The pedicled intercostal neurovascular island skin flap for lumbosacral trunk reconstruction

Clinical Applications of the Intercostal Artery Perforator Flap for Trunk Reconstruction

Background  Trunk defects can occur because of surgical site infections after spinal surgery, resection of malignant tumors, or trauma. Herein, we present our experience of using intercostal artery perforator (ICAP) flaps to reconstruct trunk defects without noteworthy complications. Fourteen patients underwent reconstruction with ICAP flaps between March 2015 and March 2019. Methods  Patients' data, including age, sex, the cause of the defect, defect size, perforator location, flap size, complications, and follow-up period, were retrospectively reviewed. The mean age of the patients was 56.5 years (range, 19-80 years). All operations were performed after the results of bacterial culture from the wound showed no microbial growth. We found reliable perforators around the defect using Doppler ultrasonography. The perforator flaps were elevated with a pulsatile perforator and rotated in a propeller fashion to the defects. We performed five dorsal and two lateral ICAP flaps. The mean flap dimensions were 12 × 5.5 cm ² (range, 6 × 5 to 18 × 8 cm ² ). Results  Primary closure of the donor site was performed. Marginal congestion was observed as a complication in one case, but it healed with no need for revision. The mean follow-up period was 8 months. All patients were satisfied with the surgical outcomes. Conclusion  ICAP flaps can be easily mobilized, thereby reducing donor site morbidity without sacrificing the underlying muscles for trunk reconstruction. Therefore, these flaps are useful options for the reconstruction of trunk defects.

Extended latissimus dorsi flap with propeller ascending design for reconstruction of a complex lateral lumbar defect: A case report and review of the literature

Lateral lumbar defects are rarely encountered and difficult to manage because of the limited reach of loco-regional flaps and the unfavorable position of recipient vessels for microsurgical transfer. The purpose of this report is to describe the innovative application of an extended latissimus dorsi (LD) flap with propeller ascending design in the field of lumbar reconstruction, reviewing current reconstructive options accepted for lateral lumbar defect. A 68-year-old male patient underwent wide full thickness resection for a solitary hepatocellular carcinoma metastatic lesion arising in the left lumbar region, resulting in an extensive soft-tissue defect (20 x 13 cm) with deep structures exposure. An extended LD flap with propeller ascending orientation was obliquely designed, with the distal third of the skin island laying over the trapezius muscle. The skin paddle measured 34 x 9 cm. The flap, including a cuff of proximal LD muscle spared by the oncological resection and a fasciocutaneous superior extension, underwent 90°clockwise rotation on the main thoracodorsal artery perforator and further caudal advancement allowed by section of the LD cranial tendinous insertion. The rotation-advancement movement allowed tension-free flap insetting, while donor site was closed by primary intention. The post-operative course was uneventful without any complications registered. At 12-months follow-up, a satisfactory result and a stable coverage were achieved. Due to the surgical complexity traditionally associated with the repair of defects located in the lumbar region, the case reported may help to provide a new alternative solution to extend the indications of local flaps in similar cases and simplify such reconstructions.

Reconstruction of Lumbar Spinal Defects: Case Series, Literature Review, and Treatment Algorithm

Background:

Lumbar spinal defects present a distinct challenge for the reconstructive surgeon and are often complicated by previous spinal surgery, the presence of hardware, and prior radiation. There are a variety of reconstructive options described but no clear treatment algorithm for these challenging defects.

Methods:

A literature search was performed to review the described treatment options for lumbar spinal soft-tissue defects. Treatments for myelomeningocele or pressure ulcers were excluded. In addition, a retrospective case review was performed for patients with lumbar defects treated with pedicled superior gluteal artery perforator (SGAP) flap reconstruction.

Results:

A literature review revealed 2,022 articles pertaining to lumbar defect reconstruction, of which 56 met inclusion criteria. These articles described 13 individual reconstructive techniques for this anatomic area. The most commonly described techniques were evaluated and a treatment algorithm designed based on patient and wound characteristics. The clinical course of 5 patients with radiated lumbar spinal defects treated with SGAP flaps is presented.

Conclusions:

There are many treatment options for lumbar spinal defects and treatment should be tailored to the patient and the characteristics of the defect. For large or radiated lumbar wounds, the pedicled SGAP flap is an excellent reconstructive choice, as it has reliable anatomy that is outside the zone of injury, adequate bulk, and minimal donor-site deficits.

Management of Posterior Trunk Defects

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with reconstruction of the back. 2. Perform preoperative assessment, decision making, and counseling of patients. 3. Describe current surgical planning, including careful analysis of the defect and appropriate selection of tissue to provide coverage while maximizing form and function.

BACKGROUND

The plastic surgeon is called to reconstruct defects in the posterior truck that involve an extensive zone of injury. Simple solutions, such as wide undermining and primary closure, will not result in a stable closed wound. Successful closure of these wounds depends on preoperative evaluation of tissue needs and host defects, and selection of the most appropriate flap to close dead space and provide vascularized tissue to the wound bed.

METHODS

The authors examined the literature regarding the available treatment options surrounding reconstruction of posterior back wounds. They review the important details surrounding the use of each flap and present select cases from their own experience regarding reconstruction of the back.

RESULTS

: The posterior trunk benefits from multiple flaps that can be used in reconstruction of the back. The wound must be evaluated in terms of tissue requirements and host issues, such as infection or previous radiation. Most wounds can be closed in a single stage, after careful flap section based on the wound's needs and anatomic location, with minimal postoperative complications. Early and aggressive treatment of these wounds improves patient outcomes and can reduce the time spent in hospital.

CONCLUSIONS

Reconstruction of the posterior trunk depends on careful analysis of the tissue defects, host issues, and application of functional anatomy. The majority of wounds can be reconstructed after thorough débridement with a vascularized muscle flap.

Use of the Lateral Intercostal Perforator-Based Pedicled Abdominal Flap for Upper-Limb Wounds From Severe Electrical Injury

BACKGROUND

Upper-extremity wounds can be covered with a variety of flaps. However, pedicled distant flaps still have a place in treatment, especially in the early stages of wound restoration after a severe electrical injury. The purpose of this clinical study was to present the use of the pedicled abdominal flap, using the blood supply of the lateral intercostal perforator vessel, to cover defects caused by severe electrical injury.

METHODS

Between 2003 and 2005, 6 cases of deep burn wounds were treated with a lateral intercostal perforator-based pedicled abdominal cutaneous flap, with the blood supply originating from the lateral perforator branches of the seventh to 10th intercostal arteries. This flap was used to repair deep burn wounds on the elbow, forearms, and hands that were the result of severe electrical injuries.

RESULTS

Flaps were harvested in sizes ranging from 16 cm x 12 cm to 9 cm x 7 cm. The pedicle was separated from 18 to 21 days after the operation. Five flaps survived entirely. The sixth underwent marginal necrosis (1.5 cm x 3 cm) at the distal portion of the flap because flap cutting exceeded the paraumbilical line. Results were cosmetically satisfactory for all patients.

CONCLUSIONS

This flap is suitable for covering defects in hands, forearms, and elbows. The procedure was performed easily, safely, and reliably, and the flap has several advantages over other commonly used techniques for upper-limb wounds from severe electrical injury. We recommend this flap as the treatment of choice.