Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels

Gaster, Richard S.; Bhatt, Kirit A.; Shelton, Andrew; Lee, Gordon K.

doi:10.1002/micr.21981

Cited by 22 publications

(21 citation statements)

References 19 publications

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“…While locoregional flaps are the standard of care in most sacral wound defects, they are not plausible in many scenarios. Numerous local flap options have been reported, including gluteal artery perforator flaps (13–16), gluteus maximus sliding flaps (17), paraspinal flaps (18), V-Y advancement flaps (19, 20), and regional anterolateral thigh flaps (21). However, they are relatively contraindicated in oncological sacral defects.…”

Section: Discussionmentioning

confidence: 99%

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection

García-Tutor¹,

Romeo²,

Chae³

et al. 2016

Front. Surg.

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BackgroundLocoregional flaps are sufficient in most sacral reconstructions. However, large sacral defects due to malignancy necessitate a different reconstructive approach, with local flaps compromised by radiation and regional flaps inadequate for broad surface areas or substantial volume obliteration. In this report, we present our experience using free muscle transfer for volumetric reconstruction, in such cases, and demonstrate three-dimensional (3D) haptic models of the sacral defect to aid preoperative planning.MethodsFive consecutive patients with irradiated sacral defects secondary to oncologic resections were included, surface area ranging from 143–600 cm2. Latissimus dorsi (LD)-based free flap sacral reconstruction was performed in each case, between 2005 and 2011. Where the superior gluteal artery was compromised, the subcostal artery (SA) was used as a recipient vessel. Microvascular technique, complications, and outcomes are reported. The use of volumetric analysis and 3D printing is also demonstrated, with imaging data converted to 3D images suitable for 3D printing with Osirix software (Pixmeo, Geneva, Switzerland). An office-based, desktop 3D printer was used to print 3D models of sacral defects, used to demonstrate surface area and contour and produce a volumetric print of the dead space needed for flap obliteration.ResultsThe clinical series of LD free flap reconstructions is presented, with successful transfer in all cases, and adequate soft-tissue cover and volume obliteration achieved. The original use of the SA as a recipient vessel was successfully achieved. All wounds healed uneventfully. 3D printing is also demonstrated as a useful tool for 3D evaluation of volume and dead space.ConclusionFree flaps offer unique benefits in sacral reconstruction where local tissue is compromised by irradiation and tumor recurrence, and dead space requires accurate volumetric reconstruction. We describe for the first time the use of the SA as a recipient in free flap sacral reconstruction. 3D printing of haptic bio-models is a rapidly evolving field with a substantial role in preoperative planning.

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Section: Discussionmentioning

confidence: 99%

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection

García-Tutor¹,

Romeo²,

Chae³

et al. 2016

Front. Surg.

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“…After radical debridement, resurfacing with highly vascularized tissue is the generally accepted treatment of choice . Most publications on radiation ulcers and osteoradionecrosis highlight the covering of soft tissues; however, treatment of the radiation‐induced osteomyelitis must precede this soft tissue coverage. Therefore, we suggest that osteoradionecrosis should be treated aggressively, just as in the treatment protocol for long bone osteomyelitis.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, radical debridement destroys normal anatomical structures, causing chronic fibrosis and inflammation damage to surrounding tissues, and even the vessel walls can become severely fibrosed. It is important to note that perforators can be located starting from one‐third of the distance between the posterior superior iliac spine and the greater trochanter, where the superior gluteal artery perforator emerges . Preoperative CT angiography may help in locating the perforator before surgery.…”

Section: Discussionmentioning

confidence: 99%

Reconstruction of severely infected gluteal osteoradionecrosis using negative‐pressure wound therapy and latissimus dorsi musculocutaneous flaps

et al. 2015

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Radiotherapy is mandatory for aggressive cancer treatment. Unfortunately, the high-energy radiation used can lead to severe osteoradionecrosis. Radical debridement of devitalized bone and soft tissue coupled with reconstruction using well-vascularized tissues is the accepted treatment for this condition. However, osteoradionecrosis cannot be controlled easily or rapidly. The aim of this study was to present the results of the use of serial negative-pressure wound therapy (NPWT) in combination with a latissimus dorsi myocutaneous flap for treatment of gluteal osteoradionecrosis in a consecutive series of patients. Between January 2003 and December 2012, nine patients underwent reconstruction using serial NPWT and latissimus dorsi myocutaneous flaps. We applied negative-pressure dressings for at least 8 weeks. Final reconstruction was performed after the infection was controlled. The superior gluteal artery and vein were used as recipient vessels in all the cases. The mean interval between operation and radiation therapy was 28.3 ± 8.3 years, and the mean number of debridement performed was 6.3 ± 1. NPWT dressings were applied for 8-12 weeks (mean, 9.3 ± 2 weeks). The defects ranged in size from 14 × 8 cm to 18 × 15 cm. The flap size ranged from 15 × 10 cm to 18 × 15 cm. All flaps survived uneventfully except in one patient who experienced chronic seroma and wound dehiscence. There were no recurrences of osteomyelitis during the follow-up periods (mean, 14 ± 6.1 months). Based on the results obtained from this consecutive series of patients, we suggest that this methodology may provide an alternative approach for the treatment of severe osteoradionecrosis of the gluteal region.

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“…Myocutaneous flaps (e.g. rectus abdominis flap, semitendinous and semimenbranous flaps, and gluteal flap) have significant bulk and robust vascularization . On the downside, muscle is not an ideal option in ambulatory patients.…”

Section: Discussionmentioning

confidence: 99%

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients

et al. 2014

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Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh.

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Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels

Cited by 22 publications

References 19 publications

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection

3D Volumetric Modeling and Microvascular Reconstruction of Irradiated Lumbosacral Defects after Oncologic Resection

Reconstruction of severely infected gluteal osteoradionecrosis using negative‐pressure wound therapy and latissimus dorsi musculocutaneous flaps

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients

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