Autocastration and penile reconstruction in a patient with obsessive-compulsive disorder.
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Adult↗
Biomedical subjects
Hung-Chi Chen
Publications and source records attributed to Hung-Chi Chen.
Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction?
BACKGROUND: Mastodynia is among the most frequently reported symptoms in women with breast complaints; it is usually classified as cyclic, noncyclic, or nonbreast in origin. A useful response with medical or conservative therapy is obtained in the majority of these patients. There is a subset of patients, however, who have exhausted every medical effort and psychiatric counseling and will desire mastectomy with breast reconstruction in the hope of alleviating their chronic pain. METHODS: Three patients with noncyclical, bilateral mastodynia referred for breast reconstruction options from December of 2000 to March of 2004 are presented in this article. Daily breast pain charts with a visual analogue scale for pain assessment were analyzed and recorded for all patients throughout the study period. RESULTS: Two patients underwent delayed reconstruction and had complete resolution of pain 6 to 8 weeks after bilateral mastectomy, with no recurrence of mastalgia after reconstruction. One patient underwent bilateral mastectomy with immediate reconstruction and achieved complete resolution of her pain 3 months postoperatively. Histopathologic findings of all breast specimens revealed benign breast tissue with proliferative breast disease consistent with mastodynia. CONCLUSIONS: This modality, which includes mastectomy with or without reconstruction, is a viable alternative after exhaustion of all other nonsurgical options and when quality of life is significantly affected. Although mastectomy for the treatment of mastodynia refractory to medical therapy does not guarantee alleviation of chronic breast pain, it should be considered in these often desperate patients.
Adult↗
Simultaneous double second toe transfer for reconstruction of adjacent fingers.
BACKGROUND: The authors reviewed their results with simultaneous double second toe transfer for reconstruction of adjacent fingers. METHODS: From January of 1984 to January of 2003, simultaneous double second toe transfer was performed for reconstruction of adjacent fingers in 140 patients (48 before wound closure, 92 after). Functional thumbs were present in all of them. There were 104 male and 36 female patients, with an average age of 29.1 years (range, 2 to 57 years). Index and middle fingers were reconstructed in 90 patients, middle and ring fingers in 49 patients, and ring and little fingers in one patient. The average operation time was 11 hours 25 minutes, which was much shorter than double the average time of a single second toe transfer (8 hours 31 minutes; double time, 17 hours 2 minutes). Twenty-six toes were reexplored for vascular insufficiency and three of them were lost. Secondary surgery was performed in 98 patients to improve function and cosmesis. RESULTS: Patients were followed up at an average period of 47.5 months (range, 2 to 210 months). Forty-two patients had complete functional evaluation at a minimum 2-year follow-up. The mean active range of motion of the reconstructed finger joints in these patients was 69.4 degrees for metacarpophalangeal joints, 31.1 degrees for proximal interphalangeal joints, and 8.2 degrees for distal interphalangeal joints. Two-point discrimination was between 3 and 13 mm (average, 7.5 mm). All donor sites were closed primarily and no obvious donor-site morbidity was noted, except for one hallux valgus deformity that was corrected by surgery. CONCLUSIONS: The functional and aesthetic results of double second toe transfers for adjacent two-finger reconstruction are superior to those of a single second toe-to-single finger reconstruction in multiple-finger amputations. Double second toe transfer performed simultaneously reduces the cost and total time of the operation, enables faster rehabilitation, and hastens patient adaptation.
Adolescent↗
Selection of recipient vessels in double free-flap reconstruction of composite head and neck defects.
