Background: Lymphatic complications, including lymphorrhea, lymphatic fistula, lymphocele, and secondary lymphedema, are well-recognized sequelae of vascular and cardiothoracic procedures involving groin or extremity dissection. These conditions may lead to delayed wound healing, infection, prolonged hospitalization, and considerable patient morbidity. Although conservative management and lymphatic ligation remain standard treatment options, refractory cases continue to present significant therapeutic challenges. Supermicrosurgical lymphaticovenous anastomosis (LVA) offers a physiologic approach capable of restoring lymphatic drainage while minimizing surgical morbidity. Methods: We reviewed five consecutive lymphatic complications managed at our institution using individualized supermicrosurgical strategies guided by preoperative lymphoscintigraphy and indocyanine green (ICG) lymphography. Clinical presentations included persistent lymphorrhea following great saphenous vein harvest for coronary artery bypass grafting, ECMO-related groin lymphatic leakage, lymphocele formation, and extremity lymphedema following vascular procedures. Surgical interventions included in-situ LVA at the site of leakage, distal LV bypass with selective lymphatic ligation, and adjunctive muscle flap reconstruction when dead space obliteration was required. Results: ICG lymphography allowed characterization of lymphatic flow patterns and identification of disrupted lymphatic pathways, facilitating tailored surgical planning. Depending on the underlying pathophysiology, LVAs were performed either directly at the leakage site or distal to the site. Lymphatic diameters ranged from 0.5 to 1.0 mm, demonstrating the applicability of supermicrosurgical techniques in these complex settings. All patients experienced clinical improvement, including resolution of lymphatic leakage, reduction in drainage output, improvement of limb swelling, and successful wound healing. Cases with persistent dead space benefited from adjunctive sartorius or gracilis muscle flap reconstruction. Conclusions: Supermicrosurgical LVA offers a physiological and minimally invasive solution for postoperative lymphatic complications. Preoperative evaluation with lymphoscintigraphy and ICG lymphography allows precise characterization of lymphatic dysfunction, distinguishing lymphatic leakage from obstructive pathology and guiding individualized treatment. Based on our clinical experience, we present a practical management algorithm that integrates modern lymphatic imaging, physiological reconstruction, and conventional treatment modalities. This comprehensive approach expands the reconstructive options available for challenging lymphatic complications and promotes tailored, mechanism-based care following cardiovascular and vascular interventions.

Background: Recent discoveries regarding the glymphatic and meningeal lymphatic systems have highlighted their critical role in clearing metabolic waste products—specifically amyloid-beta and tau proteins—from the central nervous system. Impaired lymphatic drainage through the deep cervical lymph nodes (dCLNs) is increasingly recognized as a key contributor to the pathogenesis and progression of Alzheimer’s disease (AD). Supermicrosurgical deep cervical lymphaticovenous anastomosis (dcLVA) has emerged as a novel, mechanism-driven structural intervention designed to bypass these lymphatic outflow obstructions and enhance cranial clearance. This study presents our preliminary experience evaluating the safety and technical feasibility of neck LVA in patients with AD at Kaohsiung Chang Gung Memorial Hospital (KCGMH). Methods: A prospective series of three patients with confirmed diagnoses of Alzheimer's disease underwent bilateral cervical supermicrosurgical LVA. Indocyanine green (ICG) lymphography was utilized intraoperatively to map the cervical lymphatic anatomy and identify functional lymph channels. Under high-power magnification, supermicrosurgical anastomoses were performed to connect the identified cervical lymphatic vessels directly to adjacent small recipient veins. Perioperative safety profiles, technical execution parameters, and early postoperative cognitive and functional outcomes (assessed via [e.g., MMSE]) were documented at a follow-up interval of [e.g., 1, 3, 6, and 12] months. Results: Bilateral neck LVA was successfully executed in all three cases without intraoperative technical failure. Either cervical lymphaticovenous anastomoses or Split LN-vein end-to-side anastomoses were performed. No serious adverse events (SAEs), such as severe hematoma, deep neck infection, or permanent neurological deficits, were observed in the immediate post-operative period. Early follow-up assessments revealed improvements in some motor function in all 3 patients]. Conclusion: Our early, three-case experience at KCGMH demonstrates that deep cervical LVA is a technically feasible and safe supermicrosurgical intervention for patients with Alzheimer's disease. While these preliminary data show promising perioperative safety and initial functional stability, longer longitudinal tracking and rigorous, larger-scale controlled clinical trials are required to establish the sustained efficacy of dcLVA on cognitive decline.

