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The ‘buddy flap’ concept of soft-tissue-defect reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1475e1482
The ‘buddy flap’ concept of soft-tissue-defect reconstruction Yuanbo Liu a,*, Mengqing Zang a, Bin Song a, Shan Zhu a, Ji Jin a, Shengji Yu b, Libin Xu b, Donghong Liu a, Qiang Ding a a
Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Ba-Da-Chu Road 33#, Beijing 100144, China b Cancer Hospital, Peking Union Medical College, Beijing, China Received 20 February 2011; accepted 15 May 2011
KEYWORDS Soft-tissue reconstruction; Pedicle flap; Donor site morbidity; Perforator flap
Summary Background: Closure of donor-site defects from large cutaneous flap harvesting often faces significant morbidity, which limits the utility of workhorse flaps in large-softtissue defect reconstruction. To overcome this limitation, we introduced the concept of a second ‘buddy’ flap to reconstruct the donor-site defect. Methods: Between 2007 and 2010, the buddy flap concept was applied in 12 patients. In each case, the primary flap, which included the latissimus dorsi myocutaneous flap, parascapular flap, transverse rectus abdominis myocutaneous flap, superficial inferior epigastric artery flap and anterolateral thigh flap, was transferred to repair the primary defect. In addition, a secondary pedicle flap, either an axial flap or a perforator flap, was chosen as a buddy flap for closure of the donor-site defect. Results: The primary defects ranged from 10 7 to 35 20 cm in size. Donor-site closure was accomplished using buddy flaps with preserved normal contour and acceptable scars. Additional time for the buddy flap harvesting and insetting was within 1 h. All flaps survived completely. There were three cases with complications, such as seroma, wound infection and haematoma, which were managed accordingly without compromising the viability of flaps. Conclusions: The buddy flap approach achieved reliable coverage of large donor-site defects with low morbidity and excellent aesthetic results. This technique allows reconstructive surgeons to harvest large cutaneous flaps without being limited by significant donor-site morbidity. We demonstrate that this technique can diminish the concern regarding donorsite defect in large soft-tissue reconstruction. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 88771985; fax: þ86 88964137. E-mail address: [email protected] (Y. Liu). 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.2011.05.019
1476 All flap surgery “robs Peter to pay Paul,” and the art is to strike the appropriate balance between defect reconstruction and donor-site morbidity.1 Often, large flaps are necessary to provide wound coverage of the primary defect, which forces the surgeon to accept significant donor-site morbidity. In these situations, the donor sites are closed either under great tension or with skin grafting, which will often lead to wound dehiscence, unacceptable scarring and contour deformity. These donor-site problems compromise the overall reconstructive outcomes, and thus concerns over donor-site morbidity are raised when elevating a large cutaneous flap. To decrease donor-site morbidity, many authors endeavoured to achieve primary closure of donor sites of various workhorse flaps by using pre-transfer tissue expansion.2,3,4 However, those options are often not possible when urgent tissue coverage is required. The radial forearm flap is a workhorse for head and neck reconstruction. However, donor-site morbidity remains its main disadvantage. Elliot et al.5 first introduced a secondflap based on the ulnar artery to aid in direct closure of the radial-forearm-flap donor site with VeY advancement. Later, Hsieh et al.6 and Shoaib et al.7 improved the secondflap technique to further reduce the forearm-donor-site morbidity using an island flap based on ulnar-artery perforators. We found this second-flap concept could be applied to other workhorse flaps, such as the parascapular flap,8 the superficial inferior epigastric artery (SIEA) flap9 and the reverse latissimus dorsi myocutaneous (LDM) flap,10 if a known independent vessel is available in adjacent regions on which a pedicle flap can be raised and transferred to the donor site. Those second ‘buddy’ flaps were very useful in aiding donor-site closure after large flaps were harvested. Recently, the freestyle perforator flap concept was introduced by Wei and Mardini.11 The freestyle approach allows the design of a flap over any cutaneous vessel based solely on the characteristics of its Doppler signal.11 This approach provides surgeons with a greater degree of freedom in terms of reconstructive options and also allows us to develop the buddy flap concept for wider clinical applications. In this article, we summarise the clinical applications of the buddy flap concept, which was used to aid in the closure of donor defects at various parts of the body. These regions include back, abdomen and anterior thigh, where workhorse flaps, such as the LDM flap, the parascapular flap, the transverse rectus abdominis myocutaneous (TRAM) flap, the SIEA flap and the anterolateral thigh (ALT) flaps, were harvested with wide cutaneous paddles for coverage of large soft-tissue defect.
Patients and methods Between March 2007 and December 2010, the buddy flap approach was applied by the senior author to 12 patients for reconstruction of oncologic defects (n Z 5) and postburn sequelae (n Z 7) located at various anatomical sites: head and neck (n Z 2), anterior trunk (n Z 3), posterior trunk (n Z 3), perineal/gluteal (n Z 2) and upper limb (n Z 2). There were two males and 10 females with a mean age of 34 years (range, 5e67 years). The size of the
Y. Liu et al. primary flap for defect reconstruction, the buddy flap design for donor-site closure and the reconstructive outcomes were retrospectively reviewed (Table 1).
