Strategic Use of Biodegradable Temporizing Matrix (BTM) in Wound Healing: A Case Series in Asian Patients.

Skin and soft tissue reconstruction has long been based on the reconstructive ladder. However, a skin substitute has become popular due to its predictable outcomes, without donor-site morbidity. The biodegradable temporizing matrix (BTM; NovoSorb, PolyNovo Ltd., Port Melbourne, Australia) is a synthetic skin substitute that has recently gained its clinical application. Compared with those of other dermal templates, the clinical efficacy and performance of the BTM are not well established, especially among the Asian population. This study aims to share our experience and strategy of using BTM in various wound conditions. The data of patients who underwent skin and soft tissue reconstruction with BTM at a single institution between January 2022 and December 2023 were reviewed. The patient demographics, wound characteristics, surgical details, secondary procedures, and complications were recorded and analyzed. Postoperative 6-month photographs were collected and independently evaluated by two plastic surgeons and two wound care center nurses using the Manchester Scar Scale (MSS). This study included 37 patients, consisting of 22 males and 15 females with a mean age of 51.8 years (range, 18-86 years old). The wound etiologies included trauma (67.6%), necrotizing soft tissue infection (16.2%), burns (10.8%), toe gangrene (2.7%), and scar excision (2.7%). The average wound area covered by BTM was 50.6 ± 47.6 cm2. Among the patients, eight received concomitant flap surgery and BTM implantation, 20 (54.1%) underwent subsequent split-thickness skin grafts (STSG), and 17 had small wounds (mean: 21.6 cm2) healed by secondary intention. Infection was the most common complication, affecting six patients (n = 6 [16.2%]), five of whom were treated conservatively, and only one required debridement. Thirty-three patients (89.2%) had good BTM take, and only four had BTM failure, requiring further reconstruction. At the last follow-up, 35 out of the 37 patients (94.6%) achieved successful wound closure, and the total MSS score was 10.44 ± 2.94, indicating a satisfactory scar condition. The patients who underwent BTM grafting without STSG had better scar scores than those who received STSG (8.71 ± 2.60 vs. 11.18 ± 2.84, p = 0.039). In conclusion, the BTM is effective and feasible in treating various wounds, with relatively low complication rates, and it can thus be considered as an alternative for skin and soft tissue reconstruction. When combined with adipofasical flap reconstruction, it achieves a more comprehensive anatomical restoration.

Versatile Use of V-Y Advancement Flap for Facial Defect Reconstruction: A Case Series in Asian Patients.

BACKGROUND: V-Y advancement flap (VYAF) is a commonly used flap for facial reconstruction, but it is not popular in Asian society with limited aesthetic outcome evaluation. OBJECTIVE: To demonstrate our experience of facial VYAF with the quantitative aesthetic outcome assessment. METHODS AND MATERIALS: From January 2013 to December 2022, patients who underwent facial VYAF reconstruction were reviewed. Postoperative photographs were collected and independently graded by three plastic surgeons, three nurses, and six non-medical personnel using Manchester scar scale (MSS). The representative preoperative images were selected for surgeons' reconstruction preferences survey. RESULTS: Forty-eight patients (27 females and 21 males), with a mean age of 66.8 (23-97) years, were included in this study. All flaps survived with no flap necrosis. Only six patients (12.5%) developed minor postoperative complications, and they were treated conservatively and resolved uneventfully. The total MSS score was 7.8 ± 1.9 (scale of 4 [best scar] to 24 [worst scar]) and the overall scar VAS rating was 1.9 ± 1.1 (0 [best scar] to 10 [worst scar]), indicating satisfactory postoperative scar condition. From the survey of 22 plastic surgeons and 11 scenarios, VYAF was rarely chosen among other local flaps which only accounted for 8.7%. CONCLUSION: VYAF is an easy and safe method for facial reconstruction with low morbidity, but its usefulness is underappreciated. With a proper design and cautious dissection, we believe that good aesthetic and functional outcomes can be achieved with VYAF. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Percutaneous Coronary Intervention-Related Radiation Ulcer: Diagnosis, Management, and Prevention Strategy.

