Publications by authors named "Cheng-Hung Lin"

112 Publications

"Does inclination of the toe proximal phalangeal head affect the outcomes of vascularized joint transfers?" Retrospective study of 22 vascularized joint transfers.

Plast Reconstr Surg 2022 Jul 29. Epub 2022 Jul 29.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.

Background: Different shapes of the proximal phalangeal head of toe PIPJs - oval shaped and circular are observed in the vascularized joint transfers (VJTs). The difference in shape implies the varying degrees of inclination of the articular surfaces between different toes. There have not been any reports in the literature that describe such a correlation. This study investigates the impact of articular inclination of toe proximal interphalangeal joints (PIPJs) on outcomes after toe VJTs for finger PIPJ reconstruction.

Methods: 21 patients (15 males and 6 females) who underwent VJT for finger PIPJ reconstruction from May 2009 to May 2018 were included. The mean age was 33.4 years and the mean follow-up period was 28.9 months. All patients were type I Te's classification central slip. Articular surface inclination was measured on lateral radiographic views.

Results: The passive ROM of the toe PIPJ before VJT was 71.1° ± 9.6°. The functional ROM of the reconstructed PIPJ was 60.0° ± 17.0°. The extensor lag (the amount of ROM change) after the VJT was 9.4° ± 19.6°. The articular inclination of toe PIPJ was 71.9° ± 9.7°. A Pearson's correlation analysis of all variables including age, pre-OP ROM of toe PIPJ, post-OP ROM of reconstructed PIPJ, articular inclination of toe PIPJ and extensor lag of reconstructed PIPJ with toe articular inclination was performed. There was no significant correlation between articular inclination of toe PIPJ and extensor lag of reconstructed PIPJ. (p=0.226).

Conclusions: The articular surface of the toe PIPJ did not affect the functional ROM after VJT.
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http://dx.doi.org/10.1097/PRS.0000000000009529DOI Listing
July 2022

Neuromyelitis Optica Spectrum Disorder: From Basic Research to Clinical Perspectives.

Int J Mol Sci 2022 Jul 18;23(14). Epub 2022 Jul 18.

Institute of Eye Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, 707 Sec. 3 Chung-Yung Road, Hualien 970, Taiwan.

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disease of the central nervous system characterized by relapses and autoimmunity caused by antibodies against the astrocyte water channel protein aquaporin-4. Over the past decade, there have been significant advances in the biologic knowledge of NMOSD, which resulted in the IDENTIFICATION of variable disease phenotypes, biomarkers, and complex inflammatory cascades involved in disease pathogenesis. Ongoing clinical trials are looking at new treatments targeting NMOSD relapses. This review aims to provide an update on recent studies regarding issues related to NMOSD, including the pathophysiology of the disease, the potential use of serum and cerebrospinal fluid cytokines as disease biomarkers, the clinical utilization of ocular coherence tomography, and the comparison of different animal models of NMOSD.
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http://dx.doi.org/10.3390/ijms23147908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9323454PMC
July 2022

Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation.

Sci Rep 2022 Jul 14;12(1):12044. Epub 2022 Jul 14.

Institute of Medicine, Chung Shan Medical University, Taichung, 402, Taiwan, ROC.

Successful weaning from ventilators not only improves the quality of life of patients, but also reduces medical expenses. The aim of this study was to explore the association between nutritional provision and successful ventilator weaning. In this retrospective study data from the Respiratory Care Center of Chung Shan Medical University Hospital between October, 2017 and July, 2019 on patient characteristics, amount of nutrition delivered, and clinical outcomes were retrieved. A total of 280 ventilated patients were enrolled and divided into successful extubation and failed weaning groups. There were 178 males (63.6%) and 102 females (36.4%) with a mean age of 67.3 ± 16.9 years. The successful extubation group consisted of patients who tended towards ideal body weight during the weaning process (BMI 23.9 ± 5.0 versus 22.7 ± 4.8 kg/m, p < 0.001). Patients from both groups initially received the same nutritional intervention, while patients of successful extubation received significantly more calories and protein after weaning (23.8 ± 7.8 kcal versus 27.8 ± 9.1 kcal, p < 0.001 and 0.97 ± 0.36 g versus 1.14 ± 0.42 g, p < 0.001). Successful weaning was associated with higher survival rate (p = 0.016), shortened hospital stay (p = 0.001), and reduced medical costs (p < 0.001). Overall, nutritional support with high calories and protein was associated with the probability of successful ventilator weaning in patients undergoing prolonged mechanical ventilation. Adequate nutrition is a determinant of successful ventilator weaning.
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http://dx.doi.org/10.1038/s41598-022-15917-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9283331PMC
July 2022

Association of General Anesthesia and Neuraxial Anesthesia in Caesarean Section with Maternal Postpartum Depression: A Retrospective Nationwide Population-Based Cohort Study.

J Pers Med 2022 Jun 14;12(6). Epub 2022 Jun 14.

Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.