Operative technique Prior to surgery, the dimension of potential defect from tumour ablation or scar-contracture release was estimated and outlined. A primary flap was selected and designed to match the size and shape of the defect. In four cases, tissue expansion was performed first to create larger flaps (case 1, 2, 3 and 8). In the vicinity of the primary flap, either a known axial flap or a perforator flap was chosen to close the potential donor-site defect. The vascular pedicle of the secondary flap should be independent from that of the primary flap, and its location was determined by using ultrasound Doppler. In case of the perforator flap, the Doppler signal intensity was used to guide perforator selection. The best available perforator in terms of vessel diameter and location as a pivot point for flap transfer was determined. Next, the buddy flap skin island based on the vascular pedicle was designed so that its shape and dimension would render an easy closure of the primary flap donor site (Figure 1). Once the primary and the buddy flaps are selected and marked, the primary flap is elevated first. During elevation of the flap, care is taken not to injure the neighbouring vascular pedicle of the buddy flap. Upon insetting of the primary flap, we then proceed to raise the buddy flap. The vascular pedicle of the buddy flap is identified and traced retrograde to a pivot point that will allow adequate mobility of the flap. The buddy flap is then either rotated or advanced to close the donor-site defect. The resultant defect of the buddy flap donor site is primarily closed without tension.
Results The size of primary defects in various anatomic locations ranged from 10 7 to 35 20 cm (Table 1). In this series, six LDM flaps based on thoracodorsal vessels or posterior intercostal vessels were used to repair the defects on the chest wall or in the posterior lumber area. These donor sites were closed by the use of ascending scapular fasciocutaneous flaps. Two parascapular free flaps were transferred to resurface cervical defects, with their donor sites closed by either a perforator flap or an LDM flap, based on the thoracodorsal artery, as buddy flaps. Abdominal flaps, such as the TRAM flap or the SIEA flap, were used to reconstruct the lateral thigh or hand dorsal defects, respectively. These abdominal flaps donor sites were closed with the deep inferior epigastric perforator (DIEP) flap. One perineal reconstruction was performed by using ALT flap. The resultant donor defect was repaired using a neighbouring freestyle perforator flap as the buddy flap. The additional operative time for the elevation and inset of all buddy flaps was within 1 h in each case. Complete primary closure was achieved in all recipient and donor sites. Normal contour at back, abdomen and anterior thigh was preserved, and the resulting scar was linear. All flaps survived completely. Complications were
The ‘buddy flap’ concept of soft-tissue-defect reconstruction Table 1
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Summary of all primary and buddy flaps in this series.
Case Sex/ Wound No. Age location
Cause of defect
Primary flap
Secondary Defect Primary flap Secondary flap Complications flap size (cm) size (cm) size (cm)
1 2 3 4 5 6 7 8 9 10 11 12
Postburn Contracture Postburn contracture Postburn contracture Soft-tissue sarcoma Soft-tissue sarcoma Soft-tissue sarcoma Postburn contracture Postburn contracture Soft-tissue Sarcoma Postburn contracture Postburn contracture Granular cell myoblastoma
LDMa LDMa LDMa RLDM RLDM RLDM Parascapular Parascapulara TRAM SIEA SIEA ALT
AS AS ASa AS AS AS TAP LDMa DIEP DIEP DIEP Freestyle
F 23 M 36 F5 F 39 F 59 F46 F 32 F 20 F 67 F 54 M6 F 19
R. Chest L. Chest R. Chest R. Lumbar R. Lumbar L. Lumbar Neck Neck R. Thigh L. Hand R. Hand Perineal
21 35 29 13 22 12 18 25 20 12 10 12
12 20 13 12 14 10 14 16 16 12 8 12
31 35 29 13 26 16 18 25 20 12 10 16
14 20 13 13 14 10 14 16 17 12 8 10
18 23 20 13 20 14 14 10 20 8 9 10
7 7 8 6 8 5 8 14 8 7 7.5 6
None None None Seroma None None None None Infection None None Haematoma
AbbreviationR: Right; L: Left; LDM: Latissimus dorsi myocutaneous; RLDM: Reverse latissimus dorsi myocutaneous; AS: Ascending scapular; TAP: Thoracodorsal artery perforator; TRAM: Transverse rectus abdominus myocutaneous; DIEP: Deep inferior epigastric perforator; SIEA: Superficial inferior epigastric artery; ALT: Anterolateral thigh. a Pre-expanded flap.
developed in three patients. One patient (case 4) developed a seroma after surgery under the second flap, which was treated with repeated aspiration and resolved. Wound infection occurred in one case (case 9), which involved the use of Prolene polypropylene mesh for the repair of rectus fascia after TRAM-flap elevation. The mesh was removed, and local debridement was performed, resulting in a wellhealed wound with no hernia or abdominal bulge. One patient (case 12) developed a postoperative haematoma under the primary flap and was treated with surgical drainage promptly, without compromise on the flap survival.
Representative cases Case 1 A 23-year-old female patient presented with a hypertrophic, contracted scar over her anterior chest wall following burn injury. Her post-burn sequela was reconstructed with a 31 14-cm pedicle LDM flap, which was expanded for 16 weeks prior to transfer (Figure 1). An elliptical, ascending, scapular flap measuring 18 7 cm was raised, and its vascular pedicle was dissected to the triangular space. The flap was rotated 180 and inset to close the donor site (Figure 2). The postoperative course was uneventful.
Figure 1 Design of primary and secondary flaps (Case 1). (Left) the dimension of the potential defect was estimated and outlined. (Right) LDM flap was selected and pre-expanded to repair the defect on the chest wall. Ascending scapular flap based on circumflex scapular artery was designed to aid in donor-site closure of LDM flap.
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Y. Liu et al.
Figure 2 Case 1. (Left) Excellent reconstructive outcome by pedicle LDM flap was shown on the chest wall two weeks postoperatively. (Right) The donor-site showed good healing and the normal contour of the back was preserved.
