Medial Orbital Wall Reconstruction With Porous Polyethylene by Using a Transconjunctival Approach With a Caruncular Extension.

BACKGROUND: The reported rate of isolated medial orbital wall fractures varies widely but has been found to be as high as 55% of all orbital fractures. Identifying and repairing medial orbital wall defects by using appropriate materials improves patient outcome considerably; however, most related research has focused on orbital floor defect management rather than medial orbital wall treatment, and no consensus on repairing medial orbital wall fractures exists. Furthermore, medial orbital wall fracture is a main cause of posttraumatic enophthalmos. In this study, we introduce a modified surgical technique for repairing large medial wall fractures stably, also reviewed relevant literature and established an algorithm for managing medial orbital wall fractures. METHODS: We reviewed the outcomes of facial trauma patients who underwent facial bone reduction and internal fixation surgery in our hospital between October 1, 2010, and October 1, 2013. The patients were all treated medial orbital wall reconstruction with porous polyethylene by using a transconjunctival approach with a caruncular extension for large medial orbital wall fractures. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were trauma mechanism, clinical findings of ocular injury, preoperative and postoperative ocular symptoms, degree of enophthalmos, and orbital volume restoration after surgery. RESULTS: Transconjunctival approach with a caruncular extension was performed without any complications. The incidence of diplopia was 47.4% and enophthalmos (>2 mm) was 31.6%, with no significant diplopia and enophthalmos after surgery. Patients were symptom-free on follow-up. The average enophthalmos was successfully corrected from 0.88 mm preoperatively to 0.26 mm and orbital volume was corrected from 26.22 to 22.99 cm after surgery; these results also showed P less than 0.001. CONCLUSIONS: The current results suggest that the proposed method of medial orbital wall reconstruction, in which porous polyethylene is implanted by using a transconjunctival approach with a caruncular extension, yields favorable outcomes. The approach facilitates a wide visualization of the operative field, which provides sufficient working space for implant insertion and is consequently free from iatrogenic trauma or surgery-related complications.

Adipose-Derived Stem Cell Modulation of T-Cell Regulation Correlates with Heme Oxgenase-1 Pathway Changes.

BACKGROUND: The authors' previous proteome study revealed that haptoglobin was involved in adipose-derived stem cell modulation of allotransplant survival and T-cell regulation to induce immune tolerance. This study investigated whether adipose-derived stem cells could modulate T-cell regulation through haptoglobin and the downstream heme oxgenase-1 pathway in vitro. METHODS: Splenocytes were isolated from Lewis rat spleens and then CD3 T cells were purified using anti-CD3 beads. Adipose-derived stem cells were harvested from Lewis rats and co-cultured with the T cells. After Transwell co-culture at different periods, the authors analyzed cell proliferation with a bromodeoxyuridine assay. Cell extractions and culture supernatants were collected for further analysis. Heme oxgenase-1 and related protein expression levels from the adipose-derived stem cells and T cells were detected using Western blotting. The related cytokine expression levels were analyzed with enzyme-linked immunosorbent assay kits. Flow cytometry was used to detect the regulatory T-cell proportion. RESULTS: The adipose-derived stem cells significantly suppressed T-cell proliferation. The regulatory T-cell percentages were significantly increased in the adipose-derived stem cells that were co-cultured with T cells compared with T cells alone without adipose-derived stem cell co-culture. Heme oxgenase-1 expression in concanavalin A-stimulated T cells that were co-cultured with adipose-derived stem cells revealed a significant increase compared with concanavalin A-stimulated T cells alone. Cytokine assays of the culture supernatants revealed that transforming growth factor-ß and interleukin-10 were significantly increased and interferon-γ was statistically decreased in the adipose-derived stem cell-co-cultured T-cell group compared with other groups; however, blockade with a heme oxgenase-1 inhibitor (zinc protoporphyrin IX) protected against these changes. CONCLUSION: Adipose-derived stem cells modulate T-cell proliferation and enhance regulatory T-cell expression, and this correlated with heme oxgenase-1 expression and related cytokine pathway changes.

Combination of Vascular Intervention Surgery and Free Tissue Transfer for Critical Diabetic Limb Salvage.

