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Ehrl D, Wachtel N, Braig D, Kuhlmann C, Dürr HR, Schneider CP, Giunta RE. Defect Coverage after Forequarter Amputation—A Systematic Review Assessing Different Surgical Approaches. J Pers Med 2022; 12:jpm12040560. [PMID: 35455676 PMCID: PMC9031327 DOI: 10.3390/jpm12040560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/10/2022] Open
Abstract
Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.
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Affiliation(s)
- Denis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Nikolaus Wachtel
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
- Correspondence:
| | - David Braig
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Constanze Kuhlmann
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
| | - Hans Roland Dürr
- Orthopaedic Oncology, Department of Orthopaedics and Trauma Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany;
| | - Christian P. Schneider
- Department of Thoracic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany;
| | - Riccardo E. Giunta
- Department of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany; (D.E.); (D.B.); (C.K.); (R.E.G.)
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Corkum JP, Garvey PB, Baumann DP, Abraham J, Liu J, Hofstetter W, Butler CE, Clemens MW. Reconstruction of massive chest wall defects: A 20-year experience. J Plast Reconstr Aesthet Surg 2020; 73:1091-1098. [PMID: 32269009 DOI: 10.1016/j.bjps.2020.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 10/22/2019] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions. METHODS A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors. RESULTS We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm2). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; p = 0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (p = 0.021 and p < 0.001, respectively). CONCLUSIONS Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.
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Affiliation(s)
- Joseph P Corkum
- The Division of Plastic Surgery, Dalhousie University, Nova Scotia, Canada
| | - Patrick B Garvey
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Donald P Baumann
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Jasson Abraham
- The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Jun Liu
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Charles E Butler
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Mark W Clemens
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA.
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Temiz G, Şirinoğlu H, Yeşiloğlu N, Sarıcı M, Çardak ME, Demirhan R, Bozkurt M. A salvage maneuver for the caudal part of the pectoralis major muscle in the reconstruction of superior thoracic wall defects: The pectoralis kite flap. J Plast Reconstr Aesthet Surg 2015; 68:698-704. [PMID: 25704731 DOI: 10.1016/j.bjps.2015.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/11/2015] [Indexed: 11/18/2022]
Abstract
The pectoralis major muscle flap is the most commonly used option for chest wall reconstruction. However, its utilization should be avoided in chest wall tumors infiltrating the muscle. This article presents the utilization of the caudal part of the pectoralis major muscle as a pedicled flap in cases requiring the resection of the cranial part of the muscle due to tumor infiltration. Fourteen patients with a mean age of 60.3 years were operated for malignant thoracic wall tumors between 2011 and 2014. All tumors were located on the upper thoracic area with a mean defect size of 16.6 × 12 cm. During tumor resection, the thoracoacromial vessels and pectoral branch were preserved and dissected until reaching the pectoralis muscle. After the resection of the cranial part of the muscle, the caudal part is prepared as a pedicled island flap and used for the coverage of the resultant defect. The mean postoperative follow-up period was 10.9 months. All flaps survived without any partial or total flap loss. A case of local recurrence, two cases of hematoma requiring drainage, and two cases of local wound-healing problems were the encountered complications. The pectoral kite flap is a versatile and reliable option for the coverage of small to medium upper chest wall defects with minimal morbidity, and it gives the reconstructive surgeon the opportunity to use the non-infiltrated caudal part of the pectoralis muscle instead of an unnecessary resection of the whole muscle.
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Affiliation(s)
- Gökhan Temiz
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | - Hakan Şirinoğlu
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey.
| | - Nebil Yeşiloğlu
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | - Murat Sarıcı
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | | | - Recep Demirhan
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Thoracic Surgery, Istanbul, Turkey
| | - Mehmet Bozkurt
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
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Dragu A, Hohenberger W, Lang W, Schmidt J, Horch RE. [Forequarter amputation of the right upper chest: limitations of ultra radical interdisciplinary oncological surgery]. Chirurg 2011; 82:834-8. [PMID: 21811891 DOI: 10.1007/s00104-011-2136-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total forearm free flap procedures after forequarter amputations have been sparsely described in the literature. Using the amputated arm as a "free filet flap" remains a viable surgical option after radical forequarter amputations performed for the resection of large, invasive tumors of the shoulder or thoracic wall region. Using the forequarter specimen as a donor site seems favorable in that it eliminates the usual donor site morbidity. Nevertheless, in our patient with invasive ductal carcinoma of the breast and a fibrosarcoma suffering from severe pain and septic conditions - which failed to respond properly to conservative therapy - as well as rapidly progressive tumor ulceration despite repeated radiation therapy, we decided to attempt complete tumor removal by hemithoracectomy as a last resort. This decision was taken following multiple interdisciplinary consultations and thorough patient information. Although technically feasible with complete tumor removal and safe soft tissue free flap coverage, the postoperative course raises questions about the advisability of such ultra radical surgical procedures, as well as about the limitations of respiratory recovery after hemithoracectomy with removal of the sternum. Hence, based on our experience with such radical tumor surgery, we discuss the issues of diminished postoperative pulmonary function, intensive care possibilities and ethical issues. The English full-text version of this article is available at SpringerLink (under "Supplemental").
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Affiliation(s)
- A Dragu
- Klinik für Plastische und Handchirurgie, Universitätsklinikum, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland.
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