- Email: [email protected]
Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation
+
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation
reduces the functional and social impact of forequarter amputation. Between 2009 and 2013, we have performed three microsurgical osteomyocutaneous reconstructions following resection of shoulder malignancy by means of forequarter amputation (Figures 1 and 2). One further reconstruction was prevented by the presence of a humeral endoprosthesis. We continue to use the technique originally described by Osanai, firstly because of concerns that a single
Dear Sir, The recent article by Koulaxouzidis et al.1 describes the use of an osteomyocutaneous free fillet flap to reconstruct the contour deformity that follows forequarter amputation. Osanai originally described the use of an osteomyocutaneous free fillet flap using the olecranon and a flexed elbow to restore shoulder contour following forequarter amputation in 2005.2 The technique used by Koulaxouzidis is a modification of this method. Osanai elevates anteromedial and anterolateral fasciocutaneous forearm flaps that are inset, along with the distal forearm skin that results from amputation of the hand, to the thoracic resection margin. The radius and ulna are sutured to the ribs, producing a stable triangular construct. In contrast to Osanai et al. and to our own practice, Koulaxouzidis preserves the skin envelope of the flap in order to create a cleft between the chest wall and the flap, mimicking the axillary fold, and closes the distal forearm skin following amputation of the hand. The radius and ulna remain in the distal stump unattached to the thorax. Hence, Koulaxouzidis creates the appearance of a proximal humeral amputation, whereas Osanai uses the flap to reconstruct any soft tissue defect and recreate the shoulder profile. As Koulaxouzidis clearly describes, lack of shoulder reconstruction following forequarter amputation produces a displeasing shoulder profile often requiring the use of shoulder pads,3 limits clothing choices and greatly reduces prosthetic options.4 Reconstruction using the methods described by either Osanai or Koulaxouzidis potentially
DOI of original j.bjps.2013.10.040.
article:
http://dx.doi.org/10.1016/
Figure 1 Post operative appearance of the thorax following forequarter amputation and reconstruction using an osteomyocutaneous free fillet flap of the elbow unclothed (a) and clothed (b).
http://dx.doi.org/10.1016/j.bjps.2014.03.026 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. . Please cite this article in press as: Wilks DJ, et al., Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/ 10.1016/j.bjps.2014.03.026
+
MODEL
2
Correspondence and communication more than 90 minutes of additional time and offers considerable benefits.
Funding None.
Conflict of interest None.
References
Figure 2 Radiographic appearance of the thorax following forequarter amputation and reconstruction using an osteomyocutaneous free fillet flap of the elbow.
osteosynthesis of humerus and clavicle unsupported by chest wall attachment may be insufficient to bear the weight of a prosthesis. Secondly, hygiene may be difficult to maintain in the presence of the narrow, non-mobile cleft that is used to simulate the axillary fold. Finally, we do not perceive a benefit to mimicking an axillary fold: the major aesthetic concern of our patients is the shoulder contour and the inability to wear normal clothing without a cumbersome and awkward prosthesis. In our series, reconstruction facilitated application of an upper limb prosthesis in one case although, as is common to all types of amputee,5 the patient chose not to use it for more than a few weeks. The other two patients have, so far, chosen not to seek prosthetic solutions. Free fillet flap reconstruction is a valuable adjunct to the ablative procedure in those cases where oncological resections margins are not compromised, and requires little
1. Koulaxouzidis G, Simunovic F, Bjo G. Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthetic Surg 2014;67(1):81e6. 2. Osanai T, Kashiwa H, Ishikawa A, Takahara M, Ogino T. Improved shoulder contour following forequarter amputation with an osteomyocutaneous free flap from the amputated extremity: two cases. Br J Plast Surg 2005 Mar;58(2):165e9. 3. Bhagia S, Elek E, Grimer R, Carter S, Tilman R. Forequarter amputation for high-grade tumours of the shoulder girdle. J Bone Jt Surg Br 1997;79B(6):924e6. 4. Daigeler A, Lehnhardt M, Khadra A, et al. Proximal major limb amputations e a retrospective analysis of 45 oncological cases. World J Surg Oncol 2009 Jan;7:15. 5. Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int 2007 Sep;31(3):236e57.
