Fu-chan Wei - Academia.edu (original) (raw)

Papers by Fu-chan Wei

Plastic and Reconstructive Surgery, May 1, 2006

Background: Simultaneous reconstruction of two separate defects by two free flaps is time consumi... more Background: Simultaneous reconstruction of two separate defects by two free flaps is time consuming and often requires two donor sites. The anterior and lateral aspect of the thigh is an ideal donor site for free tissue harvest without incurring significant morbidity. In this article, the authors describe their recently developed technique that allows for harvesting two independent fasciocutaneous free flaps from the same descending branch of lateral circumflex femoral vessel as a new clinical application of the versatile anterolateral thigh flap. Methods: A total of eight flaps were developed from left thighs of four patients. There were two male and two female patients, with a mean age of 42.0 years. The defects were either on the lower extremity (n ϭ 2) or in the oral cavity (n ϭ 2). Each anterolateral aspect of the thigh was used to develop two perforator flaps, based on one perforator each. The anterolateral thigh flap was elevated in the standard manner based on at least two cutaneous vessels of the descending branch of the lateral circumflex femoral artery. The skin flaps were tailored to the recipient site requirement and the main descending branches of the lateral femoral circumflex vessels were divided in between to be used as the pedicle of both flaps. The mean flap dimensions ranged from 2.5 ϫ 4 cm to 8 ϫ 12 cm (mean, 5 ϫ 8 cm). The mean operation time was 11 hours 30 minutes. The mean length of the pedicle was 9 cm (ranged, 8 to 11 cm). The mean external diameter of the descending branch in the mid thigh and where it joined to the lateral circumflex femoral artery was 1.75 mm and 3 mm, respectively. Three donor sites were closed directly and one was grafted. Results: All flaps survived completely. No complications were encountered. Donor-site morbidity was negligible. Hospitalization averaged 9.9 Ϯ 1.7 days. Conclusion: Two fasciocutaneous flaps based on independent skin vessels can be reliably harvested from the same descending branch of the lateral femoral circumflex artery for simultaneous reconstruction of two separate defects.

Free tissue transfer is the epitome of reconstruction that has revolutionized our reconstructive ... more Free tissue transfer is the epitome of reconstruction that has revolutionized our reconstructive approach all over the human body. Nevertheless, certain defects arising from animal bites, ballistic tr

Clinics in plastic surgery, 2016

Fistulas, either between oral cavity and external face or between oral and nasal cavity, are majo... more Fistulas, either between oral cavity and external face or between oral and nasal cavity, are major complications after microsurgical head and neck reconstruction. Any flaw in surgical planning, design, and execution may lead to this untoward outcome. Once fistula develops, it may interface with oncologic treatment, endanger the reconstruction, and increase overall patient suffering. This article analyzes individual factors involved in development of fistulas in spite of successful transfer of a free flap and proposes treatment guideline.

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010

Oral submucous fibrosis causes health-related and social problems for affected patients. Free fla... more Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Plastic and Reconstructive Surgery, 2007

Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 t... more Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome. Methods: Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compromise was identified and correlated with salvage outcome. Results: Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed completely. Ninety-three flaps (82.3 percent) presented with circulatory compromise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the microsurgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p ϭ 0.01). Conclusions: The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special microsurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes. (Plast.

Plastic and Reconstructive Surgery, 2002

World Journal of Surgery, 2001

Small bone defects of the mandible and maxilla can be surgically treated with conventional bone g... more Small bone defects of the mandible and maxilla can be surgically treated with conventional bone grafts provided local conditions are optimal for bone healing. However, when the bone defect is large, is associated with soft tissue loss, or when conventional bone grafting fails, a free vascularized bone graft often becomes an important alternative to ensure adequate healing. As free vascularized bone grafting is today considered a more reliable procedure for bone reconstruction, with success rates over 96%, we prefer to treat even smaller segmental bone defects with this technique when local conditions are less than ideal. The technique also allows for simultaneous insertion of osteointegrated dental implants at the time of vascularized bone grafting, thereby facilitating earlier total oral rehabilitation.

