- Email: [email protected]
Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation
Accepted Manuscript Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation. M. Hubmer , A. Leithner , L.P. Kamolz , M.D., Ph.D., M.Sc. PII:
S1748-6815(14)00226-5
DOI:
10.1016/j.bjps.2014.05.010
Reference:
PRAS 4193
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 25 April 2014 Revised Date:
5 May 2014
Accepted Date: 7 May 2014
Please cite this article as: Hubmer M, Leithner A, Kamolz L, Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation.
RI PT
Hubmer M1, Leithner A1, Kamolz LP1
1 Division of Plastic, Aesthetic and Reconstructive Surgery,
SC
Department of Surgery, Medical University Graz
Medical University of Graz
TE D
Corresponding author:
M AN U
2 Department of Orthopaedic Surgery,
Lars-Peter Kamolz M.D., Ph.D., M.Sc.
EP
Division of Plastic, Aesthetic and Reconstructive Surgery Department of Surgery
AC C
Medical University of Graz Auenbruggerplatz 29 A-8036 Graz
[email protected]
1
ACCEPTED MANUSCRIPT Dear Sir, With great interest we have read the recent article by Koulaxouzidis et al. (1) and the recent letter of Wilks et al. (2); both authors describe their techniques to correct the contour deformity that follows forequarter amputation. We absolutely agree that free flaps
RI PT
including the elbow are suitable or even are the optimal techniques to solve this aesthetic and functional problem. Osanai et al. (3), who originally described the use of an osteomyocutaneous free fillet flap using the olecranon and a flexed elbow to restore
SC
shoulder contour following forequarter amputation, uses anteromedial and anterolateral fasciocutaneous forearm flaps along with the distal forearm skin that results from
M AN U
amputation of the hand in order to perform this reconstruction. Furthermore, they were connecting the humerus to the clavicle and the radius and ulna to the ribs in order to produce a stable triangular construct.
The technique recently presented by Koulaxouzidis et al. (1) is in contrast this; they are
TE D
preserving the skin envelope of the flap in order to create a cleft between the chest wall and the flap and thereby trying to mimic an axillary fold. Furthermore they are closing the distal forearm skin following amputation of the hand, and the radius and ulna remains
EP
unattached to the thorax in order to create the appearance of a proximal humeral amputation. We think that this technique is of interest and should be kept in mind, but we
AC C
think that the primary aim of reconstruction is to create an almost normal and stable shoulder profile.
In our institution, we are normally using a technique, which is very close to technique of Osanai (3) and Wilkis (2), because our primary aim of reconstruction is to optimize the contour of the reconstructed shoulder and thereby to allow the patient to wear normal clothing (Figure 1-3). The second, but not less important aim is to avoid any clefts and strictures due to hygienic, like mentioned by Wilkis et al. (2), and aesthetic reasons. We think that a reconstructed axillary fold, which is going up to the shoulder does not look 2
ACCEPTED MANUSCRIPT natural, because the normal should profile is interrupted and the reconstructed shoulder even looks less natural. But beside the aesthetic aspects, we think that the patients do not have functional benefits due to this new technique, too (1). Based on these first results presented in the publication, we think that we will continue to
Conflicts of Interest and Funding Statement: None declared
Koulaxouzidis G, Simunovic F, Bjo G. Shoulder silhouette and axilla reconstruction
M AN U
1
SC
Ethical Approval: N/A
RI PT
use our old technique, but we will keep this new one in mind.
with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthetic Surg 2014;67(1):81e6. 2.
Wilks DJ, Hassan Z, Bhasker D, Kay SP. Re: Shoulder silhouette and axilla
TE D
reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthet Surg. 2014 Mar 27. 3.
Osanai T, Kashiwa H, Ishikawa A, Takahara M, Ogino T. Improved shoulder
EP
contour following forequarter amputation with an osteomyocutaneous free flap from the
AC C
amputated extremity: two cases. Br J Plast Surg 2005 Mar;58(2):165e9.
3
ACCEPTED MANUSCRIPT Figure Legends: Postoperative appearance of the shoulder and thorax after forequarter amputation and reconstruction using an osteomyocutaneous free flap of the elbow (frontal
AC C
EP
TE D
M AN U
SC
RI PT
view (Figure 1) and view from the back Figure 2).
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
5
ACCEPTED MANUSCRIPT Figure 3: The lateral 1 cm of the remaining part of the clavicle is placed into the stump of the humerus and fixed by use of a plate. The radius and the muscles including the fascia of the forearm are sutured and fixed to the thorax. The ulna is not directly attached and fixed to the thorax but covered with muscle and fascia, which is also sutured to the thorax.
AC C
EP
TE D
M AN U
SC
reconstructed shoulder without any clefts and strictures.
