Case Report
Reconstructive Extended V-Y Advancement Flap Reconstruction of a Large Posterior Upper Midline Trunk Defect Eugene Y. Fukudome, MD Deepak R. Bharadia, MD, MPH Douglas L. Helm, MD Indranil Sinha, MD
Summary: Large posterior upper trunk defects can be challenging to reconstruct. Trapezius or latissimus dorsi myocutaneous flaps are principally utilized for reconstruction; however, some defects may not be amenable to this standard approach. Here, we describe a patient with a full-thickness skin and subcutaneous tissue loss of the upper back and inferior cervical region after dermatofibrosarcoma protuberans resection. A large, extended V-Y flap was used for closure of this wound secondary to its location, size, and orientation. This approach preserves shoulder function, allows for readvancement of the flap as needed, and is a reconstructive option for patients with large upper back defects. (Plast Reconstr Surg Glob Open 2016;4:e713; doi: 10.1097/GOX.0000000000000722; Published online 20 May 2016.)
CASE PRESENTATION
A 35-year-old man was transferred from an outside institution with a 4-month history of an enlarging, painful, posterior trunk mass. His relevant medical history includes intravenous drug abuse and tobacco smoking. Initially, this painful mass was diagnosed as an abscess and was treated with incision and drainage. The incision never healed, the mass continued to enlarge, and the area became erythematous and drained purulent material. He was transferred to our hospital for further care. Physical examination revealed a large posterior neck/ upper back mass (16 cm transverse × 10 cm craniocaudal) with overlying skin necrosis and surrounding erythema (Fig. 1). The WBC count was elevated at 13. A computed tomography scan and magnetic resonance imaging demonstrated a heterogeneous mass with areas of necrosis, concerning for soft tissue malignancy. He underwent an uneventful resection From the Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, Mass. Received for publication February 9, 2016; accepted March 23, 2016. Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000722
of this mass with wide margins, and pathology subsequently demonstrated a fibrosarcomatous variant (higher grade) of dermatofibrosarcoma protuberans. The wound was initially treated with a negative pressure wound dressing while the diagnosis was being made, and while margins were assessed. Eleven days later, margins were re-excised, and 2 days later, the patient returned to the operating room for reconstruction utilizing an extended V-Y advancement flap (Figs. 2, 3). His postoperative course was complicated by a polymicrobial abscess (Enterobacter cloacae complex, Klebsiella oxytoca, and Staphylococcus aureus) that developed rapidly on postoperative day 2, despite our efforts to ensure a clean wound before reconstruction. This was treated with drainage, antibiotics, and 3 sessions of irrigation and debridement in the operating room on postoperative days 5, 8, and 11. The flaps were readvanced to close the wound 14 days after the initial attempt at closure. The patient was discharged from the hospital in stable condition with no flap loss (Fig. 4). Shoulder range of motion and function was noted to be preserved at follow-up.
DISCUSSION
Large oncologic defects in the upper thoracic/ posterior neck region can be a reconstructive challenge. Skin grafts have limited long-term durability
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016
Fig. 1. A 35-year-old man presented with an enlarging, painful, posterior trunk mass. Pathology was consistent with a fibrosarcomatous variant of dermatofibrosarcoma protuberans.
on the back1 and are also relatively intolerant of radiation therapy. In this region, a trapezius myocutaneous flap based on either the superficial branch of the transverse cervical artery or the dorsal scapular artery would be the first-line option for reconstruc-
Fig. 2. Intraoperative view of the central soft tissue defect, and the extended V-Y advancement flap used for reconstruction. The flap width is designed to be wider than the defect to create 2 limbs that are hinged toward the defect. This design takes advantage of both tissue advancement and transposition of the extension limbs.
