Bilateral gluteal thigh flaps for closure of large defects in the lumbosacral region and perineal region

Lumbar Perforator Flaps for Coverage of Extensive Defects With Osteomyelitis

INTRODUCTION

Lumbar osteomyelitis is a rare, although serious condition if not appropriately treated, potentially leading to neurologic complications, such as radiculopathy. Traditionally, studies have suggested the preferred use of muscle or myocutaneous flaps to prevent recurrent infections. However, late evidence suggests that radical debridement and dead space obliteration are more important than the type of flap. The lumbar perforator flap is a reliable local option with low donor site morbidity. It is a powerful tool for local trunk reconstruction, but its use in case of osteomyelitis is scarcely described. We aimed to report long-term outcomes of lumbar perforator flaps to cover lumbar soft tissue defects with chronic osteomyelitis.

MATERIAL AND METHODS

This retrospective investigation was performed on a prospectively maintained database including 7 consecutive patients (10 flaps), all presenting extensive defects of the posterior midline at L2-S1 level (defect size 287 ± 136 cm [average ± SD]). Four patients presented defects after recurrent tumor resection, whereas in 2 patients, the defect was due to vascular jeopardy of internal iliac arteries with consequent necrosis. Last defect derived from debridement of a neglected wound in a paraplegic patient. All patients had concomitant bone infection. Infectious details and postoperative complications were recorded.

RESULTS

Patients were in general poor medical condition (including peripheral arterial disease, hypertension, diabetes, or a combination of these). Eight flaps were raised as propeller perforator, whereas 2 as V-Y perforator. One propelled flap had venous congestion on postoperative day 1 and required a revision surgery to be converted to V-Y. Subsequent partial flap necrosis was treated conservatively. One patient presented a wound dehiscence that required surgical revision. All flaps were closed primarily except for 1 patient whose flap presented a mild intraoperative congestion, which was treated by delayed closure on postoperative day 6, with uneventful outcome. Time to complete healing was 29 ± 17 days (mean ± SD). No flap loss occurred, and all patients benefited from effective coverage at a mean follow-up of 20 months.

CONCLUSIONS

Lumbar perforator flap is a reliable option to cover large soft tissue defects in the lumbar area despite chronic osteomyelitis, with low morbidity and acceptable cosmetic outcome.

Reconstruction of large perineal defects after advanced malignant tumour resection: a simple gluteal thigh flap modification

Reconstruction of large defects in the perineal region, after resection of advanced malignant tumours is challenging because both coverage of the perineal skin defect and adequate filling of the pelvic space must be achieved simultaneously. This manuscript introduces a simple gluteal posterior thigh flap modification for the reconstruction of such defects. A trilobed flap, in the gluteal and posterior thigh regions, was designed to be of an adequate size to repair the dermal and pelvic floor defects. After the flap was elevated and rotated 90^°, the posterior thigh portion was denuded. The lateral portion of the deep gluteal fascia was incised to allow medial advancement. Thus, the flap could be easily moved to fill the defect, without tension. To evaluate the results, we reviewed 8 patients with large (>10 cm in diameter) advanced perineal carcinomas. For each patient, the defect was successfully reconstructed using the technique described. A secondary operation was required for one patient, due to atheromatosis that developed several months after the operation. Another patient developed donor site wound dehiscence and was treated with skin grafting. The described technique facilitates the effective reconstruction of large perineal defects.

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.

Anatomical Basis and Clinical Application of the Infragluteal Perforator Flap

BACKGROUND

When selecting flaps for coverage of pressure ulcers of the sacrum and perineal region in paraplegic patients, long-term high recurrence rates should be considered. Therefore, the authors developed an infragluteal perforator flap to avoid "burning bridges" for future reconstruction.

METHODS

Infragluteal perforator flaps were dissected in five fresh human cadavers to define the anatomy of the cutaneous branches of the descending branch of the inferior gluteal artery and cluneal nerves and define anatomical landmarks for clinical application. In a series of 13 paraplegic patients, the authors used perforator-based flaps (additional skin bridge) to cover four perineal ulcers and one sacral ulcer and perforator flaps to cover six perineal and two sacral ulcers. Donor sites were closed by direct approximation.

RESULTS

Twelve of 13 flaps healed uneventfully. In all cadaver and clinical dissections, one or two cutaneous branches of the descending branch of the inferior gluteal artery and one or two cluneal nerves were found at the lower border of the gluteus maximus muscle supplying the infragluteal perforator flap. These direct cutaneous branches allowed dissection of inferior gluteal perforator flaps with improved flap mobility compared with the perforator-based flaps. The descending branch of the inferior gluteal artery could always be spared for future flaps.

CONCLUSIONS

The infragluteal perforator flap is a versatile and reliable flap for coverage of ischial and sacral pressure sores. It can be designed as a perforator-based or perforator flap and could provide a sensate flap in ambulatory patients. Donor-site morbidity is minimal, and options for future flaps of the gluteal and posterior thigh region are preserved.

