MICROSURGERY
Free Latissimus Dorsi MuscleYChimeric Thoracodorsal Artery Perforator Flaps for Reconstruction of Complicated Defects Does Muscle Still Have a Place in the Domain of Perforator Flaps? Kyeong-Tae Lee, MD, Elrica Sapphira Wiraatmadja, MD, and Goo-Hyun Mun, MD, PhD Purpose: The reconstruction of complicated defects with 3-dimensional deficits remains challenging. The reconstruction of these defects requires not only coverage of surface but also appropriate obliteration of dead space, and muscleYchimeric perforator flaps can be a valuable option. Here, we present our experience with free latissimus dorsi (LD) muscleYchimeric thoracodorsal artery perforator (TDAP) flaps for the treatment of complicated defects. Methods: A retrospective chart review was performed for patients who underwent a free LD muscleYchimeric TDAP f lap procedure for the treatment of complicated wounds with 3-dimensional tissue deficits between March 2005 and October 2012. The surgical technique, clinical outcomes, and postoperative complications were evaluated. Results: A total of 24 cases were included. All f laps survived and no partial f lap losses were encountered. Large skin f laps of 115 cm2 average size were elevated, with an average of 38-cm2 muscle segments. The total length of pedicle was 12.2 cm on average, with 7.3 cm of common pedicle, 4.9 cm of skin paddle, and 3.4 cm of muscle segments. Muscle segments could be inset in the underlying dead space with spatial freedom. The mean follow-up period was 34.1 months. Wounds successfully healed in all cases without significant postoperative complications. The donor-site complication rate of the chimeric f lap group was similar to that of the simple TDAP group. Conclusions: The use of LD muscleYchimeric TDAP flaps with Y-pedicle configurations allowed efficient positioning of both skin and muscle components for their specific purposes and successful healing of complicated wounds. The muscle components of chimeric f laps acted as ‘‘filler f laps’’ and were an effective addition to the perforator f lap technique for the reconstruction of complicated defects without the addition of significant donor-site morbidity. Key Words: thoracodorsal artery perforator flap, chimeric flap, complicated defect (Ann Plast Surg 2015;74: 565Y572)
R
econstruction of complicated wounds involving losses of multiple tissues and 3-dimensional tissue defects has been challenging. Such wounds can be accompanied by extensive soft tissue defects and dead spaces of varying location and extent. Their reconstruction requires not only coverage of surface defects but also obliteration of dead space to achieve successful wound healing and prevent postoperative complications.
Received March 11, 2013, and accepted for publication, after revision, July 19, 2013. From the Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Goo-Hyun Mun, MD, PhD, Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong 50, Gangnam-gu, Seoul 135-710, South Korea. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0565 DOI: 10.1097/SAP.0b013e3182a6363c
Annals of Plastic Surgery
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Historically, muscle or musculocutaneous f laps have been widely used for the reconstruction of complicated defects, such as open fracture sites1,2 or osteomyelitis wounds.3,4 Recently, a few studies have advocated the use of fasciocutaneous f laps or perforator f laps excluding muscle tissues and reporting comparable surgical outcomes, while commenting the drawbacks of muscle f laps, including potential donor-site morbidity, inferior aesthetic outcome, and the necessity of further debulking procedures.5Y7 However, because the inherent advantages of muscle tissue1,2,8 over other tissues including high vascularity and ability to adapt to defect shapes remain important, muscle tissues have been generally preferred for the reconstruction of complicated defects. Chimeric f laps were first reported by Hallock9 in the lateral thigh and have been applied in various reconstructive fields.10,11 Several studies have reported the advantages of chimeric flaps, including economy of donor incision and superior aesthetic outcomes.12 The latissimus dorsi (LD) muscleYchimeric thoracodorsal artery perforator (TDAP) f lap has been reported to be useful for the reconstruction of massive soft tissue defects.11,13,14 However, most of these f laps were designed for the reconstruction of extensive defects with 2-dimensional tissue losses. In these cases, muscle tissues were used to increase the dimension of the f lap to cover extensive defects and a large part of the LD muscle had to be harvested, eventually leading to considerable donor morbidity. When reconstructing complicated wounds with 3-dimensional tissue deficits, different customized chimeric flap designs are required for efficient coverage of superficial defects and effective obliteration of dead space. In addition, if the volume of the harvested muscle is kept as small as possible, merit of minimal donor-site morbidity in perforator flap can be maintained even in muscleYchimeric design perforator flap. However, to the best of our best knowledge, the use of selectively designed muscle tissue to reconstruct complicated defects has not been studied in the context of free TDAP flaps. Here, we present our experience of using free LD muscleYchimeric TDAP f laps for reconstructions of complicated defects.
PATIENTS AND METHODS Data regarding patients having complicated defects treated with a free LD muscleYchimeric TDAP flap procedure from March 2005 to October 2012 were collected based on chart review. The patients who underwent conventional or muscle-sparing musculocutaneous LD f lap and simple skin TDAP flap rotation above LD muscle without complete separation of the 2 components were excluded. All reconstructive surgeries were performed by a single surgeon (G.M.).
Surgical Technique Patients were placed in a lateral decubitus position and the scapular angle tip and borders of the LD muscle were marked. Thoracodorsal artery perforators were mapped with a sterile Doppler probe. A skin f lap was designed along the axis lying parallel to the relaxed skin tension line in a transverse fashion. Muscle segments to be harvested were designed referring to the size of dead space to be www.annalsplasticsurgery.com
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obliterated. An initial incision line was made at the central portion of the superior border of the f lap and dissection proceeded along the loose areolar plane above the dorsal thoracic fascia. After identifying the marked perforator by suprafascial elevation of the f lap inferiorly, an entire incision was made along the skin paddle margins. After full suprafascial elevation of the skin paddle, intramuscular dissection of the perforator was initiated. When the perforator pedicle met the sizable intramuscular branch, which was usually the main descending branch of the thoracodorsal vessel, the branch was dissected to follow its course in a proximal-to-distal direction for adequate distance and a muscle segment of suitable size was then harvested. The size of muscle flaps was determined mainly by focusing on the size of dead space to be obliterated in recipient sites. When large muscle segments are necessary, the main descending branch of thoracodorsal vessels was used for pedicle of muscle flaps, and in cases needing small size of muscle segments, such as less than 10 cm2, intramuscular branches of those vessels were used. Pedicle dissection proximal to the confluence point of pedicles was performed as usual to gain sufficient pedicle length. By careful dissection, intramuscular branches of the thoracodorsal nerve were preserved as much as possible with the exception of the distal branch entering the muscle segment harvested. Ultimately, a muscleYchimeric TDAP flap with Y-shaped pedicle configuration composed of common pedicle and independent pedicle for each component was harvested. The flap was temporarily inset and microvascular anastomosis was performed. The muscle segment was placed to fill the dead space and also to provide an even healthy bed for subsequent skin paddle of the flap (Fig. 1). The skin paddle was then inset after generous defatting to preserve the subdermal plexus and achieve optimal flap thickness. During insetting of both tissue segments, careful attention was paid to avoiding pedicle kinking, twisting, or tension that might occur, especially in distal independent pedicle portions. A sufficient length of each distal limb of Y-shaped pedicle allowed freedom in the spatial arrangement of each component to effectively reconstruct the 3-dimensional defect (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A139, which demonstrates harvesting and insetting of LDYchimeric TDAP flap). The donor site was closed primarily in all cases after placement of suction drains.
Evaluating Donor-Site Complications To evaluate donor-site morbidity, we compared postoperative complication rates of donor site, amount of drainage, and duration of drain maintenance in the muscleYchimeric group with other groups. First, the donor-site complication rates were compared in 3 groups as follows: the simple TDAP f lap group having only a skin component, the LD muscle f lap group having only a muscle component, and the LD muscleYchimeric TDAP f lap group in the patients undergoing reconstructive surgery using the same donor site consecutively during the same study period. A total of 191 consecutive patients underwent free flap reconstruction based on the thoracodorsal artery system, including 147 simple TDAP flaps, 20 LD muscle flaps, and 24 cases of LD muscleYchimeric TDAP flaps. The donor-site complications including infection, hematoma, seroma, and wound dehiscence were analyzed. Next, the groups were also compared with regard to the total amount of drainage and the duration of drain maintenance from donor sites. Among 147 simple TDAP f lap patients, 24 cases having the skin paddles most similar in size with those of the chimeric f lap group were chosen as a matched control group, because the dimensions of harvested skin paddles can inf luence the amount of drainage from donor sites. Pearson W2 test was used for categorical variables, and the Mann-Whitney test and Kruskal-Wallis test were used for continuous variables, because data did not follow a normal distribution in this study. A P value of less than 0.05 was considered statistically significant. Statistical analysis was performed using the 566
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FIGURE 1. Harvest and inset of LD muscleYchimeric TDAP f laps for complicated defect reconstruction. An LD muscleYchimeric TDAP f lap with Y-shaped pedicle configuration composed of common pedicle and independent pedicle for each f lap component was harvested. Then, the dead space could be obliterated with muscle segments and surface defects could be covered with perforator f laps. Each f lap component could be placed for their original purpose with spatial freedom.
