Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR)

Background: This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed. Methods: A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset. Results: No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall. Conclusions: The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections. Presented at the Cine Clinic, 50th Annual Cancer Symposium, Society of Surgical Oncology, March 21, 1997, Chicago, Illinois. The opinions expressed in this article are those of the authors alone, and are not the opinions of the United States Air Force or the Department of Defense.     

?Forequarter-Amputation�� des rechten oberen Rumpfs

Total forearm free flap procedures after forequarter amputations have been sparsely described in the literature. Using the amputated arm as a ??free filet flap?? remains a viable surgical option after radical forequarter amputations performed for the resection of large, invasive tumors of the shoulder or thoracic wall region. Using the forequarter specimen as a donor site seems favorable in that it eliminates the usual donor site morbidity. Nevertheless, in our patient with invasive ductal carcinoma of the breast and a fibrosarcoma suffering from severe pain and septic conditions ?C which failed to respond properly to conservative therapy ?C as well as rapidly progressive tumor ulceration despite repeated radiation therapy, we decided to attempt complete tumor removal by hemithoracectomy as a last resort. This decision was taken following multiple interdisciplinary consultations and thorough patient information. Although technically feasible with complete tumor removal and safe soft tissue free flap coverage, the postoperative course raises questions about the advisability of such ultra radical surgical procedures, as well as about the limitations of respiratory recovery after hemithoracectomy with removal of the sternum. Hence, based on our experience with such radical tumor surgery, we discuss the issues of diminished postoperative pulmonary function, intensive care possibilities and ethical issues. The English full-text version of this article is available at SpringerLink (under ??Supplemental??).     

Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity

Background: Malignant tumors of the upper extremity involving a considerable portion of the medial axillary wall may require forequarter amputation to achieve gross resection of tumor. These resections frequently leave a large defect, often requiring a split thickness skin graft or free flap to close the wound. To address this problem of wound closure, we have modified our technique and devised a reconstructive component as part of our forequarter amputation procedure. Methods: The medical records of seven patients who underwent forequarter amputation and fasciocutaneous deltoid flap reconstruction between 1982 and 1994 were reviewed. Results: All the amputation sites were completely closed with a fasciocutaneous deltoid flap without the use of additional skin grafts or free flaps. After a median follow-up of 12 months, there were no local recurrences. Three patients (43%) are alive and disease free 5, 12, and 19 months after their forequarter amputation. One patient is alive with disease after 14 months. The remaining three patients died of their disease. Conclusion: The fasciocutaneous deltoid flap is technically easy to perform, provides wound coverage without the use of skin grafts, and is especially useful for tumors involving the media axillary wall and in patients with previous axillary radiation.Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Improved shoulder contour following forequarter amputation with an osteomyocutaneous free flap from the amputated extremity: two cases.

To cover a large soft-tissue defect and to reconstruct the shoulder contour after forequarter amputation, we used an osteomyocutaneous free flap incorporating an elbow joint from the amputated extremity in two patients. These flaps were well vascularised and reliable. They provided excellent coverage of large soft-tissue defects and they maintained shoulder contours. This procedure is useful for reconstruction after extended forequarter amputation and chest wall resection.     

The “epaulette” flap: replantation of osteomyocutaneous forearm segments in interscapulothoracic amputations

Summary Despite the sophisticated artificial limb devices now available, forequarter amputation following trauma or tumor resection always results in severe impairment of function. To close the extensive post-traumatic or oncologically acquired defects and to improve prosthetic replacement, cover of the thoracic wall should be performed by utilising the whole forearm as an osteomyocutaneous flap. In cases of concomitant serial rib resection, the radius and ulna can serve as stabilizers of the thoracic wall, thus, avoiding a flail chest. Indications, technical details and clinical outcome of three salvage replantations following interscapulothoracic ablation are discussed.     