Early-stage lymphedema on lymphoscintigraphy is traditionally assumed to reflect fluid-dominant disease favorable for physiologic procedures like lymphovenous anastomosis (LVA). In a retrospective review of 187 extremity lymphedema patients, a subgroup showed severe fat-dominant tissue change despite early Taiwan Lymphoscintigraphy Staging. Younger age, higher BMI, male sex, and infection-related etiology were significantly associated with this discordant phenotype. These patients had modest volume reduction after technically successful LVA, since physiologic procedures don't address established adipose hypertrophy. Findings suggest tissue phenotype—not lymphoscintigraphy stage alone—should guide selection between physiologic and excisional (debulking) surgical approaches.

Receiving the 2026 Fu Chan Wei's Young Microsurgeon Award is a tremendous honor and an important milestone in my career. During the past decade, my clinical practice and research have focused on advancing reconstructive microsurgery while pursuing innovation that improves patient outcomes. This lecture summarizes my journey through three major fields of reconstructive microsurgery. First, I will present our experience in head and neck reconstruction, focusing on recipient vessel selection, free flap reconstruction, management of difficult salvage cases, and functional restoration following oncologic ablation. Second, I will discuss our recent work in robotic-assisted reconstructive surgery, highlighting the integration of robotic technology into microsurgical reconstruction and its potential role in minimally invasive reconstructive procedures. Finally, I will introduce our experience in supermicrosurgery, particularly lymphaticovenous anastomosis (LVA) for the treatment of extremity lymphedema. Recent developments combining artificial intelligence, and augmented reality navigation have further expanded the precision and possibilities of lymphatic surgery. Through these experiences, I hope to demonstrate how innovation, collaboration, and persistent clinical practice can continuously advance reconstructive microsurgery. More importantly, I hope to encourage young plastic surgeons to embrace reconstructive surgery, continue exploring new technologies, and contribute to the future development of microsurgery.

Introduction: Brachial plexus injury (BPI) is a devastating condition that frequently affects young and working-age adults, resulting in severe upper-extremity disability, chronic pain, prolonged rehabilitation, and substantial psychosocial burdens. Although advances in microsurgical nerve reconstruction have improved functional outcomes, successful recovery depends not only on surgery but also on patient engagement in continuous rehabilitation. To address these challenges, our institution developed a patient-centered integrated care pathway for BPI reconstruction. Methods: Since 2022, we have established a multidisciplinary program that integrates hand surgeons, neurosurgeons, physiatrists, rehabilitation therapists, nurses, social workers, and case managers into a coordinated care team. The case manager serves as the central coordinator, facilitating communication among healthcare professionals, patients, and families throughout the treatment journey. The care pathway encompasses preoperative evaluation and rehabilitation planning, shared decision-making, microsurgical reconstruction, early postoperative rehabilitation, long-term functional monitoring, psychosocial support, and community reintegration. One-stop multidisciplinary outpatient services, standardized outcome assessments, digital educational materials, and messaging platforms further enhance continuity of care. Results: Between 2022 and 2025, 46 patients were managed using this integrated care pathway. Rehabilitation adherence improved substantially, with rehabilitation linkage rates increasing from 53% to 92%. Patient anxiety scores decreased by 36.5%, while patient satisfaction scores improved from 7.4 to 9.2 on a 10-point scale (0 = least satisfied; 10 = most satisfied). Conclusions: A patient-centered multidisciplinary care pathway extends the value of brachial plexus reconstruction beyond surgical success alone. By integrating surgical treatment, rehabilitation, psychosocial support, and long-term follow-up, this model improves care continuity and facilitates functional recovery, providing a replicable strategy for BPI management.