Statistical Package for the Social Sciences version 18.0 (SPSS Inc, Chicago, Ill).
RESULTS A total of 24 free LD muscleYchimeric TDAP flaps were performed in 23 patients for the treatment of complicated wounds with 3-dimensional tissue deficits. The mean age at surgery was 45.0 years (range, 7Y75 years). There were 5 diabetic patients and 2 active smokers at the time of surgery in our sample. The causes of defects were chronic wounds accompanied by osteomyelitis in 12 cases, oncologic defects in 7 cases, and traumatic defects in 5 cases. All wounds presented 3-dimensional tissue deficits consisting of surface defects and underlying or contiguous dead space. The mean size of surface defects was 112.9 cm2 (range, 25Y297 cm2), and the average estimated dead space was 35 cm3 (range, 3Y150 cm3). The origins of dead space development were soft tissue loss in 9 cases and bony defect in 15 cases (Table 1). Flaps survived completely in all cases without any partial flap loss. In 2 patients, flap congestions were encountered at postoperative day 1, and emergent explorations were performed, resulting in successful salvage of entire flaps by venous revision in both cases. All wounds healed successfully without significant postoperative complications, including recurrence of disease in osteomyelitis patients. Minor wound dehiscence occurred around the flap margins in 2 patients having diabetes with poor control due to noncompliance of patients. The wounds were healed completely with conservative management. The mean size of skin f laps was large, 115.2 cm2 (range, 27Y297 cm2) and the mean size of muscle segments incorporated was 38.1 cm2 (range, 3Y160 cm2). The average total length of pedicle was 12.2 cm, composed of 7.3 cm of common pedicle; 4.9 cm of skin * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
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LD MuscleYChimeric TDAP Flaps for Reconstruction
TABLE 1. Patients’ Demographics and Operation Data Flap Size, cm2 Defects Site
Cause of Defects
Skin Paddle
Muscle Segments 2.5 2.5 22 94 4.5 4 44 31 64 83 33 77 77 88 83 15 2 84 31
Pedicle Length, cm Common
To Skin Paddle
To Muscle Segments
Harvested Perforator Numbers
Recipient Vessels
8
6
7
2
Medial sural a.
None
8 4
4.5 6
3 7
2 2
PTA SFA
None None
5 7 7 7 7 10 8 8 10 10 7
4 5 4 5 5 6 5 5 6 7 4
3 4 3 2 3 4 4 4 3 3 3
1 1 1 1 1 1 1 1 1 1 1
DPA ECA ATA PTA PTA Popliteal a. STA ATA ATA Medial sural a. DPA
Case
Sex
Age, y
1
M
55
Lower leg
Chronic OM
14.5 7.5
2 3
M M
65 56
Foot Knee
Diabetic foot Chronic OM
17 6 15 5
4 5 6 7 8 9 10 11 12 13 14
F F M F M M M F F M F
53 51 16 55 36 73 65 21 61 24 47
Foot Cheek Heel Heel Heel Knee Scalp Lower leg Lower leg Lower leg Heel
Chronic OM Oncologic Trauma Diabetic foot Chronic OM Chronic OM Chronic OM Trauma Oncologic Trauma Diabetic foot
10 6 14 7 13 9 6 4.5 13 8 22 13 17 8 20 8 18 8 27 11 10 6.5
15 16 17 18 19 20
M M M F M M
7 57 40 75 13 59
Lower leg Heel Heel Elbow Lower leg Sacrum
Oncologic Diabetic foot Diabetic foot Oncologic Oncologic Sacral sore
14.5 7 86 10 5 15 10 15 7 16 9.5
16 10 4 3.5 33 53 15 10 10 2 10 3
6 7 7 8 5 8
4 5 5 6 4 4
2 3 4 3 3 2
1 1 2 2 1 1
DFA DPA PTA TDA PTA SGA
21 22 23 24
M M M M
15 34 37 66
Knee Ankle Elbow Foot
Oncologic Trauma Trauma Oncologic
14 7 13 10 17 6.5 75
87 53 10 5 3 1.5
8 6 8 5
4 4 7 3
3 3 4 2
1 1 1 2
Medial sural a. PTA GSV LCA
Complication
None None None None None None None None None None Flap margin dehiscence None None None None None Donor site and flap margin dehiscence None None None None
ATA, anterior tibial artery; DPA, dorsalis pedis artery; ECA, external carotid artery; GSV, greater saphenous vein grafted; LCA, lateral calcaneal artery; OM, osteomyelitis; PTA, posterior tibial artery; SFA, superficial femoral artery; SGA, superior gluteal artery; STA, superficial temporal artery.
paddle, and 3.4 cm of muscle segment, respectively. Surface defects were successfully covered using skin perforator f laps and the underlying dead spaces were obliterated using customized muscle f laps. The hospitalization period after reconstructive surgery varied from 10 to 33 days with an average of 23 days. The average follow-up period was 34.1 months (range, 2Y79 months). The transferred f laps conformed well to the transplant site and achieved pleasing contours. Secondary debulking procedures of the f laps were not necessary except in 1 case of plantar reconstruction that had a large dimension of transferred skin f laps, resulting in excision of redundant skin f lap during the follow-up period. Regarding the donor-site complications, wound dehiscence developed in 1 case, which was healed successfully after revision surgery. The average total amount of drainage from the donor site was 295.8 mL, and mean duration of drain maintenance was 7.46 days. The causes of complicated defects, defect sites, and sex did not inf luence donor complications or drainage data. Among the 191 cases undergoing LD muscleYchimeric TDAP, simple TDAP, and LD muscle f laps, donor-site complications occurred in 11 cases, including 5 cases of wound dehiscence, 4 seroma formations, and 2 wound infections. The complication rate of the LD muscleYchimeric TDAP f lap group was similar with that of the simple TDAP f lap group but significantly lower than that of the LD * 2015 Wolters Kluwer Health, Inc. All rights reserved.
muscle group. (LD chimeric vs simple TDAP vs LD group, 4.2% vs 4.1% vs 20.0%, P = 0.015) (Table 2). When comparing the total amount of drainage and the duration of drain maintenance, similar differences were observed (LD chimeric vs simple TDAP vs LD group, 295.8 vs 297.8 vs 562.35 mL, 7.46 vs 7.54 vs 9.35 days, respectively) (Table 3). TABLE 2. Comparison of Donor-Site Complications Among Simple TDAP Flap Group, LD MuscleYChimeric TDAP Flap Group, and LD Muscle Flap Group Simple TDAP Patients number Skin paddle size, cm2 Muscle segment size Donor complication (%)
LD MuscleYChimeric LD TDAP Muscle
147 98.5 0 6 (4.1)
24 115.2 38.1 1 (4.2)
Infection: 2 Dehiscence: 4
Dehiscence: 1
P
20 N/A 0.052 153.3 4 (20.0) 0.015 Seroma: 4
N/A indicates not applicable.