BACKGROUND: Complex, nontraumatic diabetic foot ulcers with peripheral vascular compromise often lead to extensive lower-limb amputation. The aim of this study is to determine the outcome of combined vascular intervention and free tissue transfer for critical diabetic limb salvage. MATERIALS AND METHODS: A total of 26 consecutive diabetic patients with 28 legs with diabetic foot ulcers who underwent limb salvage with a combination of revascularization (bypass surgery or endovascular angioplasty) and free flap transfers were reviewed. There were 14 male and 12 female patients. The average age was 58.8 years (range, 35-85 years). Amputation-free survival and complete wound healing were defined as the primary endpoints. All preoperative and postoperative data were retrospectively analyzed. RESULTS: Thirty flaps were used for reconstruction in 28 legs, including 21 free anterolateral thigh (ALT) perforator flaps, 3 ALT myocutaneous flaps, 5 gracilis muscle flaps, and 1 latissimus dorsi muscle flap. All flaps used end-to-side anastomoses for the recipient artery and end-to-end anastomoses for the recipient vein. The overall flap success rate was 90% (27/30). Two flaps failed completely because of severe arteriosclerosis, which resulted in anastomosed vessel thrombosis. New flaps were applied in both cases after debridement and trimming of necrotic tissue. One flap failed because of restenosis and inadequate perfusion combined with severe infection, resulting in pedicle thrombosis. A below-knee amputation was subsequently performed. Seven flaps exhibited a partial loss, including 6 ALT perforator flaps and 1 latissimus dorsi flap, because of inadequate margin perfusion. After debridement, the flap revision and wound care, 5 flaps healed uneventfully without additional intervention. The remaining 2 ALT perforator flaps required debridement with a skin graft. The limb-salvage rates were 92.8% after 1 year and 89.2% after 5 years. CONCLUSIONS: The combination of peripheral arterial intervention and free tissue transfer resulted in successful wound healing and limb salvage instead of amputation in select diabetic patients with difficult-to-heal wounds.

Free medial plantar artery perforator flap for finger pulp reconstruction: report of a series of 10 cases.

PURPOSE: Treatment of composite tissue loss in the finger pulp is often difficult. The purpose of this report is to present our experience on using medial plantar artery perforator flap for repair of finger pulp defects and to restore fingertip sensation after traumatic injury. PATIENTS AND METHODS: The free medial plantar artery perforator (MPAP) flaps were performed for digital pulp reconstruction in ten patients (eight fingertips and two thumbtips) between June, 2006 and December, 2007. This flap blood supply was perforator vessel of medial plantar artery, which was through the intermuscular septum between the abductor hallucis muscle and the flexor digitorum muscle. The recipient vessels were digital artery and dorsal digital vein. The flap was not reinnervated during transfer procedures. The donor sites were closed primarily in all cases. RESULTS: Flap size ranged from 15 x 25 mm to 60 x 20 mm. All flaps were survival. Partial loss occurred in one flap, due to venous congestion caused by excessive stitch tension. The donor sites healed unevenfully in eight cases, but mild wound dehiscence occurred in two cases. The follow-ups ranged from 6 to 29 months with the mean of 18.1 months. The mean of s-2PD and m-2PD were 8.8 mm and 6.8 mm at patients' last visits, respectively. CONCLUSION: MPAP flaps are good in terms of general morbidity, cosmetic results, and durability. This flap is a valuable alternative method of repairing the glabrous finger pulp and tip defects.

AQUACEL Ag in the treatment of toxic epidermal necrolysis (TEN).

Toxic Epidermal Necrolysis (TEN) is life-threatening dermatological disease characterized by extensive destruction of the epidermis is associated with a 25-60% mortality rate in adults. We presented one patient with TEN with 86% skin slough treated successfully using AQUACEL Ag exclusively. All of the wounds were healed completely 8 days after onset of TEN. AQUACEL Ag is an efficient and cost-effective adjunct in the treatment of TEN.

Reversed-flow superior thyroid artery: an alternative recipient vessel in head and neck reconstruction.

In neoadjuvant intra-arterial infusion chemotherapy patients, the common recipient arteries are frequently damaged owing to preoperative chemotherapy-induced intima injury. When antegrade arterial inflow to the free flap is not available, end-to-side carotid arterial anastomosis or exploration of another recipient artery may be an appropriate solution. However, reversed arterial flow is an alternative to such a situation. We report a case with squamous cell carcinoma on the right buccal area, which was successfully reconstructed using a free anterolateral thigh flap with reverse superior thyroid arterial inflow. This alternative method might shorten the operation time and also reduce further exploration injury in the operation field.

