatous and microdissected chondroid tumor cells. Our case confirms the actual existence of MLS with cartilaginous differentiation and the neoplastic nature of chondroid component.

Skin necrosis after intravenous calcium chloride administration as a complication of parathyroidectomy for secondary hyperparathyroidism: report of four cases.

Intravenous (i.v.) calcium chloride is usually given to treat symptomatic hypocalcemia; however, the extravasation of calcium solution may cause soft tissue and skin necrosis. After parathyroidectomy and autotransplantation for secondary hyperparathyroidism associated with end-stage renal failure, i.v. calcium infusion is often necessary to treat severe postoperative hypocalcemia. We reviewed 371 patients who underwent parathyroidectomy for secondary hyperparathyroidism between January 2000 and June 2005, 96 of whom received i.v. calcium postoperatively for symptomatic hypocalcemia. We report the cases of three (3%) of our own patients and of one patient referred to our hospital, who suffered skin necrosis after i.v. calcium solution administration. These reports show that i.v. calcium should be administered into large veins, or via a central line, and diluted in an appropriate volume of solution. Moreover, the calcium solution infusion should be ceased if the patient complains of tenderness over the injection site. If skin necrosis develops, we suggest early debridement and a simple split thickness skin graft to repair the skin defect. We report our experience to remind surgeons of the danger of calcium chloride injection and to discuss ways of preventing and treating this complication.

Teleconsultation with the mobile camera-phone in remote evaluation of replantation potential.

BACKGROUND: The purpose of the present study was to investigate the feasibility of teleconsultation with the mobile camera-phone to transfer clinical images and communicate on line for evaluation of replantation potential in completely amputated fingers. METHODS: Teleconsultations including clinical images of the amputated portion and stump as well as patient information were transmitted between the physicians in the emergency room and the consultant phlstic surgeon through Panasonic camera-phones, which had a built-in 110,000-pixel digital camera and a 65,536 colors display. The digital images displayed on the screen were further evaluated by three remote plastic surgeons individually and the evaluations were compared with the decision made according to onsite inspection by the consultant surgeon. RESULTS: The study population consisted of 35 patients with a total of 60 digital injures occurring between January to October 2003. The ability to identify the amputation location and status of amputation kwel from remote diagnosis was demonstrated by all three surgeons in 90% and 87% of these sixty amputated digits respectively. Of the 42 digits that were considered to have replantation potential during onsite evaluation, 38 (90%) digits were considered to be so by all three surgeons in group agreement during remote diagnosis. Of the 18 digits that were not considered to be replantable during onsite evaluation, 15 (83%) digits were also deemed without replantation potential, thus making the sensitivity and specificity of recognizing digital replantation potential, 90% and 83_'O re,_1pectively. CONCLUSIONS: The camera-phone is a feasible tool for remote evaluation regarding the replantation potential of completely amputated fingers and it holds significant promise in avoiding unnecessary patient transfer by providing useful information.

Reconstruction of traumatic Stensen duct defect using a vein graft as a conduit: two case reports.

Treatment of Stensen duct defect is still controversial. The authors describe the successful use of a retrograde vein graft as a conduit for traumatic segmental Stensen duct defect reconstruction. One patient sustained facial trauma with severe duct crushing and severance, the other had multiple cutting injuries with segmental duct defect. However, primary repair was impossible. A retrograde vein graft harvested from forearm for Stensen duct defect reconstruction was performed using microsurgical technique. A silicon stent was retained for 8 weeks. The sialographic examination showed good functional results without stricture postoperatively. This could be an option for treating such a complicated defect.

Heterotopic replantation in mutilating hand injury.

To achieve optimal hand function in the reconstruction of a mutilated hand is quite a challenge, and every salvage procedure should be tried, especially for amputated parts that cannot be replanted to their original anatomic sites. Five patients who sustained work-related mutilating hand injuries and who underwent digital heterotopic replantation are reported. Two patients had irreparably crushed, amputated thumbs. One patient (patient 1) received heterotopic replantation of the ring finger to the thumb's position; the other patient (patient 2) received heterotopic replantation of the middle finger to the thumb. Three additional patients received digital heterotopic replantation to enhance hand function. Patient 3 underwent heterotopic replantation of the middle finger to the index finger's position. Patient 4 underwent transplantation of the middle finger to the index finger's position, the ring finger to the middle finger's position, and the little finger to the ring finger's position. In patient 5, the ring finger was transplanted to the index finger's position. In all patients, satisfactory results were achieved in hand function and wound healing. In these patients, the restoration of a functional thumb was the first priority, followed by establishing at least two opposable fingers at the sites where metacarpophalangeal joints were functional.