Coverage of a large soft-tissue defect of the chest with a free fillet forearm and hand flap

The authors present a case in which a free circumferential fasciocutaneous flap from the forearm and hand, after radical tumor resection and forequarter amputation, was used successfully to cover the large soft-tissue defect on the chest wall.     

Forearm fillet flap for defect closure after chest wall resection in a breast cancer patient after forequarter amputation

Summary BACKGROUND: Widespread local recurrence of breast cancer and extension to the chest wall and other nearby structures in patients after radio- and chemotherapy is not rare. Recurrence might be associated with ulceration and severe pain after radiation therapy. Paralysis of the arm might result from compression of the brachial plexus. METHODS: We report here on a breast cancer patient in whom chest wall resection to deal with tumor invasion was followed by reconstruction undertaken with a flap raised from the forearm of the amputated upper extremity which had been paralysed by tumor extension. RESULTS: The patient was reintegrated into family life, thus saving her from social isolation and psychological suffering caused by her stinking ulcer. In addition, her extreme physical suffering was ameliorated to a great degree despite accompanying mutilation. CONCLUSIONS: Palliative forequarter amputation, chest wall resection, and subsequent chest wall reconstruction might be considered in patients without detectable metastases for improving the patients quality of life, even though it may not be curative and chances of long-term survival may be poor. The patient, however, must find the price of severe mutilation acceptable.     

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE: To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall. SUMMARY BACKGROUND DATA: Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction. METHODS: From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap. RESULTS: There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months. CONCLUSIONS: Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.     

The epaulette flap: replantation of osteomyocutaneous forearm segments in interscapulo-thoracic amputation]

Despite sophisticated artificial limb devices available today, forequarter amputation following trauma or tumor resection will lead to severe impairment of function. To close the posttraumatic or oncologically required extended defects and to improve prosthetic supplementation coverage of the thoracic wall should be performed by sparing the whole forearm as an osteomyocutaneous flap. In cases of concomitant serial rib resection radius and ulna will serve as stabilizators of the thoracic wall, thus avoiding a flail chest. Indications, technical details and clinical outcome of three salvage replantations after interscapulo-thoracic ablation will be discussed.     

Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the “spare parts concept.” Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor‐site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41‐year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft‐tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor‐site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:700–704, 2016.     

Conservation of normal tissue in the treatment of massive basal cell carcinoma.

Reconstruction of a defect of the shoulder and chest wall following resection of extensive basal cell carcinoma is demonstrated using classic principles of flap design and delay. Preservation of the normal tissue in an arm before amputation allowed for closure of a wound that could not be covered with musculocutaneous, omental, or microvascular free flaps.     

A bipedicled chest wall flap to cover an open elbow joint in a burned infant

A 7-month-old girl sustained a deep and extensive burn of the posterior aspect of the left upper arm and forearm, complicated by an open wound of the elbow joint with exposed bone and articular cartilage. A bipedicled chest wall flap was used to cover the defect. The limb was preserved along with good function in the elbow joint. An above-elbow amputation was thus avoided.     

Traumatic scapulothoracic dissociation

Scapulothoracic dissociation is an infrequent injury with a potentially devastating outcome. The diagnosis is based on clinical and radiographic findings of forequarter disruption. These include massive soft tissue swelling of the shoulder, displacement of the scapula and neurovascular injuries (brachial plexus, subclavian artery and osseous-ligamentous injuries). The mechanism of injury appears to be the delivery of severe rotational force sheering the shoulder girdle from its chest wall attachments around the scapula, shoulder joint and at the clavicle. Early recognition of the entity and aggressive treatment are crucial. Outcome is not dependent on management of the arterial injury, but rather on the severity of the neurological deficit.     

