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Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1158e1161
CASE REPORT
Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap M.P. Serra*, P. Longhi, M. Carminati, B. Righi, E. Robotti Department of Plastic and Reconstructive Surgery, ‘‘Ospedali Riuniti di Bergamo’’, Largo Barozzi n. 1, 24122 Bergamo (BG), Italy Received 2 March 2006; accepted 6 June 2006
KEYWORDS Scalp and skull reconstruction; Scalp and skull defects; Infection of the scalp; Irradiation of the scalp
Summary A combined microvascular flap composed of serratus anterior myoosseous and a latissimus dorsi myocutaneous flap has been performed for resurfacing massive scalp and skull defects, accompanied by chronic infection and heavy radiation damage. The authors present a case report where the combined procedure allowed a single-stage reconstruction of this complex defect. ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Defects of the scalp may result from trauma, tumour ablation, infections, congenital lesions and radiation treatment. Although local flaps1 have been described for the reconstruction of these defects, free flaps are the preferred choice when a significant area of soft tissue coverage is required, especially if infection and radiation damage are the major concerns. Myocutaneous or muscle flaps2e5 are usually selected for their capacity to resist infection and provide blood supply to the surrounding tissues * Corresponding author. Tel.: þ39 349 0909111. E-mail address: [email protected] (M.P. Serra).
that may be irradiated preoperatively or require postoperative radiotherapy. Among these, the latissimus dorsi2,6e8 is the best choice for the coverage of wide defects, because of its reliable anatomy, large surface area and a long vascular pedicle. This flap can be raised in combination with the serratus anterior muscle or myo-osseous flap, on a single thoracodorsal vascular pedicle, to provide an additional soft tissue bulk and a more reliable vascularity of the anterior ribs,9,10 compared with the uncertain blood supply to the ribs, when they are elevated on fascial connections of the latissimus dorsi.11
1748-6815/$ - see front matter ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.06.020
Microsurgical scalp and skull reconstruction using a combined flap
1159
Moreover this combination allows a variety of possible spatial orientations of the bone, which otherwise would be constrained as in other composite flap designs. The authors present a case report where a large scalp and skull defect, accompanied by chronic infection and radiation damage, were reconstructed by a microsurgical combined flap, composed of serratus anterior myo-osseous and latissimus dorsi myocutaneous flap.
Case report The patient was a 52-year-old female who underwent an ablation of meningioma in 1986, followed by radiotherapy. In 2001 she required a further operation for a recurrence, after which she developed a severe infection followed by osteoradionecrosis of the parietal and occipital bones and a progressive necrosis of the scalp, the blood supply of which had been compromised by the radiotherapy. She was treated with antibiotic therapy and hyperbaric oxygen therapy, for two years. Two years later she attended our clinic for a consultation. On examination she presented with a wide defect of the skull and scalp and massive infection (Fig. 1). Tc-99 scintigraphy confirmed the diagnosis of osteoradionecrosis of the parietal and occipital bones. We therefore decided to perform a wide debridement to remove the occipito-parietal bone and the necrotic scalp tissue, overlying the bone. The open wound with the resulting defect at operation measured 25 20 cm (Figs. 2 and 3). The radical debridement was followed by immediate
Figure 1
A preop. showing the defect.
Figure 2
The resulting scalp defect at operation.
reconstruction with a microsurgical combined flap composed of serratus anterior myo-osseous and latissimus dorsi myocutaneous flaps (Fig. 4). The segments of ribs of the serratus anterior flap were fixed to the skull by means of plates and screws. The lower third of the serratus anterior muscle was raised, from the sixth to the ninth muscle slips, to avoid scapular winging and three ribs were included with the muscle. The thoracodorsal vessels were anastomosed to the left superficial temporal vessels and the muscle was covered with meshed skin grafts (Fig. 5). A skin paddle was included on the latissimus dorsi for monitoring of the viability of the flap and to cover the thinnest part of the muscle, in order to minimize the risk of bone exposure, following atrophy of the muscle.
Figure 3
The resulting skull defect at operation.
1160
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Figure 4
The combined flap.
