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1.
Medicine (Baltimore) ; 102(35): e34963, 2023 Sep 01.
Article in English | MEDLINE | ID: mdl-37657023

ABSTRACT

RATIONALE: Cranioplasty after decompressive craniectomy provides brain protection and improves cerebral hemodynamics. However, recurrent infection and sinking skin flap syndrome after cranioplasty remain cumbersome complications that require a well-planned reconstruction strategy. PATIENT CONCERNS: A 74-year-old man presented with traumatic subdural hematoma and underwent decompressive craniectomy. Cranioplasty using an original bone flap, bone cement with wires, and a titanium mesh were complicated and resulted in recalcitrant infection and sinking skin flap syndrome. DIAGNOSES: Recurrent infection and sinking skin flap syndrome post-cranioplasty. INTERVENTIONS: We designed a two-stage "kebab" reconstruction technique using a combination of free latissimus dorsi myocutaneous flap and delayed non-vascularized free rib graft. A well-vascularized musculocutaneous flap can obliterate dead space in skull defects and reduce bacterial inoculation in deep infections. Subsequently, delayed rib grafts act as the scaffold to expand the sunken scalp flap. OUTCOMES: At the 3-year follow-up, the patient showed improvement in headache, without evidence of surgical site infection. LESSONS: The novel "kebab" technique using a combination of a free myocutaneous flap and delayed rib graft can eliminate bacterial growth in infected calvarial defects, reverse sinking skin flap syndrome, and minimize potential donor-site morbidity, and is therefore suitable for patients who require multiple cranioplasties and are unable to withstand major reconstructions.


Subject(s)
Myocutaneous Flap , Reinfection , Male , Humans , Aged , Brain , Bone Cements , Syndrome , Skull/surgery
2.
Microsurgery ; 43(2): 131-141, 2023 Feb.
Article in English | MEDLINE | ID: mdl-35553089

ABSTRACT

BACKGROUND: 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. METHODS: We retrospectively reviewed the medical records of a total of 205 patients aged >18 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. RESULTS: 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 (ß: -0.56, SE: 0.26, and p = 0.034). CONCLUSIONS: 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.


Subject(s)
Free Tissue Flaps , Mandibular Neoplasms , Mandibular Reconstruction , Osteoradionecrosis , Plastic Surgery Procedures , Humans , Thigh/surgery , Fibula/surgery , Osteoradionecrosis/surgery , Quality of Life , Retrospective Studies , Free Tissue Flaps/surgery , Mandibular Neoplasms/surgery , Postoperative Complications/surgery , Mandible/surgery
3.
J Craniofac Surg ; 32(7): 2539-2541, 2021 Oct 01.
Article in English | MEDLINE | ID: mdl-34406156

ABSTRACT

ABSTRACT: Unilateral sphenoid dysplasia is a rare but distinctive manifestation of neurofibromatosis type 1, causing pulsatile exophthalmos, decreased vision, and facial deformity. Surgical intervention is required to prevent visual deterioration. However, the reconstruction of a complex cranial base defect while fulfilling cosmetic needs is challenging. The asymmetric anatomy impedes identification and preservation of vital structures, and the use of bone grafts is often unsustainable due to resorption. Here we demonstrate a multimodal technique combining mirror-image-based virtual surgical planning, stereolithography, and neuronavigation to achieve skull base reconstruction and restore facial symmetry in an neurofibromatosis type 1 patient with sphenoid dysplasia. Preoperative surgical planning involved mirror-image simulation based on the unaffected contralateral counterpart and a stereolithographic skull-base model fabricated to design a patient-specific titanium mesh. Surgical reconstruction via the transcranial approach under intraoperative neuronavigation was performed. Immediate resolution of pulsatile proptosis was observed postoperatively. With the help of virtual surgical planning, stereolithography, and neuronavigation, precise and sustainable reconstruction with patient-specific implants can be tailored for a complex skull base defect.


