Treatment of breast deformity with free deep inferior epigastric perforator flap secondary to pectoralis major flap harvesting

SummaryHead and neck cancer is less common in women than in men. Free tissue transfer is the first choice in reconstructive option for head and neck tumor. Pedicle pectoralis major (PM) flap was a common option in head neck reconstruction in the past, but has become the salvage procedure when free flap fails. However, it is not suitable for female patients because of severe breast deformity and induced psychosocial distress. We present a female patient who had breast deformity due to PM flap reconstruction and was successfully treated with free deep inferior epigastric perforator (DIEP) flap. A 48-year-old woman had squamous cell carcinoma in the left side buccal mucosa, T2N0M0, stage II s/p wide excision with partial resection of maxilla and marginal resection of mandible. Free anterolateral thigh flap had been tried but in vain, then alternatively salvaged with a pedicle PM flap 3 years earlier. She presented with malposition of the left breast, nipple retraction, and high riding. We adequately released the contracture and reconstructed with a free DIEP flap. The free DIEP flap survived completely and restored a balanced breast with good shape and symmetry at 1-year follow-up. Although PM flap is a good modality in head and neck reconstruction, it should be used cautiously especially in female patients. The free DIEP flap is not only suitable for breast reconstruction in breast cancer patient, but also a good choice for a different purpose of breast reconstruction such as this patient with breast deformity due to PM flap harvest

Bizarre parosteal osteochondromatous proliferation on a phalanx with periosteal erosion

SummaryBizarre parosteal osteochondromatous proliferation (BPOP) is an uncommon benign hand tumor with a high rate of local recurrence, marked proliferative activity, and an atypical histological appearance. The aim of this paper is to present a rare and illustrative example of BPOP with periosteal erosion. A 64-year-old male presented with a 10-year history of a mass, measuring approximately 3 cm in diameter, on the dorsal aspect of the right index finger. On physical examination, the mass was hard, indolent, and located at the level of the proximal phalanx. Roentgenograms displayed a soft tissue mass over the right index finger with erosion of the periosteum. Magnetic resonance imaging revealed a few well-defined lobulated tumors over the right index finger proximal interphalangeal joint with periosteal reaction. The soft tissue tumors were excised and found to have soft consistencies. Pathological findings demonstrated that the tumor was compatible with BPOP. BPOP is a benign but locally aggressive fibro-osseous mass yielding radiographic findings that bear striking clinical similarities to those of other diseases, such as osteochondroma, osteosarcoma, and myositis ossificans. As the radiographic findings of BPOP are equivocal, the differential diagnosis must be based on the pathological results. With this case report, we aim to inform physicians that a hand tumor with an aggressive clinical picture may be benign in origin

Determinants of Women’s Choice of Breast Reconstruction after Mastectomy and Health-Related Quality of Life