Although cesarean section (CS) has become a common method of child delivery in recent decades, the choice between general anesthesia (GA) and neuraxial anesthesia (NA) for CS must be carefully considered. Depending on the type of anesthesia used in CS, a major outcome observed is the occurrence of postpartum depression (PPD). This study investigated the association between PPD risk and the anesthesia method used in CS by using data from three linked nationwide databases in Taiwan, namely, the National Health Insurance Research Database, the National Birth Reporting Database, and the National Death Index Database. After propensity score matching by baseline depressive disorders, maternal demographics, status at delivery, infant's health, maternal diseases during pregnancy, and age of partner, we included women who had natural births ( = 15,706), cesarean sections with GA ( = 15,706), and cesarean sections with NA ( = 15,706). A conditional logistic regression was used to estimate the odds ratios and 95% confidence intervals (CIs) of PPDs, including depression, sleep disorder, and medication with hypnotics or antidepressants, under anesthesia during CS. The prevalence rates of combined PPDs were 26.66%, 43.87%, and 36.30% in natural births, CS with GA, and CS with NA, respectively. In particular, the proportions of postpartum use of hypnotic drugs or antidepressants were 21.70%, 39.77%, and 31.84%, which were significantly different. The aORs (95% CIs) were 2.15 (2.05-2.25) for the included depressive disorders, 1.10 (1.00-1.21) for depression, 1.03 (0.96-1.11) for sleep disorder, and 2.38 (2.27-2.50) for medication with hypnotics or antidepressants in CS with GA compared with natural births. Women who underwent CS with GA had a significantly higher risk of depressive disorders and a higher need for antidepressants for sleep problems than those who underwent CS with NA. The risks of PPD were significantly associated with the anesthesia method, especially GA. Our results can assist physicians in carefully considering the appropriate anesthesia method for CS delivery, particularly with regard to postpartum drug abuse and drug safety.
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http://dx.doi.org/10.3390/jpm12060970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9224722PMC
June 2022

Comparison of the effectiveness of local anesthesia for the digital block between single-volar subcutaneous and double-dorsal finger injections: a systematic review and meta-analysis of randomized control trials.

J Plast Surg Hand Surg 2022 May 6:1-14. Epub 2022 May 6.

Department of Plastic and Reconstructive Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.

Local anesthesia is an effective method to perform digital nerve blocks. In this study, we compare the effectiveness of single-volar subcutaneous and double-dorsal injection through a systematic review and meta-analysis of randomized controlled trials (RCTs). A systematic search of PubMed, Embase, and the Cochrane Library from inception to 7 April 2021 was performed. RCTs with the effects of single-volar subcutaneous and double-dorsal injection were eligible. Meta-analysis was performed using random effect models with pooled standardized mean differences (SMDs) and 95% confidence intervals (CI). RoB 2.0 and GRADE of Recommendation Assessment, Development, and Evaluation criteria were applied for evaluating the bias. A total of 2484 studies were initially identified, with 11 eligible RCTs finally included in the meta-analysis (1363 patients). The pooled data of nine studies showed single-volar injection had a statistically significantly lower pain score (pooled SMD: 0.20, 95% CI, 0.01 to 0.39,  = 0.041, I2 = 58%,  = 1187) and higher patient preference but invalid anesthesia at the dorsal proximal digit. No significant differences were observed in the onset of anesthesia, adjacent digit invalid numbness, distal phalanx invalid anesthesia, additional injection rate, and adverse effects. In conclusion, this meta-analysis of RCTs showed that the single-volar injection was associated with a lower pain sensation during injection and higher patient satisfaction with a reduced anesthetic effect over the proximal dorsal phalanx. Further high-quality RCTs with a higher number of cases are needed to validate our results.
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http://dx.doi.org/10.1080/2000656X.2022.2070177DOI Listing
May 2022

Vision-Based Learning from Demonstration System for Robot Arms.

Sensors (Basel) 2022 Mar 31;22(7). Epub 2022 Mar 31.

Department of Electrical Engineering, National Taiwan Normal University, Taipei 106, Taiwan.

Robotic arms have been widely used in various industries and have the advantages of cost savings, high productivity, and efficiency. Although robotic arms are good at increasing efficiency in repetitive tasks, they still need to be re-programmed and optimized when new tasks are to be deployed, resulting in detrimental downtime and high cost. It is therefore the objective of this paper to present a learning from demonstration (LfD) robotic system to provide a more intuitive way for robots to efficiently perform tasks through learning from human demonstration on the basis of two major components: understanding through human demonstration and reproduction by robot arm. To understand human demonstration, we propose a vision-based spatial-temporal action detection method to detect human actions that focuses on meticulous hand movement in real time to establish an action base. An object trajectory inductive method is then proposed to obtain a key path for objects manipulated by the human through multiple demonstrations. In robot reproduction, we integrate the sequence of actions in the action base and the key path derived by the object trajectory inductive method for motion planning to reproduce the task demonstrated by the human user. Because of the capability of learning from demonstration, the robot can reproduce the tasks that the human demonstrated with the help of vision sensors in unseen contexts.
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http://dx.doi.org/10.3390/s22072678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9002941PMC
March 2022

School-based universal screening for hypercholesterolemia in children.

Pediatr Neonatol 2022 07 22;63(4):355-360. Epub 2022 Mar 22.

Education Department, Taitung County Government, Taiwan.

Background: In 2011, the American Academy of Pediatrics recommended universal lipid screening during childhood and adolescence. However, this approach was shown to be lacking in adherence. Only 6% of non-high-risk children received lipid screening by age 12. Our study designed a school-based universal screening for hypercholesterolemia in children. The goal was to investigate a feasible strategy for lipid screening of children.

Methods: The study enrolled all the fourth-grade students of 30 elementary schools from 2020 to 2021. Non-fasting non-HDL was used as a screening tool. These students were classified into three groups: acceptable group (non-HDL < 120 mg/dL), borderline group (120-144 mg/dL), and abnormal group (≥145 mg/dL). The abnormal group was referred to our hospital for confirmatory fasting lipid studies. The complete rate and timing were calculated.

Results: Six hundred students were enrolled in this study. In the abnormal group (95 children), a total of 92 students received confirmatory fasting lipid studies. These confirmatory studies were completed within three months after the family received their reports. The study had a rate of coverage of 62% and the referred percentage of the abnormal group was 97%. BMI had poor association with fasting LDL (CORR = 0.06752, p = 0.444). In the abnormal group, only 29.5% children had family history of early CVD or dyslipidemia.