Injury, 2015

Background Degloving injuries of the hand are rare but alarming (Supplemental Digital Content: Vi... more Background Degloving injuries of the hand are rare but alarming (Supplemental Digital Content: Video 1). As the soft tissue envelope supplies blood to the distal hand, ischemia and necrosis of the denuded parts may be imminent without expedient vascularised tissue transfer. In the spirit of replacing like with like, replantation is ideal but often impossible [1-4]. Even when amputated and degloved parts are available, neurovascular trauma at multiple levels and an extensive zone of injury deem flap survival and functional restoration unlikely. If degloving is accompanied by amputation (Fig. 1), dependable tissue coverage provides a platform for digital reconstruction and toe-to-hand transfer (Fig. 2A-D) [5-7]. The perfect reconstructive strategy would restore intricate hand functions and a specialised anatomy; the current methods, including replantation, fall short in both categories. Distant pedicled options from the groin and abdomen have been favoured since the 1970s. These methods do not require a microsurgical technique and they permit a two-team approach. Groin flaps are reliable, provide ample

Eplasty, Jan 16, 2010

Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgica... more Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgical planning. Effective transplantation involves 3 main considerations: residual hand function, functional needs and desires of the patient, and optimal surgical management to maximize outcome and minimize patient morbidity. The following is a clinical example of the metacarpal hand in which the patient underwent initial reconstruction at an outside hospital and was referred to our institution. This demonstrates how the initial planning and surgical management could have been further optimized to minimize functional deficits and donor-site morbidities as well as reduce the number of subsequent revisional surgeries and rehabilitation time. Several important points in metacarpal hand reconstruction are described given specific level of amputation and residual function after the injury-the timing and sequence of operative strategy depending on the type of injury, the selection of donor-site d...

Plastic and reconstructive surgery, 2009

The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospecti... more The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospective intraoperative analysis of the vascular anatomy of the lateral thigh that focuses on clinically important variations that impact flap harvest. Eighty-nine consecutive anterolateral thigh flaps were harvested. A detailed intraoperative analysis was performed of the vasculature anatomy and variations of the pedicle encountered during dissection. Fasciocutaneous flaps were harvested in 82 percent (73 of 89) and myocutaneous flaps were harvested in 17 percent of cases (15 of 89). Sizable perforators were absent in 1 percent of the cases (one of 89). A mean of 1.9 sizable cutaneous vessels were identified. Musculocutaneous perforators were noted in 85 percent of cases and septocutaneous vessels were seen in 15 percent. Most septocutaneous vessels were located in the proximal thigh. In the midpoint of the thigh, musculocutaneous perforators predominate. Those located within 1 cm of the sept...

Clinics in plastic surgery, 2005

The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functi... more The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functional and esthetic results with minimal donor site morbidity. Although many flaps have been developed for bone and soft tissue reconstructions, our experience in the past years has identified the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap as the most useful flaps for head and neck reconstruction. These three flaps can be used for reconstruction of almost all kinds of defects, either as a single flap or in combination. The harvest of these flaps is relatively simple and straightforward. All flaps have adequate pedicle vessel length and caliber. Donor site morbidity is negligible. As most reconstructive microsurgeons do not have enough patient volume to master many different kinds of flaps in their professional life, we recommend focusing on these three flaps as workhorse flaps instead of hunting for many other flap...

