520324
research-article2014
IJLXXX10.1177/1534734613520324The International Journal of Lower Extremity WoundsHan and Choi
Case Report
Free-Style Dual Plane Recycling Tensor Fascia Lata Musculocutaneous Perforator Flap for Reconstruction of Recurrent Trochanteric Defects
The International Journal of Lower Extremity Wounds 2014, Vol. 13(1) 72–75 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734613520324 ijl.sagepub.com
Ba Leun Han, MD1, and Hwan Jun Choi, MD, PhD1
Abstract Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a “free-style flap” has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site. Keywords flap recycling, perforator, tensor fascia lata, flap Sequential flap coverage might be required for recurrent defects, especially in areas of the body where pressure sores occur frequently, such as in the sacral, ischial, and trochanteric areas.1 The concept of a “free-style flap” was developed to allow reconstructive surgeons to raise flaps of various designs reliably, even at sites where flap surgery has been performed previously. This concept can be very useful for treating recurrent pressure sores. Reusing a previous flap as a donor site has seldom been reported, but recycling a flap is one of the most economical and reasonable ways to manage repetitive defects if the reused flap is reliable and safe. Several reports have discussed the recycling of a perforator flap or free-style flap for reconstruction, but no study has reported the reuse of a flap as a perforator-based flap for recurrent defects in the trochanteric area. This article presents the concept of free-style recycling of a tensor fascia lata (TFL) flap into a perforator-based flap separated along 2 planes in a patient with a recurrent bilateral trochanteric defect.
Case Report A 66-year-old tetraplegic male patient presented with recurrent pressure sores and massive discharge on both trochanteric surfaces. He first underwent surgery for a decubitus ulcer 6 months earlier in another clinic. This used a TFL V-Y advancement flap. The lesion was debrided and 10 × 7 cm (left) and 7 × 7 cm (right) defects remained. Lower
extremity computed tomography angiography (CTA) showed that the perforator of the ascending branch of the lateral circumflex femoral artery was intact. Using a handheld Doppler, the perforator of the ascending branch of the lateral circumflex femoral artery was localized within the previous flap site. First, coverage of the left side was planned. Coverage of the wide muscular defect was planned by dividing it along 2 planes, involving muscle and fasciocutaneous flaps. At surgery, the patient was positioned laterally, and the flap was designed from the medial thigh to knee. After the perforator that supplied the flap was confirmed and marked using a handheld Doppler device, an incision was made along the previous surgical scar. The dissection was performed from proximal to distal until sufficient advancement was possible. While the flap was being elevated by dissecting the subfascial and submuscular planes, the connection of the musculocutaneous perforator from the TFL to the skin was confirmed. Then, the flap was elevated completely, preserving the pedicle and leaving the distal one third of the flap intact. After the defect was covered by sliding the muscle with the defect, it was sutured 1
Soonchunhyang University, Cheonan, Korea
Corresponding Author: Hwan Jun Choi, Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University 23-20, BongmyungDong, Cheonan 330-721, Korea. Email: [email protected]
Downloaded from ijl.sagepub.com by guest on November 14, 2015
73
Han and Choi
Figure 1. The coverage of recurrent left trochanteric pressure sore.
(A) After the perforator that supplies the flap was confirmed and marked by using a handheld Doppler, the incision line was designed along the operation scar. (B) While elevating the flap by dissecting to each subfascial and submuscular dual planes, the musculocutaneous perforator that is connected from TFL to skin was confirmed. (C) The muscle flap was slid into the defect and drain was applied. (D) The sutured flap at the end of the operation.
while advancing the fasciocutaneous flap to finish the operation (Figure 1). The operation on the opposite side was performed 1 month later. In the same manner, the perforator was confirmed and an incision was made in the form of a “Pac Man” flap to cover the circular defect. After the flap was elevated in the suprafascial and submuscular planes, it was mobilized by undermining the triangular parts on both sides. These 2 parts did not have to be advanced but were moved to the midline of the defect to meet each other. Then, the skin flap was sutured. The final appearance of the flaps was similar to that of “Pac Man” (Figure 2). Figure 3 shows the healed flap 3 months after surgery.
