TSRM

Free Paper Presentation

THURSDAY, DECEMBER 11, 2025

7:00 - 7:30

Room B

Speaker

Detlef Schreier

Abstract

1 Objective Selective or elective nerve transfer reduces amputation-related pain after lower leg amputation. 2 Methods At the BG Klinikum Duisburg and Hannover Medical School, selective nerve transfers were performed simultaneously with lower leg amputation as part of a study using targeted muscle reinnervation, in which the tibial nerve, saphenous nerve, superficial peroneal nerve, and deep peroneal nerve were coapted to motor branches of the flexor hallucis longus, flexor digitorum longus, peroneus brevis, and extensor hallucis longus muscles. The effect on pain perception was prospectively observed in 17 patients over a period of 12 months. Longitudinal analysis was used to determine whether there was a change in amputation-specific pain, i.e., a “TARGETED MUSCLE BENEFIT.” In addition to objective parameters, this benefit was measured primarily using PROMs. Pain intensity and impairment were measured using the van Korff scale. The Depression, Anxiety, and Stress Scales (DASS) were used as a screening tool for depression, anxiety, and stress. Health-related quality of life was assessed using the EQ-5D. 3 Results The results so far allow positive conclusions to be drawn about a sustainable reduction in pain and thus an improvement in quality of life. Of the 17 patients evaluated here (56% male, average age at the time of the accident 38±18 years), the patients decided to undergo elective amputation approximately 10 years after the actual “accident event” (average age at amputation 48±14 years). Using the DASS-21, it was found that the physical complaints of the patients decreased from 7 (T0) to 3.6 (T2) for depression and from 4.1 (T0) to 2.3 (T2) for anxiety. This corresponds to a decrease in symptoms of almost 50%. In the area of stress, a decrease in values from 9 (T0) to 6.1 at time T2 was also recorded. A significant improvement was observed in both the EQ VAS (ø 50 (T0) to ø 80 (T2)) and quality of life (ø 0.5 (T0) to ø 0.7 (T2)). In the EQ-5D, a value of 0 would be the worst possible condition. 4 Conclusion The results of the subjective outcomes indicate a significant reduction in chronic pain in all PROMs. Furthermore, an increase in health-related quality of life was measured. These and other results of the study, such as satisfaction with the prosthetic fitting, various gait parameters, and EMG of the posterior muscles, as well as long-term results of surgical treatment, could show in the future that nerve transfer leads to a lasting improvement in the reality of treatment in amputation surgery.

Speaker

Chi-Chien Hung (洪綺謙)

Abstract

INTRODUCTION A retrospective study comparing outcomes and need for re-percutaneous transluminal angioplasty (PTA) in patients with diabetic foot ulcers and peripheral artery occlusive disease (PAOD), who underwent either free flap reconstruction or without free flap reconstruction. The study aims to determine the influence of free flap reconstruction on maintaining the patency of revascularized vessels. MATERIAL AND METHODS Data from 2008 to 2023 were reviewed. Patients were divided into two groups: group 1 underwent PTA and free flap reconstruction, and group 2 only PTA without free flap reconstruction. RESULTS There were 127 patients in Group 1 and 597 patients in Group 2. Of these, 22 patients in Group 1 required repeat PTA, compared to 162 out of 597 patients in Group 2. A statistically significant difference was observed between the two groups (p = 0.028). Group 1 demonstrating a lower repeat PTA compared to Group 2. In Group 1, there were 112 free muscle flaps and 15 fasciocutaneous free flaps. Among these, 20 patients with free muscle flaps and 2 patients with fasciocutaneous free flaps required further angioplasty. When comparing free muscle flaps to fasciocutaneous free flaps, a p-value of 0.9430 indicated no statistically significant difference between the two types of free flaps in terms of the need for repeat angioplasty. DISCUSSION This study demonstrates that free flap reconstruction in diabetic patients with PAOD creates a lower resistance outflow bed, prolonging the patency of revascularized vessels. This makes free flap reconstruction more beneficial for these patients compared to those without free flap reconstruction.

Speaker

Wei-Hsiang Hsu (徐尉翔)

Abstract

【Introduction】 Neuroma pain and sensory disturbances frequently occur after oncologic resections involving major peripheral nerves. Regenerative peripheral nerve interface (RPNI) has emerged as an effective technique to mitigate neuropathic pain and improve neural signal stability, predominantly in amputees. Here, we report two cases of soft tissue sarcoma with sciatic and lower limb nerve involvement treated with wide excision and RPNI reconstruction, incorporating patient-reported outcomes for pain and quality of life assessment. 【Materials and Methods】 Two female patients with sarcoma involving major peripheral nerves underwent wide tumor resection with RPNI reconstruction. Case 1 was a 40-year-old woman with proximal-type epithelioid sarcoma and pulmonary metastases, who underwent sciatic nerve division into eight fascicles, each implanted into autologous free muscle grafts. Case 2 was a 67-year-old woman with left foot sclerosing rhabdomyosarcoma, who received below-knee osteomyoplastic amputation followed by RPNI using five muscle grafts harvested from the gastrocnemius muscle and epineurally sutured to residual nerve ends (sural, superficial/deep peroneal, saphenous, and tibial nerves). Patient-reported outcomes were assessed using the RPNI Postoperative Pain and Function Questionnaire (RPNI-PFQ), which integrates VAS, MPQ, BPI, and DN4 domains to evaluate pain intensity, neuropathic characteristics, functional interference, and satisfaction. 【Results】 Both procedures were completed without perioperative complications. At 15 weeks post‑operation (Case 1, sciatic RPNI), VAS pain decreased from 5/10 pre‑op to 4/10; pain was intermittent and throbbing over the left hip/leg with persistent numbness and paresthesia, allodynia to light touch/pressure, and radiating pain. Foot‑drop remained marked. Pain‑interference changed as follows: walking 4→2; sleep 1→1; mood 1→1; daily activities 1→1. Overall satisfaction totaled 13/20 (neutral). At 30 weeks post‑operation (Case 2, below‑knee amputation with multi‑nerve RPNIs), VAS decreased from 10/10 to 5/10 (0/10 with medication). Weekly worst/average/min pain were 6/3/0. Pain‑interference improved: walking 4→1; sleep 4→2; mood 4→1; daily activities 2→2. Satisfaction was 19/20 (high). 【Discussion】 These cases demonstrate the feasibility and efficacy of RPNI following oncologic nerve resections, extending its use beyond traumatic amputations. Integration of patient-reported outcome measures confirmed significant subjective and objective improvements in pain, function, and satisfaction. RPNI thus represents a promising strategy for neuropathic pain management and functional preservation in sarcoma surgery. Further studies with larger cohorts are warranted to validate its long-term benefits.

