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Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap
BritishJournalof PlasticSurgery(1998),51,250-254 © 1998The BritishAssociationof PlasticSurgeons
BRITISH
JOURNAL
PLASTIC
OF
SURGERY
Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap Y. Tanaka*, K. Miki*, S. Tajima*, J. Akamatsu*, Y. Tsukazaki * and T. Inomoto*
•Department of Plastic and Reconstructive Surgery, Osaka Medical College, Osaka, Japan and ~Division of Neurosurgery, Shingu City Hospital, Wakayama, Japan S U M M A R Y. A combination of split latissimus dorsi musculocutaneous flap with the serratus anterior musculoosseous flap was used to cover a very large defect of the scalp. This technique offers a new alternative for singlestage reconstruction of extensive scalp defects.
wires across the occipital bone defect (10 cm x 8 cm) and the serratus muscle covered the central portion of the defect. The latissimus dorsi musculocutaneous flap was split into medial and lateral units and was placed over the exposed skull surrounding the serratus muscle flap (Fig. 3B, C). The thoraeodorsal artery and vein were anastomosed to the occipital artery and the external jugular vein, respectively. The latissimus dorsi and serratus anterior muscle flaps were covered with meshed skin grafts, while a skin paddle over the latissimus dorsi muscle was used for postoperative monitoring (Fig. 3D, E). The postoperative course was uneventful, and the palpable cervical lymph nodes spontaneously regressed, suggesting that the reactive lymph node swelling was probably secondary to wound infection. The margins of the specimen were clear of tumour on permanent histologic sections and, therefore, radical neck dissections were not performed. Postoperative CT-scans at 11 months showed the transferred ribs had obtained the same density as normal skull without any evidence of resorption (Fig. 4A). The patient has remained well and is clinically free of disease at 1-year follow-up (Fig. 4B).
Extensive scalp defects, which include the cranial bone and underlying dura resulting from tumour ablation, present reconstructive challenges. A latissimus dorsi muscle flap with a split-thickness skin graft provides adequate coverage for large areas and has been used as the first choice for repair of large scalp defects? -6 However, when a defect is truly extensive, as in the present case, it is impossible to cover it with a single flap. We report a successful reconstruction of an extensive full-thickness cranial defect using a technique of splitting the latissimus dorsi musculocutaneous flap in combination with the serratus anterior musculoosseous flap.
Case report A 56-year-old woman was referred with a massive malignant endothelioma of the scalp that had been hidden by her long frontal hair for approximately 10 years. Examination revealed extensive foul-smelling ulcerating lesions which encompassed the entire posterior scalp and extended to the posterior neck (Fig. 1A). Cerebral pulsation was noted beneath the crust in the centre of the lesion and the cervical lymph nodes were palpable bilaterally. Head MRI showed involvement of the occipital bone and dura (Fig. 1B). MR sinography demonstrated complete occlusion of the posterior third of the superior sagittal sinus. However, 67Ga-scintigram and 99mTc-bone scintigram of the whole body revealed no apparent metastasis of the turnout. She was therefore offered the option of surgical removal to stop a process that would certainly cause her ultimate demise. En bloc resection of the involved scalp skin, including the underlying left trapezius and sternocleidomastoid muscles, occipital bone and dura was performed (Fig. 2). A small area of the brain was noted to be involved within the right parieto-occipital cortex, and this was excised together with the involved sagittal sinus. Reconstruction of the sagittal sinus was not performed because there had been no preoperative clinical symptom suggesting impairment of the cerebral venous drainage. The dural defect (8 cmx 6 cm) was reconstructed with a fascia latae graft. Then, the latissimus dorsi musculocutaneous flap and the lower half of the serratus anterior muscle flap including the 6th and 7th ribs (12 cm in length each) were raised based on the common thoracodorsal vessels (Fig. 3A). The ribs were fixed with
Discussion Microsurgical flee flap transfers are indicated when defects of the scalp are too extensive to be reconstructed by local flaps? -11 A m o n g these free flaps, the latissimus dorsi muscle with split-thickness skin graft provides coverage of the largest area and has been used by many plastic surgeons as the first choice for reconstruction of extensive scalp defects? -6 However, even this flap is inadequate for truly extensive defects as in the present case. In 1984, Batchelor et al H reported a case of total scalp reconstruction using a multiple territory free tissue transfer. Although the survival area of the skin flap was not confirmed because of the perioperative death of the patient, a multiple territory free tissue transfer is an alternative to be considered. Scalp defects after tumour treatment are usually circular and markedly convex. Therefore, as described by Pennington et al, 4 draping of a skin flap to fit the defect produces significant dog ears which require a larger skin flap than the real defect. Skin flaps are also usually too thick for the ideal resurfacing the scalp. 250
Reconstruction of an extensive scalp defect
251
Fig. 1
Fig. 2 Figure 1--(A) Preoperative view, massive malignant endothelioma of the scalp. (B) Preoperative MRI demonstrating involvement of the scalp, skull, dura and brain (arrow). Figure 2~Excision specimen. (A) Skin surface. (B) Deep surface showing extent of bone involvement.