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TABLE 3. Comparison of Donor-Site Drainage Among Skin Paddle Size-Matched Simple TDAP Flap Group, LD MuscleYChimeric TDAP Flap Group, and LD Muscle Flap Group Simple TDAP Patients number Skin paddle size, cm2 Total amount of drain, mL Duration of drain maintenance, d
LD MuscleYChimeric LD TDAP Muscle
24 114.0 297.8 7.54
24 115.2 295.8 7.46
P
20 N/A 0.975 562.35 0.005 9.35 0.041
Case 1 A 55-year-old man presented with chronic osteomyelitis accompanied by skin defects on his left anterior tibia after open fracture. The osteomyelitis was diagnosed by bone scan and magnetic resonance imaging. Soft tissue and bony debridement were performed by the orthopedic surgery team, leaving 14 7-cm skin defects with 2 bony defects. An LD muscleYchimeric TDAP flap was designed with a 14.5 7.5-cm skin paddle based on 2 perforators and 2 muscle segments sized 2.5 2.5 and 2 2 cm located along the course of the descending branch of the thoracodorsal artery. The LD muscleYchimeric TDAP flap with a Y-configuration pedicle was elevated and vascular anastomosis was performed between the pedicle and medial sural vessels in an end-to-end manner. Two muscle segments were placed into bony defects and a skin flap was inset for coverage of soft tissue defects after customized defatting. The flap survived completely and the wound
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healed successfully without any postoperative complications in both recipient and donor sites (Fig. 2). He was discharged at postoperative day 9. No functional impairment of the donor site was observed and recurrence of osteomyelitis did not develop during a 6-year follow-up period.
Case 2 A 65-year-old man visited our center with a diabetic ulcer on his left foot. Because of poor control of infection and progressive necrosis of his big toe, first toe transmetatarsal amputation was performed by the orthopedic surgery team. An abscess in the deep plantar soft tissue required extensive debridement of plantar soft tissue including muscle and tendon, leading to a 15 5-cm skin defect accompanied with dead space on the contiguous plantar region. An LD muscleYchimeric TDAP f lap with 17 6-cm skin paddle and 9 4-cm muscle segments was designed and elevated. After anastomosis with posterior tibial vessels in an end-to-side manner, the plantar dead space was filled with muscle segment and the superficial defect was covered with a skin f lap. The f lap survived well and the wound healed completely (Fig. 3). The patient was discharged without postoperative complications 2 weeks after surgery and did not present with any reconstruction-related problem, including functional impairment of the donor site during the 13-month follow-up period.
Case 3 A 56-year-old man presented with chronic osteomyelitis of his left knee, which developed after knee joint trauma 40 years ago. He underwent total knee joint replacement surgery 10 years before. However, it failed due to poor control of osteomyelitis and he underwent
FIGURE 2. Case 1. A 55-year-old man with chronic osteomyelitis of his left lower leg. Above, left, Large skin and soft tissue defects with 2 bony defects on the anterior tibia. Above, right, Design of LD muscleYchimeric TDAP f lap. Below, left, The LD muscleYchimeric TDAP with a 14.5 7.5-cm skin paddle, and 2.5 2.5 and 2 2 cm muscle segments with pedicle of Y-configuration was harvested. Below, right, The patient at 2 months after surgery with full weight bearing. 568
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Annals of Plastic Surgery
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LD MuscleYChimeric TDAP Flaps for Reconstruction
FIGURE 3. Case 2. A 65-year-old man having diabetic foot. Above, left, Extensive skin defects with considerable dead space after radical debridement on left foot. Above, right, A LD muscleYchimeric TDAP with 17 6-cm skin paddle and 9 4-cm muscle segments were elevated. Below, left, Intraoperative image of donor site after f lap harvest. Below, right, Postoperative image at 2 months after reconstruction.
implant removal and knee fusion surgery. Free tissue transfer had been performed in another hospital for treatment of chronic osteomyelitis and coverage of defects, but failed. At our center, serial debridement and vacuum dressings were performed until control of infection and adequate preparation of the wound bed for reconstructive surgery was achieved. After bony debridement by the orthopedic surgery team, an LD muscleYchimeric TDAP f lap was designed and harvested. The flap consisted of a 15 5-cm skin paddle with 2 separate 4.5 4- and 4 4-cm muscle segments. The shape of pedicle was designed to have a Y-configuration for more degree of spatial freedom in insetting of each f lap component. Vascular anastomosis was performed with superficial femoral vessels in an end-to-side manner and muscle segments were inset through the bony window to fill the proximal and distal dead space with each muscle slip (Fig. 4). There were no significant postoperative complications and the patient was discharged at postoperative week 3. During 24 months of follow-up, there was no recurrence of osteomyelitis or functional impairment of the donor site.
Case 4 A 53-year-old woman visited our center for chronic inf lammation on her right foot. She had lost her third, fourth, and fifth toes in a traffic accident 40 years previous and experienced intermittent swelling, heat sensations, and tenderness in the rest of the foot. Chronic osteomyelitis on her fifth metatarsal bone was diagnosed by * 2015 Wolters Kluwer Health, Inc. All rights reserved.
bone scan, and surgical treatment was determined. After radical debridement of the infected metatarsal bone, sequestrum, and inf lamed soft tissue in which preservation of much of the length of the metatarsal cortical shell was achieved, a 6.5 7-cm skin defect and a 3 1-cm dead space in the marrow space were created. LD muscleYchimeric TDAP flaps consisting of a 10 6-cm skin paddle and 3 1-cm muscle segments was harvested and transferred through anastomosis with the dorsalis pedis artery in an end-to-side manner. The segment of harvested muscle was inserted into the marrow space of the remnant metatarsal bone. She was discharged at postoperative day 10 with no postoperative complications (Fig. 5). No functional impairment of the donor site or recurrence of osteomyelitis was observed during a 34-month follow-up period.
DISCUSSION The obliteration of dead space is important for successful wound healing and is especially crucial in the reconstruction of complicated defects having 3-dimensional tissue deficits. Dead space can cause wound infection and abscess formation, eventually leading to delayed wound healing.15Y17 Several studies have reported the importance of dead space obliteration in various surgical fields.16Y18 In those studies, successful reconstruction could be achieved by proper obliteration of dead space using muscle tissues. www.annalsplasticsurgery.com
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FIGURE 4. Case 3. A 56-year-old man with chronic osteomyelitis on his left knee. Above, left, Large soft tissue and bony defects were made after radical debridement due to uncontrolled osteomyelitis even after knee fusion surgery. Above, right, An LD muscleYchimeric TDAP f lap was harvested with 15 5-cm skin paddle and 2 separate 4.5 4- and 4 4-cm muscle segments. Below, left, Flap inset with packing of 2 muscle segments through the bony window to fill proximal and distal dead space. Below, right, Three months postoperative result after debridement and applying an LD muscleYchimeric TDAP.
The efficacy of muscle tissue for defect coverage and wound healing has been reported in many animal and clinical studies.1,2,18,19 Muscle tissues are known to improve local blood supply and increase oxygen tension and antibiotic delivery to wounds, resulting in faster wound healing. Muscle tissues are also easy to adapt to the shape of the defects and optimal for obliteration of dead space in the wounds.18,20 Other tissues, including fasciocutaneous tissues, can also be used for reconstruction of complicated defects and several studies reported their efficacy with comparable results in the reconstruction of osteomyelitis defects, which was one of the complicated defects.5Y7 However, limitations include inadequate filling of large defects with fasciocutaneous flaps, and in the reconstruction of complicated defects with large dead space, they still had to use muscle flaps.5,6 In addition, obtaining flaps with spatial mobility to ensure adequate space filling while also covering skin defects is difficult using the conventional design of fasciocutaneous flaps. When the conventional technique of deepithelization and folding of the fasciocutaneous flap for dead space obliteration is used, a larger size of skin flap needs to be harvested with resulting additional donor-site morbidity. Thus, maintaining the inherent advantages of muscle tissues while minimizing donor-site morbidity by specific design and harvesting of muscle segments just large enough to cover the target dead 570
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space would be advantageous, and muscleYchimeric f lap could be a valuable option. However, conventional muscleYchimeric flaps have focused on the simultaneous harvest of multiple kinds of tissues without paying special attention to the pedicle length of each component and have mainly been applied for the coverage of large and extensive defects.11,13 The muscle component was used mainly to increase the dimension of the flap for coverage of large defects, providing a wellvascularized bed for skin grafts when the wound could not be covered with the skin perforator f lap alone. To efficiently cover the surface defect and simultaneously obliterate the underlying dead space for complicated defects, a different design of muscleYchimeric perforator f lap is required. In this study, we successfully reconstructed complicated wound defects having dead space with free LDYchimeric TDAP flaps. When harvesting flaps, special attention was paid to obtaining a Y-shaped pedicle configuration with adequate limb lengths for both tissue segments. Meticulous intramuscular dissection was needed for acquisition of pedicle, not only for the skin paddle but also for the muscle segment. Harvesting of muscle segment distal to the confluence point of the Y-shaped pedicle after intramuscular dissection of the intramuscular branch of the thoracodorsal vessel to obtain the required distance enabled independent mobilization and free spatial arrangement of * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
LD MuscleYChimeric TDAP Flaps for Reconstruction
FIGURE 5. Case 4. A 53-year-old woman with chronic osteomyelitis on her right fifth metatarsal bone. Above, left, After radical debridement, a 6.5 7-cm soft tissue defect and a 3 1-cm dead space in the marrow space were observed. Above, right, LD muscleYchimeric TDAP f laps with 3 1-cm muscle segments were harvested. Below, left, The muscle segments were packed into the marrow space of the remnant metatarsal bone. Below, right, Postoperative image 12 months after surgery.
