The Sensate Medial Dorsal Intercostal Artery Perforator Flap for Closure of Cervicothoracic Midline Defects After Spinal Surgery: An Anatomic Study and Case Reports

Challenging the Dogma of Dead Space Obliteration With Muscle Flaps in Deep Spinal Surgical Site Infections

Background

A deep surgical site infection (SSI) after spinal surgery is a serious complication. The defect formed is often a complex 3-dimensional dead space due to tissue loss, frequently containing spinal hardware. Traditionally, obliteration of that dead space is performed with the use of muscle flaps. We challenge this dogma in reconstructive surgery by using the medial dorsal intercostal artery perforator (MDICAP) flap as an alternative in the reconstruction. It adheres to the concept of replacing "like with like," as there are no muscles at the posterior midline.

Methods

A retrospective study was performed of a cohort of 18 patients with deep SSI and a posterior midline defect after spinal surgery who received reconstruction with the MDICAP flap. A review of postoperative imaging with focus on dead space was performed.

Results

All patients had satisfactory functional and aesthetic outcomes. No patients had a recurrent deep SSI during follow-up (average 64 mo, range 3-384 mo). In the 16 patients who had postoperative imaging performed, dead space was not present at the flaps' recipient site.

Conclusions

The MDICAP flap is a good alternative to muscle flaps in reconstructive surgery for complex posterior midline defects caused by a deep SSI after spinal surgery. Postoperative imaging showed no dead space with the use of MDICAP flaps. All patients had an uneventful postoperative course with no recurrent infections. This challenges the dogmata of (1) the need for muscle flaps in such reconstruction and (2) the obligate need for dead space obliteration at the time of operation.

Clinical Applications of the Intercostal Artery Perforator Flap for Trunk Reconstruction

Background  Trunk defects can occur because of surgical site infections after spinal surgery, resection of malignant tumors, or trauma. Herein, we present our experience of using intercostal artery perforator (ICAP) flaps to reconstruct trunk defects without noteworthy complications. Fourteen patients underwent reconstruction with ICAP flaps between March 2015 and March 2019. Methods  Patients' data, including age, sex, the cause of the defect, defect size, perforator location, flap size, complications, and follow-up period, were retrospectively reviewed. The mean age of the patients was 56.5 years (range, 19-80 years). All operations were performed after the results of bacterial culture from the wound showed no microbial growth. We found reliable perforators around the defect using Doppler ultrasonography. The perforator flaps were elevated with a pulsatile perforator and rotated in a propeller fashion to the defects. We performed five dorsal and two lateral ICAP flaps. The mean flap dimensions were 12 × 5.5 cm ² (range, 6 × 5 to 18 × 8 cm ² ). Results  Primary closure of the donor site was performed. Marginal congestion was observed as a complication in one case, but it healed with no need for revision. The mean follow-up period was 8 months. All patients were satisfied with the surgical outcomes. Conclusion  ICAP flaps can be easily mobilized, thereby reducing donor site morbidity without sacrificing the underlying muscles for trunk reconstruction. Therefore, these flaps are useful options for the reconstruction of trunk defects.

An Anatomical Study of Posterior Trunk Recipient Vessels, and Comparisons of Outcome following Pedicled- and Free-Flap Transfers for Treatment of Sarcoma in the Posterior Trunk

BACKGROUND

 Reconstruction after wide resection of a large sarcoma arising in the posterior trunk may require free-flap transfer to reduce the postoperative complications. Here, we describe the recipient vessels on the whole posterior trunk. Moreover, to show the reliability of these vessels, we describe an institutional series of free-flap reconstruction.

METHODS

 In the cadaveric study, 20 posterior trunk regions from 10 fixed cadavers were dissected. The location and the diameter of the perforating artery and vein on the posterior were documented. In the clinical study, 54 patients undergoing immediate reconstruction surgery with only a pedicled flap (n = 45) and with a free flap (n = 9) after sarcoma resection on the posterior trunk between July 2005 and September 2021 were identified. One-to-one propensity score matching was performed to compare the postoperative complications.