Background: Radiation ulcers after percutaneous coronary intervention (PCI) are increasingly common. However, their diagnosis, treatment, and prevention strategies have not been well studied. Objectives: To present our experience in the diagnosis, treatment, and prevention of PCI-related radiation ulcers. Methods: Patients diagnosed with PCI-related radiation ulcers were collected. Radiation fields of PCI were simulated using the Pinnacle treatment planning system to confirm the diagnosis. Surgical methods and outcomes were reviewed, and a prevention protocol was developed and evaluated for its effectiveness. Results: Seven male patients with ten ulcers were included. Among the patients, the right coronary artery was the most common target vessel of PCI, and the left anterior oblique was the most commonly used PCI view. Nine ulcers had undergone radical debridement and reconstruction: four smaller ones with primary closure or local flaps, and five with thoracodorsal artery perforator flaps. No new cases were identified in a 3-year follow-up period after implementing the prevention protocol. Conclusions: PCI-related ulcer diagnosis is more evident with radiation field simulation. The thoracodorsal artery perforator flap is an ideal option for back or upper arm radiation ulcer reconstruction. The proposed prevention protocol for PCI procedures was effective in lowering the incidence of radiation ulcers.

Marjolin's ulcer in an ischial pressure sore presented with necrotizing soft tissue infection: A case report.

RATIONALE: Marjolin's ulcer (MU) is a rare skin malignancy derived from a chronic wound. Pressure ulcer related MU possesses poor prognosis and high metastatic rate, and it is difficult to be differentiated, especially when superimposed infection. PATIENT CONCERNS: Here we report a case with pressure ulcer related MU which presented as necrotizing soft tissue infection (NSTI) to demonstrate the manifestation, treatment, and prognosis of this rare disease. DIAGNOSES: A 45-year-old male patient had spinal cord injury at age 2 years. He presented ischial pressure sore complicated with NSTI initially. After serial debridements and antibiotic treatment, the infection subsided. For the persistent verruca-like skin lesion, he underwent wide excision which revealed well-differentiated squamous cell carcinoma. Further image studies showed localized residual tumor without distant metastasis. INTERVENTIONS: He then underwent hip disarticulation and anterior thigh fillet flap reconstruction. Local recurrence developed 3 months later, and re-wide excision and inguinal lymph node dissection were performed. No lymph node metastasis was noted and adjuvant radiotherapy was given. OUTCOMES: He was followed for 34 months and no recurrence or metastasis was found. The patient can move with a wheelchair or a hip prosthesis, and is partially dependent for daily activities. LESSONS: MU can masquerade as NSTI and one should be alert to its malignant potential. Due to its aggressive nature, limb sacrifice can be considered in circumstances of profound involvement. As for the reconstruction method, pedicled fillet flap provided good wound coverage.

The effects of topical anesthesia on outcomes and glucose control in diabetic patients treated with split-thickness skin graft surgery.

BACKGROUND: Using split-thickness skin grafting to treat diabetic foot and leg ulcers is common. Diabetic patients usually exhibit multiple comorbidities and high risks of adverse responses to general and spinal anesthesia. Topical anesthesia can be an alternative to avoid these risks. In this study, the clinical experience of split-thickness skin grafting under topical anesthesia was demonstrated, to evaluate its effectiveness and benefits in diabetic patients. METHODS: From 2018 to 2020, diabetic patients with foot or leg wounds undergoing split-thickness skin grafting were reviewed and categorized into two groups according to the anesthesia methods: topical anesthesia and general/spinal anesthesia. Patient demographics, wound characteristics and healing status, postoperative complications, and perioperative blood glucose levels were recorded and analyzed. RESULTS: During the study period, 28 patients underwent split-thickness skin grafting under topical anesthesia and 46 under general/spinal anesthesia. The rate of complete wound healing in 4 weeks was similar in both the groups. The topical anesthesia group suffered fewer postoperative infections (3.6% vs 21.7%, p = 0.044), required shorter postoperative hospitalization (8.3 ± 6.2 vs 11.1 ± 7.2 days, p = 0.048), and exhibited lower mean blood glucose levels and less glucose variability than the general/spinal anesthesia group. CONCLUSION: Conducting split-thickness skin grafting under topical anesthesia was shown to be a safe and effective means of treating leg and foot wounds in diabetic patients.

Steroid refractory granulomatous mastitis treated by top surgery: A case report.

