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International Journal of Urology (2014) 21, 1178–1180
doi: 10.1111/iju.12545
Case Report
Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap Ingo Ludolph,1 Hendrik Apel,2 Raymund E Horch1 and Justus P Beier1 Departments of 1Plastic and Hand Surgery and 2Urology, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg, Erlangen, Germany
Abbreviations & Acronyms VRAM = vertical rectus abdominis myocutaneous Correspondence: Justus P Beier M.D., Department of Plastic and Hand Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054 Erlangen, Germany. Email: [email protected] Received 31 March 2014; accepted 28 May 2014. Online publication 8 July 2014
Abstract: We present a surgical treatment for bladder reconstruction in a case of chronic vesicocutaneous radiation-induced fistula and reconstruction of the abdominal wall after resection of a liposarcoma in the rectus abdominis muscle. Fistulas are sequelae after radiotherapy. To regain bladder function and reconstitute abdominal wall stability, a microsurgical flap approach should be considered. A male patient underwent resection of a liposarcoma in the rectus abdominis muscle with adjuvant radiotherapy, suffering from a chronic vesicocutaneous fistula. A bipedicled combined latissimus dorsi and serratus anterior flap was carried out after resection of the fistula for reconstruction of the urine bladder and the abdominal wall. Ascending urethrography 4 weeks postoperatively showed no leakage. In the 4-month follow-up period, no signs of recurrence of the fistula or herniation occurred. A bipedicled flap allowed reconstruction of the urine bladder and the abdominal wall. Using non-irradiated, well-perfused intra-abdominal muscle tissue over the urine bladder prevented recurrence of the fistula. Key words: abdominal wall reconstruction, bladder reconstruction, free latissimus dorsi flap, free serratus anterior flap, vesicocutaneous fistula.
Introduction Fistulas as a consequence of radiotherapy of the abdomen are common adverse effects. Vesicocutaneous fistulas also develop as a result of suprapubic bladder drainage, injuries such as bladder rupture and bladder calculi.1–3 There is still no guideline on how to manage vesicocutaneous fistulas, often resulting in an operative procedure due to insufficient conservative treatment methods. Using well-perfused tissue for the treatment of fistulas has been described in the literature; for example, the pedicled VRAM flap.4 Because operative therapy for vesicocutaneous fistulas of the abdominal wall is not reported in the literature, to our knowledge we present the first case with simultaneous reconstruction of the urine bladder and the lower abdominal wall in an interdisciplinary setting using a free bipedicled latissimus dorsi and serratus anterior flap in a single-staged procedure.
Case report A 69-year-old man suffered from a liposarcoma of the right rectus abdominis muscle with adjuvant radiochemotherapy after resection of the sarcoma 2 years before, and impaired wound healing of the abdominal wall. The wound was closed by a split thickness skin graft, but a vesicocutaneous fistula developed with continuous urinary leakage through the lower abdominal wall (Fig. 1a). Conservative treatment with bilateral nephrostomy was carried out, but urinary leakage remained for several months. In addition, a weakness of the abdominal wall as a result of the loss of the rectus muscle and overlying skin was observed. Finally, an interdisciplinary therapy concept was stated together with the department of urology with resection of the fistula, reconstruction of the urine bladder and simultaneous reconstruction of the abdominal wall defect. Since the initial treatment of the liposarcoma, there was no evidence of recurrence. A skin paddle overlying the latissimus dorsi muscle was marked in a horizontal position matching the size of the abdominal wall defect. The patient was placed in the right lateral position, and the left bipedicled latissimus and serratus anterior flap was harvested preserving the 1178
© 2014 The Japanese Urological Association
Free flap bladder reconstruction
(a)
(b)
Fig. 1 (a) Preoperative situation with vesicocutaneous fistula at lower abdominal wall. (b) Harvested bipedicular myocutaneous latissimus flap (*) and serratus anterior muscle flap (**); (▲), serrate branch; (↑), of thoracodorsal vessels.
