Edge De-epithelialization for Reducing Pharyngocutaneous Fistula in Patch Free Flap Reconstructions for Salvage Total Laryngectomy Defects: A Case-Control Study.

BACKGROUND: The leakage of saliva through the deep neck region from a pharyngocutaneous fistula could cause devastating complications, including vascular ruptures leading to mortality. While a partial pharyngoesophageal defect is created after total laryngectomy, a patch pattern of hypopharyngeal reconstruction is required, for which a fasciocutaneous free flap is usually applied. If radiotherapy fails to cure pharyngeal cancer, salvage total laryngectomy (STL) is needed. However, postradiation tissues tend not to heal well, and the incidence of pharyngocutaneous fistula therefore increases. We proposed an edge-epithelialization method to address this problem and conducted a retrospective study for comparison. METHODS: The inclusion criteria were patients with head and neck cancer who underwent total laryngectomy that immediately required patch free flap reconstruction at a single medical center (January 2012-December 2021). Receipt of presurgical radiotherapy, hospitalization duration, and the presence of postoperative complications were recorded. RESULTS: The included patients were separated into two groups: Group A (edge de-epithelialization not adopted) (n = 79) and Group B (edge de-epithelialization adopted) (n = 51). Forty-four and twenty-two patients in Groups A and Group B, respectively, received preoperative radiotherapies and simultaneous STL and fasciocutaneous free flap reconstructions. The incidence of pharyngocutaneous fistula was significantly lower in Group B (p = 0.0145). This phenomenon was the same for patients who underwent preoperative radiotherapy only (p = 0.0470) but not for patients who did not receive preoperative radiotherapy (p = 0.2363). CONCLUSIONS: Edge de-epithelialization is an effective method for reducing pharyngocutaneous fistula formation in patch free flap reconstructions after STLs.

Translational Potential of Baicalein in Mitigating RSL3-Induced Ferroptosis in Fibroblasts: Implications for Therapeutic Interventions.

Background: Ferroptosis is an iron-driven cell-death mechanism that plays a central role in various diseases. Recent studies have suggested that baicalein inhibits ferroptosis, making it a promising therapeutic candidate. Materials and Methods: Fibroblast cultures were treated with different agents to determine the effects of baicalein on ferroptosis. Ferroptosis-related gene expression, lipid peroxidation, and post-treatment cellular structural changes were measured using real-time quantitative polymerase chain reaction, C11-BODIPY dye, and transmission electron microscopy, respectively. Results: Baicalein significantly inhibited rat sarcoma virus selective lethal 3-induced ferroptosis in fibroblasts. Moreover, in baicalein-treated groups, reduced ferroptosis-related gene expression, decreased lipid peroxidation, and maintained cell structure was observed when compared with those of the controls. Discussion: The ability of baicalein to counteract RSL3-induced ferroptosis underscores its potential protective effects, especially in diseases characterized by oxidative stress and iron overload in fibroblasts. Conclusion: Baicalein may serve as a potent therapeutic agent against conditions in which ferroptosis is harmful. The compound's efficacy in halting RSL3-triggered ferroptosis in fibroblasts paves the way for further in vivo experiments and clinical trials.

Epidemiology of Congenital Upper-Limb Anomalies in Southern Taiwan Based on the Updated Oberg, Manske, and Tonkin Classification: A Series of 1,335 Anomalies in 1,188 Patients.

PURPOSE: This study aimed to investigate the relative frequency of congenital upper-limb anomalies (CULAs) in southern Taiwan using the 2020-updated the Oberg, Manske, and Tonkin (OMT) classification system and evaluate the practicality of the new classification system. METHODS: We retrospectively reviewed patients with CULAs from 1987 to 2021 at a referral center in southern Taiwan. All patients were analyzed based on medical records, photographs, and radiographs, and the anomalies were classified according to the 2020 OMT classification system. RESULTS: A total of 1,188 patients with 1,335 CULAs were retrospectively reviewed. The results demonstrated that the most common type of CULA was malformations (1,092 cases), followed by dysplasias (144 cases), syndromes (51 cases), and deformations (48 cases). Among the malformations, radial polydactyly was the most common anomaly (732 cases), followed by simple syndactyly (66 cases). Among the dysplasias, camptodactyly was the most common anomaly (52 cases), followed by thumb-in-palm deformity (45 cases) and vascular tumors (17 cases). In the deformations, constriction ring sequence accounted for all cases. Poland syndrome (21 cases) occurred most often in the category of syndromes. CONCLUSIONS: The results of this study show that radial polydactyly (732 cases, 55%) is the most common CULA in southern Taiwan, followed by simple syndactyly (66 cases, 5%) and then camptodactyly (52 cases, 4%). CLINICAL RELEVANCE: The OMT classification system is reasonably practical for precise classification of CULAs and enables easy comparison of studies over different time periods. However, continually updating the OMT classification system is required to better categorize the highly variable presentations of CULAs.