BACKGROUND: Massive defects of the head and neck regions after resection of advanced carcinoma often require two flaps for optimal reconstruction. This study focuses on the selection of proper recipient vessels. METHODS: A total of 262 free-flap transfers were performed in 130 patients using the two-flap approach (one patient received two flaps twice). RESULTS: For microvascular anastomosis of inner flaps (intraoral lining-bone reconstruction flaps), the ipsilateral facial artery was used in 56 flaps (42.8 percent), the ipsilateral superior thyroid artery was used in 49 flaps (37.4 percent), and a branch of the internal jugular vein was used as recipient vein in 101 flaps (77.1 percent). For external flaps (soft-tissue-external skin reconstruction flaps), the ipsilateral superior thyroid artery was used in 59 flaps (50.4 percent) and the transverse cervical artery was used in 19 flaps (16.2 percent). In 14 patients the inner flaps provided distal run-off for external flap revascularization. Only seven flaps required vein grafts; they were all used for external face reconstruction (2.8 percent). There were six total (2.3 percent) and 12 partial (4.6 percent) flap failures. CONCLUSIONS: Recipient vessel selection and preparation in primary head and neck cancer reconstruction requiring two simultaneous flaps should take into consideration (1) avoidance of unnecessary destruction during tumor ablations and preservation of as many neck vessels as possible, (2) length and diameter match between flap pedicles and recipient vessels to avoid vein grafts, and (3) possible need of another free-flap reconstruction for flap failure, complication, recurrence, or secondary primary cancers. The previously radiated or operated neck does not preclude the use of recipient vessels from that side. Distal run-off of the inner flap for external flap revascularization should be avoided if possible. Once those principles are observed, two-flap reconstruction for primary cancer presents no more difficulties than single-flap reconstruction.
Adult↗
Reconstruction of the reconstructive ladder.
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Algorithms↗
Intussusception of a transferred jejunal flap in cervical esophagus reconstruction.
Although jejunal flaps have been used frequently for esophageal reconstruction, and the techniques for transfer, as well as subsequent modification, have been well described, a variety of complications still poses problems for both physicians and patients. The challenge exists in avoidance and management of complications. The purpose of this report is to present an unusual but severe complication involving a jejunal flap that was transferred to the neck for esophageal reconstruction. Intussusception of the jejunal flap occurred 1 year after flap transfer due to redundancy of the transferred segment. The patient was a child who had esophageal reconstruction for severe dysphagia that was due to a previous history of radiation injury. The disorder was successfully treated surgically with manual reduction of the intussuscepted segment, followed by shortening of the jejunal flap to prevent future recurrence. One should keep in mind that redundancy of the reconstructed esophagus may cause dysphagia due to kinking or, in this case, intussusception, which may result in necrosis of a segment of the transferred jejunum. One of the measures that should be taken during the initial reconstruction to prevent these serious complications is to perform the final inset of the jejunal flap after revascularization. This allows for proper assessment of jejunal length, which undergoes a significant change after restoration of the vascular supply.
Child↗
Tubed deltopectoral flap for creation of a controlled esophagocutaneous fistula in patients with persistent choking following esophageal reconstruction with free diversionary jejunum.
Esophageal reconstruction in patients with abnormal pharyngeal muscles or epiglottis may result in episodes of choking. The jejunal flap has been used to prevent choking by insetting the proximal end into the gingivobuccal sulcus and separating the digestive tract from the airway. A technique has been developed to deal with patients with aspiration due to collection of food near the nonfunctioning epiglottis. Between 1997 and 2004, 25 patients underwent reconstruction with jejunal flaps inset into the gingivobuccal sulcus. Postoperatively, 5 patients presented with episodes of choking. All patients underwent creation of an esophagocutaneous fistula using a deltopectoral flap. All flaps survived. Choking resolved and vocal performance was preserved in all patients. The jejunum, inset proximally into the gingivobuccal sulcus, has been successful in reconstructing patients unable to separate the airway from the digestive tract. The deltopectoral flap provides tissue for creation of a tubed flap and allows for the creation of a long fistula that prevents aspiration and can divert oral fluids away from a tracheostomy or a fresh wound.
Airway Obstruction↗
Lipofibromatous hamartoma of the median nerve with long-term follow-up.