Figure 3 Case 9. (A) patient with soft-tissue sarcoma on her right lateral thigh. (B) A 20 17 cm pedicle TRAM flap was designed to repair the oncological defect and contralateral DIEP flap to close the donor site. (C ) The abdominal donor-site defect was repaired with a pedicle DIEP flap. (D) The flap was inset into the defect.
The ‘buddy flap’ concept of soft-tissue-defect reconstruction
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Case 9 A 67-year-old female patient presented with a right thigh lesion for which the biopsy yielded a diagnosis of spindle cell sarcoma. She underwent an extensive excision by the oncologic surgeons. A 20 17-cm pedicle island TRAM flap was transferred to repair the resultant thigh defect. Prolene polypropylene mesh was inlayed. A contralateral DIEP flap measuring 20 8 cm was raised and rotated 90 to facilitate the closure of the primary donor site. Infection was developed at the primary donor-site 3 months postoperatively. The implants were promptly removed, and surgical debridement was performed. The wound was primarily closed with adequate vascularised tissue over a drain. Wound was successfully healed and did not result in any compromise of the DIEP flap (Figure 3).
Case 12 A 19-year-old female patient presented with a giant perineal granular cell myoblastoma. The tumour was removed, and the resultant defect was repaired by a pedicle ALT flap of 16 10 cm. The flaps were tunnelled subcutaneously to reach the perineal area. A perforator adjacent to the ALT flap was detected, and an elliptical flap measuring 10 6 cm was elevated. The flap was rotated 180 to reach and close the donor site of the ALT flap. The patient suffered haematoma under the ALT flap postoperatively and was treated with a surgical drainage procedure. This did not compromise flap viability (Figure 5).
Case 11 A 6-year-old male patient suffered from burn scarring on the dorsum of the right hand for 5 years. Scar excision and contracture release was performed, resulting in a 10 8cm dorsal hand defect that was covered by a super-thin pedicle SIEA flap. A triangular island DIEP flap containing at least two major perforators was elevated and advanced medially to repair the donor-site defect of the SIEA flap. Three weeks after surgery, the pedicle was divided. The patient’s flaps survived without any complications (Figure 4).
One of the major challenges of large soft-tissue-defect reconstruction is donor-site morbidities. Closure of the secondary defect under great tension will result in wound dehiscence, widened scar and tightness.12e15 In the case that a skin graft is required, the resulting contour deformity can be remarkably unattractive, sometimes unacceptable. In addition, functional problems, such as potential motion restriction of nearby joints, might develop postoperatively in the donor site.16 High incidence of abdominal bulge and hernia has also been reported after abdominal flaps are harvested.17 Those complications will increase with skin
Discussion
Figure 4 Case 11. (A) A patient presented with severe scar contracture on dorsum of his right hand. (B) A SIEA flap and ipsilateral DIEP flap was raised based on their independent vascular pedicles. (C ) The SIEA flap was transferred to inset into the defect of dorsal hand. The DIEP flap was advanced and inset into the medial defect. (D) The SIEA flap was divided 3 weeks postoperatively.
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Figure 5 Case 12. (A) Patient with a huge perineal Granular cell myoblastoma. A pedicle ALT flap was designed to reconstruct the potential perineal defect. (B) An ALT flap was raised and a freestyle perforator flap was also elevated. (C ) The pedicle ALT flap was transferred and inset into the perineal defect. The freestyle perforator flap was rotated 180 and inset into the anterior thigh donor-site defect.
grafting. On the other hand, when applying a skin graft in regions of body that demand mobility, shear forces tend to result in graft slippage and incomplete graft take, which requires long-term postoperative immobilisation with increased inconvenience.18 These donor-site problems result in plastic surgeons’ hesitation to deploy large workhorse flaps in soft-tissue-defect reconstruction. To give more freedom to surgeons facing this demanding clinical
Y. Liu et al. scenario, we introduced a neighbouring pedicle flap to facilitate the closure of the large donor-site defect. We found that with the assistance of the secondary flap adjacent to the donor site, that is, a buddy flap, a large primary flap can be harvested with minimal donor-site morbidity. By employing the buddy flap concept, we were able to reconstruct a defect at various regions of the body and of various sizes, with excellent clinical outcome. We demonstrated that the large defects at head and neck, torso and extremities can be repaired by the most suitable flaps without concern over donor-site defects. With another flap surgery, one might be concerned with the additional operative time and advanced surgical skill. However, we found that, in all cases, the buddy flaps can be raised and inset within 1 h. Further, when compared with skin grafting, the difference in time is minimal. Furthermore, the surgical skill necessary to raise the buddy flap is the same as in case of the primary flap. The secondary defect of the buddy flap was closed directly and resulted in a lengthy linear scar at the common donor site. There is no additional donor-site morbidity, which is unavoidable when using skin grafting. Further, following the principle of repairing ‘like with like’, the normal contour of the donor site of the primary flap was well preserved with a good aesthetic results. Most importantly, major postoperative complications related to the second-flap surgery, such as partial flap necrosis and flap loss, did not occur in this series, most likely due to the reliable vascularity of the selected secondary flap and appropriate flap design. This illustrates the need for a clear understanding of the regional vasculature anatomy, which plays a critical role in preoperative planning and preservation of the pedicles of the buddy flaps. The anatomical basis for our technique is the fact that, in a particular region of the body, there is a group of cutaneous vasculature which can be used as the pedicle of the buddy flap after elevation of the primary flap. For example, in posterior trunk, the LDM flap and the circumflex scapular artery-based flaps can be harvested without damaging the intactness of the vascular pedicle of the other flap. Large LDM flap donor-site closure was aided by the ascending scapular flap. Maruyama19 demonstrated that this flap could be raised with a maximum size of 33 cm length and 10 cm width and transferred freely with its vascular pedicle dissected to a triangular space. We found it very convenient to use this flap in LDM flap donor-site closure following 180 rotation. Accordingly, the donor defect of the scapular flap can be repaired by the LDM flap or the pedicled thoracodorsal artery perforator (TDAP) with rotation or advancement. When using the ascending scapular flap as the buddy flap, the scarring in the upper back might be a source of embarrassment for patients. Thus, this technique should be confined to the patients who need an urgent reconstruction precluding pre-expansion or a large en bloc LDM flap for more significant functional reconstruction. In such clinical scenarios, patients should be informed of the pros and cons of this technique. The abdomen and the anterior thigh region also have multiple cutaneous arterial supplies.20,21 Multiple flaps can reliably be harvested from distinct skin territories, each retaining its independent vascular pedicle, which are well suited for our buddy flap approach. The use of the DIEP flap
