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Vascularised reconstruction of the clavicle
0007~1226’9l1~004i
Brimh Jmma/ o/Plasrrc Surgery (1990). 43,625-627 ci;; 1990 The Trustees of British Association of Plastic Surgeons
062.5, SII).OO
Case Report Vascularised V. S. DEVARAJ, Department
reconstruction
of the clavicle
S. P. J. KAY and A. G. G. BATCHELOR
of Plastic
Surgery,
St James’s
University
Hospital,
Leeds
Summary-A rare malignant tumour presented as a pathological fracture in the clavicle of an 1 lyear-old girl. This was resected and the defect reconstructed using a pedicled bilobed flap based on the thoracodorsal system with latissimus dorsi and serratus anterior with a rib to replace the clavicle. The innervation of both donor muscles was preserved. The reconstruction was cosmetically acceptable and maintained the function of the thoracohumeral articulation. Although the use of vascularised rib grafts in composite flaps is well documented, this is the first report of clavicular reconstruction using the technique.
Case report K.H. presented with a pathological fracture in the distal two-thirds of the left clavicle. A CAT scan confirmed a soft tissue mass with bone destruction. A bone biopsy suggested a rare malignant tumour derived from Langerbans’ cell histiocytes. She was started on combination chemotherapy and at referral had local ulceration at the biopsy site. Shoulder movements were good and there was no evidence of local lymph node spread or brachial plexus involvement. At operation. the left clavicle was excised completely together with the overlying skin. A latissimus dorsi musculocutaneous island flap was designed mainly over the anterior third of the muscle. The thoracodorsal vessels were exposed and traced to the neurovascular hilum, to identify the branch to serratus anterior (Fig. 1). The latissimus dorsi flap was elevated and reflected cranially. 10.5 cm of the fifth rib were isolated with the corresponding head of serratusanterior on the serratus branch of the thoracodorsal artery. preserving the integrity of the periosteal vessels. Functional disability in the serratus anterior was minimised by preserving the segmental innervation from the long thoracic nerve to the remaining digitations, and similarly, functional disability in the latissimus dorsi was minimised by noting the division of the neurovascular hilum and leaving one branch in situ. The two paddles were passed into the neck superficial to pectoralis minor, deep to the skin, and the rib was inset into the bed of the excised clavicle under the musculocutaneous baddle.
Discussion Strauch et al. ( 197 1) demonstrated the feasibility transferring composite rib island flaps on
Fig. 1
of the
F’lgure 1-Intraoperatlve TD= thoracodorsal
635
view (N = nerve to latlsslmu dorsi; vessels: SA = branch to serratus anterior).
626
BRITISH JOURNAL
internal mammary vessels in dogs. Medgyesi (1973) reported the extensive vascular network connecting muscle, periosteum and bone in a variety of osteomuscular flaps, including rib, in the goat. Clinical reports followed, including free vascularised rib transfers based on internal mammary vessels (Aryian and Finseth, 1978) or posterior intercostal vessels (Serafin et al., 1977). More
OF PLASTIC SURGERY
recently, Cuono and Aryian (1980) and Maruyama et al. (1985) have described pedicled osteomusculocutaneous flaps comprising rib with pectoralis major or latissimus dorsi respectively. Harii et al. (1982) described the combined use of latissimus dorsi and serratus anterior muscles as a free flap on the thoracodorsal vessel axis, and subsequently Richards et al. (1985) reported the use
Fig. 2 Figure 2-Postoperative view at 3 months. (A) Vascularised rib-natural contour replaces clavicle. serratus anterior (no winging) and satisfactory donor site. (C) Abduction in the horizontal plane >90”.
(B) Intact
nerve supply
to
VASCULARISED
RECONSTRUCTION
of the serratus anterior/rib compdsite flap in mandibular reconstruction based on the serratus branches of the thoracodorsal artery, both as free and pedicled flaps; two cases included a latissimus dorsi musculocutaneous unit on the common pedicle. The authors also noted the potential for
including centre
a vascularised
(costochondral
cartilaginous
junction)
627
OF THE CLAVICLE
and
free
growth nerve
grafts by preserving the branches of the long thoracic nerve in the flap itself, for functional muscle transfers. Conclusions The latissimus dorsi musculocutaneous and serratus anterior muscle flap with rib provided vascuralised bone and soft tissue on a single vessel axis. The intrinsic contour of the rib was ideally suited to replace clavicle and provided an excellent cosmetic reconstruction and easily closed donor site with acceptable donor scar, as previously reported with this donor site (Fig. 2A). The innervation of both muscles was identified and preserved, minimising functional disability and preventing floating of the inferior scapular angle (Fig. 2B). By replacing the excised clavicle with rib, the function of the thoracohumeral articulation in elevation and abduction of the arm above the horizontal plane was maintained (Fig. 2C).
