Publications by authors named "Hung-Chi Chen"

384 Publications

Manual lymphatic drainage guided by real-time indocyanine green lymphography in breast cancer-related lymphedema.

Arch Plast Surg 2021 Mar 15;48(2):239-240. Epub 2021 Mar 15.

Department of Surgical, Microsurgical and Medical Sciences, Plastic Surgery Unit, University of Sassari, Sassari, Italy.

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http://dx.doi.org/10.5999/aps.2020.01823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007464PMC
March 2021

Streptococcus pneumoniae endophthalmitis: clinical settings, antibiotic susceptibility, and visual outcomes.

Sci Rep 2021 Mar 18;11(1):6195. Epub 2021 Mar 18.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Streptococcus pneumoniae endophthalmitis is clinically more severe, more difficult to treat, and carry a higher risk of vision loss, evisceration, or enucleation. This study is to investigate the clinical settings, antibiotic susceptibility, and visual outcomes of S. pneumoniae endophthalmitis at a tertiary referral center in Taiwan. S. pneumoniae endophthalmitis was diagnosed in 38 eyes of 38 patients. The main clinical features were postcataract endophthalmitis (n = 13, 34%) and endophthalmitis associated with corneal ulcer (n = 12, 32%), trauma (n = 6, 16%), endogenous etiology (n = 4, 11%), trabeculectomy (n = 2, 5%), and pterygium excision-related scleral ulcer (n = 1, 3%). Presenting visual acuity ranged from counting fingers to no light perception. Pars plana vitrectomy with intravitreal antibiotics was performed in 17 eyes (39%) in primary or secondary treatments. S. pneumoniae isolates were susceptible to vancomycin (38/38, 100%), penicillin (37/38, 97%), ceftriaxone (37/38, 97%), cefuroxime (12/15, 80%), levofloxacin (13/15 ,87%), and moxifloxacin (15/17, 88%). Final visual acuity was better than 20/400 in 3 of 38 eyes (8%), 5/200 to hand motions in 3 eyes (8%), and light perception to no light perception in 32 eyes (84%). Ten eyes (26%) underwent evisceration or enucleation. Although S. pneumoniae isolates were susceptible to vancomycin, S. pneumoniae endophthalmitis had a very poor visual prognosis.
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http://dx.doi.org/10.1038/s41598-021-85456-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973428PMC
March 2021

MicroRNA-126 inhibits pathological retinal neovascularization via suppressing vascular endothelial growth factor expression in a rat model of retinopathy of prematurity.

Eur J Pharmacol 2021 Mar 13;900:174035. Epub 2021 Mar 13.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan. Electronic address:

Vascular endothelial growth factor (VEGF) is the principal growth factor responsible for the retinal neovascularization in the pathogenesis of retinopathy of prematurity (ROP). Current therapies for ROP include laser ablation and intravitreal anti-VEGF injection. However, these treatments either destroy the peripheral retina or associate with problems of persistent peripheral avascular retina or later recurrence of ROP. In the present study we investigated a new therapeutic approach by exploring the potential role of a specific microRNA, miR-126, in regulating VEGFA expression and retinal neovascularization in a rat oxygen-induced retinopathy (OIR) model. We demonstrated that miR-126 mimic and plasmid effectively suppresses VEGFA mRNA expression in both human and rat retinal pigment epithelium cell lines, quantified with qRT-PCR. Animal experiments on rat OIR model revealed that intravitreal injection of miR-126 plasmid efficiently downregulated VEGFA expression in the intraocular fluid and retinal tissues measured by ELISA, and significantly suppressed retinal neovascularization, which was confirmed by calculating sizes of neovascularization areas on fluorescence microscopic images of flat mounted retina stained with Alexa Fluor 594-conjugated isolectin B4 to visualize blood vessels. Together, these results showed that intravitreal injection of miR-126 plasmid could inhibit retinal neovascularization by down-regulating VEGFA expression, suggesting a potential therapeutic effect for ROP.
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http://dx.doi.org/10.1016/j.ejphar.2021.174035DOI Listing
March 2021

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm.

Microsurgery 2021 Mar 24;41(3):223-232. Epub 2021 Feb 24.

Department of Plastic Reconstructive and Aesthetic Surgery, China Medical University Hospital, Taichung, Taiwan.

Background: Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm.

Methods: From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery.

Results: The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants.

Conclusion: Immediate reexploration is mandatory to salvage the flap.
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http://dx.doi.org/10.1002/micr.30720DOI Listing
March 2021

Extraneous E-Cadherin Engages the Deterministic Process of Somatic Reprogramming through Modulating STAT3 and Erk1/2 Activity.