RATIONALE: Granulomatous mastitis (GM) is a rare inflammatory disease and the presentation mimics infectious mastitis or breast cancer. The disease usually develops at the unilateral breast in women with breast-feeding history at their child-bearing age. Systemic steroids had been proposed as the first-line treatment, the combination of surgery was also recommended for complicated disease. However, recurrence might still happen in some rare cases. Few studies have addressed the management of such difficult situations. PATIENT CONCERNS: We report the case of a 33-year-old androgynous and nulliparous woman who initially presented left breast erythematous swelling and was treated as infectious mastitis with debridement and antibiotics. DIAGNOSIS: After wider excision for pathology, the diagnosis of GM was confirmed. INTERVENTIONS: Steroids combined with methotrexate were prescribed. However, the symptoms only subsided temporarily and progressed to the contralateral side within 3 months. She finally underwent double-incision mastectomy and free nipple grafting. OUTCOMES: The surgery was completed uneventfully, and she had a satisfactory result with no more recurrence at the 6-month follow-up. LESSON: This GM case with the refractory treatment courses brought out the importance of surgical resection and was the first case report of treating GM with top surgery in the literature. Total mastectomy facilitated a highest complete remission rate of GM and may be advantageous for selected patients, especially in cases where steroids are intolerable.

Corrective Tendon Repair with Local Anesthesia following Wrist-level Replantation.

Wide-awake local anesthesia with no tourniquet has become a popular method to ensure correct tendon condition intraoperatively. We report the case of a 17-year-old man who underwent nearly total left wrist amputation and successful replantation. The misconnection of flexor tendons between the thumb, index, and middle finger was found postoperatively. At 1.5 months postreplantation, simultaneous tenolysis and corrective tendon repair were performed under local anesthesia. The proximal tendon origins were confirmed intraoperatively with the patient awake. Six months after replantation, the patient underwent extensor pollicis longus tendon shortening and pulley reconstruction under wide-awake local anesthesia with no tourniquet for thumb extension lag. After adequate rehabilitation, the functional outcome was satisfactory. This case report demonstrates that local anesthesia is a judicious method to intraoperatively facilitate correct tendon repair, tension adjustment, and direct conversation between the surgeon and the patient.

Use of a topical mix of lidocaine and prilocaine during split-thickness skin graft harvest improves postoperative recovery-A prospective randomized controlled trial.

PURPOSE: To provide evidence of efficacy and postoperative benefit of topical anesthesia (TA) for harvesting split-thickness skin graft (STSG) in an Asian population. MATERIALS AND METHODS: Patients with well-granulating wounds with skin grafting were randomized into TA or general anesthesia (GA) groups. In the TA group, an eutectic mixture of lidocaine and prilocaine (EMLA) was applied. Perioperative heart rate, postoperative donor site pain, adverse effects, patients' satisfaction, duration of surgery, and operation room (OR) stay duration were recorded. RESULTS: Thirty-nine patients (19 males, 20 females; mean age 54.9 ± 17.8) were included. Twenty underwent TA and 19 underwent GA for STSG. The TA group patients had tolerable pain during skin graft harvesting (VAS, 0.85 ± 1.5). Average EMLA exposure duration was 180.3 ± 65.8 min, and the amount applied was 1.72 ± 0.43 g/10 cm2. The TA group had lower donor site pain score at one hour postoperatively (1.34 ± 1.49 vs 3.08 ± 1.90, p = 0.005), lower OR stay duration (36.5 ± 6.5 min vs 65.1 ± 17.2 min, p < 0.001) and less adverse effects than the GA group. CONCLUSION: Harvesting STSG under TA with EMLA is an effective and efficient approach for most Asian patients with less early postoperative donor site pain and fewer adverse effects.

Using Dorsal Metacarpal Artery Perforator Flap in the Soft Tissue Reconstruction of Traumatic Finger Defects: A Single-Center Study.