"Shift to right flypaper technique" a refined method for postage stamp autografting preparation.

"Lack of donor skin" is a challenge condition for autografting in the treatment of extensive burns. The modified Meek technique seems to be a practical solution for this problem. However, the equipment and consumed materials for the modified Meek technique are expensive which limits routine use. Designing a less expensive, efficient and easy to apply expansion method may improve burn care quality and shorten hospital stay period. Our previous study reported the "flypaper technique" for preparation of postage stamp autografting. The time for confluence of the burned wound depends on the size of the skin islands and expansion ratio. In clinical practice, 5mm skin squares is the preferred size of the skin islands; however, the positioning procedure can be modified to improve the wound healing process. According to the chessboard diagram, the "shift to right" positioning technique shortens the 10% biggest distance in six times expansion diagrams and 20% biggest distance in nine times expansion diagrams. By using a quick cutting plate, chessboard tray and petrolatum gauze, the skin islands can be uniformly located and correctly oriented on the gauze. This method allows a true expansion ratio up to nine times. In comparison with the modified Meek technique, this method also offers rapid wound reepithilization but with lower cost. However, the burn scar needs further rehabilitation and compression therapy to improve the functional and cosmetic result. This "shift to right flypaper technique" is worthy of consideration in dealing with extensive burns.

Refinement of reverse digital arterial flap for finger defects: surgical technique.

We have designed a refinement of the reverse digital artery flap technique for soft-tissue defects on the dorsum of the fingers. In contrast with the traditional reverse digital artery flap it reduces the morbidity at the donor site and increases the ease and availability of resurfacing the defect. We suggest it is an alternative for the resurfacing of finger defects, especially over the dorsum.

Epidemiology of pediatric burn in southern Taiwan.

A 5-year retrospective review of 157 pediatric patients admitted to burn center of Kaohsiung Medical University Hospital (Kaohsiung, Taiwan) was undertaken to identify the incidence, mechanism, and agents of pediatric burn. The highest incidence of pediatric burn was in children aged 1-6 years (57.3%), followed by age group 6-14 years (31.8%). Scald burn (75.2%) made up the major cause of this injury and was dominant in each age group compared to non-scald burn. The kitchen/dining area (57.3%) and living room (29.9%) accounted for the most frequent places where pediatric burns occurred. Among the agents of scald burn, hot drink (49.2%) and soup (32.2%) were the two leading causes. There were more pediatric burns reported in colder seasons (38.2% and 33.1% in winter and fall respectively) and during dining time (19.7% in 11 a.m.-1 p.m. and 35.0% in 5 p.m.-8 p.m.). The results of this report may be closely related to special culinary habits (use of chafing-dish and making hot tea) in the south of Taiwan.

The simultaneous combination of implants and tram flaps for an aesthetically pleasing breast.

In Taiwan, there have quite often been incidences when patients have had more abundant abdominal tissue to make a TRAM flap with a volume larger than the contralateral breast. In these situations, we usually recommend performing contralateral augmentation mammoplasty with a saline implant while undergoing TRAM flap reconstruction. From February 1997 to Mar 2001, 250 breast cancer patients underwent immediate pedicled TRAM flap reconstructions at Kaohsiung Medical University Hospital. Of these, 10 cases not only had TRAM flaps, but also simultaneous insertion of a prosthesis into the contralateral/bilateral breast to form a more pleasing breast mound. These were all saline implants. Each patient was young (aged 31-51 years) and had small to medium sized breasts. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major muscle. There were no significant complications or failures. All breasts have remained soft and natural-looking during the follow-up period. Nine of 10 patients appreciated this procedure, and 8 of them would agree to convince other patients of the benefits of this operation. Using pedicled TRAM flaps and saline breast implants can achieve immediate breast reconstruction without the need for prolonged tissue expansion or an obvious back scar. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the pedicle transfer. It is a good alternative for breast cancer patients with previous hypoplasia of the breasts to achieve simultaneous therapeutic and cosmetic results.