Room 1

Speaker

Sahin Atakan Bayir

Abstract

【Introduction】 Deep burns involving the patella present significant reconstructive challenges, often requiring patellectomy when bone viability is compromised. We present a complex case of patellar reconstruction following complete patellectomy for third-degree burn injury, utilizing a multi-component approach combining a distally based reverse flow chimeric vastus lateralis (VL) + fascia lata (FL) + anterolateral thigh (ALT) perforator flap and Dacron graft for functional restoration. 【Materials and Methods】 A 22-year-old male sustained a third-degree burn to the left knee after an industrial heater fell on his leg. Following serial debridements at our burn center, the burn was found to affect the patella. Despite prolonged VAC dressing therapy, adequate wound healing and granulation were not achieved, and poor patellar viability necessitated patellectomy in consultation with orthopedics. The reconstruction strategy included: (1) Distally based reverse flow chimeric ALT flap (14 x 9 cm) for soft tissue coverage with a VL muscle component to simulate patellar bulk and movement during knee extension, designed around perforators identified by preoperative Doppler ultrasound; (2) Dacron graft for joint capsule reconstruction and (3) FL for patellar tendon reconstruction. The patella was initially excised tangentially with a burr motor, but complete resection was performed due to absent viable vascularity. The flap donor site was repaired with a split thickness skin graft, and the leg was immobilized in a long leg splint. 【Results】 Postoperatively, venous congestion developed in the distal part of the flap beginning on day 2. Despite puncture drainage and topical heparin application, superficial necrosis occurred approximately 1 cm proximal to the suture line. Conservative management resulted in successful flap survival. The patient was discharged and referred to physical therapy for ambulation training. 【Discussion】 Complex lower extremity defects pose significant challenges for reconstructive surgeons due to compromised wound healing, the unreliability of local cutaneous flaps, intricate postoperative management, and the contour irregularities that may follow free tissue transfer. Patellar defects, in particular, present additional difficulties because of their inherently limited vascular supply. When compounded by thermal injuries such as full-thickness burns, the reconstructive process becomes even more demanding and requires meticulous planning and execution. If the thigh remains uninvolved within the injury zone the ALT flap can be effectively utilized for reconstructing defects around the knee and proximal third of the leg. A distally based ALT flap, relying on reverse flow through the lateral superior geniculate artery, the profunda femoris artery, or both, offers several benefits—including reduced operative time, greater technical simplicity, and the elimination of the need for intraoperative position change—when compared to free flap reconstruction. We report a case in which patellar perfusion was markedly reduced and extensive debridement of the knee joint—including removal of affected soft tissue, the patellar tendon, and the anterior joint capsule surrounding the patella—was required. Although a reverse-flow anterolateral thigh (ALT) flap appears to be a practical reconstructive option in such scenarios, several technical considerations warrant special attention, particularly regarding the use of a distally based ALT flap and the incorporation of a Dacron vascular mesh. Because arterial flow can function bidirectionally, whereas venous return depends on small communicating channels that bypass venous valves, reverse-flow flaps inherently face challenges in venous outflow. Consequently, an optimal reverse-flow flap should incorporate an antegrade venous drainage pathway, which can be achieved through venous supercharging to the great saphenous vein. Anatomical variations in the proximal vascular anatomy of ALT flaps may influence the reliability of distally based ALT (dbALT) designs. Longer retrograde pedicles—extending distally from the perforator—allow for improved flap mobility and reach but may introduce additional venous valves that impede reverse flow, as well as a shortened proximal venous segment, which may necessitate adjunctive techniques such as vein grafting to achieve successful supercharging to the great saphenous vein. Among these, Shieh type II and IV ALT flaps (characterized by dominance of the oblique branch or a proximally arising descending branch perforator) are particularly debated for reverse-flow use due to their extended retrograde venous course and shorter proximal venous leash. Although the literature does not clearly define a precise size threshold at which venous supercharging becomes necessary for dbALT flaps, evidence indicates that the risk of distal flap necrosis increases proportionally with flap size. Current reports suggest that dbALT flaps smaller than 13 × 9 cm generally demonstrate acceptable outcomes without venous supercharging. This finding aligns with our experience, as our flap measured 14 × 9 cm, and the observed distal marginal necrosis appeared to result primarily from wound dehiscence secondary to a localized suture site infection rather than true flap loss due to venous congestion. The use of a Dacron vascular graft in reconstructing the knee extensor mechanism and anterior joint capsule provides significant biomechanical advantages by reinforcing the repair, enabling earlier mobilization, and yielding favorable outcomes across various types of knee injuries. When combined with direct suturing, allografts, or other reconstructive techniques, the Dacron graft serves as a robust reinforcing scaffold, supporting tissue integration and potentially expediting the healing process. Although the formation of a fibrous capsule around the Dacron graft—resulting from a foreign body reaction—can enhance local vascularity and perfusion of the repaired area, the synthetic nature of the material introduces an inherent risk of infection. Consequently, Dacron vascular grafts are typically reserved as secondary options in cases requiring restoration of knee extensor function, particularly when biological alternatives are unavailable or insufficient. In our case, the Dacron graft was utilized to bilaminate the reconstructed knee capsule, creating a smooth interface that allowed the vastus lateralis muscle component of the chimeric dbALT flap to glide naturally. This configuration—positioning the muscle between the outer capsule formed around the graft and the inner surface of the fascia lata component—was designed to restore knee extension in a more physiological and coordinated manner.