2 tissue segments during insetting. Working as a ‘‘filler flap,’’ the muscle segment could be exclusively placed into the dead space without tethering of pedicle, thus aiding fast wound healing. Muscle segments could also act as favorable beds for tiny perforators of skin paddle to lie on. Compared to larger vessels, small perforators are more susceptible to and affected by the unfavorable environment including small collections of hematomas or seromas, uneven surfaces caused by bony defects or large fixation plates, screws, and inflammation after incomplete tissue debridement. Muscle segments can isolate and protect the perforator from these conditions to ensure good perfusion of skin flaps during the early healing period. When incorporating the muscle tissue in the flap, donor-site morbidity is a major concern. When deciding to use muscleYchimeric perforator flaps rather than simple perforator skin flaps, the balance between donor-site morbidity and optimal reconstruction of recipient sites needs to be carefully considered. In this study, maximal preservation of the thoracodorsal nerve branches and harvesting of muscle tissue with the right dimensions for the size of dead space resulted in minimization of donor-site morbidity. Harvesting muscle-sparing LD flaps was known to result in minimal donor-site morbidity, compared with harvesting of large LD flaps.21,22 Thus, compared to musculocutaneous flaps or the unselective use of muscle in conventional muscleYchimeric perforator flaps, our TDAP flaps with muscleYchimeric design showed acceptable donor morbidity without causing functional impairment in this study population. We found that the overall donor-site complication rate and seroma drainage from the donor site were comparable with that of the simple TDAP group and size-matched control group, respectively. Certainly, split LD flaps are a good choice for 3-dimensional tissue defect reconstruction in some cases. These flaps are considered * 2015 Wolters Kluwer Health, Inc. All rights reserved.
to be simpler and less risky options than LD muscleYchimeric TDAP f laps, while large muscles were not sacrificed. However, our flaps are not also technically complicated and do not require special learning curve for most perforator microsurgeons in the technical aspects. The only additional step compared to conventional perforator flap harvest is intramuscular dissection along the intramuscular branch of the thoracodorsal artery, and the technique itself is similar with conventional perforator flap elevation. Some learning curve may rather be required in flap designs and insetting. When designing this kind of muscleYchimeric flaps, spatial distance between 2 flaps, the pedicle length required for each flap segments, and common pedicle length should be considered for optimal reconstruction, based on the knowledge of the branching pattern or intramuscular anatomy of thoracodorsal vessels. In flap insetting, special attention would be necessary for avoiding pedicle kinking, twisting, or tension, especially in distal independent pedicle portions. Using this intramuscular dissection, the independent pedicles of muscle segments can be obtained, and more accurate arrangement of f laps is possible due to increased spatial freedom. These characteristics would make the muscleYchimeric perforator f laps be well suited for those indications; the complicated defects with small overlap between surface defects and accompanying 2- or 3-dimensional dead space. Furthermore, our f lap designs allow efficient filling even of unusual space while minimizing muscle harvesting because muscle segments can be individually designed to match the exact size and shape of the dead space. The good aesthetic outcomes of muscleYchimeric TDAP f laps obtained in this study should be noted. In contrast with traditional muscle or musculocutaneous flaps, which often result in an unpleasing appearance due to large bulk of flaps, our flap design provided www.annalsplasticsurgery.com
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acceptable contour in 1 stage because of performing generous defatting of perforator skin flaps and selective harvest and use of muscle segments for filling purposes only. The disadvantages of this f lap design include increased operation time caused by added intramuscular dissection of pedicle for muscle segment, and the fact that the design of muscle f laps can only be finalized after confirming the course of the intramuscular branch of the thoracodorsal vessel distal to the conf luence point with perforator. The limitations of this study were the retrospective study design and the lack of objective evaluation regarding the functional impairment of the donor site. Although no functional impairment was observed in any cases, this conclusion depended on subjective patient symptoms. Further studies regarding objective assessment for donorsite morbidities and comparison between preoperative and postoperative functional states are needed.
CONCLUSIONS Complicated wounds can be successfully reconstructed using free LD muscleYchimeric TDAP f laps by achieving not only successful coverage of surface defects with skin perforator f laps but also effective obliteration of dead space with muscle segments. The design of f laps included limited harvest of muscle tissue and pedicle in a Y-shaped configuration to allow efficient positioning of both skin and muscle segments for specific purposes with spatial freedom. Muscle tissues with their inherent advantages remain a valuable addition to perforator f laps, playing the role of ‘‘filler f lap’’ in the reconstruction of complicated defects. REFERENCES 1. Harry LE, Sandison A, Paleolog EM, et al. Comparison of the healing of open tibial fractures covered with either muscle or fasciocutaneous tissue in a murine model. J Orthop Res. 2008;26:1238Y1244. 2. Richards RR, McKee MD, Paitich CB, et al. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone Joint Surg Am. 1991;73:1323Y1330. 3. Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast Reconstr Surg. 1991;88:311Y318. 4. Fodor L, Horesh Z, Lerner A, et al. The distally based sural musculoneurocutaneous flap for treatment of distal tibial osteomyelitis. Plast Reconstr Surg. 2007;119: 2127Y2136.
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5. Hong JP, Shin HW, Kim JJ, et al. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg. 2005; 115:142Y147. 6. Khan MA, Jose RM, Taylor C, et al. Free radial forearm fasciocutaneous flap in the treatment of distal third tibial osteomyelitis. Ann Plast Surg. 2012;68: 58Y61. 7. Zweifel-Schlatter M, Haug M, Schaefer DJ, et al. Free fasciocutaneous flaps in the treatment of chronic osteomyelitis of the tibia: a retrospective study. J Reconstr Microsurg. 2006;22:41Y47. 8. Harry LE, Sandison A, Pearse MF, et al. Comparison of the vascularity of fasciocutaneous tissue and muscle for coverage of open tibial fractures. Plast Reconstr Surg. 2009;124:1211Y1219. 9. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast Surg. 1991; 27:126Y131. 10. Giessler G, Schmidt A, Germann G, et al. The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries. J Reconstr Microsurg. 2011;27:567Y574. 11. Vanlanduyt K, Hamdi M, Blondeel P, et al. The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot. Br J Plast Surg. 2005;58:371Y378. 12. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use. Clin Plast Surg. 2003;30:457Y467. 13. Hwang JH, Kim ES, Kim KS, et al. Latissimus dorsi muscle and its short perforator-based skin compound free flap. Ann Plast Surg. 2007;58:381Y387. 14. Cavadas PC, Teran-Saavedra PP. Combined latissimus dorsiYthoracodorsal artery perforator free flap: the ‘‘razor flap’’. J Reconstr Microsurg. 2002;18: 29Y31. 15. Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg. 1999;104:107Y110. 16. Del Pinal F, Pisani D, Garcia-Bernal FJ, et al. Massive hand crush: the role of a free muscle flap to obliterate the dead space and to clear deep infection. J Hand Surg Br. 2006;31:588Y592. 17. Iioka S, Sawamura K, Mori T, et al. Surgical treatment of chronic empyema. A new one-stage operation. J Thorac Cardiovasc Surg. 1985;90:179Y185. 18. Gosain A, Chang N, Mathes S, et al. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1990;86:1152Y1162; discussion 1163. 19. Xu X-Y, Zhu Y, Liu J-H. Treatment of calcaneal osteomyelitis with free serratus anterior muscle flap transfer. Foot Ankle Int. 2009;30:1088Y1093. 20. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001;108:1029Y1041; quiz 1042. 21. Adams WP Jr, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg. 2004;53:6Y11. 22. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg. 2009;123:13Y24.
