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Fillet flap for reconstruction after hemipelvectomy: report of three cases
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e110ee111
CORRESPONDENCE AND COMMUNICATION
Fillet flap for reconstruction after hemipelvectomy: report of three cases Thirty years after it was first described,1 the use of the fillet leg flap for hemipelvectomy reconstruction is still uncommon. The authors report a series of three cases in one institution.
Case 1 A 43-year-old male with myxoid liposarcoma in the left gluteal region was submitted to hemipelvectomy and reconstruction with a fillet flap (Figure 1). The procedure lasted 7 h and 25 min, and the patient was discharged on
Figure 1
the 11th postoperative day. Two months after surgery, the patient developed acute myocardial infarction. Figure 2 shows the patient 6 months postoperatively. Twenty-six months after surgery, there was intra-abdominal and paravertebral recurrence. Despite chemotherapy, the patient died 28 months after hemipelvectomy.
Case 2 A 32-year-old female was diagnosed with malignant fibrohistiocytoma in the right gluteal region and a solitary nodule in the right lung. Before the recommended concomitant neoadjuvant radiotherapy and chemotherapy began, she presented with sepsis from intratumoral infection. Due to the patient’s declining condition, after all other measures were exhausted, surgical intervention to resect the tumour and control the infection was necessary.
(A) Ulcerated gluteal sarcoma. (B) Amputated limb. (C) Flap dissection. (D) Fillet flap.
1748-6815/$ - see front matter ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2008.06.075
Correspondence and communication
e111 relatively quick (40 to 60 min). The arterial and venous anastomoses together took no more than 40 min. The vessels are large and therefore no microscope is necessary. The aponeuroses of the gastrocnemius and soleus muscles, sutured to the abdominal wall, considered stable enough to prevent the formation of hernias and bulges and resistant enough to allow adaptation of external prosthetics, are used to enclose the organs of the abdominal cavity making marlex mesh unnecessary. Due to the small number of cases, statistical information cannot be provided, however the following outcomes were observed:
Figure 2
Six month postoperative view.
The patient underwent a right hemipelvectomy and fillet flap reconstruction, which lasted 8 h. Respiratory and renal complications led to the patient’s death on the 34th postoperative day.
Case 3 A 42-year-old male with a left pelvic tumour diagnosed as high-grade pleomorphic sarcoma had no response to chemotherapy after six cycles. Hindquarter amputation and fillet flap reconstruction lasted approximately 10 h. Recovery was uneventful and the patient was discharged on the 8th postoperative day. He underwent surgery to remove a pulmonary nodule 5 months later. The patient currently (16 months after hemipelvectomy) presents with pulmonary and osseous metastases which are being treated with chemotherapy. The fillet flap was prepared after dissection of the iliac vessels, without ligation, and before posterior sacroiliac osteotomy. After completing the amputation, the flap was removed and sutured to the pelvic defect. Anastomoses between iliac and popliteal vessels were then performed. Blood drainage of the long saphenous vein was evaluated and considered significantly low in comparison with the popliteal vein. Therefore a second venous anastomosis was not performed. All flaps remained fully viable from a vascular standpoint. Patients one and three achieved ambulation with the use of crutches. High doses of pain medication were discontinued and weight loss ceased. In hindquarter amputations, the use of distal tissue of the amputated limb is possible when not affected by the disease. The fillet leg flap is capable of repairing large defects. Some authors2,3 have expressed concern about ischaemia time during fillet flap transfer. We found dissection of the fillet flap to be technically easy and
Case 1: increased peripheral resistance due to significant reduction in body weight and consequent cardiac overload likely contributed to the patient’s myocardial infarction. Case 2: surgery was performed with urgency due to rapid and progressive decline in the patient’s clinical condition due to general infection. The ulcerated tumour itself was the primary site of infection. Case 3: patient has been in follow up almost 2 years and is undergoing chemotherapy for metastases. A small dehiscence of the surgical wound observed in cases 1 and 2 was attributed to local factors: radiotherapy and infection, respectively. Clinical reasoning in reconstructive surgery contemplates donor site morbidity and the likely aesthetic and functional recovery of the defect. A free fillet flap from the amputated leg is a good option for reconstructing hemipelvectomy defects because morbidity of other donor sites is eliminated. Our findings reinforce other studies3,4 in that we observed high rates of recurrence of distant disease and relatively short survival periods after hemipelvectomy. We further observed that, although the procedure did not change the prognosis, it significantly improved the patients’ quality of life. In two patients, mobility increased despite amputation, local pain diminished, dressing changes were no longer necessary and general clinical conditions improved.
References 1. Frey C, Matthews LS, Benjamin H, et al. A new technique for hemipelvectomy. Surg Gynecol Obstet 1976;143:753. 2. Yamamoto Y, Minakawa H, Takeda N. Pelvic reconstruction with a free fillet lower leg flap. Plast Reconstr Surg 1997;99: 1439e41. 3. Tran NV, Evans GR, Kroll SS, et al. Free filet extremity flap: indications and options for reconstruction. Plast Reconstr Surg 2000;105:99e104. 4. Yamamoto Y, Sugihara T. Pelvic reconstruction with a free fillet lower leg flap. Plast Reconstr Surg 2003;111:1475e6.
