Long-term patient-reported donor-site morbidity after free peroneal fasciocutaneous flap in head and neck reconstruction.

OBJECTIVE: Fasciocutaneous free flap based on the peroneal artery (boneless version) is an option in our practice for head and neck reconstruction. However, the associated donor-site morbidity has rarely been discussed. Thus, this study investigated the long-term patient-reported donor-site morbidity associated with peroneal flaps. METHODS: In this single-center, retrospective, observational study, 39 patients who underwent a free peroneal flap were enrolled. We evaluated donor-site morbidity with a modified questionnaire from Enneking et al. and Bodde et al. RESULTS: Patient-reported daily life limitation was relatively low (5/39; 12.9%). Donor-site morbidities, namely pain (4/39; 10.3%), sensory disturbance (9/39; 23.1%), and walking limitation (9/39; 23.1%) were reported; most were rated minimal in severity. Among patients with walking limitation, muscle weakness (3/39; 7.7%), ankle instability (6/39; 15.4%), and gait alternation (6/39; 15.4%) were reported. Six patients developed claw toe. CONCLUSION: Balancing successful reconstruction and donor-site morbidity is challenging. This long-term patient-reported survey revealed that harvesting peroneal flaps resulted in minimal or minor donor-site morbidity with no obvious impacts on the patients' daily quality of life. Although free radial forearm flaps and anterolateral thigh flaps are standard, free peroneal flaps have been proven reliable, with acceptable donor-site morbidity.

Comparison of the outcomes of anterolateral thigh flap and peroneal flap in total laryngectomy reconstruction.

Background: We usually use an ALT or peroneal flap in total laryngectomy reconstruction, depending on the surgeons' preference. No direct comparison of the outcomes of the ALT flap and peroneal flap exists. Methods: From 2014 to 2022, we reviewed patients who had total laryngectomy and were reconstructed with an ALT flap and peroneal flap. Patient characteristics and surgical outcomes were collected and compared. Results: The peroneal group had a significantly higher risk of neopharynx leakage (40% vs. 13.2%, p = .020) and late pharyngocutaneous fistula formation (30% vs. 5.3%, p = .009) than the ALT group. Peroneal flap was found to be the only independent risk factor for neopharynx leakage (p = .025, odds ratio [OR] = 5.5) and late pharyngocutaneous fistula formation (p = .02, OR = 7.7) in multivariate logistic regression. Conclusion: In the reconstruction of total laryngectomy, the ALT flap is preferable over the peroneal flap.

An innovative targeted therapy for fluoroscopy-induced chronic radiation dermatitis.

Fluoroscopy-induced chronic radiation dermatitis (FICRD) is a complication of fluoroscopy-guided intervention. Unlike acute radiation dermatitis, FICRD is different as delayed onset and usually appears without preexisting acute dermatitis. Unfortunately, the chronic and progressive pathology of FICRD makes it difficult to treat, and some patients need to receive wide excision and reconstruction surgery. Due to lack of standard treatment, investigating underlying mechanism is needed in order to develop an effective therapy. Herein, the Hippo pathway is specifically identified using an RNA-seq analysis in mild damaged skin specimens of patients with FICRD. Furthermore, specific increase of the Yes-associated protein (YAP1), an effector of the Hippo pathway, in skin region with mild damage plays a protective role for keratinocytes via positively regulating the numerous downstream genes involved in different biological processes. Interestingly, irradiated-keratinocytes inhibit activation of fibroblasts under TGF-ß1 treatment via remote control by an exosome containing YAP1. More importantly, targeting one of YAP1 downstream genes, nuclear receptor subfamily 3 group C member 1 (NR3C1), which encodes glucocorticoid receptor, has revealed its therapeutic potential to treat FICRD by inhibiting fibroblasts activation in vitro and preventing formation of radiation ulcers in a mouse model and in patients with FICRD. Taken together, this translational research demonstrates the critical role of YAP1 in FICRD and identification of a feasible, effective therapy for patients with FICRD. KEY MESSAGES: • YAP1 overexpression in skin specimens of radiation dermatitis from FICRD patient. • Radiation-induced YAP1 expression plays protective roles by promoting DNA damage repair and inhibiting fibrosis via remote control of exosomal YAP1. • YAP1 positively regulates NR3C1 which encodes glucocorticoid receptor expression. • Targeting glucocorticoid receptor by prednisolone has therapeutic potential for FICRD patient.

