COVERAGE OF SUPRAUMBILICAL ABDOMINAL WALL DEFECTS: THE TUNNELLED-PEDICLED ALT TECHNIQUE JOSE-ALBERTO FERNANDEZ-ALVAREZ, M.D.,* FERNANDO BARRERA-PULIDO, M.D., ARACELI LAGARES-BORREGO, M.D., GACTO-SANCHEZ, M.D., Ph.D., and TOMAS GOMEZ-CIA, M.D., Ph.D. ROCIO NARROS-GIMENEZ, M.D., PURIFICACION
Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22–29 3 10–14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6–68 months of follow-up. The tunneled pedicled ALT flap may provide a reliable C 2015 Wiley Periodicals, Inc. Microsurgery alternative method for abdominal wall reconstruction, including supraumbilical defects. V 00:000–000, 2015.
The
reconstruction of wide abdominal full-thickness defects, including the loss of both soft tissue and the deeper musculofascial layer, remains challenging to surgeons today. These can occur after trauma, soft tissue tumor resection, intraabdominal infections, and wound dehiscence. The objective of the reconstructive strategy should be to protect abdominal viscera restoring fascial integrity and accomplishing dynamic structural support to the abdominal wall, prevent hernia, achieve a stable soft tissue covering that minimizes contour deformities, and minimize wound related complications. Numerous techniques for fascial repair have been described. The musculofascial layer can be closed by primary fascial approximation with or without component separation, abdominal reapproximation anchor, synthetic, or bioprosthetic materials and fascial components of tissue flaps.1–3 The most frequently utilized locorregional flaps include, but are not limited to, the external oblique muscle, rectus abdominis muscle, omental flaps, latissimus dorsi muscle, rectus femoris muscle, or tensor fasciae latae muscle.3–5 The anterolateral thigh flap (ALT flap) with or without a portion of vastus lateralis muscle has been also successfully employed, both as free or pedicled flap.6–17 Pedicled flap use has been limited to groin, perineal, and lower abdominal defects,11 and is usually not considered for supraumbilical defects coverage in the Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain *Correspondence to: Jose Alberto Fernandez Alvarez, M.D., Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013-Seville, Spain. E-mail: [email protected] Received 23 November 2014; Revision accepted 8 May 2015; Accepted 19 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22437 Ó 2015 Wiley Periodicals, Inc.
most recent algorithms.12,13 However, additional pedicle length can be achieved if the flap is tunneled beneath the sartorius and rectus femoris muscles, allowing it to reach upper defects. The pedicled-tunneled ALT technique may provide a reliable alternative method for soft tissue coverage in supraumbilical area, including defects close to the xiphoid process. In this article we present the results of the use of tunneled pedicled ALT flaps for coverage of large fullthickness abdominal wall defects in due to intraabdominal injuries from trauma or surgical complications six patients.
PATIENTS AND METHODS
From July 2009 to September 2014, 6 pedicled ALT flaps were harvested to cover full-thickness abdominal wall defects, with abdominal mesh exposure (Table 1). There were 3 female and 3 male patients whose age ranged from 22 to 63 years. Four patients were treated after intraabdominal surgery following organ perforation with peritonitis, 1 patient after streptococcal puerperal sepsis, and 1 patient after abdominal wall and lower limb trauma. The size of the abdominal defects, including both fascial and skin components, ranged from 10 to 14 cm in width and from 18 to 27 cm in length. Most patients had undergone an initial primary fascial closure, with component separation where necessary, and reinforcement with underlay surgical mesh in the retrorectus plane. Peritoneum and posterior rectus fascia were closed under the mesh, which was isolated from the abdominal contents. Later the rectus muscle and anterior rectus fascia were sutured over the mesh, and direct skin closure was performed.