The ‘buddy flap’ concept of soft-tissue-defect reconstruction as the buddy flap for the SIEA flap is a good example of application of this principle. SIEA and DIEA are independent vascular systems supplying the lower abdomen. In addition, the skin paddles perfused by the separate source arteries can be safely raised without interrupting each others’ vascular pedicles.9 The secondary flap procedure has been reported in the closure of thigh donor-site defect.22 However, we learnt that it is important to choose an appropriate buddy flap. One must adhere to the principles of pedicle flap design, considering the location of the vascular pedicle and arc of rotation. The groin flap was previously used to close the donor site of the ALT flap22; however, it is not a choice for the buddy flap when the ALT flap must cross the groin region to reach the recipient sites. In such a circumstance, the freestyle pedicle perforator flap technique provided us with more reconstructive options. Wei et al.11 reported that the freestyle perforator flap can be raised reliably based on any vessel that has a Doppler signal, and adequate pedicle length is achievable by retrograde dissection. Thus, if a sizable perforator can be identified in the vicinity of the primary flap donor site, a pedicle freestyle perforator flap can be used as the buddy flap. In this series, a freestyle perforator flap was used as the buddy flap after an ALT flap was transferred to repair a large perineal defect. A skin paddle of 10 6 cm was safely harvested based on a perforator superior to the ALT flap donor site, which derived from the transverse branch of the lateral circumflex femoral artery. Such perforator flaps were previously used with VeY advancement to achieve direct donor-site closure of the ALT flap.23 However, we preferred the propeller design in this case, as the flap is able to reach more distal part of the thigh donor site. If the luxury of time is available, the ability of the buddy flap to aid in large donor-site-defect closure can be enhanced by pre-transfer tissue expansion. For example, by placing an expander under the subcutaneous fat tissue and using pre-expansion, an ascending scapular flap could be harvested with increased length and transferred to reach the lower back region, which allows the LDM flap to be raised from the whole hemi-back. It is convenient to apply the pre-expansion procedure to the primary flap and buddy flap simultaneously. The size of primary flap can be maximised with the combination of tissue expansion and buddy flap technique, which benefits the reconstruction of extensive soft-tissue defects, such as in patients suffering severe post-burn sequelae.
Conclusions Based on the knowledge of regional vascular anatomy, we could use a buddy flap to aid in donor-site closure of various workhorse flaps with low morbidity and excellent aesthetic results. This technique allowed us to harvest a large flap from posterior trunk, abdomen and anterior thigh for demanding soft-tissue reconstruction, with no concern as regards significant donor-site morbidity. With the freestyle perforator flap technique, the application of this buddy flap concept can be further expanded. We hope this concept would provide an option when plastic surgeons are faced with a critical soft-tissue defect.
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Conflict of interest None of the authors has a financial interest to disclose in relation to the content of this article.
References 1. Wei FC, Mardini S. Flaps and reconstructive surgery. New York: Elsevier; 2009. 2. Slavin SA. Improving the latissimus dorsi myocutaneous flap with tissue expansion. Plast Reconstr Surg 1994;93:811e24. 3. Russell RC, Khouri RK, Upton J, et al. The expanded scapular flap. Plast Reconstr Surg 1995;96:884e95. discussion 896e887. 4. Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg 2004;53:170e3. 5. Elliot D, Bardsley AF, Batchelor AG, et al. Direct closure of the radial forearm flap donor defect. Br J Plast Surg 1988;41: 358e60. 6. Hsieh CH, Kuo YR, Yao SF, et al. Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery. Plast Reconstr Surg 2004;113:1355e60. 7. Shoaib T, Van Niekerk WJ, Morley S, et al. The ulnar artery perforator based islanded VeY flap closure of the radial forearm flap donor site. J Plast Reconstr Aesthet Surg 2009;62: 421e3. 8. Liu Y, Song B, Jin J, et al. A freestyle pedicled thoracodorsal artery perforator flap aiding the donor-site closure of a parascapular flap. J Plast Reconstr Aesthet Surg 2010;63: e280e282. 9. Liu Y, Song B, Zhu S, et al. Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2010;63:e265e268. 10. Liu Y, Yu S, Song B, et al. Reconstruction of posterior lumbar defects in oncologic patients using two island flaps of the back in series. Ann Plast Surg 2010;65:326e9. 11. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114:910e6. 12. Adams Jr WP, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg 2004;53:6e11. 13. Boca R, Kuo YR, Hsieh CH, et al. A reliable parameter for primary closure of the free anterolateral thigh flap donor site. Plast Reconstr Surg 2010;126:1558e62. 14. Clough KB, Louis-Sylvestre C, Fitoussi A, et al. Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg 2002;109: 1904e11. 15. Hanasono MM, Skoracki RJ, Yu P. A prospective study of donorsite morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg 2010;125:209e14. 16. Kimata Y, Uchiyama K, Ebihara S, et al. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 2000;106:584e9. 17. Vyas RM, Dickinson BP, Fastekjian JH, et al. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008;121:1519e26. 18. Townley WA, Dunn RL, Crick AP. Skin graft take at the anterolateral thigh donor site. Plast Reconstr Surg 2010;126:678. author reply 679. 19. Maruyama Y. Ascending scapular flap and its use for the treatment of axillary burn scar contracture. Br J Plast Surg 1991;44:97e101.