Upper extremity spasticity following central nervous system injury may result in abnormal posture, impaired voluntary movement, and functional limitation. Surgical treatment aims to improve muscle balance and upper extremity function, and several peripheral nerve procedures have been developed for this purpose. In our practice, both nerve transfer and selective neurotomy have been used for the management of upper extremity spasticity. Nerve transfer has been applied to modify the balance between spastic agonists and weaker antagonists, while selective neurotomy has been performed using different techniques, including partial motor branch reduction, complete neurotomy with primary repair, and selective denervation of an individual muscle within a synergistic group. The clinical outcomes of these procedures have shown different patterns in terms of reduction of spasticity, recovery of active movement, preservation of muscle function, and overall functional improvement. Their effectiveness may vary according to the distribution of spasticity, residual voluntary motor control, target muscle selection, and surgical technique. These differences highlight the importance of individualized surgical planning when selecting peripheral nerve procedures for upper extremity spasticity.

Restoration of intrinsic hand function remains one of the most challenging goals in peripheral nerve reconstruction. In high or severe ulnar nerve lesions, the long distance required for axonal regeneration often results in irreversible motor endplate degeneration before regenerating axons can reach the intrinsic muscles. Supercharged end-to-side (SETS) transfer of the anterior interosseous nerve (AIN) to the motor branch of the ulnar nerve (MBUN) provides an additional source of motor axons close to the target muscles while preserving the native ulnar nerve pathway. However, as our clinical experience with this procedure has expanded, we have found that intrinsic hand paralysis cannot be adequately addressed by a uniform nerve transfer strategy. Our approach has therefore evolved from conventional SETS AIN transfer toward a function-oriented and tailored motor reconstruction. The fundamental principle is to identify not only the injured nerve, but also the specific intrinsic functions that require reinforcement. Preoperative assessment includes conventional intrinsic muscle strength and grip and pinch measurements, together with more detailed evaluation of functional deficits involving thumb control and precision, coordinated function of the four digits, and small-finger/hypothenar function. These findings provide a functional map of the individual patient’s paralysis and serve as a guide for subsequent reconstruction. Intraoperatively, the MBUN is explored and functionally mapped using direct electrical stimulation. Different fascicular regions can produce preferential responses involving the thumb, four digits, or hypothenar muscles. Our sequential stimulation experience has demonstrated that the order and location of recipient fascicular exploration influence the ability to obtain clear and reproducible motor responses. This functional mapping provides information beyond visual fascicular anatomy and allows the recipient nerve to be approached according to the motor deficit of the individual patient. The donor AIN is harvested distally with multiple terminal branches to the pronator quadratus. Rather than treating these branches as a single donor unit, they can be distributed through separate epineurial windows along selected regions of the MBUN. The number and location of coaptations can therefore be modified according to the functional domain requiring greater reinforcement. This multi-branch, multi-target SETS strategy represents an evolution from anatomical nerve transfer toward selective motor augmentation while maintaining continuity of the native ulnar motor pathway. The same reconstructive principle has been extended to diverse clinical settings. In severe ulnar neuropathy associated with degenerative elbow disease, SETS AIN transfer can be combined with cubital tunnel decompression, anterior transposition, and treatment of the underlying elbow pathology. More recently, we have applied the technique to adults with longstanding ulnar neuropathy secondary to neglected childhood lateral humeral condyle nonunion and chronic valgus deformity. In these patients, satisfactory elbow motion may coexist with severe intrinsic paralysis. A nerve-focused reconstruction combining proximal decompression and transposition with distal AIN motor augmentation may provide functional recovery without necessarily requiring complex osseous reconstruction. These experiences have progressively changed our view of AIN transfer. The procedure should not be regarded simply as an anatomical transfer from the AIN to the ulnar motor nerve. Rather, it can serve as a platform for individualized reconstruction of the paralyzed hand, integrating preoperative functional analysis, intraoperative fascicular mapping, selective donor allocation, and pathology-specific management of the proximal nerve. The future direction of hand paralysis reconstruction may therefore lie in moving from a standardized “one donor–one recipient” concept toward precision motor reconstruction, in which the pattern of paralysis determines how available donor axons are distributed. Such a tailored strategy may broaden the application of distal nerve transfer across diverse etiologies and patterns of intrinsic hand dysfunction while preserving opportunities for native nerve regeneration.

