One-stage secondary debulking procedure: A unique technique to restore the differential contour of digit after groin flap reconstruction.

BACKGROUND: Pedicled groin flap is a reliable reconstructive method for digits. However, problems with the contour, mobility, and sensation, especially while providing strict thin skin coverage still exist. PATIENTS AND METHODS: A total of 17 cases with 36 digits injured by trauma were identified. One-stage secondary debulking procedure was adopted for flap revision. The skin over the flap was harvested as a full-thickness graft. At the dorsal side of the reconstructed digit, the subcutaneous tissue and fat were debulked till the deep fascial layer. At the volar side, the flap was debulked till the superficial fascial layer. The skin was then re-grafted. The outcomes were reviewed after 12 months follow-up. RESULTS: The average timing for debulking procedure after flap reconstruction was 116 days. After removal of bolster dressing 7 days after debulking, all the grafted skin took well. A mean length of 2.5 cm of digit was preserved for the non-replantable digits. The reconstructed digits achieved comparable diameter and contour with that of the contralateral side. The two-point discrimination of the injured digits of adults was 10.4 ± 1.6 mm. Using a 5-point Likert scale, post-debulking digits showed statistically significant improvement compared to pre-debulking digits. The evaluation of the patients' satisfactory outcomes of the reconstructed digits was judged as "very satisfying" in 12 patients (75 %) and "good" in 4 patients (25 %). CONCLUSIONS: One-stage secondary debulking procedure resulted in excellent functional and esthetic outcomes for digits according to different structures of the dorsal and volar sides. LEVEL OF EVIDENCE: IV, Retrospective.

The outcomes and biliary complications of a staged biliary reconstruction in living donor liver transplantation: a propensity score matched analysis.

BACKGROUND: Uncontrolled massive bleeding and bowel edema are critical issues during liver transplantation. Temporal intra-abdominal packing with staged biliary reconstruction (SBR) yields acceptable outcomes in deceased donor liver transplantation; however, data on living donor liver transplantation (LDLT) are scarce. METHODS: A retrospective analysis of 1269 patients who underwent LDLT was performed. After one-to-two propensity score matching, patients who underwent LDLT with SBR were compared with those who underwent LDLT with one-stage biliary reconstruction (OSBR). The primary outcomes were graft survival (GS) and overall survival (OS), and the secondary outcomes were postoperative biliary complications. RESULTS: There were 55 and 110 patients in the SBR and OSBR groups, respectively. The median blood loss was 6500 mL in the SBR and 4875 mL in the OSBR group. Patients receiving SBR-LDLT had higher incidence of sepsis (69.0% vs. 43.6%; P < 0.01) and intra-abdominal infections (60.0% vs. 30.9%; P < 0.01). Biliary complication rates (14.5% vs. 19.1%; P = 0.47) and 1-and 5-year GS (87.27%, 74.60% vs. 83.64%, 72.71%; P = 0.98) and OS (89.09%, 78.44% vs. 84.55%, 73.70%; P = 0.752) rates were comparable between the two groups. CONCLUSIONS: SBR could serve as a life-saving procedure for patients undergoing complex critical LDLT, with GS, OS, and biliary outcomes comparable to those of OSBR.

Epidemiology of Congenital Upper-Limb Anomalies in Southern Taiwan Based on the Updated Oberg, Manske, and Tonkin Classification: A Series of 1,335 Anomalies in 1,188 Patients.

PURPOSE: This study aimed to investigate the relative frequency of congenital upper-limb anomalies (CULAs) in southern Taiwan using the 2020-updated the Oberg, Manske, and Tonkin (OMT) classification system and evaluate the practicality of the new classification system. METHODS: We retrospectively reviewed patients with CULAs from 1987 to 2021 at a referral center in southern Taiwan. All patients were analyzed based on medical records, photographs, and radiographs, and the anomalies were classified according to the 2020 OMT classification system. RESULTS: A total of 1,188 patients with 1,335 CULAs were retrospectively reviewed. The results demonstrated that the most common type of CULA was malformations (1,092 cases), followed by dysplasias (144 cases), syndromes (51 cases), and deformations (48 cases). Among the malformations, radial polydactyly was the most common anomaly (732 cases), followed by simple syndactyly (66 cases). Among the dysplasias, camptodactyly was the most common anomaly (52 cases), followed by thumb-in-palm deformity (45 cases) and vascular tumors (17 cases). In the deformations, constriction ring sequence accounted for all cases. Poland syndrome (21 cases) occurred most often in the category of syndromes. CONCLUSIONS: The results of this study show that radial polydactyly (732 cases, 55%) is the most common CULA in southern Taiwan, followed by simple syndactyly (66 cases, 5%) and then camptodactyly (52 cases, 4%). CLINICAL RELEVANCE: The OMT classification system is reasonably practical for precise classification of CULAs and enables easy comparison of studies over different time periods. However, continually updating the OMT classification system is required to better categorize the highly variable presentations of CULAs.