Microsurgery DOI 10.1002/micr
Sex
Female
Female
Male
Female
Male
Male
Age
22
51
39
54
63
62
Acute perforate diverticulitis
Urological complication
Acute peritonitis
Postraumatic
Acute perforate diverticulitis
Ginecological complication
Etiology
22 3 14 cm
25 3 12 cm
27 3 13 cm
23 3 13 cm
23 3 12 cm
18 3 10 cm
Defect size
24 3 15 cm
28 3 13 cm
29 3 15 cm
27 3 13 cm
26 3 13 cm
22 3 13 cm
Flap size Beneath Rectus femoris Beneath Rectus femoris and Sartorius Beneath Rectus femoris Beneath Rectus femoris and Sartorius Beneath Rectus femoris and Sartorius Beneath Rectus femoris and Sartorius
Tunneled path R
R
R
Synthetic V PROCEED
Synthetic (composite) DYNAMESH R IPOMV
Synthetic (Composite) V PHYSIOMESH Synthetic R PROCEEDV
R
Synthetic V PROCEED
Synthetic V PROCEED
Type of mesh
Direct closure
Skin graft
Skin graft
Underlay (Intraperitoneal)
Underlay (retrorectus)
Skin graft
Skin graft
Skin graft
Donor site closure
Underlay (retrorectus)
Underlay (Intraperitoneal)
Underlay (retrorectus)
Underlay (retrorectus)
Mesh placement
Table 1. Clinical Cases Using the Tunneled-Pedicled ALT Flap
100%
100%
100%
100%
95%
100%
Flap survival
–
–
Partial dehiscence of donor site.
–
Small distal flap necrosis and edge dehiscence.
–
Complications
6 months
9 months
10 months
32 months
62 months
68 months
Length of follow-up
Outcomes
Successful
Successful
Abdominal bulging
Successful
Abdominal bulging
Successful
2 Fernandez-Alvarez et al.
Tunneled ALT Flap for Abdominal Wall Coverage
3
Figure 1. Surgical technique: (a) Flap marking. (b) Detail of perforator dissection. (c) Pedicled ALT flap harvested, (d) Tunneling the flap beneath rectus femoris.
Secondarily, all patients suffered infection with extensive tissue necrosis, including skin and muscle-fascial layer, and wound dehiscence with surgical mesh exposure. We employed a homemade vacuum-assisted system for temporal wound coverage. To perform this closure system, all the surface of the clean wound is covered R ), and with a layer of paraffin sterile gauzes (LinitulV sterile polyvinyl-alcohol sponges are wrapped over the layer of Linitul. A wide caliber evacuation tube is placed through the sponges, and the whole area is sealed with adhesive drape (Steri-Drape, 3M, USA) extending 5 cm beyond the margins of the wound, thus creating an airtight seal. The proximal end of the tube is connected to a wall-suction container, and the system is placed under negative pressure at 75–125 mmHg continuously for 1–3 days. The suction machine was employed with low negative pressure over exposed meshes, not directly over the abdominal viscera, to reduce the bioburden and to stimulate the granulation of the wound. We performed a secondary reconstruction with or without synthetic mesh replacement when the general condition of the patients was stable. Operative Technique
Initially we performed surgical debridement of the abdominal wound and we evaluated the exposed mesh.
When a clean and vascularized granulation tissue over the mesh was observed we decided that surgical mesh replacement was not necessary. When persistence of wound infection was observed, the PROCEEDV mesh was replaced by a dual layer composite mesh (DYNAMESH IPOMV) which was placed in an intraperitoneal position and sutured to the remnant native fascia. The flap was designed in supine position at the midpoint of a longitudinal line drawn between the anterior superior iliac spine and the superior lateral border of the patella. Preoperatively, the location of the main cutaneous perforators from principal pedicle was detected and marked with the use of an ultrasound hand Doppler. Cutaneous island design was based on the location of these perforators. If possible, the flap was based on distal eccentric perforators in order to increase the distance that could be reached by it.14 Flap dimensions were designed always slightly (20%) longer than the dimension of the defect (Fig. 1a). A medial incision above the rectus femoris muscle was performed down to the subfascial plane. The pedicle was identified in the intermuscular septum between the rectus femoris and vastus lateralis muscles (Fig. 1b). Loupe magnification was used during perforator vessel dissection, which was always performed as far as their origin in the circumflex femoral vessels. The elevated island pedicled flap was then ready for transfer (Fig. 1c). R
R
Microsurgery DOI 10.1002/micr
4
Fernandez-Alvarez et al.