Subpopulations of exosomes purified via different exosomal markers carry different microRNA contents.

The heterogeneity of exosome populations presents a great challenge to their study. The current study was designed to investigate the potential heterogeneity miRNA contents in circulating exosomes purified via different exosomal markers. In this study, exosomes from the serum of C57BL/6 mice after cecum ligation and perforation (CLP) or sham operation were isolated by precipitation using ExoQuick-TC and affinity purified with anti-Rab5b, anti-CD9, anti-CD31, and anti-CD44 antibodies using the Exo-Flow Exosome Capture kit to collect exosome subpopulations. RNA extracted from the exosomes isolated by ExoQuick-TC were profiled by next-generation sequencing (NGS). Real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) was also employed to determine the expression profiles of four representative exosomal miRNAs (mmu-miR-486-5p, mmu-miR-10a-5p, mmu-miR-143-3p, and mmu-miR-25-3p) selected from the NGS analysis. The results revealed that the expression patterns of these miRNAs in exosomes isolated by ExoQuick-TC as determined by RT-qPCR and NGS were similar, showing upregulation of mmu-miR-10a-5p and mmu-miR-143-3p but downregulation of mmu-miR-25-3p and mmu-miR-486-5p following CLP when compared to the levels in exosomes from sham control mice. However, their expression levels in the antibody-captured exosome subpopulations varied. The miRNAs in the exosomes captured by anti-Rab5b or anti-CD9 antibodies were more similar to those isolated by ExoQuick-TC than to those captured by anti-CD44 antibodies. However, there were no significant differences in these four miRNAs in CD31-captured exosomes. This study demonstrated that purification with different exosomal markers allows the collection of different exosome subpopulations with various miRNA contents. The results of this study demonstrate the heterogeneity of circulating exosomes and suggest the importance of stratifying exosome subpopulations when using circulating exosomes as biomarkers or investigating exosome function. In addition, this study also emphasized the necessity of using a consistent exosome marker across different samples as detecting biomarkers.

Comparison of surgical outcomes between primary plate and fibular flap transfer for reconstruction of segmental mandibular defects.

PURPOSE: Although two ways of reconstruction have been reviewed for a long period, comparison of large sample size with nearly randomized patient selection is rare. Here, we compare the surgical outcomes of these two methods from two large medical institutes. METHODS: Totally 176 patients were included from two medical centers with different protocols, 62 patients from MacKay Hospital repair defects with fibula flaps using reconstruction plates. Also 114 patients from Kaohsiung ChangGung Hospital treat with reconstruction plates combine anterior lateral thigh flaps, in which 12 cases had secondary fibula flap after plate exposure. Electronic medical records were reviewed retrospectively. Short (3-12 months) and long-term (>12 months) outcomes were evaluated. RESULTS: Short-term evaluation revealed that the secondary fibula had a higher rate of vascular complications (33 vs. 6%, p = .02). Primary fibula had a higher risk of post reconstructive surgical debridement (60 vs. 40%, p = .018). Long-term follow-up revealed radiation therapy significantly worsened bone healing (p = .03). Primary fibula had a lower rate of screw loosening (14.0 vs. 40.3%, p = .002). Radiation therapy did not increase the plate exposure rate among the groups (33 vs. 27%, p = .389). Disease free survival showed no significant difference between two groups (53.1 ± 3.5 vs. 47.8 ± 2.8 months, p = .317). CONCLUSION: Primary fibula reconstruction should be considered whenever possible to reduce the risk of late complications and simplifies the management after a potential plate exposure. Notably, radiation therapy apparently has no significant effect on plate exposure rate both in ALT or fibula groups.