The combined free flap had the ability to increase the blood supply of the ischaemic area, achieving a complete wound healing in only two weeks (Fig. 6). Operating time for the procedure was eight hours and the postoperative hospital stay was 10 days. At one year evaluation the flap had a good colour and the residual scars of the recipient and donor sites were acceptable, except for the skin paddle (Figs. 7 and 8). The X-ray showed the vascularized costal bone flap incorporated with the skull (Fig. 9).
Discussion The microvascular transfer of the latissimus dorsi muscle combined with the serratus anterior myoosseous flap has been described for composite
Figure 5 grafts.
Figure 6
The postop. after two weeks.
tissue reconstruction of complex defects of the skull and scalp.12 The advantages of the latissimus dorsi muscle flap are several: the thickness is similar to normal scalp; the large available surface and pliability; good pedicle length and vessel size; excellent blood supply; acceptable donor-site morbidity; radioresistance; satisfactory cosmesis; and flap contouring at the time of surgery. This flap can be raised on a single vascular pedicle in combination with the serratus anterior myo-osseous flap, The combined flap increases the surface area, provides additional bulk and a more reliable vascularity to the anterior ribs9,10 compared with the uncertain blood supply to the ribs, when they are elevated on fascial connections of the latissimus dorsi.11 The serratus anterior muscle itself is not very bulky and the rib bone is also slender and easily contoured.10,13 In fact the thin, less bulky rib bone is ideal for the bony requirements of the calvarium.10,13
The combined flap covered with meshed skin Figure 7
Results at one year postop.
Microsurgical scalp and skull reconstruction using a combined flap
1161
Although the skull reconstruction with only myocutaneous flap has been previously described, we preferred to add free vascularized bone, in order to give a further stability to the reconstructed area. The advantages of providing muscle and bone on a single long pedicle, bony contourability, and a variety of possible spatial orientations, make this procedure ideal for the reconstruction of scalp and skull defect.
References Figure 8
Result at one year postop.
The reliable vascularity of the anterior rib suspended on the digitations of the serratus anterior muscle is well documented.14 The authors made the selection of the latissimus dorsi combined with the serratus myo-osseous flap as the ideal choice in this case report, in which both bone and soft tissue were required. Vascularized transfer rather than free costochondral graft was selected because of the infection and radiation damage to the recipient area. In accordance with some investigators12 rib graft or alloplastic implants should be secondarily inserted into a clean bed after stable flap coverage was performed.
Figure 9 postop.
The vascularized costal bone flap at one year
1. Strauch, Vasconez, Hall-Findlay. Encyclopedia of flaps. In: Head and neck, vol. 1. 2. Robson MC, Zachary LS. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989;83(3):438e42. 3. Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flap. Plast Reconstr Surg 1982;70:1. 4. Mathes SJ, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinic correlation. Plast Reconstr Surg 1982;69:815. 5. Murphy RC, Robson MC. The effect of microbial contamination on musculocutaneous and random flaps. J Surg Res 1986;75:411. 6. Pennington DG, Stern HS, Lee KK. Free-flap reconstruction of large defects of the scalp and calvarium. Plast Reconstr Surg 1989;83:655e61. 7. Furnas H, Lineaweaver WC, Alpert BS, et al. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431e43. 8. Lutz BS, Wei FC, Chen HC. Reconstruction of the scalp defects with free flaps in 30 cases. Br J Plast Surg 1998; 51:186e90. 9. Tobin GR, Moberg A, Ringberg A, et al. Mandibular reconstruction with segmentally split serratus composite flaps. Clin Plast Surg 1990;17:663e6. 10. Netscher D, Alford EL, Wigoda P, et al. Free composite myoosseous flap with serratus anterior and rib. Indications in head and neck reconstruction. Clin Plast Surg 1998:106e12. 11. Schmidt DR, Robson MC. One stage composite reconstruction using latissimus myoosteocutaneous flap. Am J Surg 1982;144:470e2. 12. Ueda K, Harashina T, Inoue T, et al. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993;31(1). 13. Chang DW, Miller MJ. A subperiosteal approach to harvesting the free serratus anterior and myo-osseous composite flap. Plast Reconstr Surg 2001;108(5):1303e4. 14. Bhathena HM, Kavarana NM. Primary reconstruction head and neck cancer with anterior rib, osteomyocutaneous composite flap. Head Neck Surg 1992;14:18.