(a)
(b)
Fig. 2 (a) Follow up 4 months postoperative. (b) Ascending urethrography after 4 weeks.
cranial vascular pedicle to the serratus muscle, which is a long branch of the thoracodorsal vessel (Fig. 1b). The second last slip of the serratus anterior muscle was harvested based on the serrate branch. To prevent a winging of the scapula, the remaining muscle parts were left intact and the corresponding long thoracic nerve was preserved. Before moving the patient in the supine position, the flap was banked in the axilla. A sterile urinary catheter was inserted transurethrally. The split thickness skin graft was excised together with the fistula, where the anterior wall of the urinary bladder showed a defect, which was first closed by a running suture in a double layer using Vicryl 3-0 with atraumatic thread, and submitted to histopathological examination. Subsequently, the flap was harvested through an anterior axillary access, and anastomosis of the subscapular to the femoral artery and coupler anastomosis of the subscapular vein to a branch of the femoral vein was carried out. The serratus muscle was placed over the sutured antero-cranial bladder wall defect in terms as a muscle patch, and the myocutaneous latissimus dorsi was used for multilayer reconstruction of the abdominal wall. The postoperative course was uneventful and with an uncomplicated recovery. The resected scar tissue at the time of reconstruction showed no recurrence of the liposarcoma in the histopathological analysis. In a follow up 4 weeks postoperatively, ascending urethrography showed no leakage of contrast medium whereupon the urinary catheter was removed leaving the nephrostomy catheters in situ in case of functional impairment of the bladder (Fig. 2). The initial urodynamic study © 2014 The Japanese Urological Association
showed a bladder capacity of 125 mL, at a level of 100 mL a slightly reflux was detected for the left ureter and for both ureters at a level of 125 mL, with no leakage from the bladder. Four months after surgery, the patient still had normal function for micturition after removal of the nephrostomy catheters. The abdominal wall showed no signs of recurrence of fistula or herniation (Fig. 2). The patient’s activity level improved constantly, and he could retain urine for up to 250 cc with a micturition frequency of approximately four to five per day and one to two per night.
Discussion Reports in the literature about vesicocutaneous fistulas are generally rare. Fistulas, such as vesicovaginal or rectovaginal fistulas, are more common complications and displeasing for the patient. Fistulas after radiotherapy can develop up to years or can recur after initial successful treatment. The reliable use of pedicled muscle flaps, especially the VRAM flap for fistula repair in the lower abdomen or salvage surgery after cancer disease, is well reported in the literature.5,6 Different reconstructive options had to be discussed in the present case of vesicocutaneous fistula – resection of parts of both rectus abdominis muscles, weakness of the abdominal wall and previous radiotherapy. A split thickness skin graft was carried out initially, but wound healing disturbance and a vesicocutaneous fistula occurred. For reconstruction of the weak and irradiated abdominal wall, and for prevention of 1179
I LUDOLPH ET AL.
fistula recurrence, a split thickness skin graft seems insufficient. Using a pedicled VRAM was not possible, because the right rectus abdominis muscle was resected. Taking the opposite rectus abdominis muscle would additionally have weakened the abdominal wall significantly, and it would not have been possible to reconstruct both structures simultaneously (intraperitoneal bladder defect and superficial abdominal wall defect), as the VRAM cannot be harvested as a bipedicled flap. Regarding a deltopectoral flap, an extended functional impairment would result in comparison with the latissimus and serratus anterior flap. Furthermore, the vascular pedicle of the deltopectoral flap is too short for the required intraperitoneal distance from the next available recipient vessels, and finally its volume and surface would have been insufficient for simultaneous reconstruction of the bladder and the abdominal wall. Using the tensor fascia lata flap is a common alternative for solitary reconstruction of the abdominal wall. In this special case, two distant problems had to be solved. On the one hand, the deep intraperitoneal bladder defect; on the other hand, the large myocutaneous abdominal wall defect. In addition, with its shorter vascular pedicle, this flap was not an alternative in the present case. The gracilis flap is known as an optimal option for reconstruction of the genitourinary system, especially as a pedicled flap. For reconstruction of intraperitoneal defects, an important disadvantage is also the short vascular pedicle, which would be too short for anastomosis to the femoral vessels as a free flap. As a pedicled flap, it might have reached the bladder through an additional perineal or anterior approach to the peritoneal cave, but the task of reconstructing the abdominal wall defect could not have been solved by using this flap solitarily. By transplanting a free latissimus dorsi muscle flap without the serratus muscle, reconstruction of the abdominal wall would have been facilitated. However, proper placing of the muscle for simultaneous reconstruction of the abdominal wall and the urine bladder with only one pedicle would not have been possible because of the long distance between the abdominal wall defect and the bladder defect (Fig. S1). Methods of tissue engineering seem promising in this context, but are not clinically available options yet.7,8 To resolve the fistula, permanently radical resection of the fistula is important. For reconstruction of the urine bladder wall and to prevent recurrence of the fistula, well-perfused tissue is necessary in the context after radiotherapy. Regarding this, a well-vascularized muscle flap, such as the bipedicled latissimus dorsi and serratus anterior muscle flap, is the most promising option, and was chosen here and reported for the first time.9,10 In the case of recurrence of the liposarcoma, it would even be possible to harvest the latissimus dorsi flap or even resect parts of it in consideration of the flap pedicle course. The fistula did not recur up to the last follow up, and the patient reported to be continent with no limitations in daily life.