Subject(s)
Dental Implants , Neurofibromatosis 1 , Plastic Surgery Procedures , Computer-Aided Design , Computers , Humans , Neurofibromatosis 1/complications , Neurofibromatosis 1/surgery , Skull Base/surgery , Sphenoid Bone/diagnostic imaging , Sphenoid Bone/surgery
4.
Materials (Basel) ; 13(16)2020 Aug 05.
Article in English | MEDLINE | ID: mdl-32764505

ABSTRACT

Properly regulating the resorption rate of a resorbable bone implant has long been a great challenge. This study investigates a series of physical/chemical properties, biocompatibility and the behavior of implant resorption and new bone formation of a newly developed Ca/P/S-based bone substitute material (Ezechbone® Granule CBS-400). Experimental results show that CBS-400 is comprised majorly of HA and CSD, with a Ca/P/S atomic ratio of 54.6/39.2/6.2. After immersion in Hank's solution for 7 days, the overall morphology, shape and integrity of CBS-400 granules remain similar to that of non-immersed samples without showing apparent collapse or disintegration. With immersion time, the pH value continues to increase to 6.55 after 7 days, and 7.08 after 14 days. Cytotoxicity, intracutaneous reactivity and skin sensitization tests demonstrate the good biocompatibility features of CBS-400. Rabbit implantation/histological observations indicate that the implanted granules are intimately bonded to the surrounding new bone at all times. The implant is not merely a degradable bone substitute, but its resorption and the formation of new cancellous bone proceed at the substantially same pace. After implantation for 12 weeks, about 85% of the implant has been resorbed. The newly-formed cancellous bone ratio quickly increases to >40% at 4 weeks, followed by a bone remodeling process toward normal cancellous bone, wherein the new cancellous bone ratio gradually tapers down to about 30% after 12 weeks.

6.
Ann Plast Surg ; 80(2S Suppl 1): S11-S14, 2018 02.
Article in English | MEDLINE | ID: mdl-29369910

ABSTRACT

BACKGROUND: Whether postoperative care in the intensive care unit (ICU) is a necessity for patients undergoing head and neck free flap reconstruction remains debatable. In August 2012, our institute initiated a policy to care for these patients in the ICU, opposed to the previous policy of care in the ward. Thus, we used this opportunity to compare outcomes between these 2 care approaches. PATIENTS AND METHODS: Patients with oral cancer who underwent cancer ablation and immediate anterolateral thigh flap reconstruction from August 2010 to July 2014 were included in this retrospective study. Patients who simultaneously received an additional flap reconstruction were excluded. Before August 2012, these patients were routinely transferred to the ward for postoperative care (ward group, n = 179). Since August 2012, these patients have routinely been transferred to the ICU for postoperative care (ICU group, n = 138). RESULTS: Both groups had comparable flap outcomes in terms of the rates of take-back, successful salvage, flap survival, and flap complication. Compared with the ward group, the ICU group showed an increased use of postoperative sedation (26.7% vs 6.8%, P = 0.000), a correspondingly longer use of mechanical ventilation (3.0 ± 2.7 days vs 0.4 ± 1.4 days, P = 0.000), and a higher incidence of sepsis (3.6% vs 0%, P = 0.015). CONCLUSIONS: Postoperative care of patients who have undergone anterolateral thigh flap reconstruction after oral cancer ablation in the ward or ICU resulted in comparable flap outcomes. Risks and benefits between ward and ICU postoperative management in terms of nursing workloads, monitoring facilities, use of sedation and mechanical ventilation, and potential for sepsis should be taken into consideration when defining postoperative care settings in these patients.


Subject(s)
Intensive Care Units/statistics & numerical data , Plastic Surgery Procedures/methods , Postoperative Care/methods , Surgery Department, Hospital/statistics & numerical data , Surgical Flaps/transplantation , Aged , Chi-Square Distribution , Cohort Studies , Female , Graft Survival , Humans , Length of Stay , Male , Middle Aged , Mouth Neoplasms/pathology , Mouth Neoplasms/surgery , Oral Surgical Procedures/methods , Prognosis , Retrospective Studies , Risk Assessment , Statistics, Nonparametric , Surgical Flaps/blood supply , Taiwan , Thigh/surgery , Treatment Outcome
7.
Am J Orthod Dentofacial Orthop ; 153(1): 70-80, 2018 Jan.
Article in English | MEDLINE | ID: mdl-29287657