Cells 2021 Jan 31;10(2). Epub 2021 Jan 31.

Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.

Although several modes of reprogramming have been reported in different cell types during iPSC induction, the molecular mechanism regarding the selection of different modes of action is still mostly unknown. The present study examined the molecular events that participate in the selection of such processes at the onset of somatic reprogramming. The activity of STAT3 versus that of Erk1/2 reversibly determines the reprogramming mode entered; a lower activity ratio favors the deterministic process and vice versa. Additionally, extraneous E-cadherin facilitates the early events of somatic reprogramming, potentially by stabilizing the LIF/gp130 and EGFR/ErbB2 complexes to promote entry into the deterministic process. Our current findings demonstrated that manipulating the pSTAT3/pErk1/2 activity ratio in the surrounding milieu can drive different modes of action toward either the deterministic or the stochastic process in the context of OSKM-mediated somatic reprogramming.
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http://dx.doi.org/10.3390/cells10020284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912071PMC
January 2021

Gelatin scaffold with multifunctional curcumin-loaded lipid-PLGA hybrid microparticles for regenerating corneal endothelium.

Mater Sci Eng C Mater Biol Appl 2021 Jan 26;120:111753. Epub 2020 Nov 26.

Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan. Electronic address:

Corneal transplantation is currently the only approach to cure corneal blindness. Cell-based strategies that employ corneal endothelial cells (CECs) grown on supporting biomaterials hold great promise as possible alternative therapies for treating corneal endothelial dysfunction. Nevertheless, most biomaterials are used merely because of their robust mechanical properties, providing passive physical support for the transplantation of CEC monolayers. Based on the versatility of curcumin in ophthalmic applications, this study aims to develop a multifunctional scaffold system that can not only support the function and transplantation of CECs but also prevents post-engraftment complications by sustained curcumin release, thus enhancing the long-term success of CEC engraftment. Curcumin-loaded lipid-poly(lactic-co-glycolic acid) (PLGA; Cur@MPs) hybrid microparticles (MPs) fabricated using an oil-in-water single emulsion method are embedded into gelatin-based scaffolds. The anti-inflammatory, antioxidative, and anti-angiogenic potentials of the developed scaffolds and their capacity in supporting CEC monolayer formation are evaluated. The Cur@MPs are capable of promoting CEC proliferation, protecting CECs from oxidative stress-induced cell death via modulating Nrf2/HO-1 signaling axis, suppressing the secretion of pro-inflammatory cytokines by macrophages, and inhibiting the migration and angiogenesis of vascular endothelial cells. By incorporating the Cur@MPs into a thin gelatin membrane, the fabricated scaffold is able to support the growth and organization of CECs into a polygonal morphology with tight junctions. These experimental results demonstrate the potential of the Cur@MPs-loaded gelatin scaffold for actively supporting the survival and function of CEC monolayers after transplantation.
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http://dx.doi.org/10.1016/j.msec.2020.111753DOI Listing
January 2021

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

J Reconstr Microsurg 2021 Jan 31. Epub 2021 Jan 31.

Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.

Background:  Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN.

Methods:  This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared.

Results:  Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%,  = 13/70 vs. 46.7%,  = 7/15,  = 0.020, Chi-square test).

Conclusion:  Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.
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http://dx.doi.org/10.1055/s-0040-1722647DOI Listing
January 2021

Microvascular anastomosis in atherosclerotic vessels: Technical challenges and recommendations.

J Plast Reconstr Aesthet Surg 2021 Jan 7. Epub 2021 Jan 7.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1016/j.bjps.2020.12.075DOI Listing
January 2021

Voice tube shortening in voice reconstruction with ileo-colon FLAP: Technical tips for a safe revision and improvement of voice quality.

J Plast Reconstr Aesthet Surg 2020 Dec 24. Epub 2020 Dec 24.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, No. 91, Xueshi Road, North District, Taichung City 404, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.bjps.2020.12.038DOI Listing
December 2020

Clinico-microbiological profile of Burkholderia cepacia keratitis: a case series.

Ann Clin Microbiol Antimicrob 2021 Jan 7;20(1). Epub 2021 Jan 7.

Department of Ophthalmology, Chang Gung Memorial Hospital, No. 199, Tung-Hwa North Road, Linkou, Taipei, Taiwan.

Background: Burkholderia cepacia, an opportunistic pathogen mainly affecting patients with cystic fibrosis or immunocompromised, has rarely been documented as a cause of corneal infection. The clinical and microbiological profiles of B. cepacia keratitis are reported herein.