Cuona, 6. a. arid Aryian, S. (1980). Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plastic and Reconstructive Surgery, 65,471. Harii, K., Yamada, A., Iskikara, K., Miki, Y. and Itoh, M. (1982). A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plastic and Reconstructive Surgery, 70,620.
Maruyama, Y., Urita, Y. and Oknishi, K. (1985). Rib-latissimus dorsi osteomyocutaneous flap in reconstruction of a mandibular defect. British Journal of Plastic Surgery, 38,234.
Medgyesi, S. (1973). Observations on pedicled grafts in goats. Scandinavian Journal of Plasticand Reconstructive Surgery, I, 110.
Richards, M. A., Poole, M. D. and Godfrey, A. M. (1985). The serratus anterior/rib composite flap in mandibular tion. British Journal of Plastic Surgery, 38,466.
reconstruc-
Serafin, D., ViRarreal-Rios,A. and Georgiade, N. G. (1977). A rib containing free flap to reconstruct mandibular defects. British JournalofPIastic
Surgery, 30,263.
Strauch, B., Bloomberg, A. E. and Lewin, M. L. (1971). An experimental approach to mandibular replacement-island vascular composite rib grafts. British JoumalofPlastic Surgery. 24,334.
The Authors V. S. Devaraj, FRCS, Registrar in Plastic Surgery. S. P. J. Kay, FRCS(Plast), Consultant Plastic Surgeon A. G. G. Batchelor, FRCS(Plast), Consultant Plastic Surgeon Department of Plastic Surgery, - . St James’s University
Hospital,
Beckett Street, Leeds LS9 7TF.
References Aryian, S. and Fmseth, F. J. (1978). The anterior chest approach for obtaining free osteocutaneous rib grafts. Plastic and Reconstructive Surgery, 62,676.
Requests
for reprints
to Mr Batchelor
Paper received 5 October 1989. Accepted 17 April 1990 after revision.
at the above address.
Brimh Jmma/ o/Plasrrc Surgery (1990). 43,625-627 ci;; 1990 The Trustees of British Association of Plastic Surgeons
062.5, SII).OO
Case Report Vascularised V. S. DEVARAJ, Department
reconstruction
of the clavicle
S. P. J. KAY and A. G. G. BATCHELOR
of Plastic
Surgery,
St James’s
University
Hospital,
Leeds
Summary-A rare malignant tumour presented as a pathological fracture in the clavicle of an 1 lyear-old girl. This was resected and the defect reconstructed using a pedicled bilobed flap based on the thoracodorsal system with latissimus dorsi and serratus anterior with a rib to replace the clavicle. The innervation of both donor muscles was preserved. The reconstruction was cosmetically acceptable and maintained the function of the thoracohumeral articulation. Although the use of vascularised rib grafts in composite flaps is well documented, this is the first report of clavicular reconstruction using the technique.
Case report K.H. presented with a pathological fracture in the distal two-thirds of the left clavicle. A CAT scan confirmed a soft tissue mass with bone destruction. A bone biopsy suggested a rare malignant tumour derived from Langerbans’ cell histiocytes. She was started on combination chemotherapy and at referral had local ulceration at the biopsy site. Shoulder movements were good and there was no evidence of local lymph node spread or brachial plexus involvement. At operation. the left clavicle was excised completely together with the overlying skin. A latissimus dorsi musculocutaneous island flap was designed mainly over the anterior third of the muscle. The thoracodorsal vessels were exposed and traced to the neurovascular hilum, to identify the branch to serratus anterior (Fig. 1). The latissimus dorsi flap was elevated and reflected cranially. 10.5 cm of the fifth rib were isolated with the corresponding head of serratusanterior on the serratus branch of the thoracodorsal artery. preserving the integrity of the periosteal vessels. Functional disability in the serratus anterior was minimised by preserving the segmental innervation from the long thoracic nerve to the remaining digitations, and similarly, functional disability in the latissimus dorsi was minimised by noting the division of the neurovascular hilum and leaving one branch in situ. The two paddles were passed into the neck superficial to pectoralis minor, deep to the skin, and the rib was inset into the bed of the excised clavicle under the musculocutaneous baddle.