The ideal scenario for ulnar nerve and median nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring, and neuroma formation in a delayed injury, creating a nerve defect. With a wrist-level nerve defect, a flexion position can help shorten the nerve gap; however, maintaining the position can be challenging intraoperatively and postoperatively. Previously, we proposed our method of using a 2.0-mm K wire for radius-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar and median nerve injury. High median nerve injury presents a particular challenge for reconstructive surgery because the distance from the injury site to the intrinsic hand muscles far exceeds the range covered by axonal regeneration. Distal nerve transfer has become a breakthrough reconstruction strategy for high-level injuries in recent years. Its principle is to move the coaptation site closer to the target muscle, thereby bypassing the inherent long-distance regeneration limitations of proximal repair, effectively shortening the regeneration distance and preserving end-organ viability. However, for complex high median nerve injuries requiring simultaneous repair of both motor and sensory functions, the literature lacks comprehensive case reports and follow-up on the staged hybrid reconstruction strategy, which combines proximal branch-directed repair and multiple distal nerve transfers. Therefore, surgical strategy planning and early efficacy observation for such complex injuries are areas worthy of further research.

Cubital tunnel syndrome (CuTS) is an ulnar nerve dysfunction at the elbow joint resulting from a combination of compression, traction, and friction. Although numerous operative procedures have been introduced for the treatment of CuTS, the optimal surgical intervention remains controversial. Simple decompression involves releasing the fascial structures superficial to the ulnar nerve; while it is technically straightforward and minimizes nerve devascularization, it has been criticized due to concerns regarding persistent postoperative symptoms. Medial epicondylectomy reduces ulnar nerve tension more effectively than simple decompression; nonetheless, potential drawbacks such as inadequate tension reduction and persistent medial elbow pain must be considered. Anterior transposition of the ulnar nerve eliminates compression, traction, and friction simultaneously by placing the nerve anterior to the ulno-humeral axis of rotation. However, this procedure requires a relatively long segment of circumferential dissection. Furthermore, the anterior relocation of the nerve may induce strain during elbow extension. Despite these concerns, anterior transposition of the ulnar nerve is considered the most comprehensive procedure, as it simultaneously addresses all pathological mechanical forces, including compression, tension, and friction. Thus, the author primarily performs ulnar nerve reposition when treating cubital tunnel syndrome. Osborne’s ligament is typically incised longitudinally, and ulnar nerve mobility is assessed during elbow flexion and extension. If the ulnar nerve exhibits restricted mobility, cubital tunnel obliteration is utilized. In cases where the ulnar nerve undergoes significant excursion over the medial epicondyle or if preoperative ulnar nerve instability is present, a superficial anterior transposition is prioritized. These methods effectively eliminate pathologic forces applied to the ulnar nerve while minimizing the typical disadvantages of transposition of ulnar nerve, such as long-segment devascularization or malposition of ulnar nerve.