However, the pedicle length often was insufficient to reach large supraumbilical defects. To achieve additional length of the pedicle, flaps were either tunneled beneath
the rectus femoris muscle, or tunneled beneath both the rectus femoris and sartorius muscles (Figs. 1d and 2), until the flap reached the defect without tension. All the ALT flaps were harvested as a fasciocutaneous flap without including vastus lateralis muscles fibers. The fascial portions of the flaps were sutured to the remnant abdominal fascia, covering the synthetic abdominal mesh. The skin islands of the flaps were then adjusted and sutured to the abdominal skin and suction drains were used in both the donor and receptor area. The donor sites were closed directly when possible, or were covered with split thickness skin grafts, if excessive closure tension occurred. Patients were advised to use a protective abdominal elastic bandage splints to prevent hernia formation. RESULTS
Figure 2. Cross-section through the upper third of the right thigh. Arrow denotes the flap passageway. AB: adductor brevis; AL: adductor longus; AM: adductor magnus; BF: biceps femoris; G: gracilis; GM: Gluteus maximus; RF: rectus femoris; S: sartorius; SM: semimembranosus; ST: semitendinosus; VI: vastus intermedius; VL: vastus lateralis; VM: vastus medialis.
Only one patient required mesh replacement due to persistence of wound infection. The size of skin islands of the ALT flaps ranged from 22 to 29 cm in length and from 10 to 14 cm in width. Two flaps were tunneled beneath the rectus femoris muscle, and 4 flaps were tunneled beneath both the rectus femoris and sartorius muscles. All 6 ALT flaps survived. Partial cutaneous distal flap necrosis (
Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22–29 3 10–14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6–68 months of follow-up. The tunneled pedicled ALT flap may provide a reliable C 2015 Wiley Periodicals, Inc. Microsurgery alternative method for abdominal wall reconstruction, including supraumbilical defects. V 00:000–000, 2015.
The
reconstruction of wide abdominal full-thickness defects, including the loss of both soft tissue and the deeper musculofascial layer, remains challenging to surgeons today. These can occur after trauma, soft tissue tumor resection, intraabdominal infections, and wound dehiscence. The objective of the reconstructive strategy should be to protect abdominal viscera restoring fascial integrity and accomplishing dynamic structural support to the abdominal wall, prevent hernia, achieve a stable soft tissue covering that minimizes contour deformities, and minimize wound related complications. Numerous techniques for fascial repair have been described. The musculofascial layer can be closed by primary fascial approximation with or without component separation, abdominal reapproximation anchor, synthetic, or bioprosthetic materials and fascial components of tissue flaps.1–3 The most frequently utilized locorregional flaps include, but are not limited to, the external oblique muscle, rectus abdominis muscle, omental flaps, latissimus dorsi muscle, rectus femoris muscle, or tensor fasciae latae muscle.3–5 The anterolateral thigh flap (ALT flap) with or without a portion of vastus lateralis muscle has been also successfully employed, both as free or pedicled flap.6–17 Pedicled flap use has been limited to groin, perineal, and lower abdominal defects,11 and is usually not considered for supraumbilical defects coverage in the Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain *Correspondence to: Jose Alberto Fernandez Alvarez, M.D., Department of Plastic and Reconstructive Surgery, Virgen del Rocio University Hospital, Manuel Siurot Av, 41013-Seville, Spain. E-mail: [email protected] Received 23 November 2014; Revision accepted 8 May 2015; Accepted 19 May 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22437 Ó 2015 Wiley Periodicals, Inc.
