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Surgical delay of expanded skin flaps in lower limb resurfacing
British JowdofPlastic
Surgery (1991). 44,266-269
Surgical delay of expanded skin flaps in lower limb resurfacing P. G. Theunis and *M. R. Masser Odstock Hospital, Salisbury and *Pinderfields Hospital, Wakefield SUMMARY. We report the details of a patient iu whom three expanded random pattern skia flaps were raised and transposed to repair lower limb defects. The importance of an additional surgical delay procedure is introduced and its efficacy is demonstrated.
Discussion
Case Report The patient suffered a road traffic accident at the age of 19. She was thrown from a motorcycle and dragged under a car for about 400 metres, sustaining multiple injuries including facial, spinal and pelvic fractures from which she made a good recovery. There were large areas of soft tissue loss especially from her left leg, exposing the greater trochanter, tibia1 tuberosity, fibular head and the common peroneal nerve. Initially the wounds were treated with split skin grafts achieving complete cover within three months. Nine years after the accident she presented complaining of tethering of the unsightly adherent skin grafts. She was offered a limited reconstruction for the most troublesome area. An expanded flap was planned to resurface the greater trochanter. The buttock skin was raised via an incision at the upper border of the scar. A 15 cm diameter round expander was inserted in which 1310 cc was injected in 10 sessions over 8 weeks. The mean peak pressure was 64 mm Hg and the mean resting pressure 28 mm Hg. An anteriorly based flap, 12 cm wide and 15 cm long was raised and transposed down. The flap became cyanotic at the tip and 2 cm slough occurred. The final result was satisfactory and the patient was so pleased that she requested elimination of the remaining skin grafts. Twocustom expanders, 22 x 5 cm were inserted superficial to deep fascia, anterior to the left thigh scar and posterior to the left lower leg scar. Incisions were at the graft borders. The lower leg expander was inflated to 1360 cc in 19 sessions over 4 months. The mean peak pressure was 79 mm Hg and the mean resting pressure 43 mm Hg. An inferiorly based flap 20 cm long and 23 cm wide at its base was raised and transposed anteriorly. The flap sloughed 1.5 cm at its tip, and this was Iater closed with a small Limberg flap. The upper leg expander was inflated to 1930~~ in 30 sessions over 6 months. The mean peak pressure was 90 mm Hg and the mean resting pressure was 55 mm Hg. Without deflating the expander the proposed transposition flap was surgically delayed by incising its borders down to but not including the capsule. The subdermal vessels were ligated and then the skin was closed. One week later the entire inferiorly based transposition flap was raised 26 cm long and 23 cm wide at its base. This achieved complete cover and primary healing occurred. 6 months postoperatively the scars were fading without any sign of stretching.
This case Gleneagles,
was presented at the Tissue Expansion
In the lower limb definitive resurfacing of large defects, to restore the appearance and chronic discomfort of deep and adherent skin g&fts, can best be achieved with local expanded flaps. For these to survive as advancement flaps, the insertion of the tissue expander provides sufficient delay. For the much longer and more efficient transposition flaps, an additional delay procedure might be required. This case report demonstrates the use of expanded transposition flaps with and without delay to resurface very large skingrafted areas in the lower limb of a single subject. If expansion is done with routine pressure measurements without exceeding diastolic blood pressure (Masser, 1990) tripling of surface areas can be accomplished. In order to avoid muscle wasting, isometric exercises were carried out. Our patient continued to work and was even married with the two leg expanders in place. Delay in non-expanded flaps is a well-known and widely accepted procedure (Milton, 1969). Insertion of an expander acts as a delay, increasing the surviving length of the flap. (Cherry et al., 1983). The surviving
length of expanded random-pattern skin flaps is longer than that of the delayed non expanded flap (Sasaki and Pang, 1984). To our knowledge no data exist on secondary delay of expanded flaps. Considering the past experience with the multistage delay of tubed pedicle flaps it is worth considering a comparable secondaj delay for certain very long expanded random-pattern flaps. Our case shows that the 2 shorter flaps (buttock and lower leg) sloughed at the tip, representing their maximum surviving length. The longest flap, on the thigh, had secondary delay and survived without any problem. (Table). This secondary delay must consist of the division of all dermal and subcutaneous vessels but avoiding exposure of the silicone shell and leaving the small vessels of the intact capsule. Sellers et al. (1986) describe resurfacing of a massive thigh wound using repeated skin expansion. They used advancement skin flaps and needed 10 expanders and 9 operative procedures to cover a similar surface area as in our case. The need for repeated skin expansion can
Symposium,
May 1989.
