Letter to the Editor: Short Report
79
Functional Reconstruction of a Large Anterior Thigh Defect Using Contralateral Anterolateral Thigh Flap with Tensor Fasciae Latae and Motorized Vastus Lateralis Sammy Sinno, MD1
Keith Blechman, MD1
1 Institute of Reconstructive Plastic Surgery, New York University
School of Medicine, New York 2 Department of Surgery, New York University School of Medicine, New York
Russell Berman, MD2
Address for correspondence Sammy Sinno, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, 307 East 33rd Street, New York, NY 10016 (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:79–82.
Reconstructive surgeons strive to return to their patients what fate has taken away, a mission particularly evident in limb salvage surgery (LSS). Patients with soft tissue sarcomas, aggressive tumors that require wide resections or amputation, have particularly benefited from strides in this field that has been made possible by cross-sectional imaging, adjuvant therapy, and microsurgery. With equal to or greater than 5year survival outcomes compared with amputation, this multimodal approach has become the standard of care.1 The anterior thigh, the most common location of soft tissue sarcomas,2 has become a focus of LSS efforts. Here, we reveal a novel approach to a massive anterolateral thigh (ALT) deficit, including the use of a neuromotor, neurosensory, composite myocutaneous ALT graft from the contralateral thigh.
Case Study A 73-year-old man presented with an 8-month history of left thigh pain and swelling. Magnetic resonance imaging and biopsy revealed a near-circumferential myxoid liposarcoma measuring 31 50 cm. The patient underwent 5 weeks of neoadjuvant radiation and preoperative tumor embolization before aggressive surgical resection and immediate reconstruction. Preoperatively, he ambulated with walker and cane.
Operative Resection Oncologic surgeons performed a wide skin excision and nearcomplete resection of the quadriceps compartment, iliotibial
received October 21, 2013 accepted after revision January 19, 2014 published online May 29, 2014
tract, and femur periosteum. En bloc removal of the 7-pound specimen left a 40 15 cm defect with exposed bone (►Fig. 1).
Reconstructive Approach The reconstructive surgery team harvested a 35 15 cm musculocutaneous free flap from the contralateral ALT including tensor fascia latae and vastus lateralis muscles with preserved motor nerve branches, iliotibial tract, and a dominant vascular pedicle from the lateral femoral circumflex system (►Fig. 2). The donor site was closed primarily. The lateral femoral circumflex artery and two accompanying venae comitantes supplying the graft were anastomosed end-to-end with those of the recipient site, followed by reapproximation of the flap’s motor supply to the contralateral posterior division of the femoral nerve. The vastus lateralis and iliotibial tract fascia were tenodesed proximally to the anterior superior iliac spine and pubis, and distally to the patella tendon. The lateral femoral cutaneous nerves of the flap and recipient site were then coapted to grant sensation to the skin island. Both motor and sensory nerve reapproximations were performed as close to the donor tissue as possible to minimize the distance required for nerve regeneration. A deep wound drain was placed, and the skin flap secured in place to achieve complete wound coverage (►Fig. 3). The reconstructive procedure, including harvest and implant of the free flap took a total of 5.5 hours, with a 200 mL estimated blood loss. The graft showed signs of perfusion once revascularized, and no signs of ischemia.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1372479. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Alexander B. Dillon, BA1 Pierre Saadeh, MD1
Novel Motorized Reconstruction of Anterior Thigh
Dillon et al.
Fig. 1 The intraoperative defect.
Postoperative Course The postoperative course was uncomplicated and included knee immobilization for 6 weeks and outpatient physical rehabilitation. After 6 months of the surgery, the patient was fully healed and able to extend his left knee 45 degrees from the seated position (see ►video). There were no notable limitations of active knee flexion or hip flexion or extension. The patient used a cane, and he ambulated without assistance at home. The graft was sensate to light touch, pain, and temperature and yielded 8-mm two-point discrimination. There was no notable donor site morbidity.
Video Postoperative functionality. Online content including video sequences viewable at: www.thieme-connect.com/ejournals/html/doi/ 10.1055/s-0034-1372479.
Discussion Debilitating soft tissue deficits, including loss of entire muscle compartments not uncommon postsarcoma resection, have prompted the use of innervated grafts to actively maintain function in addition to restoring form. Optimal motorized
Fig. 2 The donor flap on its pedicle.