The Efficacy of Subdermal Pocket Procedure in Fingertip Replantation With Composite Graft.

BACKGROUND: Microsurgical replantation of fingertip amputation is sometimes difficult because of a lack of available vessels. Composite grafting is an alternative method for nonvascularized replantation, but it has a limited success rate. The subdermal pocket (SDP) procedure is proposed to increase the survival of composite graft. AIM AND OBJECTIVES: We aimed to compare the success rate of the composite graft used in fingertip replantation with or without application of the SDP procedure. PATIENTS AND METHODS: From 2000 to 2020, 29 fingertip amputations (28 complete amputations, 1 near-complete amputation) from 28 patients were included. Five of the fingertip amputations were classified as Ishikawa zone Ib and 24 as Ishikawa zone II. Seventeen fingers underwent replantation with composite graft plus SDP procedure, whereas the remaining 12 fingers received replantation with composite graft only. RESULTS: The overall success rate was 70.59% (12 of 17) in the SDP group and 41.67% (5 of 12) in the composite graft-only group ( P = 0.119; odds ratio, 3.36). In the subgroup of Ishikawa zone II fingertip amputations, the success rate was 66.67% (10 of 15) in the SDP group and 22.22% (2 of 9) in the composite graft-only group ( P = 0.035; odds ratio, 7.0). CONCLUSIONS: The SDP procedure could increase the success rate of fingertip replantation with composite graft, especially for Ishikawa zone II amputations.

Hooked embracing plate for Rolando fracture fixation: a preliminary result.

BACKGROUND: Rolando fracture is a comminuted, intra-articular fracture over the metacarpal bone base of the thumb which often leads to joint instability and requirement of surgery. The aim of this study is to evaluate the radiological and functional outcomes of Rolando fracture following surgical fixation with a hooked embracing plate (Acumed, 1.3 mm, Rolando Fracture Hooked Plate) designed for Rolando fracture. METHOD: We retrospectively reviewed a consequence of patients between 2018 and 2022 with Rolando fracture who received open reduction internal fixation with hooked embracing plates. Primary endpoints were the quality of radiologic reduction after the operation and peri-operative complications. Secondary outcomes were bone union, pinch and grip strength, palmar abduction, opposition and radiographic osteoarthritis over the trapeziometacarpal (TMC) joint. RESULTS: A total of 5 patients were included. All patients had good quality of radiological reduction without peri-operative complications. The opposition, abduction, pinch and grip strength were nearly full-recovered for all patients with fine bone unions after 3 months follow-up. CONCLUSION: The hooked embracing plate is a good and safe option for surgical fixation in patients with Rolando fracture. Compared with traditional method such as lag screw or mini-plate fixation, the hooked embracing plate could provide rigid fixation with fine radiologic and functional outcomes with early mobilization.

Management of difficult hepatic artery reconstructions to reduce complications through continual technical refinements in living donor liver transplantations.

BACKGROUND: Hepatic artery reconstruction (HAR) for liver transplantation is crucial for successful outcomes. We evaluated transplantation outcome improvement through continual technical refinements. MATERIALS AND METHODS: HAR was performed in 1448 living donor liver transplants by a single plastic surgeon from 2008 to 2020. Difficult HARs were defined as graft or recipient hepatic artery ≤2 mm, size discrepancy (≥2 to 1), multiple hepatic arteries, suboptimal quality, intimal dissection of graft or recipient hepatic artery (HA), and immediate redo during transplantation. Technique refinements include early vessel injury recognition, precise HA dissection, the use of clips to ligate branches, an oblique cut for all HARs, a modified funneling method for size discrepancy, liberal use of an alternative artery to replace a pathologic HA, and reconstruction of a second HA for grafts with dual hepatic arteries in the graft. RESULTS: Difficult HARs were small HA (21.35%), size discrepancy (12.57%), multiple hepatic arteries (11.28%), suboptimal quality (31.1%), intimal dissection (20.5%), and immediate redo (5.18%). The overall hepatic artery thrombosis (HAT) rate was 3.04% in this series. The average HAT rate during the last 4 years (2017-2020) was 1.46% (6/408), which was significantly lower than the average HAT rate from 2008 to 2016 (39/1040, 3.8%) with a statistical significance (p = 0.025). Treatment for posttransplant HAT included anastomosis after trim back (9), reconstruction using alternatives (19), and nonsurgical treatment with urokinase (9). CONCLUSION: Careful examination of the HA under surgical microscope and selection of the appropriate recipient HA are key to successful reconstruction. Through continual technical refinements, we can reduce HA complications to the lowest degree.