Methods: We retrospectively reviewed the medical record of 17 patients with culture-proven B. cepacia keratitis, treated between 2000 and 2019 at Chang Gung Memorial Hospital, Taiwan. Our data included predisposing factors, clinical presentations, treatments, and visual outcomes of B. cepacia keratitis as well as the drug susceptibility of the causative agent.

Results: The most common predisposing factor for B. cepacia keratitis was preexisting ocular disease (seven, 41.2%), particularly herpetic keratitis (five). Polymicrobial infection was detected in seven (41.2%) eyes. All B. cepacia isolates were susceptible to ceftazidime. Main medical treatments included levofloxacin or ceftazidime. Surgical treatment was required in five (29.4%) patients. Only four (23.5%) patients exhibited final visual acuity better than 20/200.

Conclusions: B. cepacia keratitis primarily affects patients with preexisting ocular disease, particularly herpetic keratitis, and responds well to ceftazidime or fluoroquinolones. However, the visual outcomes are generally poor.
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http://dx.doi.org/10.1186/s12941-020-00407-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792197PMC
January 2021

Potential Role and Significance of Ocular Demodicosis in Patients with Concomitant Refractory Herpetic Keratitis.

Clin Ophthalmol 2020 23;14:4469-4482. Epub 2020 Dec 23.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taoyuan, 333, Taiwan.

Purpose: To evaluate the role of Demodex infestation of the eyelids in patients with recurrent herpetic keratitis.

Patients And Methods: This is a retrospective and noncomparative case series. Twenty-seven patients with ocular demodicosis and recurrent herpetic keratitis under conventional treatments were enrolled. Demographic data and clinical photographs were collected. Ocular demodicosis was confirmed by eyelash examination under a microscope. Eyelid scrub was initiated in these patients after proving Demodex infestation. Response after treatment was reviewed.

Results: Herpetic keratitis was characterized by epithelial defect, including dendritic lesions (seven eyes, 25.9%), geographic ulcer (three eyes, 11.1%), and neurotrophic ulcer (two eyes, 7.4%), associated with stromal involvement in 12 cases. Six cases with stromal reactivation, including disciform keratitis (two eyes, 7.4%), immune ring (three eyes, 11.1%), and ghost vessel (one eye, 3.7%), presented no epithelial defect. Active anterior uveitis with keratic precipitates was found in 15 cases. Demodex blepharitis was diagnosed with cylindrical dandruff along their lashes in all patients. Other ocular findings include meibomian gland dysfunction (15 eyes, 55.6%), mal-aligned lashes (eight eyes, 29.6%), telangiectasia (14 eyes, 51.9%), conjunctivitis (18 eyes, 66.7%), and ocular rosacea (three eyes, 11.1%). Initial unstable clinical presentations showed deterioration of corneal melting into descemetocele, corneal perforation, recalcitrant stromal infiltration/uveitis, and uncontrollable IOP, despite antiherpetic medication. After treatment of Demodex blepharitis, infestation was under control, followed by subjective improvement of ocular symptoms and a stable clinical outcome.

Conclusion: Ocular demodicosis should be considered in patients with unstable recurrent herpetic keratitis. A prompt diagnosis and appropriate treatment may curb the progression of herpetic corneal infection.
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http://dx.doi.org/10.2147/OPTH.S282059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767725PMC
December 2020

How to Perform a Safe, Quick, and Easy Suture Technique for Microvascular Anastomosis, Where a Single Surgeon Works Alone: The Parachute Technique.

Facial Plast Surg 2020 Dec 24;36(6):778-780. Epub 2020 Dec 24.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1055/s-0040-1717091DOI Listing
December 2020

A single-stage triple-inset vascularized gastroepiploic lymph node transfers for the surgical treatment of extremity lymphedema.

Microsurgery 2021 01 19;41(1):97-99. Epub 2020 Dec 19.

Division of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1002/micr.30696DOI Listing
January 2021

Accelerated corneal endothelial cell loss in two patients with granulomatosis with polyangiitis following phacoemulsification.

BMC Ophthalmol 2020 Dec 7;20(1):480. Epub 2020 Dec 7.

Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Linkou, Taoyuan, 33305, Taiwan.

Background: Generally, the loss rate of human endothelial cells (HCEC) in routine cataract surgery is 8.5%. When the corneal endothelial cells density (ECD) drops, the HCEC may decompensate to keep cornea dehydration which leads to corneal edema. Granulomatosis with polyangiitis (GPA) is an uncommon autoimmune disease involving multiple organs including eyes such as conjunctivitis, scleritis, uveitis, and corneal ulcer. In this study, we report two cases of GPA whose corneal ECD decreased significantly after phacoemulsification cataract surgery.