1482 20. Hester Jr TR, Nahai F, Beegle PE, et al. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast Reconstr Surg 1984;74:657e70. 21. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 1988;82: 305e10.
Y. Liu et al. 22. Zhao Y, Qiao Q, Liu Z, et al. Alternative method to improve the repair of the donor site of the anterolateral thigh flap. Ann Plast Surg 2002;49:593e8. 23. Yamada N, Kakibuchi M, Kitayoshi H, et al. A new way of elevating the anterolateral thigh flap. Plast Reconstr Surg 2001;108:1677e82.
The ‘buddy flap’ concept of soft-tissue-defect reconstruction Yuanbo Liu a,*, Mengqing Zang a, Bin Song a, Shan Zhu a, Ji Jin a, Shengji Yu b, Libin Xu b, Donghong Liu a, Qiang Ding a a
Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Ba-Da-Chu Road 33#, Beijing 100144, China b Cancer Hospital, Peking Union Medical College, Beijing, China Received 20 February 2011; accepted 15 May 2011
KEYWORDS Soft-tissue reconstruction; Pedicle flap; Donor site morbidity; Perforator flap
Summary Background: Closure of donor-site defects from large cutaneous flap harvesting often faces significant morbidity, which limits the utility of workhorse flaps in large-softtissue defect reconstruction. To overcome this limitation, we introduced the concept of a second ‘buddy’ flap to reconstruct the donor-site defect. Methods: Between 2007 and 2010, the buddy flap concept was applied in 12 patients. In each case, the primary flap, which included the latissimus dorsi myocutaneous flap, parascapular flap, transverse rectus abdominis myocutaneous flap, superficial inferior epigastric artery flap and anterolateral thigh flap, was transferred to repair the primary defect. In addition, a secondary pedicle flap, either an axial flap or a perforator flap, was chosen as a buddy flap for closure of the donor-site defect. Results: The primary defects ranged from 10 7 to 35 20 cm in size. Donor-site closure was accomplished using buddy flaps with preserved normal contour and acceptable scars. Additional time for the buddy flap harvesting and insetting was within 1 h. All flaps survived completely. There were three cases with complications, such as seroma, wound infection and haematoma, which were managed accordingly without compromising the viability of flaps. Conclusions: The buddy flap approach achieved reliable coverage of large donor-site defects with low morbidity and excellent aesthetic results. This technique allows reconstructive surgeons to harvest large cutaneous flaps without being limited by significant donor-site morbidity. We demonstrate that this technique can diminish the concern regarding donorsite defect in large soft-tissue reconstruction. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 88771985; fax: þ86 88964137. E-mail address: [email protected] (Y. Liu). 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.2011.05.019
1476 All flap surgery “robs Peter to pay Paul,” and the art is to strike the appropriate balance between defect reconstruction and donor-site morbidity.1 Often, large flaps are necessary to provide wound coverage of the primary defect, which forces the surgeon to accept significant donor-site morbidity. In these situations, the donor sites are closed either under great tension or with skin grafting, which will often lead to wound dehiscence, unacceptable scarring and contour deformity. These donor-site problems compromise the overall reconstructive outcomes, and thus concerns over donor-site morbidity are raised when elevating a large cutaneous flap. To decrease donor-site morbidity, many authors endeavoured to achieve primary closure of donor sites of various workhorse flaps by using pre-transfer tissue expansion.2,3,4 However, those options are often not possible when urgent tissue coverage is required. The radial forearm flap is a workhorse for head and neck reconstruction. However, donor-site morbidity remains its main disadvantage. Elliot et al.5 first introduced a secondflap based on the ulnar artery to aid in direct closure of the radial-forearm-flap donor site with VeY advancement. Later, Hsieh et al.6 and Shoaib et al.7 improved the secondflap technique to further reduce the forearm-donor-site morbidity using an island flap based on ulnar-artery perforators. We found this second-flap concept could be applied to other workhorse flaps, such as the parascapular flap,8 the superficial inferior epigastric artery (SIEA) flap9 and the reverse latissimus dorsi myocutaneous (LDM) flap,10 if a known independent vessel is available in adjacent regions on which a pedicle flap can be raised and transferred to the donor site. Those second ‘buddy’ flaps were very useful in aiding donor-site closure after large flaps were harvested. Recently, the freestyle perforator flap concept was introduced by Wei and Mardini.11 The freestyle approach allows the design of a flap over any cutaneous vessel based solely on the characteristics of its Doppler signal.11 This approach provides surgeons with a greater degree of freedom in terms of reconstructive options and also allows us to develop the buddy flap concept for wider clinical applications. In this article, we summarise the clinical applications of the buddy flap concept, which was used to aid in the closure of donor defects at various parts of the body. These regions include back, abdomen and anterior thigh, where workhorse flaps, such as the LDM flap, the parascapular flap, the transverse rectus abdominis myocutaneous (TRAM) flap, the SIEA flap and the anterolateral thigh (ALT) flaps, were harvested with wide cutaneous paddles for coverage of large soft-tissue defect.
