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Peri-stomal abdominal wall augmentation: Novel use of a pedicled antero-lateral thigh flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e203ee204
CORRESPONDENCE AND COMMUNICATION Peri-stomal abdominal wall augmentation: Novel use of a pedicled antero-lateral thigh flap* Dear Sir,
obstruction and intra-abdominal sepsis had left her with a short small bowel and dense intra-abdominal adhesions precluded re-siting of her stoma. Her anterior abdominal wall contour was distorted such that there was a relative excess of subcutaneous tissue above the stoma, but a deficiency below it (Figure 1). As a consequence, her urostomy appliances would not sit flush against the abdominal wall and she had developed marked excoriation and skin discomfort from constant urine leakage.
Van Abeelen and Ulrich1 have recently described a case of lipofilling to correct a leaking abdominal wall stoma and address the considerable morbidity associated with stoma leakage. The majority of troublesome stomas can be managed non-operatively by adapting stoma appliances. However, under some circumstances procedures such as abdominoplasty, liposuction, or local skin flaps may be required.2 The injection of bovine or porcine collagen fillers has also been described with variable success.1 We present what we believe to be the first use of a pedicled ALT flap for re-contouring the abdominal wall after scar revision and lipofilling had failed to correct the problem. Since its first description by Song and colleagues in 1984,3 the free antero-lateral thigh (ALT) flap has been utilised in a wide range of applications. More recently, the pedicled ALT flap has demonstrated itself to be a versatile flap for soft tissue reconstruction whilst minimising the challenges associated with free tissue transfer. On its proximal pedicle the ALT flap has been shown to have an arc of coverage extending from the lower costal margin, to the lower back, trochanteric region, anterior anal margin, and contralateral iliac fossa.4 In the majority of cases, the pedicled ALT flap is used to reconstruct defects with a substantial cutaneous, fascial or muscle element. Few reports describe its use solely to fill dead-space or provide tissue bulk5 as in our case. A 64 year-old female patient presented to our service complaining of severe difficulties from a right lower quadrant urostomy following a cystectomy and ileal conduit 30 years previously. Despite the best efforts of numerous experienced stoma therapists, it proved impossible to secure her stoma appliance with a watertight seal, causing it to leak continually. Multiple laparotomies for bowel * This work has previously been presented at the 25e27th June 2015 Summer Scientific Meeting of BAPRAS/RBSPS, Bruges.
Figure 1 Cross-hatching indicates area of soft-tissue deficiency inferior to urostomy resulting in poor stoma seal.
http://dx.doi.org/10.1016/j.bjps.2015.08.030 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e204
Correspondence and communication
Figure 2
De-epithelialised pedicled ALT flap folded into ‘croissant’ (a) and inserted into subcutaneous pocket (b).
Revision of her midline abdominal scars initially relieved her symptoms. However, once post-operative swelling had settled, her leakage problem returned to its pre-operative frequency within 2 weeks. Six months later, a lipofilling procedure was performed. Around 40 mls of fat was removed from above and medial to the stoma, and injected into the deficient infero-lateral areas but relieved symptoms for only 6 weeks. As the temporary increase in subcutaneous tissue volume produced by lipofilling appeared to ameliorate her problem, flap options which might offer sufficient bulk in this area were sought. Although generally thin with little subcutaneous fat, the patient’s thighs were relatively well covered, so an ipsilateral pedicled deepithelialised fasciocutaneous ALT flap was planned. The flap was marked in the standard way, with preoperative identification of perforators using a hand-held Doppler probe. A 27 8 cm skin island was incised and the flap raised sub-fascially based upon a single proximal septocutaneous perforator. No muscle was included with the flap. The pedicle was dissected up to rectus femoris and the flap then passed beneath this and the sartorius muscle to increase its arc of movement onto the abdominal wall. A subcutaneous pocket was then dissected inferior and lateral to the stoma, via an incision sited out with the area covered by stoma appliances over the inguinal ligament. The flap was then passed into this incision before being de-epithelialised and folded along its long axis, suturing fascia to fascia, such that a teardrop cross-section was achieved in order to produce an abdominal wall that gradually sloped away from the urostomy. The two ends of the flap (corresponding to the initial proximal and distal tips) were curved cephalad around the medial and lateral edges of the urostomy to create a ‘croissant’-shaped flap (Figure 2). These ends were fixed with prolene suspension sutures over bolsters on the skin surface and left in place for 2 weeks. The flap immediately corrected the urine leak, and continues to do so at 8 months.
We appreciate that cases like ours, where insufficient bowel or dense intra-abdominal adhesions make stoma revision or re-siting potentially hazardous, are unusual. We would however advocate the pedicled ALT in patients presenting with troublesome stomas if lipofilling fails.
Conflict of interest statement There are no conflicts of interest to declare.
References 1. van Abeelen MHA, Ulrich DJO. Lipofilling of skin contour defects in a leaking stoma: a new method to solve a difficult problem. J Plast Reconstr Aesthet Surg 2015;68(1):139e40. 2. Beck DE. Abdominal wall modification for the difficult ostomy. Clin Colon Rectal Surg 2008;21:71e5. 3. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Brit J Plast Surg 1984;37(2):149e59. 4. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of proximally-pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg 2011;127:677e88. 5. Ng RWM, Chan JYW, Mok V, Li GKH. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2008;61:158e64.