Discussion Strauch et al. ( 197 1) demonstrated the feasibility transferring composite rib island flaps on
Fig. 1
of the
F’lgure 1-Intraoperatlve TD= thoracodorsal
635
view (N = nerve to latlsslmu dorsi; vessels: SA = branch to serratus anterior).
626
BRITISH JOURNAL
internal mammary vessels in dogs. Medgyesi (1973) reported the extensive vascular network connecting muscle, periosteum and bone in a variety of osteomuscular flaps, including rib, in the goat. Clinical reports followed, including free vascularised rib transfers based on internal mammary vessels (Aryian and Finseth, 1978) or posterior intercostal vessels (Serafin et al., 1977). More
OF PLASTIC SURGERY
recently, Cuono and Aryian (1980) and Maruyama et al. (1985) have described pedicled osteomusculocutaneous flaps comprising rib with pectoralis major or latissimus dorsi respectively. Harii et al. (1982) described the combined use of latissimus dorsi and serratus anterior muscles as a free flap on the thoracodorsal vessel axis, and subsequently Richards et al. (1985) reported the use
Fig. 2 Figure 2-Postoperative view at 3 months. (A) Vascularised rib-natural contour replaces clavicle. serratus anterior (no winging) and satisfactory donor site. (C) Abduction in the horizontal plane >90”.
(B) Intact
nerve supply
to
VASCULARISED
RECONSTRUCTION
of the serratus anterior/rib compdsite flap in mandibular reconstruction based on the serratus branches of the thoracodorsal artery, both as free and pedicled flaps; two cases included a latissimus dorsi musculocutaneous unit on the common pedicle. The authors also noted the potential for
including centre
a vascularised
(costochondral
cartilaginous
junction)
627
OF THE CLAVICLE
and
free
growth nerve
grafts by preserving the branches of the long thoracic nerve in the flap itself, for functional muscle transfers. Conclusions The latissimus dorsi musculocutaneous and serratus anterior muscle flap with rib provided vascuralised bone and soft tissue on a single vessel axis. The intrinsic contour of the rib was ideally suited to replace clavicle and provided an excellent cosmetic reconstruction and easily closed donor site with acceptable donor scar, as previously reported with this donor site (Fig. 2A). The innervation of both muscles was identified and preserved, minimising functional disability and preventing floating of the inferior scapular angle (Fig. 2B). By replacing the excised clavicle with rib, the function of the thoracohumeral articulation in elevation and abduction of the arm above the horizontal plane was maintained (Fig. 2C).
Cuona, 6. a. arid Aryian, S. (1980). Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plastic and Reconstructive Surgery, 65,471. Harii, K., Yamada, A., Iskikara, K., Miki, Y. and Itoh, M. (1982). A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plastic and Reconstructive Surgery, 70,620.
Maruyama, Y., Urita, Y. and Oknishi, K. (1985). Rib-latissimus dorsi osteomyocutaneous flap in reconstruction of a mandibular defect. British Journal of Plastic Surgery, 38,234.
Medgyesi, S. (1973). Observations on pedicled grafts in goats. Scandinavian Journal of Plasticand Reconstructive Surgery, I, 110.
Richards, M. A., Poole, M. D. and Godfrey, A. M. (1985). The serratus anterior/rib composite flap in mandibular tion. British Journal of Plastic Surgery, 38,466.
reconstruc-
Serafin, D., ViRarreal-Rios,A. and Georgiade, N. G. (1977). A rib containing free flap to reconstruct mandibular defects. British JournalofPIastic
Surgery, 30,263.
Strauch, B., Bloomberg, A. E. and Lewin, M. L. (1971). An experimental approach to mandibular replacement-island vascular composite rib grafts. British JoumalofPlastic Surgery. 24,334.
The Authors V. S. Devaraj, FRCS, Registrar in Plastic Surgery. S. P. J. Kay, FRCS(Plast), Consultant Plastic Surgeon A. G. G. Batchelor, FRCS(Plast), Consultant Plastic Surgeon Department of Plastic Surgery, - . St James’s University
Hospital,
Beckett Street, Leeds LS9 7TF.
References Aryian, S. and Fmseth, F. J. (1978). The anterior chest approach for obtaining free osteocutaneous rib grafts. Plastic and Reconstructive Surgery, 62,676.
Requests
for reprints
to Mr Batchelor
Paper received 5 October 1989. Accepted 17 April 1990 after revision.
at the above address.