Patients and methods Between March 2007 and December 2010, the buddy flap approach was applied by the senior author to 12 patients for reconstruction of oncologic defects (n Z 5) and postburn sequelae (n Z 7) located at various anatomical sites: head and neck (n Z 2), anterior trunk (n Z 3), posterior trunk (n Z 3), perineal/gluteal (n Z 2) and upper limb (n Z 2). There were two males and 10 females with a mean age of 34 years (range, 5e67 years). The size of the
Y. Liu et al. primary flap for defect reconstruction, the buddy flap design for donor-site closure and the reconstructive outcomes were retrospectively reviewed (Table 1).
Operative technique Prior to surgery, the dimension of potential defect from tumour ablation or scar-contracture release was estimated and outlined. A primary flap was selected and designed to match the size and shape of the defect. In four cases, tissue expansion was performed first to create larger flaps (case 1, 2, 3 and 8). In the vicinity of the primary flap, either a known axial flap or a perforator flap was chosen to close the potential donor-site defect. The vascular pedicle of the secondary flap should be independent from that of the primary flap, and its location was determined by using ultrasound Doppler. In case of the perforator flap, the Doppler signal intensity was used to guide perforator selection. The best available perforator in terms of vessel diameter and location as a pivot point for flap transfer was determined. Next, the buddy flap skin island based on the vascular pedicle was designed so that its shape and dimension would render an easy closure of the primary flap donor site (Figure 1). Once the primary and the buddy flaps are selected and marked, the primary flap is elevated first. During elevation of the flap, care is taken not to injure the neighbouring vascular pedicle of the buddy flap. Upon insetting of the primary flap, we then proceed to raise the buddy flap. The vascular pedicle of the buddy flap is identified and traced retrograde to a pivot point that will allow adequate mobility of the flap. The buddy flap is then either rotated or advanced to close the donor-site defect. The resultant defect of the buddy flap donor site is primarily closed without tension.
Results The size of primary defects in various anatomic locations ranged from 10 7 to 35 20 cm (Table 1). In this series, six LDM flaps based on thoracodorsal vessels or posterior intercostal vessels were used to repair the defects on the chest wall or in the posterior lumber area. These donor sites were closed by the use of ascending scapular fasciocutaneous flaps. Two parascapular free flaps were transferred to resurface cervical defects, with their donor sites closed by either a perforator flap or an LDM flap, based on the thoracodorsal artery, as buddy flaps. Abdominal flaps, such as the TRAM flap or the SIEA flap, were used to reconstruct the lateral thigh or hand dorsal defects, respectively. These abdominal flaps donor sites were closed with the deep inferior epigastric perforator (DIEP) flap. One perineal reconstruction was performed by using ALT flap. The resultant donor defect was repaired using a neighbouring freestyle perforator flap as the buddy flap. The additional operative time for the elevation and inset of all buddy flaps was within 1 h in each case. Complete primary closure was achieved in all recipient and donor sites. Normal contour at back, abdomen and anterior thigh was preserved, and the resulting scar was linear. All flaps survived completely. Complications were
The ‘buddy flap’ concept of soft-tissue-defect reconstruction Table 1
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Summary of all primary and buddy flaps in this series.
Case Sex/ Wound No. Age location
Cause of defect
Primary flap
Secondary Defect Primary flap Secondary flap Complications flap size (cm) size (cm) size (cm)
1 2 3 4 5 6 7 8 9 10 11 12
Postburn Contracture Postburn contracture Postburn contracture Soft-tissue sarcoma Soft-tissue sarcoma Soft-tissue sarcoma Postburn contracture Postburn contracture Soft-tissue Sarcoma Postburn contracture Postburn contracture Granular cell myoblastoma
LDMa LDMa LDMa RLDM RLDM RLDM Parascapular Parascapulara TRAM SIEA SIEA ALT
AS AS ASa AS AS AS TAP LDMa DIEP DIEP DIEP Freestyle
F 23 M 36 F5 F 39 F 59 F46 F 32 F 20 F 67 F 54 M6 F 19
R. Chest L. Chest R. Chest R. Lumbar R. Lumbar L. Lumbar Neck Neck R. Thigh L. Hand R. Hand Perineal
21 35 29 13 22 12 18 25 20 12 10 12
12 20 13 12 14 10 14 16 16 12 8 12
31 35 29 13 26 16 18 25 20 12 10 16
14 20 13 13 14 10 14 16 17 12 8 10
18 23 20 13 20 14 14 10 20 8 9 10
7 7 8 6 8 5 8 14 8 7 7.5 6
None None None Seroma None None None None Infection None None Haematoma
AbbreviationR: Right; L: Left; LDM: Latissimus dorsi myocutaneous; RLDM: Reverse latissimus dorsi myocutaneous; AS: Ascending scapular; TAP: Thoracodorsal artery perforator; TRAM: Transverse rectus abdominus myocutaneous; DIEP: Deep inferior epigastric perforator; SIEA: Superficial inferior epigastric artery; ALT: Anterolateral thigh. a Pre-expanded flap.
developed in three patients. One patient (case 4) developed a seroma after surgery under the second flap, which was treated with repeated aspiration and resolved. Wound infection occurred in one case (case 9), which involved the use of Prolene polypropylene mesh for the repair of rectus fascia after TRAM-flap elevation. The mesh was removed, and local debridement was performed, resulting in a wellhealed wound with no hernia or abdominal bulge. One patient (case 12) developed a postoperative haematoma under the primary flap and was treated with surgical drainage promptly, without compromise on the flap survival.