Speaker

Ching-Wen Su (蘇鏡文)

Abstract

【Introduction】 Orbital exenteration involving the anterior skull base or sinonasal tract produces complex three-dimensional defects that require durable compartmental separation and adequate volumetric restoration. This single-center series reports the exclusive use of the anterolateral thigh (ALT) free flap—chosen for its modular skin, fascial, and muscular components—for post-exenteration orbital reconstruction. 【Materials and Methods】 A retrospective review was conducted on 12 consecutive patients who underwent immediate reconstruction with ALT free flaps following orbital exenteration for malignant tumors between 2016 and 2025. Clinical variables including demographics, pathology, defect extent, reconstructive configuration, prior radiotherapy, complications, and outcomes were analyzed. Flap designs comprised standard fasciocutaneous, chimeric (separate skin and muscle paddles), and inverted fascia configurations to achieve watertight separation between the orbit and sinonasal or anterior skull base cavities. The mean follow-up was 28 months. 【Results】 The cohort included 10 males and 2 females with a mean age of 56 years. Primary pathologies were predominantly squamous cell carcinoma (67%). Eight cases (67%) involved anterior skull base exposure, once case (8%) present with a penetrating orbitomaxillary defect (Kesting type IV). All flaps survived completely. Minor complications occurred in 3 patients (25%), including wound dehiscence, infection, or transient fistula, all managed conservatively. No cerebrospinal fluid leak or oronasal communication developed. Postoperative radiotherapy was well tolerated in all cases. At last follow-up, 1 (7%) succumbed to disease progression, 1 (7%) was discharged to hospice care, while the rest were alive without recurrence (83%). 【Discussion】 The ALT free flap offers a reliable, adaptable option for complex orbital exenteration defects involving the anterior skull base or sinonasal region. Its capacity to combine multiple tissue components and use inverted fascia for lining or compartmental separation makes it well suited to achieving functional isolation and satisfactory aesthetic restoration in this demanding setting.

Speaker

Yu-Chen Lin (林昱辰)

Abstract

【Introduction】 Reconstruction following upper gum or hard palate tumor resection requires simultaneous restoration of nasal and oral functions, posing significant surgical challenges. Traditional radial forearm free flaps, though widely utilized, could result in significant donor site morbidity. The anterolateral thigh (ALT) free flap offers a promising alternative; however, concerns regarding flap thickness have limited its use in nasal floor reconstructions. This study introduces a refined design algorithm for the ALT flap to address these challenges. 【Materials and Methods】 We developed a refined algorithm incorporating split flap design, partial de-epithelialization, and fascia folding tailored to defect characteristics and perforator anatomy for simultaneous nasal floor and palatal reconstruction. Eight patients undergoing reconstruction for defects arising from tumor resections were treated using this refined ALT flap algorithm. Maxillary bone defects in two patients were managed with reconstruction plates. One flap was split based on two perforators into separate islands, independently addressing nasal and palatal defects in a “stacked configuration.” The other flap utilized a single perforator, adopting a de-epithelialized central segment and a “folded configuration” for simultaneous defect coverage. Six additional patients without bony involvement underwent partial excision of the skin paddle while preserving vascularized fascia, folded intricately with a “parachute technique” for precise nasal lining reconstruction. 【Results】 A total of eight patients underwent reconstruction utilizing this ALT algorithm. All flaps survived without major complications or infections at 1-year follow-up. Primary closure was consistently achieved with minimal donor site morbidity in all cases. Functional outcomes, assessed through standardized metrics, demonstrated patent nasal airways, preserved speech intelligibility, and oral intake without need for secondary debulking procedures. Hypernasality was objectively noted in two patients, and transient dysphagia in one patient. 【Discussion】 Our novel ALT flap designing algorithm offers a versatile approach for streamlining reconstruction of complex nasal floor and palatal defects with reduced donor site morbidity. By incorporating distinct methods within the algorithm, the ALT flap serves as a reliable option for surgical reconstruction.

Speaker

Ching-En Chen (陳慶恩)

Abstract

【Introduction】 The fibula free flap (FFF) is acknowledged as the primary choice for reconstructing composite oromandibular defects (COMD), yet the impact of donor leg selection remains inadequately explored. This study aims to investigate the correlation between flap failure and the choice of donor leg and recipient vessel side. 【Materials and Methods】 In a retrospective analysis spanning 2011 to 2020, FFFs for COMD were examined using electronic records. Patient data, comorbidities, radiation history, FFF details, and intraoperative variables were considered. Laterality was categorized into "Cis" and "Trans" groups, further subclassified based on blood supply. Analyses involved logistic regression, bivariate analysis, and propensity score matching. 【Results】 A total of 155 subjects with intraoral mucosal defects repaired only by the skin paddle of FFF were included. Cases were categorized into "Cis" (n=65; 42%) and "Trans" (n=90; 58%) groups based on COMD side and donor leg selection. No significant baseline differences emerged. Logistic regression found no laterality impact on total FFF failure. Initially, gender correlated with flap failure, but adjustment diminished the association. Partial skin paddle necrosis correlated with diabetes, not laterality. Propensity score matching revealed no significant differences between right and left legs in laterality or total flap failure risk. Subgroup analysis found no differences in parameters or flap failure rates within "Cis" and "Trans" groups. 【Discussion】 Donor leg selection in COMD reconstruction with FFFs does not exhibit specificity. Furthermore, despite potential limitations in vessel anastomosis due to pedicle length or trauma history, recipient vessel side selection does not evidently affect flap failure.