Conclusion: School-based universal screening for hypercholesterolemia in children is a feasible and effective way to identify patients at high-risk for early CVD. Neither BMI nor family history was a good indicator for the screening of dyslipidemia.
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http://dx.doi.org/10.1016/j.pedneo.2021.12.013DOI Listing
July 2022

Prospective outcome analysis of ulnar tunnel syndrome: Comparing traumatic versus non-traumatic etiologies.

Asian J Surg 2022 Mar 16. Epub 2022 Mar 16.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Taoyuan, Taiwan. Electronic address:

Background: Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies.

Methods: Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength.

Results: 21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles.

Conclusions: Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.
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http://dx.doi.org/10.1016/j.asjsur.2022.03.006DOI Listing
March 2022

Popliteal Artery Injury After Fracture and/or Dislocation of the Knee: Risk Stratification for Revascularization Outcome.

Ann Plast Surg 2022 03;88(1s Suppl 1):S50-S55

From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan.

Background: Managing complex knee trauma involving both vascular and osseous injuries is challenging, yet the available guidelines for efficient popliteal artery injury management after high-velocity blunt knee trauma remain conflicting and inconsistent. In this study, the authors aim to identify the risk factors associated with delayed limb amputation and ischemic muscular sequela postrevascularization. Furthermore, we propose a treatment algorithm to improve the limb salvage rate.

Methods: Patients who presented with traumatic popliteal artery injury resulting in vessel occlusion or rupture, followed by fracture and/or dislocation of the knee from January 2008 to December 2013, were included for retrospective review.

Results: Overall delayed amputation rate was 24% (7/29) and 16% (4/25) after successful revascularization. Mangled Extremity Severity Score is higher in the delayed amputation group than the limb-salvaged group (P = 0.02). Higher-impact force (P = 0.03), ischemic limb on presentation (P = 0.03), prolonged ischemia time (P = 0.04), unstable hemodynamics (P = 0.01), longer operation time (P = 0.04), and prolonged intensive care unit stay (P = 0.03) are risk factors of delayed amputation. Longer ischemia time (P = 0.04) and length of popliteal artery injury (P = 0.02) are associated with ischemic muscular sequela.

Conclusions: Mangled Extremity Severity Score is a reliable predictor of limb salvage. An algorithmic approach may improve the outcome of popliteal artery injury after high-velocity blunt knee trauma.
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http://dx.doi.org/10.1097/SAP.0000000000003076DOI Listing
March 2022

Implantable Immunosuppressant Delivery to Prevent Rejection in Transplantation.

Int J Mol Sci 2022 Jan 29;23(3). Epub 2022 Jan 29.

Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan 333, Taiwan.

An innovative immunosuppressant with a minimally invasive delivery system has emerged in the biomedical field. The application of biodegradable and biocompatible polymer forms, such as hydrogels, scaffolds, microspheres, and nanoparticles, in transplant recipients to control the release of immunosuppressants can minimize the risk of developing unfavorable conditions. In this review, we summarized several studies that have used implantable immunosuppressant delivery to release therapeutic agents to prolong allograft survival. We also compared their applications, efficacy, efficiency, and safety/side effects with conventional therapeutic-agent administration. Finally, challenges and the future prospective were discussed. Collectively, this review will help relevant readers understand the different approaches to prevent transplant rejection in a new era of therapeutic agent delivery.
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http://dx.doi.org/10.3390/ijms23031592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8835747PMC
January 2022

The Effect of Narrow-Band Ultraviolet B Irradiation on the Vascularized Composite Allotransplantation Rat Model.

Ann Plast Surg 2022 03;88(1s Suppl 1):S22-S26

Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital.

Introduction: Vascularized composite allotransplantation (VCA) allows functional and esthetic reconstruction for patients with complex anatomical defects. However, acute and chronic graft rejections are significant obstacles to VCA. Ultraviolet light is an oncogenic environmental hazard. However, ultraviolet B (UVB) has an immunomodulation effect. Therefore, this study aims to elucidate the impact of UVB irradiation on the VCA rat model.

Methods: The rat vascularized bone marrow allotransplantation model was used. A vascularized bone marrow from a Brown Norway rat (RT1Ac) was transplanted into a Lewis rat (RT1Ab). The allograft and surrounding abdominal skin were exposed to narrow-band ultraviolet B (NB-UVB) (311 nm) radiation with an energy of 1350 mJ/cm2 3 times a week until the end of the study period. There were 5 study groups: syngeneic transplantation (group 1), allogeneic transplantation (group 2), allogenic transplantation-NB-UVB (group 3), allogenic transplantation-antilymphocyte serum (ALS)-tacrolimus (group 4), and allogenic transplantation-antilymphocyte serum-tacrolimus-NB-UVB (group 5).

Results: Group 5 had decreased graft survival compared with group 4. In the donor cell chimerism analysis, donor cell chimerism decreased significantly after UVB irradiation and was unresponsive to the administered immunosuppressants. After UVB irradiation, the CD8 T-cell ratio was increased, and the regulatory T-cell ratio was decreased.

Conclusions: The preliminary data showed that NB-UVB irradiation of the VCA rat model may decrease graft survival. However, further studies are needed to elucidate the possible mechanisms of this phenomenon.
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http://dx.doi.org/10.1097/SAP.0000000000003071DOI Listing
March 2022

Cell therapy in vascularized composite allotransplantation.

Biomed J 2022 Jan 15. Epub 2022 Jan 15.

Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address:

Allograft rejection is one of the obstacles in achieving a successful vascularized composite allotransplantation (VCA). Treatments of graft rejection with lifelong immunosuppression (IS) subject the recipients to a lifelong risk of cancer development and opportunistic infections. Cell therapy has recently emerged as a promising strategy to modulate the immune system, minimize immunosuppressant drug dosages, and induce allograft tolerance. In this review, the recent works regarding the use of cell therapy to improve allograft outcomes are discussed. The current data supports the safety of cell therapy. The suitable type of cell therapy in allotransplantation is clinically dependent. Bone marrow cell therapy is more suitable for the induction phase, while other cell therapies are more feasible in either the induction or maintenance phase, or for salvage of allograft rejection. Immune cell therapy focuses on modulating the immune response, whereas stem cells may have an additional role in promoting structural regenerations, such as nerve regeneration. Source, frequency, dosage, and route of cell therapy delivery are also dependent on the specific need in the clinical setting.
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http://dx.doi.org/10.1016/j.bj.2022.01.005DOI Listing
January 2022

Human Motion Tracking Using 3D Image Features with a Long Short-Term Memory Mechanism Model-An Example of Forward Reaching.

Sensors (Basel) 2021 Dec 31;22(1). Epub 2021 Dec 31.

Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei 112, Taiwan.

Human motion tracking is widely applied to rehabilitation tasks, and inertial measurement unit (IMU) sensors are a well-known approach for recording motion behavior. IMU sensors can provide accurate information regarding three-dimensional (3D) human motion. However, IMU sensors must be attached to the body, which can be inconvenient or uncomfortable for users. To alleviate this issue, a visual-based tracking system from two-dimensional (2D) RGB images has been studied extensively in recent years and proven to have a suitable performance for human motion tracking. However, the 2D image system has its limitations. Specifically, human motion consists of spatial changes, and the 3D motion features predicted from the 2D images have limitations. In this study, we propose a deep learning (DL) human motion tracking technology using 3D image features with a deep bidirectional long short-term memory (DBLSTM) mechanism model. The experimental results show that, compared with the traditional 2D image system, the proposed system provides improved human motion tracking ability with RMSE in acceleration less than 0.5 (m/s) X, Y, and Z directions. These findings suggest that the proposed model is a viable approach for future human motion tracking applications.
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http://dx.doi.org/10.3390/s22010292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8749597PMC
December 2021

Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions.

J Plast Reconstr Aesthet Surg 2022 05 2;75(5):1557-1566. Epub 2021 Dec 2.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan. Electronic address:

Background: Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection.

Methods: Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration.

Results: Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively.

Conclusion: Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.
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http://dx.doi.org/10.1016/j.bjps.2021.11.095DOI Listing
May 2022

Thermosensitive Polyester Hydrogel for Application of Immunosuppressive Drug Delivery System in Skin Allograft.

Gels 2021 Nov 23;7(4). Epub 2021 Nov 23.

Center for Vascularized Composite Allotransplantation, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Memorial Medical College, Chang Gung University, Taoyuan 333, Taiwan.

Tacrolimus (FK506) is a common immunosuppressive drug that is capable of suppressing acute rejection reactions, and is used to treat patients after allotransplantation. A stable and suitable serum concentration of tacrolimus is desirable for better therapeutic effects. However, daily drug administration via oral or injection routes is quite inconvenient and may encounter drug overdose or low patient compliance problems. In this research, our objective was to develop an extended delivery system using a thermosensitive hydrogel of poly ethylene glycol, D,L-lactide (L), and ϵ-caprolactone (CL) block copolymer, mPEG-PLCL, as a drug depot. The formulation of mPEG-PLCL and 0.5% PVP-dissolved tacrolimus was studied and the optimal formulation was obtained. The in vivo data showed that in situ gelling is achieved, a stable and sustained release of the drug within 30 days can be maintained, and the hydrogel was majorly degraded in that period. Moreover, improved allograft survival was achieved. Together, these data imply the potential of the current formulation for immunosuppressive treatments.
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http://dx.doi.org/10.3390/gels7040229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8628764PMC
November 2021

Probing Kinetics of Water-in-Salt Aqueous Batteries with Thick Porous Electrodes.

ACS Cent Sci 2021 Oct 16;7(10):1676-1687. Epub 2021 Sep 16.

Department of Materials Science and Chemical Engineering, Stony Brook University, Stony Brook, New York 11794, United States.

Aqueous electrochemical systems suffer from a low energy density due to a small voltage window of water (1.23 V). Using thicker electrodes to increase the energy density and highly concentrated "water-in-salt" (WIS) electrolytes to extend the voltage range can be a promising solution. However, thicker electrodes produce longer diffusion pathways across the electrode. The highly concentrated salts in WIS electrolytes alter the physicochemical properties which determine the transport behaviors of electrolytes. Understanding how these factors interplay to drive complex transport phenomena in WIS batteries with thick electrodes via deterministic analysis on the rate-limiting factors and kinetics is critical to enhance the rate-performance in these batteries. In this work, a multimodal approach-Raman tomography, X-ray diffraction refinement, and synchrotron X-ray 3D spectroscopic imaging-was used to investigate the chemical heterogeneity in LiVO-LiMnO WIS batteries with thick porous electrodes cycled under different rates. The multimodal results indicate that the ionic diffusion in the electrolyte is the primary rate-limiting factor. This study highlights the importance of fundamentally understanding the electrochemically coupled transport phenomena in determining the rate-limiting factor of thick porous WIS batteries, thus leading to a design strategy for 3D morphology of thick electrodes for high-rate-performance aqueous batteries.
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http://dx.doi.org/10.1021/acscentsci.1c00878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554840PMC
October 2021

The Mandible Ameliorates Facial Allograft Rejection and Is Associated with the Development of Regulatory T Cells and Mixed Chimerism.