Exosomes Secreted by Adipose-Derived Stem Cells Following FK506 Stimulation Reduce Autophagy of Macrophages in Spine after Nerve Crush Injury.

Macrophages emerge in the milieu around innervated neurons after nerve injuries. Following nerve injury, autophagy is induced in macrophages and affects the regulation of inflammatory responses. It is closely linked to neuroinflammation, while the immunosuppressive drug tacrolimus (FK506) enhances nerve regeneration following nerve crush injury and nerve allotransplantation with additional neuroprotective and neurotrophic functions. The combined use of FK506 and adipose-derived stem cells (ADSCs) was employed in cell therapy for organ transplantation and vascularized composite allotransplantation. This study aimed to investigate the topical application of exosomes secreted by ADSCs following FK506 treatment (ADSC-F-exo) to the injured nerve in a mouse model of sciatic nerve crush injury. Furthermore, isobaric tags for relative and absolute quantitation (iTRAQ) were used to profile the potential exosomal proteins involved in autophagy. Immunohistochemical analysis revealed that nerve crush injuries significantly induced autophagy in the dorsal root ganglia and dorsal horn of the spinal segments. Locally applied ADSC-F-exo significantly reduced autophagy of macrophages in the spinal segments after nerve crush injury. Proteomic analysis showed that of the 22 abundant exosomal proteins detected in ADSC-F-exo, heat shock protein family A member 8 (HSPA8) and eukaryotic translation elongation factor 1 alpha 1 (EEF1A1) are involved in exosome-mediated autophagy reduction.

Enhanced Nerve Regeneration by Exosomes Secreted by Adipose-Derived Stem Cells with or without FK506 Stimulation.

Exosomes secreted by adipose-derived stem cells (ADSC-exo) reportedly improve nerve regeneration after peripheral nerve injury. Herein, we investigated whether pretreatment of ADSCs with FK506, an immunosuppressive drug that enhances nerve regeneration, could secret exosomes (ADSC-F-exo) that further augment nerve regeneration. Designed exosomes were topically applied to injured nerve in a mouse model of sciatic nerve crush injury to assess the nerve regeneration efficacy. Outcomes were determined by histomorphometric analysis of semi-thin nerve sections stained with toluidine blue, mouse neurogenesis PCR array, and neurotrophin expression in distal nerve segments. Isobaric tags for relative and absolute quantitation (iTRAQ) were used to profile potential exosomal proteins facilitating nerve regeneration. We observed that locally applied ADSC-exo and ADSC-F-exo significantly enhanced nerve regeneration after nerve crush injury. Pretreatment of ADSCs with FK506 failed to produce exosomes possessing more potent molecules for enhanced nerve regeneration. Proteomic analysis revealed that of 192 exosomal proteins detected in both ADSC-exo and ADSC-F-exo, histone deacetylases (HDACs), amyloid-beta A4 protein (APP), and integrin beta-1 (ITGB1) might be involved in enhancing nerve regeneration.

Increased Angiogenesis by Exosomes Secreted by Adipose-Derived Stem Cells upon Lipopolysaccharide Stimulation.

Exosomes secreted by adipose-derived stem cells (ADSCs) enhance angiogenesis and wound healing. However, in clinical settings, wounds may be infected by various bacteria or pathogens. We investigated whether human ADSCs stimulated with lipopolysaccharide (LPS) secrete exosomes (ADSC-LPS-exo) that augment the angiogenesis of human umbilical vein endothelial cells (HUVECs). ExoQuick-TC exosome precipitation solution was used to purify exosomes from human ADSC culture media in the presence or absence of 1 µg/mL LPS treatment for 24 h. The uptake of ADSC-LPS-exo significantly induced the activation of cAMP response element binding protein (CREB), activating protein 1 (AP-1), and nuclear factor-κB (NF-κB) signaling pathways and increased the migration of and tube formation in HUVECs. RNA interference with CREB, AP-1, or NF-κB1 significantly reduced the migration of and tube formation in HUVECs treated with ADSC-LPS-exo. An experiment with an antibody array for 25 angiogenesis-related proteins revealed that only interleukin-8 expression was significantly upregulated in HUVECs treated with ADSC-LPS-exo. In addition, proteomic analysis revealed that eukaryotic translation initiation factor 4E, amyloid beta A4 protein, integrin beta-1, and ras-related C3 botulinum toxin substrate 1 may be potential candidates involved in ADSC-LPS-exo-mediated enhanced angiogenesis.