The Multiple-U Technique: A Novel Microvascular Anastomosis Technique That Guarantees Everted Anastomosis Sites with Solid Intima-to-Intima Contact.

SUMMARY: The key to successful microvascular anastomosis is achieving intima-to-intima contact, which is not always easy. In this article, the authors propose the multiple-U technique, which is a novel microvascular anastomosis technique that characterizes easy and reliable intima-to-intima contact. The technique was performed on patients who underwent free flap reconstruction for head and neck defects at the Kaohsiung Chang Gung Memorial Hospital from September 1, 2020, to November 30, 2020. The immediate patency test results for all vessel anastomoses were positive, and the postoperative recovery courses of the patients were without any vascular complications. In conclusion, the multiple-U technique is a widely available technique that guarantees everted anastomosis sites and solid intima-to-intima contact. This technique can be performed on both arterial and venous anastomoses regardless of vessel size and wall thickness.

Revisiting Management Strategies for Popliteal Artery Injuries.

BACKGROUND: Popliteal artery injuries (PAIs) were reported to own the highest rates of limb loss in vascular injuries of extremities. The complex nature of PAIs makes the treatment more difficult. We aimed to present our cases using our proposed algorithm and revisit the strategies for management. PATIENTS AND METHODS: A retrospective study of 45 cases with PAIs managed at the Kaohsiung Chang Gung Memorial Hospital over a 10-year period was conducted. The proposed algorithm for decision making was applied, which contains variables including the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, the acquisition of preoperative angiography, and the existence of collateral circulation. Whether the injured limbs were salvaged successfully avoiding amputation was recorded. RESULTS: Of all the included 45 patients, the rate of a successful salvage of the injured limb from amputation was 71.1%. Six patients did not receive revascularization because of their poor conditions of the injured limbs. In terms of limb salvage in PAIs, the interval before surgery, the revascularization being delayed or not, the presence of fasciotomy, or the acquisition of preoperative angiography did not make a significant difference (P > 0.05). Instead, an existence of collateral circulation at the distal injured limb was correlated to a significant higher rate of salvage, regardless of having revascularization or not (P = 0.001 and < 0.001, respectively). Seven patients had the injured vessels repaired directly and all were prevented from amputation. In other patients who underwent vascular repair using a graft, vein graft (n = 20) showed a higher successful rate in salvage significantly than Gore-Tex graft (n = 9, P < 0.001). CONCLUSIONS: Collateral circulation determines much of the fate of limb salvage in PAIs. As a result, a delayed revascularization could be accepted as long as there is existence of collateral circulation at the distal injured limb. An autologous vein graft is favored when a direct repair is not able to be performed for revascularization. Although fasciotomy was not found to be associated with a successful salvage in this study, its importance could not be neglected and it should be performed when there is an observed or impending compartment syndrome.

Can Microscopic Biliary Reconstruction Reduce Biliary Complication Rate in ABO-Incompatible Adult Living Donor Liver Transplantation?

BACKGROUND With the introduction of rituximab, ABO-incompatible (ABOi) living donor liver transplantation (LDLT) has been considered a feasible and safe procedure to overcome the shortage of organ donors. However, higher biliary complication rates remain an unresolved problem in the ABOi group. In our center, biliary anastomosis has been done with microscopic biliary reconstruction (MBR), which effectively reduced the biliary complication rate. The aim of the current study was to investigate whether the microscopic approach reduced anastomotic biliary complications in ABOi LDLT. MATERIAL AND METHODS From March 2006 to December 2018, 30 adult ABOi and 60 ABO-compatible (ABOc) LDLT patients were selected from over 1300 recipients through 1: 2 propensity score-matched cohorts. All patients received MBR during the transplantation. Biliary complications included bile leakage and biliary stricture. Patients with diffuse intrahepatic biliary stricture were excluded from analysis. RESULTS Patient characteristics were similar in the 2 groups. There was no in-hospital mortality in the ABOi LDLT. The long-term survival rates of the ABOi patients were comparable to those of the patients that underwent ABOc LDLT (87.1% vs 87.4%, P=0.964). Those in the ABOi group with anastomotic biliary complications were about 40%, which was higher than in the ABOc patients (40% vs 15%, P=0.01). CONCLUSIONS Microscopic biliary reconstruction does not help to reduce the high biliary complication rate in ABOi LDLT. Further investigation and identification regarding other risk factors and precautionary measures involving immunologic and adaptation mechanisms are needed.