266
Fig. 2 Figure l-(A) initial injuries to the left thigh and lower leg. (B) the lower leg wound. (C) the thigh wound. Figure 2--(A) buttock flap designed. (8, C) early result after transposition of the buttock flap.
British Journal of Plastic Surgery
268
Fig. 3
Fig. 4
1
3 C) u II
*
w 1SCM 26 CM 2ocM c C
x
J
Fig. 5 Figure WA, B) expanders in situ at the upper and lower leg. (C)artist’s impression showing the surgical delay (inset). Figure WA) shows the proposed upper leg flap after delay. (B, C) flap raised. Figure 5-(A, B) result 1 year postoperatively. (C) areas covered by the individual flaps raised.
269
Surgical Delay of Expanded Skin Flaps in Lower Limb Resurfacing Table
Acknowledgements
Comparison of the three flaps’ data
Site Volume Expansions Mean trough pressure Mean peak pressure Flap length Delay Necrosis
Flap I
Flap 2
Flap 3
Buttock 1310 cc 10 28 mmHg 64 mmHg 15cm _
Calf 1360 cc 19 43 mmHg 79 mmHg 20 cm _
2cm
1.5 cm
Thigh 1930 cc 30 55 mmHg 90 mmHg 26 cm + nil
be minimised by using very large transposition flaps facilitated by second stage delay procedures. This case suggests that the introduction of a secondary delay procedure with the expander in situ improved the survival length of the flap raised in the lower limb. If this suggestion can be substantiated by further clinical, and, if possible, experimental studies, then this procedure has the potential to provide a significant improvement in the techniques of tissue transfer in the lower limb. Conclusion This case suggests the need for a secondary delay procedure in long random pattern flaps of the lower limb. All such flaps undergo an initial delay by separation from the deep fascia and insertion of the expander. Some further augmentation of the survival length results from the expansion process. Delay by division of subdermal vessels, without incision of the capsule, 1 week prior to flap transfer, allows a true random-pattern skin flap at least 26 cm in length.
The authors wish to thank Mr R. A. W. McDowaIl for permitting usto treat this patient, and the Photographic department at Odstock Hospital for preparation of the prints.
References Cherry, G.
W., Ad, E., Pasyk, K., MeCIatehey, K. ad Robrich, R. J. (1983). Increased survival lengthand vasEularity of randctmpattern skin flaps elevated in controlled, expanded skin. Plastic and Reconstructive Surgery, 72,680. Maser, M. R. (1990). The pre-expanded radial free flap. Plastic and Reconstructive Surgery, 86,295. MIMI, S. H. (1969). The effects of delay on the survival length of experimental pedicled skin flaps. British Journal of Surgery, 22, 244. Sasakl, G. H. and Pang, C. Y. (1984). Pathophysiology of skin flaps raised on expanded pig skin. Plastic and Reconstructive Surgery, 74,59. !Mlers, D. S., Miller, S. H., Demuth, R. J. and Klabadm, M. E. (1986). Repeated skin expansion to resurface a massive thigh wound. Plastic and Reconstructive Surgery, 77,654.
The Authors P. G. Tbeunis, MD, St Rochusstraat 147, B-2100 Deume, Belgium, formerSH0 in Plastic Surgery, Odstock Hospital, Salisbury, UK. The late M. R. Masser, FRCS, Consultant Plastic Surgeon, Pindefields Hospital, Wakefield, UK. Now assistant plastic surgeon, A.Z. St. Jan Brugge Belgium. Requests for reprints to Dr Theunis at the above address. Paper received 10 October 1990. Accepted 28 November
1990.