Salvage treatment of an irradiated, infected lumbosacral wound

A 60-year-old male with lumbosacral multiple myeloma received 5100 cGy of external-beam radiation, thalidomide, and Decadron. He subsequently underwent excision of the epidural tumor, decompressive L4, L5, and S1 laminectomies, and bilateral L4-5 and L5-S1 medial facetectomies. The patient developed osteoradionecrosis, cerebrospinal fluid leak, wound infection, and sepsis. Debridement and bilateral V-Y fasciocutaneous advancement flaps failed. Pedicled omental transposition flap through a Petit triangle tunnel was successfully performed. Omental transposition provides a safe option for salvage treatment of irradiated, infected lumbosacral wounds. The plastic and trophic qualities of the omentum make it an excellent choice to fill poorly vascularized wounds. In addition to its immunologic and neoangiogenic properties, the omentum has a dense lymphatic network with tremendous absorptive potential. Its biologic advantages must be weighed against the need for celiotomy and available local options according to circumstances.

[Coverage an irradiated wound of the lower lumbar area with a latissimus dorsi musculocutaneous free flap by lengthening the vascular pedicle with interpositional vein grafts]

Reconstruction of radionecrosis of the lower lumbar area is a challenging problem because of the difficulty of mobilization of the irradiated local tissues, absence of a reliable locoregional procedures and prolongation of the receiving vessels of the free flaps. The ideal treatment is a wide excision of the irradiated tissues and an immediate reconstruction in one step, which is better to be done by using a musculocutaneous flap. The latissimus dorsi musculocutaneous flap is ideal for this indication. The authors prefer to do the revascularization of the latissimus dorsi flap by its'thoracodorsal pedicle because of the possibility to have a high pressure blood flow which allow to use long venous bypass, the exposure of the recipient vessels at the same time of dissecting the flap and to have the anastamosis site away from the irradiated tissue. The authors are presenting their experience in treating a case of radionecrosis in the lower lumbar region with exposed vertebrae by a latissimus dorsi musculocutaneous free flap with exposed vertebrae by a latissimus dorsi musculocutaneous free flap with the lengthening of its'pedicle by two 30 cm interposition saphenous vein grafts.

Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery

BACKGROUND

Perineal wound complications may occur after visceral pelvic surgery. We reviewed our experience to determine indications for immediate tissue transfer (TT) to prevent complications.

METHODS

Hospital records and computerized data were reviewed on 175 perineal repairs in 156 patients treated at The University of Texas M.D. Anderson Cancer Center for tumors involving the alimentary tract (135 of 175), genitourinary tract (15 of 175), perineum (19 of 175), or sacrum (6 of 175). Patients had either resection of only the colorectum and anus (APR) (46 of 175) or multivisceral resection (MVR) (129 of 175), and the perineal wound was closed by using TT (108 of 175) or primary closure (PC) (67 of 175) on the basis of the surgeon's judgment. Complications were compared between PC and TT groups.

RESULTS

Complications occurred in 57% (100 of 175). There was no significant difference overall in PC and TT procedures or in the APR subgroup. There were significantly fewer complications for TT patients in the MVR subgroup (P =.0001). There were significantly fewer complications for TT patients with prior irradiation in both APR (P =.01) and MVR (P =.007) subgroups.

CONCLUSIONS

Immediate TT for perineal wound closure is associated with fewer healing complications than PC in a subset of patients with multivisceral resection or prior radiotherapy. Surgical planning in these cases should consider immediate soft tissue reconstruction.

Lower back coverage with endoscopically harvested pedicled greater omental flap

An alternative surgical treatment is proposed here for radionecrosis of the lower back. A 78-year-old patient was treated successfully for a nonhealing ulcer with a pedicled omental flap. The omentum was harvested endoscopically and brought out of abdominal cavity through a limited incision on lateral left side of abdominal wall. The omentum was then tunneled to the back for coverage the lower back. The combination of an endoscopic harvest of an omental flap performed by a general surgeon and wound debridement and skin grafting of the omentum by a plastic surgeon allows minimal donor-site morbidity and avoids the use of delicate microsurgical technique. Additionally, omentum is an ideal flap for the treatment of radionecrosis.

Myocutaneous flaps in genitourinary oncology

Between January 1983 and September 1992, 32 myocutaneous flaps were fashioned in 28 patients for reconstruction following treatment of genitourinary malignancies or complex pelvic fistulas. Of the myocutaneous flaps 14 were used to obtain primary soft tissue coverage of large but otherwise uncomplicated wounds and 10 were used to cover previously irradiated resection sites. Four myocutaneous flaps were used to repair complex radiation-induced fistulas involving the bladder, vagina, urethra and rectum. Flaps were used to cover infected or nonhealing open wounds in 8 cases, 4 of which also had been previously irradiated. Myocutaneous flap donor sites were the tensor fascia lata in 11 cases, gracilis in 9, rectus abdominis in 10 and rectus femoris in 2. There was 1 major complication (flap loss) and 9 minor complications. There were no perioperative deaths. Myocutaneous flaps are an effective means of covering large groin, perineal and lower abdominal surgical defects after radical surgery.