Risk factors associated with postoperative complications of free anterolateral thigh flap placement in patients with head and neck cancer: Analysis of propensity score-matched cohorts.

BACKGROUND: From the perspective of a surgeon, knowledge of the operative risk factors that may affect postoperative outcomes is important in free anterolateral thigh (ALT) flap reconstruction for head and neck defects after tumor ablation. Therefore, this study was designed to examine the surgical intervention factors related to postoperative complications in a propensity score matched patient population. PATIENTS AND METHODS: A total of 1,284 head and neck cancer patients who received free ALT flap repair over a 9-year period from March 1, 2008, to February 28, 2017, at a single medical center were selected and divided into two groups (without complications, n = 845 and with complications, n = 439) according to the presence or absence of complications at the recipient site. Complications were defined as the detection of hematoma, surgical site infection, partial flap loss, oral fistula formation, flap partial necrosis, and flap loss. Well-balanced propensity score-matched cohorts with 292 patients each were created using the 1:1 Greedy algorithm, with adjustment for significant baseline patient characteristics. RESULTS: The patients with postoperative complications had a higher proportion of individuals with betel nut chewing (91.8% vs. 86.6%, p = .008), diabetes mellitus (23.0% vs. 17.8%, p = .029), and preoperative chemotherapy (31.7% vs. 25.3%, p = .019), and higher serum creatinine levels (median [Q1-Q3]: 0.92 [0.80-1.07] vs. 0.89 [0.77-1.06], p = .008) and lower serum albumin levels (4.2 [3.9-4.5] vs. 4.3 [4.1-4.5], p < .001) than those without postoperative complications. Individual operator (p < .001), the length of flap (20 [15-23] cm vs. 20 [15-25] cm, p < .001), operative time (6.9 hr [5.7-8.3 hr] vs. 7.3 hr [5.9-8.7 hr], p = .001), operation start time (p = .003), and units of transfused packed red blood cells (0.0 [0.0-0.0] units vs. 0.0 [0.0-2.0] units, p < .001) were the factors significantly associated with the occurrence of postoperative complications. However, in the matched patient cohorts, individual operator (p = .003), flap length (18 [15-22] cm vs. 20 [15-25] cm, p < .001) and length-to-width ratio (2.6 [2.0-3.3] vs. 3.0 [2.5-3.6], p < .001), and operative time (6.9 hr [5.7-8.3 hr] vs. 7.2 hr [5.9-8.7 hr], p = .019) were associated with the occurrence of postoperative complications, but the operation start time (p = .285) and units of transfused packed red blood cells (p = .917) were not. CONCLUSIONS: This study demonstrated in matched patient cohorts that individual operator, flap size, and operative time were associated with postoperative complications of free ALT flap reconstruction in patients with head and neck cancer. To reduce the postoperative complication rate, this study implies the importance of length and length-to-width ratio in harvesting the flap, and meanwhile the surgeon experience in free-flap reconstruction.

Optimal Result of One-Stage Secondary Debulking Procedure After Flap Reconstruction of the Ankle.

Skin and soft tissue defect of the ankle usually mandates flap reconstruction; however, bulky flap and difficulty ambulance have been the major disadvantages after flap reconstruction of this area. We used the concept of full-thickness skin graft as a 1-stage method of secondary debulking procedure to achieve both aesthetic and functional results. METHODS: Since January of 2004 to June of 2016, 22 one-stage secondary debulking procedures were performed on 22 patients who had received reconstruction with flaps for ankle defects. Nineteen cases were free myocutaneous flaps, 2 cases were free fasciocutaneous flaps, and 1 case was a distally based sural artery flap. In the operative technique, the full-thickness skin was harvested from the flap and regrafted on the defatted fascia with tie-over dressing. The functional and cosmetic outcomes as well as complications were reviewed. RESULTS: The overall mean follow-up time was 12 months. After the debulking procedure, all of the grafted skins took well. The patients were able to wear their own shoes without difficulty and regained ease of ambulation. The reconstructed area was found to decrease to an average of 28.92% as compared with predebulking area. The reconstructed ankles achieve good symmetry with regard to the contralateral side (P < 0.05). All of the patients were satisfied with the results of the reconstructed ankles. CONCLUSIONS: The 1-stage secondary debulking procedure is a safe and reproducible technique that achieves good functional and aesthetic outcomes after flap reconstruction of the ankle.