Lipofibromatous hamartoma is a rare, benign tumor that most often involves the median nerve. A 16-year-old male with lipofibromatous hamartoma of the median nerve at the wrist level is described. This patient was a child when the mass was first noted. Although there were no symptoms or signs of carpal tunnel compression, the growth of the tumor was progressing. In addition to the release of the carpal tunnel, microsurgical intraneural dissection was done to preserve the thenar motor branch. Then segmental excision of the residual sensory component with sural nerve grafting was performed. Subjectively the patient did not notice the minor motor deficit, however, the patient did experience numbness of fingertips after surgery. There were no scars or trophic ulcers on fingertips at 3 years of follow-up regardless of the inadequate sensory return. Treatment of this benign tumor is still controversial. The relevant reports in the literature are reviewed.
Adolescent↗
Congenital radioulnar synostosis treated using a microvascular free fasio-fat flap.
Congenital radioulnar synostosis, which is caused by fusion between the proximal end of the radius and ulna, is an uncommon deformity of the upper extremity. It is characterized by the forearm being fixed in some degree of pronation and patients present with a variety of functional limitations of the involved limb. This condition may lead to difficulties in daily activities, such as writing, eating, and accepting objects in an open palm. Many operative procedures have been developed to mobilize the fixed forearm but the long-term results are disappointing. Herein, we reported a 12-year-old female patient with congenital radioulnar synostosis of the bilateral forearm who was treated with separation of the bony bridge between the left radius and ulna combined with a free groin flap transfer into the separated space. The functional results are good and no recurrent ankylosis occurred during a period of 28 months postoperatively. The flap size and volume of the subcutaneous fat are the key factors for satisfactory results.
Adipose Tissue↗
"Airborne" suture tying technique for the microvascular anastomosis.
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Anastomosis, Surgical↗
Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators.
Since the advent of perforator flaps, a wide variety of applications have been documented. This study focuses on free flaps based on musculocutaneous perforators, because they have not been well-described in the literature of upper-limb reconstruction. They can be trimmed to be thin and pliable, and may provide large flaps with multiple components on the same pedicle to facilitate three-dimensional inset of flaps. Microvascular free flaps based on musculocutaneous perforators were performed in 36 cases for reconstruction of the thumb and thenar web, palm, dorsum of the hand, wrist, and forearm. They included the anterolateral thigh perforator flap (27 cases), thoracodorsal perforator flap (5 cases), and deep inferior epigastric perforator flap (4 cases). In 2 other cases not included in this series, the thoracodorsal perforator flap could not be elevated due to anatomical variations. There was no failure in this series, but complications included: 1) hematoma in 2 cases, and 2) infection in 2 cases with flap rim necrosis which was treated by a local rotation flap and skin graft. The thin flaps facilitated secondary reconstructive procedures, and only minor effort was required for the debulking procedure of the flaps. On average, these patients required 2.3 occasions of secondary procedures for further reconstruction following coverage with a perforator flap. The perforator flaps provide medium-thickness flaps for coverage of large defects in the upper limb with improved aesthetics and function. With careful dissection of the musculocutaneous perforators and primary thinning of the flaps, the use of a perforator flap is quite safe. Preservation of the muscles leads to better preservation of donor-site functions. Less requirement of secondary debulking procedures is a great advantage. However, caution should be taken in the presence of wound infection.
Adolescent↗
Traumatic major muscle loss in the upper extremity: reconstruction using functioning free muscle transplantation.