1180
Because of the uneventful course and good wound healing, we expect no recurrence of herniation or fistula in future. For similar cases, we recommend the bipedicled latissimus dorsi and serratus anterior muscle flap as an option. This technique allows a single-staged reconstruction of the abdominal wall and defects of the bladder or other intrapelvic or intra-abdominal defects, which is facilitated by the large separate pedicle to the serratus muscle. Like other muscle flaps, this technique is considered best to prevent recurrence of the initial fistula.
Conflict of interest None declared.
References 1 Petru E, Herzog K, Kurschel S, Tamussino K, Winter R. Vesicocutaneous fistula mimicking an abdominal wall abscess 2 years after radical abdominal hysterectomy. Gynecol. Oncol. 2003; 90: 494. 2 Kosaka T, Asano T, Azuma R, Yoshii H, Yamanaka Y, Hayakawa M. A case of vesicocutaneous fistula to the thigh. Urology 2009; 73: 929.e7–8. 3 Lau K, Cheng C. Delayed vesicocutaneous fistula after radiation therapy for advanced vulvar cancer. A case report. Ann. Med. Singapore 1998; 27: 705–6. 4 Horch RE, Gitsch G, Schultze-Seemann W. Bilateral pedicled myocutaneous vertical rectus abdominis muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds. Urology 2002; 60: 502–7. 5 Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br. J. Surg. 2003; 90: 575–80. 6 Viennas LK, Alonso AM, Salama V. Repair of radiation-induced vesicovaginal fistula with a rectus abdominis myocutaneous flap. Plast. Reconstr. Surg. 1995; 96: 1435–7. 7 Horch RE, Kneser U, Polykandriotis E, Schmidt VJ, Sun J, Arkudas A. Tissue engineering and regenerative medicine – where do we stand? J. Cell. Mol. Med. 2012; 16: 1157–65. 8 Horch RE, Boos AM, Quan Y et al. Cancer research by means of tissue engineering – is there a rationale? J. Cell. Mol. Med. 2013; 17: 1197–206. 9 Phan T, Spilker G, Theodorou P, Gossmann A, Heiss M, Weinand C. Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction. Microsurgery 2011; 31: 529–34. 10 Serra MP, Longhi P, Carminati M, Righi B, Robotti E. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myoosseous flap and latissimus dorsi myocutaneous flap. J. Plast. Reconstr. Aesthet. Surg. 2007; 60: 1158–61.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Fig. S1 (a) Schematic illustration of intraoperative situation after transplantation of the flaps with the latissimus dorsi muscle (left) for reconstruction the abdominal wall and the serratus anterior muscle (right) for patching the bladder (yellow) defect. (b) Schematic illustration of the situation at the end of the procedure, with the common pedicle of both flaps; that is, the subscapular artery and vein anastomosed to the left femoral vessels (end-to-side fashion), and both flaps in place.
© 2014 The Japanese Urological Association
Copyright of International Journal of Urology is the property of Wiley-Blackwell 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.