Representative cases Case 1 A 23-year-old female patient presented with a hypertrophic, contracted scar over her anterior chest wall following burn injury. Her post-burn sequela was reconstructed with a 31 14-cm pedicle LDM flap, which was expanded for 16 weeks prior to transfer (Figure 1). An elliptical, ascending, scapular flap measuring 18 7 cm was raised, and its vascular pedicle was dissected to the triangular space. The flap was rotated 180 and inset to close the donor site (Figure 2). The postoperative course was uneventful.
Figure 1 Design of primary and secondary flaps (Case 1). (Left) the dimension of the potential defect was estimated and outlined. (Right) LDM flap was selected and pre-expanded to repair the defect on the chest wall. Ascending scapular flap based on circumflex scapular artery was designed to aid in donor-site closure of LDM flap.
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Figure 2 Case 1. (Left) Excellent reconstructive outcome by pedicle LDM flap was shown on the chest wall two weeks postoperatively. (Right) The donor-site showed good healing and the normal contour of the back was preserved.
Figure 3 Case 9. (A) patient with soft-tissue sarcoma on her right lateral thigh. (B) A 20 17 cm pedicle TRAM flap was designed to repair the oncological defect and contralateral DIEP flap to close the donor site. (C ) The abdominal donor-site defect was repaired with a pedicle DIEP flap. (D) The flap was inset into the defect.
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Case 9 A 67-year-old female patient presented with a right thigh lesion for which the biopsy yielded a diagnosis of spindle cell sarcoma. She underwent an extensive excision by the oncologic surgeons. A 20 17-cm pedicle island TRAM flap was transferred to repair the resultant thigh defect. Prolene polypropylene mesh was inlayed. A contralateral DIEP flap measuring 20 8 cm was raised and rotated 90 to facilitate the closure of the primary donor site. Infection was developed at the primary donor-site 3 months postoperatively. The implants were promptly removed, and surgical debridement was performed. The wound was primarily closed with adequate vascularised tissue over a drain. Wound was successfully healed and did not result in any compromise of the DIEP flap (Figure 3).
Case 12 A 19-year-old female patient presented with a giant perineal granular cell myoblastoma. The tumour was removed, and the resultant defect was repaired by a pedicle ALT flap of 16 10 cm. The flaps were tunnelled subcutaneously to reach the perineal area. A perforator adjacent to the ALT flap was detected, and an elliptical flap measuring 10 6 cm was elevated. The flap was rotated 180 to reach and close the donor site of the ALT flap. The patient suffered haematoma under the ALT flap postoperatively and was treated with a surgical drainage procedure. This did not compromise flap viability (Figure 5).
Case 11 A 6-year-old male patient suffered from burn scarring on the dorsum of the right hand for 5 years. Scar excision and contracture release was performed, resulting in a 10 8cm dorsal hand defect that was covered by a super-thin pedicle SIEA flap. A triangular island DIEP flap containing at least two major perforators was elevated and advanced medially to repair the donor-site defect of the SIEA flap. Three weeks after surgery, the pedicle was divided. The patient’s flaps survived without any complications (Figure 4).
One of the major challenges of large soft-tissue-defect reconstruction is donor-site morbidities. Closure of the secondary defect under great tension will result in wound dehiscence, widened scar and tightness.12e15 In the case that a skin graft is required, the resulting contour deformity can be remarkably unattractive, sometimes unacceptable. In addition, functional problems, such as potential motion restriction of nearby joints, might develop postoperatively in the donor site.16 High incidence of abdominal bulge and hernia has also been reported after abdominal flaps are harvested.17 Those complications will increase with skin
Discussion
Figure 4 Case 11. (A) A patient presented with severe scar contracture on dorsum of his right hand. (B) A SIEA flap and ipsilateral DIEP flap was raised based on their independent vascular pedicles. (C ) The SIEA flap was transferred to inset into the defect of dorsal hand. The DIEP flap was advanced and inset into the medial defect. (D) The SIEA flap was divided 3 weeks postoperatively.
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Figure 5 Case 12. (A) Patient with a huge perineal Granular cell myoblastoma. A pedicle ALT flap was designed to reconstruct the potential perineal defect. (B) An ALT flap was raised and a freestyle perforator flap was also elevated. (C ) The pedicle ALT flap was transferred and inset into the perineal defect. The freestyle perforator flap was rotated 180 and inset into the anterior thigh donor-site defect.