Journal of Reconstructive Microsurgery
Vol. 31
No. 1/2015
Fig. 3 The closed recipient site.
donor flap considerations include the size, strength, and excursion of the muscle, the availability of overlying skin, the functional role and redundancy of donor site musculature, ease of access and dissection, and sustainability including blood supply and innervation. At present, no level I or level II evidence exists to support specific treatment options for anterior thigh muscle defects, due to small case numbers and retrospective study designs. We “replaced like with like,” namely, our patient’s resected thigh tissue with that of his contralateral thigh, ensuring an optimal muscle and skin match. We used the vastus lateralis because it is the largest, most powerful head of the quadriceps, yet its absence results in minimal donor site impairment.3 The noninnervated tensor fasciae latae muscle transfer conveniently restored bulk to the recipient site, due to its close proximity, with low cost, given its nonessential role in knee stabilization. The partial iliotibial band transfer helped stabilize the lateral knee and assist in hip mobility, while the generous ALT skin island easily covered the large surface area of the defect, and availability of its sensory nerve, the lateral femoral cutaneous, allowed it to be reinnervated, maximizing the chance of resensitization. Though comparison across the small studies4–9 of various approaches to similar defects is difficult, functional outcomes appear most favorable when there is residual musculature to accompany that transferred, and when local, pedicled muscle transfers augment free muscle grafts. Whether or not the latter combination represents the ideal treatment for functional ALT deficits, the optimal free flap remains to be determined.7,10 Our technique allowed all missing tissue components to be replaced with a single flap. Our patient required no intraoperative repositioning, and his supine position allowed for an expedited two-team approach. Moreover, our flap lends more coverage than the others described, with minimal donor site morbidity. Its long pedicle length and large caliber artery help ensure its survival and sustainability at the recipient site. Indeed, our patient’s graft survived in entirety, and he expressed satisfaction with it. In summary, we report the first successful use of a composite, sensate ALT flap with tensor fasciae latae and
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
80
Novel Motorized Reconstruction of Anterior Thigh
Conflict of Interest None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.
4 Fansa H, Plogmeier K, Feistner H, Schneider WJ. Plasticity and
5
6
7
References
8
1 Rosenberg SA, Tepper J, Glatstein ELI, et al. The treatment of soft-
tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982;196(3):305–315 2 Shiu MH, Castro EB, Hajdu SI, Fortner JG. Surgical treatment of 297 soft tissue sarcomas of the lower extremity. Ann Surg 1975; 182(5):597–602 3 Markhede G, Stener B. Function after removal of various hip and thigh muscles for extirpation of tumors. Acta Orthop Scand 1981; 52(4):373–395
81
9
10
function—the fate of a free, neurovascular muscle graft ten years post-reconstruction. J Reconstr Microsurg 1997;13(8):551–554 Grinsell D, Di Bella C, Choong PFM. Functional reconstruction of sarcoma defects utilising innervated free flaps. Sarcoma 2012; 2012:315190 Ihara K, Shigetomi M, Kawai S, Doi K, Yamamoto M. Functioning muscle transplantation after wide excision of sarcomas in the extremity. Clin Orthop Relat Res 1999;(358):140–148 Innocenti M, Abed YY, Beltrami G, Delcroix L, Balatri A, Capanna R. Quadriceps muscle reconstruction with free functioning latissimus dorsi muscle flap after oncological resection. Microsurgery 2009;29(3):189–198 Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Hashimoto T, Taguchi T. Transfer of latissimus dorsi muscle for the functional reconstruction of quadriceps femoris muscle following oncological resection of sarcoma in the thigh. J Plast Reconstr Aesthet Surg 2011;64(8):1068–1074 Wechselberger G, Ninkovic M, Pülzl P, Schoeller T. Free functional rectus femoris muscle transfer for restoration of knee extension and defect coverage after trauma. J Plast Reconstr Aesthet Surg 2006;59(9):994–998 Lo SJ, Yeo M, Puhaindran M, Hsu CC, Wei FC. A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss. J Bone Joint Surg Br 2012;94(8):1016–1023
Journal of Reconstructive Microsurgery
Vol. 31
No. 1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
motorized vastus lateralis muscles to reconstruct the anterior thigh and quadriceps compartment, representing what we believe to be the optimal free flap for this defect.
Dillon et al.