International Journal of Urology (2014) 21, 1178–1180
doi: 10.1111/iju.12545
Case Report
Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap Ingo Ludolph,1 Hendrik Apel,2 Raymund E Horch1 and Justus P Beier1 Departments of 1Plastic and Hand Surgery and 2Urology, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg, Erlangen, Germany
Abbreviations & Acronyms VRAM = vertical rectus abdominis myocutaneous Correspondence: Justus P Beier M.D., Department of Plastic and Hand Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054 Erlangen, Germany. Email: [email protected] Received 31 March 2014; accepted 28 May 2014. Online publication 8 July 2014
Abstract: We present a surgical treatment for bladder reconstruction in a case of chronic vesicocutaneous radiation-induced fistula and reconstruction of the abdominal wall after resection of a liposarcoma in the rectus abdominis muscle. Fistulas are sequelae after radiotherapy. To regain bladder function and reconstitute abdominal wall stability, a microsurgical flap approach should be considered. A male patient underwent resection of a liposarcoma in the rectus abdominis muscle with adjuvant radiotherapy, suffering from a chronic vesicocutaneous fistula. A bipedicled combined latissimus dorsi and serratus anterior flap was carried out after resection of the fistula for reconstruction of the urine bladder and the abdominal wall. Ascending urethrography 4 weeks postoperatively showed no leakage. In the 4-month follow-up period, no signs of recurrence of the fistula or herniation occurred. A bipedicled flap allowed reconstruction of the urine bladder and the abdominal wall. Using non-irradiated, well-perfused intra-abdominal muscle tissue over the urine bladder prevented recurrence of the fistula. Key words: abdominal wall reconstruction, bladder reconstruction, free latissimus dorsi flap, free serratus anterior flap, vesicocutaneous fistula.
Introduction Fistulas as a consequence of radiotherapy of the abdomen are common adverse effects. Vesicocutaneous fistulas also develop as a result of suprapubic bladder drainage, injuries such as bladder rupture and bladder calculi.1–3 There is still no guideline on how to manage vesicocutaneous fistulas, often resulting in an operative procedure due to insufficient conservative treatment methods. Using well-perfused tissue for the treatment of fistulas has been described in the literature; for example, the pedicled VRAM flap.4 Because operative therapy for vesicocutaneous fistulas of the abdominal wall is not reported in the literature, to our knowledge we present the first case with simultaneous reconstruction of the urine bladder and the lower abdominal wall in an interdisciplinary setting using a free bipedicled latissimus dorsi and serratus anterior flap in a single-staged procedure.
Case report A 69-year-old man suffered from a liposarcoma of the right rectus abdominis muscle with adjuvant radiochemotherapy after resection of the sarcoma 2 years before, and impaired wound healing of the abdominal wall. The wound was closed by a split thickness skin graft, but a vesicocutaneous fistula developed with continuous urinary leakage through the lower abdominal wall (Fig. 1a). Conservative treatment with bilateral nephrostomy was carried out, but urinary leakage remained for several months. In addition, a weakness of the abdominal wall as a result of the loss of the rectus muscle and overlying skin was observed. Finally, an interdisciplinary therapy concept was stated together with the department of urology with resection of the fistula, reconstruction of the urine bladder and simultaneous reconstruction of the abdominal wall defect. Since the initial treatment of the liposarcoma, there was no evidence of recurrence. A skin paddle overlying the latissimus dorsi muscle was marked in a horizontal position matching the size of the abdominal wall defect. The patient was placed in the right lateral position, and the left bipedicled latissimus and serratus anterior flap was harvested preserving the 1178
© 2014 The Japanese Urological Association
Free flap bladder reconstruction
(a)
(b)
Fig. 1 (a) Preoperative situation with vesicocutaneous fistula at lower abdominal wall. (b) Harvested bipedicular myocutaneous latissimus flap (*) and serratus anterior muscle flap (**); (▲), serrate branch; (↑), of thoracodorsal vessels.
