Surgical repair of abdominal wall]

Surgical repair of abdominal wall defects following tumour resection only raises real problems when the nature of the tumour required wide, or even transfixing excision, as in the case of sarcomas or very advanced carcinomas. Superficial repair is performed according to the algorithm of the simplest technique: secondary healing, partial suture, total suture, transplant, or flap (pedicled or free). In the case of transfixing resection, the combination of a biomaterial for reconstruction of the deep plane and a superficial flap is necessary. For very large transfixing defects of the abdomen, a free flap may be required and, in this case, delayed insertion after initial transfer may further reduce the operative risk ("apple turnover" technique). The complications observed in a detailed series of 9 cases operated at Saint-Louis Hospital consisted of one intraoperative cardio-circulatory arrest during second-stage surgery and one late infection at three years. The authors believe that the indications for delayed insertion of a free flap are still very topical in cases in which a very large grafted free flap is necessary in conjunction with a prosthesis. Large abdominal defects after cancer resection can be reconstructed by modern reconstructive surgery.     

The serratus anterior free flap in limb reconstruction. About 30 cases

Between 2001 and 2003, 30 serratus anterior free flaps have been realized in our unit for reconstruction of lower limb. The flaps were indicated for repair of traumatic soft tissue defect in 19 cases, for chronic wound in six cases, for purpura fulminans in two cases, for pressure sore in one case and after tumor resection in 1 case. There were 29 patients: 25 males and four females. They ranged in age from 5 to 64 years. The size of the soft tissue defects ranged between 15 and 180 cm(2). Four different types of serratus anterior flaps were used: 20 muscle flaps ; four myocutaneous flaps ; five costo-osteomuscular flap ; one costo-osteomyocutaneous flap . In all cases we used osteo flap (8 th rib) in order to restore bone defect, which ranged from 9 to 15 cm. Necrosis occurred in two flaps because of venous thrombosis. The functional outcome was good for all patients and the aesthetic sequelae at the donor site were considered as minor. The serratus anterior flap can be used in many different ways: different kinds of flaps (osteo-cutaneous-muscle); very variable size of flap (15 to 180 cm(2) in our series) , different length of pedicle possible. Because of his versatility and his absence of major functional or aesthetic sequelae the serratus anterior free flap has become day by day our favourite option in limb reconstruction.     

软组织肉瘤切除后的修复重建

目的探讨修复重建在技术手术治疗软组织肉瘤中的作用和地位。方法１９９０年１１月～１９９６年１１月,治疗软组织肉瘤１０７例,其中３２例进行了一期修复重建手术。３２例中,恶性纤维组织细胞瘤１２例,滑膜肉瘤６例,脂肪肉瘤３例,神经纤维肉瘤３例,横纹肌肉瘤３例,皮隆突纤维肉瘤２例,纤维肉瘤２例,上皮样肉瘤１例;４例为原发,２８例为复发;外科分期为ⅠＢ３例,ⅡＡ３例和ⅡＢ２６例。根治性切除１３例,广泛切除１７例,局部切除２例。手术加化疗１３例,手术加放疗７例。血管重建３例,动力功能重建１６例,皮肤缺损修复２２例。结果术后随访到３０例,随访时间４个月～６年６个月,肉瘤局部控制率为８０％,血管重建保肢率为１００％,动力功能重建优良率为８７．５％,缺损组织修复成活率为９６％。结论修复重建是软组织肉瘤切除后外科治疗的延续,是减低肿瘤的复发率,提高患者生活质量的重要措施之一。     

Latissimus dorsi flap closure of the irradiated clavicular wound

Partial or total resection of a previously irradiated clavicle and surrounding soft tissues is a difficult clinical problem. Attempts to close the defect with local tissue often result in wound breakdown and exposure of any remaining clavicle. Furthermore, the most appealing local muscle flap, the pectoralis major, is often unsuitable for reconstruction because of previous resection or radiation damage. Over a 3-year period, 8 patients had resection of a previously irradiated clavicle and surrounding soft tissues. Four underwent excision for sarcoma and four for osteoradionecrosis complicated by chronic wounds. All defects were reconstructed with a pedicled latissimus dorsi muscle flap. No patient had a flap failure, and all had closed wounds at a minimum 18-month follow-up. Our series demonstrates the success of latissimus dorsi flap coverage for post-claviculectomy defects in an irradiated field. To our knowledge, this is the first described series of such patients. The latissimus dorsi muscle flap should be considered for all difficult wounds involving the clavicle and surrounding soft tissues.     

腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝部软组织缺损

目的 探讨腓动脉穿支为蒂的腓浅神经营养血管皮瓣移植修复足踝部软组织缺损的临床疗效.方法 自2007年以来,我院采用腓动脉穿支为蒂的腓浅神经营养血管皮瓣对17例足踝部创面进行修复.结果 17例皮瓣中,15例顺利成活;1例发生肿胀、静脉瘀滞,持续2个月后消退,成活;1例远端坏死,经换药后愈合.修复后的足踝外形及功能良好.结论 采用腓动脉穿支为蒂的腓浅神经营养血管皮瓣移植修复足踝部软组织缺损是一种可靠的、疗效满意的术式.     

Recurrent osteoblastoma of the hamate bone. A two-stage reconstruction with a free vascularized iliac crest flap.

An osteoblastoma in a carpal bone is very rare and presents a problem of reconstruction after wide tumour excision. We report a case of recurrent osteoblastoma of the right hamate bone with involvement of the ulnar carpal bones and soft tissues that was successfully treated by en bloc resection, temporary interposition of bone cement and fixation with K-wires, followed by reconstruction with a free vascularized iliac crest flap, tailored to the exact size of the defect, in a second procedure. Rapid fusion was achieved and hand function preserved with no evidence of recurrence 3 years postoperatively.     

Malignant fibrous histiocytoma of the rib: a case report of repetitive extensive resections and reconstruction of the chest wall

A forty-seven-year-old woman visited our hospital in March 1987 suffering from the local recurrence of the tumor. Her right 7th and 8th rib had been resected 2 years and 11 months before because of the malignant fibrous histiocytoma (MFH) originated from the right 7th rib. In May 1987, wide resection of the right lateral chest wall and partial resection of the right diaphragm were done. Dacron meshed silicon plate (Silastic) and musculocutaneous flap of the right latissimus dorsi were used to reconstruct the chest wall. Seven months after the second operation, local recurrence occurred again on the anterior chest wall, involving the right diaphragm and right lower lobe of the lung. In March 1988, extensive resection of the anterior chest wall with partial resection of the right diaphragm and the right lower lobe was followed by reconstruction of the chest wall by Silastic. The patient recovered uneventfully without any respiratory disturbances after both operations which included wide resection of the chest wall. Multiple pulmonary metastases were found 4 months after the operation, and she died of respiratory failure 7 months after the final operation. Although MFH was one of the most common sarcomas of the soft tissues, only one case of the MFH originated from the rib had been reported previously in this country. Silastic was proved to be a useful prosthesis for the reconstruction of widely resected chest wall.     

Reconstruction of soft tissue defects including the Achilles tendon with free neurovascular tensor fascia lata flap and fascia lata. Case report

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenge. These patients need not only skin coverage but also dynamic, functioning repair. Two cases of major defects after tumour resection are presented. In each case the tendon was reconstructed using the remaining gastrocnemius aponeurosis reinforced with fascia lata. This was covered by a free tensor fascia lata (TFL) flap. In one of the cases the flap was transferred as a neurovascular free flap.     