RESULTS

 In the cadaveric study, a total of 178 perforators were identified. The average diameter of the superficial cervical artery (SCA) and vein, dorsal scapular artery (DSA) and vein, medial branch of dorsal intercostal artery perforator (m-DICAP) and vein, lateral branch of dorsal intercostal artery perforator (l-DICAP) and vein, and dorsolateral intercostal artery perforator (DLICAP) and vein were 1.03, 1.67, 1.38, 1.84, 1.28, 1.84, 1.01, 1.60, 1.11, and 1.70 mm. In the clinical study, the propensity score-matched analysis involving eight pairs showed a significantly higher occurrence of total complications in the pedicled-flap group than the free-flap group (62.5 vs. 0%, p = 0.03).

CONCLUSION

 The cadaveric study showed that the perforators from the SCA, DSA, and posterior intercostal artery are constantly present. The clinical study demonstrated the feasibility and reliability of a free-flap transfer.

Perforator-Based Flaps for Defect Reconstruction of the Posterior Trunk

INTRODUCTION

Full-thickness soft tissue defects of the back remain challenging clinical problems for reconstructive surgeons. Among a vast variety of local flap options, perforator-based local flaps gain increasing popularity lately. Because mostly heterogeneous patient cohort comparison of different perforator flaps is difficult and decision-making algorithms are lacking.

METHODS

Patients, who received a local perforator-based soft tissue reconstruction between 2012 and 2019, were evaluated retrospectively. Patients' data were evaluated in terms of flap type and dimension, wound size and cause, surgery time, postoperative complications, and hospitalization. A focus was set on decision making concerning reconstructive techniques and flap choice for defect closure.

RESULTS

Thirty-six patients (17 women, 19 men) were included, who received 40 perforator-based local flaps to reconstruct extended defects of the posterior trunk. Mean patient age was 56.3 years and mean hospitalization was 29 days. Average time of flap surgery was 179.7 minutes. Mean flap size was 160.8 cm and average defect size was 110 cm. Defects occurred because of tumor resection (50%), orthopedic/trauma surgery (16.7%), or pressure sores (33.3%). Twenty-eight propeller flaps (PPFs, 70%) and 12 perforator-based VY-advancement flaps (P-VYF, 30%) were transferred. In 4 patients, a bilateral approach using more than one flap was necessary. Revision surgery was required in 9 patients (25%) because of postoperative hematoma (n = 3), postoperative wound infection (n = 3), partial flap necrosis (1× P-VYF) and 2 flap losses (2× PPFs).

CONCLUSIONS

Pedicled perforator flaps are a reliable option for soft tissue reconstruction of complex wounds of the posterior trunk. A flexible surgical strategy is mandatory, and the individual perforator anatomy has to be considered. In most cases, P-VYFs or PPFs are reliably possible and allow sufficient defect reconstruction. However, skin incisions should always be performed in a way that classic random pattern flaps are still possible. Even in large defects combined, local perforator flaps may lead to sustainable soft tissue reconstructions without functional donor site deficits.

Reconstruction of Spinal Soft Tissue Defects With Perforator Flaps From the Paraspinal Region

BACKGROUND/AIM

Reconstruction of spinal soft tissue defects is challenging, especially when neural structures or prosthetic material are exposed. They should be covered with well-vascularized tissue such as paraspinal perforator flaps.

MATERIALS AND METHODS

This is a retrospective study of soft tissue reconstructions with paraspinal perforator flaps from 2011 to 2018. The technique is described and risk factors for poor wound healing were assessed. Postoperative complications are reported.

RESULTS

Twenty patients with a mean age of 63.65 years were included. Defects had an average size of 47 cm² and were mainly located in the lumbosacral region (9 patients). Twelve patients suffered from infection following spinal stabilization, seven of whom were diagnosed with osteomyelitis, two patients presented with pressure sore and one patient experienced wound dehiscence. One partial flap necrosis with a lumbar defect occurred, which required revision surgery. No total flap loss occurred. Stable, closed wounds were achieved at their final follow-up.