Int J Mol Sci 2021 Oct 14;22(20). Epub 2021 Oct 14.

Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.

Vascularized composite allografts contain various tissue components and possess relative antigenicity, eliciting different degrees of alloimmune responses. To investigate the strategies for achieving facial allograft tolerance, we established a mouse hemiface transplant model, including the skin, muscle, mandible, mucosa, and vessels. However, the immunomodulatory effects of the mandible on facial allografts remain unclear. To understand the effects of the mandible on facial allograft survival, we compared the diversities of different facial allograft-elicited alloimmunity between a facial osteomyocutaneous allograft (OMC), including skin, muscle, oral mucosa, and vessels, and especially the mandible, and a myocutaneous allograft (MC) including the skin, muscle, oral mucosa, and vessels, but not the mandible. The different facial allografts of a BALB/c donor were transplanted into a heterotopic neck defect on fully major histocompatibility complex-mismatched C57BL/6 mice. The allogeneic OMC (Allo-OMC) group exhibited significant prolongation of facial allograft survival compared to the allogeneic MC group, both in the presence and absence of FK506 immunosuppressive drugs. With the use of FK506 monotherapy (2 mg/kg) for 21 days, the allo-OMC group, including the mandible, showed prolongation of facial allograft survival of up to 65 days, whereas the myocutaneous allograft, without the mandible, only survived for 34 days. The Allo-OMC group also displayed decreased lymphocyte infiltration into the facial allograft. Both groups showed similar percentages of B cells, T cells, natural killer cells, macrophages, and dendritic cells in the blood, spleen, and lymph nodes. However, a decrease in pro-inflammatory T helper 1 cells and an increase in anti-inflammatory regulatory T cells were observed in the blood and lymph nodes of the Allo-OMC group. Significantly increased percentages of donor immune cells were also observed in three lymphoid organs of the Allo-OMC group, suggesting mixed chimerism induction. These results indicated that the mandible has the potential to induce anti-inflammatory effects and mixed chimerism for prolonging facial allograft survival. The immunomodulatory understanding of the mandible could contribute to reducing the use of immunosuppressive regimens in clinical face allotransplantation including the mandible.
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http://dx.doi.org/10.3390/ijms222011104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8537927PMC
October 2021

Preconditioned Mesenchymal Stromal Cells to Improve Allotransplantation Outcome.

Cells 2021 09 6;10(9). Epub 2021 Sep 6.

Center for Vascularized Composite Allotransplantation, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.

Mesenchymal stromal cells (MSCs) are tissue-derived progenitor cells with immunomodulatory as well as multilineage differentiation capacities, and have been widely applied as cellular therapeutics in different disease systems in both preclinical models and clinical studies. Although many studies have applied MSCs in different types of allotransplantation, the efficacy varies. It has been demonstrated that preconditioning MSCs prior to in vivo administration may enhance their efficacy. In the field of organ/tissue allotransplantation, many recent studies have shown that preconditioning of MSCs with (1) pretreatment with bioactive factors or reagents such as cytokines, or (2) specific gene transfection, could prolong allotransplant survival and improve allotransplant function. Herein, we review these preconditioning strategies and discuss potential directions for further improvement.
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http://dx.doi.org/10.3390/cells10092325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8469056PMC
September 2021

Design nanoporous metal thin films solid state interfacial dealloying.

Nanoscale 2021 Nov 4;13(42):17725-17736. Epub 2021 Nov 4.

Department of Materials Science and Chemical Engineering, Stony Brook University, Stony Brook, NY 11794, USA.

Thin-film solid-state interfacial dealloying (thin-film SSID) is an emerging technique to design nanoarchitecture thin films. The resulting controllable 3D bicontinuous nanostructure is promising for a range of applications including catalysis, sensing, and energy storage. Using a multiscale microscopy approach, we combine X-ray and electron nano-tomography to demonstrate that besides dense bicontinuous nanocomposites, thin-film SSID can create a very fine (5-15 nm) nanoporous structure. Not only is such a fine feature among one of the finest fabrications by metal-agent dealloying, but a multilayer thin-film design enables creating nanoporous films on a wider range of substrates for functional applications. Through multimodal synchrotron diffraction and spectroscopy analysis with which the materials' chemical and structural evolution in this novel approach is characterized in details, we further deduce that the contribution of change in entropy should be considered to explain the phase evolution in metal-agent dealloying, in addition to the commonly used enthalpy term in prior studies. The discussion is an important step leading towards better explaining the underlying design principles for controllable 3D nanoarchitecture, as well as exploring a wider range of elemental and substrate selections for new applications.
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http://dx.doi.org/10.1039/d1nr03709aDOI Listing
November 2021

Automatic Polyp Segmentation in Colonoscopy Images Using a Modified Deep Convolutional Encoder-Decoder Architecture.

Sensors (Basel) 2021 Aug 20;21(16). Epub 2021 Aug 20.

Department of Electrical and Electronic Engineering, Universiti Teknologi PETRONAS, Seri Iskandar 32610, Malaysia.