most recent algorithms.12,13 However, additional pedicle length can be achieved if the flap is tunneled beneath the sartorius and rectus femoris muscles, allowing it to reach upper defects. The pedicled-tunneled ALT technique may provide a reliable alternative method for soft tissue coverage in supraumbilical area, including defects close to the xiphoid process. In this article we present the results of the use of tunneled pedicled ALT flaps for coverage of large fullthickness abdominal wall defects in due to intraabdominal injuries from trauma or surgical complications six patients.
PATIENTS AND METHODS
From July 2009 to September 2014, 6 pedicled ALT flaps were harvested to cover full-thickness abdominal wall defects, with abdominal mesh exposure (Table 1). There were 3 female and 3 male patients whose age ranged from 22 to 63 years. Four patients were treated after intraabdominal surgery following organ perforation with peritonitis, 1 patient after streptococcal puerperal sepsis, and 1 patient after abdominal wall and lower limb trauma. The size of the abdominal defects, including both fascial and skin components, ranged from 10 to 14 cm in width and from 18 to 27 cm in length. Most patients had undergone an initial primary fascial closure, with component separation where necessary, and reinforcement with underlay surgical mesh in the retrorectus plane. Peritoneum and posterior rectus fascia were closed under the mesh, which was isolated from the abdominal contents. Later the rectus muscle and anterior rectus fascia were sutured over the mesh, and direct skin closure was performed.
Microsurgery DOI 10.1002/micr
Sex
Female
Female
Male
Female
Male
Male
Age
22
51
39
54
63
62
Acute perforate diverticulitis
Urological complication
Acute peritonitis
Postraumatic
Acute perforate diverticulitis
Ginecological complication
Etiology
22 3 14 cm
25 3 12 cm
27 3 13 cm
23 3 13 cm
23 3 12 cm
18 3 10 cm
Defect size
24 3 15 cm
28 3 13 cm
29 3 15 cm
27 3 13 cm
26 3 13 cm
22 3 13 cm
Flap size Beneath Rectus femoris Beneath Rectus femoris and Sartorius Beneath Rectus femoris Beneath Rectus femoris and Sartorius Beneath Rectus femoris and Sartorius Beneath Rectus femoris and Sartorius
Tunneled path R
R
R
Synthetic V PROCEED
Synthetic (composite) DYNAMESH R IPOMV
Synthetic (Composite) V PHYSIOMESH Synthetic R PROCEEDV
R
Synthetic V PROCEED
Synthetic V PROCEED
Type of mesh
Direct closure
Skin graft
Skin graft
Underlay (Intraperitoneal)
Underlay (retrorectus)
Skin graft
Skin graft
Skin graft
Donor site closure
Underlay (retrorectus)
Underlay (Intraperitoneal)
Underlay (retrorectus)
Underlay (retrorectus)
Mesh placement
Table 1. Clinical Cases Using the Tunneled-Pedicled ALT Flap
100%
100%
100%
100%
95%
100%
Flap survival
–
–
Partial dehiscence of donor site.
–
Small distal flap necrosis and edge dehiscence.
–
Complications
6 months
9 months
10 months
32 months
62 months
68 months
Length of follow-up
Outcomes
Successful
Successful
Abdominal bulging
Successful
Abdominal bulging
Successful
2 Fernandez-Alvarez et al.
Tunneled ALT Flap for Abdominal Wall Coverage
3
Figure 1. Surgical technique: (a) Flap marking. (b) Detail of perforator dissection. (c) Pedicled ALT flap harvested, (d) Tunneling the flap beneath rectus femoris.
