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The bilobed flap as a lifeboat flap for a forearm soft tissue defect
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e2
CORRESPONDENCE AND COMMUNICATION The bilobed flap as a lifeboat flap for a forearm soft tissue defect Dear Sir, The bilobed flap is most commonly suited to reconstruct defects on the nasal tip. However its use has been extended to other anatomical locations including the upper limb. Onishi et al. described the use of the bilobed fasciocutaneous flap for large upper arm soft tissue defects. They reported its reliability, ease of dissection and also the selection of perforators to maintain a robust blood supply to the flap.1 Other authors have described its use for correction of radial club hand2 and closure of radial forearm donor site.3 We describe its use in a challenging case where reconstructive options were limited. A 62-year-old lady presented with local recurrence of epitheloid sarcoma in her right arm. Previously she had excision of this tumour from the dorsum of her forearm and soft tissue and bony resection required a free osseocutaneous fibula flap, which had been anastomosed end-to-side onto her radial artery. A staging CT also revealed metastatic spread of the sarcoma to distant sites (Pulmonary, Hepatic). Further palliative excision of the upper limb sarcoma was advised after MDT discussion. However several challenges were present, firstly the patient would not tolerate a prolonged general anaesthetic or procedure due to diminished pulmonary function and metastatic disease. One option proposed was a radial forearm flap, however no radial pulse was felt on palpation. An ulnar artery based flap was also deemed too risky and would possibly jeopardize the vascularlty of the hand. Furthermore free tissue transfer into an irradiated site was felt inappropriate in light of the patient’s comorbidities. Local fasciocutaneous options such as a large hatchet flap or Keystone type flap4 were considered however these flaps could not close the large defect or would require skin grafting of the donor site. The original recurrent sarcoma had been excised 1 month ago at another surgical institution and the patient had been referred to us for a reconstructive procedure. The
wound bed had atrophic muscle, scar tissue and was not amenable to skin grafting or dermal substitute. Decision was made to perform a bilobed flap to reconstruct the defect (Figure 1). The procedure was taken under general anaesthesia and an upper arm tourniquet was used to control bleeding. Suitable perforators were identified with a hand held Doppler. The first lobe of the flap was made the same size as the defect; the second lobe was made almost
Figure 1 weeks.
Flap design, elevation, inset and outcome at 2
http://dx.doi.org/10.1016/j.bjps.2015.03.022 1748-6815/ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Please cite this article in press as: Nikkhah D, Jones M, The bilobed flap as a lifeboat flap for a forearm soft tissue defect, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.022
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MODEL
2 twice as long as the first flap but half the width of the primary flap. Donor site tissues were assessed for suitable laxity and an appropriate arc of rotation for the flaps was chosen. The flaps were raised with the underlying fascia, undermining was necessary to allow tensionless closure. The patient was finally placed in a resting cast with the hand and wrist in the position of function. At review at two weeks in clinic both flaps had survived with good colour match, minimal bulk and no distortion to the surrounding tissues. There was 1 cm2 area of epidermolysis at the tip of second flap however no distal flap necrosis. There was also no evidence of wound dehiscence. At 4 weeks the wounds had fully healed. Although the bilobed flap is well described, its use is uncommon in the upper limb. This is the first description of the use of this flap as a reconstructive option on the dorsum of the forearm in an adult patient. In scenarios such as this where reconstructive options are limited and significant patient comorbidities exist, it can be considered as a robust and quickly executed lifeboat flap.
Conflicts of interest None.
Funding
Correspondence and communication
Ethical approval N/A.
References 1. Onishi K, Maruyama Y, Okada E. Bilobed fasciocutaneous flap for primary repair of a large upper arm defect with secondary closure of the donor site without a skin graft. Ann Plastic Surg 1997;39(2):205e9. 2. Evans DM, Gateley DR, Lewis JS. The use of a bilobed flap in the correction of radial club hand. J Hand Surg 1995;20(3):333e7. 3. Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plastic Reconstr Surg 2004;113(5):1355e60. 4. Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003;73(3):112e20.
Dariush Nikkhah Martin Jones The Queen Victoria Hospital, UK E-mail addresses: [email protected], [email protected] 8 March 2015
None.