Traumatic crushing injuries of the muscle compartments will occasionally cause major muscle or muscle-group loss with concomitant irreparable nerve injuries. Those cases with or without the availability of local muscle transfers form another indication for functioning free muscle transplantation (FFMT). The authors report their experience with 20 FFMTs in 14 patients with severe muscle loss from 1986 to 1996. They were selected because all their major muscle loss was primarily due to muscle avulsion, avascularity, and necrosis, but not secondarily due to nerve injury or ischemic injury. The motor nerves innervating these muscles were either disrupted after muscle debridement or avulsed from the neuromuscular junction concomitantly. The initial injury in this series was so severe that in many cases amputation was advised. Fractures were present in almost half the cases (6/14). Half the cases required revascularization due to rupture of major vessels (7/14), and the need for free-tissue transfer for soft-tissue coverage was demonstrated in over two-thirds (8/14). All FFMTs were innervated by the motor nerve which originally innervated the lost major muscle(s), and to replace palmar arm compartment (elbow flexors, 6 cases), palmar forearm compartment (finger flexors, 6 cases), and dorsal forearm compartment (finger extensors, 8 cases). Postoperative follow-up ranged from 3 to 12.5 years (average: 8.3 years). The success rate, i.e., achieving M4 muscle strength, was nearly 90 percent (18 of 20 FFMTs). Two cases with sub-optimal results were performed in the acute stage for the purpose of soft-tissue coverage and functional results. These reconstructions make the originally compromised limb useful for most activities of daily living. This type of injury should be recognized as providing a good prognosis after application of the FFMT, and arbitrary amputation should be avoided.
Adolescent↗
Extended trapezius myocutaneous free flap for the reconstruction of a foot defect lacking adjacent recipient vessels.
Foot reconstruction requires tissue that is durable and can withstand the extremes of pressure and stress. The trapezius myocutaneous flap has not been used previously as a free flap for foot reconstruction. In this report, the trapezius was used as an extended myocutaneous free flap for the reconstruction of a foot wound lacking adjacent and adequate recipient vessels. The extended trapezius flap may be one of the longest free flaps that can be harvested. The indications for the use of this flap are limited. In an extremity that lacks adequate recipient vessels adjacent to the defect, this flap can be extended such that more proximal vessels in the leg can be used as the recipient vessels without the need for vein grafts to bridge the distance. The donor-site morbidity of this flap is minimal when the superior fibers of the trapezius muscle and its innervation are preserved.
Accidents, Traffic↗
Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex facial paralysis.
Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.
Adolescent↗
Bowel preparation before microvascular free colon transfer for head and neck reconstruction: is it necessary?
Mechanical bowel preparation before any intestinal operation, especially when the large intestine is involved, is routine practice for most surgeons. This practice has been questioned by many colorectal surgeons, with convincing data showing the lack of benefit of preoperative mechanical bowel preparation. Free microvascular transfer of the large intestine is occasionally performed for reconstruction of the upper esophagus, as it provides a better size match for the oropharynx than other visceral organs. Nine patients underwent reconstruction of the cervical esophagus and voice tube using a segment of ileocolon. In all patients, the cervical esophagus was reconstructed using the ascending colon and the voice tube was reconstructed using the ileal segment. Both were transferred as one free flap. All patients underwent the procedure without any form of preoperative mechanical bowel preparation. The patients were able to tolerate a solid diet at the end of the mean follow-up period of 7 months, and all esophagograms showed no evidence of stricture formation. One patient developed a fistula at the recipient site that was treated with a regional flap, one patient developed a superficial wound infection of the abdominal wall, and one patient developed a postoperative abdominal wound dehiscence after several episodes of excessive coughing. Microvascular transfer of a large intestinal segment without preoperative mechanical bowel preparation for the reconstruction of the esophagus is a safe procedure. It can avoid the discomfort and complications associated with mechanical bowel preparation. If preoperative mechanical bowel preparation is preferred, the results of this study, which are based on nine patients, demonstrate the safety of this practice in cases where the patient did not follow proper instructions or in cases where the use of the colon was not anticipated preoperatively.
Aged↗
Conversion from pedicled to free flap for salvage of the compromised pectoralis major myocutaneous flap in head and neck reconstruction.
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Aged↗
Strategies for a successful corrective Asian blepharoplasty after previously failed revisions.