Plastic and Reconstructive Surgery, 2007

Background: The skin paddle of the fibula osteoseptocutaneous flap is reliably vascularized by se... more Background: The skin paddle of the fibula osteoseptocutaneous flap is reliably vascularized by septocutaneous perforators from the peroneal artery. However, in 5 to 10 percent of lower limbs, these perforators are absent. This anatomical study evaluated use of the soleus musculocutaneous perforator for skin paddle salvage in such situations. Methods: Latex injection studies were performed on 20 cadaveric lower limbs. The presence, prevalence, and location of the musculocutaneous perforators in the distal leg were documented. The perforators were traced proximally to determine their origins. Results: Of the 20 cadaveric limbs, one or more musculocutaneous perforators of at least 0.5 mm in diameter were noted in 18 specimens (90 percent). They were located within 6 cm of the junction of the middle and lower thirds of the fibula. The soleus musculocutaneous perforators originated in the peroneal artery in 10 specimens (50 percent), the posterior tibial artery in seven (35 percent), and the tibioperoneal trunk in one (5 percent). This information was successfully used to salvage the skin paddle in two of our clinical cases. Conclusions: Use of the soleus musculocutaneous perforator depends on its origin. When it arises from the peroneal artery, a single set of anastomoses is all that is necessary for flap revascularization, with the skin paddle serving as a monitor for the bone flap. When it originates from the posterior tibial artery or tibioperoneal trunk, a second set of anastomoses is needed and the skin paddle cannot monitor the bone flap. The authors propose that one or two soleus musculocutaneous perforators be preserved during harvest until existence of the septocutaneous perforator is confirmed.

Seminars in Plastic Surgery, 2010

Advances in head and neck reconstruction have resulted in improved outcomes with single-stage rep... more Advances in head and neck reconstruction have resulted in improved outcomes with single-stage repair of defects ranging from intraoral to pharyngoesophageal to skull base defects. Key to success of surgery is choosing an appropriate reconstructive option based on the patient's wishes and fitness for major surgery. Where possible, free tissue transfer provides the best functional and aesthetic outcomes for the vast majority of defects. In this article, we present an algorithm to guide choice of flap selection and review principles of reconstruction and secondary surgery for head and neck defects.

Microsurgery, 2015

The distally-based anterolateral thigh flap is an attractive option for proximal leg and knee cov... more The distally-based anterolateral thigh flap is an attractive option for proximal leg and knee coverage but venous congestion is common. Restoration of antegrade venous drainage via great saphenous vein supercharge to the proximal flap vein is proposed. The purpose of this study was to evaluate and compare outcomes of 18 large, distally-based anterolateral thigh flaps with and without venous augmentation on the basis of flap size, venous congestion, and clinical course. The average age of 12 men and 6 women was 35.9-year old (range, 16-50 years old). Wounds resulting from trauma, burn sequela, sarcoma, and infection were localized to the knee, proximal leg, knee stump and popliteal fossa. The mean defect was 17.6 3 9.4 cm 2 (range, 6 3 7 cm 2 to 22 3 20 cm 2). The mean flap size was 21.4 3 8.8 cm 2 (range, 12 3 6 to 27 3 12 cm 2). There were 14 cases in the venous supercharged group and 4 cases in the group without supercharge. The mean size of flaps in the venous supercharged group was significantly larger than that in the group without supercharge (22.6 6 3.8 3 9.1 6 1.7 cm vs. 17.5 6 4.4 3 7.8 6 1.7 cm, P 5 0.03). Venous congestion occurred in all four flaps without supercharge that lasted 3-7 days and partial flap loss occurred in two cases. There was no early venous congestion and partial flap loss in supercharged flaps but venous congestion secondary to anastomotic occlusion developed in two cases. Early exploration with vein grafting resolved venous congestion in one case. Late exploration in the other resulted in flap loss. Preventive venous supercharge is suggested for the large, distally-based anterolateral thigh flap.

Current Opinion in Otolaryngology & Head and Neck Surgery, 2014

Purpose of review The benefit of using multiple simultaneous free flaps for postablative extensiv... more Purpose of review The benefit of using multiple simultaneous free flaps for postablative extensive composite head and neck reconstruction has gradually become increasingly accepted worldwide, with recent case series being reported from several continents. This review summarizes the cogent conclusions that can be drawn from this growing international experience. Recent findings Running themes include: firstly, that careful organization of the operation is critical to expediency to the extent that double and single free flap reconstructions are not greatly different in duration; secondly, that the functional results of double free flap reconstructions are generally better than single free flap reconstructions when the defect is appropriately extensive; and thirdly, that there remains a lack of consensus regarding which patients would and would not benefit from a double free flap approach from a survival perspective. Summary Local audit should guide local practice for when double free flap reconstructions are or are not appropriate, as survival data are greatly variable internationally because of the differences in treatment, margins status for resections and, amongst other factors, cause and aggression of tumors. This is especially the case for the most infiltrative malignancies that mandate extensive composite resections for which a double free flap procedure would likely provide the best long-term functional and aesthetic results.