Colorectal cancer has become the third most commonly diagnosed form of cancer, and has the second highest fatality rate of cancers worldwide. Currently, optical colonoscopy is the preferred tool of choice for the diagnosis of polyps and to avert colorectal cancer. Colon screening is time-consuming and highly operator dependent. In view of this, a computer-aided diagnosis (CAD) method needs to be developed for the automatic segmentation of polyps in colonoscopy images. This paper proposes a modified SegNet Visual Geometry Group-19 (VGG-19), a form of convolutional neural network, as a CAD method for polyp segmentation. The modifications include skip connections, 5 × 5 convolutional filters, and the concatenation of four dilated convolutions applied in parallel form. The CVC-ClinicDB, CVC-ColonDB, and ETIS-LaribPolypDB databases were used to evaluate the model, and it was found that our proposed polyp segmentation model achieved an accuracy, sensitivity, specificity, precision, mean intersection over union, and dice coefficient of 96.06%, 94.55%, 97.56%, 97.48%, 92.3%, and 95.99%, respectively. These results indicate that our model performs as well as or better than previous schemes in the literature. We believe that this study will offer benefits in terms of the future development of CAD tools for polyp segmentation for colorectal cancer diagnosis and management. In the future, we intend to embed our proposed network into a medical capsule robot for practical usage and try it in a hospital setting with clinicians.
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http://dx.doi.org/10.3390/s21165630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8402594PMC
August 2021

Formation of three-dimensional bicontinuous structures via molten salt dealloying studied in real-time by in situ synchrotron X-ray nano-tomography.

Nat Commun 2021 Jun 9;12(1):3441. Epub 2021 Jun 9.

Department of Materials Science and Chemical Engineering, Stony Brook University, Stony Brook, NY, USA.

Three-dimensional bicontinuous porous materials formed by dealloying contribute significantly to various applications including catalysis, sensor development and energy storage. This work studies a method of molten salt dealloying via real-time in situ synchrotron three-dimensional X-ray nano-tomography. Quantification of morphological parameters determined that long-range diffusion is the rate-determining step for the dealloying process. The subsequent coarsening rate was primarily surface diffusion controlled, with Rayleigh instability leading to ligament pinch-off and creating isolated bubbles in ligaments, while bulk diffusion leads to a slight densification. Chemical environments characterized by X-ray absorption near edge structure spectroscopic imaging show that molten salt dealloying prevents surface oxidation of the metal. In this work, gaining a fundamental mechanistic understanding of the molten salt dealloying process in forming porous structures provides a nontoxic, tunable dealloying technique and has important implications for molten salt corrosion processes, which is one of the major challenges in molten salt reactors and concentrated solar power plants.
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http://dx.doi.org/10.1038/s41467-021-23598-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190292PMC
June 2021

Automatic colonic polyp detection using integration of modified deep residual convolutional neural network and ensemble learning approaches.

Comput Methods Programs Biomed 2021 Jul 14;206:106114. Epub 2021 Apr 14.

Department of Electrical and Electronic Engineering, Universiti Teknologi PETRONAS, 32610 Seri Iskandar, Perak, Malaysia. Electronic address:

Background And Objective: The increased incidence of colorectal cancer (CRC) and its mortality rate have attracted interest in the use of artificial intelligence (AI) based computer-aided diagnosis (CAD) tools to detect polyps at an early stage. Although these CAD tools have thus far achieved a good accuracy level to detect polyps, they still have room to improve further (e.g. sensitivity). Therefore, a new CAD tool is developed in this study to detect colonic polyps accurately.

Methods: In this paper, we propose a novel approach to distinguish colonic polyps by integrating several techniques, including a modified deep residual network, principal component analysis and AdaBoost ensemble learning. A powerful deep residual network architecture, ResNet-50, was investigated to reduce the computational time by altering its architecture. To keep the interference to a minimum, median filter, image thresholding, contrast enhancement, and normalisation techniques were exploited on the endoscopic images to train the classification model. Three publicly available datasets, i.e., Kvasir, ETIS-LaribPolypDB, and CVC-ClinicDB, were merged to train the model, which included images with and without polyps.

Results: The proposed approach trained with a combination of three datasets achieved Matthews Correlation Coefficient (MCC) of 0.9819 with accuracy, sensitivity, precision, and specificity of 99.10%, 98.82%, 99.37%, and 99.38%, respectively.

Conclusions: These results show that our method could repeatedly classify endoscopic images automatically and could be used to effectively develop computer-aided diagnostic tools for early CRC detection.
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http://dx.doi.org/10.1016/j.cmpb.2021.106114DOI Listing
July 2021

A 19-Year Experience With Clavicular Defects: An Algorithm for Flap Selection and Surgical Outcomes.

Ann Plast Surg 2021 05;86(5):562-567

Background: The clavicle contributes to the stability and functional integrity of the shoulder. Clavicle bone defects are uncommon, and the strategy for their management is variable.

Method: Six patients presented with clavicle bone defects. The causes were as follows: traumatic defects (2 patients), electric injury (1 patient), osteoradionecrosis (2 patients), and nonunion (1 patient). One patient had upper limb palsy for 40 years, and another had posttraumatic shoulder function impairment. A pedicled pectoralis major myocutaneous flap was used for the patient with a dysfunctional limb, and 5 bone flaps (3 free fibular flaps, 1 free iliac flap, and 1 pedicled rib flap) were used for reconstruction in the other patients.

Result: All flaps (2 pedicled flaps and 4 free flaps) were successfully used for wound repair; the pedicled rib flap demonstrated partial marginal necrosis, and the free fibular flap required reexploration for venous kinking. Five functionally impaired upper limbs showed functional improvements postoperatively.

Conclusion: For functionless composite clavicles and soft tissue defects, a soft tissue flap will be required for wound repair. A bone flap, especially a fibular flap, is required for the upper limb to show functional recovery. The variety of flaps will be planned according to the defect size comparison between the bone and soft tissue, and ipsilateral upper limb function, and a proposed algorithm will be discussed.
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http://dx.doi.org/10.1097/SAP.0000000000002547DOI Listing
May 2021

The Medial Sural Artery Perforator Flap in Lower Extremity Reconstruction.

Clin Plast Surg 2021 Apr 5;48(2):249-257. Epub 2021 Feb 5.