(a)
(b)
Fig. 2 (a) Follow up 4 months postoperative. (b) Ascending urethrography after 4 weeks.
cranial vascular pedicle to the serratus muscle, which is a long branch of the thoracodorsal vessel (Fig. 1b). The second last slip of the serratus anterior muscle was harvested based on the serrate branch. To prevent a winging of the scapula, the remaining muscle parts were left intact and the corresponding long thoracic nerve was preserved. Before moving the patient in the supine position, the flap was banked in the axilla. A sterile urinary catheter was inserted transurethrally. The split thickness skin graft was excised together with the fistula, where the anterior wall of the urinary bladder showed a defect, which was first closed by a running suture in a double layer using Vicryl 3-0 with atraumatic thread, and submitted to histopathological examination. Subsequently, the flap was harvested through an anterior axillary access, and anastomosis of the subscapular to the femoral artery and coupler anastomosis of the subscapular vein to a branch of the femoral vein was carried out. The serratus muscle was placed over the sutured antero-cranial bladder wall defect in terms as a muscle patch, and the myocutaneous latissimus dorsi was used for multilayer reconstruction of the abdominal wall. The postoperative course was uneventful and with an uncomplicated recovery. The resected scar tissue at the time of reconstruction showed no recurrence of the liposarcoma in the histopathological analysis. In a follow up 4 weeks postoperatively, ascending urethrography showed no leakage of contrast medium whereupon the urinary catheter was removed leaving the nephrostomy catheters in situ in case of functional impairment of the bladder (Fig. 2). The initial urodynamic study © 2014 The Japanese Urological Association
showed a bladder capacity of 125 mL, at a level of 100 mL a slightly reflux was detected for the left ureter and for both ureters at a level of 125 mL, with no leakage from the bladder. Four months after surgery, the patient still had normal function for micturition after removal of the nephrostomy catheters. The abdominal wall showed no signs of recurrence of fistula or herniation (Fig. 2). The patient’s activity level improved constantly, and he could retain urine for up to 250 cc with a micturition frequency of approximately four to five per day and one to two per night.
Discussion Reports in the literature about vesicocutaneous fistulas are generally rare. Fistulas, such as vesicovaginal or rectovaginal fistulas, are more common complications and displeasing for the patient. Fistulas after radiotherapy can develop up to years or can recur after initial successful treatment. The reliable use of pedicled muscle flaps, especially the VRAM flap for fistula repair in the lower abdomen or salvage surgery after cancer disease, is well reported in the literature.5,6 Different reconstructive options had to be discussed in the present case of vesicocutaneous fistula – resection of parts of both rectus abdominis muscles, weakness of the abdominal wall and previous radiotherapy. A split thickness skin graft was carried out initially, but wound healing disturbance and a vesicocutaneous fistula occurred. For reconstruction of the weak and irradiated abdominal wall, and for prevention of 1179
I LUDOLPH ET AL.
fistula recurrence, a split thickness skin graft seems insufficient. Using a pedicled VRAM was not possible, because the right rectus abdominis muscle was resected. Taking the opposite rectus abdominis muscle would additionally have weakened the abdominal wall significantly, and it would not have been possible to reconstruct both structures simultaneously (intraperitoneal bladder defect and superficial abdominal wall defect), as the VRAM cannot be harvested as a bipedicled flap. Regarding a deltopectoral flap, an extended functional impairment would result in comparison with the latissimus and serratus anterior flap. Furthermore, the vascular pedicle of the deltopectoral flap is too short for the required intraperitoneal distance from the next available recipient vessels, and finally its volume and surface would have been insufficient for simultaneous reconstruction of the bladder and the abdominal wall. Using the tensor fascia lata flap is a common alternative for solitary reconstruction of the abdominal wall. In this special case, two distant problems had to be solved. On the one hand, the deep intraperitoneal bladder defect; on the other hand, the large myocutaneous abdominal wall defect. In addition, with its shorter vascular pedicle, this flap was not an alternative in the present case. The gracilis flap is known as an optimal option for reconstruction of the genitourinary system, especially as a pedicled flap. For reconstruction of intraperitoneal defects, an important disadvantage is also the short vascular pedicle, which would be too short for anastomosis to the femoral vessels as a free flap. As a pedicled flap, it might have reached the bladder through an additional perineal or anterior approach to the peritoneal cave, but the task of reconstructing the abdominal wall defect could not have been solved by using this flap solitarily. By transplanting a free latissimus dorsi muscle flap without the serratus muscle, reconstruction of the abdominal wall would have been facilitated. However, proper placing of the muscle for simultaneous reconstruction of the abdominal wall and the urine bladder with only one pedicle would not have been possible because of the long distance between the abdominal wall defect and the bladder defect (Fig. S1). Methods of tissue engineering seem promising in this context, but are not clinically available options yet.7,8 To resolve the fistula, permanently radical resection of the fistula is important. For reconstruction of the urine bladder wall and to prevent recurrence of the fistula, well-perfused tissue is necessary in the context after radiotherapy. Regarding this, a well-vascularized muscle flap, such as the bipedicled latissimus dorsi and serratus anterior muscle flap, is the most promising option, and was chosen here and reported for the first time.9,10 In the case of recurrence of the liposarcoma, it would even be possible to harvest the latissimus dorsi flap or even resect parts of it in consideration of the flap pedicle course. The fistula did not recur up to the last follow up, and the patient reported to be continent with no limitations in daily life.