Haematogenous Klebsiella pneumoniae osteomyelitis.

OBJECTIVES: Klebsiella pneumoniae infection has been associated with alcoholic and diabetic patient populations, especially in Asian populations. K. pneumonia wound infection is common, but K. pneumonia without wound osteomyelitis (OM) is relatively rare. However, the pathogenesis of haematogenous K. pneumonia without open wound OM still unclear until now. In our research, we are trying to collect patients with haematogenous K. pneumonia osteomyelitis (K.p OM) at our hospital and to evaluate their contributing factors. METHODS: We compiled a retrospective database of haematogenous K. pneumonia osteomyelitis (K.p OM) from 1990 to 2019 at our hospital. Patients' bone cultures without K. pneumonia infection were excluded. Sixteen patients with haematogenous K.p OM were recruited. Patients' basic information, comorbidities, wound history, the biochemical examination of the blood, bacterial blood, bone, urine, and liver abscess cultures, the location of OM, corresponding treatments, and post operation K.p wound infection history were reviewed retrospectively. The collected data were analyzed using SPSS software. RESULTS: Unwounded haematogenous K.p OM had a statistically significant and positive correlation with liver insufficiency (P = .037; OR = 2.200), advanced age (≥ 65 years) (P = .037; OR = 2.200) and male gender (P = .03; OR = 1.833). DM, hypertension, steroid usage, GI or GU tract K.p infection, post operation K.p wound infection, hypoalbuminemia, and the location of K.p OM had no significant relationship to outcomes. CONCLUSION: Male patients of advanced age (> 65 years) and patients with liver insufficiency, including liver cirrhosis and hepatitis, have a strong correlation with unwounded haematogenous K.p OM.

Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction.

BACKGROUND: Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. METHODS: This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. RESULTS: Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). CONCLUSION: Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

Bisphosphonate-Related Osteonecrosis of the Jaw.

OBJECTIVES: Antiresorptive agents for bone pain were widely used to treat patients with advanced osteoporosis, multiple myeloma, and bone metastatic cancer. In recent years, however, bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been a rare but major complication of this therapy. Most patients with BRONJ undergo dental procedures during treatment with antiresorptive agents. However, BRONJ may also occur spontaneously. This study reports 13 BRONJ patient cases at Kaohsiung Veterans General Hospital, Taiwan, and their related treatments. We also compare patients with cancer with patients with osteoporosis in treatment outcomes. METHODS: Thirteen symptomatic patients with BRONJ were reviewed between 1985 and 2018 at Kaohsiung Veterans General Hospital. We included patients at advanced stage who were hospitalized for infection control of osteonecrosis of the jaw and excluded asymptomatic patients at stage 0 and stage 1. Four multiple myeloma, 3 patients with bone metastatic breast cancer and 6 patients with advanced osteoporosis (average ages, 63.57 ± 14.54 years in cancer patients and 79.5 ± 9.31 years in osteoporosis patients; average drug durations, 25.86 ± 27.23 months in cancer patients and 58.33 ± 23.87 months in osteoporosis patients; average follow-up times, 22.71 ± 14.46 months in cancer patients and 28.08 ± 36.35 months in osteoporosis patients) were included. RESULTS: Seven patients were defined as having stage 3 (53.8%) and 6 as having stage 2 (46.2%) medication-related osteonecrosis of the jaw, according to the American Association of Oral and Maxillofacial Surgeons classification. The complete response rate with totally healed mucosa was 61.5%. Four cancer patients received free fibular flap (FFF) reconstruction with a high complete response rate (100%). All of them had a relatively better performance status, and the average age was also younger than osteoporosis patients. CONCLUSION: Free fibular flap with a high complete response rate may improve pain relief and infection control for patients with BRONJ. Younger age is seemed to be a great indicator for FFF, but poor self-care ability (Eastern Cooperative Oncology Group status >3) is not suitable for these surgical treatments.

Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction.