研究目的: 乳癌發生率逐年攀升，為增加幅度最高的女性癌症，高居婦女癌症的第一位。乳癌的早期診斷治療，大幅提升了乳癌患者的存活率。但乳癌切除治療將使乳癌婦女喪失乳房，造成婦女生理、心理極大的衝擊。國外許多文獻顯示在切除乳房後，若配合適當的乳房重建手術對於乳癌術後婦女身、心、社會各方面都具有正面的影響結果。但在台灣，病患接受乳房重建與否的相關因素、乳房重建對身體形象的影響、滿意度或健康相關生活品質的研究不多，是相當值得研究的議題。 研究方法：本研究係採橫斷式、立意取樣、非開放式的結構型問卷收集資料。以北部四所醫學中心的乳癌病友團體為研究對象，共收案165位乳癌婦女。探討乳癌切除的婦女接受乳房重建與否與「個人特質」、「社會支持度」、「乳房疾病特徵」、「乳房重建認知」、之相關性。以「身體形像量表」、「健康相關生活品質」為研究工具，並分析乳房重建者的滿意度 。使用SPSS 12 for Windows電腦統計套裝軟體進行描述性與推論性統計分析。 結果：研究結果發現：病患平均年齡51± 10.2歲(24~80)，其中52人(31.5%)接受乳房重建手術，重建手術的方法選擇用鹽水袋的有27人（51.92%），選擇自體組織的有25人（48.08%）。當時決定接受乳房重建最主要的考量因素為「穿衣服的方便」（44人, 17.3%）、其次是「心理上的需要」（38人, 14.9%）、「美觀」（35人, 13.7%）。當時如何決定接受重建以「自己決定」、「醫師建議」和「親人支持」為最主要因素，分別為38人（40%）、20人（21.1%）、18人（18.9%）。至於沒有接受重建手術的原因最主要為「害怕手術」（40人, 15.3 %），其次為「有沒有乳房無所謂」（34人, 13.0%）、「擔心手術併發症」和「費用太高」（28人, 10.7 %）。多變項羅吉士迴歸分析，在控制其他變項後，年齡、親人支持度和乳癌手術方式為影響是否接受乳房重建的顯著相關因素。乳癌切除後婦女的身體形象因素，雖然在雙變項以及初步迴歸中達到統計上的顯著意義，在最終模式中並無顯著意義；但有接受重建手術者，其術前術後身體形象分數顯著改善。至於是否接受乳房重建手術與健康相關生活品質之相關性，在生理功能（PF）、因身體健康所導致的角色限制（RP）、一般健康狀況（GH）、因情緒問題所導致的角色限制（RE）與生理面向健康生活品質，皆呈現了統計上的正相關顯著意義。對乳房重建的滿意度方面，整體的滿意度為可接受及滿意者達86.4%，92.2%的人會再一次選擇乳房重建，94.2%的人會推薦乳房重建手術給其他病友。 結論：(一) 本研究可促進臨床醫護人員對影響是否接受乳房重建之相關因素的了解，提供乳癌治療之完整性，並提升乳癌治療之品質。(二) 重建手術可以明顯改善乳癌切除婦女的身體形象。(三)接受乳房重建者比起未接受乳房重建者，在生理功能、因身體健康所導致的角色限制、一般健康狀況、因情緒問題所導致的角色限制與生理面向上，有較高的健康生活品質。(四)對乳房重建整體的滿意度相當高，而且樂意推薦其他病友，顯示乳房重建是值得推廣的手術。Background and Purpose: Breast cancer is the leading cancer of women in Taiwan nowadays and also in the western countries. Most studies are focused on the cancer epidermiology, pathology, diagnosis, and treatment modalities. The purpose of this study was to investigate the influence factors of breast cancer women’s decisions for or against breast reconstruction,, health-related Quality of life (QOL SF-36), and satisfaction of breast reconstruction. Material and Method: We performed a cross-sectional, purposive sampling study in 4 breast-supporting groups in 4 teaching-based hospitals in Taipei. From Jan. 1997 to Dec. 2006, women had mastectomy and/or breast reconstruction at any of hospitals were considered eligible for the study. No age restrictions were imposed. However, women were excluded from the study if they had cancer metastasis. Postal Questionnaires were delivered and collected for analysis of patients' demographics, diseases