股前外侧游离穿支皮瓣修复头面部和四肢肿瘤切除后软组织缺损

目的探讨应用股前外侧穿支皮瓣,修复头面部和四肢肿瘤切除术后的方法及其效果。方法2004年4月-2006年4月,收治头面部及四肢肿瘤切除术后造成的软组织缺损,采用股前外侧穿支皮瓣游离移植共16例,男13例,女3例;年龄26-72岁。头面部肿瘤9例,其中头顶部基底细胞癌1例,面部鳞状细胞癌4例（包括肿瘤复发1例）,腮腺癌4例;软组织缺损范围8cm×6cm-20cm×13cm,病程6-24个月。四肢肉瘤7例,其中上肢2例,下肢4例,小腿复发1例;软组织缺损范围10cm×7cm-21cm×12cm,病程2-18个月。结果16例应用股前外侧穿支皮瓣游离移植修复,15例皮瓣全部成活,1例皮瓣远端约2.5cm宽范围缺血坏死;14例创口期愈合;2例创口期愈合,其中1例经切除坏死组织,直接缝合后期愈合,另1例创口有3cm裂口,经换药后期愈合。术后随访1-18个月,肿瘤无复发,供受区外观良好,平整,无明显瘢痕及功能影响;受区修复效果满意。结论股前外侧穿支皮瓣游离移植,修复效果好,对供区损伤小,是一种较理想的修复头面和四肢肿瘤切除术后软组织缺损的方法。     

Buried inferiorly based gluteus maximus musculocutaneous flap for reconstruction of large, recurrent ischiopubic pressure sores

The ischium is the most common site for recurrence of pressure sores in the paraplegic population. Successful reconstruction of these wounds depends on the total excision of ulcer, soft tissue debris, bony prominence, and the durability of the soft tissue repair. The V-Y gluteus maximum musculocutaneous flap based on the inferior gluteal vessels can be advanced medially, deepithelialized, and buried to fill large, deep soft tissue ischial wounds. Local rotational flaps close the superficial wound. This buried flap, although not previously described, is useful for the reconstruction of large ischiopubic pressure sores initially or at the time of recurrence.     

Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.     

Clinical outcome of reconstruction of the lateral oropharyngeal wall with an anterolateral thigh free flap

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44-83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13-68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.     

Results of treatment of malignant soft tissue tumours in the groin

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or – if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.     

Results of treatment of malignant soft tissue tumours in the groin

Soft tissue sarcomas of the inguinal region are a challenge with regard to achieving clear margins, reconstruction of the femoral vessels, and soft tissue coverage. Six men aged 39 to 48 years and one woman of 56 were treated for soft tissue sarcomas of the groin. All patients were treated with local en bloc resections including the femoral artery, vein, and nerve. In two patients the soft tissue defect was covered primarily with an ipsilateral rectus abdominis muscle flap, in two others (because of wound dehiscence) coverage was achieved with the opposite rectus abdominis muscle pedicle flap as we were afraid of closure of the ipsilateral deep epigastric vessels. In the others local measures were sufficient, however, wound healing was usually delayed. Histopathological examination showed tumour-free margins in each case. One patient developed a local recurrence, but had had no radiotherapy because of problems with wound healing. A high rate of local tumour control in soft tissue sarcomas of the inguinal region can be achieved with the combination of surgical resection and radiotherapy. No compromise should be made with aggressive soft tissue coverage to protect the vascular reconstruction, control wound healing after neoadjuvant radiotherapy, or allow immediate adjuvant radiotherapy. At primary wound closure we would generally use an ipsilaterally distally pedicled rectus abdominis muscle flap if the deep epigastric vessels can be preserved or - if the ipsilateral vessels need be resected to achieve clearance of tumour - use a contralateral flap.     

桥式交叉逆行股前外侧皮瓣转移修复对侧小腿中下段软组织缺损

目的 报道以桥式交叉逆行股前外侧皮瓣转移修复对侧小腿软组织缺损的方法和效果.方法 对于小腿中下段皮肤软组织缺损伴对侧小腿软组织损伤或胫后动脉破坏5例,采用对侧逆行股前外侧皮瓣桥式交叉转移予以修复. 结果 术后皮瓣血运良好,6周后断蒂,皮瓣均存活.术后随访12～15个月,皮瓣质地优良、外形美观,伴骨骼、肌腱缺损者均顺利完成二期修复手术.供区愈合良好,供侧肢体无明显影响. 结论 对于小腿中下段较大面积皮肤软组织缺损伴周围软组织受损,且对侧小腿血管质量不佳的病例,以对侧逆行股前外侧皮瓣桥式交叉转移修复是一种优良的手段.     

