Morbidity of donor and recipient sites after free flap surgery. A prospective study

Combined use of lower medial thigh perforator (LMTP) flap and pedicled medial sural artery perforator flap (MSAP) for lateral knee defects coverage after sarcoma resection: A case report and literature review of soft tissue defect around knee reconstruction

Reconstruction of knee defects still represents a challenge for reconstructive surgeons. After an extensive resection, the primary aim is to reach a stable result, while maintaining a good range of motion and aesthetic unity. The use of pedicled perforator-based flaps makes it possible to achieve these goals. Many are the flaps that can be used in this region, and the pedicle medial sural artery perforator (mSAP) flap is considered among one of the first-choice techniques. The purpose of this case report is to describe for the first time the use of pedicled mSAP flap to cover a lateral knee defect. A 79-year-old patient underwent extensive excision of sarcoma on the lateral side of the left knee, with removal of distal portion of the vastus lateralis muscle and portion of the biceps femoris tendon. The resulting defect from the excision measured 10 cm × 10 cm. To cover the postero-inferior part of the defect we decided to use a mSAP flap, with a skin paddle 10 cm × 5 cm, which was tunneled posteriorly to the popliteal artery and vein in order to reach the affected site. We then used a lower medial thigh perforator (pLMT) flap with a 15 cm × 5 cm skin paddle, rotated by 90° in a propeller fashion to cover the antero-superior portion of the defect. The decision to use two flaps was justified by the fact we wanted to close the donor areas with direct suturing for a better aesthetic result. The post-operative course was regular with only a small wound dehiscence that had healed by secondary intention. At 6 months postoperatively, the patient showed a complete active range of motion of the knee joint and absolute aesthetic satisfaction with flaps donor site and knee shape. A review of literature is also provided, with a specific focus on the different procedures for soft tissue defects reconstruction around the knee. According to our experience, the pedicle of the MSAP flap may be safely used as an additional reconstructive option for lateral knee defects.

Evaluation of Shoulder Muscle Improvement in Patients Following Free Latissimus Dorsi Muscle Pedicle Flap Transfer

Aim: This study aimed to evaluate the clinical outcomes, shoulder muscle strength, and donor site morbidity following the free latissimus dorsi (LD) muscle pedicle flap transfer. Materials: Patients with free LD muscle pedicle flap reconstructions and with asymptomatic shoulders (affected and contralateral side) were included. The follow-up duration was 12 months. The combined shoulder range of motion (ROM), Constant-Murley shoulder (CMS), and quick disabilities of the arm, shoulder, and hand (QuickDASH) scores were measured preoperatively and at 1 year postoperatively. The ratio of the isokinetic muscle strength and total work was measured with an isokinetic dynamometer (Cybex 350®) both preoperatively and at sixth month postoperatively. Results: Twenty patients with a mean age of 37.06 ± 9.74 years and a mean body mass index of 23.49 ± 8.6 kg/m2 were included. The difference in shoulder ROM and CMS and increase in QuickDASH were not significant at the first postoperative year. The peak torque and total work performed decreased by 13%-16% for the adductor and extensor functions at the six month postoperatively, and these differences were significant. Although the adductor peak torque was significantly lower in the postoperative test of the operated side, no significant difference was found between the operated and unaffected shoulder peak torque values. Moreover, no significant difference was noted between the operated and unaffected shoulders in all isokinetic tests pre- and postoperatively. Conclusion: The free LD muscle pedicle flap harvest did not decrease function and ROM at the first postoperative year. The muscle strength and total work of shoulders after the LD muscle transfer returned to the preoperative condition at the sixth month, except adductor and extensor muscle strengths. However, adductor and extensor muscle strengths of the operated shoulders were not significantly different postoperatively.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps

BACKGROUND

The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap.

METHODS

Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed.

RESULTS

A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder.

CONCLUSIONS

Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Function-Sparing Free Split Latissimus Dorsi Flap for Lower-Extremity Reconstruction: Five-Year Consecutive Single-Surgeon Series

BACKGROUND

The free split latissimus dorsi flap for lower-extremity reconstruction has some advantages over the traditional latissimus dorsi flap. The flap is harvested with the patient in the supine position and is associated with minimal morbidity as the function of the remaining latissimus dorsi muscle is preserved through the posterior division of the thoracodorsal nerve.