Purpose: Neurogenic tumors are classified as various subentities, and a cautious diagnostic approach is necessary. Schwannoma is a benign, encapsulated tumor originating from Schwann cells of the peripheral nerve sheath. Granular cell tumor is a rare neoplasm derived from Schwann cells, characterized by distinct pathologic findings. The tumor has been called “granular cell myoblastoma,” since the biologic origins of this lesion were unclear. Nonetheless, Fisher and Wechsler et al. demonstrated histiogenesis of the lesion from Schwann cells using immunohistochemistry, including S100 protein. The tumor should be treated to avoid recurrence or metastasis. In this study, we present patients with Schwannomas and granular cell tumors that exhibit atypical features. Methods: Data on 37 patients with Schwannoma and 4 patients with granular cell tumors were reviewed. Among the Schwannoma patients, three did not show typical signs, such as numbness or aching pain. Among the four granular cell tumors, one tumor arose from a previous neurofibroma site. Notably, one granular cell tumor exhibited malignant features, necessitating in-depth analysis. Results: Clinical presentation and imaging studies of significant patients are described. A 71-year-old patient presented with a palpable mass on the wrist. For a diagnostic imaging study, computed tomography (CT) was performed. There was a round, homogeneous mass in the volar wrist, superficial to the flexor tendons/muscles, and the impression was a ganglion cyst or schwannoma. During the operation, the lesion was connected with median nerve branches, and the pathologic report showed schwannoma. A 66-year-old patient presented with a mass on the left thigh. MRI showed a high-signal mass within the muscle. The impression was a hypervascular soft-tissue tumor or sarcoma. Intra-operative findings exhibited a connection to femoral nerve branches, and the pathologic report showed schwannoma. A 43-year-old patient showed a recurrent mass (previous neurofibroma) on her abdomen. Ultrasonography showed increased vascularity. Recurrent neurofibroma or angioleiomyoma was possible. After surgical excision, a granular cell tumor was diagnosed. A 51-year-old patient presented with a mass on her mid-back. MRI showed heterogeneous enhancement, and a soft-tissue sarcoma was possible. A wide surgical excision was performed with safe resection margins, and the pathologic report showed a malignant granular cell tumor. Conclusion: Neurogenic tumors typically show symptoms based on the tumor's location. Characteristic MRI findings include a highly hyperintense lesion, or the "target Sign". Nonetheless, patients who do not reveal typical symptoms and images showing other tumor characteristics can also be diagnosed as schwannoma or granular cell tumor. In this regard, a wide range of considerations is necessary during the interview and preoperative examination.

Enhanced Recovery After Surgery (ERAS) has become an important framework for improving perioperative care in breast reconstruction, particularly by standardizing multidisciplinary pathways that support faster recovery, reduced opioid exposure, and shorter hospital stays without compromising surgical outcomes. This talk reviews our experience applying an ERAS protocol to microsurgical breast reconstruction, with emphasis on translating evidence-based principles into a practical, team-based workflow. We will discuss key components across the perioperative continuum, including patient education, preoperative optimization, multimodal analgesia, anesthesia coordination, goal-directed fluid management, early mobilization, diet advancement, flap monitoring, and discharge planning. Drawing from our practice, we will highlight implementation challenges, protocol refinements, patient-centered outcomes, and lessons learned in aligning surgeons, anesthesiologists, nurses, and allied health professionals around a shared recovery pathway. The goal is to provide attendees with actionable insights for adapting ERAS principles to their own microsurgical breast reconstruction programs while maintaining safety, efficiency, and high-quality reconstructive care.

Breast cancer patients are increasingly seeking breast reconstruction that restores not only breast shape but also sensory function. Various neurotization techniques have been explored to reestablish breast and nipple sensation, yielding promising outcomes. However, optimal approaches remain undefined. A scoping review of PubMed and EMBASE was conducted, focusing on studies of breast neurotization in both autologous and implant-based reconstructions. The use of quantitative tools enables objective assessment of breast sensation across these various reconstruction types. Neurotization of autologous flaps improves recovery of protective and erogenous sensation and enhances physical well-being without significantly increasing surgical risk. Furthermore, neurotization on implant-based breast reconstruction using nerve grafts has shown promising sensory outcomes. Autografts support consistent nerve regeneration but are technically demanding; allografts simplify surgery and reduce morbidity but are currently costly and require further study. While preclinical data favor superficial neurotization, both superficial and deep approaches produce good clinical outcomes. Neurotization significantly improves postoperative sensation and patient-reported outcomes. Future research should focus on optimizing technique selection and validating long-term benefits. Standardized prospective studies are needed to understand the effectiveness of different approaches better. Specifically, further investigation is necessary into the potential for techniques such as double fascicles and vascularized stumps to fasten the recovery process. This will help to establish the best practices for improving patient outcomes in breast reconstruction. Also, some animal models can be created to help elucidate details of reinnervation.