Daniel J. Wilks Zahid Hassan Diana Bhasker Simon P.J. Kay The Department of Plastic, Reconstructive and Hand Surgery, Leeds General Infirmary, Leeds, UK E-mail address: [email protected] 23 January 2014
Please cite this article in press as: Wilks DJ, et al., Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/ 10.1016/j.bjps.2014.03.026
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2
CORRESPONDENCE AND COMMUNICATION Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation
reduces the functional and social impact of forequarter amputation. Between 2009 and 2013, we have performed three microsurgical osteomyocutaneous reconstructions following resection of shoulder malignancy by means of forequarter amputation (Figures 1 and 2). One further reconstruction was prevented by the presence of a humeral endoprosthesis. We continue to use the technique originally described by Osanai, firstly because of concerns that a single
Dear Sir, The recent article by Koulaxouzidis et al.1 describes the use of an osteomyocutaneous free fillet flap to reconstruct the contour deformity that follows forequarter amputation. Osanai originally described the use of an osteomyocutaneous free fillet flap using the olecranon and a flexed elbow to restore shoulder contour following forequarter amputation in 2005.2 The technique used by Koulaxouzidis is a modification of this method. Osanai elevates anteromedial and anterolateral fasciocutaneous forearm flaps that are inset, along with the distal forearm skin that results from amputation of the hand, to the thoracic resection margin. The radius and ulna are sutured to the ribs, producing a stable triangular construct. In contrast to Osanai et al. and to our own practice, Koulaxouzidis preserves the skin envelope of the flap in order to create a cleft between the chest wall and the flap, mimicking the axillary fold, and closes the distal forearm skin following amputation of the hand. The radius and ulna remain in the distal stump unattached to the thorax. Hence, Koulaxouzidis creates the appearance of a proximal humeral amputation, whereas Osanai uses the flap to reconstruct any soft tissue defect and recreate the shoulder profile. As Koulaxouzidis clearly describes, lack of shoulder reconstruction following forequarter amputation produces a displeasing shoulder profile often requiring the use of shoulder pads,3 limits clothing choices and greatly reduces prosthetic options.4 Reconstruction using the methods described by either Osanai or Koulaxouzidis potentially
DOI of original j.bjps.2013.10.040.
article:
http://dx.doi.org/10.1016/
Figure 1 Post operative appearance of the thorax following forequarter amputation and reconstruction using an osteomyocutaneous free fillet flap of the elbow unclothed (a) and clothed (b).
http://dx.doi.org/10.1016/j.bjps.2014.03.026 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. . Please cite this article in press as: Wilks DJ, et al., Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/ 10.1016/j.bjps.2014.03.026
+
MODEL
2
Correspondence and communication more than 90 minutes of additional time and offers considerable benefits.
Funding None.
Conflict of interest None.
References
Figure 2 Radiographic appearance of the thorax following forequarter amputation and reconstruction using an osteomyocutaneous free fillet flap of the elbow.
osteosynthesis of humerus and clavicle unsupported by chest wall attachment may be insufficient to bear the weight of a prosthesis. Secondly, hygiene may be difficult to maintain in the presence of the narrow, non-mobile cleft that is used to simulate the axillary fold. Finally, we do not perceive a benefit to mimicking an axillary fold: the major aesthetic concern of our patients is the shoulder contour and the inability to wear normal clothing without a cumbersome and awkward prosthesis. In our series, reconstruction facilitated application of an upper limb prosthesis in one case although, as is common to all types of amputee,5 the patient chose not to use it for more than a few weeks. The other two patients have, so far, chosen not to seek prosthetic solutions. Free fillet flap reconstruction is a valuable adjunct to the ablative procedure in those cases where oncological resections margins are not compromised, and requires little
1. Koulaxouzidis G, Simunovic F, Bjo G. Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation. J Plast Reconstr Aesthetic Surg 2014;67(1):81e6. 2. Osanai T, Kashiwa H, Ishikawa A, Takahara M, Ogino T. Improved shoulder contour following forequarter amputation with an osteomyocutaneous free flap from the amputated extremity: two cases. Br J Plast Surg 2005 Mar;58(2):165e9. 3. Bhagia S, Elek E, Grimer R, Carter S, Tilman R. Forequarter amputation for high-grade tumours of the shoulder girdle. J Bone Jt Surg Br 1997;79B(6):924e6. 4. Daigeler A, Lehnhardt M, Khadra A, et al. Proximal major limb amputations e a retrospective analysis of 45 oncological cases. World J Surg Oncol 2009 Jan;7:15. 5. Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: a survey of the last 25 years. Prosthet Orthot Int 2007 Sep;31(3):236e57.
Daniel J. Wilks Zahid Hassan Diana Bhasker Simon P.J. Kay The Department of Plastic, Reconstructive and Hand Surgery, Leeds General Infirmary, Leeds, UK E-mail address: [email protected] 23 January 2014
Please cite this article in press as: Wilks DJ, et al., Re: Shoulder silhouette and axilla reconstruction with free composite elbow tissue transfer following interscapulothoracic amputation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/ 10.1016/j.bjps.2014.03.026