Plastic and reconstructive surgery, Jan 2, 2015

A Technical Pearl to Ensure Reliable Harvest of the Anterolateral Thigh Myocutaneous Flap Sir: T ... more A Technical Pearl to Ensure Reliable Harvest of the Anterolateral Thigh Myocutaneous Flap Sir: T anterolateral thigh flap is qualified to be close to an ideal soft-tissue flap.1 The flap has the versatility of transferring different tissue components to fulfill the requirements of reconstruction. In particular, the muscle is invaluable for providing bulk, obliterating dead space, or neutralizing a hostile wound. Muscle viability is therefore of utmost importance.2 The myocutaneous anterolateral thigh flap is traditionally harvested en bloc without skin vessel dissection.3 This approach does not provide the opportunity to visualize the vascular connection between the muscle and skin to confirm the venous turbocharge procedure, however, is not always feasible because of the length of the superficial inferior epigastric vein, the size of the flap, the configuration and anatomy of the vascular pedicle, and occasional problems with the left internal mammary vein. Several alternative venous drainage routes to the basilic, lateral thoracic, pectoral branch of the thoracoacromial, external jugular, intercostal, thoracodorsal, second intercostal space internal mammary perforator, or retrograde limb of the internal mammary vein have been described. The issues of consistency of configuration, anatomy, diameter match, and extent of the dissection pose some limitations to each of these approaches. The cephalic vein has a long history of use in vascular surgery and microsurgery because of its consistent anatomy, superficial location, excellent size match to most free flaps, and minimal morbidity associated with harvest.5 The cephalic vein is strategically located in the area of the superficial inferior epigastric vein of the free transverse rectus abdominis musculocutaneous/ deep inferior epigastric artery perforator flap during breast reconstruction procedures; therefore, transposition of the cephalic vein is an effective drainage procedure for venous congestion of the superficial system. The cephalic vein is commonly harvested through a longitudinal incision of the upper arm. The patients undergoing bilateral microvascular breast reconstruction are frequently overweight or obese, which compromises the precision of surgical exposure. Importantly, these patients with large breast flaps (1) are prone to venous insufficiency, (2) have an anatomical barrier to a turbocharge procedure because of the flap size, and (3) frequently have a large dominant superficial venous system in the abdominal flap. Preoperative ultrasound vein mapping improves precision of vein conduit harvest and is routinely used in cardiac and vascular surgery where vein graft harvest is an expected component of the revascularization procedure. In breast and chest wall reconstruction, cephalic transposition is used occasionally as the second-line drainage procedure, whereas the reverse-flow venous turbocharge procedure to one of the deep inferior epigastric veins of the flap remains the operation of choice because no additional dissection is needed. In the author’s experience, five cephalic transpositions were needed in 141 consecutive breast reconstructions (3.6 percent) performed in the past 3 years, which makes routine preoperative cephalic vein mapping not cost effective. Portable high-frequency ultrasound units are widely available in the operating room for line placement and can be brought to the operating field sterilely for intraoperative cephalic vein mapping. On axial ultrasound cuts, the vein is seen as a superficially located, hypoechoic, round, compressible structure, and the flow can be ascertained within the color mode. The ultrasound localization greatly improves the precision of cephalic vein exploration and allows harvest of the cephalic vein of adequate length through one or two small transverse incisions by using a headlight and standard instrumentation. Although the second incision in the deltopectoral groove (Fig. 1, above) can be avoided by conducting dissection through a mastectomy pocket, multiple small venous branches coming off the proximal cephalic vein, and the presence of small arteries in this area, make this dissection challenging; therefore, the second incision in this location is prudent to enhance the safety of this highly effective procedure (Fig. 1, below).

Journal of hand and microsurgery, 2010

Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. ... more Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. It can be used to correct almost any thumb defect. However, for optimal functional and esthetic results, proper initial care, preoperative planning, proper selection of suitable techniques, adjunct or secondary procedures and proper, postoperative rehabilitation are important.