INTRODUCTION: The reconstruction of soft tissue defects of fingers is a challenge due to the limitations of local tissue availability. The dorsal metacarpal artery perforator (DMAP) flap is a vascular island flap raised on the dorsum of the hand, and it is a good option for finger reconstruction by replacing similar-for-similar in a single operation. In this study, we would like to share our experience of using the DMAP flap in cases of various traumatic finger defects. MATERIALS AND METHODS: From November 2016 to May 2019, patients who had traumatic finger injuries and had undergone DMAP flap for soft tissue reconstruction were examined. The patients' demographic data, injury and flap characteristics, wound healing status, and complications were collected and studied. The functional and aesthetic outcomes were evaluated using the Michigan Hand Outcomes Questionnaire. RESULTS: There was a total of 10 patients included in this study, of which 9 were male and 1 was female. The average age was 43 years (17-66 years). Seven patients were administered general anesthesia, and 3 others wide-awake local anesthesia. The average flap size was 4.9 × 2.0 cm, and all the donor sites were primarily closed. Nearly half of the patients had temporary venous congestion, but most of the flaps survived well ultimately. Only 1 patient had a partial flap necrosis, which required an additional skin graft. CONCLUSIONS: The DMAP flap offers a thin and pliable skin to reconstruct finger defects within 1-stage surgery. It is easy to harvest with reliable and constant circulation. With adequate design, the DMAP flap can be used to resurface both volar and dorsal finger defects and also can reach the tip of the little finger. The DMAP flap is the ideal flap for reconstruction of traumatic finger defect with either local or general anesthesia.

Reconstruction of a secondary scalp defect using the crane principle and a split-thickness skin graft.

BACKGROUND: Scalp reconstruction is a common challenge for surgeons, and there are many different treatment choices. The "crane principle" is a technique that temporarily transfers a scalp flap to the defect to deposit subcutaneous tissue. The flap is then returned to its original location, leaving behind a layer of soft tissue that is used to nourish a skin graft. Decades ago, it was commonly used for forehead scalp defects, but this useful technique has been seldom reported on in recent years due to the improvement of microsurgical techniques. Previous reports mainly used the crane principle for the primary defects, and here we present a case with its coincidental application to deal with a complication of a secondary defect. CASE REPORT: We present a case of a 75-year-old female patient with a temporoparietal scalp squamous cell carcinoma (SCC). After tumor excision, the primary defect was reconstructed using a transposition flap and the donor site was covered by a split-thickness skin graft (STSG). Postoperatively, the occipital skin graft was partially lost resulting in skull bone exposure. For this secondary defect, we applied the crane principle to the previously rotated flap as a salvage procedure and skin grafting to the original tumor location covered by a viable galea fascia in 1.5 months. Both the flap and skin graft healed uneventfully. CONCLUSIONS: Currently, the crane principle is a little-used technique because of the familiarity of microsurgery. Nevertheless, the concept is still useful in selected cases, especially for the management of previous flap complications.

Tomotherapy as an Alternative Irradiative Treatment for Complicated Keloids.

The aim of this study was to investigate the treatment of complicated keloids with helical tomotherapy (HT) and electron beam radiotherapy. From July 2018 to September 2018, 11 patients with 23 keloid lesions treated with HT were enrolled. Additionally, 11 patients with 20 lesions treated with electron beam radiotherapy in the same period were enrolled. Patients in both groups were treated within 24 h after surgical excision of the keloid lesion with 13.5 Gy in three consecutive daily fractions. The median follow-up period was 15 months. The local control rate was 91.3% and 80% in the HT group and the electron beam group, respectively. No acute adverse effects were observed in either group, but most patients exhibited pigmentation. No radiation-induced cancer occurred in these patients up to the time of this report. Pain and pruritus improved for all patients and more obviously for three patients with complicated keloids treated with HT. The measured surface dose was 103.7-112.5% and 92.8-97.6% of the prescribed dose in the HT group and the electron beam group, respectively. HT can be considered an alternative in cases where it is not feasible to use multiple electron fields, due to encouraging clinical outcomes.

Postoperative Hematoma in Microvascular Reconstruction of the Head and Neck.