profiles, social support, body image scale, and QOL SF-36. Data were analyzed using SPSS for Windows version 12. Result: Total 165 patients were valid for study including 52(31.5%) women who had postmastectomy breast reconstruction. Expert content validity and Cronbach's alpha reliability were reported in the context. The results showed that: (1) Age, family support, and mastectomy types were important factors for women’s decision for or against breast reconstruction. (2)The most frequently reason for not having breast reconstruction was fear of the reconstructive operation, followed by not essential for the breast, fear of the surgical complications, and expenses. The most frequently reason for having reconstruction was to be able to wear many different types of clothing, psychological demand, and cosmetic. (4) The participants who had undergone breast reconstruction had better global health-related quality of life. (5) The overall satisfaction of breast reconstruction was high and recommendable. Conclusion: This study provides important informations for clinical staffs to understand the determinants for women to have or not breast reconstrtuction. Family support is important factor for women to have breast reconstruction. Breast reconstruction can significantly improve patients’ body image scale and make a substantial contribution to health-realted Quality of life for breast cancer patients especially for the younger women.誌謝……………………………………………………………………Ⅰ 中文摘要………………………………………………………………Ⅲ 英文摘要………………………………………………………………Ⅴ 第一章 緒論……………………………………………………………1 第一節 研究背景與動機………………………………………………1 第二節 研究目的………………………………………………………5 第二章文獻探討…………………………………………………………6 第一節 乳癌流行病學、治療方式與預後……………………………6 第二節 乳癌切除手術對婦女的影響及乳房重建手術的介紹………15 第三節.乳癌切除婦女接受乳房重建的決定相關因素……………21 第四節.健康相關生活品質的概念…………………………………26 第五節綜合討論……………………………………………………28 第三章 研究設計與方法……………………………………………31 第一節.研究設計與架構………………………………………………31 第二節.研究變項………………………………………………………32 第三節.研究假說………………………………………………………33 第四節.研究對象與場所、研究工具…………………………………33 第五節.