Surgery (1991). 44,266-269
Surgical delay of expanded skin flaps in lower limb resurfacing P. G. Theunis and *M. R. Masser Odstock Hospital, Salisbury and *Pinderfields Hospital, Wakefield SUMMARY. We report the details of a patient iu whom three expanded random pattern skia flaps were raised and transposed to repair lower limb defects. The importance of an additional surgical delay procedure is introduced and its efficacy is demonstrated.
Discussion
Case Report The patient suffered a road traffic accident at the age of 19. She was thrown from a motorcycle and dragged under a car for about 400 metres, sustaining multiple injuries including facial, spinal and pelvic fractures from which she made a good recovery. There were large areas of soft tissue loss especially from her left leg, exposing the greater trochanter, tibia1 tuberosity, fibular head and the common peroneal nerve. Initially the wounds were treated with split skin grafts achieving complete cover within three months. Nine years after the accident she presented complaining of tethering of the unsightly adherent skin grafts. She was offered a limited reconstruction for the most troublesome area. An expanded flap was planned to resurface the greater trochanter. The buttock skin was raised via an incision at the upper border of the scar. A 15 cm diameter round expander was inserted in which 1310 cc was injected in 10 sessions over 8 weeks. The mean peak pressure was 64 mm Hg and the mean resting pressure 28 mm Hg. An anteriorly based flap, 12 cm wide and 15 cm long was raised and transposed down. The flap became cyanotic at the tip and 2 cm slough occurred. The final result was satisfactory and the patient was so pleased that she requested elimination of the remaining skin grafts. Twocustom expanders, 22 x 5 cm were inserted superficial to deep fascia, anterior to the left thigh scar and posterior to the left lower leg scar. Incisions were at the graft borders. The lower leg expander was inflated to 1360 cc in 19 sessions over 4 months. The mean peak pressure was 79 mm Hg and the mean resting pressure 43 mm Hg. An inferiorly based flap 20 cm long and 23 cm wide at its base was raised and transposed anteriorly. The flap sloughed 1.5 cm at its tip, and this was Iater closed with a small Limberg flap. The upper leg expander was inflated to 1930~~ in 30 sessions over 6 months. The mean peak pressure was 90 mm Hg and the mean resting pressure was 55 mm Hg. Without deflating the expander the proposed transposition flap was surgically delayed by incising its borders down to but not including the capsule. The subdermal vessels were ligated and then the skin was closed. One week later the entire inferiorly based transposition flap was raised 26 cm long and 23 cm wide at its base. This achieved complete cover and primary healing occurred. 6 months postoperatively the scars were fading without any sign of stretching.
This case Gleneagles,
was presented at the Tissue Expansion
In the lower limb definitive resurfacing of large defects, to restore the appearance and chronic discomfort of deep and adherent skin g&fts, can best be achieved with local expanded flaps. For these to survive as advancement flaps, the insertion of the tissue expander provides sufficient delay. For the much longer and more efficient transposition flaps, an additional delay procedure might be required. This case report demonstrates the use of expanded transposition flaps with and without delay to resurface very large skingrafted areas in the lower limb of a single subject. If expansion is done with routine pressure measurements without exceeding diastolic blood pressure (Masser, 1990) tripling of surface areas can be accomplished. In order to avoid muscle wasting, isometric exercises were carried out. Our patient continued to work and was even married with the two leg expanders in place. Delay in non-expanded flaps is a well-known and widely accepted procedure (Milton, 1969). Insertion of an expander acts as a delay, increasing the surviving length of the flap. (Cherry et al., 1983). The surviving
length of expanded random-pattern skin flaps is longer than that of the delayed non expanded flap (Sasaki and Pang, 1984). To our knowledge no data exist on secondary delay of expanded flaps. Considering the past experience with the multistage delay of tubed pedicle flaps it is worth considering a comparable secondaj delay for certain very long expanded random-pattern flaps. Our case shows that the 2 shorter flaps (buttock and lower leg) sloughed at the tip, representing their maximum surviving length. The longest flap, on the thigh, had secondary delay and survived without any problem. (Table). This secondary delay must consist of the division of all dermal and subcutaneous vessels but avoiding exposure of the silicone shell and leaving the small vessels of the intact capsule. Sellers et al. (1986) describe resurfacing of a massive thigh wound using repeated skin expansion. They used advancement skin flaps and needed 10 expanders and 9 operative procedures to cover a similar surface area as in our case. The need for repeated skin expansion can
Symposium,
May 1989.
