Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage

Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction

BACKGROUND

Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed.

MATERIALS AND METHODS

We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described.

RESULTS

Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended.

CONCLUSION

Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.

The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds

OBJECTIVE

To determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns.

METHODS

This was a retrospective case review of 9 patients with sternal wound dehiscence over an 18-month period between 2013 and 2015. Seven of the 9 patients received a single IMAP flap to cover full-length sternal wounds, including 4 with a fasciocutaneous flap and 3 with a musculocutaneous flap.

RESULTS

All of the patients were male, with a mean age of 68 years. The mean number of perforators was 1.3, with a mean perforator diameter of 1.5 mm. In all cases, the torsion angle was 80 degrees, with a translational pedicle movement of 1 to 2 cm. There were no instances of total flap failure and only 2 cases of partial flap necrosis, which were managed conservatively. One flap, performed when both internal mammary arteries had been harvested previously, showed complete survival.

CONCLUSIONS

The IMAP flap has an advantage in its the ability to reconstruct the entire length of a sternotomy wound from the suprasternal notch to the xiphisternum with relatively minimal dissection and morbidity compared with more conventional flaps such as pectoralis major, rectus, and omental flaps. Nevertheless, caveats for its use remain, such as in patients with vasopressor therapy and the resulting subclavicular scar, which is unaesthetic in women. Overall, the IMAP flap is an attractive reconstructive tool specifically in stable male patients with noninfected sternotomy wound dehiscence with a defect width of up to 7 cm. In this patient subset, it is the ideal first-line reconstructive tool.

[Reconstruction of an abdominal wall defect with a superior epigastric perforator propeller flap: case report]

Perforators flaps take a special place in reconstructive surgery. These flaps can be dissected and turned as a propeller blade on its pedicule axis. We report the case of a 54-year-old man presenting a recurrence of a dermatofibrosarcoma in the right hypochondrium. Tumor resection caused a large abdominal wall defect taking the anterior aponeurosis of the rectus abdominis. An angioscanner was realized in preoperative to locate the perforators of the deep superior epigastric artery. We realized a propeller flap based on a perforator of the left superior epigastric artery who allowed to cover the wall defect. We set up a patch of Vicryl® to reconstruct the aponeurosis plan at the same operative time. We didn't note any necrosis and complete healing occurred in 2 weeks. The margins were healthy. The cosmetic result and the low morbidity make this flap a good therapeutic option. This flap seems reliable, arteries perforators are constant with good diameter.