The author shares his 20 years’ experience in head and neck reconstruction covering areas like recipient vessel selection, flap selection and complications. The second part of the talk looks at how a 3D planning system for fibula flap was developed in his institution and the lessons learnt from it.

Background: Quality of life and functional improvement have emerged as important treatment goals for patients with oncologic diseases. For patients with head and neck cancer, free anterolateral thigh (ALT) flaps provide reliable reconstruction and provide functional restoration. Nevertheless, the factors affecting the resumption of oral feeding have been rarely described. This study aimed to evaluate and compare the oral feeding outcomes among patients with different oncologic defect patterns and reconstructive ALT flap designs. Methods: We retrospectively reviewed patients with head and neck cancer who underwent oncologic ablation and free anterolateral thigh (ALT) flap reconstruction between January 2016 andApril 2018 at National Taiwan University Hospital. Patients were categorized into two groups as through-and-through (T&T) and non–through-and-through (non-T&T) according to the defect pattern. T&T patients were further subdivided into lip resection/lip sparing based on lip involvement. Two reconstructive ALT flap designs were used, folded (F-ALT) and chimeric (C-ALT). Oral feeding outcomes were analyzed using descriptive statistics, and differences between groups were compared using the Student’s t test. Results: We identified 233 patients who underwent oncologic ablation and free ALT flap reconstruction. There was no significant difference in functional recovery between the T&T and non-T&T groups (81.2% vs 73%, P = 0.137). However, among patients who successfully resumed oral feeding, those in the lip-sparing group demonstrated better functional recovery, including earlier resumption of oral feeding within 6 months and nasogastric tube removal, than those in the lip-resection group (100% vs 83.3%, P = 0.001). Moreover, the folded ALT(F-ALT) flap design was associated with a higher success rate in of successful oral feeding resumption than the chimeric ALT (C-ALT) flap design (90.5% vs 54.6%, P = 0.032). Conclusions: Patients with head and neck cancer and through-and-throug (T&T) defects had higher rates of secondary flap revision and showed a trend toward delayed resumption of oral feeding. In the long term, the folded anterolateral thigh (F-ALT) flap design was associated with better oral feeding outcomes than the chimeric anterolateral thigh (C-ALT) flap design among patients with T&T defect. Key Words: head and neck cancer, free anterolateral thigh flaps, functional outcomes, oral feeding

Background: The proximal lateral lower leg flap is a flap suited for the reconstruction of small and thin defects. The purpose of this study was to map the position and consistency of the perforator vessels and to review its reliability and technical considerations clinically. Methods: The location, number, and size of perforator vessels in the proximal third of the lateral lower leg were investigated in 20 fresh frozen cadaveric lower limbs. This was analyzed together with 22 clinical cases. Results: Cadaveric dissection showed that there were 1-2 perforators in the proximal third of the lateral lower leg and these perforator vessels were found to be 63% septocutaneous and 37% musculocutaneous. The source vessel of the perforators was variable. Clinically the recipient site consisted of the head and neck in 8 cases, the foot and ankle region in 13 cases, and 1 case in the hand. The mean thickness of this flap was 5.8 ± 0.8 mm. Vascular pedicle length ranged from 5 to 8.5 cm. The mean diameter of flap artery was 1.3 ± 0.3 mm. One flap failure was seen due to arterial thrombosis. The overall flap survival rate was 95%. Conclusions: The proximal lateral lower leg flap has the advantages of being thin and pliable, quick to harvest with no major arteries sacrificed. There is minimal donor site morbidity and primary closure of the donor site is possible in the majority of cases.