資料處理與分析……………………………………………38 第 四 章 研究結果……………………………………………………68 第一節描述性分析……………………………………………………68 第二節雙變項分析……………………………………………………75 第三節多變項分析……………………………………………………77 第五章討論……………………………………………………………110 第一節研究資料之品質………………………………………………110 第二節研究結果討論…………………………………………………111 第三節研究限制………………………………………………………115 第六章結論與建議……………………………………………………116 第一節結論……………………………………………………………116 第二節建議……………………………………………………………117 參考文獻………………………………………………………………118 附錄一參與研究同意書………………………………………………127 附錄二乳癌切除婦女是否接受乳房重建問卷………………………128 附錄三專家效度名單…………………………………………………142 附錄四專家效度評估分數之平均及CVI值…………………………143 附錄五、是否重建與身體形象（乳癌切除後）之比較（每一題）…………………………………………………………………………146 附錄六、乳房重建者接受重建前後身體形象之比較（每一題）…………………………………………………………………………147 表目錄 表2-1 　民國92年與91年女性十大癌症發生率比較（不含原位癌）…………………8 表2-2　　 台灣地區歷年女性乳癌每十萬人口死亡率…………………10 表3-1　　　研究變項之操作型定義…………………40 表3-2-1　　「社會支持滿意度」量表之Cronbach’s Alpha信度…………………67 表3-2-2　　「身體形象」量表之Cronbach’s Alpha信度…………………67 表3-2-3　　「SF-36」量表之Cronbach’s Alpha信度…………………67 表3-2-4　　「乳房重建滿意度」量表之Cronbach’s Alpha信度.…………………67 表4-1　個人基本資料之描述性統計結果…………………80 表4-2　社會支持滿意度之描述性統計結果…………………83 表4-3　乳房疾病特徵之描述性統計結果…………………86 表4-4　是否接受乳房重建手術之描述性統計結果…………………87 表4-5-1　身體形象（乳癌切除後）之描述性統計結果……………88 表4-5-2　身體形象（乳房重建後）之描述性統計結果……………90 表4-6　SF-36各構面之評分結果……………………………………92 表4-7　　乳房重建者問卷之描述性統計結果…………………93 表4-8　　變項合併對照表……………………………………………96 表4-8-1　乳癌切除婦女是否接受乳房重建手術之雙變項分析（卡方）…………………………………………………98 表4-8-2　　乳癌切除婦女是否接受乳房重建手術之雙變項分析（羅吉士迴歸）…………………101 表4-8-3　　是否重建與身體形象（乳癌切除後）之比較………………………………101 表4-8-4　　乳房重建婦女接受乳房重建前後身體形象之比較…………………………102 表4-8-5-1　生理功能（PF）與是否接受乳房重建手術之線性迴歸分析………………102 表4-8-5-2　因身體健康所導致的角色限制（RP）與是否接受乳房重建手術之線性迴歸分析…………………………102 表4-8-5-3　身體疼痛（BP）與是否接受乳房重建手術之線性迴歸分析………………103 表4-8-5-4　一般健康狀況（GH）與是否接受乳房重建手術之線性迴歸分析…………103 表4-8-5-5　活力狀況（VT）與是否接受乳房重建手術之線性迴歸分析………………103 表4-8-5-6　社交功能（SF）與是否接受乳房重建手術之線性迴歸分析………………104 表4-8-5-7　因情緒問題所導致的角色限制（RE）與是否接受乳房重建手術之線性迴歸分析……………………………………………………………...104 表4-8-5-8　心理健康（MH）與是否接受乳房重建手術之線性迴歸分析………………………………104 表4-8-5-9　生理面向與是否接受乳房重建手術之線性迴歸分析………………………105 表4-8-5-10 心理面向與是否接受乳房重建手術之線性迴歸分析………………………105 表4-9　　　乳癌切除婦女是否接受乳房重建手術之初步迴歸分析 （Logistic Regression）……………………………………………………….106 表4-10　　 乳癌切除婦女是否接受乳房重建手術之最終迴歸分析 （Final Logistic Regression）…………………………………………………109 表 5-1　　　各醫院之樣本回收率……………………………………………………….110 圖目錄 圖1.1　　第一期乳管癌病患接受皮膚保留式乳房切除…………………………………3 圖1.2　　以橫式腹直肌皮瓣重建乳房……………………………………………………3 圖1.3　　以徽章式皮瓣重建乳頭…………………………………………………………3 圖1.4　　乳房重建後之外觀、形狀、柔軟度……………………………………………3 圖2.1　　第一期乳管癌病患接受皮膚保留式乳房切除…………………………………4 圖2.2　　以橫式腹直肌皮瓣重建乳房……………………………………………………4 圖2.3　　乳房、乳頭、乳暈重建後之外觀、形狀、柔軟度都接近對側乳房…………………4 圖3　　文獻探討的思考邏輯圖……………………………………28 圖3-1　研究架構……………………………………………………3

Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy

Heel ulcers in patients with severe peripheral artery occlusive disease represent a challenge to the treating physician. They become more difficult to treat with underlying medical comorbidities. We report a case of 76-year-old man with hypertension, diabetes mellitus, and end-stage renal disease in uremia status presented to our hospital with a 3-month history of a diabetic foot ulcer on his right heel. He was diagnosed with near total artery occlusion below the knee at the local hospital, and vascular reconstruction failed. After admission, surgical debridement was performed with subsequent partial calcanectomy facilitating wound closure without tension. After surgery, the foot was immobilized with a short-leg splint for 2 weeks. Thereafter, ankle immobilization was accomplished using a thermal protective plastic splint and cast shoes with a posterior window for wound care. The wound healed well with no recurrence during the 12-month follow-up period, and the patient may return to an ambulatory status, including a normal gait pattern. In this case, we demonstrate that the partial calcanectomy is practical for the treatment of plantar heel ulcers in a patient with severe comorbidities. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle

Autologous fat grafting for treating lipoatrophy secondary to lupus erythematosus panniculitis

AbstractLupus erythematosus panniculitis (LEP) is an uncommon variant of LE and accounts for only 1–3% of cutaneous LE cases. LEP lesions often heal with cutaneous scarring and lipoatrophy resulting in disfigurement. Studies regarding the treatment of permanent lipoatrophy and disfigurement caused by LEP are lacking in the literature. Here, we report our experience with a rare case of lipoatrophy caused by LEP that was treated using autologous fat grafting. A 41-year-old woman presented with indurated, flesh-colored, depressed plaques on both buttocks. After a series of investigations, LEP was diagnosed by a rheumatologist. Magnetic resonance imaging (MRI) showed a markedly decreased volume of the subcutaneous fatty layer and thickening over the covering cutis. After the inflammatory disease was controlled, we attempted to restore her body contour with autologous fat grafting. We arranged an MRI study after a follow-up period of 12 months. The volume of subcutaneous fat was calculated by integrating cross-sectional area data from consecutive images. The patient was satisfied with her body contour following the injection of 350 mL of fat into the right buttock and 50 mL into the left buttock in a two-stage procedure. No complications were observed following the procedure. Follow-up laboratory results were negative for anti-double-stranded DNA antibody and showed normal complement levels. After a follow-up period of 12 months, no nodules or disease reactivation was noted. The MRI showed a marked improvement in the volume of the subcutaneous fat of the buttock, and the survival ratio of transferred fat was calculated to be 65%. Lipoatrophy secondary to LEP is a rare disease that can cause distress to patients. Autologous fat grafting is a simple, fast, and effective method for alleviating depression deformities in patients with LEP. It has a potentially long-lasting effect in treating patients with permanent lipoatrophy and disfigurement caused by LEP but should be preferably performed only in patients with quiescent disease

Adipose-Derived Neural Stem Cells Combined with Acellular Dermal Matrix as a Neural Conduit Enhances Peripheral Nerve Repair

Reconstruction to close a peripheral nerve gap continues to be a challenge for clinical medicine, and much effort is being made to develop nerve conduits facilitate nerve gap closure. Acellular dermal matrix (ADM) is mainly used to aid wound healing, but its malleability and plasticity potentially enable it to be used in the treatment of nerve gaps. Adipose-derived stem cells (ADSCs) can be differentiated into three germ layer cells, including neurospheres. We tested the ability of ADSC-derived neural stem cells (NSCs) in combination with ADM or acellular sciatic nerve (ASN) to repair a transected sciatic nerve. We found that NSCs form neurospheres that express Nestin and Sox2, and could be co-cultured with ADM in vitro, where they express the survival marker Ki67. Following sciatic nerve transection in rats, treatment with ADM+NSC or ASN+NSC led to increases in relative gastrocnemius weight, cross-sectional muscle fiber area, and sciatic functional index as compared with untreated rats or rats treated with ADM or ASN alone. These findings suggest that ADM combined with NSCs can improve peripheral nerve gap repair after nerve transection and may also be useful for treating other types of neurological gaps

Ten-year experience of superior gluteal artery perforator flap for reconstruction of sacral defects in Tri-Service General Hospital

Background: Despite advances in reconstruction techniques, sacral sores continue to present a challenge to the plastic surgeon. The superior gluteal artery perforator (SGAP) flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. However, the dissection of the perforator is tedious and carries a risk of compromising the perforator vessels. Patients and Methods: During the period between April 2003 and March 2013, 30 patients presented to our section with sacral wounds causing by pressure sores or infected pilonidal cysts. Of a total of 30 patients, 13 were female and 17 were male. Their ages ranged from 22 to 92 years old (mean 79.8 years old). Surgical intervention was performed electively with immediate or delayed reconstruction using a SGAP flap. The characteristics of patients′ age, and sex, and cause of sacral defect, co-morbidities, wound culture, flap size, perforator number, hospital stay, and outcome were reviewed. Results: For all operations, the length of the pedicle dissection will not exceed 1 cm because of the vascular anatomy of the SGAP, which lies adjacent to the sacral region. Due to short pedicle dissection, all SGAP flap were elevated around an hour. All flaps survived except two, which had partial flap necrosis and were finally treated by contralateral V-Y advancement flaps coverage. The mean follow-up period was 14.8 months (range 3-24). No flap surgery-related mortality was found. Conclusion: Perforator-based flaps have become popular in modern reconstructive surgery because of low donor site morbidity and good preservation of muscle. Our study shows that deep pedicle dissection is unnecessary when the surgery involves an accurate indicating perforator, adequate flap size design, and correct selection of flap utilization between tunnel and rotation. The advantages of this modification include a faster operation, less bleeding, and less trauma of the pedicle, which make the SGAP flaps an alternative choice for sacral sores coverage