Please cite this article in press as: Nikkhah D, Jones M, The bilobed flap as a lifeboat flap for a forearm soft tissue defect, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.022
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e2
CORRESPONDENCE AND COMMUNICATION The bilobed flap as a lifeboat flap for a forearm soft tissue defect Dear Sir, The bilobed flap is most commonly suited to reconstruct defects on the nasal tip. However its use has been extended to other anatomical locations including the upper limb. Onishi et al. described the use of the bilobed fasciocutaneous flap for large upper arm soft tissue defects. They reported its reliability, ease of dissection and also the selection of perforators to maintain a robust blood supply to the flap.1 Other authors have described its use for correction of radial club hand2 and closure of radial forearm donor site.3 We describe its use in a challenging case where reconstructive options were limited. A 62-year-old lady presented with local recurrence of epitheloid sarcoma in her right arm. Previously she had excision of this tumour from the dorsum of her forearm and soft tissue and bony resection required a free osseocutaneous fibula flap, which had been anastomosed end-to-side onto her radial artery. A staging CT also revealed metastatic spread of the sarcoma to distant sites (Pulmonary, Hepatic). Further palliative excision of the upper limb sarcoma was advised after MDT discussion. However several challenges were present, firstly the patient would not tolerate a prolonged general anaesthetic or procedure due to diminished pulmonary function and metastatic disease. One option proposed was a radial forearm flap, however no radial pulse was felt on palpation. An ulnar artery based flap was also deemed too risky and would possibly jeopardize the vascularlty of the hand. Furthermore free tissue transfer into an irradiated site was felt inappropriate in light of the patient’s comorbidities. Local fasciocutaneous options such as a large hatchet flap or Keystone type flap4 were considered however these flaps could not close the large defect or would require skin grafting of the donor site. The original recurrent sarcoma had been excised 1 month ago at another surgical institution and the patient had been referred to us for a reconstructive procedure. The
wound bed had atrophic muscle, scar tissue and was not amenable to skin grafting or dermal substitute. Decision was made to perform a bilobed flap to reconstruct the defect (Figure 1). The procedure was taken under general anaesthesia and an upper arm tourniquet was used to control bleeding. Suitable perforators were identified with a hand held Doppler. The first lobe of the flap was made the same size as the defect; the second lobe was made almost
Figure 1 weeks.
Flap design, elevation, inset and outcome at 2
http://dx.doi.org/10.1016/j.bjps.2015.03.022 1748-6815/ª 2015 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Please cite this article in press as: Nikkhah D, Jones M, The bilobed flap as a lifeboat flap for a forearm soft tissue defect, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.022
+
MODEL
2 twice as long as the first flap but half the width of the primary flap. Donor site tissues were assessed for suitable laxity and an appropriate arc of rotation for the flaps was chosen. The flaps were raised with the underlying fascia, undermining was necessary to allow tensionless closure. The patient was finally placed in a resting cast with the hand and wrist in the position of function. At review at two weeks in clinic both flaps had survived with good colour match, minimal bulk and no distortion to the surrounding tissues. There was 1 cm2 area of epidermolysis at the tip of second flap however no distal flap necrosis. There was also no evidence of wound dehiscence. At 4 weeks the wounds had fully healed. Although the bilobed flap is well described, its use is uncommon in the upper limb. This is the first description of the use of this flap as a reconstructive option on the dorsum of the forearm in an adult patient. In scenarios such as this where reconstructive options are limited and significant patient comorbidities exist, it can be considered as a robust and quickly executed lifeboat flap.
Conflicts of interest None.
Funding
Correspondence and communication
Ethical approval N/A.
References 1. Onishi K, Maruyama Y, Okada E. Bilobed fasciocutaneous flap for primary repair of a large upper arm defect with secondary closure of the donor site without a skin graft. Ann Plastic Surg 1997;39(2):205e9. 2. Evans DM, Gateley DR, Lewis JS. The use of a bilobed flap in the correction of radial club hand. J Hand Surg 1995;20(3):333e7. 3. Hsieh CH, Kuo YR, Yao SF, Liang CC, Jeng SF. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plastic Reconstr Surg 2004;113(5):1355e60. 4. Behan FC. The Keystone design perforator island flap in reconstructive surgery. ANZ J Surg 2003;73(3):112e20.
Dariush Nikkhah Martin Jones The Queen Victoria Hospital, UK E-mail addresses: [email protected], [email protected] 8 March 2015
None.
Please cite this article in press as: Nikkhah D, Jones M, The bilobed flap as a lifeboat flap for a forearm soft tissue defect, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.03.022