The American Journal of Surgery, 2008

Plastic and Reconstructive Surgery, May 1, 2006

Background: Simultaneous reconstruction of two separate defects by two free flaps is time consumi... more Background: Simultaneous reconstruction of two separate defects by two free flaps is time consuming and often requires two donor sites. The anterior and lateral aspect of the thigh is an ideal donor site for free tissue harvest without incurring significant morbidity. In this article, the authors describe their recently developed technique that allows for harvesting two independent fasciocutaneous free flaps from the same descending branch of lateral circumflex femoral vessel as a new clinical application of the versatile anterolateral thigh flap. Methods: A total of eight flaps were developed from left thighs of four patients. There were two male and two female patients, with a mean age of 42.0 years. The defects were either on the lower extremity (n ϭ 2) or in the oral cavity (n ϭ 2). Each anterolateral aspect of the thigh was used to develop two perforator flaps, based on one perforator each. The anterolateral thigh flap was elevated in the standard manner based on at least two cutaneous vessels of the descending branch of the lateral circumflex femoral artery. The skin flaps were tailored to the recipient site requirement and the main descending branches of the lateral femoral circumflex vessels were divided in between to be used as the pedicle of both flaps. The mean flap dimensions ranged from 2.5 ϫ 4 cm to 8 ϫ 12 cm (mean, 5 ϫ 8 cm). The mean operation time was 11 hours 30 minutes. The mean length of the pedicle was 9 cm (ranged, 8 to 11 cm). The mean external diameter of the descending branch in the mid thigh and where it joined to the lateral circumflex femoral artery was 1.75 mm and 3 mm, respectively. Three donor sites were closed directly and one was grafted. Results: All flaps survived completely. No complications were encountered. Donor-site morbidity was negligible. Hospitalization averaged 9.9 Ϯ 1.7 days. Conclusion: Two fasciocutaneous flaps based on independent skin vessels can be reliably harvested from the same descending branch of the lateral femoral circumflex artery for simultaneous reconstruction of two separate defects.

Free tissue transfer is the epitome of reconstruction that has revolutionized our reconstructive ... more Free tissue transfer is the epitome of reconstruction that has revolutionized our reconstructive approach all over the human body. Nevertheless, certain defects arising from animal bites, ballistic tr

Clinics in plastic surgery, 2016

Fistulas, either between oral cavity and external face or between oral and nasal cavity, are majo... more Fistulas, either between oral cavity and external face or between oral and nasal cavity, are major complications after microsurgical head and neck reconstruction. Any flaw in surgical planning, design, and execution may lead to this untoward outcome. Once fistula develops, it may interface with oncologic treatment, endanger the reconstruction, and increase overall patient suffering. This article analyzes individual factors involved in development of fistulas in spite of successful transfer of a free flap and proposes treatment guideline.

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010

Oral submucous fibrosis causes health-related and social problems for affected patients. Free fla... more Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Plastic and Reconstructive Surgery, 2007

Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 t... more Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome. Methods: Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compromise was identified and correlated with salvage outcome. Results: Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed completely. Ninety-three flaps (82.3 percent) presented with circulatory compromise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the microsurgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p ϭ 0.01). Conclusions: The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special microsurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes. (Plast.

Plastic and Reconstructive Surgery, 2002

World Journal of Surgery, 2001

Small bone defects of the mandible and maxilla can be surgically treated with conventional bone g... more Small bone defects of the mandible and maxilla can be surgically treated with conventional bone grafts provided local conditions are optimal for bone healing. However, when the bone defect is large, is associated with soft tissue loss, or when conventional bone grafting fails, a free vascularized bone graft often becomes an important alternative to ensure adequate healing. As free vascularized bone grafting is today considered a more reliable procedure for bone reconstruction, with success rates over 96%, we prefer to treat even smaller segmental bone defects with this technique when local conditions are less than ideal. The technique also allows for simultaneous insertion of osteointegrated dental implants at the time of vascularized bone grafting, thereby facilitating earlier total oral rehabilitation.

