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Fadel ZT, Basaeed AJ, Ashi MB, Aljaaly HA. Vastus lateralis flap for trochanteric sarcoma reconstruction following prior main pedicle dissection: A case report. Exp Ther Med 2024; 27:249. [PMID: 38682109 PMCID: PMC11046181 DOI: 10.3892/etm.2024.12537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
The reconstruction of trochanteric defects presents a challenge to the reconstructive surgeon. There have been a number of locoregional reconstructive options described in the literature. These include flaps based on the lateral circumflex femoral artery and its branches, such as the tensor fascia lata, vastus lateralis (VL), anterolateral thigh (ALT) flaps. The present case further complicated this challenge as the patient had multiple recurrences of a sarcoma overlying the trochanteric region, with previous surgical resections, reconstruction and radiotherapy. The present case study describes an approach to harvesting the VL flap in a patient with previously harvested ALT.
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Affiliation(s)
- Zahir T. Fadel
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Kingdom of Saudi Arabia
| | - Amani J. Basaeed
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Kingdom of Saudi Arabia
| | - Mohammed B. Ashi
- Department of Plastic and Reconstructive Surgery, National Guard Hospital, Jeddah 21423, Kingdom of Saudi Arabia
| | - Hattan A. Aljaaly
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Kingdom of Saudi Arabia
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2
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Finlay JR, Vijayakumar G, Braun A, Almajnooni A, Yu A, Miller I, Kokosis G, Wang D, Blank A, Gitelis S. Enormous myxoid/round cell liposarcoma: A case report. Rare Tumors 2024; 16:20363613241255668. [PMID: 38766573 PMCID: PMC11100375 DOI: 10.1177/20363613241255668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
Myxoid/round cell liposarcomas (MRCLPS) are a rare soft tissue sarcoma. We report the largest sarcoma in our institutional history. We discuss the patient's surgical management and treatment of the tumor and challenges given its dimensions. Several complications arose following primary resection that were managed by a multidisciplinary team. Although MRCLPS can vary in size, large MRCLPS must be treated cautiously given the potential for complications. Additionally, multidisciplinary treatment of MRCLPS is essential in diagnosing and treating these complex cases.
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Affiliation(s)
- Joshua R. Finlay
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Gayathri Vijayakumar
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Ankica Braun
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | | | - Austin Yu
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Ira Miller
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - George Kokosis
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Alan Blank
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Steven Gitelis
- Department of Orthopedic Surgery, Division of Orthopedic Oncology, Rush University Medical Center, Chicago, IL, USA
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3
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LaValley MN, Dugue D, Diaddigo SE, Kuonqui KG, Tyler WK, Bogue JT. A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202403000-00001. [PMID: 38421606 PMCID: PMC10906598 DOI: 10.5435/jaaosglobal-d-23-00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND The orthoplastic approach to patient care has changed the way patients with a wide variety of lower extremity pathology are treated. Through a systematic review, we aim to analyze outcomes in adult patients with lower extremity soft tissue sarcomas who undergo an orthoplastic flap management approach to their care. METHODS A systematic review of adult lower extremity soft tissue sarcoma excision with plastic surgery flap reconstruction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching the Pubmed, Embase, and Web of Science databases from inception to April 2023. RESULTS After removal of duplicates, title and abstract screening, and full-text review, 26 articles were accepted for inclusion. The total mean follow-up duration was 32.0 ± 24.3 months. Reconstruction used microvascular free flaps in 65.5% (487/743), while 34.5% (256/743) were local flaps. 85.8% (307/358) of patients ambulated postoperatively. Revision surgery was required in 21% of patients during their respective follow-up periods. The limb salvage rate was 93.4% (958/1,026). Among pooled surgical outcomes, 22.2% (225/1,012) of patients experienced a perioperative complication. DISCUSSION Our study demonstrates that although complication rates in lower extremity soft tissue sarcoma reconstruction may be further optimized, a multidisciplinary flap reconstructive approach provides high rates of limb salvage and functional postoperative ambulation.