Excellent Outcome in Living Donor Liver Transplantation: Treating Patients With Acute-on-Chronic Liver Failure.

Acute-on-chronic liver failure (ACLF) is a fatal condition, and liver transplantation (LT) is a vital option for these patients. However, the result of living donor LT (LDLT) for ACLF is not well investigated. This study investigated the outcomes of LDLT in patients with ACLF compared with patients without ACLF. This was a single-center, retrospective, matched case-control study. From July 2002 to March 2017, a total of 112 patients with ACLF who underwent LDLT were enrolled according to the consensus of the Asian Pacific Association for the Study of the Liver. A total of 224 patients were selected for control comparison (non-ACLF) with demographic factors (sex, age, and body mass index) matched (1:2). Patients with ACLF were stratified into ACLF 1, 2, and 3 categories according to the number of organ failures based on the Chronic Liver Failure-Sequential Organ Failure Assessment score. Survival and surgical outcomes after LDLT were analyzed. The Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores in the ACLF group were significantly higher than those in the non-ACLF group (P < 0.001). The 90-day, 3-year, and 5-year survival rates in the ACLF and non-ACLF groups were 97.3%, 95.5%, 92.9%, respectively, and 96.9%, 94.2%, and 91.1%, respectively (P = 0.58). There was more intraoperative blood loss in the ACLF group than in the non-ACLF group (P < 0.001). The other postoperative complications were not significantly different between the groups. A total of 20 patients (17.9%) in the ACLF group presented with 3 or more organ system dysfunctions (ACLF 3), and the 90-day, 3-year, and 5-year survival rates were comparable with those of ACLF 1 and ACLF 2 (P = 0.25). In carefully selected patients, LDLT gives excellent outcomes in patients with ACLF regardless of the number of organs involved. Comprehensive perioperative care and timely transplantation play crucial roles in saving the lives of patients with ACLF.

Functional Evaluation of Ankle Joint After 1-Stage Secondary Debulking Procedure After Flap Reconstruction.

OBJECTIVE: Free or local flaps that are used to reconstruct the lower limb often result in poor functional outcome because of bulkiness of the flap and scar contracture over ankle joint region. The aim of this study was to evaluate the functional results of ankle joint after 1-stage secondary debulking procedure for lower limb trauma. MATERIAL AND METHODS: From January of 2002 to October of 2018, debulking procedures were performed for 66 patients after flap reconstructions of the lower limb. Thirty-eight patients (group 1) of foot injury without ankle joint involvement and 20 patients (group 2) with ankle joint involvement were included. Range of motion (ROM) of ankle joint before and after debulking procedure was measured after 6 months of follow-up. RESULTS: After debulking procedure, all the patients were able to dress in their preinjury shoes without any difficulty and with ease of ambulation. For all patients, with or without ankle involvement, the postdebulking ROM versus predebulking ROM improved significantly (P < 0.01). The ROM improvements for patients with ankle involvement were significantly better then patients without ankle involvement (P = 0.032). CONCLUSIONS: One-stage debulking procedure can provide long-term constant, reliable, thin skin coverage for the lower limb after flap reconstruction with improved ankle ROM. This allows better functional results, especially for lower limb trauma patients with initial ankle involvement.

Reconstruction of Tibia Fracture With Soft Tissue Defect.