252
British Journal of Plastic Surgery
skull
Fig. 3 Figure 3 (A-C)--Intraoperative view. (A) Defect of scalp and cranial bone. The dura repaired with a fascia latae graft. (B) The split latissimus dorsi muscle, and the serratus anterior musculo-osseous flap placed over the bone defect. (C) Schematic illustration of the reconstruction.
Reconstruction of an extensive scalp defect
253
Lateral i ~ splliatbtissimus
~I~
Fig. 3 Figure 3 (D, E)--Immediately after surgery (D) and its schematic illustration (E).
Fig. 4 Figure 4~(A) Postoperative CT-scan. The transferred rib (arrow) showing the same density as the cranial bone. (B) Eight-month postoperative view.
254 F u r t h e r m o r e , a larger skin flap inevitably requires a skin graft to its d o n o r site, which w o u l d prevent the s i m u l t a n e o u s harvest o f b o t h the muscle a n d ribs. F o r these reasons, skin flaps are n o t generally suitable for r e c o n s t r u c t i o n o f extensive scalp defects. In 1981, T o b i n et al m~ r e p o r t e d an a n a t o m i c a l study a n d the clinical versatility o f the split latissimus dorsi muscle o r m u s c u l o c u t a n e o u s flap. M a n y split latissimus dorsi free flaps have since been r e p o r t e d ? 4,1~ In the present case, the split latissimus dorsi flap was used in c o m b i n a t i o n with the serratus a n t e r i o r m u s c u l o osseous flap to resurface the entire p o s t e r i o r defect o f the scalp. This p r o c e d u r e has n o t been r e p o r t e d previously a n d has the a d v a n t a g e s t h a t it provides (1) suitable coverage o f an extensive convex defect o f the scalp, (2) s i m u l t a n e o u s calvarial b o n y r e c o n s t r u c t i o n with vascularised ribs a n d (3) a reliable l o n g v a s c u l a r pedicle for m i c r o v a s c u l a r transfer. T h e b o n y r e c o n s t r u c t i o n o f cranial b o n e defects r e m a i n s c o n t r o v e r s i a l ? s Free vascularised b o n e grafts are rarely used b e c a u s e free b o n e grafts are usually successful. However, the occipital region is a weight b e a r i n g a r e a o f the head; a reliable b o n y reconstruction is therefore m a n d a t o r y to reduce the risk o f postoperative c o m p l i c a t i o n s especially when p o s t o p e r a t i v e i r r a d i a t i o n t h e r a p y is anticipated. In the present case, the ribs were well vascularised on flap elevation a n d have n o t u n d e r g o n e r e s o r p t i o n as visualised on p o s t o p e r a t i v e C T scan. The b o n y r e c o n s t r u c t i o n has been well t o l e r a t e d in her daily life a n d the c o n t o u r was also well m a i n t a i n e d at 1-year follow-up. A l t h o u g h the transferred muscle showed p o s t o p e r a t i v e a t r o p h y a n d the p a t i e n t h a d no sensory recovery in the recons t r u c t e d area, no u l c e r a t i o n developed. The fact that the serratus a n d the intercostal muscle h a d firmly a t t a c h e d to the b o n y segments m a y have c o n t r i b u t e d to the r e s t o r a t i o n o f b o t h b o n y structure a n d c o n t o u r by preventing friction between the t r a n s f e r r e d muscle a n d bone.
Acknowledgements
We would like to thank Professor W. A. Morrison, Bernard O'Brien Institute of Microsurgery, for his advice in preparing this manuscript.
