Dr. Wei Fu-chan: Medical Legend, Pride of Taiwan

Reconstructive microsurgery is a subfield of plastic surgery. One of its key techniques involves the reconnection of blood vessels that are often just one millimeter in diameter. These blood vessels are so small that suturing them together requires a microscope and a selection of needles of just 0.005–0.01 mm in diameter (roughly the thickness of a human hair).

Taiwan’s Dr. Wei Fu-chan has become internationally renowned within the field of microsurgery for his introduction of three new techniques: toe-to-hand transplantation for traumatic digital amputation, vascularized fibula tissue transplantation, and perforator flap transplantation. Moreover, he has been able to develop applications for these procedures in oncology and chronic wound treatment, as well as plastic surgery.

Wei Fu-chan’s three major innovations

In September 2006, the American Society of Plastic Surgeons named what it considered to be the 20 greatest innovators in the history of plastic surgery.

Dr. Joseph Murray, the American plastic surgeon and Nobel laureate, is perhaps the best known of these “medical legends.” Murray, who passed away in 2012, performed the first successful kidney transplant on identical twins. Dr. Wei is one of six living innovators to have made the ASPS list, an honor he earned for his outstanding contributions to micro and transplant surgery. He is distinguished by being the only Asian physician to have been named.

Dr. Wei recalls his three major innovations very well.

Dr. Wei Fu-chan, Taiwan’s “maestro” of reconstructive microsurgery, trains foreign surgeons in his vascularized fibula flap transplant technique.

One of those memories revolves around an image of a boy with big feet. It was drawn by a young man who had had an accident at the age of five that cost him all ten fingers and left him unable to drink or even go to the bathroom without assistance. His parents brought him to Wei more than 20 years ago seeking treatment.

“When you lose a thumb, your hand loses 50% of its functionality,” explains Dr. Wei. “Its functionality declines even further when you have no digits at all.” He explained to the boy’s parents that the only treatment he could offer was to transplant the boy’s toes to his hands, placing priority on creating functional thumbs.

After meticulously planning the surgery, Wei and his team transplanted the big toe of the boy’s left foot to his right thumb, the second toe of his left foot to his left thumb, and three other toes to fingers, relying on microsurgical techniques to reattach the nerves and blood vessels.

The boy regained most of the function in his hands after the surgery, and when he graduated from high school he presented Wei with the drawing he had made of a boy with big feet.

But, for all that Wei’s toe-to-hand transplantation technique has transformed lives, his response to questions about it is to humbly state that he just built on the earlier achievements of the giants of his field.

The medical literature does indeed provide earlier examples of toe transplantations, but their existence does nothing to diminish Dr. Wei’s innovation. His pre-transplantation “shaping” technique makes the toe more closely resemble a finger and greatly increases patients’ post-surgical acceptance of the newly reconstructed digit. He also introduced the idea of transplanting two adjacent toes simultaneously to reduce the amount of time the patient spends in surgery and on recovering function after surgery.

When Dr. Samuel Noordhoff (center) instructed Dr. Wei (left) to pursue advanced training in Canada 36 years ago, he set Wei on the path to becoming a reconstructive microsurgeon.

In building on the techniques of the past, Dr. Wei has always made the well-being of patients his priority. Viewed through that lens, vascularized fibula tissue transplantation represents a tremendous innovation.

One of two bones in the lower leg, the fibula is located on the outer side. Because the fibula is functionally less important than the neighboring tibia, the fibula can donate tissue for transplantation to other long bones in the body.

This is very helpful for treating injuries such as a shattered lower leg. Doctors used to recommend amputation in such circumstances, even when donor tissue was available from the other fibula, because of the risk of infection associated with bone exposure.

That changed when a 40-year old Dr. Wei developed his vascularized fibula tissue transplantation technique and presented it to the annual convention of the American Surgical Association in 1984.

From his anatomical studies, Dr. Wei knew that blood vessels in the tissue overlaying the fibula—including the epidermis, dermis, and subcutaneous vascularized tissue—are connected to the blood vessels in the fibula itself. He realized that transplanting a flap of this tissue together with the bone, and connecting its blood vessels to the corresponding blood vessels in the recipient tissue, would allow the transplant to survive, eliminating the need for amputation.

Dr. Wei is known for his upbeat, confident, energetic, and accessible personality.

Dr. Wei developed his first “transformed” application for vascularized fibula tissue transplantation in 1989. Brought in to do reconstructive work on a patient who had had a section of their jaw removed to treat ameloblastoma (a type of slow-growing tumor), he removed the fibula from one of the patient’s legs, reshaped the donor tissue, used microsurgical techniques to attach blood vessels and reconstruct the jawbone, then rebuilt the cheeks using the fibula flap.

Wei was also the first doctor in the world to combine a vascularized fibula graft with tooth implantation. After shaping the fibula, he implanted artificial teeth, and grafted the reconstructed jawbone into the oral cavity, completing the transplant and implant surgeries together to reduce the patient’s pain and suffering.

There are currently only three medical centers in the world capable of offering Dr. Wei’s combined mandibular reconstruction and tooth implantation procedure, and Wei’s team at Chang Gung Memorial Hospital is the global leader in terms of both caseload and surgical quality.