BACKGROUND: A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction. MATERIALS AND METHODS: Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed. RESULTS: A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%. CONCLUSION: A peroneal flap might be an alternative option for the reconstruction of head and neck defects.

Different histopathologic profiles and outcomes between sun-exposed BCC and non-sun-exposed BCC.

Asian population is a low-risk group for basal cell carcinoma (BCC) and there is little data available in this setting. Sun-exposed BCC (SEBCC) may possess a different pathogenic mechanism from non-sun-exposed BCC (NSEBCC). To compare the histopathological profiles and outcomes between SEBCC and NSEBCC, and to assess the risk factors for tumor recurrences. Retrospective cohort study on 372 patients with pathologically diagnosed BCC from January 1, 1990 to August 31, 2017. Data were derived from a single medical center in Taiwan. SEBCC presented with higher Clark level and more high-risk factors for recurrence than NSEBCC. Nodular, micronodular, infiltrating/mixed infiltrating, basosquamous, and adenoid types were predominant in SEBCC, as superficial type in NSEBCC. Risk factors for recurrence included infiltrating/mixed-infiltrating subtypes and synchronous basosquamous cell carcinoma. No recurrence events were observed in NSEBCC. Our study showed an acceptable recurrence rate (4.2%) of the whole population after excision even under a smaller surgical margin width than suggested by current guidelines. SEBCC had a higher recurrence rate with a significantly different tumor characteristic from NSEBCC and a greater tumor depth than NSEBCC. A wider surgical margin in SEBCC than NSEBCC is suggested.

Risk of Free Flap Failure in Head and Neck Reconstruction: Analysis of 21,548 Cases From A Nationwide Database.

BACKGROUND: Head and neck reconstruction is complicated and is made even more challenging by free flap failure. We identified risk factors associated with free flap failure in records extracted from a nationwide database of a 23 million populations. METHODS: We used International Classification of Diseases, Ninth Version, codes 140 to 149 and 161 to identify patients in Taiwan's National Health Insurance Research Database with head and neck cancer between 2000 and 2013. Patient's age, sex, neoadjuvant treatment, comorbidities, and anticoagulation use were also retrieved. Free flap reconstruction twice, or free flap and pedicle flap reconstructions during the same hospitalization were recorded as free flap failure. Logistic regression was used to identify factors that increased risk of free flap failure. RESULTS: A total of 21,548 patients with head and neck cancer were identified; 883 (4.1%) experienced free flap failure. Use of aspirin, clopidogrel, urokinase, prostaglandin (PGE1), low-molecular-weight heparin, and operation time were associated with free flap failure. However, some potential confounders could not be identified from the database. CONCLUSIONS: Several statistically significant findings were prone to influence by potential confounders. The clinically applicable result was that longer operation time and preoperative chemotherapy could increase the likelihood of free flap failure. On the other hand, several factors were proved to be irrelevant to free flap failure.

Clinical Importance and Risk Factors for Postoperative Late-Onset Pneumonia After Major Oral Cancer Surgery With Microvascular Reconstruction.

BACKGROUND: Pulmonary complications are common among patients who have undergone major oral cancer surgery with microvascular reconstruction. Current literatures focused on early-onset pneumonia in the postoperative acute stage. In contrast, we are aiming to identify the clinical importance and the risk factors associated with late-onset pneumonia in oral cancer patients after acute stage. METHODS: In total, 195 patients were included from May 2014 to December 2016 and followed up for up to 1 year after surgery. Their medical histories were reviewed to identify the risk factors of late-onset pneumonia and outcome. Primary outcome was late-onset pneumonia. Other outcome measures included early-onset pneumonia, tumor recurrence, and death within 1 year after surgery. RESULTS: Patients with late-onset pneumonia have demonstrated a significantly higher rate of tumor recurrence (P < 0.001) and death within 1 year (P < 0.001). Independent risk factors of late-onset pneumonia identified were age (P = 0.031), previous radiotherapy (P = 0.017), postoperative radiotherapy (P = 0.002), flap size (P = 0.001), flap type other than osteocutaneous fibula flap (P = 0.009), and tumor recurrence (P < 0.001). CONCLUSIONS: Late-onset pneumonia can act as a warning sign for oral cancer patients who have received microsurgical reconstruction, for its high correlation with tumor recurrence and mortality rate.