Room 2

Speaker

Jaemin Lee

Abstract

【Introduction】 Lymph-interpositional flap transfer (LIFT) is an emerging lymphatic reconstruction technique designed to align donor and recipient lymphatic vessels, thereby promoting lymphatic regeneration without lymph node harvest. Although conceptually sound and increasingly applied in clinical practice, its experimental validation has been limited. This study aimed to evaluate the functional and molecular effects of lymphatic vessel interposition within the framework of the lymph axiality concept. 【Materials and Methods】 A rabbit hindlimb model was established to assess the role of lymphatic alignment. Limbs were divided into two groups: LIFT (+), in which lymph axiality was maintained through lymphatic interposition, and LIFT (–), in which alignment was disrupted by rotational misorientation. Six weeks postoperatively, outcomes included limb volume measurement, indocyanine green (ICG) lymphography, histological and immunohistochemical analysis, and RT-PCR quantification of lymphangiogenic and fibrotic markers. 【Results】 At postoperative week 3, the LIFT (+) group demonstrated significantly reduced hindlimb volume compared with the LIFT (–) group (p = 0.02). ICG lymphography showed a higher rate of lymphatic reconnection in the LIFT (+) group (p = 0.021). Histological and immunohistochemical analyses confirmed newly formed lymphatic structures within the interposed flap. RT-PCR revealed upregulated VEGF-C and podoplanin expression (p = 0.01) and reduced TGF-β levels in adjacent popliteal lymph nodes (p < 0.05). 【Discussion】 LIFT facilitates lymphatic flow restoration by maintaining lymph axiality and enhancing lymphangiogenesis in a rabbit model. This experimental evidence provides mechanistic validation for the LIFT concept and supports its potential clinical application in physiologic lymphatic reconstruction, although further validation of the model is warranted.

Speaker

Chiu-Fang Shih (施九方)

Abstract

【Introduction】 Surgical scarring affects not only physical appearance but also functional and psychological outcomes. Closed-incision negative pressure wound therapy (ciNPWT) is increasingly utilized to reduce surgical site complications and optimize post-surgical healing. Our primary objective was to synthesize current evidence to clarify the effectiveness of ciNPWT on scar quality from both patient and clinician perspectives, as well as quantitative scar metrics. 【Materials and Methods】 A comprehensive literature search was performed on the Cochrane Library, Embase, PubMed, Scopus, and Web of Science databases from their inception through Oct 8, 2025. Eligible studies compared ciNPWT to standard postoperative care and reported outcomes pertain to scar morphology using validated subjective scales—including Vancouver Scar Scale (VSS), Manchester Scar Scale (MSS), Stony Brook Scar Evaluation Scale (SBSES), Visual Analog Scale (VAS), and the Patient and Observer Scar Assessment Scale (POSAS)—and objective (scar elasticity, scar width/dimension) assessment tools. Meta-analyses were performed by random effect models. Continuous variables were assessed using the difference in means for outcomes measured on an identical scale and the standardized difference in means for those reported using various measurement instruments. 【Results】 After a systematic review of all relevant articles, 20 studies qualified for inclusion. Preliminary meta-analyses demonstrated that ciNPWT was associated with statistically non-significant improvement in subjective scales (VSS, MSS, SBSES, VAS, and POSAS) compared with standard postoperative care. Objective outcomes such as scar elasticity and scar width likewise did not differ significantly between ciNPWT and control groups on pooled analysis. 【Discussion】 Closed-incision negative pressure wound therapy does not demonstrate significant benefits on scar quality as assessed by both subjective and objective measurement tools. The application of ciNPTW to improve scar morphology should be tailored to each patient, based on an assessment of their individual risk factors and the specific clinical context.

Speaker

Sheng-Lian Lee (李聖聯)

Abstract

Background: Tumor-like lesions of the hand in patients with autoimmune disease or chronic immunosuppression are rare and unusually found at clinics. Here were two cases, one having a growing mass at the dorsal wrist and the other having multiple masses in the hand. The former has a long history of rheumatoid arthritis (RA) and receives long-term disease-modifying anti-rheumatic drugs (DMARDs). The latter has long-term medication with immunosuppressive therapy after kidney allotransplantation. Case Presentation: Case 1: A 49-year-old woman with long-standing RA, treated with abatacept, hydroxychloroquine, and low-dose corticosteroids, presented with acute erythematous swelling of the left wrist following minor surgery for a presumed ganglion. Operative exploration revealed a gray, lobulated mass arising from the ulnar-carpal joint with intact extensor tendons. Complete excision was performed. Histopathology demonstrated central fibrinoid necrosis surrounded by palisading histiocytes, fibrosis, and mixed inflammatory infiltrates, consistent with a rheumatoid nodule with secondary inflammation. Case 2: A 66-year-old renal-transplant recipient with diabetic nephropathy, on chronic immunosuppression (tacrolimus, mycophenolate, and prednisolone) for 20 years. He developed multiple masses in the left hand involving the first web space, lateral thumb, and dorsal index-metacarpophalangeal joint. Operative exploration revealed a large granulomatous mass with necrotic tissues encasing the flexor pollicis longus (FPL) tendon and extending proximally beneath the transverse carpal ligament to the median nerve. The sesamoid bone was also invaded by the lesion and was excised. Histopathology demonstrated necrotizing granulomatous inflammation with epithelioid histiocytes, Langhans-type giant cells, and rare acid-fast bacilli, diagnostic of tuberculous granulomatous infection. Extrapulmonary TB with left wrist affected was diagnosed. Anti-TB medications were given and he continuously followed up at the Chest department. Conclusion: Rheumatoid granulomas and tuberculous infection granuloma may appear clinically indistinguishable but differ fundamentally in etiology and management. Meticulous clinicopathologic correlation, supported by imaging, intraoperative findings, and special stains, is essential to establish an accurate diagnosis and guide targeted therapy. Awareness of these atypical presentations can help surgeons and clinicians avoid misdiagnosis, prevent unnecessary extensive resections, and ensure appropriate antimicrobial or immunomodulatory treatment.