BACKGROUND: Free tissue transfer has become a safe and reliable means for repairing soft tissue and bony defects of the head and neck region. Although the success rate is high, the incidence of postoperative complications is common. One significant complication is postoperative hematoma formation. However, few published studies have addressed its incidence, etiology, or outcome. We performed a retrospective analysis to investigate this issue. METHODS: A retrospective review was conducted of 293 consecutive microvascular free tissue transfers in the head and neck region in a single institute from January 2013 to December 2015. Patients with postoperative hematoma were identified, and demographic data, perioperative conditions, medications, and outcomes were evaluated by chart review. RESULTS: A total of 34 patients (11.8%) had postoperative hematoma. Compared with the patients without hematoma, this group had a longer hospital stay (P = 0.06) and required more secondary procedures (P = 0.001). The use of nonsteroidal anti-inflammatory drugs (NSAIDs; P < 0.001) was associated with a higher incidence of hematoma formation. Among the 34 patients with hematoma, 16 (47.1%) had flap compromise and underwent emergent reexploration. The salvage rate was higher than that in the nonhematoma group (87.5% vs 59.3%, P = 0.086). CONCLUSIONS: Postoperative hematoma after head and neck microvascular reconstruction is not a rare complication and may lead to poor outcome and more complications. The avoidance of NSAIDs preoperatively may prevent hematoma formation. Surgeons should be alert to this situation, and immediate return to the operative room for hematoma evacuation is necessary. Early intervention may contribute to a high salvage rate.

Vascular Complications and Free Flap Salvage in Head and Neck Reconstructive Surgery: Analysis of 150 Cases of Reexploration.

INTRODUCTION: Despite the excellent reliability of free tissue transfer, flap failure is devastating, and in addition to patient morbidity, it may increase hospital stay and associated costs. Previous studies have evaluated factors related to flap salvage, regarding the operative strategy for flap salvage surgery. The present study aimed to share our experience of reexploration and describe operative standards dealing with vascular thrombosis. METHODS: We retrospectively reviewed 150 (of 1258) free flaps for head and neck reconstruction that showed signs of vascular compromise at our institution during a 13-year period between 2002 and 2015. Patient demographics, including sex, age, premorbid health status, personal history, indication for reexploration, flap type, and number of recipient vessels, were analyzed. Days between the end of initial surgery and salvage surgery were also recorded. The incidence of postsalvage complications (hematoma formation, wound dehiscence, and infection requiring surgical intervention) and the overall flap survival were recorded. RESULTS: Of the 150 flaps, 87 flaps had evident arterial or venous thrombosis; 34 of these failed and required a second free flap or pedicle flap reconstruction. The remaining 53 were successfully salvaged. Although vascular thrombosis was found to be a major contributing factor in flap loss, no significant differences in any factor were found between patients with salvageable flaps and those with unsalvageable flaps. CONCLUSIONS: Vascular thrombosis is a major contributing factor in flap loss. The incidence of venous thrombosis is higher, but arterial thrombosis may be more severe. Improvements in the surgical technique and perioperative management are highly reliable. We believe that strict models of flap monitoring; well-trained, dedicated staff; and immediate reexploration will potentially further improve flap survival and optimize the quality of life.

Clinicopathology of Immunoglobulin G4-Related Chronic Sclerosing Sialadenitis: A Single-Center Study.

OBJECTIVES: To investigate the clinicopathologic characteristics of patients with immunoglobulin G4-related chronic sclerosing sialadenitis (IgG4-RCSS), a recently recognized disease. STUDY DESIGN: Case series with chart review and pathology study. SETTINGS: Tertiary care hospital. SUBJECTS AND METHODS: We evaluated chronic sialadenitis specimens obtained over 11 years using pathologic examination and IgG4 immunohistochemistry staining. The specimens were assigned a revised diagnosis of IgG4-RCSS or chronic sialadenitis not otherwise specified, and clinicopathologic data from each group were compared. RESULTS: Of the 84 patients, 21 were diagnosed with IgG4-RCSS and 63 with chronic sialadenitis not otherwise specified. IgG4-RCSS patients were older (68.2 ± 13.9 vs 54.2 ± 15.8 years, P = .001), predominantly male (85.7% vs 61.9%, P = .036), and more likely to present with painless swelling (75% vs 44.3%, P = .001) and bilateral involvement (52.4% vs 6.3%, P < .001). Ratio of IgG4-positive plasma cells to IgG-positive plasma cells in IgG4-RCSS tissues was 0.81 ± 0.14. The mean value of serum IgG4 in IgG4-RCSS patients was 918.8 mg/dL. CONCLUSION: IgG4-RCSS is more common in older male patients and frequently presents with bilateral involvement. Informing head and neck surgeons of the clinical features of IgG4-RCSS and promoting a combined approach of clinical evaluation, imaging, and biopsy can improve the accuracy of preoperative diagnoses.