Asian blepharoplasty, although a common procedure, has a relatively high rate of complications. Subtle imperfections and more serious iatrogenic complications often require immediate attention by the aesthetic surgeon. After attempted correction of the deformities, residual problems or new ones can arise. Blepharoptosis, supratarsal depression, an excessively high or low crease, a short or discontinuous crease, multiple creases, and asymmetric creases are the most commonly encountered complications that require special attention in this group, which has already undergone more than one surgical procedure. Between January of 1996 and December of 2002, 168 Asian blepharoplasty revisions were performed by one surgeon (S. H.-T. Chen); of these, 36 patients (21 percent) had previously undergone failed revisions. This subgroup of patients consisted of six with blepharoptosis, six with asymmetrical eyelid creases, three with supratarsal depressions, three with high creases, two with short creases, and 16 with combinations of these deformities. The results were graded as excellent, good, fair, or poor, based on the symmetry of the eyelids, palpebral fissures, crease heights, lengths, shapes, eyelid fullness, and overall aesthetics of the final outcome. A survey was performed of patient and surgeon satisfaction and factored into the grading system. With an average follow-up period of 16 months (6 to 60 months), 22 patients (61 percent) were found to have excellent results, 10 (28 percent) had good results, two (5.6 percent) had fair results, and two (5.6 percent) had poor results. Corrective procedures after failed revision Asian blepharoplasty require special strategic considerations because of the presence of extensive scarring and inadequate skin, muscle, and preaponeurotic fat and because of the occasional presence of dehiscence of the levator aponeurosis. By using careful preoperative evaluation, accurate measurements, precise preoperative planning, intraoperative fat repositioning or grafting, skin excision or redraping, and proper placement of anchoring sutures, successful outcomes can be achieved. The authors evaluate the outcomes and detail the surgical procedures that were used to achieve successful outcomes in this particularly challenging group of patients.
Asian People↗
Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity.
The radial forearm flap is commonly used for reconstruction of tongue defects following tumor extirpation. This flap is easy to harvest and offers thin tissue with large-caliber vessels. However, its use leaves behind a conspicuous aesthetic deformity in the forearm and requires the sacrifice of a major artery of that limb, the radial artery. The anterolateral thigh cutaneous flap has found clinical applications in the reconstruction of soft-tissue defects requiring thin tissue. More recently, in a thinned form, the anterolateral thigh flap has been used for reconstructing defects of the tongue with functional results equivalent to that of the radial forearm flap. For the reconstruction of tongue defects, these two flaps could provide similar soft-tissue coverage, but they seem to result in different donor-site appearances. The donor site is closed primarily, leaving only a linear scar that is inconspicuous with normal clothing, and no functional deficit is left behind in the thigh. Thus, for the supply of flaps for tongue defects, a comparison between the radial forearm flap and the anterolateral thigh flap donor sites is provided in this study. Between December of 2000 and August of 2002, 41 patients who underwent reconstruction of defects of the tongue using either a radial forearm flap or an anterolateral thigh flap were evaluated. The focus was on the evaluation of the functional and aesthetic outcome of the donor site after harvesting these flaps for the purpose of reconstructing either total or partial tongue defects. Finally, a comparison was performed between the donor sites of the two flaps. The disadvantages of the radial forearm flap include the conspicuous unattractive scar in the forearm region, pain, numbness, and the sacrifice of a major artery of the limb. In some patients, the donor-site scar of the forearm acted as a social stigma, preventing these patients from leading a normal life. In contrast, the anterolateral thigh cutaneous flap, after thinning, achieved the same results in reconstructing defects of the tongue without the associated donor-site morbidity. Most importantly, the donor site in the thigh could be closed primarily in almost all patients without any functional deficit. The thinned anterolateral thigh cutaneous flap is a viable substitute for the radial forearm flap when reconstructing defects of the tongue. The results achieved are similar to those of the radial forearm flap, and the donor-site morbidity is significantly decreased.
Adult↗