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Free Latissimus Dorsi MuscleYChimeric Thoracodorsal Artery Perforator Flaps for Reconstruction of Complicated Defects Does Muscle Still Have a Place in the Domain of Perforator Flaps? Kyeong-Tae Lee, MD, Elrica Sapphira Wiraatmadja, MD, and Goo-Hyun Mun, MD, PhD Purpose: The reconstruction of complicated defects with 3-dimensional deficits remains challenging. The reconstruction of these defects requires not only coverage of surface but also appropriate obliteration of dead space, and muscleYchimeric perforator flaps can be a valuable option. Here, we present our experience with free latissimus dorsi (LD) muscleYchimeric thoracodorsal artery perforator (TDAP) flaps for the treatment of complicated defects. Methods: A retrospective chart review was performed for patients who underwent a free LD muscleYchimeric TDAP f lap procedure for the treatment of complicated wounds with 3-dimensional tissue deficits between March 2005 and October 2012. The surgical technique, clinical outcomes, and postoperative complications were evaluated. Results: A total of 24 cases were included. All f laps survived and no partial f lap losses were encountered. Large skin f laps of 115 cm2 average size were elevated, with an average of 38-cm2 muscle segments. The total length of pedicle was 12.2 cm on average, with 7.3 cm of common pedicle, 4.9 cm of skin paddle, and 3.4 cm of muscle segments. Muscle segments could be inset in the underlying dead space with spatial freedom. The mean follow-up period was 34.1 months. Wounds successfully healed in all cases without significant postoperative complications. The donor-site complication rate of the chimeric f lap group was similar to that of the simple TDAP group. Conclusions: The use of LD muscleYchimeric TDAP flaps with Y-pedicle configurations allowed efficient positioning of both skin and muscle components for their specific purposes and successful healing of complicated wounds. The muscle components of chimeric f laps acted as ‘‘filler f laps’’ and were an effective addition to the perforator f lap technique for the reconstruction of complicated defects without the addition of significant donor-site morbidity. Key Words: thoracodorsal artery perforator flap, chimeric flap, complicated defect (Ann Plast Surg 2015;74: 565Y572)
R
econstruction of complicated wounds involving losses of multiple tissues and 3-dimensional tissue defects has been challenging. Such wounds can be accompanied by extensive soft tissue defects and dead spaces of varying location and extent. Their reconstruction requires not only coverage of surface defects but also obliteration of dead space to achieve successful wound healing and prevent postoperative complications.
Received March 11, 2013, and accepted for publication, after revision, July 19, 2013. From the Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Conflicts of interest and sources of funding: none declared. Reprints: Goo-Hyun Mun, MD, PhD, Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong 50, Gangnam-gu, Seoul 135-710, South Korea. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405-0565 DOI: 10.1097/SAP.0b013e3182a6363c
Annals of Plastic Surgery
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Historically, muscle or musculocutaneous f laps have been widely used for the reconstruction of complicated defects, such as open fracture sites1,2 or osteomyelitis wounds.3,4 Recently, a few studies have advocated the use of fasciocutaneous f laps or perforator f laps excluding muscle tissues and reporting comparable surgical outcomes, while commenting the drawbacks of muscle f laps, including potential donor-site morbidity, inferior aesthetic outcome, and the necessity of further debulking procedures.5Y7 However, because the inherent advantages of muscle tissue1,2,8 over other tissues including high vascularity and ability to adapt to defect shapes remain important, muscle tissues have been generally preferred for the reconstruction of complicated defects. Chimeric f laps were first reported by Hallock9 in the lateral thigh and have been applied in various reconstructive fields.10,11 Several studies have reported the advantages of chimeric flaps, including economy of donor incision and superior aesthetic outcomes.12 The latissimus dorsi (LD) muscleYchimeric thoracodorsal artery perforator (TDAP) f lap has been reported to be useful for the reconstruction of massive soft tissue defects.11,13,14 However, most of these f laps were designed for the reconstruction of extensive defects with 2-dimensional tissue losses. In these cases, muscle tissues were used to increase the dimension of the f lap to cover extensive defects and a large part of the LD muscle had to be harvested, eventually leading to considerable donor morbidity. When reconstructing complicated wounds with 3-dimensional tissue deficits, different customized chimeric flap designs are required for efficient coverage of superficial defects and effective obliteration of dead space. In addition, if the volume of the harvested muscle is kept as small as possible, merit of minimal donor-site morbidity in perforator flap can be maintained even in muscleYchimeric design perforator flap. However, to the best of our best knowledge, the use of selectively designed muscle tissue to reconstruct complicated defects has not been studied in the context of free TDAP flaps. Here, we present our experience of using free LD muscleYchimeric TDAP f laps for reconstructions of complicated defects.
PATIENTS AND METHODS Data regarding patients having complicated defects treated with a free LD muscleYchimeric TDAP flap procedure from March 2005 to October 2012 were collected based on chart review. The patients who underwent conventional or muscle-sparing musculocutaneous LD f lap and simple skin TDAP flap rotation above LD muscle without complete separation of the 2 components were excluded. All reconstructive surgeries were performed by a single surgeon (G.M.).
Surgical Technique Patients were placed in a lateral decubitus position and the scapular angle tip and borders of the LD muscle were marked. Thoracodorsal artery perforators were mapped with a sterile Doppler probe. A skin f lap was designed along the axis lying parallel to the relaxed skin tension line in a transverse fashion. Muscle segments to be harvested were designed referring to the size of dead space to be www.annalsplasticsurgery.com
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obliterated. An initial incision line was made at the central portion of the superior border of the f lap and dissection proceeded along the loose areolar plane above the dorsal thoracic fascia. After identifying the marked perforator by suprafascial elevation of the f lap inferiorly, an entire incision was made along the skin paddle margins. After full suprafascial elevation of the skin paddle, intramuscular dissection of the perforator was initiated. When the perforator pedicle met the sizable intramuscular branch, which was usually the main descending branch of the thoracodorsal vessel, the branch was dissected to follow its course in a proximal-to-distal direction for adequate distance and a muscle segment of suitable size was then harvested. The size of muscle flaps was determined mainly by focusing on the size of dead space to be obliterated in recipient sites. When large muscle segments are necessary, the main descending branch of thoracodorsal vessels was used for pedicle of muscle flaps, and in cases needing small size of muscle segments, such as less than 10 cm2, intramuscular branches of those vessels were used. Pedicle dissection proximal to the confluence point of pedicles was performed as usual to gain sufficient pedicle length. By careful dissection, intramuscular branches of the thoracodorsal nerve were preserved as much as possible with the exception of the distal branch entering the muscle segment harvested. Ultimately, a muscleYchimeric TDAP flap with Y-shaped pedicle configuration composed of common pedicle and independent pedicle for each component was harvested. The flap was temporarily inset and microvascular anastomosis was performed. The muscle segment was placed to fill the dead space and also to provide an even healthy bed for subsequent skin paddle of the flap (Fig. 1). The skin paddle was then inset after generous defatting to preserve the subdermal plexus and achieve optimal flap thickness. During insetting of both tissue segments, careful attention was paid to avoiding pedicle kinking, twisting, or tension that might occur, especially in distal independent pedicle portions. A sufficient length of each distal limb of Y-shaped pedicle allowed freedom in the spatial arrangement of each component to effectively reconstruct the 3-dimensional defect (see Video, Supplemental Digital Content 1, at http://links.lww.com/SAP/A139, which demonstrates harvesting and insetting of LDYchimeric TDAP flap). The donor site was closed primarily in all cases after placement of suction drains.
Evaluating Donor-Site Complications To evaluate donor-site morbidity, we compared postoperative complication rates of donor site, amount of drainage, and duration of drain maintenance in the muscleYchimeric group with other groups. First, the donor-site complication rates were compared in 3 groups as follows: the simple TDAP f lap group having only a skin component, the LD muscle f lap group having only a muscle component, and the LD muscleYchimeric TDAP f lap group in the patients undergoing reconstructive surgery using the same donor site consecutively during the same study period. A total of 191 consecutive patients underwent free flap reconstruction based on the thoracodorsal artery system, including 147 simple TDAP flaps, 20 LD muscle flaps, and 24 cases of LD muscleYchimeric TDAP flaps. The donor-site complications including infection, hematoma, seroma, and wound dehiscence were analyzed. Next, the groups were also compared with regard to the total amount of drainage and the duration of drain maintenance from donor sites. Among 147 simple TDAP f lap patients, 24 cases having the skin paddles most similar in size with those of the chimeric f lap group were chosen as a matched control group, because the dimensions of harvested skin paddles can inf luence the amount of drainage from donor sites. Pearson W2 test was used for categorical variables, and the Mann-Whitney test and Kruskal-Wallis test were used for continuous variables, because data did not follow a normal distribution in this study. A P value of less than 0.05 was considered statistically significant. Statistical analysis was performed using the 566
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FIGURE 1. Harvest and inset of LD muscleYchimeric TDAP f laps for complicated defect reconstruction. An LD muscleYchimeric TDAP f lap with Y-shaped pedicle configuration composed of common pedicle and independent pedicle for each f lap component was harvested. Then, the dead space could be obliterated with muscle segments and surface defects could be covered with perforator f laps. Each f lap component could be placed for their original purpose with spatial freedom.