METHODS

A consecutive single-surgeon 5-year series of free split latissimus dorsi muscle flaps for lower-extremity reconstruction (n = 42) was evaluated. Donor site morbidity was evaluated through assessment of the strength of the remaining latissimus dorsi at least 1 month after surgery. Shoulder function was evaluated postoperatively using the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Shoulder Pain and Disability Index (SPADI).

RESULTS

The mean age of the 42 patients was 40.7 years. The mean length and width of the flaps were 17.9 cm and 8.6 cm. The majority (71%) of the wounds were due to acute trauma. Of the 42 flap procedures performed, 95% (40) were successful. Assessment of remaining latissimus dorsi strength at least 1 month postoperatively, during 3 activities, showed a Medical Research Council (MRC) grade of 5 in all patients. The mean and median scores were 6.4 and 0 according to the DASH, 6.0/6.4 and 0/0 on the SPADI pain/disability scales, and 90.7 and 100 on the ASES.

CONCLUSIONS

The free split latissimus dorsi flap is a large reliable muscle flap with negligible donor site morbidity that is particularly advantageous for lower-extremity resurfacing following trauma.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acellular dermal matrix combined with oxidized regenerated cellulose for partial breast reconstruction: Two case reports

RATIONALE

Filling materials for partial defect of the breast have rarely been developed because of safety and durability.

PATIENT CONCERNS

Two female patients (ages, 53 and 50 years) with breast cancer underwent partial mastectomy with sentinel lymph node biopsy.

DIAGNOSIS

Core needle biopsy revealed an invasive ductal carcinoma in both patients. Breast ultrasound showed hypoechoic nodules with irregular margins. Breast magnetic resonance imaging showed an irregularly shaped enhancing mass with duct extension in Patient 1 and irregularly shaped multifocal, enhancing masses with non-mass enhancement in Patient 2.

INTERVENTION

A combination method using acellular dermal matrix and oxidized regenerated cellulose was used for partial breast reconstruction. The safety and cosmetic outcomes were evaluated for both patients.

OUTCOMES

There were no significant complications, and the breast shape and volume were well maintained, even 2 years after surgery. There was no postoperative tumor recurrence.

CONCLUSION

The combination of acellular dermal matrix and oxidized regenerated cellulose for partial breast reconstruction can be a good option based on oncological safety and cosmetic outcome.

The influence of reconstruction choice and inclusion of radiation therapy on functional shoulder biomechanics in women undergoing mastectomy for breast cancer

PURPOSE

The functional implications of reconstructing the breast mound with a latissimus dorsi (LD) flap or placing an implant under the pectoralis major (PM) muscle is complicated by potential comorbidities from disinserting these muscles and adjuvant radiotherapy. We utilized novel robot-assisted measures of shoulder stiffness and strength to dissociate how breast reconstruction choice and inclusion of radiation therapy impact shoulder morbidity in post-mastectomy reconstruction patients.

METHODS

Shoulder strength and stiffness were collected from 10 irradiated LD flap breast reconstruction patients, 14 two-stage subpectoral implant reconstruction patients (subpectoral), and 10 irradiated deep inferior epigastric perforator (DIEP) flap patients an average of 659 days post-reconstruction. Univariate ANOVAs examined surgical group differences in strength and stiffness.

RESULTS

There were main effects of surgical group on vertical adduction, vertical abduction, and internal rotation strength. The LD flap group was significantly weaker than the subpectoral group in all measures and significantly weaker than the DIEP group during vertical adduction. There was also a main effect of surgical group on vertical adduction stiffness, where the LD group exhibited significantly reduced stiffness while producing vertical adduction torque. No significant differences between the subpectoral and DIEP groups existed for any measure of shoulder strength or stiffness.

CONCLUSIONS

Disinsertion of the LD, not the disinsertion of the PM or radiotherapy, contributes to strength deficits following LD flap breast reconstructions. The combined disinsertion of the PM and LD compromises shoulder stability in the vertical plane. Shoulder function should be a focal point of the surgical decision-making process and postsurgical care.