Discussion In 1983, Asko-Seljavaara -Selijavaara introduced the term free-style free flap and suggested that any skin island could be harvested if a vessel supplying it could be identified and
dissected.2 Havlik and Ariyan described the repeated use of the same myocutaneous flap in difficult second operations on the head and neck.3 Recently, Feng and colleagues introduced the concept of a “free-style puzzle flap.”4 They treated 13 patients from whom 12 pedicles with free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects in various anatomical locations. They proposed that a local or free flap could be harvested for recycling where an obvious Doppler signal had been detected. In this case, 2 perforators on the left side and 3 perforators on the right side were detected with a Doppler device. In addition, CTA was used preoperatively to detect these perforators. These methods helped the authors to raise the flap easily and understand the vasculature of the adjacent soft tissue. Given the limitations in donor sites and local tissues, when a defect forms in an area that had been reconstructed with flaps, it is a great challenge to the plastic surgeon to
Downloaded from ijl.sagepub.com by guest on November 14, 2015
74
The International Journal of Lower Extremity Wounds 13(1)
Figure 2. The coverage of recurrent right trochanteric pressure sore.
(A) and (B) In the same manner as stated previously, the perforator was confirmed, and the incision line was designed in the form of “Pac Man” flap to cover the defect of circular shape. (C) After elevating the flap to suprafascial, submuscular dual planes, it was enabled to move by completely undermining the triangular parts on both sides. (D) Skin flap was sutured. The final view of the flaps was similar to “Pac Man.”
Figure 3. Healed flap 3 months after surgery. Bilateral trochanteric defect was covered completely with no tension on the flap: (A) left side; (B) right side.
reconstruct the defect. When the surgeon plans to reconstruct a pressure sore in a paraplegic or quadriplegic patient,
he or she must consider the economy of the donor site because relapse can occur after the surgery. Numerous methods have been attempted to solve this problem, including V-Y re-advancement or reuse of myocutaneous flaps to manage recurrent lesions in the sacral, ischial, or trochanteric area.5,6 Lee and Mun introduced the concept of recycling a previous flap into a perforator flap for a recurrent sacral defect.7 However, there have been no reports of the recycling of a perforator-based flap for recurrent trochanteric defects. A trochanteric sore is often deep and wide, involving the fascia and muscles. In 1978, Nahai et al first described the TFL musculocutaneous flap in the trochanteric area.8 Numerous modifications have been developed, such as V-Y advancement, retropositioning, and bilobed flaps. However, all these modifications were random-pattern flaps and there were concerns regarding the vascularity of the distal flap.9 In our case, re-advancement of a skin flap was attempted in the same manner. However, while elevating the flap, it was divided into 2 planes by dissecting the subfascial and submuscular planes. Since the musculocutaneous perforator from the TFL to the skin was preserved through meticulous dissection, the 2 flaps were slid separately and re-advanced. Moreover, unlike a random flap, these flaps were reliable.
Downloaded from ijl.sagepub.com by guest on November 14, 2015
75
Han and Choi Moreover, the concept of a “perforator-based flap” is distinct from that of a “perforator flap.”9 Following to the concept of a “perforator-based flap,” no further dissection is needed to find the proximal source of vessels or to dissect the area around the perforator.9 Since the undissected proximal portion of the flap always includes numerous invisible “microperforators” that penetrate the TFL, these modifications provide greater versatility and reliability than the perforator flap. This case shows that if a reliable perforator is preserved and identified using CTA or a Doppler device within the tissues of the previous flap site, a new perforator flap can be designed and raised. Theoretically, through the development of this concept with Doppler mapping and meticulous dissection, all regions of the body are potential donor sites for skin flaps. The method described here should be a good treatment option for recurrent defects anywhere. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received the financial support for the research, authorship, and/or publication of this article: This work was supported by the Soonchunhyang University Research Fund.