CASE REPORT
Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap M.P. Serra*, P. Longhi, M. Carminati, B. Righi, E. Robotti Department of Plastic and Reconstructive Surgery, ‘‘Ospedali Riuniti di Bergamo’’, Largo Barozzi n. 1, 24122 Bergamo (BG), Italy Received 2 March 2006; accepted 6 June 2006
KEYWORDS Scalp and skull reconstruction; Scalp and skull defects; Infection of the scalp; Irradiation of the scalp
Summary A combined microvascular flap composed of serratus anterior myoosseous and a latissimus dorsi myocutaneous flap has been performed for resurfacing massive scalp and skull defects, accompanied by chronic infection and heavy radiation damage. The authors present a case report where the combined procedure allowed a single-stage reconstruction of this complex defect. ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Defects of the scalp may result from trauma, tumour ablation, infections, congenital lesions and radiation treatment. Although local flaps1 have been described for the reconstruction of these defects, free flaps are the preferred choice when a significant area of soft tissue coverage is required, especially if infection and radiation damage are the major concerns. Myocutaneous or muscle flaps2e5 are usually selected for their capacity to resist infection and provide blood supply to the surrounding tissues * Corresponding author. Tel.: þ39 349 0909111. E-mail address: [email protected] (M.P. Serra).
that may be irradiated preoperatively or require postoperative radiotherapy. Among these, the latissimus dorsi2,6e8 is the best choice for the coverage of wide defects, because of its reliable anatomy, large surface area and a long vascular pedicle. This flap can be raised in combination with the serratus anterior muscle or myo-osseous flap, on a single thoracodorsal vascular pedicle, to provide an additional soft tissue bulk and a more reliable vascularity of the anterior ribs,9,10 compared with the uncertain blood supply to the ribs, when they are elevated on fascial connections of the latissimus dorsi.11
1748-6815/$ - see front matter ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.06.020
Microsurgical scalp and skull reconstruction using a combined flap
1159
Moreover this combination allows a variety of possible spatial orientations of the bone, which otherwise would be constrained as in other composite flap designs. The authors present a case report where a large scalp and skull defect, accompanied by chronic infection and radiation damage, were reconstructed by a microsurgical combined flap, composed of serratus anterior myo-osseous and latissimus dorsi myocutaneous flap.
Case report The patient was a 52-year-old female who underwent an ablation of meningioma in 1986, followed by radiotherapy. In 2001 she required a further operation for a recurrence, after which she developed a severe infection followed by osteoradionecrosis of the parietal and occipital bones and a progressive necrosis of the scalp, the blood supply of which had been compromised by the radiotherapy. She was treated with antibiotic therapy and hyperbaric oxygen therapy, for two years. Two years later she attended our clinic for a consultation. On examination she presented with a wide defect of the skull and scalp and massive infection (Fig. 1). Tc-99 scintigraphy confirmed the diagnosis of osteoradionecrosis of the parietal and occipital bones. We therefore decided to perform a wide debridement to remove the occipito-parietal bone and the necrotic scalp tissue, overlying the bone. The open wound with the resulting defect at operation measured 25 20 cm (Figs. 2 and 3). The radical debridement was followed by immediate
Figure 1
A preop. showing the defect.
Figure 2
The resulting scalp defect at operation.
reconstruction with a microsurgical combined flap composed of serratus anterior myo-osseous and latissimus dorsi myocutaneous flaps (Fig. 4). The segments of ribs of the serratus anterior flap were fixed to the skull by means of plates and screws. The lower third of the serratus anterior muscle was raised, from the sixth to the ninth muscle slips, to avoid scapular winging and three ribs were included with the muscle. The thoracodorsal vessels were anastomosed to the left superficial temporal vessels and the muscle was covered with meshed skin grafts (Fig. 5). A skin paddle was included on the latissimus dorsi for monitoring of the viability of the flap and to cover the thinnest part of the muscle, in order to minimize the risk of bone exposure, following atrophy of the muscle.
Figure 3
The resulting skull defect at operation.
1160
M.P. Serra et al.
Figure 4
The combined flap.