Association between operation- and operator-related factors and surgical complications among patients undergoing free-flap reconstruction for head and neck cancers: A propensity score-matched study of 1,865 free-flap reconstructions.

OBJECTIVE: Efforts have been devoted to clarify the possible factors related to postoperative complications in free-flap reconstruction. While patient-related factors have been widely discussed, studies regarding the operation/operator-related factors are rather limited in the literature. This study was designed to investigate the relationship between operation/operator-related factors and the surgical complications in free-flap reconstruction following head and neck cancer resection. METHODS: Data of 1,841 patients with a total of 1,865 free-flap reconstructions (24 double free-flap reconstructions) between March 2008 and February 2017 were retrieved from the registered microsurgery database of the hospital. The association of operation/operator-related factors (including flap length and length-width ratio, flap types, use of vein graft, opposite side microanastomosis, number of microanastomoses, operators, operator experience, and operation time) with surgical complications was assessed by 1:1 propensity score-matched study groups. RESULTS: After propensity score matching of the patient-related factors, the rate of vein grafting was significantly higher (0.6% vs. 2.2%, p = .038) and the operation time was longer (7.0 [5.8-8.5] vs. 7.4 [6.1-8.8] hr, p = .006) in the complication group. In addition, flap length and length-width ratio, flap types, opposite side microanastomosis, number of microanastomoses, operators, and operator experience were not associated with surgical complications. CONCLUSIONS: In a hospital that consisted of surgeons with high-volume or very-high-volume experience, the operators or operation experience were not significantly associated with the surgical complications. Only a longer operation time was associated with surgical complications in the patients who underwent free-flap reconstruction for head and neck cancer.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

BACKGROUND: Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. METHODS: In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. RESULTS: All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. CONCLUSIONS: The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

The free inverted omega-shaped flap for circumferential hypopharyngeal reconstruction with simultaneous neck skin defect.

BACKGROUND: Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem. METHODS: From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy. RESULTS: The average flap size was 29 × 8 cm (range: 25-31 × 6-10 cm2 ). An average of 2.6 perforators was included in each flap (2-4 perforators/flap). All flaps survived. One venous thrombosis was noted and salvaged after thrombolectomy and vein graft. The mean follow-up period was 25 months. The fistula rate was 21.4% (three patients). One fistula never healed because of early recurrence; one fistula healed after surgical intervention; and one fistula need a loco-regional flap for secondary reconstruction. Three postoperative strictures were noted (21.4%). CONCLUSION: For the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:51-59, 2018.

The protective effect of helmet use in motorcycle and bicycle accidents: a propensity score-matched study based on a trauma registry system.