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Affiliation(s)
- Myles N. LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - David Dugue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Sarah E. Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Kevin G. Kuonqui
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Wakenda K. Tyler
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Jarrod T. Bogue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
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Raza A, Siraj I, Malik S, Mohammed R, Shariff MA. A Case of Locally Advanced Fibrosarcoma in a Young Male. Cureus 2023; 15:e44095. [PMID: 37750151 PMCID: PMC10518120 DOI: 10.7759/cureus.44095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
Fibrosarcoma is a rare, highly malignant tumor that develops from uncontrolled overgrowth of fibroblastic cells. It may start as a painless lump or swelling under the skin. But as it grows, it can push surrounding structures - organs, muscles, nerves, or blood vessels - and lead to pain and tenderness. The treatment of fibrosarcoma depends on several factors such as size, grade, location of primary tumor, extent of spread, age, and general health condition of the patient. The main treatment is surgical removal of the primary tumor with wide-margin excision and amputation if localized in the limb. Prior to surgical intervention, radiotherapy can be applied to reduce the tumor size or following surgery to lower the risk of recurrence. Chemotherapy is indicated in cases of metastasis. Unfortunately, the prognosis of fibrosarcoma is not favorable. For high-grade fibrosarcoma, the five-year survival rate is around 30% and for low-grade fibrosarcoma, it is 50-80%, with recurrence in the first two to five years post-surgery. We encountered a case of high-grade fibrosarcoma with aggressive growth in a 36-year-old male, requiring above-knee amputation.
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Affiliation(s)
- Ali Raza
- Surgical Oncology, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Imrana Siraj
- Cancer Center Research Services, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Sabina Malik
- Cancer Center, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Raji Mohammed
- Pathology and Laboratory Medicine, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Masood A Shariff
- Surgical Oncology, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
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5
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Hassan AM, Tesfaye EA, Rashiwala A, Roubaud MJ, Mericli AF. Functional Muscle Transfer after Oncologic Extremity Resection. J Reconstr Microsurg 2023; 39:195-208. [PMID: 35768008 DOI: 10.1055/a-1887-7530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Functional muscle transfer (FMT) can provide wound closure and restore adequate muscle function for patients with oncologic extremity defects. Herein we describe our institutional experience with FMT after oncological resection and provide a systematic review and meta-analysis of the available literature on this uncommon procedure. METHODS A single-institution retrospective review was performed, including all patients who received FMT after oncological resection from 2005 to 2021. For the systematic review and meta-analysis, PubMed, Cochrane, Medline, and Embase libraries were queried according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; results were pooled, weighted by study size, and analyzed. RESULTS The meta-analysis consisted of seven studies with 70 patients overall, demonstrating a mean Medical Research Council (MRC) score of 3.78 (95% confidence interval: 2.97-4.56; p < 0.01). The systematic review included 28 studies with 103 patients. Receipt of adjuvant chemotherapy was associated with significantly lower mean MRC score (3.00 ± 1.35 vs. 3.90 ± 1.36; p = 0.019). Seventy-four percent of the patients underwent free FMT, with the most common donor muscle being the latissimus dorsi (55%). The flap loss rate was 0.8%. Neoadjuvant chemotherapy (p = 0.03), radiotherapy (p = 0.05), pedicled FMTs (p = 0.01), and a recipient femoral nerve (p = 0.02) were associated with significantly higher complication rates. The institutional retrospective review identified 13 patients who underwent FMT after oncological resection with a median follow-up time of 21 months (range: 6-74 months). The most common tumor necessitating FMT was undifferentiated pleomorphic sarcoma (77%), and the most common donor muscle was the latissimus dorsi (62%). A high body mass index was associated with prolonged neuromuscular recovery (R = 0.87, p = 0.002). CONCLUSION FMT after oncological resection may contribute to improved extremity function. Careful consideration of risk factors and preoperative planning is imperative for successful FMT outcomes.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eliora A Tesfaye
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Abhi Rashiwala
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas
| | - Margaret J Roubaud
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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6
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Grigor EJM, Bitoiu B, Zeitouni C, Zhang J. Patient-reported outcomes following free flap lower extremity reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 76:251-267. [PMID: 36566631 DOI: 10.1016/j.bjps.2022.08.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Free flap reconstruction in the lower extremity has shown success for the management of large and complex defects, restoration of function, and favorable aesthetic outcomes. Patient-reported outcomes (PROs) have not been well explored in previous literature. This meta-analysis aimed to provide a comprehensive summary of PROs after free flap reconstruction in the lower extremity. METHODS We searched MEDLINE and Embase from 1946 to 2021 for studies reporting on PROs following free flap reconstruction in the lower extremity. RESULTS Overall, 53 studies were included, and 11 studies reported validated PRO measures for meta-analysis. A total of 1953 patients underwent reconstruction with 1958 free flaps for lower limb defects with a mean follow-up of 3.26 (0.25-7.83) months. The mean postoperative Lower Extremity Functional Scale (LEFS) scores were 60.3 (±12) out of 80 points (4 studies, 85 patients). The mean postoperative AOFAS scores were 75.1 (±15) out of 100 points (4 studies, 68 patients). The mean postoperative SF-36 scores were 88.1 (±8.0) out of 100 points; mental health component was 48.7 (±8.9), and physical component was 38.4 (±8.2), out of 50 points (4 studies, 88 patients). CONCLUSION Our findings demonstrated that patients report improved physical health, mental health, and function following lower extremity reconstruction with free flaps. Patients reported similar improvements in functional scores following lower extremity reconstruction regardless of their free flap type. Furthermore, patients with myocutaneous flaps may have improved mental health and worse physical health scores when compared to perforator flaps. The evidence profiles presented in this review indicate that additional research is needed to help guide future decision-making.