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
79
Functional Reconstruction of a Large Anterior Thigh Defect Using Contralateral Anterolateral Thigh Flap with Tensor Fasciae Latae and Motorized Vastus Lateralis Sammy Sinno, MD1
Keith Blechman, MD1
1 Institute of Reconstructive Plastic Surgery, New York University
School of Medicine, New York 2 Department of Surgery, New York University School of Medicine, New York
Russell Berman, MD2
Address for correspondence Sammy Sinno, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, 307 East 33rd Street, New York, NY 10016 (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:79–82.
Reconstructive surgeons strive to return to their patients what fate has taken away, a mission particularly evident in limb salvage surgery (LSS). Patients with soft tissue sarcomas, aggressive tumors that require wide resections or amputation, have particularly benefited from strides in this field that has been made possible by cross-sectional imaging, adjuvant therapy, and microsurgery. With equal to or greater than 5year survival outcomes compared with amputation, this multimodal approach has become the standard of care.1 The anterior thigh, the most common location of soft tissue sarcomas,2 has become a focus of LSS efforts. Here, we reveal a novel approach to a massive anterolateral thigh (ALT) deficit, including the use of a neuromotor, neurosensory, composite myocutaneous ALT graft from the contralateral thigh.
Case Study A 73-year-old man presented with an 8-month history of left thigh pain and swelling. Magnetic resonance imaging and biopsy revealed a near-circumferential myxoid liposarcoma measuring 31 50 cm. The patient underwent 5 weeks of neoadjuvant radiation and preoperative tumor embolization before aggressive surgical resection and immediate reconstruction. Preoperatively, he ambulated with walker and cane.
Operative Resection Oncologic surgeons performed a wide skin excision and nearcomplete resection of the quadriceps compartment, iliotibial
received October 21, 2013 accepted after revision January 19, 2014 published online May 29, 2014
tract, and femur periosteum. En bloc removal of the 7-pound specimen left a 40 15 cm defect with exposed bone (►Fig. 1).
Reconstructive Approach The reconstructive surgery team harvested a 35 15 cm musculocutaneous free flap from the contralateral ALT including tensor fascia latae and vastus lateralis muscles with preserved motor nerve branches, iliotibial tract, and a dominant vascular pedicle from the lateral femoral circumflex system (►Fig. 2). The donor site was closed primarily. The lateral femoral circumflex artery and two accompanying venae comitantes supplying the graft were anastomosed end-to-end with those of the recipient site, followed by reapproximation of the flap’s motor supply to the contralateral posterior division of the femoral nerve. The vastus lateralis and iliotibial tract fascia were tenodesed proximally to the anterior superior iliac spine and pubis, and distally to the patella tendon. The lateral femoral cutaneous nerves of the flap and recipient site were then coapted to grant sensation to the skin island. Both motor and sensory nerve reapproximations were performed as close to the donor tissue as possible to minimize the distance required for nerve regeneration. A deep wound drain was placed, and the skin flap secured in place to achieve complete wound coverage (►Fig. 3). The reconstructive procedure, including harvest and implant of the free flap took a total of 5.5 hours, with a 200 mL estimated blood loss. The graft showed signs of perfusion once revascularized, and no signs of ischemia.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1372479. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Alexander B. Dillon, BA1 Pierre Saadeh, MD1
Novel Motorized Reconstruction of Anterior Thigh
Dillon et al.
Fig. 1 The intraoperative defect.
Postoperative Course The postoperative course was uncomplicated and included knee immobilization for 6 weeks and outpatient physical rehabilitation. After 6 months of the surgery, the patient was fully healed and able to extend his left knee 45 degrees from the seated position (see ►video). There were no notable limitations of active knee flexion or hip flexion or extension. The patient used a cane, and he ambulated without assistance at home. The graft was sensate to light touch, pain, and temperature and yielded 8-mm two-point discrimination. There was no notable donor site morbidity.
Video Postoperative functionality. Online content including video sequences viewable at: www.thieme-connect.com/ejournals/html/doi/ 10.1055/s-0034-1372479.
Discussion Debilitating soft tissue deficits, including loss of entire muscle compartments not uncommon postsarcoma resection, have prompted the use of innervated grafts to actively maintain function in addition to restoring form. Optimal motorized
Fig. 2 The donor flap on its pedicle.