Jose Carlos Faria Samuel Aguiar Jr. Fabio de Oliveira Ferreira Ademar Lopes Hospital do Cancer A C Camargo, Sao Paulo, SP Brazil E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
Fillet flap for reconstruction after hemipelvectomy: report of three cases Thirty years after it was first described,1 the use of the fillet leg flap for hemipelvectomy reconstruction is still uncommon. The authors report a series of three cases in one institution.
Case 1 A 43-year-old male with myxoid liposarcoma in the left gluteal region was submitted to hemipelvectomy and reconstruction with a fillet flap (Figure 1). The procedure lasted 7 h and 25 min, and the patient was discharged on
Figure 1
the 11th postoperative day. Two months after surgery, the patient developed acute myocardial infarction. Figure 2 shows the patient 6 months postoperatively. Twenty-six months after surgery, there was intra-abdominal and paravertebral recurrence. Despite chemotherapy, the patient died 28 months after hemipelvectomy.
Case 2 A 32-year-old female was diagnosed with malignant fibrohistiocytoma in the right gluteal region and a solitary nodule in the right lung. Before the recommended concomitant neoadjuvant radiotherapy and chemotherapy began, she presented with sepsis from intratumoral infection. Due to the patient’s declining condition, after all other measures were exhausted, surgical intervention to resect the tumour and control the infection was necessary.
(A) Ulcerated gluteal sarcoma. (B) Amputated limb. (C) Flap dissection. (D) Fillet flap.
1748-6815/$ - see front matter ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2008.06.075
Correspondence and communication
e111 relatively quick (40 to 60 min). The arterial and venous anastomoses together took no more than 40 min. The vessels are large and therefore no microscope is necessary. The aponeuroses of the gastrocnemius and soleus muscles, sutured to the abdominal wall, considered stable enough to prevent the formation of hernias and bulges and resistant enough to allow adaptation of external prosthetics, are used to enclose the organs of the abdominal cavity making marlex mesh unnecessary. Due to the small number of cases, statistical information cannot be provided, however the following outcomes were observed:
Figure 2
Six month postoperative view.
The patient underwent a right hemipelvectomy and fillet flap reconstruction, which lasted 8 h. Respiratory and renal complications led to the patient’s death on the 34th postoperative day.
Case 3 A 42-year-old male with a left pelvic tumour diagnosed as high-grade pleomorphic sarcoma had no response to chemotherapy after six cycles. Hindquarter amputation and fillet flap reconstruction lasted approximately 10 h. Recovery was uneventful and the patient was discharged on the 8th postoperative day. He underwent surgery to remove a pulmonary nodule 5 months later. The patient currently (16 months after hemipelvectomy) presents with pulmonary and osseous metastases which are being treated with chemotherapy. The fillet flap was prepared after dissection of the iliac vessels, without ligation, and before posterior sacroiliac osteotomy. After completing the amputation, the flap was removed and sutured to the pelvic defect. Anastomoses between iliac and popliteal vessels were then performed. Blood drainage of the long saphenous vein was evaluated and considered significantly low in comparison with the popliteal vein. Therefore a second venous anastomosis was not performed. All flaps remained fully viable from a vascular standpoint. Patients one and three achieved ambulation with the use of crutches. High doses of pain medication were discontinued and weight loss ceased. In hindquarter amputations, the use of distal tissue of the amputated limb is possible when not affected by the disease. The fillet leg flap is capable of repairing large defects. Some authors2,3 have expressed concern about ischaemia time during fillet flap transfer. We found dissection of the fillet flap to be technically easy and
Case 1: increased peripheral resistance due to significant reduction in body weight and consequent cardiac overload likely contributed to the patient’s myocardial infarction. Case 2: surgery was performed with urgency due to rapid and progressive decline in the patient’s clinical condition due to general infection. The ulcerated tumour itself was the primary site of infection. Case 3: patient has been in follow up almost 2 years and is undergoing chemotherapy for metastases. A small dehiscence of the surgical wound observed in cases 1 and 2 was attributed to local factors: radiotherapy and infection, respectively. Clinical reasoning in reconstructive surgery contemplates donor site morbidity and the likely aesthetic and functional recovery of the defect. A free fillet flap from the amputated leg is a good option for reconstructing hemipelvectomy defects because morbidity of other donor sites is eliminated. Our findings reinforce other studies3,4 in that we observed high rates of recurrence of distant disease and relatively short survival periods after hemipelvectomy. We further observed that, although the procedure did not change the prognosis, it significantly improved the patients’ quality of life. In two patients, mobility increased despite amputation, local pain diminished, dressing changes were no longer necessary and general clinical conditions improved.
References 1. Frey C, Matthews LS, Benjamin H, et al. A new technique for hemipelvectomy. Surg Gynecol Obstet 1976;143:753. 2. Yamamoto Y, Minakawa H, Takeda N. Pelvic reconstruction with a free fillet lower leg flap. Plast Reconstr Surg 1997;99: 1439e41. 3. Tran NV, Evans GR, Kroll SS, et al. Free filet extremity flap: indications and options for reconstruction. Plast Reconstr Surg 2000;105:99e104. 4. Yamamoto Y, Sugihara T. Pelvic reconstruction with a free fillet lower leg flap. Plast Reconstr Surg 2003;111:1475e6.
Jose Carlos Faria Samuel Aguiar Jr. Fabio de Oliveira Ferreira Ademar Lopes Hospital do Cancer A C Camargo, Sao Paulo, SP Brazil E-mail address: [email protected]