Speaker

Hokuto Morii

Abstract

Background: The Gustilo-Anderson classification (GAC) is widely recognized as the classification of open fractures of the lower leg. However, varying degrees of vascular injuries within the types undermine the usefulness of GAC as predictor of deep infection and acute phase amputation. In 2018, Ricci et al. revised GAC to reflect the number of injured arteries. The objective of the study is to assess efficacy of revised GAC as predictor of deep infection and/or acute phase amputation. Methods: Out of 178 cases with GAC types IIIB and IIIC treated in our institute, 146 cases, who underwent assessment of major leg arterial injuries by CE-CT or angiography were enrolled. Multivariate logistic regression model analyses were conducted assigning incidence of deep infection and/or acute phase amputation as objective variate, and age, sex, history of DM, and revised GAS or Ganga Hospital Injury Severity Score (GHOIS) as explanatory variates. Revised GAC was defined according to the number of intact major leg arteries as RG3B-3 (no arterial injury), RG3B-2 (two intact arteries), RG3B-1 (one intact artery) and RG3B-0 (total ischemia). Deep infection was diagnosed according to the definition of deep incisional SSI by the Center for Disease Control and Prevention 2021. Results: 33 cases were diagnosed with deep infection and 7 cases underwent acute phase amputation. Revised GAS (OR 0.23 [95%CI 0.14-0.38]), GHOIS (1.51 [1.29 -1.77]), were significant independent predictors deep infection and/or acute phase amputation. Conclusion: The revised GAS is a simple tool for assessing the severity of soft tissue injury in patients with open leg fractures, useful for determining treatment strategies.

FRIDAY, DECEMBER 12, 2025

7:00 - 7:30

Room B

Speaker

Ji-Sup Kim

Abstract

Background: The spinal accessory nerve (SAN) is vital for trapezius function and shoulder stability.Iatrogenic injury during cervical lymph node biopsy often causes scapular winging, pain, andloss of abduction. When primary repair is not feasible, nerve transfer offers an alternative. The C7 pectoralis fascicle, a pure motor branch with consistent anatomy, has been suggested as a donor, but feasibility data remain limited. Methods: Cadaveric dissections were performed on 16 heminecks (8 cadavers) to assess the feasibility of direct coaptation between the C7 pectoralis fascicle and the distal SAN. Measurements included fascicle length, distance to trapezius, overlap length, and donor–recipient diameters. Additionally, a 27-year-old female with iatrogenic SAN injury after lymph node biopsy underwent C7 fascicle transfer using a single supraclavicular approach. Results: The mean C7 fascicle length was 30.7 ± 3.9 mm, distance to trapezius 26.7 ± 4.0 mm, and overlap length 20.4 ± 2.7 mm, consistently permitting tension-free neurorrhaphy without grafting. Diameters were 2.0 ± 0.2 mm (C7) and 1.9 ± 0.2 mm (SAN), showing favorable matching. In the clinical case, end-to-end coaptation was tension-free, and at one-year follow-up the patient regained full shoulder motion, abduction above 150°, and resolution of scapular winging. Conclusion: The C7 pectoralis fascicle provides sufficient length and diameter compatibility for direct SAN transfer, enabling consistent tension-free repair. Cadaveric and clinical findings support this technique as a reliable reconstructive option for SAN injury.

Speaker

Keiko Onaka

Abstract

【Introduction】 Nerve transfer reinnervate injured nerves that subserve critical functions by sacrificing the function of an expendable, healthy donor nerve. If impairment of the healthy motor nerve occurs, patients may perceive the lost function as more important than the function gained. We verify the function of both the candidate donor nerve and the nerve intended for preservation by intraoperative electrical stimulation and proceed with harvest only when both exhibit favorable responses. We evaluated the method to verify the function of both the candidate donor nerve and the nerve intended for preservation by intraoperative electrical stimulation and proceed with harvest only when both exhibit favorable responses. 【Materials and Methods】 We examined contralateral C7 (CC7), ulnar nerve fascicles (Oberlin procedure), and FDS branch, which are commonly used in nerve transfer. The cohort comprised 24 CC7, 34 Oberlin, and 10 FDS branch cases performed by a single surgeon between August 2019 and July 2025, each with at least 1 year of follow up. Median age was 30 years (19–62) for CC7, 24 years (12–73) for the Oberlin procedure, and 35.5 years (19–47) for the FDS branch. The male : female ratios were 21:3, 27:7, and 7:3, respectively. The median surgical waiting times were 4 months (3–5), 4 months (3–7), and 4.25 months (3–12) , respectively. Median follow up durations were 45.5 months (24–71), 43 months (14–72), and 24 months (15–50), respectively. Hemi- and total- CC7 transfers were performed in 18 and 6 cases, respectively. 【Results】 At the final follow-up, donor-site motor function was assessed using the Medical Research Council (MRC) grading system. In all cases, the relevant functions were MRC grade 5: for CC7, elbow extension and wrist/finger extension; for the Oberlin procedure, intrinsic function of hand for ulnar nerve fascicles; and for the FDS branch, wrist and finger extension. 【Discussion】 Various strategies for donor nerve selection have been reported, including anatomical considerations, nerve stimulation, and intraoperative neurophysiological monitoring. However, these approaches primarily focus on evaluating the nerve to be harvested, and assessment of the function to be preserved remains insufficiently defined. We demonstrated that intraoperative confirmation of good function in the nerve planned for preservation could prevent donor site motor deficits. 【Conclusion】 These findings in this study suggest that this approach enables donor nerve selection in a safer and more straightforward manner.