Department of Plastic and Reconstructive Surgery, Chiayi Chang Gung Memorial Hospital, 6, Sec. West, Chia-Pu Road, Putzu City, Chiayi County, Taiwan.

Medial sural artery perforator (MSAP) flap is a thin, pliable, and versatile flap. It is a fasciocutaneous flap with chimeric design capacity. The donor site permits the synchronous harvesting of nonvascularized tendons and nerves. Free MSAP flap is suitable for foot, ankle, and distal one-third of the leg reconstructions. Pedicled MSAP flap is an alternative flap for knee and proximal two-thirds of leg defects, covering classical lower limb reconstruction territories of soleus, medial, and lateral gastrocnemius muscle flap. Computed tomography angiography, indocyanine green, and endoscopic-assist dissection enhances MSAP flap surgical planning and reduces its technical adversities and complications.
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http://dx.doi.org/10.1016/j.cps.2021.01.003DOI Listing
April 2021

Sonoelastography in the Diagnosis of Carpal Tunnel Syndrome: A Systematic Review of Diagnostic Values Compared With the Normative Population.

Ann Plast Surg 2021 03;86(3S Suppl 2):S299-S311

Background: Sonoelastography (SEL) is widely used for assessing tissue stiffness and pathophysiology. It has also been used to diagnose carpal tunnel syndrome (CTS). However, the current criteria to diagnose CTS in SEL are diverse. The aim of this study was to systematically review the literature and assess the diagnostic value of SEL for CTS.

Methods: A literature review was performed using MEDLINE (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles using the keywords sonoelastography and carpal tunnel syndrome. Data related to diagnostic and cutoff value were extracted. Bias assessment was performed.

Results: A total of 121 publications were reviewed. Nineteen primary case series met the inclusion criteria and were selected for full analysis. Different diagnostic approaches were identified, with units/expressions including kilopascals, conduct velocity, and strain ratio. The kilopascals and conduct velocity were measured using shear wave elastography, whereas strain ratio was calculated by relative compression quantification. A mean shear modulus cutoff value from 38.25 to 86 kPa and an acoustic radiation force impulse cutoff value of 3.0 to 3.23 m/s were used to diagnose CTS. Eight articles reported strain ratio between the median nerve and nearby tissues with diverse results due to different reference points. The other 3 additional diagnostic values were reported.

Conclusions: Sonoelastography is a useful noninvasive and promising modality to diagnose CTS. It may reflect both the condition of soft tissue scarring and quantitative values for CTS and median nerve stiffness. A diversity of examination values was found in different modalities. A high level of evidence was absent.
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http://dx.doi.org/10.1097/SAP.0000000000002686DOI Listing
March 2021

End-to-Side Anterior Interosseous Nerve Transfer: A Valuable Alternative for Traumatic High Ulnar Nerve Palsy.

Ann Plast Surg 2021 02;86(2S Suppl 1):S102-S107

From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan.

Background: The prognosis of high ulnar nerve injury is poor despite nerve repair or grafting. Anterior interosseous nerve (AIN) transfers provide a satisfactory recovery. However, the efficacy of end-to-side (ETS) AIN transfer and optimal timing in Sunderland grade IV/V of high ulnar nerve injury is lacking.

Objective: The goals were to compare the outcomes of high ulnar nerve injury managed with ETS AIN transfers with those managed with conventional procedures (nerve repair or graft only) and identify differences between early and delayed transfers.

Methods: Patients with isolated high ulnar nerve injury (Sunderland grade IV/V) from 2010 to 2017 were recruited. Patients with conventional treatments and AIN transfers were designated as the control and AIN groups, respectively. Early transfer was defined as the AIN transfer performed within 8 weeks postinjury. Outcomes were measured and analyzed by the British Medical Research Council (BMRC) score, grip strength, and pinch strength.

Results: A total of 24 patients with high ulnar nerve injury (Sunderland grade IV/V) were included. There were 11 and 13 patients in the control and AIN groups, respectively. In univariate analysis, both early and delayed AIN transfers demonstrated significantly better motor recovery among BMRC score and strength of grip and pinch at 12 months (P < 0.05). No statistical significance was found between early and delayed transfer. In multivariate analysis, both early and delayed transfers were regarded as strong and independent factors for motor recovery of ulnar nerve. Compared with the control, early [odds ratio (OR), 1.83; P < 0.001] and delayed (OR, 1.59; P < 0.001) transfers showed significant improvement with regard to BMRC scores. The pinch strength in early (OR, 31.68; P < 0.001) and delayed (OR, 26.45; P < 0.001) transfers was also significantly better.

Conclusion: The ETS AIN transfer, in either early or delayed fashion, significantly improved intrinsic motor recovery in high ulnar nerve injuries classified as Sunderland grade IV/V. The early transfer group demonstrated a trend toward better functional recovery with less downtime.
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http://dx.doi.org/10.1097/SAP.0000000000002657DOI Listing
February 2021

Unraveling the Crucial Roles of FoxP3+ Regulatory T Cells in Vascularized Composite Allograft Tolerance Induction and Maintenance.

Transplantation 2021 06;105(6):1238-1249

Department of Plastic and Reconstructive Surgery, Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Gueishan, Taiwan.

Background: The role of regulatory T cells (Treg) in tolerance induction of vascularized composite allotransplantation (VCA) remains unclear. This study was designed to examine characteristics of Treg after VCA and their capacity to rescue allografts from rejection.

Methods: Osteomyocutaneous allografts were transplanted from Balb/c to C57BL/6 mice. All mice received costimulatory blockade and a short course of rapamycin. To elucidate the role of Treg for tolerance induction, Treg depletion was performed at postoperative day (POD) 0, 30, or 90. To assess capacity of Treg to rescue allografts from rejection, an injection of 2 × 106 Treg isolated from tolerant mice was applied.