Case Presentation: In the first case of 69-year-old male with GPA, the ECD dropped 39.6% (OD) four months after phacoemulsification and 38.1% (OS) six months postoperatively respectively. At the final follow-up, the residual ECD was only 55% in the right eye in the 49 month, and 56% remained in the left eye in the 39 month. In the second case of 54-year old female, left ECD dropped 63.9% at the 4 month after surgery and 69.6% ECD remained at the 15 month postoperatively while similar ECD of right eye before and after left eye surgery.

Conclusion: Extensive preoperative ophthalmic evaluation and meticulous postoperative inflammation control should be applied to prevent severe loss of HCEC in GPA patients.
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http://dx.doi.org/10.1186/s12886-020-01752-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720459PMC
December 2020

Modified Clavien-Dindo Classification and Outcome Prediction in Free Flap Reconstruction among Patients with Head and Neck Cancer.

J Clin Med 2020 Nov 22;9(11). Epub 2020 Nov 22.

Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung 404332, Taiwan.

Because of limitations caused by unique complications of free flap reconstruction, the Clavien-Dindo classification was modified to include grade "IIIc" for "partial or total free flap failure." From 2013 to 2018, 116 patients who had undergone free flap reconstruction for head and neck cancer with grade III or higher postoperative complications were grouped using the "Modified" Clavien-Dindo classification. Alcoholism displayed significant predictive effects between grade IIIb and IIIc (72.7% vs. 50%, = 0.028). Significant differences were observed between grade IIIb and IIIc in the duration of hospital stay (23.1 ± 10.1 vs. 28.6 ± 11.9 days, = 0.015), duration of intensive care unit stay (6.0 ± 3.4 vs. 8.7 ± 4.3 days, = 0.001), reoperation times during the current hospitalization (1.4 ± 0.8 vs. 2.0 ± 1.0 times, < 0.001), and wound infection rate (29.9% vs. 62.5%, = 0.002). The severity levels were significantly positively correlated with reoperation times during the current hospitalization ( < 0.001), ICU stay ( = 0.001), and hospital stay ( < 0.001). The modified Clavien-Dindo classification with grade IIIc describes the perioperative complications of head and neck free flap reconstruction to predict clinical outcomes based on severity.
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http://dx.doi.org/10.3390/jcm9113770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700532PMC
November 2020

The Existence of Periodontal Disease and Subsequent Ocular Diseases: A Population-Based Cohort Study.

Medicina (Kaunas) 2020 Nov 18;56(11). Epub 2020 Nov 18.

Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan.

We aimed to evaluate the correlation between periodontal disease (PD) and following ocular diseases via the National Health Insurance Research Database in Taiwan. A retrospective cohort study was conducted. Subjects were regarded as having PD according to the diagnostic codes. For comparison, each subject with PD was matched to one non-PD individual from the database after exclusion. The main outcome was defined as the development of infectious keratitis, endophthalmitis, orbital cellulitis, lacrimal duct infection, uveitis and infectious scleritis. Cox proportional hazard regression was used to yield the adjusted hazard ratios (aHR) of ocular diseases between the study and control groups. A total of 426,594 subjects were enrolled in both the study and control groups. In the multivariable analysis, significantly higher rates of infectious keratitis (aHR: 1.094, 95% CI: 1.030-1.161), uveitis (aHR: 1.144, 95% CI: 1.074-1.218) and infectious scleritis (aHR: 1.270, 95% CI: 1.114-1.449) were found in the study group. Concerning the PD interval, infectious keratitis (aHR: 1.159, 95% CI: 1.041-1.291) and infectious scleritis (aHR: 1.345, 95% CI: 1.055-1.714) would significantly occur in PD patients with an interval shorter than two years, individuals with a PD interval that ranged from two to five years were under a higher risk of developing uveitis (aHR: 1.184, 95% CI: 1.065-1.315) and infectious scleritis (aHR: 1.386, 95% CI: 1.125-1.708), and the rate of uveitis (aHR: 1.149, 95% CI: 1.038-1.272) was significantly higher if PD persisted more than five years. The presence of PD was moderately associated with the risk of developing infectious keratitis, uveitis and infectious scleritis.
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http://dx.doi.org/10.3390/medicina56110621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698707PMC
November 2020

Correction of Myopic Astigmatism with Topography-Guided Laser In Situ Keratomileusis (TOPOLINK).

Healthcare (Basel) 2020 Nov 11;8(4). Epub 2020 Nov 11.