ABSTRACT

INTRODUCTION: Little is known regarding how the mandible rotates in facial asymmetry. The purpose of this study was to study mandibular misalignment with a new plane-to-plane analysis method in patients with facial asymmetry. METHODS: Optimal symmetry planes (OSPs) were generated by computing the greatest count of paired voxels on opposing sides of the computerized tomography image of the structure. The mandibular OSP was measured against the midfacial OSP for its alignment. The deviation angle formed by the 2 OSPs was broken down into a y-axis component (frontal deviation angle) and a z-axis component (horizontal deviation angle). Fifty-nine patients who sought correction for facial asymmetry were included for study. RESULTS: The new analysis method was feasible. Fifty patients (83%) had significant mandibular misalignment (deviation, ≥4° or 4 mm). The locations of the rotational axes exhibited significant variations that could explain the varied features of the asymmetry. The frontal deviation angle (mean, 3.80° ± 3.89°) was significantly larger than the horizontal deviation angle (mean, 2.77° ± 1.71°). There was no significant correlation between the horizontal deviation angle and the anterior deviation distance or the posterior deviation distance. CONCLUSIONS: Proper mandibular realignment was suggested to be the primary aim in surgical correction of most jawbone asymmetries. Because of the greatly varied rotational axes and the obscure z-axis rotation, realignment could be difficult with the traditional approach. The OSP-based analysis is advocated to guide planning.


Subject(s)
Facial Asymmetry/diagnostic imaging , Mandible/diagnostic imaging , Tomography, X-Ray Computed , Cephalometry , Humans , Imaging, Three-Dimensional , Retrospective Studies
8.
Plast Reconstr Surg Glob Open ; 4(11): e1099, 2016 Nov.
Article in English | MEDLINE | ID: mdl-27975015

ABSTRACT

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.

9.
Plast Reconstr Surg ; 138(2): 481-489, 2016 Aug.
Article in English | MEDLINE | ID: mdl-27465170

ABSTRACT

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 patients with oral cancer who, between August of 2010 and July of 2014, had undergone ablative surgery and then immediate reconstruction with the anterolateral thigh flap. Patients who underwent simultaneous reconstruction with additional free flaps were excluded. The patients were subgrouped into newly diagnosed (n = 221) and previously treated (n = 100) groups and then subgrouped into one-vein and two-vein groups. RESULTS: Overall, operative time was significantly longer (366.8 ± 112.7 minutes versus 336.3 ± 99.7 minutes; p = 0.009) and hospitalization was significantly shorter (22.0 ± 13.3 days versus 24.5 ± 13.8 days; p = 0.027) in the two-vein group. In the newly diagnosed two-vein group, operative time was also significantly longer (355.5 ± 91.7 minutes versus 319.9 ± 95.9 minutes; p = 0.008), anterolateral thigh flap take-backs for vascular compromise (3.2 percent versus 10.9 percent; p = 0.041) and venous congestion (1.1 percent versus 7.8 percent; p = 0.027) were fewer, and flap survival was greater (100 percent versus 95.3 percent; p = 0.041). Differences between the one-vein and two-vein previously treated subgroups were not significant. CONCLUSION: In newly diagnosed patients undergoing anterolateral thigh flap reconstruction after oral cancer ablation, better outcomes are achieved with two venous anastomoses rather than one. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Subject(s)
Catheter Ablation/methods , Free Tissue Flaps/blood supply , Mouth Neoplasms/surgery , Muscle, Skeletal/transplantation , Plastic Surgery Procedures/methods , Thigh/surgery , Veins/surgery , Adult , Aged , Aged, 80 and over , Anastomosis, Surgical/methods , Female , Follow-Up Studies , Humans , Male , Middle Aged , Retrospective Studies , Young Adult
10.
Mater Sci Eng C Mater Biol Appl ; 37: 60-7, 2014 Apr 01.
Article in English | MEDLINE | ID: mdl-24582223

ABSTRACT

In-vitro and in-vivo studies have been conducted on an in-house-developed tetracalcium phosphate (TTCP)/dicalcium phosphate anhydrous (DCPA)/calcium sulfate hemihydrate (CSH)-derived composite cement. Unlike most commercial calcium-based cement pastes, the investigated cement paste can be directly injected into water and harden without dispersion. The viability value of cells incubated with a conditioned medium of cement extraction is >90% that of Al2O3 control and >80% that of blank medium. Histological examination reveals excellent bonding between host bone and cement without interposition of fibrous tissues. At 12 weeks-post implantation, significant remodeling activities are found and a new bone network is developed within the femoral defect. The 26-week samples show that the newly formed bone becomes more mature, while the interface between residual cement and the new bone appears less identifiable. Image analysis indicates that the resorption rate of the present cement is much higher than that of TTCP or TTCP/DCPA-derived cement under similar implantation conditions.