Injury, 2015

Background Degloving injuries of the hand are rare but alarming (Supplemental Digital Content: Vi... more Background Degloving injuries of the hand are rare but alarming (Supplemental Digital Content: Video 1). As the soft tissue envelope supplies blood to the distal hand, ischemia and necrosis of the denuded parts may be imminent without expedient vascularised tissue transfer. In the spirit of replacing like with like, replantation is ideal but often impossible [1-4]. Even when amputated and degloved parts are available, neurovascular trauma at multiple levels and an extensive zone of injury deem flap survival and functional restoration unlikely. If degloving is accompanied by amputation (Fig. 1), dependable tissue coverage provides a platform for digital reconstruction and toe-to-hand transfer (Fig. 2A-D) [5-7]. The perfect reconstructive strategy would restore intricate hand functions and a specialised anatomy; the current methods, including replantation, fall short in both categories. Distant pedicled options from the groin and abdomen have been favoured since the 1970s. These methods do not require a microsurgical technique and they permit a two-team approach. Groin flaps are reliable, provide ample

Eplasty, Jan 16, 2010

Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgica... more Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgical planning. Effective transplantation involves 3 main considerations: residual hand function, functional needs and desires of the patient, and optimal surgical management to maximize outcome and minimize patient morbidity. The following is a clinical example of the metacarpal hand in which the patient underwent initial reconstruction at an outside hospital and was referred to our institution. This demonstrates how the initial planning and surgical management could have been further optimized to minimize functional deficits and donor-site morbidities as well as reduce the number of subsequent revisional surgeries and rehabilitation time. Several important points in metacarpal hand reconstruction are described given specific level of amputation and residual function after the injury-the timing and sequence of operative strategy depending on the type of injury, the selection of donor-site d...

Plastic and reconstructive surgery, 2009

The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospecti... more The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospective intraoperative analysis of the vascular anatomy of the lateral thigh that focuses on clinically important variations that impact flap harvest. Eighty-nine consecutive anterolateral thigh flaps were harvested. A detailed intraoperative analysis was performed of the vasculature anatomy and variations of the pedicle encountered during dissection. Fasciocutaneous flaps were harvested in 82 percent (73 of 89) and myocutaneous flaps were harvested in 17 percent of cases (15 of 89). Sizable perforators were absent in 1 percent of the cases (one of 89). A mean of 1.9 sizable cutaneous vessels were identified. Musculocutaneous perforators were noted in 85 percent of cases and septocutaneous vessels were seen in 15 percent. Most septocutaneous vessels were located in the proximal thigh. In the midpoint of the thigh, musculocutaneous perforators predominate. Those located within 1 cm of the sept...

Clinics in plastic surgery, 2005

The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functi... more The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functional and esthetic results with minimal donor site morbidity. Although many flaps have been developed for bone and soft tissue reconstructions, our experience in the past years has identified the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap as the most useful flaps for head and neck reconstruction. These three flaps can be used for reconstruction of almost all kinds of defects, either as a single flap or in combination. The harvest of these flaps is relatively simple and straightforward. All flaps have adequate pedicle vessel length and caliber. Donor site morbidity is negligible. As most reconstructive microsurgeons do not have enough patient volume to master many different kinds of flaps in their professional life, we recommend focusing on these three flaps as workhorse flaps instead of hunting for many other flap...

Plastic and Reconstructive Surgery, 2007

Background: The skin paddle of the fibula osteoseptocutaneous flap is reliably vascularized by se... more Background: The skin paddle of the fibula osteoseptocutaneous flap is reliably vascularized by septocutaneous perforators from the peroneal artery. However, in 5 to 10 percent of lower limbs, these perforators are absent. This anatomical study evaluated use of the soleus musculocutaneous perforator for skin paddle salvage in such situations. Methods: Latex injection studies were performed on 20 cadaveric lower limbs. The presence, prevalence, and location of the musculocutaneous perforators in the distal leg were documented. The perforators were traced proximally to determine their origins. Results: Of the 20 cadaveric limbs, one or more musculocutaneous perforators of at least 0.5 mm in diameter were noted in 18 specimens (90 percent). They were located within 6 cm of the junction of the middle and lower thirds of the fibula. The soleus musculocutaneous perforators originated in the peroneal artery in 10 specimens (50 percent), the posterior tibial artery in seven (35 percent), and the tibioperoneal trunk in one (5 percent). This information was successfully used to salvage the skin paddle in two of our clinical cases. Conclusions: Use of the soleus musculocutaneous perforator depends on its origin. When it arises from the peroneal artery, a single set of anastomoses is all that is necessary for flap revascularization, with the skin paddle serving as a monitor for the bone flap. When it originates from the posterior tibial artery or tibioperoneal trunk, a second set of anastomoses is needed and the skin paddle cannot monitor the bone flap. The authors propose that one or two soleus musculocutaneous perforators be preserved during harvest until existence of the septocutaneous perforator is confirmed.