1180
Because of the uneventful course and good wound healing, we expect no recurrence of herniation or fistula in future. For similar cases, we recommend the bipedicled latissimus dorsi and serratus anterior muscle flap as an option. This technique allows a single-staged reconstruction of the abdominal wall and defects of the bladder or other intrapelvic or intra-abdominal defects, which is facilitated by the large separate pedicle to the serratus muscle. Like other muscle flaps, this technique is considered best to prevent recurrence of the initial fistula.
Conflict of interest None declared.
References 1 Petru E, Herzog K, Kurschel S, Tamussino K, Winter R. Vesicocutaneous fistula mimicking an abdominal wall abscess 2 years after radical abdominal hysterectomy. Gynecol. Oncol. 2003; 90: 494. 2 Kosaka T, Asano T, Azuma R, Yoshii H, Yamanaka Y, Hayakawa M. A case of vesicocutaneous fistula to the thigh. Urology 2009; 73: 929.e7–8. 3 Lau K, Cheng C. Delayed vesicocutaneous fistula after radiation therapy for advanced vulvar cancer. A case report. Ann. Med. Singapore 1998; 27: 705–6. 4 Horch RE, Gitsch G, Schultze-Seemann W. Bilateral pedicled myocutaneous vertical rectus abdominis muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds. Urology 2002; 60: 502–7. 5 Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br. J. Surg. 2003; 90: 575–80. 6 Viennas LK, Alonso AM, Salama V. Repair of radiation-induced vesicovaginal fistula with a rectus abdominis myocutaneous flap. Plast. Reconstr. Surg. 1995; 96: 1435–7. 7 Horch RE, Kneser U, Polykandriotis E, Schmidt VJ, Sun J, Arkudas A. Tissue engineering and regenerative medicine – where do we stand? J. Cell. Mol. Med. 2012; 16: 1157–65. 8 Horch RE, Boos AM, Quan Y et al. Cancer research by means of tissue engineering – is there a rationale? J. Cell. Mol. Med. 2013; 17: 1197–206. 9 Phan T, Spilker G, Theodorou P, Gossmann A, Heiss M, Weinand C. Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction. Microsurgery 2011; 31: 529–34. 10 Serra MP, Longhi P, Carminati M, Righi B, Robotti E. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myoosseous flap and latissimus dorsi myocutaneous flap. J. Plast. Reconstr. Aesthet. Surg. 2007; 60: 1158–61.
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Fig. S1 (a) Schematic illustration of intraoperative situation after transplantation of the flaps with the latissimus dorsi muscle (left) for reconstruction the abdominal wall and the serratus anterior muscle (right) for patching the bladder (yellow) defect. (b) Schematic illustration of the situation at the end of the procedure, with the common pedicle of both flaps; that is, the subscapular artery and vein anastomosed to the left femoral vessels (end-to-side fashion), and both flaps in place.
© 2014 The Japanese Urological Association
Copyright of International Journal of Urology is the property of Wiley-Blackwell 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.