Association between blood pressure and postoperative hematomas in the patients undergoing head and neck cancer reconstruction.

BACKGROUND: Postoperative hematoma is one of the most common complications of free flap reconstruction and compromises the perfusion of pedicles and perforators. Therefore, we reviewed our patients to analyze the associated risk factors. METHOD: This study involved a retrospective chart review from 2014 to 2016. We identified the patients undergoing free flap reconstructions for head and neck cancer. Patients with postoperative hematoma requiring surgical intervention were included. RESULT: We enlisted 289 patients undergoing head and neck reconstructions. Eighteen patients (6.2%) had postoperative hematomas of which 12 hematomas occurred within the first 3 days and 9 in the first 24 hours. Elevated systolic blood pressure increased the risk of hematoma formation, but hematoma was not associated with higher failure rate. Tachycardia was observed in the patients with hematoma. CONCLUSIONS: Transient elevated blood pressure increased the risk of hematoma. We suggest controlling systolic blood pressure below 150 mm Hg for prevention of hematoma.

The safety and benefit of using oxidized regenerated cellulose to position free flap pedicle in head and neck reconstruction.

BACKGROUND: Oxidized regenerated cellulose (ORC; Surgicel®; Ethicon, Neuchâtel, Switzerland) is an absorbable hemostatic agent used for hemostasis in operation, although some surgeons use it to position free flap pedicles. The increasing risk of vessel compromise is a huge concern. However, no scientific data to date demonstrate the safety and benefit of using ORC in microvascular surgery. In the present study, we compared the outcome of microvascular head and neck reconstruction with and without pedicle placement using ORC. MATERIALS AND METHODS: From January 2015 to December 2017, we reviewed patients undergoing microvascular surgery with free fibular osteocutaneous flap in our hospital. The patients were divided into the ORC group and non-ORC group and their baseline characteristics and outcomes were compared. RESULTS: In total, there were 27 patients in the ORC group and 67 in the non-ORC group. The non-ORC group had significantly higher cigarette consumption (70.4% vs. 89.6%; p = .022). The outcome of the ORC group was better regarding arterial thrombosis (0% vs. 3%), flap failure (0% vs. 4.5%), hematoma (7.4% vs. 10.4%), and wound complications (25.9% vs. 44.8%). The ORC group had a worse result than the non-ORC group for vein thrombosis (7.4% vs. 4.5%) and duration of hospitalization (24.111 days vs. 23.627 days). However, none of above results was significant. CONCLUSIONS: Though this study was underpowered to detect the differences, the results showed a trend toward better outcomes of flaps and wounds in the ORC group. It seems that using ORC in this field is safe and beneficial.

Obliquely-arranged double skin paddles: A novel design to reconstruct extensive head and neck defects with a single fibula or peroneal flap.

OBJECTIVE: To reconstruct extensive head and neck defects usually necessitates double free flaps, which require a time-and-manpower-consuming surgical procedure. We present using a single fibula or peroneal flap with the novel design of obliquely-arranged double skin paddles to reconstruct an extensive head and neck defect. METHODS: From 1998 to 2016, eight patients with the age of 52.25 (35-71) years old had extensive head and neck defects after oral cancer ablation. All of the defects were through and through with the size of 16.25 (12-24) cm × 8.8 (4.5-11) cm. Six of the defects were due to buccal cancer. One was due to tongue cancer, and another one was due to gingiva cancer. All the defects were reconstructed with obliquely-arranged double-paddle free fibula or peroneal flaps. The long axis of the skin paddles was arranged at certain angle (30-45 degrees) to the long axis of lower leg, and the two separate skin paddles were used as the form of island flaps by isolating the cutaneous perforators to create a true chimeric flap. RESULTS: The skin paddle sizes were 14 cm × 3 cm-24 cm × 11 cm and 9.5 cm × 4.5 cm-13 cm × 8 cm. The average length of harvested fibula was 19 (10-30) cm. All of the eight flaps survived without obvious donor site morbidity. One patient had partial skin necrosis over recipient site, requiring surgical debridements and closure. One patient had superficial necrosis over the edge of outer skin paddle, which healed spontaneously. After the follow-up periods of 1 month to 3 year and 8 months, two patients died of sepsis. Six of them could resume soft diet and had no saliva drooling. The remaining two remained nasogastric diet and had saliva drooling. CONCLUSION: With the design of obliquely-arranged double paddles, we may maximize the harvested skin area of lateral lower leg to reconstruct an extensive head and neck defect with a single free flap.

