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Delayed autologous free anterolateral thigh flap failure
420 recurrence and the previous pretrichial incision has been completely hidden by newly grown hair. Endoscopic techniques have allowed operations to be performed with remote scars placed in less visible locations. The advantages of endoscopic techniques are hidden scars and the opportunity for complete resection allowing minimal analgesia and decreased risk of recurrence.1,5 This is a distinct advantage over piece meal excision2,3 with scar placed conspicuously over the lesion. Moreover piece meal excision has the risk of leaving residual tumour that may lead to recurrence. Distinct advantage with the technique described here is that there is no need for sophisticated equipment which increase learning time & cost. The scar in the pretrichial region is bevelled to allow preservation of hair follicles which will grow through the scar. The zig-zag pattern increases the wound length to improve exposure. The key step is the careful elevation of the subcutaneous plane under direct vision to preserve a uniform thickness of the subcutaneous tissue. This minimises the damage to the overlying skin which is associated with post inflammatory hyperpigmentation and contour irregularity. In the initial post-op period, there is some redundancy of the soft tissue on the lipoma which spontaneously contracts in 2e3 months. Hence there is no actual skin excess. The placement of the incision more anteriorly in the hairline rather than more posterior in the hair bearing scalp as used in endoscopic brow access discounts the technical difficulty of passing the instruments over the frontal bone curvature, providing a more vertical and easier access to the forehead lipoma. The technique described enables the complete removal of forehead lipomas with good aesthetic outcome without the need for demanding endoscopic techniques (Figure 2). This method can be used as an alternative technique to reduce the cost of expensive instruments as well as operative time.
Correspondence and communications Lim Kim Zhuan Hnin Hnin Hlaing Lee Shu Jin Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery National University Hospital Singapore, 5 Lower Kent Ridge Road, Singapore 119074 E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.07.025
Delayed autologous free anterolateral thigh flap failure Flap reconstruction following excision of large tumours is a common plastic surgical procedure. Failure of the flap most often happens within the seven days of surgery and monitoring is not required beyond 3e4 days.1,2 We report a case of a 59-year-old gentleman who had an anterolateral thigh free flap for a grade II leiomyosarcoma and radiotherapy, who had flap failure 16 months, post surgery. A 59-year-old self employed heavy goods vehicle driver was referred to the sarcoma service from the general surgeons after having a lower limb swelling biopsied at the time of an elective hernia repair in February 2008. This was
Conflict of interest None.
Funding None.
References 1. Lin SD, Lee SS, Chang KP, et al. Endoscopic excision of benign tumors in the forehead and brow. Ann Plast Surg 2001 Jan;46:1e4. 2. Gupta S, Pandhi R, Kumar B . ‘Pot-lid’ technique for aesthetic removal of small lipoma on the face. Int J Dermatology 2001;40: 420e4. 3. Chandwarkar RY, Rodriguez P, Roussalis J, et al. Minimal-scar segmental extraction of lipomas: study of 122 consecutive procedures. Dermatol Surg 2005;31:59e64. 4. Funayama E, Minakawa H, Oyama A. Forehead lipoma resection via a small remote incision using a surgical raspatory. J Am Acad Dermatol 2007 Mar;56:458e9. 5. Meningaud JP, Pitak-Arnnop P, Rigolet A, et al. Endoscopic excision of forehead lipomas. Int J Oral Maxillofac Surg 2006 Oct;35:951e3.
Figure 1 A 59-year-old man with cellulitis of right leg with the start of necrosis on anterolateral free flap site 15 months post surgery.
Correspondence and communications demonstrated to be a grade II leiomyosarcoma. He had no significant past medical history or allergies, was a smoker with a 12 pack year history. The patient had a wider excision of the biopsy site from the right leg and the skin defect was closed with a free autologous anterolateral thigh flap three weeks after the initial surgery. There were no immediate post-operative complications and the patient was discharged from hospital on day six post operation. Three months later 34 cycles of radiotherapy 50 Gy in 25 fractions were given over six weeks from May to June 2008. Regular follow ups in the sarcoma clinic and clinical examinations were unremarkable and surveillance CT and MRI scans showed no evidence of recurrence of the malignancy. In June 2009, 15 months following his wider excision and ALT free flap and 12 months after completing his course of radiotherapy he presented to the department with erythema over the flap site which started after a scratch while gardening a week before (Figure 1). Investigations showed no evidence of a collection, or DVT and with Intravenous antibiotics (IV) the cellulites subsided. Over the following twenty-seven days only the area occupied by the previous free tissue transfer became necrotic (Figure 2). Recurrent wound swabs taken over this period only demonstrated mixed growth of coliforms and Gram-negative bacilli. The wound was negative to MRSA and other organisms. To the best of our knowledge the patient was complaint with treatment, he had no psychiatric/deliberate self harm history and denied tampering with his wounds that would explain the occurrence of this organism.
