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Recycling delayed perforator flap: Deep inferior epigastric artery perforator-based propeller flap from a prior vertical rectus abdominis musculocutaneous flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1238e1241
CASE REPORT
Recycling delayed perforator flap: Deep inferior epigastric artery perforator-based propeller flap from a prior vertical rectus abdominis musculocutaneous flap Ju Young Go, So Young Lim, Goo Hyun Mun, Sa Ik Bang, Kap Sung Oh, Jai Kyong Pyon* Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-gu, Seoul 135-710, Republic of Korea Received 18 June 2010; accepted 26 January 2011
KEYWORDS Vertical rectus abdominis flap; Flap recycling; Perforator flap
Summary This article reports a case of re-elevating a prior vertical rectus abdominis musculocutaneous flap as a deep inferior epigastric artery perforator-based propeller flap to cover a recurrent chest wall defect. This case demonstrates that a conventional musculocutaneous flap tissue with a preserved perforator can be recycled as a perforator flap. Furthermore, this technique can be a promising new surgical option for recurring abdominal and chest defects. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sequential flap coverage may be required for recurrent defects and adjacent tissues or tissues from the contralateral side that have not been used previously as a flap resource. Moreover, reusing a prior flap can also be an alternative method for providing coverage to a relapsing lesion. A biceps femoris myocutaneous flap for ischial ulcers, a tensor fascia lata myocutaneous flap for trochanteric ulcers and gluteal myocutaneous or fasciocutaneous flap for
sacral ulcers are examples of reusable flaps in the repair of recurrent pressure ulcers.1 However, there are few reports on the reuse of a flap as a perforator-based propeller flap, which had been elevated within the boundaries of the previous flap.2 Here, we introduce the concept of recycling a previous myocutaneous flap as a perforator flap through a case study of recurrent chest wall defects.
Case report * Corresponding author. Tel.: þ82 2 3410 2235; fax: þ82 2 3410 0036. E-mail address: [email protected] (J.K. Pyon).
A 57-year-old female presented with a right anterolateral chest wall mass that had been diagnosed as a liposarcoma
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.01.020
Recycled perforator flap by a fine needle aspiration. A wide excision of the lesion with the underlying muscle and 6th to 8th rib was performed. A skeletal reconstruction was achieved using a Composix mesh and 11 11 cm-sized muscle defect was covered with a latissimus dorsi muscle flap. After surgery, she underwent adjuvant radiotherapy. The postoperative course was uneventful until the findings indicated a relapse of the lesion 3 years after the previous operation. The patient revisited our clinic due to a recurrent sarcoma on the same site. A wide excision including the remnant 7th rib was performed again and the exposed pleural space was covered with 2-mm Gore-Tex. As a result, 13 15 cm-sized musculocutaneous defect was formed. An ipsilateral superiorly based vertical rectus abdominis musculocutaneous flap with a 14 7 cm-sized skin paddle was designed precisely to be rotated clockwise 120 to cover the defect (Figure 1). The patient returned with the complaint of wound dehiscence in the upper flap margin 2 months after adjuvant chemotherapy. Minimal debridement and wound closure were performed in an outpatient clinic. Nevertheless, the wound dehiscence recurred and the lesion size and depth were aggravated. Moreover, fibrous changes in the wound margin and bed occurred secondary to radiotherapy and reoperation scarring (Figure 2A). The wound margin was debrided and a 5 4 cm defect was formed. A hand-held Doppler showed that a perforator, which was previously the right deep inferior epigastric artery, was localised within the previous rectus abdominis musculocutaneous flap. After confirming good blood flow of
Figure 1 (A) Prior vertical rectus abdominis musculocutanous flap (B) Immediate postoperative photography.
1239 the perforator pedicle, an incision was made along the flap boundary. The dissection was started on the anterior chest wall through the suprafascial plane. The perforator, which was localised with the Doppler, was visualised directly(Figure 2B). As the flap was totally elevated, a further intramuscular dissection of the pedicle was carried out through the rectus abdominis muscle to provide adequate mobility for advancement. This perforator flap was re-rotated 180 clockwise and was advanced more posteriorly to cover the defect and closed in a VeY fashion. Complete coverage of the chest wall defect was possible with minimal tension on the flap and intact blood circulation of the flap was confirmed. In the 2nd postoperative week, a seroma under the flap was evacuated and minimal debridement was performed again in the area of flap necrosis, which healed uneventfully. During the 12-month follow-up period, there were no additional wound problems or evidence of relapse (Figure 2C).