Speaker

Peiwen Lee

Abstract

【Introduction】 Sensate anterolateral (ALT) flaps using the lateral femoral cutaneous nerve (LFCN) can restore sensation, yet discriminative recovery and patient comfort remain inconsistent. We evaluated outcomes in three LFCN-inclined ALT reconstructions and contrasted them with current literature and the concept of spontaneous reinnervation. 【Materials and Methods】 The subjects were three male patients with a mean age of 50.7 years and a mean postoperative observation period of 40.7 months. The causative diseases were two cases of trauma (extensive degloving injury of the foot and contusion of the hand) and one case of type 2 CRPS(Hand) due to injury of the lateral antebrachial cutaneous nerve (LABCN). In all cases, the ALT flap with LFCN was elevated and sutured to the target nerve. At the final postoperative follow-up, perceptual evaluation (SWT, 2PD), pain evaluation (NRS), and complications were performed. 【Results】 Normal sensory recovery was not achieved. All patients regained protective sensation, somehow discriminative function remained limited and bothersome tingling/dysesthesia persisted. 【Discussion】 Findings align with reports that spontaneous reinnervation often restores protective sensation within 6-24 months, implying that routine nerve coaptation is not always necessary. Outcomes appear design-dependent: safe thinning (6-7mm above fascia) and preservation of intraflap LFCN micro-branches likely shorten the axonal path and provide Schwann-tube guidance without compromising perfusion. Further work should include preoperative mapping of cutaneous nerve density and design-controlled prospective studies emphasizing patient comfort.

Room 1

Speaker

Jo-Yun Sun (孫若紜)

Abstract

【Introduction】 Vascularized nerve graft is indicated for the nerve defect more than 15cm. However, although sural nerve is the first choice for nerve gap reconstruction, the setup of the vascularized sural nerve graft is tricky since no obvious nearby artery along the course of the sural nerve. In this study we investigated different designs and applications of free vascularized sural nerve flap. 【Materials and Methods】 Between 2018 and 2020, 6 cases had received nerve reconstruction using 8 free vascularized sural nerve grafts in Chang Gung Memorial Hospital, Linkou; for brachial plexus (n=2, in one patient), median nerve (n=1), ulnar nerve (n=1), posterior tibial nerve (n=2), and sciatic nerve (n=2, in one patient). Free vascularized nerve flaps were designed with different fashions, including shunt-restricted arterialized venous flap (n=3), true vascularized nerve flap (n=1), and peroneal artery perforator flap with the sural nerve included (n=4). 【Results】 One flap had loss the circulation after the operation due to recurrent arterial thrombosis, which was unsalvageable, then shifted to the conventional nerve graft. One case also simultaneously bridges the ulnar artery defect. For the venous flaps, after few days of the mild congestion, circulation had subsided gradually. For all cases, the Tinel’s sign had progress smoothly after the operation. 【Conclusions】 Free vascularized sural nerve flap is a good alternative when the long nerve gap presented. All the designs are practical and able to vascularize the injured nerve. The surgeon may find the most suitable and reliable solution method for such complex nerve defect.

Speaker

Takuya Yokoi

Abstract

【Purpose】 We report a case of painful terminal neuromas that developed after a mangled hand injury, in which pain relief was successfully achieved by capping the nerve stumps using a nerve conduit. 【Case】 A 73-year-old man sustained a crush injury to his left hand when it was caught in a press machine during labor. Except for the little finger, the thumb and fingers were extensively damaged, presenting as a mangled hand. Revision amputations were performed for the index and middle fingers; replantation of the ring finger and heterotopic replantation of the middle finger to the thumb position were also performed. Postoperatively, the patient experienced severe spontaneous pain with electric shock–like nocturnal pain. A local anesthetic block test confirmed the presence of painful neuromas. Painful neuromas were identified in the superficial branch of the radial nerve, the first common palmar digital nerve, and the second common palmar digital nerve. Surgical capping using a nerve conduit was performed for each neuroma. Following surgery, the electric shock–like pain disappeared, and the resting pain gradually improved. 【Discussion】 In severe hand injuries, including mangled hand, wound scarring is unavoidable and normal anatomical structures are disrupted, making it difficult to localize and identify sources of pain. Additionally, extensive scarring around the neuroma often prevents adequate coverage or burial of the nerve stump with sufficiently elastic soft tissue. Capping with a nerve conduit can be performed regardless of the surrounding soft tissue condition and may represent a useful treatment option for neuromas following severe hand trauma.

Speaker

Yu-Cheng Tian (田澄諭)

Abstract

Introduction: Musculoskeletal disorders are the leading cause of disability worldwide and are associated with reduced quality of life, poor mental health, limited mobility, and medical comorbidities. Limb paresis is particularly challenging to treat. Although wearable exoskeletons offer promise for functional restoration, their performance is constrained by the poor reliability of motor control signals. The Muscle Cuff Regenerative Peripheral Nerve Interface (MC-RPNI) was developed as a biologic construct to amplify efferent action potentials from the peripheral nerve and improve the motor signal quality. We previously showed that MC-RPNIs achieve a 10-20x amplification of peripheral nerve signals after a 3-month maturation. However, the long-term stability of this interface remains unclear, which is important as a chronically viable interface is needed in clinical settings. In this study, we evaluated the longevity of the MC-RPNI construct at 12 months post-surgery in situ, which is roughly equivalent to 30 years in humans. Materials and Methods: Twelve rats were assigned to 3-month or 12-month endpoints (n=6 per timepoint). MC-RPNIs were created using extensor digitorum longus muscle (EDL) grafts (trimmed to 1 cm) from donor rats on the intact common peroneal (CP) nerve in all rats (n=12). To evaluate the long-term viability of the MC-RPNI to provide exoskeleton control signals, electrophysiological testing was performed at each endpoint by surgically re-exposing the CP nerve and the MC-RPNI. The proximal CP nerve was electrically stimulated, and the maximum evoked compound muscle action potentials (CMAPs) generated by the construct were recorded to quantify signal output. The MC-RPNI constructs were then harvested for histology, including hematoxylin and eosin (H&E) and immunohistochemistry (IHC) staining. Results: At both 3- and 12-month endpoints, all MC-RPNI constructs demonstrated excellent muscle turgor and revascularization (Figure 1). H&E analysis showed preserved muscle architecture without pathological degeneration (Figure 2A), and IHC staining confirmed sustained muscle reinnervation (Figure 2B). Electrophysiologic testing at 12 months revealed robust, high-amplitude CMAPs following proximal CP nerve stimulation, with an average maximum CMAP signal of 4.08 ± 1.41 mV. Conclusion: MC-RPNIs remain viable and functional for at least 12 months in a rat model. These constructs demonstrated sustained revascularization, reinnervation, preserved muscle morphology, and robust electrophysiological signal generation. These findings support the MC-RPNI as a long-term biologic neural interface with significant translational potential for providing stable, reliable motor control signals for long-term exoskeleton applications.