CONCLUSION

Perforator paraspinal flaps are suitable for immediate reconstruction of spinal defects.

Perforator-Guided Drug Injection in the Treatment of Abdominal Wall Pain

BACKGROUND

Pain from the abdominal wall can be caused by nerve entrapment, a condition called abdominal cutaneous nerve entrapment syndrome (ACNES). As an alternative to surgery, ACNES may be treated with injection of local anesthetics, corticosteroids, or botulinum toxin at the point of maximal pain.

METHOD

The point of maximal pain was marked on the abdominal skin. Using color Doppler ultrasound, the corresponding exit point of perforating blood vessels through the anterior fascia of the rectus abdominis muscle was identified. Ultrasound-guided injection of botulinum toxin in close proximity to the perforator's exit point was performed below and above the muscle fascia.

RESULTS

The technique was used from 2008 to 2014 on 15 patients in 46 sessions with a total of 128 injections without complications. The injection technique provided safe and accurate administration of the drug in proximity to the affected cutaneous nerves. The effect of botulinum toxin on ACNES is beyond the scope of this article.

CONCLUSION

Perforator-guided injection enables precise drug administration at the location of nerve entrapment in ACNES in contrast to blind injections.

Closure of Complex Posterior Midline Defects After Spinal Surgery With Sensate Midline-based Perforator Flaps and the Long-term Results

STUDY DESIGN

Prospective study.

OBJECTIVE

Evaluating the use of a midline-based perforator flap for closure of complex midline defects after spine surgery complicated with implant exposure and deep subfascial infection.

SUMMARY OF BACKGROUND DATA

Traditionally, muscle flaps are used to close complex defects after spine surgery complicated by exposed spinal implants and deep subfascial infections. There are no reports on the long-term results on the use of perforator flaps to close these defects.

METHODS

Information was prospectively registered of all patients in whom a medial dorsal intercostal artery perforator (MDICAP) flap was used for closure of a complex midline defect with exposed spinal implant and deep subfascial infection after spine surgery.

RESULTS

In 9 patients, 10 MDICAP flaps were used. All flaps survived with only 1 flap experiencing marginal flap necrosis. The flaps provided stable coverage of all defects and spinal instrumentation could be retained in all patients. The perforator flaps provided in all patients, except in the patient with a meningomyelocele, protective sensibility in the reconstructed areas. The mean postoperative hospital stay after closure of the defects was 10 days (range 4-21). During follow-up (mean 65 mo, range 7-106) only 1 patient developed an infection in the operated area which occurred 81 months postoperatively. None of the patients had any functional loss at the donor site of the flap.

CONCLUSION

The medial dorsal intercostal artery perforator flap seems to be a reliable alternative for treatment of complex midline defects with exposed spinal implants and deep subfascial surgical site infections. Protective sensibility may be obtained in the reconstructed area with this flap. Donor site morbidity is minimal. In case of recurrence, complex reconstructive procedures using muscle flaps are still possible. The use of this perforator flap may contribute to shorter hospital stays and reduction of costs.

LEVEL OF EVIDENCE

4.

Complications, pitfalls, and outcomes after chest wall reconstruction

Chest wall and mediastinal wounds may be life-threatening. Although modern reconstruction methods with various muscle flaps have reduced morbidity and mortality, chest wall reconstruction presents unique challenges. Major categories of adverse outcomes include (1) persistent infection; (2) interference with respiratory mechanics; (3) functional deficits of the shoulder; and (4) hernias. Persistent infection may be resolved by providing coverage via muscle or omental flap, performing thorough debridement, filling the "dead space" with adequate volume, buttressing repair of visceral fistulae, and covering exposed prosthetic material with vascularized flaps. Potential deficits in respiratory mechanics and shoulder function may be avoided by stabilizing the chest wall skeleton and decreasing donor muscle functional loss. Hernias may be minimized by maintaining visceral "right of domain" to the chest and abdominal cavities. Complex reconstructive cases represent an intricate interplay of physiology, structural protection, and aesthetic considerations and require integration of several management principles.