Subject(s)
Bone Cements/chemistry , Calcium Phosphates/chemistry , Calcium Sulfate/chemistry , Animals , Bone Cements/therapeutic use , Bone Cements/toxicity , Cell Survival/drug effects , Compressive Strength , Femoral Fractures/pathology , Femoral Fractures/therapy , Femur/pathology , Male , Mice , NIH 3T3 Cells , Porosity , Rabbits
11.
Eur J Clin Microbiol Infect Dis ; 33(6): 1011-8, 2014 Jun.
Article in English | MEDLINE | ID: mdl-24419406

ABSTRACT

In Taiwan, the aquatic environment and endemic hepatitis contribute to the high susceptibility of Vibrio vulnificus infection. A multidisciplinary treatment protocol for necrotizing fasciitis caused by V. vulnificus was developed in our institute, namely, ceftriaxone or ceftazidime combined with doxycycline or minocycline followed by an emergency fasciotomy and intensive care unit admission. We retrospectively reviewed 100 cases to evaluate the effectiveness of our treatment protocol and identify independent predictors of mortality to improve clinical outcomes. Cases of culture-confirmed V. vulnificus infection between January 1996 and December 2011 were reviewed. Necrotizing fasciitis was surgically diagnosed if these criteria were met: necrotic fascia, "dishwater discharge", and loss of resistance while doing finger dissection along the fascia plane. One hundred cases met these criteria and were included for analysis. Eighteen patients died (18 % mortality). Unknown injury events, presence of multiple skin lesions, leukocytes < 10,000 cells/mm(3), platelets < 100,000/mm(3), serum creatinine ≥1.3 mg/dL, serum albumin < 2.5 mg/dL, and delayed treatment beyond 3 days post-injury or symptom onset were associated with significantly higher mortality. Multivariate analysis showed that treatment delayed beyond 3 days is an independent factor indicating a poor prognosis (OR 10.75, 95 % CI 1.02-113.39, p = 0.048). Early diagnosis and prompt treatment within 3 days post-injury or symptom onset should be the goal for treating patients with necrotizing fasciitis caused by V. vulnificus. Additional investigations to rescue patients with a prolonged disease course of necrotizing fasciitis (≥3 days) may be important.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Debridement , Fasciitis, Necrotizing/mortality , Fasciitis, Necrotizing/therapy , Vibrio Infections/mortality , Vibrio Infections/therapy , Vibrio vulnificus/isolation & purification , Adolescent , Adult , Aged , Aged, 80 and over , Child , Fasciitis, Necrotizing/microbiology , Fasciitis, Necrotizing/pathology , Female , Humans , Male , Middle Aged , Prognosis , Retrospective Studies , Survival Analysis , Taiwan , Treatment Outcome , Vibrio Infections/microbiology , Vibrio Infections/pathology , Young Adult
12.
Microsurgery ; 34(5): 409-12, 2014 Jul.
Article in English | MEDLINE | ID: mdl-24442986

ABSTRACT

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.


Subject(s)
Carcinoma, Squamous Cell/surgery , Head and Neck Neoplasms/surgery , Mouth Neoplasms/surgery , Perforator Flap , Humans , Male , Middle Aged , Plastic Surgery Procedures/methods , Salvage Therapy , Squamous Cell Carcinoma of Head and Neck , Tissue and Organ Harvesting , Treatment Failure
13.
J Craniofac Surg ; 24(3): e260-5, 2013 May.
Article in English | MEDLINE | ID: mdl-23714985

ABSTRACT

Computer-aided design has gained increasing popularity in clinical practice, and the advent of rapid prototyping technology has further enhanced the quality and predictability of surgical outcomes. It provides target guides for complex bony reconstruction during surgery. Therefore, surgeons can efficiently and precisely target fracture restorations. Based on three-dimensional models generated from a computed tomographic scan, precise preoperative planning simulation on a computer is possible. Combining the interdisciplinary knowledge of surgeons and engineers, this study proposes a novel surgical guidance method that incorporates a built-in occlusal wafer that serves as the positioning reference.Two patients with complex facial deformity suffering from severe facial asymmetry problems were recruited. In vitro facial reconstruction was first rehearsed on physical models, where a customized surgical guide incorporating a built-in occlusal stent as the positioning reference was designed to implement the surgery plan. This study is intended to present the authors' preliminary experience in a complex facial reconstruction procedure. It suggests that in regions with less information, where intraoperative computed tomographic scans or navigation systems are not available, our approach could be an effective, expedient, straightforward aid to enhance surgical outcome in a complex facial repair.