266
Fig. 2 Figure l-(A) initial injuries to the left thigh and lower leg. (B) the lower leg wound. (C) the thigh wound. Figure 2--(A) buttock flap designed. (8, C) early result after transposition of the buttock flap.
British Journal of Plastic Surgery
268
Fig. 3
Fig. 4
1
3 C) u II
*
w 1SCM 26 CM 2ocM c C
x
J
Fig. 5 Figure WA, B) expanders in situ at the upper and lower leg. (C)artist’s impression showing the surgical delay (inset). Figure WA) shows the proposed upper leg flap after delay. (B, C) flap raised. Figure 5-(A, B) result 1 year postoperatively. (C) areas covered by the individual flaps raised.
269
Surgical Delay of Expanded Skin Flaps in Lower Limb Resurfacing Table
Acknowledgements
Comparison of the three flaps’ data
Site Volume Expansions Mean trough pressure Mean peak pressure Flap length Delay Necrosis
Flap I
Flap 2
Flap 3
Buttock 1310 cc 10 28 mmHg 64 mmHg 15cm _
Calf 1360 cc 19 43 mmHg 79 mmHg 20 cm _
2cm
1.5 cm
Thigh 1930 cc 30 55 mmHg 90 mmHg 26 cm + nil
be minimised by using very large transposition flaps facilitated by second stage delay procedures. This case suggests that the introduction of a secondary delay procedure with the expander in situ improved the survival length of the flap raised in the lower limb. If this suggestion can be substantiated by further clinical, and, if possible, experimental studies, then this procedure has the potential to provide a significant improvement in the techniques of tissue transfer in the lower limb. Conclusion This case suggests the need for a secondary delay procedure in long random pattern flaps of the lower limb. All such flaps undergo an initial delay by separation from the deep fascia and insertion of the expander. Some further augmentation of the survival length results from the expansion process. Delay by division of subdermal vessels, without incision of the capsule, 1 week prior to flap transfer, allows a true random-pattern skin flap at least 26 cm in length.
The authors wish to thank Mr R. A. W. McDowaIl for permitting usto treat this patient, and the Photographic department at Odstock Hospital for preparation of the prints.
References Cherry, G.
W., Ad, E., Pasyk, K., MeCIatehey, K. ad Robrich, R. J. (1983). Increased survival lengthand vasEularity of randctmpattern skin flaps elevated in controlled, expanded skin. Plastic and Reconstructive Surgery, 72,680. Maser, M. R. (1990). The pre-expanded radial free flap. Plastic and Reconstructive Surgery, 86,295. MIMI, S. H. (1969). The effects of delay on the survival length of experimental pedicled skin flaps. British Journal of Surgery, 22, 244. Sasakl, G. H. and Pang, C. Y. (1984). Pathophysiology of skin flaps raised on expanded pig skin. Plastic and Reconstructive Surgery, 74,59. !Mlers, D. S., Miller, S. H., Demuth, R. J. and Klabadm, M. E. (1986). Repeated skin expansion to resurface a massive thigh wound. Plastic and Reconstructive Surgery, 77,654.
The Authors P. G. Tbeunis, MD, St Rochusstraat 147, B-2100 Deume, Belgium, formerSH0 in Plastic Surgery, Odstock Hospital, Salisbury, UK. The late M. R. Masser, FRCS, Consultant Plastic Surgeon, Pindefields Hospital, Wakefield, UK. Now assistant plastic surgeon, A.Z. St. Jan Brugge Belgium. Requests for reprints to Dr Theunis at the above address. Paper received 10 October 1990. Accepted 28 November
1990.