J. Warbrick-Smith N. Bowen P.J. Drew Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, Wales, SA6 6NL, United Kingdom E-mail address: [email protected] 4 August 2015
CORRESPONDENCE AND COMMUNICATION Peri-stomal abdominal wall augmentation: Novel use of a pedicled antero-lateral thigh flap* Dear Sir,
obstruction and intra-abdominal sepsis had left her with a short small bowel and dense intra-abdominal adhesions precluded re-siting of her stoma. Her anterior abdominal wall contour was distorted such that there was a relative excess of subcutaneous tissue above the stoma, but a deficiency below it (Figure 1). As a consequence, her urostomy appliances would not sit flush against the abdominal wall and she had developed marked excoriation and skin discomfort from constant urine leakage.
Van Abeelen and Ulrich1 have recently described a case of lipofilling to correct a leaking abdominal wall stoma and address the considerable morbidity associated with stoma leakage. The majority of troublesome stomas can be managed non-operatively by adapting stoma appliances. However, under some circumstances procedures such as abdominoplasty, liposuction, or local skin flaps may be required.2 The injection of bovine or porcine collagen fillers has also been described with variable success.1 We present what we believe to be the first use of a pedicled ALT flap for re-contouring the abdominal wall after scar revision and lipofilling had failed to correct the problem. Since its first description by Song and colleagues in 1984,3 the free antero-lateral thigh (ALT) flap has been utilised in a wide range of applications. More recently, the pedicled ALT flap has demonstrated itself to be a versatile flap for soft tissue reconstruction whilst minimising the challenges associated with free tissue transfer. On its proximal pedicle the ALT flap has been shown to have an arc of coverage extending from the lower costal margin, to the lower back, trochanteric region, anterior anal margin, and contralateral iliac fossa.4 In the majority of cases, the pedicled ALT flap is used to reconstruct defects with a substantial cutaneous, fascial or muscle element. Few reports describe its use solely to fill dead-space or provide tissue bulk5 as in our case. A 64 year-old female patient presented to our service complaining of severe difficulties from a right lower quadrant urostomy following a cystectomy and ileal conduit 30 years previously. Despite the best efforts of numerous experienced stoma therapists, it proved impossible to secure her stoma appliance with a watertight seal, causing it to leak continually. Multiple laparotomies for bowel * This work has previously been presented at the 25e27th June 2015 Summer Scientific Meeting of BAPRAS/RBSPS, Bruges.
Figure 1 Cross-hatching indicates area of soft-tissue deficiency inferior to urostomy resulting in poor stoma seal.
http://dx.doi.org/10.1016/j.bjps.2015.08.030 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e204
Correspondence and communication
Figure 2
De-epithelialised pedicled ALT flap folded into ‘croissant’ (a) and inserted into subcutaneous pocket (b).
Revision of her midline abdominal scars initially relieved her symptoms. However, once post-operative swelling had settled, her leakage problem returned to its pre-operative frequency within 2 weeks. Six months later, a lipofilling procedure was performed. Around 40 mls of fat was removed from above and medial to the stoma, and injected into the deficient infero-lateral areas but relieved symptoms for only 6 weeks. As the temporary increase in subcutaneous tissue volume produced by lipofilling appeared to ameliorate her problem, flap options which might offer sufficient bulk in this area were sought. Although generally thin with little subcutaneous fat, the patient’s thighs were relatively well covered, so an ipsilateral pedicled deepithelialised fasciocutaneous ALT flap was planned. The flap was marked in the standard way, with preoperative identification of perforators using a hand-held Doppler probe. A 27 8 cm skin island was incised and the flap raised sub-fascially based upon a single proximal septocutaneous perforator. No muscle was included with the flap. The pedicle was dissected up to rectus femoris and the flap then passed beneath this and the sartorius muscle to increase its arc of movement onto the abdominal wall. A subcutaneous pocket was then dissected inferior and lateral to the stoma, via an incision sited out with the area covered by stoma appliances over the inguinal ligament. The flap was then passed into this incision before being de-epithelialised and folded along its long axis, suturing fascia to fascia, such that a teardrop cross-section was achieved in order to produce an abdominal wall that gradually sloped away from the urostomy. The two ends of the flap (corresponding to the initial proximal and distal tips) were curved cephalad around the medial and lateral edges of the urostomy to create a ‘croissant’-shaped flap (Figure 2). These ends were fixed with prolene suspension sutures over bolsters on the skin surface and left in place for 2 weeks. The flap immediately corrected the urine leak, and continues to do so at 8 months.
We appreciate that cases like ours, where insufficient bowel or dense intra-abdominal adhesions make stoma revision or re-siting potentially hazardous, are unusual. We would however advocate the pedicled ALT in patients presenting with troublesome stomas if lipofilling fails.
Conflict of interest statement There are no conflicts of interest to declare.
References 1. van Abeelen MHA, Ulrich DJO. Lipofilling of skin contour defects in a leaking stoma: a new method to solve a difficult problem. J Plast Reconstr Aesthet Surg 2015;68(1):139e40. 2. Beck DE. Abdominal wall modification for the difficult ostomy. Clin Colon Rectal Surg 2008;21:71e5. 3. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Brit J Plast Surg 1984;37(2):149e59. 4. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of proximally-pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg 2011;127:677e88. 5. Ng RWM, Chan JYW, Mok V, Li GKH. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2008;61:158e64.
J. Warbrick-Smith N. Bowen P.J. Drew Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Swansea, Wales, SA6 6NL, United Kingdom E-mail address: [email protected] 4 August 2015