Subject(s)
Computer-Aided Design , Facial Asymmetry/surgery , Fiducial Markers , Patient Care Planning , Plastic Surgery Procedures/methods , Splints , Surgery, Computer-Assisted , Adolescent , Computer Simulation , Female , Fibrous Dysplasia of Bone/surgery , Fractures, Comminuted/surgery , Frontal Bone/injuries , Humans , Image Processing, Computer-Assisted/methods , Imaging, Three-Dimensional/methods , Jaw Relation Record/instrumentation , Male , Mandibular Diseases/surgery , Mandibular Reconstruction/methods , Maxilla/surgery , Middle Aged , Models, Anatomic , Orbit/surgery , Orbital Fractures/surgery , Osteotomy, Le Fort/methods , Tomography, X-Ray Computed/methods , User-Computer Interface , Zygomatic Fractures/surgery
14.
Ann Plast Surg ; 69(6): 598-601, 2012 Dec.
Article in English | MEDLINE | ID: mdl-23154328

ABSTRACT

Trismus is a common problem among oral cancer patients. This report aimed to study the inciting factors of trismus and to find out the rationale of trismus release. Between 1996 and 2008, 61 oral cancer patients with retrievable records of interincisor distance (IID) were analyzed by retrospective chart review. The IID decreased from 31.4 (12.4) to 24.9 (12.0) mm in 36 patients undergoing cancer ablation only (P = 0.001). Other variables prompting trismus include buccal cancer (P = 0.017), radiotherapy (P = 0.008), and recurrence (P = 0.001). In contrast, the IID improved from 11.7 (7.1) to 22.7 (11.9) mm in 25 patients receiving cancer ablative and trismus releasing surgeries (P = 0.000). The improvement fared better in individuals with IID less than 15 mm than the others (P = 0.037). In conclusion, involvement of buccal region, ablative surgery, radiotherapy, and recurrence are provocative factors of trismus. Patients with IID less than 15 mm will benefit from releasing surgery significantly. Others may better be handled with conservative managements firstly, and enrolled as candidates of surgical release only until the patients entertained a 28-month period of disease-free interval, by which time the risk of recurrence would be markedly reduced.


Subject(s)
Mouth Neoplasms/complications , Trismus/etiology , Trismus/surgery , Adult , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Mouth Neoplasms/pathology , Mouth Neoplasms/surgery , Neoplasm Staging , Retrospective Studies , Treatment Outcome
17.
Microsurgery ; 30(8): 632-5, 2010 Nov.
Article in English | MEDLINE | ID: mdl-20734432

ABSTRACT

Recalcitrant epidural abscess following cranioplasty is a complicated problem, which becomes even more trying when large span of dura and skull bone are being replaced by alloplastic materials. A 22-year-old male underwent right fronto-temporo-parietal craniectomy and duroplasty with artificial dura graft after traumatic brain injury. Epidural abscesses recurred after cranioplasty with autologous bone graft as well as with a methyl methacrylate bone plate. The massive defects of both the dura and skull bone (15 × 9 cm) caused by radical debridement were reconstructed successfully with a combined free latissimus dorsi and serratus anterior myo-osseous flap transfer plus galea flap transposition. Proper contour and adequate stability of the construct were maintained during 2-year follow up without episodes of relapsing infection.


Subject(s)
Epidural Abscess/surgery , Free Tissue Flaps , Plastic Surgery Procedures/methods , Skull Fractures/surgery , Bone Plates , Brain Injuries/surgery , Cerebral Hemorrhage/surgery , Debridement , Decompressive Craniectomy , Dura Mater/surgery , Humans , Male , Recurrence , Scalp/surgery , Young Adult
18.
J Plast Reconstr Aesthet Surg ; 63(8): e622-6, 2010 Aug.
Article in English | MEDLINE | ID: mdl-20304713

ABSTRACT

BACKGROUND: The desmoid tumour is a monoclonal neoplasm originating from musculoaponeurotic tissues. It is benign in histological presentations and yet its locally invasive behaviour could lead to dire consequences such as disfigurement, functional impairment or even mortality. Surgical resection, radiotherapy, chemotherapy, hormonal therapy, non-steroidal anti-inflammatory drugs and even a wait-and-see policy, either alone or in combination, were advocated as treatment modalities. We experienced an extremely difficult case who had a huge nuchal desmoid tumour measuring 45x35x20 cm in dimension with extension to the anterior neck and thoracic paraspinal area. Its intimacy with the carotid artery, jugular vein and brachial plexus made margin-free resection infeasible. Moreover, the tumour burden was so immense that the patient was plunged into profound hypoproteinaemic, septic and anaemic status, with severe pain, bleeding and odour that mandated prompt and daring management. METHODS: In an effort to prevent uncontrollable tumour bleeding, we embarked on a series of strategic measures, including pre-surgical embolisation, innovative tourniquet technique, a novel method of ligature deployment, staged tumour excision and adjunct methods, such as ethanol injection and irradiation therapy. RESULTS: The huge nuchal desmoid tumour was successfully excised under the planned strategies. The patient went through a number of complications such as sepsis, acute respiratory distress and renal failure. Fortunately, she eventually survived and exhibited no evidences of tumour relapse at 2 years' follow-up. She has resumed daily activity independently without noticeable functional deficit. CONCLUSION: We believe that multimodality strategies and innovative surgical techniques are the key to success in managing such a difficult case.