BACKGROUND: We aimed to compare different methods to treat lower leg soft tissue defects with tibia fracture using free flaps and pedicled flaps. We also highlighted the aesthetic outcome after using 1-stage secondary debulking procedure for tibia area. PATIENTS AND METHODS: From December 2000 to March 2017, 83 patients with lower leg defects and tibia fractures were reconstructed using 71 free flaps and 12 pedicled flaps. One-stage secondary debulking procedures were performed for 39 patients after flap reconstruction. Infection control and aesthetic outcomes using 5-point Likert scale were reviewed after a 16-month follow-up. RESULTS: Twenty-five myocutaneous free flaps, 45 fasciocutaneous free flaps, 1 fibula free flap, 12 pedicled flaps of which 8 were distally based sural artery flaps, and 4 medial gastrocnemius flaps were used. The flap survival rate was 100%. There was no recurrence of osteomyelitis in any patient after reconstruction with any of these flaps. Using a 5-point Likert scale, performance of a 1-stage secondary debulking procedure showed statistically significant difference in terms of contour, color, and texture compared with the group without debulking procedure. CONCLUSIONS: The use of free flaps and pedicled flaps in the reconstruction of lower leg defects with tibia fracture is reliable and results in good infection control. A 1-stage secondary debulking procedure delivers excellent long-term aesthetic outcome after reconstruction of the tibia area.

Optimizing biliary outcomes in living donor liver transplantation: Evolution towards standardization in a high-volume center.

Biliary complications have always been a dreaded cause of morbidity after living donor liver transplantation. While intrinsic variations in both graft and recipient biliary anatomy remain a significant factor to the difficulty of biliary reconstruction, our institution has taken advantage of its high volume of cases to critically review and evaluate modifiable operative risk factors, in particular, our surgical protocols. We present herein, the evolution of our reconstructive biliary technique from conventional methods to our current standard of microsurgical biliary reconstruction for both graft and recipient ducts. Over this period of transition, our center has created a classification system for biliary reconstruction that decreased the biliary complication rates from 40.0% to 10.2%.

Long-term Results in Comparative Analysis of Merits in Using Polypropylene and Polydioxanone for Microsurgical Biliary Reconstruction in Living Donor Liver Transplantation.

BACKGROUND: Bile duct complications hamper patient recovery from a transplant, curtail patient quality of life, and may impair the function and persistent survival of the allograft. The aim of this study is to compare the results of biliary reconstruction using 6-0 polypropylene and 6-0 polydioxanone. METHODS: A single-center retrospective study was performed on 133 patients who underwent microsurgical biliary reconstruction during living donor liver transplantation between November 2014 and December 2015. 6-0 polypropylene (Prolene) and 6-0 polydioxanone suture (PDS) were used for biliary reconstruction in 80 and 53 cases, respectively. The factors of age, sex, disease, and comorbidity were evenly distributed in these 2 groups. The average follow-up time was 43 months (36-50 months). There were 49 right lobe grafts and 31 left lobe grafts in the polypropylene group and 27 right lobe grafts, 25 left lobe grafts, and 1 left lateral segment in the polydioxanone group. RESULTS: The overall biliary complication rate was 11.25% in the polypropylene group. The overall biliary complication rate was 11.32% in the polydioxanone group. All biliary complications were managed successfully, and no mortality was observed. There was no statistically significant difference between complication rates with the use of different suture material (P = .990). CONCLUSION: The theoretical advantages of polydioxanone over polypropylene in biliary reconstruction could not be explained with this study.

Bilateral proficiency over time leads to reduced donor morbidity in living donor hepatectomy.

BACKGROUND: Although left-lobe donation is considered safer, right-sided donor hepatectomy predominates in adult living donor liver transplantation (LDLT). We hypothesized that bilateral proficiency with donor hepatectomy reduces overall donor complications. METHODS: A retrospective review of 834 adult LDLT donors (221 left lobes) from January 2004 to December 2014 was performed, dividing cases into two eras based on left-graft experience. Donor complications within 6 months were investigated, focusing on graft side and surgical era. RESULTS: The overall complication rate was 17.6%, and was higher in right-lobe donors. In Era 2, during which left-lobe donation rates were three times higher, total complications decreased (14.7% vs. 20.9%, P=0.02). A significant reduction in postoperative ascites accounted for the lower overall complication rate. The proportion of major biliary complications (BCs) was halved from 62.5% to 25.0%. Right-lobe donor complications also decreased significantly (15.8% vs. 22.9%, P=0.032), demonstrating that it was not only increased left-lobe donations leading to lowered complication rates, but also greater experience with donor hepatectomy in general. CONCLUSIONS: Accumulating experience with bilateral donor hepatectomy leads to decreased donor morbidity and comparable outcomes for right and left lobes, further enhancing the goal of donor safety while balancing recipient needs.