Statistical Package for the Social Sciences version 18.0 (SPSS Inc, Chicago, Ill).
RESULTS A total of 24 free LD muscleYchimeric TDAP flaps were performed in 23 patients for the treatment of complicated wounds with 3-dimensional tissue deficits. The mean age at surgery was 45.0 years (range, 7Y75 years). There were 5 diabetic patients and 2 active smokers at the time of surgery in our sample. The causes of defects were chronic wounds accompanied by osteomyelitis in 12 cases, oncologic defects in 7 cases, and traumatic defects in 5 cases. All wounds presented 3-dimensional tissue deficits consisting of surface defects and underlying or contiguous dead space. The mean size of surface defects was 112.9 cm2 (range, 25Y297 cm2), and the average estimated dead space was 35 cm3 (range, 3Y150 cm3). The origins of dead space development were soft tissue loss in 9 cases and bony defect in 15 cases (Table 1). Flaps survived completely in all cases without any partial flap loss. In 2 patients, flap congestions were encountered at postoperative day 1, and emergent explorations were performed, resulting in successful salvage of entire flaps by venous revision in both cases. All wounds healed successfully without significant postoperative complications, including recurrence of disease in osteomyelitis patients. Minor wound dehiscence occurred around the flap margins in 2 patients having diabetes with poor control due to noncompliance of patients. The wounds were healed completely with conservative management. The mean size of skin f laps was large, 115.2 cm2 (range, 27Y297 cm2) and the mean size of muscle segments incorporated was 38.1 cm2 (range, 3Y160 cm2). The average total length of pedicle was 12.2 cm, composed of 7.3 cm of common pedicle; 4.9 cm of skin * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
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LD MuscleYChimeric TDAP Flaps for Reconstruction
TABLE 1. Patients’ Demographics and Operation Data Flap Size, cm2 Defects Site
Cause of Defects
Skin Paddle
Muscle Segments 2.5 2.5 22 94 4.5 4 44 31 64 83 33 77 77 88 83 15 2 84 31
Pedicle Length, cm Common
To Skin Paddle
To Muscle Segments
Harvested Perforator Numbers
Recipient Vessels
8
6
7
2
Medial sural a.
None
8 4
4.5 6
3 7
2 2
PTA SFA
None None
5 7 7 7 7 10 8 8 10 10 7
4 5 4 5 5 6 5 5 6 7 4
3 4 3 2 3 4 4 4 3 3 3
1 1 1 1 1 1 1 1 1 1 1
DPA ECA ATA PTA PTA Popliteal a. STA ATA ATA Medial sural a. DPA
Case
Sex
Age, y
1
M
55
Lower leg
Chronic OM
14.5 7.5
2 3
M M
65 56
Foot Knee
Diabetic foot Chronic OM
17 6 15 5
4 5 6 7 8 9 10 11 12 13 14
F F M F M M M F F M F
53 51 16 55 36 73 65 21 61 24 47
Foot Cheek Heel Heel Heel Knee Scalp Lower leg Lower leg Lower leg Heel
Chronic OM Oncologic Trauma Diabetic foot Chronic OM Chronic OM Chronic OM Trauma Oncologic Trauma Diabetic foot
10 6 14 7 13 9 6 4.5 13 8 22 13 17 8 20 8 18 8 27 11 10 6.5
15 16 17 18 19 20
M M M F M M
7 57 40 75 13 59
Lower leg Heel Heel Elbow Lower leg Sacrum
Oncologic Diabetic foot Diabetic foot Oncologic Oncologic Sacral sore
14.5 7 86 10 5 15 10 15 7 16 9.5
16 10 4 3.5 33 53 15 10 10 2 10 3
6 7 7 8 5 8
4 5 5 6 4 4
2 3 4 3 3 2
1 1 2 2 1 1
DFA DPA PTA TDA PTA SGA
21 22 23 24
M M M M
15 34 37 66
Knee Ankle Elbow Foot
Oncologic Trauma Trauma Oncologic
14 7 13 10 17 6.5 75
87 53 10 5 3 1.5
8 6 8 5
4 4 7 3
3 3 4 2
1 1 1 2
Medial sural a. PTA GSV LCA
Complication
None None None None None None None None None None Flap margin dehiscence None None None None None Donor site and flap margin dehiscence None None None None
ATA, anterior tibial artery; DPA, dorsalis pedis artery; ECA, external carotid artery; GSV, greater saphenous vein grafted; LCA, lateral calcaneal artery; OM, osteomyelitis; PTA, posterior tibial artery; SFA, superficial femoral artery; SGA, superior gluteal artery; STA, superficial temporal artery.
paddle, and 3.4 cm of muscle segment, respectively. Surface defects were successfully covered using skin perforator f laps and the underlying dead spaces were obliterated using customized muscle f laps. The hospitalization period after reconstructive surgery varied from 10 to 33 days with an average of 23 days. The average follow-up period was 34.1 months (range, 2Y79 months). The transferred f laps conformed well to the transplant site and achieved pleasing contours. Secondary debulking procedures of the f laps were not necessary except in 1 case of plantar reconstruction that had a large dimension of transferred skin f laps, resulting in excision of redundant skin f lap during the follow-up period. Regarding the donor-site complications, wound dehiscence developed in 1 case, which was healed successfully after revision surgery. The average total amount of drainage from the donor site was 295.8 mL, and mean duration of drain maintenance was 7.46 days. The causes of complicated defects, defect sites, and sex did not inf luence donor complications or drainage data. Among the 191 cases undergoing LD muscleYchimeric TDAP, simple TDAP, and LD muscle f laps, donor-site complications occurred in 11 cases, including 5 cases of wound dehiscence, 4 seroma formations, and 2 wound infections. The complication rate of the LD muscleYchimeric TDAP f lap group was similar with that of the simple TDAP f lap group but significantly lower than that of the LD * 2015 Wolters Kluwer Health, Inc. All rights reserved.
muscle group. (LD chimeric vs simple TDAP vs LD group, 4.2% vs 4.1% vs 20.0%, P = 0.015) (Table 2). When comparing the total amount of drainage and the duration of drain maintenance, similar differences were observed (LD chimeric vs simple TDAP vs LD group, 295.8 vs 297.8 vs 562.35 mL, 7.46 vs 7.54 vs 9.35 days, respectively) (Table 3). TABLE 2. Comparison of Donor-Site Complications Among Simple TDAP Flap Group, LD MuscleYChimeric TDAP Flap Group, and LD Muscle Flap Group Simple TDAP Patients number Skin paddle size, cm2 Muscle segment size Donor complication (%)
LD MuscleYChimeric LD TDAP Muscle
147 98.5 0 6 (4.1)
24 115.2 38.1 1 (4.2)
Infection: 2 Dehiscence: 4
Dehiscence: 1
P
20 N/A 0.052 153.3 4 (20.0) 0.015 Seroma: 4
N/A indicates not applicable.