One case that his team has handled involved a woman from Hong Kong named Yik Siu-ling who had been shot while traveling in the Philippines in 2010. The bullet passed through her face and neck, leading to 33 surgeries before she sought treatment from the team at Chang Gung.

Dr. Wei handled the key parts of Yik’s reconstructive surgery himself, extracting, trimming and transplanting the left fibula and tissue flap all in a single surgery. By reconstructing her mandible and chin, and replacing the skin she had lost from her neck, Wei helped her rebuild her life.

Foreign doctors gather round as Wei conducts his teaching outpatient clinic.

Flap transplants are incredibly versatile. For example, when a section of myofascia (a sheath of white tissue that covers muscles and lies just beneath our subcutaneous fat) is used as a “patch,” a flap can be transplanted with it to increase the likelihood of the transplant’s success.

Dr. Wei mentions a case in which a neurosurgeon had used artificial tissue to repair the ruptured dura mater (a layer of protective tissue around the brain) of a patient injured in an automobile accident. When the patient’s scalp failed to heal and became necrotic, the dura mater was exposed, became infected, and visibly throbbed in time with the patient’s pulse.

After evaluating the patient, Dr. Wei decided to transplant a flap of skin from the outside of the patient’s thigh, along with the underlying myofascia, to the patient’s scalp to patch both the skin and the dura mater, performing both the excision of the donor tissue and the transplant in the same surgery.

Dr. Wei has also used donor myofascia rolled into a tube-like shape to reconstruct a severely ruptured Achilles tendon that had been deemed irreparable.

“Fibular transplants used to have only one application,” says Dr. Wei. “But now that we’re doing flap transplants­, they now have ten or even 100 times as many.” Dr. Wei’s perforated flap transplant technique has been the key to these multiplying applications, making possible many surgeries previously considered impossible.

Microsurgery requires tremendous concentration. Dr. Wei (in the pink tie) encourages medical teams to spend their spare time unwinding in natural settings. Here, Wei, his colleagues in the CGMH plastic surgery department, and the foreign doctors training with them, pose for a photo on a Linkou golf course.

The fact that flaps need their blood vessels to deliver nourishment used to place constraints on their transplantation: only those flaps linked to a few specific blood vessels were considered transplantable.

Those “specific” blood vessels were the intermuscular blood vessels. But because they comprise only a small proportion of the body’s blood vessels, the microsurgeons of 20 years ago often had no access to flaps they could use.

The majority of the body’s blood vessels are not inter­muscular, but either intramuscular or perforator vessels (the latter so called because they perforate the deep tissue of the muscles). The medical community used to consider these blood vessels largely unusable because their location within muscles made them too difficult to extract.

That changed when Dr. Wei developed a technique for extracting perforator flaps (i.e. flaps with perforator blood vessels attached) without damaging the surrounding muscle tissue. Over the last 20-odd years, perforator flap extraction and transplantation has become mainstream, greatly increasing the number of usable flaps. The technique has led to tremendous advances in reconstructive microsurgery, and also benefited other medical specialties.

Oncology is a case in point. The removal of a cancer from the tongue can cause a patient to experience difficulty in speaking and swallowing. Dr. Wei reconstructs such patients’ tongues by removing an anterolateral thigh flap, trimming it into a tongue shape, and microsurgically connecting it to the blood vessels of the neck. Wei’s success with this procedure led the International Federation of Head and Neck Oncological Societies to name him one of the top 100 20th-century contributors to the treatment of head and neck cancers at its annual convention in July 2014.

Major plastic and hand surgery societies around the world have awarded Dr. Wei their highest honors. In 2006, the American Society for Reconstructive Microsurgery recognized his contributions by naming him its Harry J. Buncke lecturer, an honor widely considered to be microsurgery’s Nobel Prize.

More than ten internationally renowned medical schools, including those of Harvard, Stanford, Johns Hopkins and the Mayo Clinic, have similarly honored him with visiting professorships. In Taiwan, he has twice received the Executive Yuan’s Outstanding Contribution in Science and Technology Award (in 1989 and 2008), and has become known as the father of Taiwanese reconstructive microsurgery.

Dr. Wei received Taiwan’s highest academic honor in 2012 when he was named an academician of the Academia Sinica.

He is the first surgeon to have been so honored; all previous medical academicians have been internists. That circumstance led him to remark, “The entire surgical community is very excited to finally be acknowledged as a science. In the past, we had been deemed to be technicians, practitioners of skills manual rather than mental.”

Dr. Wei has been a prolific writer on plastic surgery as well, having authored or edited 11 books and placed nearly 500 articles in major international journals. Though his research focuses on anatomy, physiology, biomechanics and pathology rather than the currently fashionable genetics and molecular biology, it has succeeded in delivering real and timely aid to patients. Because his research generates results that are rapidly “translatable” into treatments, Wei expects it to soon see wider use within the scientific community.

As a young man, Wei had no particular goals for his life and career. He grew up in Ping­tung, attended Kao­hsiung Medical University, and ended up a surgeon, as he says, “Because there was something larger than life about surgeons, and they seemed to have a devil-may-care attitude.”