British Journal of Plastic Surgery 3. Oishi SN, Luce EA. The difficult scalp and skull wound. Clin Plast Surg 1995; 22: 51-9. 4. Pennington DG, Stern HS, Lee KK. Free-flap reconstruction of large defects of the scalp and calvarium. Plast Reconstr Surg 1989; 83: 655-61. 5. Robson MC, Zachary LS, Schmidt DR, Faibisoff B, Hekmatpanah J. 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: 438-42. 6. Earley M J, Green MF, Milling MAR A critical appraisal of the use of free flaps in primary reconstruction of combined scalp and calvarial cancer defects. Br J Plast Surg 1990; 43: 283-9. 7. Hirase Y, Kojima T, Kinoshita Y, Bang HH, Sakaguchi T, Kijima M. Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps. Plast Reconstr Surg 1991; 87: 555-6t. 8. Shen Z. Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer. Microsurgery 1994; 15: 633-8, 9. Chicarilli ZN, Ariyan S, Cuono CB. Single-stage repair of complex scalp and cranial defects with the free radial forearm flap. Plast Reconstr Surg 1986; 77: 577-85. 10. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92: 421-8. 11. Batchelor AG, Sully L. A multiple territory free tissue transfer for reconstruction of a large scalp defect. Br J Plast Surg 1984; 37: 76-9. 12. Tobin GR, Schusterman M, Peterson GH, Nichols G, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981; 67: 63741. 13. Tobin GR, Moberg AW, DuBou RH, Weiner LJ, Bland KI. The split latissimus dorsi myocutaneous flap. Ann Plast Surg 1981; 7: 272-80. 14. Elliott LF, Raffel B, Wade J. Segmental latissimus dorsi free flap. Clinical applications. Ann Plast Surg 1989; 23:231 8. 15. Chiang YC, Wei FC. Simultaneous coverage of two separate defects with two free hemiflaps harvested from one latissimus dorsi muscle. Plast Reconstr Surg 1995; 95: 385-9.
The Authors Yoshio Tanaka MD, Associate Professor Sadao Tajima MD, Professor Jun Akamatsu MD
Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigakucho, Tukatsuki City, Osaka 569, Japan. Kazuhito Miki MD, Head of Neurosurgery
References
1. Jones NF, Hardesty RA, Swartz WM, Ramasastry SS, Heckler FR, Newton ED. Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction. Plast Reconstr Surg 1988; 82: 937-52. 2. Jones TR, Jones NF. Advances in reconstruction of the upper aerodigestive tract and cranial base with free tissue transfer. Clin Plast Surg 1992; 19: 819-3i.
Yuji Tsukazaki MD Takaaki Inomoto MD
Division of Neurosurgery, Shingu City Hospital, Wakayama, Japan. Correspondence to Yoshio Tanaka. Paper received 29 January 1997. Accepted 23 January 1998, after revision.
BRITISH
JOURNAL
PLASTIC
OF
SURGERY
Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap Y. Tanaka*, K. Miki*, S. Tajima*, J. Akamatsu*, Y. Tsukazaki * and T. Inomoto*
•Department of Plastic and Reconstructive Surgery, Osaka Medical College, Osaka, Japan and ~Division of Neurosurgery, Shingu City Hospital, Wakayama, Japan S U M M A R Y. A combination of split latissimus dorsi musculocutaneous flap with the serratus anterior musculoosseous flap was used to cover a very large defect of the scalp. This technique offers a new alternative for singlestage reconstruction of extensive scalp defects.
wires across the occipital bone defect (10 cm x 8 cm) and the serratus muscle covered the central portion of the defect. The latissimus dorsi musculocutaneous flap was split into medial and lateral units and was placed over the exposed skull surrounding the serratus muscle flap (Fig. 3B, C). The thoraeodorsal artery and vein were anastomosed to the occipital artery and the external jugular vein, respectively. The latissimus dorsi and serratus anterior muscle flaps were covered with meshed skin grafts, while a skin paddle over the latissimus dorsi muscle was used for postoperative monitoring (Fig. 3D, E). The postoperative course was uneventful, and the palpable cervical lymph nodes spontaneously regressed, suggesting that the reactive lymph node swelling was probably secondary to wound infection. The margins of the specimen were clear of tumour on permanent histologic sections and, therefore, radical neck dissections were not performed. Postoperative CT-scans at 11 months showed the transferred ribs had obtained the same density as normal skull without any evidence of resorption (Fig. 4A). The patient has remained well and is clinically free of disease at 1-year follow-up (Fig. 4B).
Extensive scalp defects, which include the cranial bone and underlying dura resulting from tumour ablation, present reconstructive challenges. A latissimus dorsi muscle flap with a split-thickness skin graft provides adequate coverage for large areas and has been used as the first choice for repair of large scalp defects? -6 However, when a defect is truly extensive, as in the present case, it is impossible to cover it with a single flap. We report a successful reconstruction of an extensive full-thickness cranial defect using a technique of splitting the latissimus dorsi musculocutaneous flap in combination with the serratus anterior musculoosseous flap.