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Affiliation(s)
- Emma J M Grigor
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ontario, Ottawa, Canada; MD Program, Faculty of Medicine, University of Ottawa, Ontario, Ottawa, Canada
| | - Brendon Bitoiu
- Department of Surgery, Division of Plastics and Reconstructive Surgery, The Ottawa Hospital, Ontario, Ottawa, Canada
| | - Camille Zeitouni
- MD Program, Faculty of Medicine, University of Ottawa, Ontario, Ottawa, Canada
| | - Jing Zhang
- Department of Surgery, Division of Plastics and Reconstructive Surgery, The Ottawa Hospital, Ontario, Ottawa, Canada.
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7
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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8
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Surgical Management of Lower Limb Sarcomas. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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9
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Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:755-767. [PMID: 33277214 DOI: 10.1016/j.bjps.2020.10.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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10
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Othman S, Azoury SC, Weber KL, Kovach SJ. Free flap reconstruction of sarcoma defects in the setting of radiation: a ten-year experience. J Plast Surg Hand Surg 2020; 54:365-371. [PMID: 32657200 DOI: 10.1080/2000656x.2020.1791893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Neoadjuvant treatment and surgical resection for sarcoma patients can often leave devastating wounds necessitating soft-tissue coverage in the form of free flaps. There is still debate as to the optimal flap for reconstruction of defects in irradiated fields. We aim to describe our experiences with free fasciocutaneous and free muscle flaps for sarcoma reconstruction in the setting of radiation therapy. A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to sarcoma resection from January 2010 to June 2019. Patient characteristics, flap viability and post-operative healing outcomes were all recorded and examined. In total, 49 patients who underwent 51 free-flaps were identified. Of these, 30 flaps were fasciocutaneous, while 21 were muscle-based. Most patients received pre-operative radiotherapy (76.5%), although these rates were not different between groups of flap type, and had no significant association with post-operative outcomes. Complication rates (31.3%) and re-operative rates (21.6%) were also comparable between flap types. Diabetes mellitus was significantly associated with delayed wound healing (p < .016), while the presence of peripheral vascular disease had a significant association with post-operative infection (p < .006). This study shows that free fasciocutaneous and free muscle-based flaps are both viable options for soft-tissue reconstruction demanded by sarcoma resection, even in the setting of radiation. Peripheral vascular disease and diabetes mellitus may confer increased wound complications.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristy L Weber
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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11
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Mazur N, Osinga R, Lo S. Split median superficial sural artery perforator (MSSAP) flap and medial sural artery perforator (MSAP) flap for posterior thigh sarcoma reconstruction. BMJ Case Rep 2020; 13:13/2/e233352. [PMID: 32029521 DOI: 10.1136/bcr-2019-233352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Reconstruction of composite defects of the posterior thigh and knee is challenging. Pedicled medial gastrocnemius flaps are the traditional reconstructive approach, but late contractures related to skin grafted muscle may affect knee function. More recently, the medial sural artery perforator (MSAP) flap has been described for such defects, although may necessitate skin grafting of the donor site. To minimise the drawbacks with these options, we describe a combination of a median superficial sural artery perforator (MSSAP) flap and MSAP flap. This allows both tension free closure of the donor site without skin grafting, and facilitates coverage of a round defect by splitting the flap into two adjacent triangular flaps. This is the first report of posterior thigh defect reconstruction with a combination of MSSAP and MSAP flaps.
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Affiliation(s)
- Natalia Mazur
- Medical School, Medical University of Gdansk, Gdansk, Poland.,Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Rik Osinga
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK .,Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Steven Lo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK.,Translational Research Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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