References 1. Hallock CG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg. 2003;51:617-620. 2. Asko-Seljavaara S. Free style free flaps. Paper presented at: Seventh Congress of the International Society of Reconstructive Microsurgery; June 19-30, 1983; New York, NY. 3. Havlik R, Ariyan S. Repeated use of the same myocutaneous flap in difficult second operations of the head and neck. Plast Reconstr Surg. 1994;93:481-488. 4. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: the concept of recycling perforator flap. Plast Reconstr Surg. 2013;131:258-263. 5. Kroll SS, Hamilton S. Multiple and repetitive uses of the extended hamstring V-Y myocutaneous flap. Plast Reconstr Surg. 1989;84:296-302. 6. Tobin GR, Brown GL, Derr JW, Barker JH, Weiner LJ. V-Y advancement flaps. Reusable flaps for pressure ulcer repair. Clin Plast Surg. 1990;17:727-732. 7. Lee TS, Mun GH. Recycling a flap: making a perforator flap from a previous gluteal fasciocutaneous flap. J Plast Surg Hand Surg. 2011;45:165-167. 8. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fascia lata musculocutaneous flap. Ann Plast Surg. 1978;1: 372-379. 9. Kim YH, Kim SW, Kim JT, Kim CY. Tensor fascia lata flap versus tensor fascia lata perforator-based island flap for the coverage of extensive trochanteric pressure sore. Ann Plast Surg. 2013;70:684-690.
Downloaded from ijl.sagepub.com by guest on November 14, 2015
research-article2014
IJLXXX10.1177/1534734613520324The International Journal of Lower Extremity WoundsHan and Choi
Case Report
Free-Style Dual Plane Recycling Tensor Fascia Lata Musculocutaneous Perforator Flap for Reconstruction of Recurrent Trochanteric Defects
The International Journal of Lower Extremity Wounds 2014, Vol. 13(1) 72–75 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734613520324 ijl.sagepub.com
Ba Leun Han, MD1, and Hwan Jun Choi, MD, PhD1
Abstract Sequential flap coverage might be required for recurrent defects, but reusing a flap as a donor site has seldom been reported. The concept of a “free-style flap” has been developed, and it allows reconstructive surgeons to raise flaps with various designs reliably, even at sites of previous flap surgery. This article presents the concept of free-style recycling of a tensor fascia lata flap into a perforator-based flap separated in 2 planes in a patient with a recurrent bilateral trochanteric defect. If a reliable perforator is preserved and identified within the tissues by computed tomography angiography or a Doppler device, a new perforator flap can be designed and raised at the previous flap site. Keywords flap recycling, perforator, tensor fascia lata, flap Sequential flap coverage might be required for recurrent defects, especially in areas of the body where pressure sores occur frequently, such as in the sacral, ischial, and trochanteric areas.1 The concept of a “free-style flap” was developed to allow reconstructive surgeons to raise flaps of various designs reliably, even at sites where flap surgery has been performed previously. This concept can be very useful for treating recurrent pressure sores. Reusing a previous flap as a donor site has seldom been reported, but recycling a flap is one of the most economical and reasonable ways to manage repetitive defects if the reused flap is reliable and safe. Several reports have discussed the recycling of a perforator flap or free-style flap for reconstruction, but no study has reported the reuse of a flap as a perforator-based flap for recurrent defects in the trochanteric area. This article presents the concept of free-style recycling of a tensor fascia lata (TFL) flap into a perforator-based flap separated along 2 planes in a patient with a recurrent bilateral trochanteric defect.