Case report A 56-year-old woman was referred with a massive malignant endothelioma of the scalp that had been hidden by her long frontal hair for approximately 10 years. Examination revealed extensive foul-smelling ulcerating lesions which encompassed the entire posterior scalp and extended to the posterior neck (Fig. 1A). Cerebral pulsation was noted beneath the crust in the centre of the lesion and the cervical lymph nodes were palpable bilaterally. Head MRI showed involvement of the occipital bone and dura (Fig. 1B). MR sinography demonstrated complete occlusion of the posterior third of the superior sagittal sinus. However, 67Ga-scintigram and 99mTc-bone scintigram of the whole body revealed no apparent metastasis of the turnout. She was therefore offered the option of surgical removal to stop a process that would certainly cause her ultimate demise. En bloc resection of the involved scalp skin, including the underlying left trapezius and sternocleidomastoid muscles, occipital bone and dura was performed (Fig. 2). A small area of the brain was noted to be involved within the right parieto-occipital cortex, and this was excised together with the involved sagittal sinus. Reconstruction of the sagittal sinus was not performed because there had been no preoperative clinical symptom suggesting impairment of the cerebral venous drainage. The dural defect (8 cmx 6 cm) was reconstructed with a fascia latae graft. Then, the latissimus dorsi musculocutaneous flap and the lower half of the serratus anterior muscle flap including the 6th and 7th ribs (12 cm in length each) were raised based on the common thoracodorsal vessels (Fig. 3A). The ribs were fixed with
Discussion Microsurgical flee flap transfers are indicated when defects of the scalp are too extensive to be reconstructed by local flaps? -11 A m o n g these free flaps, the latissimus dorsi muscle with split-thickness skin graft provides coverage of the largest area and has been used by many plastic surgeons as the first choice for reconstruction of extensive scalp defects? -6 However, even this flap is inadequate for truly extensive defects as in the present case. In 1984, Batchelor et al H reported a case of total scalp reconstruction using a multiple territory free tissue transfer. Although the survival area of the skin flap was not confirmed because of the perioperative death of the patient, a multiple territory free tissue transfer is an alternative to be considered. Scalp defects after tumour treatment are usually circular and markedly convex. Therefore, as described by Pennington et al, 4 draping of a skin flap to fit the defect produces significant dog ears which require a larger skin flap than the real defect. Skin flaps are also usually too thick for the ideal resurfacing the scalp. 250
Reconstruction of an extensive scalp defect
251
Fig. 1
Fig. 2 Figure 1--(A) Preoperative view, massive malignant endothelioma of the scalp. (B) Preoperative MRI demonstrating involvement of the scalp, skull, dura and brain (arrow). Figure 2~Excision specimen. (A) Skin surface. (B) Deep surface showing extent of bone involvement.
252
British Journal of Plastic Surgery
skull
Fig. 3 Figure 3 (A-C)--Intraoperative view. (A) Defect of scalp and cranial bone. The dura repaired with a fascia latae graft. (B) The split latissimus dorsi muscle, and the serratus anterior musculo-osseous flap placed over the bone defect. (C) Schematic illustration of the reconstruction.
Reconstruction of an extensive scalp defect
253
Lateral i ~ splliatbtissimus
~I~
Fig. 3 Figure 3 (D, E)--Immediately after surgery (D) and its schematic illustration (E).
Fig. 4 Figure 4~(A) Postoperative CT-scan. The transferred rib (arrow) showing the same density as the cranial bone. (B) Eight-month postoperative view.