Journal of Reconstructive Microsurgery
Vol. 31
No. 1/2015
Fig. 3 The closed recipient site.
donor flap considerations include the size, strength, and excursion of the muscle, the availability of overlying skin, the functional role and redundancy of donor site musculature, ease of access and dissection, and sustainability including blood supply and innervation. At present, no level I or level II evidence exists to support specific treatment options for anterior thigh muscle defects, due to small case numbers and retrospective study designs. We “replaced like with like,” namely, our patient’s resected thigh tissue with that of his contralateral thigh, ensuring an optimal muscle and skin match. We used the vastus lateralis because it is the largest, most powerful head of the quadriceps, yet its absence results in minimal donor site impairment.3 The noninnervated tensor fasciae latae muscle transfer conveniently restored bulk to the recipient site, due to its close proximity, with low cost, given its nonessential role in knee stabilization. The partial iliotibial band transfer helped stabilize the lateral knee and assist in hip mobility, while the generous ALT skin island easily covered the large surface area of the defect, and availability of its sensory nerve, the lateral femoral cutaneous, allowed it to be reinnervated, maximizing the chance of resensitization. Though comparison across the small studies4–9 of various approaches to similar defects is difficult, functional outcomes appear most favorable when there is residual musculature to accompany that transferred, and when local, pedicled muscle transfers augment free muscle grafts. Whether or not the latter combination represents the ideal treatment for functional ALT deficits, the optimal free flap remains to be determined.7,10 Our technique allowed all missing tissue components to be replaced with a single flap. Our patient required no intraoperative repositioning, and his supine position allowed for an expedited two-team approach. Moreover, our flap lends more coverage than the others described, with minimal donor site morbidity. Its long pedicle length and large caliber artery help ensure its survival and sustainability at the recipient site. Indeed, our patient’s graft survived in entirety, and he expressed satisfaction with it. In summary, we report the first successful use of a composite, sensate ALT flap with tensor fasciae latae and
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
80
Novel Motorized Reconstruction of Anterior Thigh
Conflict of Interest None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.
4 Fansa H, Plogmeier K, Feistner H, Schneider WJ. Plasticity and
5
6
7
References
8
1 Rosenberg SA, Tepper J, Glatstein ELI, et al. The treatment of soft-
tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982;196(3):305–315 2 Shiu MH, Castro EB, Hajdu SI, Fortner JG. Surgical treatment of 297 soft tissue sarcomas of the lower extremity. Ann Surg 1975; 182(5):597–602 3 Markhede G, Stener B. Function after removal of various hip and thigh muscles for extirpation of tumors. Acta Orthop Scand 1981; 52(4):373–395
81
9
10
function—the fate of a free, neurovascular muscle graft ten years post-reconstruction. J Reconstr Microsurg 1997;13(8):551–554 Grinsell D, Di Bella C, Choong PFM. Functional reconstruction of sarcoma defects utilising innervated free flaps. Sarcoma 2012; 2012:315190 Ihara K, Shigetomi M, Kawai S, Doi K, Yamamoto M. Functioning muscle transplantation after wide excision of sarcomas in the extremity. Clin Orthop Relat Res 1999;(358):140–148 Innocenti M, Abed YY, Beltrami G, Delcroix L, Balatri A, Capanna R. Quadriceps muscle reconstruction with free functioning latissimus dorsi muscle flap after oncological resection. Microsurgery 2009;29(3):189–198 Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Hashimoto T, Taguchi T. Transfer of latissimus dorsi muscle for the functional reconstruction of quadriceps femoris muscle following oncological resection of sarcoma in the thigh. J Plast Reconstr Aesthet Surg 2011;64(8):1068–1074 Wechselberger G, Ninkovic M, Pülzl P, Schoeller T. Free functional rectus femoris muscle transfer for restoration of knee extension and defect coverage after trauma. J Plast Reconstr Aesthet Surg 2006;59(9):994–998 Lo SJ, Yeo M, Puhaindran M, Hsu CC, Wei FC. A reappraisal of functional reconstruction of extension of the knee following quadriceps resection or loss. J Bone Joint Surg Br 2012;94(8):1016–1023
Journal of Reconstructive Microsurgery
Vol. 31
No. 1/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
motorized vastus lateralis muscles to reconstruct the anterior thigh and quadriceps compartment, representing what we believe to be the optimal free flap for this defect.
Dillon et al.
Copyright of Journal of Reconstructive Microsurgery is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