RI PT
This kind of fixation and reconstruction allows a natural and stable contour of the
6
S1748-6815(14)00226-5
DOI:
10.1016/j.bjps.2014.05.010
Reference:
PRAS 4193
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 25 April 2014 Revised Date:
5 May 2014
Accepted Date: 7 May 2014
Please cite this article as: Hubmer M, Leithner A, Kamolz L, Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation.
RI PT
Hubmer M1, Leithner A1, Kamolz LP1
1 Division of Plastic, Aesthetic and Reconstructive Surgery,
SC
Department of Surgery, Medical University Graz
Medical University of Graz
TE D
Corresponding author:
M AN U
2 Department of Orthopaedic Surgery,
Lars-Peter Kamolz M.D., Ph.D., M.Sc.
EP
Division of Plastic, Aesthetic and Reconstructive Surgery Department of Surgery
AC C
Medical University of Graz Auenbruggerplatz 29 A-8036 Graz
[email protected]
1
ACCEPTED MANUSCRIPT Dear Sir, With great interest we have read the recent article by Koulaxouzidis et al. (1) and the recent letter of Wilks et al. (2); both authors describe their techniques to correct the contour deformity that follows forequarter amputation. We absolutely agree that free flaps
RI PT
including the elbow are suitable or even are the optimal techniques to solve this aesthetic and functional problem. Osanai et al. (3), who originally described the use of an osteomyocutaneous free fillet flap using the olecranon and a flexed elbow to restore
SC
shoulder contour following forequarter amputation, uses anteromedial and anterolateral fasciocutaneous forearm flaps along with the distal forearm skin that results from
M AN U
amputation of the hand in order to perform this reconstruction. Furthermore, they were connecting the humerus to the clavicle and the radius and ulna to the ribs in order to produce a stable triangular construct.
The technique recently presented by Koulaxouzidis et al. (1) is in contrast this; they are
TE D
preserving the skin envelope of the flap in order to create a cleft between the chest wall and the flap and thereby trying to mimic an axillary fold. Furthermore they are closing the distal forearm skin following amputation of the hand, and the radius and ulna remains
EP
unattached to the thorax in order to create the appearance of a proximal humeral amputation. We think that this technique is of interest and should be kept in mind, but we
AC C
think that the primary aim of reconstruction is to create an almost normal and stable shoulder profile.
In our institution, we are normally using a technique, which is very close to technique of Osanai (3) and Wilkis (2), because our primary aim of reconstruction is to optimize the contour of the reconstructed shoulder and thereby to allow the patient to wear normal clothing (Figure 1-3). The second, but not less important aim is to avoid any clefts and strictures due to hygienic, like mentioned by Wilkis et al. (2), and aesthetic reasons. We think that a reconstructed axillary fold, which is going up to the shoulder does not look 2
ACCEPTED MANUSCRIPT natural, because the normal should profile is interrupted and the reconstructed shoulder even looks less natural. But beside the aesthetic aspects, we think that the patients do not have functional benefits due to this new technique, too (1). Based on these first results presented in the publication, we think that we will continue to
Conflicts of Interest and Funding Statement: None declared
Koulaxouzidis G, Simunovic F, Bjo G. Shoulder silhouette and axilla reconstruction
M AN U
1
SC
Ethical Approval: N/A
RI PT
use our old technique, but we will keep this new one in mind.
with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthetic Surg 2014;67(1):81e6. 2.
Wilks DJ, Hassan Z, Bhasker D, Kay SP. Re: Shoulder silhouette and axilla
TE D
reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthet Surg. 2014 Mar 27. 3.
Osanai T, Kashiwa H, Ishikawa A, Takahara M, Ogino T. Improved shoulder
EP
contour following forequarter amputation with an osteomyocutaneous free flap from the
AC C
amputated extremity: two cases. Br J Plast Surg 2005 Mar;58(2):165e9.
3
ACCEPTED MANUSCRIPT Figure Legends: Postoperative appearance of the shoulder and thorax after forequarter amputation and reconstruction using an osteomyocutaneous free flap of the elbow (frontal
AC C
EP
TE D
M AN U
SC
RI PT
view (Figure 1) and view from the back Figure 2).
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
5
ACCEPTED MANUSCRIPT Figure 3: The lateral 1 cm of the remaining part of the clavicle is placed into the stump of the humerus and fixed by use of a plate. The radius and the muscles including the fascia of the forearm are sutured and fixed to the thorax. The ulna is not directly attached and fixed to the thorax but covered with muscle and fascia, which is also sutured to the thorax.
AC C
EP
TE D
M AN U
SC
reconstructed shoulder without any clefts and strictures.
RI PT
This kind of fixation and reconstruction allows a natural and stable contour of the
6