Department of Medicine, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan.

We aim to assess the feasibility of topography-guided laser in situ keratomileusis (TOPOLINK) for correcting pre-existing and surgical-induced astigmatism. A retrospective, single center cohort study was conducted. Patients with pre-existing irregular myopic astigmatism were recruited into the primary group and those with irregular myopic astigmatism following laser in situ keratomileusis (LASIK) were recruited into the enhancement group. The changes in uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), maximum astigmatism, spherical equivalent (SE) and patient satisfaction were recorded. The Chi-square test, Mann-Whitney U test and Generalized Linear Mixed Model were utilized for the analysis in the current study. A total of 18 eyes were studied in the primary group and 14 eyes were examined in the enhancement group. One year postoperatively, the UCVA, BCVA, maximum astigmatism and SE improved significantly in both the primary and the enhancement groups (all < 0.05). The UCVA ( = 0.046) and SE ( = 0.003) were worse in the primary group preoperatively but became similar in both groups postoperatively, while the BCVA and maximum astigmatism remained identical between groups throughout the study period (all < 0.05). In addition, the rate of high and moderate satisfaction reached 90.0% in the primary and the enhancement groups, without significant differences ( = 0.871). In conclusion, the TOPOLINK showed high predictability and will contribute to similar outcomes between primary and postoperative irregular myopic astigmatism concerning visual acuity, refractive status and subject satisfaction.
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http://dx.doi.org/10.3390/healthcare8040477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712020PMC
November 2020

The "Crater" Arteriotomy: A Technique Aiding Precise Intimal Apposition in End-to-side Microvascular Anastomosis.

Plast Reconstr Surg Glob Open 2020 Oct 28;8(10):e3014. Epub 2020 Oct 28.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

End-to-side arterial anastomoses require a high level of technical competency. The main challenge to a successfully patent anastomosis is intimal interposition during the standardized microvascular suturing. Technical errors during arteriotomy pose a significant challenge for the microsurgical technique, making the end-to-side anastomosis prone to failure. We describe a basic yet fundamental method of performing an arteriotomy, the "crater" technique, which facilitates good visualization of all vessel layers before placement of microsurgical sutures. Using curved microsurgical scissors, the adventitia layer is dissected off the outer surface of the side vessel, a V-shaped cut is then made obliquely at a 30-45 degrees angle to the longitudinal axis of the vessel, and a full thickness oblique cut is made along an elliptical circumference, as the curved scissors enable the creation of a slope-like crater. This concept ensures the intimal layer is adequately exposed through the complete circumference of the arteriotomy rim, while enabling a variable increase in the arterial wall hypotenuse-width circumference. When performed in a standardized manner, the crater arteriotomy can minimize the risk of endothelial misalignment and further technical errors during suturing, thus minimizing the risk of anastomotic failure.
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http://dx.doi.org/10.1097/GOX.0000000000003014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647664PMC
October 2020

Ocular manifestation, comorbidities, and detection of severe acute respiratory syndrome-coronavirus 2 from conjunctiva in coronavirus disease 2019: A systematic review and meta-analysis.

Taiwan J Ophthalmol 2020 Jul-Sep;10(3):153-166. Epub 2020 Sep 16.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan.

The coronavirus disease 2019 (COVID 19) pandemic has presented major challenges to ophthalmologists. Reports have shown that ocular manifestations can be the first presenting symptoms of COVID 19 infection and conjunctiva may be a portal of entry for the severe acute respiratory syndrome (SARS) associated coronavirus 2 (SARS CoV 2). The purpose of this article is to provide general guidance for ophthalmologists to understand the prevalence of ocular presentation in COVID 19 patients and to reduce the risk of transmission during practice. Relevant studies published in the period of November 1, 2019, and July 15, 2020, regarding ocular manifestations of COVID 19 and detection of SARS CoV 2 in the eye were included in this systematic review and meta analysis. The pooled prevalence of the ocular manifestations has been estimated at 7% (95% confidence interval [CI]: 0.03-0.10) among COVID 19 patients. The pooled detection rate of SARS CoV 2 from conjunctiva was low (1%, 95% CI: 0.00-0.03). Conjunctival symptoms were the most common ocular manifestations in COVID 19, but the positive detection rate of the SARS CoV 2 virus by reverse transcription-polymerase chain reaction of conjunctival tears or secretions remained low. No study has shown a definite transmission of COVID 19 through ocular mucosa or secretions. In summary, ocular manifestations in COVID 19 patients commonly comprise ocular surface symptoms. Although a low prevalence of ocular symptoms was encountered among patients infected by SARS CoV 2, it is imperative for all ophthalmologists to understand the full spectrum of COVID 19 symptoms or signs including those of the eyes as well as to adopt appropriate protective measures during clinical practice.
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http://dx.doi.org/10.4103/tjo.tjo_53_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585479PMC
September 2020

Exophthalmos myxedema acropachy syndrome.

