A shocking craniofacial penetrating injury by a steel bar.

Owing to the diversity in cause and damage, there is no standard surgical treatment method for a complicated penetrating craniofacial injury. The treatment of a complicated penetrating head injury caused by a steel bar is presented here. A 66-year-old woman fell onto a steel bar at a construction site and it penetrated the mandible, entered the sinus and orbital cavities, and reached the base of the frontal bone. A multi-disciplinary team including a neurosurgeon, otolaryngologist, and plastic surgeon was involved in removing the steel bar. The patient survived without sequelae except for blindness in the right eye. Despite the lack of standardized surgical treatment for a complicated penetrating craniofacial injury, aggressive treatment by a multidisciplinary team can result in good outcomes.

A novel surgical technique: single-incision transumbilical laparoscopic Roux-en-Y gastric bypass.

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a "liver suspension tape" that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.

Reconstruction of knee joint soft tissue and patellar tendon defects using a composite anterolateral thigh flap with vascularized fascia lata.

Reconstruction of a complex knee trauma with knee joint exposure and composite soft tissue and patellar tendon deficiency remains a challenging task. Multiple-stage reconstruction is time-consuming and produces considerable suffering for patients. Early mobilization following knee reconstruction has achieved good outcomes. Herein, we reported one-stage reconstruction with an ALT myocutaneous flap with vascularized fascia lata was utilized for one patient with a large complex knee joint soft tissue defect, and segmental deficiency of the patellar tendon. The fascia lata sheet was rolled to mimic a patellar tendon. The exposed knee joint was obturated by the vastus lateralis muscle of the ALT myocutaneous flap. The skin and soft tissue defect was reconstructed using the skin paddle of the ALT flap. The patient's postoperative course was uneventful. An MRI examination demonstrated good continuity of the reconstructed patellar tendon. The active ROM of the injured knee reached 100 degrees (extension deficiency 20 degrees and flexion 120 degrees ) at 5 years. Objective functional assessment of the patella-femoral joint utilized a kinetic communicator machine (Kin-Com 500H, Chattecx, Chattanooga, TN, USA) revealed still mild extension insufficiency. However, the patient reported that he was able to perform normal daily activities without difficulty at 5-year follow-up.

Porcine heterotopic composite tissue allograft transplantation using a large animal model for preclinical studies.

BACKGROUND: Composite tissue allograft (CTA) transplantation is currently limited by the risks of side effects resulting from long-term high-dose immunosuppression. Therefore, preclinical animal models are essential to help CTA transplantation advance into clinical reality. Evidence has shown that small-animal model (rodents) immunotherapy protocols cannot be directly applied to humans. This study investigated whether a miniature porcine model is reproducible for preclinical studies. METHODS: Based on the concept of vascularized skeletal tissue allograft transplantation, limb heterotopic allograft tissue from a mismatched donor miniature pig consisting of the distal femur, knee joint, tibia, fibula, and surrounding muscle with a vascularized skin paddle model supplied by the superficial femoral vessels was transplanted into recipient pigs. Swine viability and rejection signs of the allograft were monitored postoperatively. Histopathological changes in the allograft tissues were examined using hematoxylin and eosin staining if the allo-skin flap was rejected. RESULTS: The recipient pigs were ambulatory immediately following surgery. The flaps showed no visible signs of rejection over the first 4 days of observation. The skin flaps appeared bluish-purple and edematous on postoperative days 5 approximately 7, and progressed to tissue necrosis and rejection on postoperative days 8 approximately 13. Histological examination revealed marked mononuclear cell infiltration and necrotic changes in the all rejected tissues, especial in the allograft skin tissues (skin > muscle > bone > cartilage). CONCLUSIONS: The results showed this the porcine CTA model is reproducible and suitable for preclinical training for human CTA transplantation. Monitoring of the allo-skin flap is a useful strategy to evaluate composite tissue allograft rejection.

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery.

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.