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TABLE 3. Comparison of Donor-Site Drainage Among Skin Paddle Size-Matched Simple TDAP Flap Group, LD MuscleYChimeric TDAP Flap Group, and LD Muscle Flap Group Simple TDAP Patients number Skin paddle size, cm2 Total amount of drain, mL Duration of drain maintenance, d
LD MuscleYChimeric LD TDAP Muscle
24 114.0 297.8 7.54
24 115.2 295.8 7.46
P
20 N/A 0.975 562.35 0.005 9.35 0.041
Case 1 A 55-year-old man presented with chronic osteomyelitis accompanied by skin defects on his left anterior tibia after open fracture. The osteomyelitis was diagnosed by bone scan and magnetic resonance imaging. Soft tissue and bony debridement were performed by the orthopedic surgery team, leaving 14 7-cm skin defects with 2 bony defects. An LD muscleYchimeric TDAP flap was designed with a 14.5 7.5-cm skin paddle based on 2 perforators and 2 muscle segments sized 2.5 2.5 and 2 2 cm located along the course of the descending branch of the thoracodorsal artery. The LD muscleYchimeric TDAP flap with a Y-configuration pedicle was elevated and vascular anastomosis was performed between the pedicle and medial sural vessels in an end-to-end manner. Two muscle segments were placed into bony defects and a skin flap was inset for coverage of soft tissue defects after customized defatting. The flap survived completely and the wound
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healed successfully without any postoperative complications in both recipient and donor sites (Fig. 2). He was discharged at postoperative day 9. No functional impairment of the donor site was observed and recurrence of osteomyelitis did not develop during a 6-year follow-up period.
Case 2 A 65-year-old man visited our center with a diabetic ulcer on his left foot. Because of poor control of infection and progressive necrosis of his big toe, first toe transmetatarsal amputation was performed by the orthopedic surgery team. An abscess in the deep plantar soft tissue required extensive debridement of plantar soft tissue including muscle and tendon, leading to a 15 5-cm skin defect accompanied with dead space on the contiguous plantar region. An LD muscleYchimeric TDAP f lap with 17 6-cm skin paddle and 9 4-cm muscle segments was designed and elevated. After anastomosis with posterior tibial vessels in an end-to-side manner, the plantar dead space was filled with muscle segment and the superficial defect was covered with a skin f lap. The f lap survived well and the wound healed completely (Fig. 3). The patient was discharged without postoperative complications 2 weeks after surgery and did not present with any reconstruction-related problem, including functional impairment of the donor site during the 13-month follow-up period.
Case 3 A 56-year-old man presented with chronic osteomyelitis of his left knee, which developed after knee joint trauma 40 years ago. He underwent total knee joint replacement surgery 10 years before. However, it failed due to poor control of osteomyelitis and he underwent
FIGURE 2. Case 1. A 55-year-old man with chronic osteomyelitis of his left lower leg. Above, left, Large skin and soft tissue defects with 2 bony defects on the anterior tibia. Above, right, Design of LD muscleYchimeric TDAP f lap. Below, left, The LD muscleYchimeric TDAP with a 14.5 7.5-cm skin paddle, and 2.5 2.5 and 2 2 cm muscle segments with pedicle of Y-configuration was harvested. Below, right, The patient at 2 months after surgery with full weight bearing. 568
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LD MuscleYChimeric TDAP Flaps for Reconstruction
FIGURE 3. Case 2. A 65-year-old man having diabetic foot. Above, left, Extensive skin defects with considerable dead space after radical debridement on left foot. Above, right, A LD muscleYchimeric TDAP with 17 6-cm skin paddle and 9 4-cm muscle segments were elevated. Below, left, Intraoperative image of donor site after f lap harvest. Below, right, Postoperative image at 2 months after reconstruction.
implant removal and knee fusion surgery. Free tissue transfer had been performed in another hospital for treatment of chronic osteomyelitis and coverage of defects, but failed. At our center, serial debridement and vacuum dressings were performed until control of infection and adequate preparation of the wound bed for reconstructive surgery was achieved. After bony debridement by the orthopedic surgery team, an LD muscleYchimeric TDAP f lap was designed and harvested. The flap consisted of a 15 5-cm skin paddle with 2 separate 4.5 4- and 4 4-cm muscle segments. The shape of pedicle was designed to have a Y-configuration for more degree of spatial freedom in insetting of each f lap component. Vascular anastomosis was performed with superficial femoral vessels in an end-to-side manner and muscle segments were inset through the bony window to fill the proximal and distal dead space with each muscle slip (Fig. 4). There were no significant postoperative complications and the patient was discharged at postoperative week 3. During 24 months of follow-up, there was no recurrence of osteomyelitis or functional impairment of the donor site.
Case 4 A 53-year-old woman visited our center for chronic inf lammation on her right foot. She had lost her third, fourth, and fifth toes in a traffic accident 40 years previous and experienced intermittent swelling, heat sensations, and tenderness in the rest of the foot. Chronic osteomyelitis on her fifth metatarsal bone was diagnosed by * 2015 Wolters Kluwer Health, Inc. All rights reserved.
bone scan, and surgical treatment was determined. After radical debridement of the infected metatarsal bone, sequestrum, and inf lamed soft tissue in which preservation of much of the length of the metatarsal cortical shell was achieved, a 6.5 7-cm skin defect and a 3 1-cm dead space in the marrow space were created. LD muscleYchimeric TDAP flaps consisting of a 10 6-cm skin paddle and 3 1-cm muscle segments was harvested and transferred through anastomosis with the dorsalis pedis artery in an end-to-side manner. The segment of harvested muscle was inserted into the marrow space of the remnant metatarsal bone. She was discharged at postoperative day 10 with no postoperative complications (Fig. 5). No functional impairment of the donor site or recurrence of osteomyelitis was observed during a 34-month follow-up period.
DISCUSSION The obliteration of dead space is important for successful wound healing and is especially crucial in the reconstruction of complicated defects having 3-dimensional tissue deficits. Dead space can cause wound infection and abscess formation, eventually leading to delayed wound healing.15Y17 Several studies have reported the importance of dead space obliteration in various surgical fields.16Y18 In those studies, successful reconstruction could be achieved by proper obliteration of dead space using muscle tissues. www.annalsplasticsurgery.com
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FIGURE 4. Case 3. A 56-year-old man with chronic osteomyelitis on his left knee. Above, left, Large soft tissue and bony defects were made after radical debridement due to uncontrolled osteomyelitis even after knee fusion surgery. Above, right, An LD muscleYchimeric TDAP f lap was harvested with 15 5-cm skin paddle and 2 separate 4.5 4- and 4 4-cm muscle segments. Below, left, Flap inset with packing of 2 muscle segments through the bony window to fill proximal and distal dead space. Below, right, Three months postoperative result after debridement and applying an LD muscleYchimeric TDAP.
The efficacy of muscle tissue for defect coverage and wound healing has been reported in many animal and clinical studies.1,2,18,19 Muscle tissues are known to improve local blood supply and increase oxygen tension and antibiotic delivery to wounds, resulting in faster wound healing. Muscle tissues are also easy to adapt to the shape of the defects and optimal for obliteration of dead space in the wounds.18,20 Other tissues, including fasciocutaneous tissues, can also be used for reconstruction of complicated defects and several studies reported their efficacy with comparable results in the reconstruction of osteomyelitis defects, which was one of the complicated defects.5Y7 However, limitations include inadequate filling of large defects with fasciocutaneous flaps, and in the reconstruction of complicated defects with large dead space, they still had to use muscle flaps.5,6 In addition, obtaining flaps with spatial mobility to ensure adequate space filling while also covering skin defects is difficult using the conventional design of fasciocutaneous flaps. When the conventional technique of deepithelization and folding of the fasciocutaneous flap for dead space obliteration is used, a larger size of skin flap needs to be harvested with resulting additional donor-site morbidity. Thus, maintaining the inherent advantages of muscle tissues while minimizing donor-site morbidity by specific design and harvesting of muscle segments just large enough to cover the target dead 570
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space would be advantageous, and muscleYchimeric f lap could be a valuable option. However, conventional muscleYchimeric flaps have focused on the simultaneous harvest of multiple kinds of tissues without paying special attention to the pedicle length of each component and have mainly been applied for the coverage of large and extensive defects.11,13 The muscle component was used mainly to increase the dimension of the flap for coverage of large defects, providing a wellvascularized bed for skin grafts when the wound could not be covered with the skin perforator f lap alone. To efficiently cover the surface defect and simultaneously obliterate the underlying dead space for complicated defects, a different design of muscleYchimeric perforator f lap is required. In this study, we successfully reconstructed complicated wound defects having dead space with free LDYchimeric TDAP flaps. When harvesting flaps, special attention was paid to obtaining a Y-shaped pedicle configuration with adequate limb lengths for both tissue segments. Meticulous intramuscular dissection was needed for acquisition of pedicle, not only for the skin paddle but also for the muscle segment. Harvesting of muscle segment distal to the confluence point of the Y-shaped pedicle after intramuscular dissection of the intramuscular branch of the thoracodorsal vessel to obtain the required distance enabled independent mobilization and free spatial arrangement of * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
& Volume 74, Number 5, May 2015
LD MuscleYChimeric TDAP Flaps for Reconstruction
FIGURE 5. Case 4. A 53-year-old woman with chronic osteomyelitis on her right fifth metatarsal bone. Above, left, After radical debridement, a 6.5 7-cm soft tissue defect and a 3 1-cm dead space in the marrow space were observed. Above, right, LD muscleYchimeric TDAP f laps with 3 1-cm muscle segments were harvested. Below, left, The muscle segments were packed into the marrow space of the remnant metatarsal bone. Below, right, Postoperative image 12 months after surgery.