Postgrad Med J 2020 Sep 22. Epub 2020 Sep 22.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan

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http://dx.doi.org/10.1136/postgradmedj-2020-138668DOI Listing
September 2020

Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema.

J Plast Reconstr Aesthet Surg 2021 01 21;74(1):168-173. Epub 2020 Aug 21.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan. Electronic address:

The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.
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http://dx.doi.org/10.1016/j.bjps.2020.08.042DOI Listing
January 2021

Proposed measures to be taken by ophthalmologists during the coronavirus disease 2019 pandemic: Experience from Chang Gung Memorial Hospital, Linkou, Taiwan.

Taiwan J Ophthalmol 2020 Apr-Jun;10(2):80-86. Epub 2020 May 6.

Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Purpose: Although Taiwan was one of the first countries to develop coronavirus disease 2019 (COVID-19), with effective antiepidemic measures, Taiwan has effectively controlled the spread of the disease. The purpose of this article is to provide useful safety strategies for ophthalmologists in daily practice during the COVID-19 pandemic.

Materials And Methods: Infection control strategies in the hospital and Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, are discussed.

Results: Ophthalmologists are at high risk of contracting COVID-19 infection, as they have close contact with patients during ocular examinations, and are also facing high patient volume in outpatient clinics as well as emergency consultations. Furthermore, ocular symptoms, such as conjunctivitis, may be the presenting signs of COVID-19 infection. We provide our strategies, which include hospital's gate control with triage station, patient volume control, proper personal protective equipment, and consultation with telemedicine technology, to decrease the risk of cross-infection between medical staffs and patients.

Conclusion: To achieve the goal of preventing viral spread and maximizing patient and medical staffs' safety, besides providing proper protective equipment, it is also crucial for staffs and patients to strictly follow antiepidemic measures. We hope that our experience can help ophthalmologists and health-care workers to have a safer working environment when facing COVID-19 pandemic.
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http://dx.doi.org/10.4103/tjo.tjo_21_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442097PMC
May 2020

How to ensure immediate and long-term good blood supply by the careful dissection of the marginal artery and supercharge with neck vessels in esophageal reconstruction with the colon segment interposition: 35 years of experience.

J Plast Reconstr Aesthet Surg 2021 01 14;74(1):101-107. Epub 2020 Aug 14.

Department of Plastic Surgery, China Medical University Hospital, 2 Yuh-Der Road, Taichung 40447, Taiwan.

Background: Colon interposition for total esophageal replacement cases represents one of the most challenging procedures in surgery. A retrospective study has been conducted and suggestions are proposed according to the analysis of 268 patients who underwent colon interposition for esophageal replacement. Complication rates and the duration of hospital stay were retrospectively analyzed.

Methods: A total of 268 patients were operated between 1984 and 2018. In group 1, 164 patients underwent colon interposition without supercharging with neck vessels and in group 2, 104 patients underwent colon interposition with supercharging. Data regarding flap loss, anastomotic leakage, the duration of hospital stay, and stricture formation in the long-term were statistically analyzed and compared between two groups.

Results: The success rate of reconstruction was 98,1% (161 of 164 patients) and 99% (103 of 104 patients) for group 1 and 2, respectively. Early complication (anastomotic leakage) rate was 4,9% in group 1 and 1% in group 2. The differences between two groups regarding flap loss and anastomotic leakage rates were not statistically significant (p = 0,495 and p = 0,077, respectively). The hospital stay was 26,3 days for patients without supercharging (group1) and 20,5 days for patients with supercharging (group 2). In group 1, 6,7% (11/164) of patients had narrowing at the junction of the pharynx and colon; however, in group 2, proximal anastomotic stricture formation was observed in only 1% (1/104) of the patients. The stricture rate was significantly lower in group 2 when compared to group 1 (p = 0,021).

Conclusion: The careful dissection of the marginal artery and supercharging with neck vessels provide lower complication rates in colon interposition for esophageal reconstruction.
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http://dx.doi.org/10.1016/j.bjps.2020.08.013DOI Listing
January 2021

Filamentous Fungal Keratitis in Taiwan: Based on Molecular Diagnosis.

Transl Vis Sci Technol 2020 07 21;9(8):32. Epub 2020 Jul 21.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.