Speaker

Mai Anh Bui

Abstract

Introduction: Peripheral nerve damage can lead to a loss of nerve continuity for a long time and cause a gap between the nerve endings. With scientific evidence, using vascularized nerve graft (VNG) for long and large-diameter peripheral nerve grafts is one of the optimal indications. This paper aims to present the study's initial results using VNG with peripheral nerve defect at Viet Duc Hospital. Patients and methods: A cross-sectional descriptive study, longitudinal follow-up of patients with peripheral nerve injury in the extremities with nerve grafts > 10 cm surgically VNG by microsurgery technique from 2020 to 2024 at Viet Duc University Hospital. Evaluation of results based on recovery time, muscle strength, and neurological sequelae. Results: 10 patients with microsurgery grafted saphenous nerve segment with feeding vessel. The male/female ratio is 9/1, and the mean age is 32.8. 08 patients were transversed with phrenic nerve with the musculocutaneous nerve in patients with brachial plexus injury and 01 with sciatic nerve injury. A VNG average length is 17.6cm, average recovery time is 4.75 months. Reach M3, M4: 8/10 patients, Conclusions: VNG is one of the good choices for longitudinal peripheral nerve defects or large diameter of the injured nerve, scarred recipient bed Keywords: Vascularized nerve graft (VNG), nerve injury, saphenous nerve, microsurgery.

Room 2

Speaker

Chi-Chien Hung (洪綺謙)

Abstract

【Introduction】 Dermatofibrosarcoma protuberans (DFSP) is a form of rare, low-grade malignant tumor, arising from fibroblasts in the dermis. DFSP had high local recurrence, but low metastatic potential, and mainly occurs on the trunk, followed by extremities, head and neck. Cases mainly occur in adults aged between 20 and 50. The primary treatment is complete resection. 【Materials and Methods】 A 28-year-old female presented with massive multilobulated recurrent facial tumor for 3 years. 4 years previously, the tumor had been excised and diagnosed as DFSP. Upon admission, the tumor with ulceration and necrosis was huge, and covered an approximately 25 x 20 cm area located mainly on her left forehead and cheek, and overhung her chest. The tumor was completely excised and reconstruction was performed using an ALT flap and a RFFF. 【Results】 Both the ALT flap and RFFF survived well and the patient was pleased with the aesthetic results. A local tumor recurred at left cheek region 3 years after the operation, which tumor was excised completely and reconstructed with a contralateral RFFF. Followed-up 30 months after the operation indicated no local or distant recurrence. 【Discussion】 DFSP is a locally aggressive tumor with high recurrence of up to 66%. The rate of regional or distant metastasis is less than 5% and is frequently preceded by multiple local recurrences. DFSP occurs mainly in young and middle-aged adults and most common site is the trunk, followed by the extremities, head, and neck. After DFSP has been confirmed, complete surgical resection is the primary treatment. More than 90% of DFSP cases are characterized by a translocation between chromosomes 17 and 22 [t (17; 22)(q22;q13)], fusing part of the COL1A1 gene from chromosome 17 with part of the PDGFB gene from chromosome 22. For patients with unresectable, recurrent, or metastatic DFSP, Imatinib, a tyrosine kinase inhibitor, has been indicated as a single agent or adjuvant treatment by the US Food and Drug Administration since 2006. Studies revealed that radiation therapy improved local control in some cases. Semiannual follow-up is recommended since DFSP may recurrence after years, especially in the first 3 years after surgery, which is when 80% of recurrences occur.

Speaker

Wun-Shih Chen (陳文士)

Abstract

【Introduction】 Advanced oral submucous fibrosis (OSF) can progress to oral cavity squamous cell carcinoma and often mandates bilateral mucosal release in addition to oncologic resection. Single-stage reconstruction for dual intraoral defects is challenging. We report outcomes using two bipaddled options—radial forearm (BRFF) and peroneal artery perforator (BPAP) flaps—from a single donor site to resurface simultaneous defects after tumor excision and contralateral OSF release. 【Materials and Methods】 We retrospectively reviewed 14 consecutive patients with oral malignancy and advanced OSF treated with a standardized protocol: (1) wide tumor excision, (2) contralateral buccal fibrosis release, (3) masticatory muscle myotomy and coronoidotomy when indicated, and (4) reconstruction using either a bipaddled radial forearm flap (n=6) or bipaddled peroneal artery flap (n=8). Defect sizes for tumor resection were 4×6 to 6×8 cm; contralateral mucosal strips measured 8.5–9.5 cm in length and 2–2.5 cm in width. Primary outcomes included mouth opening (pre-, intra-, and postoperative), flap survival, and procedure-related complications. 【Results】 Preoperative interincisal distance was 2–15 mm (mean 9.5 mm). After OSF release, intraoperative opening increased to 15–20 mm (mean 24.8 mm), and further to 36–48 mm (mean 40.3 mm) after adjunct myotomy/coronoidotomy. Twelve flaps survived uneventfully. One flap developed arterial thrombosis on postoperative day 2 and was salvaged; one flap had venous thrombosis with total loss. Two patients required debulking for bulkiness. One patient had TMJ dislocation with locking; subcondylar osteotomy achieved reduction. At a mean follow-up of 20 months, postoperative mouth opening was 18–41 mm (mean 28.2 mm), with a mean gain of 22.5 mm. 【Discussion】 Bipaddled designs enable simultaneous resurfacing of two separate oral defects using a single donor site, obviating a second free flap. The peroneal artery flap provided comparable reliability with advantages of reduced donor-site morbidity and more favorable scar cosmesis compared with BRFF in our experience. Meticulous thrombosis surveillance remains essential during the early postoperative period.