2 tissue segments during insetting. Working as a ‘‘filler flap,’’ the muscle segment could be exclusively placed into the dead space without tethering of pedicle, thus aiding fast wound healing. Muscle segments could also act as favorable beds for tiny perforators of skin paddle to lie on. Compared to larger vessels, small perforators are more susceptible to and affected by the unfavorable environment including small collections of hematomas or seromas, uneven surfaces caused by bony defects or large fixation plates, screws, and inflammation after incomplete tissue debridement. Muscle segments can isolate and protect the perforator from these conditions to ensure good perfusion of skin flaps during the early healing period. When incorporating the muscle tissue in the flap, donor-site morbidity is a major concern. When deciding to use muscleYchimeric perforator flaps rather than simple perforator skin flaps, the balance between donor-site morbidity and optimal reconstruction of recipient sites needs to be carefully considered. In this study, maximal preservation of the thoracodorsal nerve branches and harvesting of muscle tissue with the right dimensions for the size of dead space resulted in minimization of donor-site morbidity. Harvesting muscle-sparing LD flaps was known to result in minimal donor-site morbidity, compared with harvesting of large LD flaps.21,22 Thus, compared to musculocutaneous flaps or the unselective use of muscle in conventional muscleYchimeric perforator flaps, our TDAP flaps with muscleYchimeric design showed acceptable donor morbidity without causing functional impairment in this study population. We found that the overall donor-site complication rate and seroma drainage from the donor site were comparable with that of the simple TDAP group and size-matched control group, respectively. Certainly, split LD flaps are a good choice for 3-dimensional tissue defect reconstruction in some cases. These flaps are considered * 2015 Wolters Kluwer Health, Inc. All rights reserved.
to be simpler and less risky options than LD muscleYchimeric TDAP f laps, while large muscles were not sacrificed. However, our flaps are not also technically complicated and do not require special learning curve for most perforator microsurgeons in the technical aspects. The only additional step compared to conventional perforator flap harvest is intramuscular dissection along the intramuscular branch of the thoracodorsal artery, and the technique itself is similar with conventional perforator flap elevation. Some learning curve may rather be required in flap designs and insetting. When designing this kind of muscleYchimeric flaps, spatial distance between 2 flaps, the pedicle length required for each flap segments, and common pedicle length should be considered for optimal reconstruction, based on the knowledge of the branching pattern or intramuscular anatomy of thoracodorsal vessels. In flap insetting, special attention would be necessary for avoiding pedicle kinking, twisting, or tension, especially in distal independent pedicle portions. Using this intramuscular dissection, the independent pedicles of muscle segments can be obtained, and more accurate arrangement of f laps is possible due to increased spatial freedom. These characteristics would make the muscleYchimeric perforator f laps be well suited for those indications; the complicated defects with small overlap between surface defects and accompanying 2- or 3-dimensional dead space. Furthermore, our f lap designs allow efficient filling even of unusual space while minimizing muscle harvesting because muscle segments can be individually designed to match the exact size and shape of the dead space. The good aesthetic outcomes of muscleYchimeric TDAP f laps obtained in this study should be noted. In contrast with traditional muscle or musculocutaneous flaps, which often result in an unpleasing appearance due to large bulk of flaps, our flap design provided www.annalsplasticsurgery.com
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acceptable contour in 1 stage because of performing generous defatting of perforator skin flaps and selective harvest and use of muscle segments for filling purposes only. The disadvantages of this f lap design include increased operation time caused by added intramuscular dissection of pedicle for muscle segment, and the fact that the design of muscle f laps can only be finalized after confirming the course of the intramuscular branch of the thoracodorsal vessel distal to the conf luence point with perforator. The limitations of this study were the retrospective study design and the lack of objective evaluation regarding the functional impairment of the donor site. Although no functional impairment was observed in any cases, this conclusion depended on subjective patient symptoms. Further studies regarding objective assessment for donorsite morbidities and comparison between preoperative and postoperative functional states are needed.
CONCLUSIONS Complicated wounds can be successfully reconstructed using free LD muscleYchimeric TDAP f laps by achieving not only successful coverage of surface defects with skin perforator f laps but also effective obliteration of dead space with muscle segments. The design of f laps included limited harvest of muscle tissue and pedicle in a Y-shaped configuration to allow efficient positioning of both skin and muscle segments for specific purposes with spatial freedom. Muscle tissues with their inherent advantages remain a valuable addition to perforator f laps, playing the role of ‘‘filler f lap’’ in the reconstruction of complicated defects. REFERENCES 1. Harry LE, Sandison A, Paleolog EM, et al. Comparison of the healing of open tibial fractures covered with either muscle or fasciocutaneous tissue in a murine model. J Orthop Res. 2008;26:1238Y1244. 2. Richards RR, McKee MD, Paitich CB, et al. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone Joint Surg Am. 1991;73:1323Y1330. 3. Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast Reconstr Surg. 1991;88:311Y318. 4. Fodor L, Horesh Z, Lerner A, et al. The distally based sural musculoneurocutaneous flap for treatment of distal tibial osteomyelitis. Plast Reconstr Surg. 2007;119: 2127Y2136.
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5. Hong JP, Shin HW, Kim JJ, et al. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg. 2005; 115:142Y147. 6. Khan MA, Jose RM, Taylor C, et al. Free radial forearm fasciocutaneous flap in the treatment of distal third tibial osteomyelitis. Ann Plast Surg. 2012;68: 58Y61. 7. Zweifel-Schlatter M, Haug M, Schaefer DJ, et al. Free fasciocutaneous flaps in the treatment of chronic osteomyelitis of the tibia: a retrospective study. J Reconstr Microsurg. 2006;22:41Y47. 8. Harry LE, Sandison A, Pearse MF, et al. Comparison of the vascularity of fasciocutaneous tissue and muscle for coverage of open tibial fractures. Plast Reconstr Surg. 2009;124:1211Y1219. 9. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast Surg. 1991; 27:126Y131. 10. Giessler G, Schmidt A, Germann G, et al. The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries. J Reconstr Microsurg. 2011;27:567Y574. 11. Vanlanduyt K, Hamdi M, Blondeel P, et al. The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot. Br J Plast Surg. 2005;58:371Y378. 12. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use. Clin Plast Surg. 2003;30:457Y467. 13. Hwang JH, Kim ES, Kim KS, et al. Latissimus dorsi muscle and its short perforator-based skin compound free flap. Ann Plast Surg. 2007;58:381Y387. 14. Cavadas PC, Teran-Saavedra PP. Combined latissimus dorsiYthoracodorsal artery perforator free flap: the ‘‘razor flap’’. J Reconstr Microsurg. 2002;18: 29Y31. 15. Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg. 1999;104:107Y110. 16. Del Pinal F, Pisani D, Garcia-Bernal FJ, et al. Massive hand crush: the role of a free muscle flap to obliterate the dead space and to clear deep infection. J Hand Surg Br. 2006;31:588Y592. 17. Iioka S, Sawamura K, Mori T, et al. Surgical treatment of chronic empyema. A new one-stage operation. J Thorac Cardiovasc Surg. 1985;90:179Y185. 18. Gosain A, Chang N, Mathes S, et al. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1990;86:1152Y1162; discussion 1163. 19. Xu X-Y, Zhu Y, Liu J-H. Treatment of calcaneal osteomyelitis with free serratus anterior muscle flap transfer. Foot Ankle Int. 2009;30:1088Y1093. 20. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001;108:1029Y1041; quiz 1042. 21. Adams WP Jr, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg. 2004;53:6Y11. 22. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg. 2009;123:13Y24.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