254 F u r t h e r m o r e , a larger skin flap inevitably requires a skin graft to its d o n o r site, which w o u l d prevent the s i m u l t a n e o u s harvest o f b o t h the muscle a n d ribs. F o r these reasons, skin flaps are n o t generally suitable for r e c o n s t r u c t i o n o f extensive scalp defects. In 1981, T o b i n et al m~ r e p o r t e d an a n a t o m i c a l study a n d the clinical versatility o f the split latissimus dorsi muscle o r m u s c u l o c u t a n e o u s flap. M a n y split latissimus dorsi free flaps have since been r e p o r t e d ? 4,1~ In the present case, the split latissimus dorsi flap was used in c o m b i n a t i o n with the serratus a n t e r i o r m u s c u l o osseous flap to resurface the entire p o s t e r i o r defect o f the scalp. This p r o c e d u r e has n o t been r e p o r t e d previously a n d has the a d v a n t a g e s t h a t it provides (1) suitable coverage o f an extensive convex defect o f the scalp, (2) s i m u l t a n e o u s calvarial b o n y r e c o n s t r u c t i o n with vascularised ribs a n d (3) a reliable l o n g v a s c u l a r pedicle for m i c r o v a s c u l a r transfer. T h e b o n y r e c o n s t r u c t i o n o f cranial b o n e defects r e m a i n s c o n t r o v e r s i a l ? s Free vascularised b o n e grafts are rarely used b e c a u s e free b o n e grafts are usually successful. However, the occipital region is a weight b e a r i n g a r e a o f the head; a reliable b o n y reconstruction is therefore m a n d a t o r y to reduce the risk o f postoperative c o m p l i c a t i o n s especially when p o s t o p e r a t i v e i r r a d i a t i o n t h e r a p y is anticipated. In the present case, the ribs were well vascularised on flap elevation a n d have n o t u n d e r g o n e r e s o r p t i o n as visualised on p o s t o p e r a t i v e C T scan. The b o n y r e c o n s t r u c t i o n has been well t o l e r a t e d in her daily life a n d the c o n t o u r was also well m a i n t a i n e d at 1-year follow-up. A l t h o u g h the transferred muscle showed p o s t o p e r a t i v e a t r o p h y a n d the p a t i e n t h a d no sensory recovery in the recons t r u c t e d area, no u l c e r a t i o n developed. The fact that the serratus a n d the intercostal muscle h a d firmly a t t a c h e d to the b o n y segments m a y have c o n t r i b u t e d to the r e s t o r a t i o n o f b o t h b o n y structure a n d c o n t o u r by preventing friction between the t r a n s f e r r e d muscle a n d bone.
Acknowledgements
We would like to thank Professor W. A. Morrison, Bernard O'Brien Institute of Microsurgery, for his advice in preparing this manuscript.
British Journal of Plastic Surgery 3. Oishi SN, Luce EA. The difficult scalp and skull wound. Clin Plast Surg 1995; 22: 51-9. 4. Pennington DG, Stern HS, Lee KK. Free-flap reconstruction of large defects of the scalp and calvarium. Plast Reconstr Surg 1989; 83: 655-61. 5. Robson MC, Zachary LS, Schmidt DR, Faibisoff B, Hekmatpanah J. 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: 438-42. 6. Earley M J, Green MF, Milling MAR A critical appraisal of the use of free flaps in primary reconstruction of combined scalp and calvarial cancer defects. Br J Plast Surg 1990; 43: 283-9. 7. Hirase Y, Kojima T, Kinoshita Y, Bang HH, Sakaguchi T, Kijima M. Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps. Plast Reconstr Surg 1991; 87: 555-6t. 8. Shen Z. Reconstruction of refractory defect of scalp and skull using microsurgical free flap transfer. Microsurgery 1994; 15: 633-8, 9. Chicarilli ZN, Ariyan S, Cuono CB. Single-stage repair of complex scalp and cranial defects with the free radial forearm flap. Plast Reconstr Surg 1986; 77: 577-85. 10. Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92: 421-8. 11. Batchelor AG, Sully L. A multiple territory free tissue transfer for reconstruction of a large scalp defect. Br J Plast Surg 1984; 37: 76-9. 12. Tobin GR, Schusterman M, Peterson GH, Nichols G, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981; 67: 63741. 13. Tobin GR, Moberg AW, DuBou RH, Weiner LJ, Bland KI. The split latissimus dorsi myocutaneous flap. Ann Plast Surg 1981; 7: 272-80. 14. Elliott LF, Raffel B, Wade J. Segmental latissimus dorsi free flap. Clinical applications. Ann Plast Surg 1989; 23:231 8. 15. Chiang YC, Wei FC. Simultaneous coverage of two separate defects with two free hemiflaps harvested from one latissimus dorsi muscle. Plast Reconstr Surg 1995; 95: 385-9.
The Authors Yoshio Tanaka MD, Associate Professor Sadao Tajima MD, Professor Jun Akamatsu MD
Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigakucho, Tukatsuki City, Osaka 569, Japan. Kazuhito Miki MD, Head of Neurosurgery
References
1. Jones NF, Hardesty RA, Swartz WM, Ramasastry SS, Heckler FR, Newton ED. Extensive and complex defects of the scalp, middle third of the face, and palate: the role of microsurgical reconstruction. Plast Reconstr Surg 1988; 82: 937-52. 2. Jones TR, Jones NF. Advances in reconstruction of the upper aerodigestive tract and cranial base with free tissue transfer. Clin Plast Surg 1992; 19: 819-3i.
Yuji Tsukazaki MD Takaaki Inomoto MD
Division of Neurosurgery, Shingu City Hospital, Wakayama, Japan. Correspondence to Yoshio Tanaka. Paper received 29 January 1997. Accepted 23 January 1998, after revision.