Discussion A repeated defect formed in an area where a reconstruction had previously been performed using flaps is a great challenge to surgeons because of the limitation of potential donor sites and local tissues. Several solutions have been proposed to overcome the issue of limited donor sites. For example, reuse of the same myocutaneous flap for the treatment of recurrent lesions in difficult second operations of the head and neck region has been reported.3 For pressure ulcers in the sacral, ischial or trochanteric area, VeY re-advancement flaps have been the key for managing recurrent lesions.1 Previous reports on the repetitive use of a prior flap focused mainly on myocutaneous or fasciocutaneous flaps. There are several reports on propeller-islanded perforator flaps based on the DIEP (deep inferior epigastric perforator) and SEA (superior epigastric artery) to reconstruct abdominal defects.4,5 The vascular territories of the superior and deep inferior epigastric arteries were examined in various studies.6,7 The superior and the deep inferior epigastric arteries were united by choke vessels in the segment of the muscle above the umbilicus. The supply to the various transverse and vertical skin flaps from the deep superior epigastric artery was defined as a series of captured anatomic territories bound by choke vessels.8 For a breast reconstruction, it would appear that a prior ligation of the deep inferior epigastric artery would be an advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap.9 In this case, the first flap was actually raised as a standard vertical rectus abdominis flap where the distal skin flap relied on retrograde filling of the deep inferior epigastric artery perforators. Furthermore, the second flap was raised as a perforator, which had originally been supplied by the deep inferior epigastric artery but now by a continuation of the superior epigastric artery. This means that the perforator flap previously raised as a propeller flap was raised on a perforating vessel that had originally been supplied by the deep inferior epigastric system. However, it is now supplied by the superior system because that system is no longer
1240
J.Y. Go et al.
Figure 2 (A) Lateral view of the right chest wall showing upper lateral flap margin dehiscence and a soft tissue deficit with extensive scarring. (B) The perforator was visualized and the perforator flap was completely raised. (C) No recurrence or wound problems were observed 12 months after the recycled perforator flap surgery.
connected. A dilatation of choke vessels and reorientation of vessels caused by a prior division of the deep inferior epigastric artery might explain this phenomenon.10 In this case, re-advancement of the flap could be attempted in the same fasciocutaneous manner. However, an increase in lateral tension on the wound would be inevitable due to the reduced movability of the soft tissues in the re-advancement. A satisfactory range and unrestricted direction of advancement can be ensured by dissecting the perforator to obtain a lengthy pedicle and elevate and rotate the flap as an island flap. An intramuscular perforator
dissection could be performed, a perforator-based flap within the boundaries of the previous flap could be elevated and the flap could be rotated as a propeller flap. This case demonstrates that despite ligation of the deep inferior epigastric system, it is still possible to raise perforator flaps within pre-existing musculocutaneous superiorly based vertical rectus abdominis flaps. This suggests that a prior flap can be re-elevated and re-transferred as a perforator flap when a reliable perforator is preserved in the supramuscular layer and is identified within the tissues of the musculocutaneous unit of a previously transferred
Recycled perforator flap flap. This concept of recycling a previous musculocutaneous or fasciocutaneous flap as a subsequent perforator flap will be very useful and applicable to recurring defects in many other locations. Therefore, reconstructive surgeons should consider this potential option.
Funding None.
Conflict of interest None.
References 1. Kroll SS, Hamilton S. Multiple and repetitive uses of the extended hamstring VeY myocutaneous flap. Plast Reconstr Surg 1989;84:296e302. 2. Mun GH. Recycled free septocutaneous perforator flap. Ann Plast Surg 2008;60:37e40.
1241 3. Havlik R, Ariyan S. Repeated use of the same myocutaneous flap in difficult second operations of the head and neck. Plast Reconstr Surg 1994;93:481e8. 4. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63:1223e6. 5. Ang GG, Rozen WM, Chauhan A, Acosta R. The pedicled ‘propeller’ deep inferior epigastric perforator (DIEP) flap for a large abdominal wall defect. J Plast Reconstr Aesthet Surg; 2010. 6. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 7. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82:815e32. 8. Hallock GG. The superior epigastric (RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 2005;55:430e2. 9. Atisha D, Alderman AK, Janiga T, Singal B, Wilkins EG. The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg 2009;63:383e8. 10. Yim HY, Park YJ. Clinical application of the delayed procedure in the distally based sural flap. J Korean Soc Plast Reconstr Surg 2010;37(6):775e8.