The Functional Impact of Breast Reconstruction: An Overview and Update

As rates of bilateral mastectomy and immediate reconstruction rise, the aesthetic and psychosocial benefits of breast reconstruction are increasingly well understood. However, an understanding of functional outcome and its optimization is still lacking. This endpoint is critical to maximizing postoperative quality of life. All reconstructive modalities have possible functional consequences. Studies demonstrate that implant-based reconstruction impacts subjective movement, but patients’ day-to-day function may not be objectively hindered despite self-reported disability. For latissimus dorsi flap reconstruction, patients also report some dysfunction at the donor site, but this does not seem to result in significant, long-lasting limitation of daily activity. Athletic and other vigorous activities are most affected. For abdominal free flaps, patient perception of postoperative disability is generally not significant, despite the varying degrees of objective disadvantage that have been identified depending on the extent of rectus muscle sacrifice. With these functional repercussions in mind, a broader perspective on the attempt to ensure minimal functional decline after breast surgery should focus not only on surgical technique but also on postoperative rehabilitation. Early directed physical therapy may be an instrumental element in facilitating return to baseline function. With the patient’s optimal quality of life as an overarching objective, a multifaceted approach to functional preservation may be the answer to this continued challenge. This review will examine these issues in depth in an effort to better understand postoperative functional outcomes with a focus on the younger, active breast reconstruction patient.

Long-term prospective assessment of shoulder function after breast reconstruction involving a latissimus dorsi muscle flap transfer and postoperative radiotherapy

BACKGROUND

Several investigators have evaluated the impaired function of the shoulder after removal of the latissimus dorsi muscle for breast reconstruction. However, a few investigators have studied whether including radiotherapy has a negative effect on functional recovery of the shoulder by a long-term follow-up after surgery. In this study, we compared objective measurements of shoulder function preoperatively and postoperatively for 3 years after latissimus dorsi muscle (LDM) flap transfer and postoperative radiotherapy (PRT).

METHODS

Eighteen patients who underwent unilateral transfer of a pedicled LDM flap and PRT within 2 months of breast-conserving surgery were enrolled in this study. Range of motion (ROM) and muscle strength in exhaustive shoulder movements were measured before surgery, and at 3 and 6 months, and 1 and 3 years.

RESULTS

The results of ROM measurements at 3months postsurgery showed significant decreases in both flexion and abduction by 7.1 and 9.2 % and at 3 years postsurgery by 4.7 and 5.7 %. The muscle strength measurements at 3 months postsurgery showed statistically significant decreases both in adduction and in the 2nd medial rotation by 30.7 and 25.9 % and at 3 years postsurgery by 36.4 and 20.4 %. A significant improvement in these impairments was not observed for 3 years after surgery compared with that at 3 months after surgery.

CONCLUSION

A combination of the LDM flap procedure and PRT could be associated with a higher incidence of tissue adhesions in both flexion and abduction and muscle deficit both in adduction and in the 2nd medial rotation.

Macrophages play a key role in angiogenesis and adipogenesis in a mouse tissue engineering model

We have previously described a mouse adipose tissue engineering model using a silicon chamber enclosing the superficial epigastric pedicle in a Matrigel based environment. We have shown that when Zymosan, a sterile inflammatory agent, is added to the chamber, angiogenesis and adipogenesis are significantly improved. As Zymosan interacts with toll-like receptors on macrophages, the role of macrophages in new tissue development in the tissue engineering chamber was assessed. Morphological and histological results showed that macrophages were presenting in high numbers at 2 weeks but had decreased significantly by 4 and 6 weeks in the chamber. Numerous immature new blood vessels had formed by 2 weeks, becoming more mature at 4 and 6 weeks. Immature adipocytes were visualized at 4 weeks and mature cells, at 6 weeks. To investigate the functional role of macrophages in the tissue engineering process, we knocked out the local macrophage population by inserting Clodronate liposomes in this chamber. This study shows for the first time that when macrophages are depleted, there is minimal new vascular and adipose tissue development. We propose a new theory for tissue engineering in which macrophages play a central role in both neovascularisation and adipogenesis.

Donor-site morbidity after fibula free flap transfer: a comparison of subjective evaluation using a visual analogue scale and point evaluation system

The aims of this study were: (1) to compare the visual analogue scale (VAS) with the point evaluation system (PES) in the subjective evaluation of donor-site morbidity after fibula free flap transfer; (2) to compare the functional outcomes of fibula free flap surgery between patients with a normal body mass index (BMI) and patients with a high BMI, and between skin paddle and non-skin paddle harvesting; and (3) to determine the correlation between functional outcomes and related factors. This study included 15 patients who underwent a vascularized fibula free flap transfer for oral and maxillofacial reconstruction. Demographic data, preoperative, intraoperative, and postoperative data were collected. Subjective self-evaluation of functional outcomes was done using a VAS followed by a PES. Comparison of the VAS and PES scores was assessed with Pearson's correlation coefficient. The statistical significance was set at P<0.05. The VAS score was significantly correlated with the PES score (r=0.63, P=0.01). The tourniquet times for the skin paddle group were longer than for the non-skin paddle group (P=0.02), while the satisfaction score of the non-skin paddle group was higher than that of the skin paddle group (P=0.03). The VAS is a potential option for the subjective evaluation of donor-site morbidity after fibula free flap transfer.