Seminars in Plastic Surgery, 2010

Advances in head and neck reconstruction have resulted in improved outcomes with single-stage rep... more Advances in head and neck reconstruction have resulted in improved outcomes with single-stage repair of defects ranging from intraoral to pharyngoesophageal to skull base defects. Key to success of surgery is choosing an appropriate reconstructive option based on the patient's wishes and fitness for major surgery. Where possible, free tissue transfer provides the best functional and aesthetic outcomes for the vast majority of defects. In this article, we present an algorithm to guide choice of flap selection and review principles of reconstruction and secondary surgery for head and neck defects.

Microsurgery, 2015

The distally-based anterolateral thigh flap is an attractive option for proximal leg and knee cov... more The distally-based anterolateral thigh flap is an attractive option for proximal leg and knee coverage but venous congestion is common. Restoration of antegrade venous drainage via great saphenous vein supercharge to the proximal flap vein is proposed. The purpose of this study was to evaluate and compare outcomes of 18 large, distally-based anterolateral thigh flaps with and without venous augmentation on the basis of flap size, venous congestion, and clinical course. The average age of 12 men and 6 women was 35.9-year old (range, 16-50 years old). Wounds resulting from trauma, burn sequela, sarcoma, and infection were localized to the knee, proximal leg, knee stump and popliteal fossa. The mean defect was 17.6 3 9.4 cm 2 (range, 6 3 7 cm 2 to 22 3 20 cm 2). The mean flap size was 21.4 3 8.8 cm 2 (range, 12 3 6 to 27 3 12 cm 2). There were 14 cases in the venous supercharged group and 4 cases in the group without supercharge. The mean size of flaps in the venous supercharged group was significantly larger than that in the group without supercharge (22.6 6 3.8 3 9.1 6 1.7 cm vs. 17.5 6 4.4 3 7.8 6 1.7 cm, P 5 0.03). Venous congestion occurred in all four flaps without supercharge that lasted 3-7 days and partial flap loss occurred in two cases. There was no early venous congestion and partial flap loss in supercharged flaps but venous congestion secondary to anastomotic occlusion developed in two cases. Early exploration with vein grafting resolved venous congestion in one case. Late exploration in the other resulted in flap loss. Preventive venous supercharge is suggested for the large, distally-based anterolateral thigh flap.

Current Opinion in Otolaryngology & Head and Neck Surgery, 2014

Purpose of review The benefit of using multiple simultaneous free flaps for postablative extensiv... more Purpose of review The benefit of using multiple simultaneous free flaps for postablative extensive composite head and neck reconstruction has gradually become increasingly accepted worldwide, with recent case series being reported from several continents. This review summarizes the cogent conclusions that can be drawn from this growing international experience. Recent findings Running themes include: firstly, that careful organization of the operation is critical to expediency to the extent that double and single free flap reconstructions are not greatly different in duration; secondly, that the functional results of double free flap reconstructions are generally better than single free flap reconstructions when the defect is appropriately extensive; and thirdly, that there remains a lack of consensus regarding which patients would and would not benefit from a double free flap approach from a survival perspective. Summary Local audit should guide local practice for when double free flap reconstructions are or are not appropriate, as survival data are greatly variable internationally because of the differences in treatment, margins status for resections and, amongst other factors, cause and aggression of tumors. This is especially the case for the most infiltrative malignancies that mandate extensive composite resections for which a double free flap procedure would likely provide the best long-term functional and aesthetic results.