Purpose: To analyze the epidemiological pattern, demographics, risk factors, and treatment outcomes of filamentous fungal keratitis at a tertiary hospital in Taiwan.

Methods: We recruited 65 patients (65 eyes) with culture-proven filamentous fungal keratitis who received diagnosis and treatment at Chang Gung Memorial Hospital between 2015 and 2018. All isolates were examined through conventional morphological identification and subjected to molecular identification with internal transcribed spacer sequencing. Data on patient demographics, predisposing factors, and treatment outcomes were collected.

Results: In total, filamentous fungi belonged to 16 genera were identified. spp. (29 cases [44.6%]) was the most commonly isolated organism overall, followed by spp. and (seven cases [10.8% for each]), and spp. (six cases [9.2%]). Some fungi that have not been regarded as human pathogens were also identified, such as and . Among 52 (80%) patients with predisposing factors, 30 (46.2%) had trauma. The ulcers of 33 (50.8%) patients resolved with medical treatment only. Additionally, six patients (9.2%) had corneal perforation, and nine patients (13.9%) required therapeutic/destructive surgical interventions including therapeutic penetrating keratoplasty (seven patients) or evisceration (two patients). Only 16 patients (24.6%) had final visual acuity of 20/40 or better.

Conclusions: Through molecular diagnosis, a high diversity of fungal pathogens was revealed along with an increasing incidence of and in Taiwan. The most common risk factor for filamentous fungal keratitis was trauma. The visual outcomes were guarded.

Translational Relevance: The molecular diagnosis provides insight into accurate identification, which affects the epidemiology and diversity of pathogens of filamentous fungal keratitis.
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http://dx.doi.org/10.1167/tvst.9.8.32DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7422771PMC
July 2020

A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy.

Microsurgery 2021 Jan 26;41(1):34-43. Epub 2020 Aug 26.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

Background: There is no consensus on the appropriate treatment of lymphedema. Proposed techniques include lymphaticovenous anastomosis (LVA), vascularized lymph nodes transfer (VLNT), and suction lipectomy (SL). The benefit of combined procedures has also been postulated. In this prospective study, a combined protocol is proposed as an alternative to single-procedure strategies.

Methods: Between January 2016 and October 2018, we enrolled patients with secondary lymphedema of lower limbs, stage II-III according to the International Society of Lymphology, progressive swelling and skin tonicity >60. Thirty-seven consecutive patients were dichotomized into group I, undergoing VLNT, and group II undergoing VLNT and LVA. Gastroepiploic lymphnode flap was harvested through laparoscopy, and in the same operation, LVAs were performed in group II on the basis of indocyanine green lymphography and patent blue findings. Two weeks later, SL was performed in all the patients. Patients were prospectively evaluated through clinical examination, circumference measurement, and skin tonicity.

Results: The average follow-up was 2 ± 0.8 years. The first consecutive 21 patients were treated with VLNT followed by SL. The next 16 patients underwent combined VLNT and LVA, followed by SL. A mean of 2.4 LVAs were performed. A significant difference in the postoperative circumference measurements was found overall (p < .05): 52.6 ± 18.9 above the knee, 42.9 ± 25 below the knee, 36.2 ± 37 at foot. The postoperative tonicity dropped by 12.7 ± 6.3% (p < .05). The episodes of cellulitis significantly decreased to 0.1 ± 0.3 (p < .05).

Conclusions: LVA, VLNT, and SL can be integrated together in a combined approach, in synergy to enhance the outcomes.
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http://dx.doi.org/10.1002/micr.30641DOI Listing
January 2021

Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts.

Mayo Clin Proc 2020 Aug 20. Epub 2020 Aug 20.

Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.

Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
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http://dx.doi.org/10.1016/j.mayocp.2020.01.006DOI Listing
August 2020

Pharyngoesophageal reconstruction with free jejunum or radial forearm flap as diversionary conduit: Functional outcomes of patients with persistent dysphagia and aspiration.

Microsurgery 2020 Sep 7;40(6):630-638. Epub 2020 Aug 7.

Department of Plastic Surgery, China Medical University, Taichung, Taiwan.

Background: A diversion loop provides an alternative pathway for food intake from the bucco-gingival sulcus into the thoracic esophagus. Therefore, the bolus does not pass via pharynx where choking may occur in case of severe dysphagia. The data about outcomes and complications of the diversionary procedure are short and they refer to small cohort with brief follow-up.