Fasciocutaneous flaps of the subscapular artery axis to reconstruct large extremity defects

INTRODUCTION

The scapular, parascapular and thoracodorsal artery perforator (TDAP) flaps represent fasciocutaneous flaps derived from the subscapular artery axis. These flaps can be harvested individually or combined as conjoint flaps, tailored to reconstruct a wide variety of defects in the extremities. ANALYSIS AND METHODS: All patients undergoing free-flap reconstruction at North Bristol trust with a fasciocutaneous flap of the subscapular axis from April 2006 until April 2010 were included. This cohort of 45 patients was retrospectively analysed. The Enneking score for return of limb function was used as an outcome measure after reconstruction. Donor-site morbidity analysis was carried out prospectively using Oxford Medical Research Council (MRC) score, Vancouver Scar Scale and disability of arm, shoulder and hand questionnaire (DASH) scores.

RESULTS

A total of 45 patients had extremity reconstruction using flaps of the subscapular artery axis following severe limb trauma, often comprising open tibial fractures. A total of 42 patients had lower limb injuries and three had upper limb injuries. All flaps survived. The mean Injury Severity Score (ISS) was 9.3, the mean Enneking score was 27 at 12 months mean follow-up. In the nine conjoint flaps, the mean area of tissue resurfaced was 257 cm2.

CONCLUSIONS

In this case series of fasciocutaneous flaps of the subscapular artery axis, we establish that these flaps are robust and versatile. They replace 'like-with-like' and have good patient satisfaction. The donor site can be closed primarily, is discrete and has minimal donor morbidity. The conjoint flaps can be used for reconstruction of very large defects without the need to sacrifice functionally important muscle.

Latissimus Dorsi Free Flap Harvesting May Affect the Shoulder Joint in Long Run

Background:

The latissimus dorsi (LD) muscle or myocutaneous flap is one of the most commonly used flaps and is believed to result in minimal donor-side morbidity. The impact on shoulder function from LD removal is important due to the common nature of this procedure. Previous studies have been performed after relatively short follow-up time and mostly after breast reconstruction. The purpose of this study was to objectively evaluate shoulder function years after latissimus dorsi muscle free flap operation.

Methods:

Between 1998 and 2004, eight patients who underwent LD-free flap for lower limb (7) or head and neck (1) soft tissue reconstruction were enrolled in this study. Scar, shoulder pain, function, mobility, stability and strength were evaluated and measured by using the Patient Scar Assessment Questionnaire (PSAQ), the Scar Evaluation Scale (SES) score, the American Shoulder and Elbow Surgeons (ASES) form, goniometer and isokinetic tests. Measurements of the operated sides were compared to the non-operated sides.

Results:

Mean age was 54 ± 21 years and mean follow-up was 92.5 ± 36 months after surgery. Mean PSAQ was 73 (65%), mean SES score was 2 ± 1. When comparing the operated sides to the unoperated sides, ASES score was significantly lower in the operated side (76 versus 93, p = 0.008); The range of motion in active and passive endorotation, active extrarotation and active forward elevation were significantly reduced after surgery. Operated side revealed a significant joint instability (3.6 versus 1.2, p = 0.007) using the ASES form. Isokinetic tests revealed that only intra-rotation strength was significantly reduced (35.74 Newton-metre versus 42.7 Newton-metre, p = 0.03) in the operated side.

Conclusion:

LD harvesting can affect the function of the shoulder joint in the long run. Reduced mobility, instability and weakness could be obtained with objective measurements. However, the results should be interpreted with caution because of the small sample size, internal controls and retrospective nature of this study.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Shoulder function after harvesting a thoracodorsal artery perforator flap

BACKGROUND

Converting the latissimus dorsi musculocutaneous flap to a thoracodorsal artery perforator flap has been reported for breast reconstruction. The goal of this article is to evaluate the donor site after harvesting a thoracodorsal artery perforator flap in patients who underwent breast surgery and to show the advantages of sparing the latissimus dorsi muscle on the function of the shoulder.