CASE REPORT
Recycling delayed perforator flap: Deep inferior epigastric artery perforator-based propeller flap from a prior vertical rectus abdominis musculocutaneous flap Ju Young Go, So Young Lim, Goo Hyun Mun, Sa Ik Bang, Kap Sung Oh, Jai Kyong Pyon* Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-gu, Seoul 135-710, Republic of Korea Received 18 June 2010; accepted 26 January 2011
KEYWORDS Vertical rectus abdominis flap; Flap recycling; Perforator flap
Summary This article reports a case of re-elevating a prior vertical rectus abdominis musculocutaneous flap as a deep inferior epigastric artery perforator-based propeller flap to cover a recurrent chest wall defect. This case demonstrates that a conventional musculocutaneous flap tissue with a preserved perforator can be recycled as a perforator flap. Furthermore, this technique can be a promising new surgical option for recurring abdominal and chest defects. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sequential flap coverage may be required for recurrent defects and adjacent tissues or tissues from the contralateral side that have not been used previously as a flap resource. Moreover, reusing a prior flap can also be an alternative method for providing coverage to a relapsing lesion. A biceps femoris myocutaneous flap for ischial ulcers, a tensor fascia lata myocutaneous flap for trochanteric ulcers and gluteal myocutaneous or fasciocutaneous flap for
sacral ulcers are examples of reusable flaps in the repair of recurrent pressure ulcers.1 However, there are few reports on the reuse of a flap as a perforator-based propeller flap, which had been elevated within the boundaries of the previous flap.2 Here, we introduce the concept of recycling a previous myocutaneous flap as a perforator flap through a case study of recurrent chest wall defects.
Case report * Corresponding author. Tel.: þ82 2 3410 2235; fax: þ82 2 3410 0036. E-mail address: [email protected] (J.K. Pyon).
A 57-year-old female presented with a right anterolateral chest wall mass that had been diagnosed as a liposarcoma
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.01.020
Recycled perforator flap by a fine needle aspiration. A wide excision of the lesion with the underlying muscle and 6th to 8th rib was performed. A skeletal reconstruction was achieved using a Composix mesh and 11 11 cm-sized muscle defect was covered with a latissimus dorsi muscle flap. After surgery, she underwent adjuvant radiotherapy. The postoperative course was uneventful until the findings indicated a relapse of the lesion 3 years after the previous operation. The patient revisited our clinic due to a recurrent sarcoma on the same site. A wide excision including the remnant 7th rib was performed again and the exposed pleural space was covered with 2-mm Gore-Tex. As a result, 13 15 cm-sized musculocutaneous defect was formed. An ipsilateral superiorly based vertical rectus abdominis musculocutaneous flap with a 14 7 cm-sized skin paddle was designed precisely to be rotated clockwise 120 to cover the defect (Figure 1). The patient returned with the complaint of wound dehiscence in the upper flap margin 2 months after adjuvant chemotherapy. Minimal debridement and wound closure were performed in an outpatient clinic. Nevertheless, the wound dehiscence recurred and the lesion size and depth were aggravated. Moreover, fibrous changes in the wound margin and bed occurred secondary to radiotherapy and reoperation scarring (Figure 2A). The wound margin was debrided and a 5 4 cm defect was formed. A hand-held Doppler showed that a perforator, which was previously the right deep inferior epigastric artery, was localised within the previous rectus abdominis musculocutaneous flap. After confirming good blood flow of
Figure 1 (A) Prior vertical rectus abdominis musculocutanous flap (B) Immediate postoperative photography.
1239 the perforator pedicle, an incision was made along the flap boundary. The dissection was started on the anterior chest wall through the suprafascial plane. The perforator, which was localised with the Doppler, was visualised directly(Figure 2B). As the flap was totally elevated, a further intramuscular dissection of the pedicle was carried out through the rectus abdominis muscle to provide adequate mobility for advancement. This perforator flap was re-rotated 180 clockwise and was advanced more posteriorly to cover the defect and closed in a VeY fashion. Complete coverage of the chest wall defect was possible with minimal tension on the flap and intact blood circulation of the flap was confirmed. In the 2nd postoperative week, a seroma under the flap was evacuated and minimal debridement was performed again in the area of flap necrosis, which healed uneventfully. During the 12-month follow-up period, there were no additional wound problems or evidence of relapse (Figure 2C).