Results: Eighty percent of VCA recipient mice using costimulatory blockade and rapamycin regimen developed tolerance. The tolerant recipients had a higher ratio of circulating Treg to effector T cells and elevated interleukin-10 at POD 30. A significantly higher rejection rate was observed when Treg were depleted at POD 30. But Treg depletion at POD 90 had no effect on tolerance. Treg from tolerant recipients showed stronger suppressive potential and the ability to rescue allografts from rejection. Furthermore, transplanted Treg-containing skin grafts from tolerant mice delayed rejection elicited by adoptively transferred effector T cells to Rag2-/- mice.

Conclusions: Circulating Treg are crucial for inducing VCA tolerance in the early posttransplant phase, and allograft-residing Treg may maintain tolerance. Treg may, therefore, serve as a potential cellular therapeutic to improve VCA outcomes.
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http://dx.doi.org/10.1097/TP.0000000000003509DOI Listing
June 2021

Nano- to microscale three-dimensional morphology relevant to transport properties in reactive porous composite paint films.

Sci Rep 2020 Oct 27;10(1):18320. Epub 2020 Oct 27.

Department of Materials Science and Chemical Engineering, Stony Brook University, Stony Brook, NY, 11794, USA.

The quantitative evaluation of the three-dimensional (3D) morphology of porous composite materials is important for understanding mass transport phenomena, which further impact their functionalities and durability. Reactive porous paint materials are composites in nature and widely used in arts and technological applications. In artistic oil paintings, ambient moisture and water and organic solvents used in conservation treatments are known to trigger multiple physical and chemical degradation processes; however, there is no complete physical model that can quantitatively describe their transport in the paint films. In the present study, model oil paints with lead white (2PbCO·Pb(OH)) and zinc white (ZnO) pigments, which are frequently found in artistic oil paintings and are associated with the widespread heavy metal soap deterioration, were studied using synchrotron X-ray nano-tomography and unilateral nuclear magnetic resonance. This study aims to establish a relationship among the paints' compositions, the 3D morphological properties and degradation. This connection is crucial for establishing reliable models that can predict transport properties of solvents used in conservation treatments and of species involved in deterioration reactions, such as soap formation.
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http://dx.doi.org/10.1038/s41598-020-75040-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591493PMC
October 2020

Does muscle improve validated outcome measures in open tibial fractures? New insights from a cohort study of the anterolateral thigh flap (ALT) versus ALT-Vastus lateralis flaps.

J Plast Reconstr Aesthet Surg 2021 02 15;74(2):268-276. Epub 2020 Sep 15.

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan. Electronic address:

The benefits of the muscle in open lower limb fractures remain to be determined. This study compared statistically equivalent groups of open tibial fractures treated by free anterolateral thigh (ALT) flaps or ALT flaps incorporating muscle (ALT-Vastus lateralis/ALT- VL). Method and Results: Chang Gung Memorial Hospital, Taiwan, 2004-2008, 49 free flaps in open lower limb fractures (38 open tibial) were specifically reconstructed with free ALT or ALT-VL flaps. Risk factors for non-union: equivalent between the two groups, with no differences in smoking, steroids, diabetes, time to flap and the AO classification of soft tissue and bone injury. Comparison of union rates: no difference was noted between groups in the Radiographic Union Score in Tibial Fractures (RUST) at 3, 6, 9 and 12 months. The only factor significantly associated with non-union was presence of a SPRINT trial defined 'critical' bone defect with odds ratio 14.4 (95% CI 1.36 - 131.5), with no association with AO bone classification, flap type, comorbidity or flap size. Patient-reported outcomes: the ALT-VL group showed improved patient satisfaction (p = 0.01, Cohen's d = 1.1). Functional outcomes (Enneking score) were not statistically significant, but the ALT-VL group trended towards significance in function and skin quality domains. Conclusions: Based on the results of this study, one can conclude that the degree of bone injury (specifically a 'critical' defect) is of greater relevance than flap choice with regard to fracture consolidation. Muscle does not result in improvements to union, the speed of union or deep infection. However, better PROMs may be related to the inclusion of the muscle around the fracture site.
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http://dx.doi.org/10.1016/j.bjps.2020.08.097DOI Listing
February 2021

The Medial Sural Artery Perforator Flap: Lessons Learned from 200 Consecutive Cases.

Plast Reconstr Surg 2020 11;146(5):630e-641e

From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University.

Background: The medial sural artery perforator flap is a versatile option in reconstructive microsurgery. However, most reports of this flap have been limited by sample size. This study reviews the experience of a single large-volume center using the medial sural artery perforator flap and its variants for a variety of reconstructive purposes.

Methods: A retrospective review of all patients who received the medial sural artery perforator flap reconstruction between March of 2006 and July of 2014 was performed.

Results: Two-hundred medial sural artery perforator flaps were used at three anatomical regions: head and neck (n = 129), upper extremity (n = 47), and lower extremity (n = 24). Flaps were transferred as free (n = 189) and pedicled (n = 11). Overall flap survival was 96 percent. Flap variants used included chimeric flap (n = 11) and dual skin paddle (n = 2). Plantaris tendon and saphenous/sural nerve graft were harvested in conjunction in 20 and seven patients, respectively. In 5 percent of the cases harvested in the conventional manner, a reliable perforator could not be found.

Conclusions: The medial sural artery perforator flap is a reliable, alternative workhorse flap for nearly any small- to medium-size defect. It can be harvested as free or pedicled and the option to include multiple tissue components further expands its versatility.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007282DOI Listing
November 2020
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