Plastic and reconstructive surgery, Jan 2, 2015

A Technical Pearl to Ensure Reliable Harvest of the Anterolateral Thigh Myocutaneous Flap Sir: T ... more A Technical Pearl to Ensure Reliable Harvest of the Anterolateral Thigh Myocutaneous Flap Sir: T anterolateral thigh flap is qualified to be close to an ideal soft-tissue flap.1 The flap has the versatility of transferring different tissue components to fulfill the requirements of reconstruction. In particular, the muscle is invaluable for providing bulk, obliterating dead space, or neutralizing a hostile wound. Muscle viability is therefore of utmost importance.2 The myocutaneous anterolateral thigh flap is traditionally harvested en bloc without skin vessel dissection.3 This approach does not provide the opportunity to visualize the vascular connection between the muscle and skin to confirm the venous turbocharge procedure, however, is not always feasible because of the length of the superficial inferior epigastric vein, the size of the flap, the configuration and anatomy of the vascular pedicle, and occasional problems with the left internal mammary vein. Several alternative venous drainage routes to the basilic, lateral thoracic, pectoral branch of the thoracoacromial, external jugular, intercostal, thoracodorsal, second intercostal space internal mammary perforator, or retrograde limb of the internal mammary vein have been described. The issues of consistency of configuration, anatomy, diameter match, and extent of the dissection pose some limitations to each of these approaches. The cephalic vein has a long history of use in vascular surgery and microsurgery because of its consistent anatomy, superficial location, excellent size match to most free flaps, and minimal morbidity associated with harvest.5 The cephalic vein is strategically located in the area of the superficial inferior epigastric vein of the free transverse rectus abdominis musculocutaneous/ deep inferior epigastric artery perforator flap during breast reconstruction procedures; therefore, transposition of the cephalic vein is an effective drainage procedure for venous congestion of the superficial system. The cephalic vein is commonly harvested through a longitudinal incision of the upper arm. The patients undergoing bilateral microvascular breast reconstruction are frequently overweight or obese, which compromises the precision of surgical exposure. Importantly, these patients with large breast flaps (1) are prone to venous insufficiency, (2) have an anatomical barrier to a turbocharge procedure because of the flap size, and (3) frequently have a large dominant superficial venous system in the abdominal flap. Preoperative ultrasound vein mapping improves precision of vein conduit harvest and is routinely used in cardiac and vascular surgery where vein graft harvest is an expected component of the revascularization procedure. In breast and chest wall reconstruction, cephalic transposition is used occasionally as the second-line drainage procedure, whereas the reverse-flow venous turbocharge procedure to one of the deep inferior epigastric veins of the flap remains the operation of choice because no additional dissection is needed. In the author’s experience, five cephalic transpositions were needed in 141 consecutive breast reconstructions (3.6 percent) performed in the past 3 years, which makes routine preoperative cephalic vein mapping not cost effective. Portable high-frequency ultrasound units are widely available in the operating room for line placement and can be brought to the operating field sterilely for intraoperative cephalic vein mapping. On axial ultrasound cuts, the vein is seen as a superficially located, hypoechoic, round, compressible structure, and the flow can be ascertained within the color mode. The ultrasound localization greatly improves the precision of cephalic vein exploration and allows harvest of the cephalic vein of adequate length through one or two small transverse incisions by using a headlight and standard instrumentation. Although the second incision in the deltopectoral groove (Fig. 1, above) can be avoided by conducting dissection through a mastectomy pocket, multiple small venous branches coming off the proximal cephalic vein, and the presence of small arteries in this area, make this dissection challenging; therefore, the second incision in this location is prudent to enhance the safety of this highly effective procedure (Fig. 1, below).

Journal of hand and microsurgery, 2010

Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. ... more Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. It can be used to correct almost any thumb defect. However, for optimal functional and esthetic results, proper initial care, preoperative planning, proper selection of suitable techniques, adjunct or secondary procedures and proper, postoperative rehabilitation are important.

The American Journal of Surgery, 2008