METHODS

Between 2002 and 2004, 22 patients who had a partial breast reconstruction using a pedicled thoracodorsal artery perforator flap were enrolled in a functional study to evaluate shoulder function postoperatively. Latissimus dorsi muscle strength, shoulder mobility, and latissimus dorsi thickness were measured by using the MicroFet2, a goniometer, and ultrasound examination, respectively. The measurements of the operated and contralateral (unoperated) sides were analyzed statistically.

RESULTS

When comparing the operated sides to the unoperated sides, latissimus dorsi strength seemed to be maintained after surgery. Shoulder mobility was also similar in all movements, but both active and passive forward elevation and passive abduction were reduced significantly after surgery, and latissimus dorsi thickness was not affected by harvesting the thoracodorsal artery perforator flaps. No seroma formation was found in any of the donor sites.

CONCLUSIONS

Donor-site morbidity after harvesting a thoracodorsal artery perforator flap was reduced to a minimum. Therefore, perforator flaps should be considered in reconstruction whenever adequate perforators can be identified and safely dissected.

Soft tissue coverage of the elbow in a developing country

Two cases that required soft tissue coverage to the anterior aspect of the elbow are presented. A fasciocutaneous intercostal perforator chest wall flap was used for one patient when only skin and fascia coverage was required. A latissimus dorsi myocutaneous flap was used to provide soft tissue coverage and supply motor power for elbow flexion after contracture release in the other. The surgical techniques for each of these flaps are discussed in the context of addressing soft tissue traumatic injuries about the elbow in a developing country with limited resources.

Autologous diaphragm reconstruction with the pedicled latissimus dorsi flap

The latissimus dorsi (LD) muscle has been previously described to repair diaphragmatic defects, but as a "reverse" flap, relying on secondary blood supply from the perforating lumbar vessels rather than primary inflow from the dominant thoracodorsal artery. We report resection of a retroperitoneal synovial sarcoma, with reconstruction of the hemidiaphragm using the LD rotated on its primary neurovascular bundle. By using the dominant pedicle, the vascularity of the flap is improved, minimizing the chance of flap tip loss. Maintaining an intact nerve supply prevents atrophy. As the distal origin of the LD is broad and flat, it is ideally suited for diaphragm repair. A latissimus-sparing thoracotomy incision is required to enable this method of diaphragm reconstruction.

Pedicled perforator flaps in breast reconstruction: a new concept

INTRODUCTION

Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction.

MATERIAL AND METHODS

Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III.

RESULTS

The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap.

CONCLUSION

Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.

A Clinical Experience with Perforator Flaps in the Coverage of Extensive Defects of the Upper Extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.

Aesthetic and functional considerations in the reconstruction of large skin defects with free flaps

Free flaps can be used effectively in the primary reconstruction of large defects after resection of large tumors. The ultimate goal is radical excision of tumors and achievement of primary wound healing with a single procedure and long-term local control of disease. Although this can be obtained with the use of free tissue transfer, patients often seek more aesthetic results. Therefore, refinements of reconstructive techniques with minimal functional donor site morbidity are now the gold standard in our practice.

Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries

OBJECTIVE

To evaluate the results of a vacuum-assisted closure device in patients presenting with open high-energy soft tissue injuries.

DESIGN

Consecutive nonrandomized clinical study.

SETTING/PARTICIPANTS

From August 1999 through October 2000, 21 patients, with 21 high-energy soft tissue wounds (6 tibial, 10 ankle, and 5 with wounds of the forearm, elbow, femur, pelvis, and a below-knee stump) were treated with a vacuum-assisted closure device at a Level 1 trauma center.

INTERVENTION

A negative atmospheric pressure device used for the management of complex open injuries. Infected wounds had dressings changed every 48 hours, whereas all others had dressings changed every 72 to 96 hours.

MAIN OUTCOME MEASUREMENTS

The duration of vacuum-assisted closure use, final wound closure outcome, costs versus standard dressing changes or free flaps, and a list of all complications were recorded. All patients were followed for 6 months postcoverage.

RESULTS

Patients averaged 4.1 sponge changes, 77% performed at bedside, with the device used an average of 19.3 days. Twelve wounds (57%) required either no further treatment or a split-thickness skin graft, and 9 (43%) required a free tissue transfer.

CONCLUSIONS

The vacuum-assisted closure appears to be a viable adjunct for the treatment of open high-energy injuries. Application can be performed as a bedside procedure but additional soft tissue reconstruction may be needed for definitive coverage. This device does not replace the need for formal debridement of necrotic tissue, but it may avoid the need for a free tissue transfer in some patients with large traumatic wounds.