Case Report A 66-year-old tetraplegic male patient presented with recurrent pressure sores and massive discharge on both trochanteric surfaces. He first underwent surgery for a decubitus ulcer 6 months earlier in another clinic. This used a TFL V-Y advancement flap. The lesion was debrided and 10 × 7 cm (left) and 7 × 7 cm (right) defects remained. Lower
extremity computed tomography angiography (CTA) showed that the perforator of the ascending branch of the lateral circumflex femoral artery was intact. Using a handheld Doppler, the perforator of the ascending branch of the lateral circumflex femoral artery was localized within the previous flap site. First, coverage of the left side was planned. Coverage of the wide muscular defect was planned by dividing it along 2 planes, involving muscle and fasciocutaneous flaps. At surgery, the patient was positioned laterally, and the flap was designed from the medial thigh to knee. After the perforator that supplied the flap was confirmed and marked using a handheld Doppler device, an incision was made along the previous surgical scar. The dissection was performed from proximal to distal until sufficient advancement was possible. While the flap was being elevated by dissecting the subfascial and submuscular planes, the connection of the musculocutaneous perforator from the TFL to the skin was confirmed. Then, the flap was elevated completely, preserving the pedicle and leaving the distal one third of the flap intact. After the defect was covered by sliding the muscle with the defect, it was sutured 1
Soonchunhyang University, Cheonan, Korea
Corresponding Author: Hwan Jun Choi, Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University 23-20, BongmyungDong, Cheonan 330-721, Korea. Email: [email protected]
Downloaded from ijl.sagepub.com by guest on November 14, 2015
73
Han and Choi
Figure 1. The coverage of recurrent left trochanteric pressure sore.
(A) After the perforator that supplies the flap was confirmed and marked by using a handheld Doppler, the incision line was designed along the operation scar. (B) While elevating the flap by dissecting to each subfascial and submuscular dual planes, the musculocutaneous perforator that is connected from TFL to skin was confirmed. (C) The muscle flap was slid into the defect and drain was applied. (D) The sutured flap at the end of the operation.
while advancing the fasciocutaneous flap to finish the operation (Figure 1). The operation on the opposite side was performed 1 month later. In the same manner, the perforator was confirmed and an incision was made in the form of a “Pac Man” flap to cover the circular defect. After the flap was elevated in the suprafascial and submuscular planes, it was mobilized by undermining the triangular parts on both sides. These 2 parts did not have to be advanced but were moved to the midline of the defect to meet each other. Then, the skin flap was sutured. The final appearance of the flaps was similar to that of “Pac Man” (Figure 2). Figure 3 shows the healed flap 3 months after surgery.
Discussion In 1983, Asko-Seljavaara -Selijavaara introduced the term free-style free flap and suggested that any skin island could be harvested if a vessel supplying it could be identified and
dissected.2 Havlik and Ariyan described the repeated use of the same myocutaneous flap in difficult second operations on the head and neck.3 Recently, Feng and colleagues introduced the concept of a “free-style puzzle flap.”4 They treated 13 patients from whom 12 pedicles with free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects in various anatomical locations. They proposed that a local or free flap could be harvested for recycling where an obvious Doppler signal had been detected. In this case, 2 perforators on the left side and 3 perforators on the right side were detected with a Doppler device. In addition, CTA was used preoperatively to detect these perforators. These methods helped the authors to raise the flap easily and understand the vasculature of the adjacent soft tissue. Given the limitations in donor sites and local tissues, when a defect forms in an area that had been reconstructed with flaps, it is a great challenge to the plastic surgeon to
Downloaded from ijl.sagepub.com by guest on November 14, 2015
74
The International Journal of Lower Extremity Wounds 13(1)
Figure 2. The coverage of recurrent right trochanteric pressure sore.
(A) and (B) In the same manner as stated previously, the perforator was confirmed, and the incision line was designed in the form of “Pac Man” flap to cover the defect of circular shape. (C) After elevating the flap to suprafascial, submuscular dual planes, it was enabled to move by completely undermining the triangular parts on both sides. (D) Skin flap was sutured. The final view of the flaps was similar to “Pac Man.”