2
tion.1,2 The trapezius flap width of around 7 cm will allow primary closure of the donor site.3 We felt that this flap width would be inadequate to close this oncologic defect and did not wish to consider a skin graft to close the donor site. A latissimus dorsi myocutaneous flap can potentially be utilized for upper thoracic wound reconstruction, but the superior aspect of this wound appeared to be beyond the arc of rotation. Free tissue transfer provides robust, vascularized soft tissue coverage but is limited due to a paucity of suitable recipient vessels. The V-Y advancement flap is commonly used to reconstruct small defects, particularly on the face, where there is ample and mobile adjacent tissue.4 The advanced tissue has many similarities including color, thickness, hair growth, and texture to the area being reconstructed, and this contributes to acceptable esthetic outcomes. Several modifications have been described in the literature to close defects where a conventional V-Y advancement flap may be insufficient. Pribaz et al4 first described an extended V-Y flap where the flap width is designed to be larger than the defect. The design results in 1 or 2 limbs that can be hinged toward the defect to help in its closure. This technique was originally described to close face and scalp defects in areas of decreased tis-
Fig. 3. Immediate postoperative view, showing the final inset of the extended V-Y advancement flap.
Fukudome et al. • Extended V-Y Advancement Flap sive tumor with poorer clinical outcomes that warrants more aggressive treatment.9 Our goal was to design the reconstruction so that the wound could be closed as soon as possible, even in the setting of complications so as not to delay adjuvant radiation therapy. Our patient did develop an abscess that required irrigation, debridement and negative pressure wound therapy, but we demonstrate that despite this complication, there was adequate tissue to allow for flap readvancement and closure of the wound in a timely manner.
CONCLUSIONS
Fig. 4. Postoperative result at 6 weeks demonstrates healed incisions and adequate reconstruction of the original defect.
sue mobility. Several authors have reported modifications and different applications of the extended V-Y flap.5–7 Likewise, we have found this technique to be useful in this patient with an upper back defect where tissue mobility was relatively limited. This technique had several advantages in this particular case. First, we felt that this method maximized recruitment of tissue. It was clear that a standard V-Y advancement flap would not have adequately closed this wound due to the relative immobility of the midline back skin. Similarly, we felt that a large keystone flap8 may also be inadequate. A rhomboid flap would take advantage of the lateral tissue with more laxity; however, we were not confident that this technique would close the wound. We felt that our extended V-Y flap design had the highest chance of success because we were taking advantage of both tissue advancement and transposition of the extension limbs, thereby recruiting extra skin from the shoulder area. Second, we had chosen this method because of the potential to re-elevate and readvance the flap in an event of wound dehiscence or flap necrosis. The fibrosarcomatous phenotype of dermatofibrosarcoma protuberans is a more aggres-
Defects involving the posterior truck are typically reconstructed with either a trapezius myocutaneous flap for cervical defects or a latissimus dorsi flap for upper thoracic defects. Occasionally, when these flaps are not suitable, alternative strategies must be entertained. The extended V-Y flap is most commonly used in facial reconstruction, but this concept can be applied elsewhere. In this case, we were able to achieve closure of the wound without muscle harvest, and the large flap design allowed for readvancement to address a complication. Although we do not consider this a first-line method of reconstruction, it does represent a viable option when the more conventional myocutaneous flaps are not suitable. Indranil Sinha, MD 75 Francis St., Boston, MA 02115 E-mail: [email protected]
REFERENCES
1. Hallock GG. Reconstruction of posterior trunk defects. Semin Plast Surg. 2011;25:78–85. 2. Can A, Orgill DP, Dietmar Ulrich JO, et al. The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg. 2014;67:1669–1679. 3. Lee GK, Yamin F, Ho OH. Vertical island trapezius myocutaneous flap for cervical esophagoplasty: case report and review of the literature. Ann Plast Surg. 2012;68:362–365. 4. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg. 1992;90:275–280. 5. Ulusoy MG, Akan IM, Sensöz O, et al. Bilateral, extended V-Y advancement flap. Ann Plast Surg. 2001;46:5–8. 6. Prowse P, Morton J. Extending the extended V-Y flap. J Plast Reconstr Aesthet Surg. 2012;65:818–820. 7. Campus GV, Lissia M, Pancrazi E. The amplified sliding flap. Ann Plast Surg. 1993;31:318–321. 8. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112–120. 9. Llombart B, Serra-Guillén C, Monteagudo C, et al. Dermatofibrosarcoma protuberans: a comprehensive review and update on diagnosis and management. Semin Diagn Pathol. 2013;30:13–28.