Use of the reverse latissimus muscle flap for closure of complex back wounds in patients with spinal cord injury

STUDY DESIGN

Our study was designed as a retrospective review of spinal cord patients with complex back wounds in whom the reverse latissimus muscle flap was used for closure.

OBJECTIVES

The objective was to evaluate the efficacy and outcomes in these patients.

SUMMARY OF BACKGROUND DATA

Earlier publications give only anecdotal reports on the treatment of complex back wounds in patients with spinal cord syndrome. The data so far available do not allow any comparison of the various methods used.

METHODS

Fourteen patients with congenital or acquired spinal cord syndrome and with an average age of 31.2 years (range 12-76 years) had complex back wounds in the thoracic and lumbar regions, which were closed in each case with a reverse latissimus dorsi muscle flap. The patients had deep wound infection and wound dehiscence following spondylodesis (n = 6), dead space and wound dehiscence following laminectomy (n = 6), or decubitus ulcers over the spine (n = 2). The spinal cord syndrome was chronic in nine patients and acute in five. The pre- and postoperative treatment and the actual operation were all done in a spinal cord injury center. In nine patients, the back wound was closed in a primary procedure, and in five, a split-thickness skin graft was used to close it. In 11 patients, primary wound healing was achieved with no complications after closure, whereas in 3 patients, complications with the back wound or the donor site led to disturbances of wound healing lasting up to 25 weeks. Five operations had to be performed specifically because of these complications.

RESULTS

At follow-up 27.4 months (mean; range 8-114 months) after the operation, all back wounds were closed, free of irritation, and completely healed. The patients did not report any handicaps in everyday life, loss of strength in the upper extremities, or functional restrictions. One patient had a deep vein thrombosis in one leg. No further complications linked with the spinal cord syndrome were ascertained. The instrumentation used during the spondylodesis operation was left in place in four cases. The spondylodesis became solidly fused in each of these cases.

CONCLUSION

Use of the reverse latissimus muscle flap is a reliable method of closing complex back wounds in patients with spinal cord syndrome. Should there be complications in the area of the flap, secondary wound healing can be achieved by wound debridement and closure of the wound by means of split-thickness skin grafting. There is no loss of function in the upper extremities. The complications typically seen in spinal cord patients can be avoided when the treatment is carried out in the conditions that obtain in a specialized spinal cord injury center.

Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.

Free flap reconstructions of 100 tibial fractures

OBJECTIVE

Reconstructive microsurgery has been part of the treatment for severe tibial fractures for over 20 years.

METHODS

In this study, we have analyzed 100 patients with 104 microvascular reconstructions to the lower leg in a 15-year period (1980-1994). Sixty-three of the reconstructions were made during the past 5 years (1990-1994), which means that microvascular reconstruction is increasing as a treatment of severe tibial fractures.

RESULTS

Free flap transfer is a safe procedure: the failure rate among the patients studied was 2%, and the amputation rate was 5%.

CONCLUSION

In the past 5 years, the flap survival rate and the microvascular free flap operation methods were the same as they were in the 1980s, but the methods for enhancing the fracture union or reconstructing the bone defect has changed.

Donor-site morbidity of the segmental rectus abdominis muscle flap

The donor-site morbidity of the segmental rectus abdominis muscle flap was evaluated in 20 patients with an average follow-up time of 47 months. Our criteria were based on static and dynamic functional results including relaxation and hernia of the abdominal wall, aesthetic outcome and patient satisfaction. The dynamic functional tests of the abdominal wall showed good results corresponding to the reported minimal impairment of quality of life. There was one abdominal hernia after wound infection and secondary healing. There was no evidence of abdominal wall instability in any of the other patients. The aesthetic outcome was excellent when a transverse lower abdominal incision, asymmetrically elongated to the donor site, was used and moderate in the case of a paramedian vertical incision. Ninety-five per cent of the patients were completely satisfied or satisfied with the result at the donor site. In the segmental use of the free rectus abdominis flap a high degree of subjective patient satisfaction reflects the favourable outcome of our examinations. On the other hand there is a clinically significant functional donor-site defect of this flap. As this procedure is still widely used, and as its indication is closely linked to its absolute and relative donor-site defect, comparisons with the alternatives, e.g. the partial latissimus dorsi muscle flap, the extended gracilis muscle flap or the serratus anterior muscle flap will have to be made.