Atypical Lipomatous Tumors of the Extremities and Trunk Wall-The First Case Series of Chinese Population With 45 Cases.

BACKGROUND: Atypical lipomatous tumor (ALT) is a low-grade, slow-growing, locally aggressive malignant mesenchymal neoplasm. ALT of the extremities and trunk wall is associated with a relatively favorable outcome. However, these tumors can still recur locally and secondary dedifferentiation after recurrence has been reported. There is currently no consensus about the optimal surgical treatment of ALT. Therefore, we aimed to clarify the clinical behavior, appropriate treatment, and outcomes of ALT of the extremities and trunk wall. METHODS: We retrospectively reviewed the files of 45 patients treated between 2000 and 2014 with the diagnosis of atypical lipomatous tumors of the extremities and trunk wall at our institution. The median follow-up period was 84.5 months (range, 24-183 months). The patient demographics, clinical presentation, surgical methods, margin status, and administration of radiation therapy were recorded. Patients were evaluated for their local recurrence, dedifferentiation, and postoperative complications. RESULTS: Wide resection was performed on 11 patients, and marginal resection was performed on 34 patients. Seven patients underwent adjuvant radiotherapy. The overall recurrence rate was 17.8% (8/45), and dedifferentiation rates was 0% (0/8). The mean time to local recurrence was 5.25 years (range, 2.6-10.6 years). No ALT-related deaths occurred during the follow-up period. There were no differences in recurrence-free survival for the different surgical methods (P = 0.337) and radiotherapy (P = 0.228), whereas the R0 resection had better recurrence-free survival (P = 0.031). The postoperative complication rates were higher in wide resection group than in marginal resection group. (45.5% vs 14.7%, P = 0.048). CONCLUSIONS: Atypical lipomatous tumors of the extremities and trunk wall are associated with a favorable overall survival and do not metastasis. Although they have a tendency to recur, the risk of secondary dedifferentiation is small. Wide resection had similar recurrence rates to marginal resection, but it might lead to more complications. Therefore, marginal resection is considered appropriate for the treatment of ALTs.

Epidemiology of digital amputation and replantation in Taiwan: A population-based study.

BACKGROUND: Publications on digital amputation and replantation have been mostly derived from case series in high-volume hand surgery practices, and epidemiological studies are few. This study used a population-based dataset to illustrate the incidence of digital amputation, patient and hospital characteristics, and their relationships with replantation. METHODS: A claim for reimbursement dataset (2008) was provided as a research database by the Bureau of National Health Insurance, Taiwan. Patients with ICD-9-CM coded as digital amputation (885 and 886) were included. These were cross-referenced with procedure codes for replantation procedures (84.21 and 84.22). We defined the patients who underwent thumb replantation (84.21) and thumb amputation (84.01) during a single hospitalization as replantation failure. Patient and hospital characteristics were studied with statistical analysis. RESULTS: In total, 2358 patients with digital amputation were admitted (1859 male, 499 female), mean age 39.2 ± 15.5 years. The incidence was 10.2/100,000 person-years. The highest incidence was 14.7/100,000 person-years in the age group 45-54 years. Machinery and powered hand tools caused 68.8% of digital amputations. Thumb amputation [odds ratio (OR): 1.35, p = 0.01], private hospital (OR: 1.40, p = 0.01), medical center (OR: 2.38, p < 0.001), regional hospital (OR: 2.41, p < 0.001) and hospitals with an annual volume >20 digital amputations (OR: 4.23, p < 0.001) were associated with higher attempt rates for replantation. Elderly patients (age >65 years) had higher risk of thumb replantation failure (OR: 32.30, p = 0.045), while hospitals with >20 annual replantations had lower risk (OR: 0.11, p = 0.02). CONCLUSION: Our study of the National Health Insurance database characterized the epidemiology of digital amputation patients undergoing replantation and the facilities in Taiwan where these procedures are performed. The hospitals treating more digital amputation patients had higher attempt rates and lower thumb failure rates.