Factors contributing to surgical site infection in patients with oral cancer undergoing microvascular free flap reconstruction.

PURPOSE: Surgical site infections (SSIs) are associated with considerable medical expenditure. While head and neck free flap reconstruction has gradually become routine management following an ablative oncologic resection, reports on factors contributing to the SSIs are lacking. METHODS: We retrospectively analyzed 173 new patients with oral cancer without any antecedent treatment at a tertiary medical center from 2010 to 2015. We determined incidence rates of SSIs within 30 days postoperatively and identified independent risk factors using multivariate logistic regression analysis. RESULTS: Of 173 patients, 67 (38.7%) had SSIs. Multivariate analysis demonstrated operative time [odds ratio (OR) = 1.199, 95% confidence interval (CI) = 1.036-1.389], mandibulectomy (OR = 2.759; 95% CI = 1.245-6.111), and oro-neck communication (OR = 5.358; 95% CI = 2.150-13.355) as independent predictors for SSIs. CONCLUSIONS: For patients with oral cancer undergoing free tissue reconstruction, mandibulectomy, oro-neck communication, and prolonged operative time were associated with increased incidence of SSIs.

Risk Factors For Radiation-Induced Skin Ulceration in Percutaneous Coronary Interventions of Chronic Total Occluded Lesions: A 2-Year Observational Study.

Relationship between radiation-induced skin ulceration (RSU) and variables in percutaneous coronary interventions (PCI) was rarely reported. RSU is a severe complication in PCIs, especially for chronic total occlusion (CTO) lesions. We investigated the RSUs and their risk factors in patients receiving CTO PCIs over a 2-year period. Data were analyzed using chi-square tests, t-tests and receiver operating characteristic (ROC) curve. Of 238 patients, 11 patients (4.6%) had RSUs all at right upper back. RSUs were significantly associated with use of left anterior oblique (LAO) views (100% vs. 47.1%, p < 0.001), retrograde techniques (36.3% vs. 7.9%, p = 0.012), or a procedure time (PT) defined as a time duration between the first and last angiograms of > 120, 180, or 240 minutes (p < 0.05). ROC analysis showed a long PT was an accurate predictor of RSUs (AUC = 0.88; p < 0.001) at a cut-off of 130 minutes (sensitivity = 0.91, specificity = 0.81). The results showed risk factors for RSUs containing use of large LAO views, retrograde techniques, and prolonged PTs. This study suggests that, to minimize RSU, interventionalists should limit PT to roughly 2 hours in fixed LAO views.

Peroneal Flap for Tongue Reconstruction.

Background For large tongue defects, reconstructive surgeons have devised a variety of feasible options, such as radial forearm free flap and anterolateral thigh (ALT) flap. In our institution, peroneal flap has been the workhorse flap for the soft tissue defect in head and neck reconstruction. We present our experience using peroneal flap in tongue reconstruction. Patients and Methods The study included 47 patients who had undergone tongue reconstructions with peroneal flaps after tumor resection. The size and location of the defect after tumor resection determined whether the peroneal flaps could be harvested as pure septocutaneous flaps to solely reconstruct the neotongue or to carry an additional muscle bulk to fill the adjacent defect. Retrospective chart review was used to look for postoperative complications and to perform functional assessments (which were also performed through telephone inquiry). Results Of the 47 patients, 3 (6%) had flap failure and 1 (2.1%) had partial flap necrosis. The hemiglossectomy group had better results than the total glossectomy group with respect to speech and diet, but neither of these results reached statistical significance (p = 1.0 for speech and p = 0.06 for diet). The results of the subtotal glossectomy group were better than those of the total glossectomy group with respect to diet (p = 0.03). No statistically significant differences were noted among the three groups with respect to cosmetic aspect (p = 0.64). Conclusions Considering its reasonable postoperative complication rates and functional results, peroneal flap can be considered a feasible option for tongue reconstruction.