Methods: This retrospective study analyzed data of 48 patients, mean aged 34.3 years (range, 22-58 years), undergoing the creation of a diversion loop in two stages. Patients complained of aspiration, choking, and dysphagia. Swallowing disorders were caused by corrosive injury, radiation damage, or neurologic injury, and were investigated through laryngoscopy and esophagography. A diversion loop was created in 45 cases with free jejunal flap and in 3 cases with radial forearm flap. Complications, functional outcomes, and revision rate were reviewed. The mean follow-up was 26.3 months.

Results: We reported one failure (2%) and one partial necrosis of the free flaps. The most frequent complication was hematoma (8%). One case of esophagocutaneous fistula (2%) and two cases of stricture (4%) were also observed. Forty-two patients (87%) took all of the daily diet from their mouths through the diversionary conduit. A poor functional outcome was significantly associated with pre-operative radiotherapy (p < .0001).

Conclusions: The diversion loop offers an alternative route for alimentation. Patients are freed from their choking obsession; moreover, they are rehabilitated into society without the drawbacks of permanent jejunostomy feeding. The technique was upgraded with caudal marginal mandibulectomy to improve the outcomes. Patients undergoing a diversionary procedure due to radiation damage should be carefully informed about the expected functional results.
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http://dx.doi.org/10.1002/micr.30623DOI Listing
September 2020

Preliminary dissection of recurrent laryngeal nerve during esophageal reconstruction for corrosive esophageal injury.

Microsurgery 2020 Oct 9;40(7):825-826. Epub 2020 Jul 9.

Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.

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http://dx.doi.org/10.1002/micr.30624DOI Listing
October 2020

Combined Free Fibula Osteocutaneous and Anterolateral Thigh-Vastus Lateralis Free Flaps for Clavicule and Extensive Chest Wall Reconstruction After Sarcoma Resection.

Cureus 2020 Jun 1;12(6):e8391. Epub 2020 Jun 1.

Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, TWN.

Combined extensive chest and neck reconstructions is a challenging procedure. The rapid development in microvascular surgery has allowed the cancer surgeons to successfully resect and reconstruct advanced malignancies in the neck and thoracic region. Herein we present a young female diagnosed with malignant mesenchymal sarcoma of the right side of the neck extending to right upper lung and anterior mediastinum. The patient was successfully treated with two microvascular free flaps in a multidisciplinary approach. Wide local resection of the tumor was done along with removal of right upper pulmonary lobe and the subclavian vessels. Vascular reconstruction was done with polytetrafluoroethylene grafts. A free fibula osteocutaneous flap was used for stabilization and reconstruction of the clavicle. Anterolateral thigh flap with vastus lateralis muscle was used for soft tissue reconstruction. All flaps survived and the patient had a good recovery at three months of follow-up. Future reports suggesting guidelines or algorithms for complex chest wall reconstruction should benefit of similar scenarios to the one reported here.
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http://dx.doi.org/10.7759/cureus.8391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331900PMC
June 2020

Myopia in school-aged children with preterm birth: the roles of time spent outdoors and serum vitamin D.

Br J Ophthalmol 2021 Apr 19;105(4):468-472. Epub 2020 Jun 19.

Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan

Aims: To analyse the factors associated with myopia in school-aged children with preterm birth and with or without retinopathy of prematurity (ROP).

Methods: Children born prematurely between January 2010 and December 2011 were enrolled in this cross-sectional study when they reached school age between April 2017 and June 2018 in a referral centre. The main parameters were cycloplegic refraction, time spent outdoors and serum 25-hydroxyvitamin D (25(OH)D) concentration.

Results: A total of 99 eyes from 99 children with a mean age of 6.8 years underwent analysis. The average time spent outdoors was significantly higher in the non-myopic group (0.9 ± 0.5 hours/day) than in the myopic group (0.7 ± 0.3 hours/day) ( = 0.032). After adjustment for age, sex, number of myopic parents, ROP severity, near-work time and serum 25(OH)D concentration, more time spent outdoors was correlated with a lower odds of myopia (OR, 0.13 per additional hour per day; 95% CI, 0.02-0.98; = 0.048). Mean serum 25(OH)D concentrations were similar between the myopic and non-myopic groups (49.7 ± 13.6 and 48.8 ± 14.0 nmol/mL; = 0.806) and were not correlated with spherical equivalence power ( = -0.09; = 0.418). Vitamin D insufficiency was present in 57% of the participants.

Conclusions: Among preterm children with or without ROP, more time spent outdoors was associated with lower odds of myopia. The serum 25(OH)D concentration was not associated with myopia, but a high proportion of the participants had insufficient levels.
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http://dx.doi.org/10.1136/bjophthalmol-2019-315663DOI Listing
April 2021