421 The wound was debrided and a negative pressure wound dressing was applied. Histology of the necrotic area revealed no evidence of recurrent leiomyosarcoma. Two months post debridement and intensive IV antibiotic therapy the wound still appeared indurated and slougy. The patient was closely followed up in the outpaients department managed conservatively with dressings and the wound started to show signs of healing. Repeat wound cultures during this period demonstrated only moderate growth of colioforms. Six months after the initial debridement the defect was skin grafted. This healed with no further complications. This flap had an uneventful immediate post-operative course and survived full cycle of radiotherapy. A normally non pathological skin breach set off a series of events with the flap that lead to its unpredicted very late failure. A literature search yielded very few other reported cases of such late complete flap failure. A possible theory could be that surgery and radiation therapy results in scar tissue formation and disruption of lymphatics preventing the clearance of infectious organisms. There are reports of heparin induced thrombocytopaenia syndrome3 and Pyodrema gangrenosum4,5 as a cause of flap failure, however this patient neither received any heparin and the histology showed no evidence of pyoderma grangrenosum in the biopsies.
Conflict of interest statement We declare no conflict of interest (personal or financial) in the publication of this paper.
References 1. Kroll SS, Schusterman MA, Reece G, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast. Reconstr. Surg 1996;98:1230e3. 2. Bui DT, Cordeiro PG, Hu QY, et al. Free flap reexploration: indication, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092e100. 3. Tremblay DM, Harris PG, Gagnon AR, et al. Heparin-induced thrombocytopenia syndrome as a cause of flap failure: a report of two cases. J Plast Reconstr Aesthet Surg 2008;61:78e83. 4. Rajapakse Y, Bunker CB, Ghattaura A, et al. Case report: pyoderma gangrenosum following deep inferior epigastric perforator free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2010;63:e395e6. 5. Jejurikar SS, Kuzon Jr WM, Cederna PS. Recurrence of pyoderma gangrenosum within a chronic wound following microvascular free-tissue transfer. J Reconstr Microsurg 2000;16:535e9.
W. Bhat J.D. Wiper A.J. Platt Castle Hill Hospital, Hull, HU16 5JQ, U.K E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Figure 2 Same patient with loss of anterolateral free flap 18 months post surgery.
doi:10.1016/j.bjps.2010.06.021
Correspondence and communications Lim Kim Zhuan Hnin Hnin Hlaing Lee Shu Jin Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery National University Hospital Singapore, 5 Lower Kent Ridge Road, Singapore 119074 E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.07.025
Delayed autologous free anterolateral thigh flap failure Flap reconstruction following excision of large tumours is a common plastic surgical procedure. Failure of the flap most often happens within the seven days of surgery and monitoring is not required beyond 3e4 days.1,2 We report a case of a 59-year-old gentleman who had an anterolateral thigh free flap for a grade II leiomyosarcoma and radiotherapy, who had flap failure 16 months, post surgery. A 59-year-old self employed heavy goods vehicle driver was referred to the sarcoma service from the general surgeons after having a lower limb swelling biopsied at the time of an elective hernia repair in February 2008. This was
Conflict of interest None.
Funding None.
References 1. Lin SD, Lee SS, Chang KP, et al. Endoscopic excision of benign tumors in the forehead and brow. Ann Plast Surg 2001 Jan;46:1e4. 2. Gupta S, Pandhi R, Kumar B . ‘Pot-lid’ technique for aesthetic removal of small lipoma on the face. Int J Dermatology 2001;40: 420e4. 3. Chandwarkar RY, Rodriguez P, Roussalis J, et al. Minimal-scar segmental extraction of lipomas: study of 122 consecutive procedures. Dermatol Surg 2005;31:59e64. 4. Funayama E, Minakawa H, Oyama A. Forehead lipoma resection via a small remote incision using a surgical raspatory. J Am Acad Dermatol 2007 Mar;56:458e9. 5. Meningaud JP, Pitak-Arnnop P, Rigolet A, et al. Endoscopic excision of forehead lipomas. Int J Oral Maxillofac Surg 2006 Oct;35:951e3.