Speaker

Toshiya Kudo

Abstract

Background In recent years, flap surgery has become critical in reconstructing severe limb injuries by covering essential areas such as fractures and exposed functional tissues. Open fractures with extensive degloving injuries pose a major challenge due to multiple, separated bone and joint injuries requiring coverage. While the Double Flap approach, using multiple free flaps, offers one solution, it increases risks like vascular complications due to multiple donor sites. Alternatively, we have applied the "Combined Mega-Flap" technique, which utilizes a single, large contiguous flap to effectively reconstruct various lower limb traumas, reducing complications and enhancing reconstruction outcomes. Materials and methods From 2020 to 2024, we treated six cases using the Combined Mega-Flap technique: one femur case and five lower leg cases. Five cases involved an LD + iCAP (intercostal artery perforator) flap, while one case involved an LD + iCAP + SCIP flap. The total length of the skin flap ranged from 42 to 70 cm with a width of 8 to 9 cm (with a maximum width including the latissimus dorsi flap reaching 26 cm), which was fully reconstructed using intricate in-flap anastomosis techniques, allowing complete coverage with a “huge” single skin flap. Results In all cases, the donor sites were successfully closed without skin grafts. The extensive flaps survived without any congestion or partial necrosis. Conclusions Our Giant Flap (LD+iCAP /SCIP) has demonstrated significant value in extensive lower limb trauma reconstruction, enabling the simultaneous transfer of a large, stable skin flap and a muscle flap for effective dead space filling. This presentation will outline key techniques and pitfalls in using the Giant Flap, with insights derived from cadaveric dissection studies.

Speaker

Ayman Khoury

Abstract

Introduction Thoracic outlet syndrome (TOS) remains a subject of debate, particularly regarding the origin of its neurological and vascular manifestations. We report a case in which an abnormal first-rib morphology, characterized by a medial sternal spur with dense ligamentous attachment, led to predominately lower brachial plexus symptoms and combined neurogenic and arterial compression. Materials and Methods A 58-year-old man presented with progressive right upper-limb weakness and hand atrophy, three years after a high-speed motor vehicle accident with clavicular fracture. Clinical examination demonstrated dominant lower plexus involvement. Electrophysiological and vascular studies confirmed combined neurogenic and arterial TOS with chronic brachial plexopathy. The patient underwent right first-rib resection, scalenectomy, and neurolysis of the lower brachial plexus. Results Intraoperative findings revealed a prominent bony spur at the medial and inferior sternal end of the first rib, with thick ligamentous attachments that hindered rib extraction. This structural variation likely contributed to progressive lower plexus dysfunction and right-hand impairment. Postoperatively, radial artery pulsation improved markedly. However, transient postoperative upper plexus neurapraxia was noted, presenting as shoulder drop and weak elbow flexion. Pain in the right hand significantly improved, and ongoing physical therapy with electrical stimulation was initiated. Discussion This case highlights the clinical significance of first-rib anatomical variants in the pathophysiology of thoracic outlet syndrome. A sternal-end spur with firm ligamentous tethering can cause both mechanical vascular compromise and traction-related lower plexus neuropathy. Recognition of such variations is essential for accurate diagnosis, selection of surgical approach, and prevention of persistent or recurrent symptoms.

Speaker

Kuan-Ju Chiang (江冠儒)

Abstract

【Introduction】 DiGeorge syndrome (22q11.2 deletion syndrome) is a genetic disorder affecting about 1 in 4000 live births. It causes conotruncal heart defects, characteristic facies, velopharyngeal insufficiency, cleft palate, T-cell immunodeficiency, and hypocalcemia. Rarely, facial palsy occurs, requiring multidisciplinary, personalized management due to anatomical and systemic complexities in affected children. 【Materials and Methods】 A 6-year-old girl with genetically confirmed DiGeorge syndrome presented with incomplete left congenital facial paralysis, weak eye closure, asymmetric smile, and absent lower lip movement. Additional findings included right microtia, submucosal cleft palate (repaired at age 4), bilateral conductive hearing loss, speech disturbance, atrial septal defect, and immunodeficiency. 【Results】 At age six, the patient underwent two-stage facial reanimation at Linkou Chang Gung Memorial Hospital by Prof. David C.C. Chuang. The first stage (15/11/2023) involved cross-facial nerve grafting using sural nerves to restore smile and lower lip movement. The second stage, delayed to 18 months later due to medical issues, included free gracilis muscle transfer. Intraoperatively, the gracilis muscle showed abnormal bipennate anatomy, thick central tendon, and atypical vessel course, complicating dissection and requiring careful adjustment. The muscle was rotated, partially reduced in volume, and positioned for optimal vascular flow and aesthetic contour. Postoperative healing was complete after three weeks. 【Discussion】 This case may be the first to report abnormal muscle morphology and vessel anatomy in a DiGeorge syndrome patient. Facial paralysis treatment in DGS is challenging due to anatomical and systemic complexities. A tailored two-stage microsurgical approach using gracilis transfer for smile restoration and anterior digastric for lower lip reanimation proved effective. Awareness of possible anatomical variations, including bipennate gracilis structure and aberrant vessels, is essential for successful surgical planning and outcomes.