Combined laparoscopically harvested omental flap with meshed skin grafts and vacuum-assisted closure for reconstruction of complex chest wall defects

BACKGROUND: Chest wall reconstruction after radiation damage is a challenge in oncologic and plastic surgery. The defect can be reconstructed with laparoscopically harvested omental flap and meshed skin grafts. Our aim was to evaluate the use of vacuum-assisted closure (V.A.C.) in combination with laparoscopically harvested omental flap and meshed skin graft for treating these complex wounds. METHODS: Between October 2003 and December 2004, 11 patients underwent a chest wall reconstruction with laparoscopic omentoplasty and V.A.C. treatment of severe chest wall radionecrosis after breast cancer treatment (n = 10) or for locally advanced breast cancer treated first by irradiation (n = 1). RESULTS: Laparoscopic harvesting was uneventful in 10 cases. One patient had a laparoscopic transverse colic resection because of a middle colic artery injury. Mean time of the laparoscopic procedure was 53 minutes (range: 35-120). Wound surface area averaged 360 cm (range: 80-750). The mean duration of V.A.C. treatment was 9.3 days (range: 6-16). Nine patients showed primary wound healing without adverse events. Complications occurred in 3 patients. One developed a pulmonary infection and died after healing during the postoperative course. One presented a partial flap loss, leading to delayed healing after 45 days. One patient with severe radiation damage and a complete brachial plexus paralysis required a shoulder amputation after an extensive necrosis. All but 1 patient are alive and resumed their normal daily activities. CONCLUSIONS: Combination of laparoscopic omentoplasty and V.A.C. can successfully be used for reconstruction of complex chest wall radiation damage.     

Mitral valve reconstruction in sickle cell disease

We describe a variation of the technique of transthoracic forequarter amputation, consisting of a completely anterior approach, removal of the left forequarter en bloc with the chest wall and lung, and sparing of the scapula. This latter bone is mobilized and is used, along with the transposition of the lower ribs, to stabilize the chest wall.     

Wide resection of the upper right hemithorax combined with amputation of the right arm for a recurrent desmoid tumor

A 66-year-old woman had a recurrent desmoid tumor in the right thoracic apex. The tumor infiltrated the brachial plexus and eventually rendered the upper right extremity functionless. The tumor was removed by aggressive wide resection of the right upper hemithorax with simultaneous amputation of the functionless right arm. Reconstruction of the chest wall was accomplished, utilizing the soft tissues of the remnant arm as a pedicled flap to cover the full-thickness defect. Aggressive wide resection of the chest wall with limb amputation is technically challenging but unavoidable in some cases of recurrent desmoid tumor.     

Chest wall resections and reconstruction: a 25-year experience

Background. Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions.

Methods. A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed.

Results. Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 ± 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was 14 ± 14 days. Mean intensive care unit stay was 5 ± 9 days. In-hospital and 30-day survival was 93%.

Conclusions. Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.     

Reconstruction of the chest wall following extended interscapulothoracic amputation and chest wall resection

Summary Extended interscapulothoracic amputation is a major operative procedure indicated in the treatment of malignant primary bony and soft tissue tumors involving the shoulder girdle and chest wall. The technique of chest wall resection and its reconstruction is described in two patients with recurrent malignant fibrous histiocytoma following extended interscapulothoracic amputation some months earlier. The stability of the chest wall was restored by using marlex mesh as a sandwich of two layers of mesh with methylmethacrylate interposed. Because of damage of the tissue around the chest wall resection by previous radiation therapy, free myocutaneous flaps were used for closure of the defects. Using this technique for reconstruction of large areas of the chest wall, it is feasible to restore sufficient pulmonary function and to obtain closure under unfavorable conditions. This operative technique can be used as a curative or palliative treatment following interscapulothoracic amputation of recurrent musculoskeletal tumors.     

肺癌根治术后胸壁缺损重建方法的探讨

目的 探讨肺癌直接侵犯胸壁的根治性手术和胸壁重建的不同方法和效果.方法 回顾性总结27例肺癌直接侵犯胸壁根治手术的临床资料,行肺叶切除24例,全肺切除3例,所有患者手术中同时切除肺癌直接侵犯的胸壁,胸壁切除范围从6.5 cm×5.4 cm×5.0 cm至15.5 cm×12.5 cm×10.0 cm,切除肿瘤所侵犯的肋...