Figure 1 A 59-year-old man with cellulitis of right leg with the start of necrosis on anterolateral free flap site 15 months post surgery.
Correspondence and communications demonstrated to be a grade II leiomyosarcoma. He had no significant past medical history or allergies, was a smoker with a 12 pack year history. The patient had a wider excision of the biopsy site from the right leg and the skin defect was closed with a free autologous anterolateral thigh flap three weeks after the initial surgery. There were no immediate post-operative complications and the patient was discharged from hospital on day six post operation. Three months later 34 cycles of radiotherapy 50 Gy in 25 fractions were given over six weeks from May to June 2008. Regular follow ups in the sarcoma clinic and clinical examinations were unremarkable and surveillance CT and MRI scans showed no evidence of recurrence of the malignancy. In June 2009, 15 months following his wider excision and ALT free flap and 12 months after completing his course of radiotherapy he presented to the department with erythema over the flap site which started after a scratch while gardening a week before (Figure 1). Investigations showed no evidence of a collection, or DVT and with Intravenous antibiotics (IV) the cellulites subsided. Over the following twenty-seven days only the area occupied by the previous free tissue transfer became necrotic (Figure 2). Recurrent wound swabs taken over this period only demonstrated mixed growth of coliforms and Gram-negative bacilli. The wound was negative to MRSA and other organisms. To the best of our knowledge the patient was complaint with treatment, he had no psychiatric/deliberate self harm history and denied tampering with his wounds that would explain the occurrence of this organism.
421 The wound was debrided and a negative pressure wound dressing was applied. Histology of the necrotic area revealed no evidence of recurrent leiomyosarcoma. Two months post debridement and intensive IV antibiotic therapy the wound still appeared indurated and slougy. The patient was closely followed up in the outpaients department managed conservatively with dressings and the wound started to show signs of healing. Repeat wound cultures during this period demonstrated only moderate growth of colioforms. Six months after the initial debridement the defect was skin grafted. This healed with no further complications. This flap had an uneventful immediate post-operative course and survived full cycle of radiotherapy. A normally non pathological skin breach set off a series of events with the flap that lead to its unpredicted very late failure. A literature search yielded very few other reported cases of such late complete flap failure. A possible theory could be that surgery and radiation therapy results in scar tissue formation and disruption of lymphatics preventing the clearance of infectious organisms. There are reports of heparin induced thrombocytopaenia syndrome3 and Pyodrema gangrenosum4,5 as a cause of flap failure, however this patient neither received any heparin and the histology showed no evidence of pyoderma grangrenosum in the biopsies.
Conflict of interest statement We declare no conflict of interest (personal or financial) in the publication of this paper.
References 1. Kroll SS, Schusterman MA, Reece G, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast. Reconstr. Surg 1996;98:1230e3. 2. Bui DT, Cordeiro PG, Hu QY, et al. Free flap reexploration: indication, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092e100. 3. Tremblay DM, Harris PG, Gagnon AR, et al. Heparin-induced thrombocytopenia syndrome as a cause of flap failure: a report of two cases. J Plast Reconstr Aesthet Surg 2008;61:78e83. 4. Rajapakse Y, Bunker CB, Ghattaura A, et al. Case report: pyoderma gangrenosum following deep inferior epigastric perforator free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2010;63:e395e6. 5. Jejurikar SS, Kuzon Jr WM, Cederna PS. Recurrence of pyoderma gangrenosum within a chronic wound following microvascular free-tissue transfer. J Reconstr Microsurg 2000;16:535e9.
W. Bhat J.D. Wiper A.J. Platt Castle Hill Hospital, Hull, HU16 5JQ, U.K E-mail address: [email protected] ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Figure 2 Same patient with loss of anterolateral free flap 18 months post surgery.
doi:10.1016/j.bjps.2010.06.021