Wei went on to train with Dr. Samuel Noordhoff, an American surgeon who served as the first director of the Chang Gung Memorial Hospital and as its head of plastic surgery. Wei then pursued advanced training at the University of Toronto Faculty of Medicine in 1979, and, after surgically reattaching a finger, decided to focus on reconstructive microsurgery.

Wei’s decision to take up microsurgery coincided with a period of rapid development in the field. By the time he returned to CGMH in 1981, he was on its cutting edge and developing important innovations.

CGMH established itself at the top of the field in the late 1980s, and Wei doesn’t expect that position to be challenged within the next decade. “Our foundations are just too solid.”

The foundation to which he refers includes the National Health Insurance system, which helps patients afford expensive reconstructive surgeries, as well as CGMH’s micro­surgery intensive care unit and post-operative rehab­ilitation. Established in 1988 at the urging of Formosa Plastics founder Wang Yung-ching, CGMH’s dedicated facilities remain a relative rarity in the medical world.

Though reconstructive microsurgical procedures are grueling affairs lasting from eight to 12 hours, Wei’s team is devoted to its work and discounts the cost in time and manpower. These strengths have enabled it to lead the world in both the number and variety of reconstructive microsurgeries it has performed. From 1985 to 2013, the team operated on more than 25,000 patients, achieving a success rate of 98%. Flap transplants were the most common of those surgeries, accounting for more than 18,000 of them.

That success attracted the interest of plastic surgeons from around the world. Over the years, more than 1,000 foreign surgeons have made it through Wei’s selection process and been invited to Taiwan to train with the team.

Dr. Nidal Al Deek, a Syrian surgeon who trained in plastic surgery at Damascus University and the University of Illinois at Chicago, has spent two years with the team. Dr. Al Deek believes Wei’s achievements mark him as one of the greats of the field, among luminaries such as Dr. Joseph Murray, a Nobel laureate, and Dr. Harry Buncke, the “father of microsurgery.”

Dr. Al Deek says that CGMH’s plastic surgery department possesses discipline and vision, and is peerless in its experience and innovativeness. He believes it provides the best training in the world. “I think it is kind of unfair to compare Professor Wei and CGMH with other medical professionals and teams,” says Al Deek. “You cannot compare Gods to humans!”

Dr. Georgios Kolios trained in plastic surgery at the teaching hospital of the University of Hamburg, Germany, and joined Dr. Wei’s team a year and half ago. Kolios, who hopes to develop new microsurgical techniques of his own one day, says “Professor Wei’s group is setting the standard worldwide” in head and neck surgery.

What impresses Kolios and Al Deek most about Wei and his team is their dedication to their patients. No matter how challenging the surgery, they simply never give up.

Under Wei’s leadership, CGMH’s plastic surgery department has made a point of sharing its knowledge abroad, while also cultivating international-caliber microsurgeons here at home.

Dr. Lin Chih-hung, who chairs CGMH Lin­kou’s plastic surgery department, is a case in point. An international authority on limb reconstruction, he specializes in using fibula transplants for leg reconstruction. Dr. David ­Chwei-chin ­Chuang, also a member of the department, is Taiwan’s first specialist in brachial plexus reconstruction and a world leader in the field. He also happens to be the president-elect of the World Society for Reconstructive Microsurgery. Dr. ­Cheng Ming-huei, a CGMH vice president, studied breast reconstruction in the US at Wei’s behest and has gone on to become a highly respected expert on the microsurgical treatment of lymphedema.

Other surgeons who have trained with Wei include Dr. Chen Hung-chi, the head of the international medical center of the China Medical University Hospital and a specialist in using the intestine to reconstruct the esophagus, and Dr. Jeng Seng-feng, a vice superintendent with E-Da Hospital whom Wei has called “the top microsurgeon in the world.”

But microsurgical reconstruction can’t fix everything. Injuries that cover large areas of the body or affect multiple organs are still beyond its scope. Victims of such injuries must instead place their hopes in allogenic transplants. In an effort to develop better methods for treating these patients, CGMH has established the Wei-led Center for Vascularized Composite Allotransplantation.

Wei says that the CGMH team used not to perform allogenic transplants, even though such transplants had been carried out abroad and CGMH had Ministry of Health approval for human trials in Taiwan. They hesitated to begin them because the patients must take immuno­suppress­ants for the rest of their lives, putting them at much greater risk of kidney disease and cancer. However, now that they’ve developed a vascularized composite allotransplantation technique that potentially eliminates the need for lifelong immunosuppression, they are hoping to begin trials in late 2014 or early 2015, provided they can find suitable candidates.

Vascularized composite allotransplantation has the potential to further the capabilities of reconstructive microsurgery. Wei has been at the top of the international reconstructive microsurgery field for more than 30 years, his skill with a blade, his focus, and his determination the match for any samurai of yore. While most of his cutting and suturing have taken place in the realm of the microscopic, Dr. Wei has had a profound impact upon the larger world, inarguably changing it for the better. He truly is the pride of Taiwan.