BACKGROUND: Transportation by motorcycle and bicycle has become popular in Taiwan, this study was designed to investigate the protective effect of helmet use during motorcycle and bicycle accidents by using a propensity score-matched study based on trauma registry system data. METHODS: Data of adult patients hospitalized for motorcycle or bicycle accidents between January 1, 2009 and December 31, 2015 were retrieved from the Trauma Registry System. These included 7735 motorcyclists with helmet use, 863 motorcyclists without helmet use, 76 bicyclists with helmet use, and 647 bicyclists without helmet use. The primary outcome measurement was in-hospital mortality. Secondary outcomes were the hospital length of stay (LOS), intensive care unit (ICU) admission rate, and ICU LOS. Normally distributed continuous data were analyzed by the unpaired Student t-test, and non-normally distributed data were compared using the Mann-Whitney U-test. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. Propensity score matching (1:1 ratio using optimal method with a 0.2 caliper width) was performed using NCSS software, adjusting for the following covariates: sex, age, and comorbidities. Further logistic regression was used to evaluate the effect of helmet use on mortality rates of motorcyclists and bicyclists, respectively. RESULTS: The mortality rate for motorcyclists with helmet use (1.1%) was significantly lower than for motorcyclists without helmet use (4.2%; odds ratio [OR] 0.2; 95% confidence interval [CI]: 0.17-0.37; p < 0.001). Among bicyclists, there was no significant difference in mortality rates between the patients with helmet use (5.3%) and those without helmet use (3.7%; OR 1.4; 95% CI: 0.49-4.27; p = 0.524). After propensity-score matching for covariates, including sex, age, and comorbidities, 856 well-balanced pairs of motorcyclists and 76 pairs of bicyclists were identified for outcome comparison, showing that helmet use among motorcyclists was associated with lower mortality rates (OR 0.2; 95% CI: 0.09-0.44; p < 0.001). In contrast, helmet use among bicyclists was not associated with a decrease in mortality (OR 1.3; 95% CI: 0.30-5.96; p = 0.706). The hospital LOS was also significantly shorter for motorcyclists with helmet use than for those without (9.5 days vs. 12.0 days, respectively, p < 0.001) although for bicyclists, helmet use was not associated with hospital LOS. Fewer motorcyclists with helmet use were admitted to the ICU, regardless of the severity of injury; however, no significant difference of ICU admission rates was found between bicyclists with and without helmets. CONCLUSIONS: Motorcycle helmets provide protection to adult motorcyclists involved in traffic accidents and their use is associated with a decrease in mortality rates and the risk of head injuries. However, no such protective effect of helmet use was observed for bicyclists involved in collisions.

Traumatic injuries among adult obese patients in southern Taiwan: a cross-sectional study based on a trauma registry system.

BACKGROUND: The adverse impact of obesity has been extensively studied in the general population; however, the added risk of obesity on trauma-related mortality remains controversial. This study investigated and compared mortality as well injury patterns and length of stay (LOS) in obese and normal-weight patients hospitalized for trauma in the hospital and intensive care unit (ICU) of a Level I trauma center in southern Taiwan. METHODS: Detailed data of 880 obese adult patients with body mass index (BMI) ≥ 30 kg/m(2) and 5391 normal-weight adult patients (25 > BMI ≥ 18.5 kg/m(2)) who had sustained a trauma injury between January 1, 2009 and December 31, 2013 were retrieved from the Trauma Registry System. Pearson's chi-squared, Fisher's exact, and independent Student's t-tests were used to compare differences between groups. Propensity score matching with logistic regression was used to evaluate the effect of obesity on mortality. RESULTS: In this study, obese patients were more often men, motorcycle riders and pedestrians, and had a lower proportion of alcohol intoxication compared to normal-weight patients. Analysis of Abbreviated Injury Scale scores revealed that obese trauma patients presented with a higher rate of injury to the thorax, but a lower rate of facial injuries than normal-weight patients. No significant differences were found between obese and normal-weight patients regarding Injury Severity Score (ISS), Trauma-Injury Severity Score (TRISS), mortality, the proportion of patients admitted to the ICU, or LOS in ICU. After propensity score matching, logistic regression of 66 well-matched pairs did not show a significant influence of obesity on mortality (odds ratio: 1.51, 95% confidence interval: 0.54-4.23 p = 0.438). However, significantly longer hospital LOS (10.6 vs. 9.5 days, respectively, p = 0.044) was observed in obese patients than in normal-weight patients, particularly obese patients with pelvic, tibial, or fibular fractures. CONCLUSION: Compared to normal-weight patients, obese patients presented with different injury characteristics and bodily injury patterns but no difference in mortality.

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

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

The new innovation of the lower medial thigh perforator flap for head and neck reconstruction.