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Reconstructive Extended V-Y Advancement Flap Reconstruction of a Large Posterior Upper Midline Trunk Defect Eugene Y. Fukudome, MD Deepak R. Bharadia, MD, MPH Douglas L. Helm, MD Indranil Sinha, MD
Summary: Large posterior upper trunk defects can be challenging to reconstruct. Trapezius or latissimus dorsi myocutaneous flaps are principally utilized for reconstruction; however, some defects may not be amenable to this standard approach. Here, we describe a patient with a full-thickness skin and subcutaneous tissue loss of the upper back and inferior cervical region after dermatofibrosarcoma protuberans resection. A large, extended V-Y flap was used for closure of this wound secondary to its location, size, and orientation. This approach preserves shoulder function, allows for readvancement of the flap as needed, and is a reconstructive option for patients with large upper back defects. (Plast Reconstr Surg Glob Open 2016;4:e713; doi: 10.1097/GOX.0000000000000722; Published online 20 May 2016.)
CASE PRESENTATION
A 35-year-old man was transferred from an outside institution with a 4-month history of an enlarging, painful, posterior trunk mass. His relevant medical history includes intravenous drug abuse and tobacco smoking. Initially, this painful mass was diagnosed as an abscess and was treated with incision and drainage. The incision never healed, the mass continued to enlarge, and the area became erythematous and drained purulent material. He was transferred to our hospital for further care. Physical examination revealed a large posterior neck/ upper back mass (16 cm transverse × 10 cm craniocaudal) with overlying skin necrosis and surrounding erythema (Fig. 1). The WBC count was elevated at 13. A computed tomography scan and magnetic resonance imaging demonstrated a heterogeneous mass with areas of necrosis, concerning for soft tissue malignancy. He underwent an uneventful resection From the Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, Mass. Received for publication February 9, 2016; accepted March 23, 2016. Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000722
of this mass with wide margins, and pathology subsequently demonstrated a fibrosarcomatous variant (higher grade) of dermatofibrosarcoma protuberans. The wound was initially treated with a negative pressure wound dressing while the diagnosis was being made, and while margins were assessed. Eleven days later, margins were re-excised, and 2 days later, the patient returned to the operating room for reconstruction utilizing an extended V-Y advancement flap (Figs. 2, 3). His postoperative course was complicated by a polymicrobial abscess (Enterobacter cloacae complex, Klebsiella oxytoca, and Staphylococcus aureus) that developed rapidly on postoperative day 2, despite our efforts to ensure a clean wound before reconstruction. This was treated with drainage, antibiotics, and 3 sessions of irrigation and debridement in the operating room on postoperative days 5, 8, and 11. The flaps were readvanced to close the wound 14 days after the initial attempt at closure. The patient was discharged from the hospital in stable condition with no flap loss (Fig. 4). Shoulder range of motion and function was noted to be preserved at follow-up.
DISCUSSION
Large oncologic defects in the upper thoracic/ posterior neck region can be a reconstructive challenge. Skin grafts have limited long-term durability
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016
Fig. 1. A 35-year-old man presented with an enlarging, painful, posterior trunk mass. Pathology was consistent with a fibrosarcomatous variant of dermatofibrosarcoma protuberans.
on the back1 and are also relatively intolerant of radiation therapy. In this region, a trapezius myocutaneous flap based on either the superficial branch of the transverse cervical artery or the dorsal scapular artery would be the first-line option for reconstruc-
Fig. 2. Intraoperative view of the central soft tissue defect, and the extended V-Y advancement flap used for reconstruction. The flap width is designed to be wider than the defect to create 2 limbs that are hinged toward the defect. This design takes advantage of both tissue advancement and transposition of the extension limbs.