Breast volume replacement using the latissimus dorsi miniflap

Background: Mastectomy is often recommended to women with early breast cancer who have large tumours or where the breast volume requiring resection to achieve adequate tumour clearance is too great to allow for a satisfactory cosmetic result after breast conservation surgery. The use of a latissimus dorsi muscular flap (latissimus dorsi miniflap (LDMF)) to replace the volume loss after major breast sector resection is an option where the tumour to breast volume ratio is large. The present study describes the technique and evaluates the experience of the LDMF at Royal Adelaide Hospital, Adelaide, Australia. Methods: Between August 1997 and April 2002, 18 women aged 37–64 years underwent wide local excision for primary breast cancer with LDMF reconstruction. Tumour characteristics, breast specimen weight and postoperative sequelae were assessed. Quality of life measurements and objective assessments of aesthetic outcome were evaluated. Results: Tumour diameter ranged from 13 to 80 mm (median 30 mm). Nine patients had multifocal or extensive intraductal component positive tumours. The weight of the resected specimens ranged from 75 to 395 g (median 130 g). There were no major postoperative complications, with a range of inpatient stay of 3–10 days. Seromas were aspirated in 14 patients but did not delay adjuvant treatment. Quality of Life results showed high patient satisfaction in all but one patient. A satisfactory cosmetic result was achieved in all but one patient who subsequently required mastectomy. Conclusion: The LDMF procedure allows breast conservation to be achieved in women with large tumour to breast volume ratios, with satisfactory resection margins and good cosmetic and functional results. In the present experience standard oncological adjuvant treatment is not compromised.     

Utility of the omentum in sacral reconstruction following total sacrectomy due to recurrent and irradiated giant cell tumour of the spine

Reconstruction of the lumbosacral region after surgical excision of irradiated and recurrent spinal giant cell tumours remains a challenging problem. In this case report, we describe the use of the pedicled omentum flap in reconstruction of an irradiated and infected wide sacral defect of a 19-year-old male patient. The patient had radiotherapy and subsequent wide surgical resection after recurrence of the tumour. A myocutaneous flap from the gluteal area had failed previously. Local flap options could not be used because of the recent radiotherapy to the gluteal area. Since the patient had a laparotomy for tumour resection and a colostomy, abdominal muscles were not considered reliable for reconstructive procedures. A pedicled omentum flap was chosen as a reconstructive option because of its rich blood supply, large surface area, and angiogenic capacity. This report aims to describe the use of the pedicled omentum flap for reconstruction of the lumbosacral area following surgical resection of a spinal tumour, when gluteal and abdominal flap options for reconstruction are jeopardised.KEY WORDS: Omentum flap, radiotherapy, reconstruction, sacral tumour     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

PRIMARY RECONSTRUCTION AFTER EXTENSIVE CHEST WALL RESECTION

Background : Chest wall resection and reconstruction has been proven to be a safe surgical procedure. This is particularly useful for breast cancer patients with chest wall recurrences or for those who first present with locally advanced cancer in the chest wall where there is both a large soft tissue and bony defect that need repair. In addition, many of these patients have had irradiation or chemotherapy, which can significantly impair wound healing. Methods : Thirty-four patients underwent chest wall resection and primary reconstruction over an 8-year period. Results : Twenty-three patients had breast carcinomas and six had breast and chest wall sarcomas. Of the breast carcinoma patients, 12 had local recurrences and 11 presented with locally advanced primary disease. Bony resection of the chest wall was required in 16 (47%) cases. Thirty myocutaneous flaps (18 rectus abdominis, four pectoralis major, eight latissimus dorsi) and three omental flaps were used for reconstruction. One required a deltovertebral skin flap. Skeletal reconstruction was necessary in four cases. All except one (97%) achieved primary wound healing. There was one mortality (3%) and three patients required further surgery for complications that were related to the reconstruction. Post-resection metastases occurred in 13 (42%) patients and only 2 (6%) had local recurrences. The 2-year survival rate was 78% with a mean survival time of 25.5 months. Conclusions : Primary reconstruction for curative or palliative purposes is a useful and safe surgical procedure for patients with recurrent or locally advanced chest malignancies after extensive chest wall resection. Pedicled myocutaneous flap is the preferred option for skeletal and soft-tissue coverage.