Secondarily, all patients suffered infection with extensive tissue necrosis, including skin and muscle-fascial layer, and wound dehiscence with surgical mesh exposure. We employed a homemade vacuum-assisted system for temporal wound coverage. To perform this closure system, all the surface of the clean wound is covered R ), and with a layer of paraffin sterile gauzes (LinitulV sterile polyvinyl-alcohol sponges are wrapped over the layer of Linitul. A wide caliber evacuation tube is placed through the sponges, and the whole area is sealed with adhesive drape (Steri-Drape, 3M, USA) extending 5 cm beyond the margins of the wound, thus creating an airtight seal. The proximal end of the tube is connected to a wall-suction container, and the system is placed under negative pressure at 75–125 mmHg continuously for 1–3 days. The suction machine was employed with low negative pressure over exposed meshes, not directly over the abdominal viscera, to reduce the bioburden and to stimulate the granulation of the wound. We performed a secondary reconstruction with or without synthetic mesh replacement when the general condition of the patients was stable. Operative Technique
Initially we performed surgical debridement of the abdominal wound and we evaluated the exposed mesh.
When a clean and vascularized granulation tissue over the mesh was observed we decided that surgical mesh replacement was not necessary. When persistence of wound infection was observed, the PROCEEDV mesh was replaced by a dual layer composite mesh (DYNAMESH IPOMV) which was placed in an intraperitoneal position and sutured to the remnant native fascia. The flap was designed in supine position at the midpoint of a longitudinal line drawn between the anterior superior iliac spine and the superior lateral border of the patella. Preoperatively, the location of the main cutaneous perforators from principal pedicle was detected and marked with the use of an ultrasound hand Doppler. Cutaneous island design was based on the location of these perforators. If possible, the flap was based on distal eccentric perforators in order to increase the distance that could be reached by it.14 Flap dimensions were designed always slightly (20%) longer than the dimension of the defect (Fig. 1a). A medial incision above the rectus femoris muscle was performed down to the subfascial plane. The pedicle was identified in the intermuscular septum between the rectus femoris and vastus lateralis muscles (Fig. 1b). Loupe magnification was used during perforator vessel dissection, which was always performed as far as their origin in the circumflex femoral vessels. The elevated island pedicled flap was then ready for transfer (Fig. 1c). R
R
Microsurgery DOI 10.1002/micr
4
Fernandez-Alvarez et al.
However, the pedicle length often was insufficient to reach large supraumbilical defects. To achieve additional length of the pedicle, flaps were either tunneled beneath
the rectus femoris muscle, or tunneled beneath both the rectus femoris and sartorius muscles (Figs. 1d and 2), until the flap reached the defect without tension. All the ALT flaps were harvested as a fasciocutaneous flap without including vastus lateralis muscles fibers. The fascial portions of the flaps were sutured to the remnant abdominal fascia, covering the synthetic abdominal mesh. The skin islands of the flaps were then adjusted and sutured to the abdominal skin and suction drains were used in both the donor and receptor area. The donor sites were closed directly when possible, or were covered with split thickness skin grafts, if excessive closure tension occurred. Patients were advised to use a protective abdominal elastic bandage splints to prevent hernia formation. RESULTS
Figure 2. Cross-section through the upper third of the right thigh. Arrow denotes the flap passageway. AB: adductor brevis; AL: adductor longus; AM: adductor magnus; BF: biceps femoris; G: gracilis; GM: Gluteus maximus; RF: rectus femoris; S: sartorius; SM: semimembranosus; ST: semitendinosus; VI: vastus intermedius; VL: vastus lateralis; VM: vastus medialis.
Only one patient required mesh replacement due to persistence of wound infection. The size of skin islands of the ALT flaps ranged from 22 to 29 cm in length and from 10 to 14 cm in width. Two flaps were tunneled beneath the rectus femoris muscle, and 4 flaps were tunneled beneath both the rectus femoris and sartorius muscles. All 6 ALT flaps survived. Partial cutaneous distal flap necrosis (