The combined free flap had the ability to increase the blood supply of the ischaemic area, achieving a complete wound healing in only two weeks (Fig. 6). Operating time for the procedure was eight hours and the postoperative hospital stay was 10 days. At one year evaluation the flap had a good colour and the residual scars of the recipient and donor sites were acceptable, except for the skin paddle (Figs. 7 and 8). The X-ray showed the vascularized costal bone flap incorporated with the skull (Fig. 9).
Discussion The microvascular transfer of the latissimus dorsi muscle combined with the serratus anterior myoosseous flap has been described for composite
Figure 5 grafts.
Figure 6
The postop. after two weeks.
tissue reconstruction of complex defects of the skull and scalp.12 The advantages of the latissimus dorsi muscle flap are several: the thickness is similar to normal scalp; the large available surface and pliability; good pedicle length and vessel size; excellent blood supply; acceptable donor-site morbidity; radioresistance; satisfactory cosmesis; and flap contouring at the time of surgery. This flap can be raised on a single vascular pedicle in combination with the serratus anterior myo-osseous flap, The combined flap increases the surface area, provides additional bulk and a more reliable vascularity to the anterior ribs9,10 compared with the uncertain blood supply to the ribs, when they are elevated on fascial connections of the latissimus dorsi.11 The serratus anterior muscle itself is not very bulky and the rib bone is also slender and easily contoured.10,13 In fact the thin, less bulky rib bone is ideal for the bony requirements of the calvarium.10,13
The combined flap covered with meshed skin Figure 7
Results at one year postop.
Microsurgical scalp and skull reconstruction using a combined flap
1161
Although the skull reconstruction with only myocutaneous flap has been previously described, we preferred to add free vascularized bone, in order to give a further stability to the reconstructed area. The advantages of providing muscle and bone on a single long pedicle, bony contourability, and a variety of possible spatial orientations, make this procedure ideal for the reconstruction of scalp and skull defect.
References Figure 8
Result at one year postop.
The reliable vascularity of the anterior rib suspended on the digitations of the serratus anterior muscle is well documented.14 The authors made the selection of the latissimus dorsi combined with the serratus myo-osseous flap as the ideal choice in this case report, in which both bone and soft tissue were required. Vascularized transfer rather than free costochondral graft was selected because of the infection and radiation damage to the recipient area. In accordance with some investigators12 rib graft or alloplastic implants should be secondarily inserted into a clean bed after stable flap coverage was performed.
Figure 9 postop.
The vascularized costal bone flap at one year
1. Strauch, Vasconez, Hall-Findlay. Encyclopedia of flaps. In: Head and neck, vol. 1. 2. Robson MC, Zachary LS. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989;83(3):438e42. 3. Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flap. Plast Reconstr Surg 1982;70:1. 4. Mathes SJ, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinic correlation. Plast Reconstr Surg 1982;69:815. 5. Murphy RC, Robson MC. The effect of microbial contamination on musculocutaneous and random flaps. J Surg Res 1986;75:411. 6. Pennington DG, Stern HS, Lee KK. Free-flap reconstruction of large defects of the scalp and calvarium. Plast Reconstr Surg 1989;83:655e61. 7. Furnas H, Lineaweaver WC, Alpert BS, et al. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431e43. 8. Lutz BS, Wei FC, Chen HC. Reconstruction of the scalp defects with free flaps in 30 cases. Br J Plast Surg 1998; 51:186e90. 9. Tobin GR, Moberg A, Ringberg A, et al. Mandibular reconstruction with segmentally split serratus composite flaps. Clin Plast Surg 1990;17:663e6. 10. Netscher D, Alford EL, Wigoda P, et al. Free composite myoosseous flap with serratus anterior and rib. Indications in head and neck reconstruction. Clin Plast Surg 1998:106e12. 11. Schmidt DR, Robson MC. One stage composite reconstruction using latissimus myoosteocutaneous flap. Am J Surg 1982;144:470e2. 12. Ueda K, Harashina T, Inoue T, et al. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993;31(1). 13. Chang DW, Miller MJ. A subperiosteal approach to harvesting the free serratus anterior and myo-osseous composite flap. Plast Reconstr Surg 2001;108(5):1303e4. 14. Bhathena HM, Kavarana NM. Primary reconstruction head and neck cancer with anterior rib, osteomyocutaneous composite flap. Head Neck Surg 1992;14:18.