Subject(s)
Embolization, Therapeutic/methods , Fibromatosis, Aggressive/therapy , Head and Neck Neoplasms/therapy , Suture Techniques/instrumentation , Tourniquets , Female , Fibromatosis, Aggressive/diagnosis , Follow-Up Studies , Head and Neck Neoplasms/diagnosis , Humans , Neck Dissection/methods , Time Factors , Young Adult
19.
J Plast Reconstr Aesthet Surg ; 63(1): e28-31, 2010 Jan.
Article in English | MEDLINE | ID: mdl-19541558

ABSTRACT

Oral cancers in association with trismus are commonly seen in clinical practice. Such a situation deserves special attention as it may complicate the tumour-ablative surgery and interfere with postoperative cancer surveillance. It follows that the simultaneous tackling of oral cancer and trismus should be pursued at any rate. In this presentation, a novel surgical approach using a cross-cheek anterolateral thigh (ALT) flap is introduced. With the special design in length, shape and orientation, this flap is capable of closing a wider defect area, sometimes extending across two functional regions (viz., posterior palate and trigonal area) without resort to two free flaps. As such, complex defects resulting from trismus release and tumour ablation can be readily repaired in a single stage. The advantages of such a technique include abundance in soft-tissue resources, proper flap quality and thickness, reliable blood supply, long and sizeable pedicle, ease in flap inset, need for only one recipient rather than two and the eradication of large area of mucosa that is predisposed to malignant transformation. The favourable outcome implicates that this innovative design could be a viable option in the management of such a clinical problem.


Subject(s)
Cheek/surgery , Mouth Neoplasms/surgery , Plastic Surgery Procedures/methods , Surgical Flaps , Trismus/surgery , Aged , Areca , Humans , Male , Middle Aged , Mouth Neoplasms/chemically induced , Neoplasm Recurrence, Local/surgery , Skin Transplantation/methods , Taiwan , Thigh
20.
Plast Reconstr Surg ; 125(2): 609-619, 2010 Feb.
Article in English | MEDLINE | ID: mdl-19910844

ABSTRACT

BACKGROUND: Over the past few decades, there has been a trend toward open reduction and internal fixation of mandibular condylar fractures. However, not all patients have fared well following the open surgical approach. A number of clinical parameters have been observed to be related to suboptimal treatment results on a long-term basis. A comprehensive investigation of the role of those risk factors is a worthwhile pursuit. METHODS: A total of 23 surgically treated patients were enrolled in the study during an 11-year period. A retrospective chart review was conducted to collect clinical and radiographic information both before and after surgery. Statistical analyses were used to determine the relationship of presurgical clinical variables to the postsurgical complications. RESULTS: Fractures of the condylar neck and head were associated with a high incidence of postoperative morbidity; all cases (seven of seven) suffered from some form of image or clinical disorder. In contrast, the subcondylar fracture fared well following surgery, with maintenance of function, cosmesis, and skeletal integrity in the majority (14 of 16) over long-term follow-up (p < 0.000). Comminution and obliquity of the fracture line were also correlated with the occurrence of postoperative morbidities. CONCLUSIONS: Results of the present study suggest that patients with subcondylar fracture fare better with open reduction in comparison with those suffering condylar neck or head fractures. Delayed-onset deformation tends to occur in patients with a short proximal segment, comminuted head, and obliquity of the fracture line. A renewed algorithm is thus provided to address the high condylar fracture problems.


Subject(s)
Mandibular Fractures/epidemiology , Mandibular Fractures/surgery , Orthopedic Procedures , Postoperative Complications/epidemiology , Adolescent , Adult , Algorithms , Female , Follow-Up Studies , Humans , Incidence , Male , Mandibular Fractures/diagnostic imaging , Middle Aged , Morbidity , Radiography , Retrospective Studies , Risk Factors , Young Adult
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