BACKGROUND: The choice of optimal flap is still a challenge for patients with resection of head and neck cancer and reconstruction, especially for recurrent cases. In this article, we report the results of the new innovation of free lower medial thigh perforator (LMTP) flap for head and neck reconstruction in a series of patients. PATIENTS AND METHODS: Fifteen patients received reconstruction with free LMTP flaps. The defect locations included the buccal area (3 cases), tongue (6 cases), lower/upper gum (5 cases), and soft palate (1 case). The perforators of flap design were detected at the distal third of the line, which was drawn from the midpoint of inguinal ligament to medial upper border of patella. The superficial temporal artery (7 cases), superior thyroid artery (6 cases), and facial artery (2 cases) were dissected as recipient vessels. RESULTS: The flap sizes varied from 12 × 5 cm(2) to 20 × 8 cm(2) . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All of flaps were survived after surgery, except one failed due to venous thrombosis. Another one flap suffered from venous thrombosis and was successfully salvaged by performing a venous thrombectomy. All donor sites were primarily closed except one skin grafting. The follow-up time ranged from 3 to 15 months (average: 7 months) and all patients had good recovery with satisfactory results. CONCLUSION: The LMTP flap indicates a pliable with constant vascular anatomy and low donor-site morbidity. It could be an alternative for reconstructing defects in head and neck region. © 2015 Wiley Periodicals, Inc. Microsurgery 36:284-290, 2016.

The lower medial thigh perforator (LMTP) flap for lower extremity reconstruction: Preliminary results.

BACKGROUND: The lower medial thigh perforator (LMTP) flap is an alternative source for lower extremity reconstruction. In this article, we report the preliminary results of reconstruction of the lower extremity with a series of patients by the lower medial thigh perforator flap. PATIENTS AND METHODS: From January 2015 until August 2015, we performed six cases of lower extremity reconstruction with the LMTP flap. The defect locations included the distal leg (1 case) and the proximal leg (2 cases), the left foot (2 cases), and the right foot (1 case). The perforators of the flap design were detected at the distal third of the line, which was drawn from the midpoint of inguinal ligament to medial upper border of patella. The dorsalis pedis artery (2 cases), anterior tibia artery (2 cases), posterior tibial artery (2 cases) were dissected as recipient vessels. RESULTS: The average size of flap was 10.5 × 5 cm (range 10-15 cm and 4-6.5 cm), and the average pedicle length was 7.6 cm (range 5-9.5 cm). 83% of the perforators (5 of 6) were musculocutaneous type, and 17% (1 of 6) were septocutaneous type. The flap survival rate was 100%; the venous congestion was observed in one flap and was successfully salvaged by performing revised venous anastomosis. The donor sites were all closed primarily with minimal morbidity. Follow-up observations were conducted for 2-6 months, and all patients had good functional recovery with satisfactory cosmetic results. CONCLUSION: The lower medial thigh perforator flap has some advantage in lower extremity reconstruction, including adequate length and vessel diameter of pedicle for microvascular anastomosis to the lower extremities recipient vessels. The LMTP flap indicates a low donor-site morbidity and it could be a safe, reliable, and aesthetically appealing new option for lower extremity reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery 36:474-479, 2016.

An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction.

BACKGROUND: The three commonly used free flaps for circumferential pharyngeal reconstruction after total pharyngo-laryngectomy are the radial forearm flap (RFF), the anterolateral thigh (ALT) flap, and the jejunum flap. This study was to objectively compare three different flaps for pharyngeal reconstruction during the past 10 years. Stricture and fistula were assessed using esophagogram and esophagoscopy. METHODS: Forty-five patients with pharyngeal reconstructions had esophagram and esophagoscopy done postoperatively to assess for strictures and fistulas. These patients were divided into three groups based on pharyngeal reconstruction by ALT, RFF, and jejunal flaps. From the results of the esophagogram and esophagoscope, the presence of a fistula or stricture was compared and analyzed. RESULTS: There was only one ALT flap failure. The rate of fistula was 33%, 50%, and 30% in the ALT, RFF, and jejunal flap group respectively. The fistula rate revealed no significant difference between ALT, RFF, jejunal flap groups (P = 0.63). The rate of stricture was 38.1%, 57.1%, and 0% in the ALT, RFA, jejunal flap groups respectively. The stricture rate in jejunal flap group revealed significant decrease (P = 0.0093). CONCLUSION: Jejunal flap has a significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps.

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps.

BACKGROUND: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. METHODS: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. RESULTS: The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. CONCLUSIONS: In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further investigations should be conducted.