2
tion.1,2 The trapezius flap width of around 7 cm will allow primary closure of the donor site.3 We felt that this flap width would be inadequate to close this oncologic defect and did not wish to consider a skin graft to close the donor site. A latissimus dorsi myocutaneous flap can potentially be utilized for upper thoracic wound reconstruction, but the superior aspect of this wound appeared to be beyond the arc of rotation. Free tissue transfer provides robust, vascularized soft tissue coverage but is limited due to a paucity of suitable recipient vessels. The V-Y advancement flap is commonly used to reconstruct small defects, particularly on the face, where there is ample and mobile adjacent tissue.4 The advanced tissue has many similarities including color, thickness, hair growth, and texture to the area being reconstructed, and this contributes to acceptable esthetic outcomes. Several modifications have been described in the literature to close defects where a conventional V-Y advancement flap may be insufficient. Pribaz et al4 first described an extended V-Y flap where the flap width is designed to be larger than the defect. The design results in 1 or 2 limbs that can be hinged toward the defect to help in its closure. This technique was originally described to close face and scalp defects in areas of decreased tis-
Fig. 3. Immediate postoperative view, showing the final inset of the extended V-Y advancement flap.
Fukudome et al. • Extended V-Y Advancement Flap sive tumor with poorer clinical outcomes that warrants more aggressive treatment.9 Our goal was to design the reconstruction so that the wound could be closed as soon as possible, even in the setting of complications so as not to delay adjuvant radiation therapy. Our patient did develop an abscess that required irrigation, debridement and negative pressure wound therapy, but we demonstrate that despite this complication, there was adequate tissue to allow for flap readvancement and closure of the wound in a timely manner.
CONCLUSIONS
Fig. 4. Postoperative result at 6 weeks demonstrates healed incisions and adequate reconstruction of the original defect.
sue mobility. Several authors have reported modifications and different applications of the extended V-Y flap.5–7 Likewise, we have found this technique to be useful in this patient with an upper back defect where tissue mobility was relatively limited. This technique had several advantages in this particular case. First, we felt that this method maximized recruitment of tissue. It was clear that a standard V-Y advancement flap would not have adequately closed this wound due to the relative immobility of the midline back skin. Similarly, we felt that a large keystone flap8 may also be inadequate. A rhomboid flap would take advantage of the lateral tissue with more laxity; however, we were not confident that this technique would close the wound. We felt that our extended V-Y flap design had the highest chance of success because we were taking advantage of both tissue advancement and transposition of the extension limbs, thereby recruiting extra skin from the shoulder area. Second, we had chosen this method because of the potential to re-elevate and readvance the flap in an event of wound dehiscence or flap necrosis. The fibrosarcomatous phenotype of dermatofibrosarcoma protuberans is a more aggres-
Defects involving the posterior truck are typically reconstructed with either a trapezius myocutaneous flap for cervical defects or a latissimus dorsi flap for upper thoracic defects. Occasionally, when these flaps are not suitable, alternative strategies must be entertained. The extended V-Y flap is most commonly used in facial reconstruction, but this concept can be applied elsewhere. In this case, we were able to achieve closure of the wound without muscle harvest, and the large flap design allowed for readvancement to address a complication. Although we do not consider this a first-line method of reconstruction, it does represent a viable option when the more conventional myocutaneous flaps are not suitable. Indranil Sinha, MD 75 Francis St., Boston, MA 02115 E-mail: [email protected]
REFERENCES
1. Hallock GG. Reconstruction of posterior trunk defects. Semin Plast Surg. 2011;25:78–85. 2. Can A, Orgill DP, Dietmar Ulrich JO, et al. The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg. 2014;67:1669–1679. 3. Lee GK, Yamin F, Ho OH. Vertical island trapezius myocutaneous flap for cervical esophagoplasty: case report and review of the literature. Ann Plast Surg. 2012;68:362–365. 4. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg. 1992;90:275–280. 5. Ulusoy MG, Akan IM, Sensöz O, et al. Bilateral, extended V-Y advancement flap. Ann Plast Surg. 2001;46:5–8. 6. Prowse P, Morton J. Extending the extended V-Y flap. J Plast Reconstr Aesthet Surg. 2012;65:818–820. 7. Campus GV, Lissia M, Pancrazi E. The amplified sliding flap. Ann Plast Surg. 1993;31:318–321. 8. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112–120. 9. Llombart B, Serra-Guillén C, Monteagudo C, et al. Dermatofibrosarcoma protuberans: a comprehensive review and update on diagnosis and management. Semin Diagn Pathol. 2013;30:13–28.
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