Discussion A repeated defect formed in an area where a reconstruction had previously been performed using flaps is a great challenge to surgeons because of the limitation of potential donor sites and local tissues. Several solutions have been proposed to overcome the issue of limited donor sites. For example, reuse of the same myocutaneous flap for the treatment of recurrent lesions in difficult second operations of the head and neck region has been reported.3 For pressure ulcers in the sacral, ischial or trochanteric area, VeY re-advancement flaps have been the key for managing recurrent lesions.1 Previous reports on the repetitive use of a prior flap focused mainly on myocutaneous or fasciocutaneous flaps. There are several reports on propeller-islanded perforator flaps based on the DIEP (deep inferior epigastric perforator) and SEA (superior epigastric artery) to reconstruct abdominal defects.4,5 The vascular territories of the superior and deep inferior epigastric arteries were examined in various studies.6,7 The superior and the deep inferior epigastric arteries were united by choke vessels in the segment of the muscle above the umbilicus. The supply to the various transverse and vertical skin flaps from the deep superior epigastric artery was defined as a series of captured anatomic territories bound by choke vessels.8 For a breast reconstruction, it would appear that a prior ligation of the deep inferior epigastric artery would be an advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap.9 In this case, the first flap was actually raised as a standard vertical rectus abdominis flap where the distal skin flap relied on retrograde filling of the deep inferior epigastric artery perforators. Furthermore, the second flap was raised as a perforator, which had originally been supplied by the deep inferior epigastric artery but now by a continuation of the superior epigastric artery. This means that the perforator flap previously raised as a propeller flap was raised on a perforating vessel that had originally been supplied by the deep inferior epigastric system. However, it is now supplied by the superior system because that system is no longer
1240
J.Y. Go et al.
Figure 2 (A) Lateral view of the right chest wall showing upper lateral flap margin dehiscence and a soft tissue deficit with extensive scarring. (B) The perforator was visualized and the perforator flap was completely raised. (C) No recurrence or wound problems were observed 12 months after the recycled perforator flap surgery.
connected. A dilatation of choke vessels and reorientation of vessels caused by a prior division of the deep inferior epigastric artery might explain this phenomenon.10 In this case, re-advancement of the flap could be attempted in the same fasciocutaneous manner. However, an increase in lateral tension on the wound would be inevitable due to the reduced movability of the soft tissues in the re-advancement. A satisfactory range and unrestricted direction of advancement can be ensured by dissecting the perforator to obtain a lengthy pedicle and elevate and rotate the flap as an island flap. An intramuscular perforator
dissection could be performed, a perforator-based flap within the boundaries of the previous flap could be elevated and the flap could be rotated as a propeller flap. This case demonstrates that despite ligation of the deep inferior epigastric system, it is still possible to raise perforator flaps within pre-existing musculocutaneous superiorly based vertical rectus abdominis flaps. This suggests that a prior flap can be re-elevated and re-transferred as a perforator flap when a reliable perforator is preserved in the supramuscular layer and is identified within the tissues of the musculocutaneous unit of a previously transferred
Recycled perforator flap flap. This concept of recycling a previous musculocutaneous or fasciocutaneous flap as a subsequent perforator flap will be very useful and applicable to recurring defects in many other locations. Therefore, reconstructive surgeons should consider this potential option.
Funding None.
Conflict of interest None.
References 1. Kroll SS, Hamilton S. Multiple and repetitive uses of the extended hamstring VeY myocutaneous flap. Plast Reconstr Surg 1989;84:296e302. 2. Mun GH. Recycled free septocutaneous perforator flap. Ann Plast Surg 2008;60:37e40.
1241 3. Havlik R, Ariyan S. Repeated use of the same myocutaneous flap in difficult second operations of the head and neck. Plast Reconstr Surg 1994;93:481e8. 4. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63:1223e6. 5. Ang GG, Rozen WM, Chauhan A, Acosta R. The pedicled ‘propeller’ deep inferior epigastric perforator (DIEP) flap for a large abdominal wall defect. J Plast Reconstr Aesthet Surg; 2010. 6. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 7. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82:815e32. 8. Hallock GG. The superior epigastric (RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 2005;55:430e2. 9. Atisha D, Alderman AK, Janiga T, Singal B, Wilkins EG. The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg 2009;63:383e8. 10. Yim HY, Park YJ. Clinical application of the delayed procedure in the distally based sural flap. J Korean Soc Plast Reconstr Surg 2010;37(6):775e8.