grafting. On the other hand, when applying a skin graft in regions of body that demand mobility, shear forces tend to result in graft slippage and incomplete graft take, which requires long-term postoperative immobilisation with increased inconvenience.18 These donor-site problems result in plastic surgeons’ hesitation to deploy large workhorse flaps in soft-tissue-defect reconstruction. To give more freedom to surgeons facing this demanding clinical
Y. Liu et al. scenario, we introduced a neighbouring pedicle flap to facilitate the closure of the large donor-site defect. We found that with the assistance of the secondary flap adjacent to the donor site, that is, a buddy flap, a large primary flap can be harvested with minimal donor-site morbidity. By employing the buddy flap concept, we were able to reconstruct a defect at various regions of the body and of various sizes, with excellent clinical outcome. We demonstrated that the large defects at head and neck, torso and extremities can be repaired by the most suitable flaps without concern over donor-site defects. With another flap surgery, one might be concerned with the additional operative time and advanced surgical skill. However, we found that, in all cases, the buddy flaps can be raised and inset within 1 h. Further, when compared with skin grafting, the difference in time is minimal. Furthermore, the surgical skill necessary to raise the buddy flap is the same as in case of the primary flap. The secondary defect of the buddy flap was closed directly and resulted in a lengthy linear scar at the common donor site. There is no additional donor-site morbidity, which is unavoidable when using skin grafting. Further, following the principle of repairing ‘like with like’, the normal contour of the donor site of the primary flap was well preserved with a good aesthetic results. Most importantly, major postoperative complications related to the second-flap surgery, such as partial flap necrosis and flap loss, did not occur in this series, most likely due to the reliable vascularity of the selected secondary flap and appropriate flap design. This illustrates the need for a clear understanding of the regional vasculature anatomy, which plays a critical role in preoperative planning and preservation of the pedicles of the buddy flaps. The anatomical basis for our technique is the fact that, in a particular region of the body, there is a group of cutaneous vasculature which can be used as the pedicle of the buddy flap after elevation of the primary flap. For example, in posterior trunk, the LDM flap and the circumflex scapular artery-based flaps can be harvested without damaging the intactness of the vascular pedicle of the other flap. Large LDM flap donor-site closure was aided by the ascending scapular flap. Maruyama19 demonstrated that this flap could be raised with a maximum size of 33 cm length and 10 cm width and transferred freely with its vascular pedicle dissected to a triangular space. We found it very convenient to use this flap in LDM flap donor-site closure following 180 rotation. Accordingly, the donor defect of the scapular flap can be repaired by the LDM flap or the pedicled thoracodorsal artery perforator (TDAP) with rotation or advancement. When using the ascending scapular flap as the buddy flap, the scarring in the upper back might be a source of embarrassment for patients. Thus, this technique should be confined to the patients who need an urgent reconstruction precluding pre-expansion or a large en bloc LDM flap for more significant functional reconstruction. In such clinical scenarios, patients should be informed of the pros and cons of this technique. The abdomen and the anterior thigh region also have multiple cutaneous arterial supplies.20,21 Multiple flaps can reliably be harvested from distinct skin territories, each retaining its independent vascular pedicle, which are well suited for our buddy flap approach. The use of the DIEP flap
The ‘buddy flap’ concept of soft-tissue-defect reconstruction as the buddy flap for the SIEA flap is a good example of application of this principle. SIEA and DIEA are independent vascular systems supplying the lower abdomen. In addition, the skin paddles perfused by the separate source arteries can be safely raised without interrupting each others’ vascular pedicles.9 The secondary flap procedure has been reported in the closure of thigh donor-site defect.22 However, we learnt that it is important to choose an appropriate buddy flap. One must adhere to the principles of pedicle flap design, considering the location of the vascular pedicle and arc of rotation. The groin flap was previously used to close the donor site of the ALT flap22; however, it is not a choice for the buddy flap when the ALT flap must cross the groin region to reach the recipient sites. In such a circumstance, the freestyle pedicle perforator flap technique provided us with more reconstructive options. Wei et al.11 reported that the freestyle perforator flap can be raised reliably based on any vessel that has a Doppler signal, and adequate pedicle length is achievable by retrograde dissection. Thus, if a sizable perforator can be identified in the vicinity of the primary flap donor site, a pedicle freestyle perforator flap can be used as the buddy flap. In this series, a freestyle perforator flap was used as the buddy flap after an ALT flap was transferred to repair a large perineal defect. A skin paddle of 10 6 cm was safely harvested based on a perforator superior to the ALT flap donor site, which derived from the transverse branch of the lateral circumflex femoral artery. Such perforator flaps were previously used with VeY advancement to achieve direct donor-site closure of the ALT flap.23 However, we preferred the propeller design in this case, as the flap is able to reach more distal part of the thigh donor site. If the luxury of time is available, the ability of the buddy flap to aid in large donor-site-defect closure can be enhanced by pre-transfer tissue expansion. For example, by placing an expander under the subcutaneous fat tissue and using pre-expansion, an ascending scapular flap could be harvested with increased length and transferred to reach the lower back region, which allows the LDM flap to be raised from the whole hemi-back. It is convenient to apply the pre-expansion procedure to the primary flap and buddy flap simultaneously. The size of primary flap can be maximised with the combination of tissue expansion and buddy flap technique, which benefits the reconstruction of extensive soft-tissue defects, such as in patients suffering severe post-burn sequelae.
Conclusions Based on the knowledge of regional vascular anatomy, we could use a buddy flap to aid in donor-site closure of various workhorse flaps with low morbidity and excellent aesthetic results. This technique allowed us to harvest a large flap from posterior trunk, abdomen and anterior thigh for demanding soft-tissue reconstruction, with no concern as regards significant donor-site morbidity. With the freestyle perforator flap technique, the application of this buddy flap concept can be further expanded. We hope this concept would provide an option when plastic surgeons are faced with a critical soft-tissue defect.
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Conflict of interest None of the authors has a financial interest to disclose in relation to the content of this article.
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1482 20. Hester Jr TR, Nahai F, Beegle PE, et al. Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery. Plast Reconstr Surg 1984;74:657e70. 21. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 1988;82: 305e10.
Y. Liu et al. 22. Zhao Y, Qiao Q, Liu Z, et al. Alternative method to improve the repair of the donor site of the anterolateral thigh flap. Ann Plast Surg 2002;49:593e8. 23. Yamada N, Kakibuchi M, Kitayoshi H, et al. A new way of elevating the anterolateral thigh flap. Plast Reconstr Surg 2001;108:1677e82.