Double-paddle peroneal flap for extensive lip defect reconstruction.

INTRODUCTION: Today, reconstructive surgeons offer an array of options to reconstruct the lip defects. Herein we present our experience of using free double-paddle peroneal flaps for extensive lip defect reconstruction. PATIENTS AND METHODS: From 1996 to 2014, 16 patients with extensive lip defects after tumor ablation were included. Free double-paddle peroneal flaps were used for reconstructions. In terms of flap design, one skin paddle superiorly placed on the lateral lower leg was used to reconstruct intraoral defects, whereas the other was inferiorly located and was used to reconstruct extraoral defects. A part of the inner skin paddle was everted, and the suture line with the outer skin paddle became the new vermilion border. A portion of the outer skin paddle could be de-epithelized and tucked into the fold of the inner skin paddle, leading to greater fullness of the new lip. RESULTS: Skin paddle sizes were 10-15 cm × 3-13 cm and 4-10.5 cm × 2.5-10.5 cm. Venous thrombosis occurred in one patient but was salvaged, and one flap had superficial necrosis over the outer paddle that was conservatively treated. In the 0.5-33 month follow-up period, all patients were able to close their mouths without obvious drooling. CONCLUSION: Free double-paddle peroneal flap transfer could augment lip definition, deepen the labial vestibule, and provide an acute-angle oral commissure, leading to satisfactory oral competency and improved cosmetic results. Therefore, this technique may be considered a viable option for extensive lip defect reconstruction.

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction.

OBJECTIVES: Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain. METHOD: We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods. RESULTS: None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications. CONCLUSIONS: The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

Contributing Factors for Complications and Outcomes in Patients With Snakebite: Experience in a Medical Center in Southern Taiwan.

OBJECTIVES: Snakebite usually results in various complications, such as significant soft tissue damage, infection, hematological, and neurological deficit. Surgical intervention, usually, is indicated in patients with tissue necrosis, infection, and compartment syndrome. To identify the contributing factors for complications and outcomes in different patients with snakebite so that outcomes can be evaluated and treatment of such patients can be initiated at the earliest. METHODS: Information was collected regarding age, sex, underlying disease, species of snake, and the course of treatment of the victims of snakebite who visited the emergency department of a medical center in southern Taiwan between 2004 and 2014. The data obtained were analyzed using SPSS 20.0. RESULTS: The bites from Taiwan cobra (Naja naja atra) significantly resulted in more complications than those from other snakes and required surgical intervention. The use of antivenin and antibiotics, immediate presentation to the hospital, and the location of the bite also were significant contributing factors. CONCLUSIONS: Taiwan cobra significantly results in higher possibility of prolonged hospitalization, operation, tissue necrosis, infection, and necrotizing fasciitis. Location of the bite, immediate presentation to the hospital, and use of antivenin and antibiotics affect the outcome of snakebite. Knowledge of these factors will help in a better management of patients with snakebite.

Management of fluoroscopy-induced radiation ulcer: One-stage radical excision and immediate reconstruction.

With increasing use of cardiac fluoroscopic intervention, the incidence of fluoroscopy-induced radiation ulcer is increasing. Radiation ulcer is difficult to manage and currently there are no treatment guidelines. To identify the optimal treatment approaches for managing cardiac fluoroscopy-induced radiation ulcers, we retrospectively reviewed medical records of 13 patients with fluoroscopy-induced radiation ulcers receiving surgical interventions and following up in our hospital from 2012 to 2015. Conventional wound care and hyperbaric oxygen therapy were of little therapeutic benefit. Twelve patients received reconstruction with advancement flap or split thick skin graft. One-stage radical excision of radiation damaged area in eight cases with immediate reconstruction led to better outcomes than conservative excisions in four cases. Radical surgical excision to remove all the radiation damaged tissues in combination with immediate reconstruction appears to offer the optimal treatment results for cardiac fluoroscopy-induced radiation ulcers. Adequate excision of the damaged areas in both vertical (to the muscular fascia) and horizontal (beyond the sclerotic areas) dimension is pivotal to achieve good treatment outcomes.