Figure 3. Healed flap 3 months after surgery. Bilateral trochanteric defect was covered completely with no tension on the flap: (A) left side; (B) right side.
reconstruct the defect. When the surgeon plans to reconstruct a pressure sore in a paraplegic or quadriplegic patient,
he or she must consider the economy of the donor site because relapse can occur after the surgery. Numerous methods have been attempted to solve this problem, including V-Y re-advancement or reuse of myocutaneous flaps to manage recurrent lesions in the sacral, ischial, or trochanteric area.5,6 Lee and Mun introduced the concept of recycling a previous flap into a perforator flap for a recurrent sacral defect.7 However, there have been no reports of the recycling of a perforator-based flap for recurrent trochanteric defects. A trochanteric sore is often deep and wide, involving the fascia and muscles. In 1978, Nahai et al first described the TFL musculocutaneous flap in the trochanteric area.8 Numerous modifications have been developed, such as V-Y advancement, retropositioning, and bilobed flaps. However, all these modifications were random-pattern flaps and there were concerns regarding the vascularity of the distal flap.9 In our case, re-advancement of a skin flap was attempted in the same manner. However, while elevating the flap, it was divided into 2 planes by dissecting the subfascial and submuscular planes. Since the musculocutaneous perforator from the TFL to the skin was preserved through meticulous dissection, the 2 flaps were slid separately and re-advanced. Moreover, unlike a random flap, these flaps were reliable.
Downloaded from ijl.sagepub.com by guest on November 14, 2015
75
Han and Choi Moreover, the concept of a “perforator-based flap” is distinct from that of a “perforator flap.”9 Following to the concept of a “perforator-based flap,” no further dissection is needed to find the proximal source of vessels or to dissect the area around the perforator.9 Since the undissected proximal portion of the flap always includes numerous invisible “microperforators” that penetrate the TFL, these modifications provide greater versatility and reliability than the perforator flap. This case shows that if a reliable perforator is preserved and identified using CTA or a Doppler device within the tissues of the previous flap site, a new perforator flap can be designed and raised. Theoretically, through the development of this concept with Doppler mapping and meticulous dissection, all regions of the body are potential donor sites for skin flaps. The method described here should be a good treatment option for recurrent defects anywhere. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received the financial support for the research, authorship, and/or publication of this article: This work was supported by the Soonchunhyang University Research Fund.
References 1. Hallock CG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg. 2003;51:617-620. 2. Asko-Seljavaara S. Free style free flaps. Paper presented at: Seventh Congress of the International Society of Reconstructive Microsurgery; June 19-30, 1983; New York, NY. 3. Havlik R, Ariyan S. Repeated use of the same myocutaneous flap in difficult second operations of the head and neck. Plast Reconstr Surg. 1994;93:481-488. 4. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: the concept of recycling perforator flap. Plast Reconstr Surg. 2013;131:258-263. 5. Kroll SS, Hamilton S. Multiple and repetitive uses of the extended hamstring V-Y myocutaneous flap. Plast Reconstr Surg. 1989;84:296-302. 6. Tobin GR, Brown GL, Derr JW, Barker JH, Weiner LJ. V-Y advancement flaps. Reusable flaps for pressure ulcer repair. Clin Plast Surg. 1990;17:727-732. 7. Lee TS, Mun GH. Recycling a flap: making a perforator flap from a previous gluteal fasciocutaneous flap. J Plast Surg Hand Surg. 2011;45:165-167. 8. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fascia lata musculocutaneous flap. Ann Plast Surg. 1978;1: 372-379. 9. Kim YH, Kim SW, Kim JT, Kim CY. Tensor fascia lata flap versus tensor fascia lata perforator-based island flap for the coverage of extensive trochanteric pressure sore. Ann Plast Surg. 2013;70:684-690.
Downloaded from ijl.sagepub.com by guest on November 14, 2015