What happened in 133 consecutive hepatic artery reconstruction in liver transplantation in 1 year?

BACKGROUND: The immediate challenges during microvascular reconstruction of hepatic artery (HAR) during liver transplantation (LT) can be many. Hence, in order to give a cross sectional view of these problems this study over a period of 1 year, showing our routine practice, was taken up. METHODS: From January 2015 to December 2015, a total of 133 LTs were performed in Kaohsiung Chang Gung Memorial Hospital, Taiwan. All hepatic artery (HA) reconstructions were performed by a microvascular surgeon under an operating microscope. RESULTS: In the 133 patients, one artery was anastomosed in 123 (92.5%) patients, two in 9 (6.8%) patients and three in 1 (0.7%) of the patient. Eleven (8.3%) arteries were less than 2 mm in size (1-1.9 mm). There were intimal dissections (IDs) involving either the donor or the recipient arteries of mild to severe nature in 9 (6.8%) patients. Immediately following graft arterial anastomosis, either there was no flow or an intraoperative hepatic artery thrombosis (HAT) was found in nine (7.1%-8 LDLT, 4.8%-1 DDLT) patients. Immediate re-do anastomosis was done in all of these patients who did well in the follow-up. The overall post-operative success rate was 99.2%. One patient (0.8%) developed postoperative HAT due to infection during follow up and died due to sepsis. CONCLUSIONS: Small vessels or HA injury are the frequently encountered problems by a micro vascular surgeon. The other problems could be ID, need to do multiple reconstructions, immediate HAT and ability to re-do the HAR immediately.

Microdermal Grafting for Color Regeneration of White Scars.

White scars are defined in this study as mature hypopigmented surgical or traumatic scars whose color is much lighter than surrounding skin, to the extent that they appear white. These scars are often obvious and very difficult to treat or mask. This 3-year retrospective study reports the outcomes from 38 recipients of a new microdermal grafting surgery we developed, which introduces melanocytes into the white scar lesion to regenerate skin color. The study shares 18 years of experience with this procedure, describes the surgical steps, offers videos of the procedures, and presents 4 cases. Between September 2013 and December 2016, 38 patients (30 females; 8 males) underwent microdermal grafting for color regeneration of white scars in our plastic surgery clinic. Most patients, 78.9%, received 1 treatment, 15.8% received 2 treatments, and 5.3% received 3 treatments. Three lay judges were asked to assess percentage pigmentation recovery by comparing photographic images of patients' preoperative and postoperative scars. Patients were also asked to assess, via a questionnaire, satisfaction and percentage improvement 1 year after surgical treatment. Lay judges found an average of 49% improvement after 1 session, 75% after 2 sessions, and 90% after 3 sessions. In total, 71.1% of the patients completed the questionnaire 1 year after the surgery. Average subjective improvement was 55% after 1 session, 88% after 2 sessions, and 95% after 3 sessions. The patient satisfaction rate was high. Microdermal grafting provides adequate treatment of white scars by regenerating melanocytes, although more than 1 session treatment may be needed.

Optimal Result of One-Stage Secondary Debulking Procedure After Flap Reconstruction of the Ankle.

Skin and soft tissue defect of the ankle usually mandates flap reconstruction; however, bulky flap and difficulty ambulance have been the major disadvantages after flap reconstruction of this area. We used the concept of full-thickness skin graft as a 1-stage method of secondary debulking procedure to achieve both aesthetic and functional results. METHODS: Since January of 2004 to June of 2016, 22 one-stage secondary debulking procedures were performed on 22 patients who had received reconstruction with flaps for ankle defects. Nineteen cases were free myocutaneous flaps, 2 cases were free fasciocutaneous flaps, and 1 case was a distally based sural artery flap. In the operative technique, the full-thickness skin was harvested from the flap and regrafted on the defatted fascia with tie-over dressing. The functional and cosmetic outcomes as well as complications were reviewed. RESULTS: The overall mean follow-up time was 12 months. After the debulking procedure, all of the grafted skins took well. The patients were able to wear their own shoes without difficulty and regained ease of ambulation. The reconstructed area was found to decrease to an average of 28.92% as compared with predebulking area. The reconstructed ankles achieve good symmetry with regard to the contralateral side (P < 0.05). All of the patients were satisfied with the results of the reconstructed ankles. CONCLUSIONS: The 1-stage secondary debulking procedure is a safe and reproducible technique that achieves good functional and aesthetic outcomes after flap reconstruction of the ankle.