Radical forequarter amputation with hemithoracectomy and free extended forearm flap: Technical and physiologic considerations

Background: A radical forequarter amputation with partial chest wall resection (one to four ribs) has been reported for benign and malignant lesions involving the shoulder and chest wall region. Concerns about reconstruction and postoperative pulmonary function have previously limited more extensive chest wall resections. The current report describes the first case in which a complete unilateral anterior and posterior chest wall resection and pneumonectomy (hemithoracectomy) accompany a forequarter amputation. A novel reconstructive technique used the full circumference of the forearm tissue with an intact ulna as a free osseomyocutaneous flap. Methods: In this case, a 21-year-old patient presented with an extensive recurrent desmoid tumor that involved the shoulder, brachial plexus, subclavian vein, and chest wall from the lateral sternal border to the midportion of the scapula and down to the eighth rib. The operative technique involved removal of the entire right hemithorax from the midline sternum to the transverse process posteriorly, down to the ninth rib inferiorly. Due to the absence of a rigid hemithorax, the uninvolved ipsilateral lung was also removed. The forearm flap was prepared before final separation of the specimen and division of the subclavian vessels. Results: Postoperatively, the patient maintained excellent oxygenation without atelectasis or fever and was extubated on the 15th postoperative day. As expected after pneumonectomy, significant decreases from preoperative to immediate postoperative values were noted for the vital capacity (VC) (from 4.87 L to 1.29 L), forced 1-s expiratory volume (FEV1) (from 3.77 L to 1.02 L), and inspiratory capacity (IC) (3.33 1 to 0.99 1). Rehabilitation included a specially designed external prosthesis to provide cosmesis and prevent scoliosis. By the 15th postoperative week the patient had returned to normal social and physical activities, with a gradual improvement in all respiratory parameters: VC 1.52 L, FEV1 1.29 L, IC 1.04 L. There has been no evidence of tumor recurrence at 1 year. Conclusions: This report provides evidence that a complete hemithoracectomy, pneumonectomy, and forequarter amputation can be safely performed for selective tumors involving the shoulder region with extensive chest wall invasion. Reconstruction may be achieved with an extended forearm osseomyocutaneous free flap with an excellent functional outcome. Presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

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.     

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.     

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.     

Reconstruction of the foot and lower leg by a fasciocutaneous cross-leg flap after traumatic amputation and circumferential soft-tissue loss

Summary The use of a fasciocutaneous cross-leg flap in two cases to cover severe soft-tissue injuries with circumferential degloving of the lower leg and foot is presented. This was preceded by local treatment with topical agents and debridement, followed by application of a mesh skin graft. The functional and aesthetic defect of the donor site is minimal.     

Utility of the free deep inferior epigastric perforator flap in chest wall reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.     

Squamous cell carcinoma in discoid lupus erythematosus: Reconstruction with a free forearm fasciocutaneous flap

We present the first free flap operation to our knowledge for a patient with squamous cell carcinoma on a lesion of discoid lupus erythematosus. Although the disease affects the skin, the defect was reconstructed successfully with a free radial forearm fasciocutaneous flap.     

Lateral chest wall fasciocutaneous flaps in the management of burn contractures on the dorsum of the hand

Summary Post-burn contracture involving the dorsum of the hand with hyperextension and volar subluxation of the metacarpophalangeal joints of the fingers plus adduction contracture of the thumb is a crippling disability. Adequate release of such contractures leaves raw areas on the dorsum of the hand, forgers and in the first web space. Fasciocutaneous flaps from the contralateral chest wall (the lateral thoracic flap and the subaxillary flap) have been used in eight patients. The comfortable fixation position, the non-hairy nature of the flaps, the excellent vascularity and a concealed donor site, which can often be primarily closed, make these flaps attractive for the defects. Within a follow-up period of five to twelve months, all the patients returned to their previous vocation.     

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTIONChondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.PRESENTATION OF CASEA 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.DISCUSSIONThe outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.CONCLUSIONThis case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.     

前臂皮瓣联合邻近组织瓣修复腭及上颌组织缺损早期疗效

目的探讨游离前臂皮瓣联合邻近组织瓣修复腭、上颌组织缺损的方法和疗效。方法 2005年3月-2010年5月收治17例腭及上颌部肿瘤患者。男11例,女6例;年龄45～74岁,平均62.5岁。良性肿瘤1例;恶性肿瘤16例,其中腭部鳞状细胞癌7例,腭部鳞状细胞癌术后复发1例,腭部恶性黑色素瘤1例,腭部腺样囊腺癌1例,上颌恶性黑色素瘤1例,上颌导管癌1例,上颌鳞状细胞癌4例。病灶切除后缺损范围为7.0cm×5.5cm～10.0cm×7.5cm;根据Brown等对上颌骨缺损的分类标准,Ⅱ类15例,Ⅲ类2例;合并眶底、眶下缘骨质缺损2例。根据腭、上颌组织缺损类型,以游离前臂皮瓣联合颊脂垫行即刻修复11例,以游离前臂皮瓣联合颊脂垫及颞肌下颌骨骨肌瓣即刻修复6例。术后观察组织瓣成活情况及语言、吞咽、呼吸功能恢复情况及患者面部外形恢复情况。结果 17例前臂皮瓣和邻近组织瓣均成活;供区植皮均成活,切口均Ⅰ期愈合。患者均获随访,随访时间6～12个月。肿瘤无复发。患者语言、吞咽、呼吸基本正常,无明显开口受限,面部外形满意,无严重畸形。合并眶底、眶下缘骨质缺损者,未出现眼球内陷。患者术后均无明显口鼻瘘,口、鼻腔功能恢复满意。结论根据腭、上颌组织缺损的情况,选择游离前臂皮瓣联合颊脂垫或颊脂垫及下颌骨骨肌瓣进行修复,可达到较好的早期疗效。     

Full thickness chest wall reconstruction after tumor resection by myocutaneous flap

Full thickness chest wall defects result when a chest wall tumor resection is necessary. The feasibility of a reconstruction is sometimes unfamiliar to the oncologist or thoracic surgeon; this can be the reason for refusing the possibility of surgical resection or inappropriate coverage of the defect. Our experiences over the last 7 years in collaboration between plastic the thoracic surgical services, shows that it is generally possible to utilize a myocutaneous flap for reconstruction of even extensive full thickness chest wall defects. The reconstruction of any full thickness chest wall defect after tumor resection by myocutaneous flaps is almost always possible with low mortality, acceptable morbidity and good results, mechanically and aesthetically. The experience with the different reconstruction techniques clearly shows the preference for the latissimus dorsi myocutaneous flap, but also emphazises that the other kinds of reconstruction must be kept in mind for special indications.     

改良前臂皮瓣在舌和口底联合缺损修复中的应用

目的：介绍改良游离前臂皮瓣在舌、口底缺损修复中的应用效果。方法：应用改良前臂皮瓣同期游离移植修复因舌癌行扩大根治切除术后的舌、底联合缺损13例,术中根据舌、口底和牙槽骨缺损的大小设计、制备、利用改良前臂皮瓣;术中常规掀起前臂皮瓣皮岛,并保留血管蒂周围蜂窝结缔组织,形成包绕桡动静脉、头静脉的蜂窝结缔组织袖,游离移植于口内,吻合血管,再造舌并修复口底缺损。结果：前臂皮瓣全部成活,患侧颌面形态和舌外形恢复满意,舌动度较好,语音较清晰。结论：改良前臂皮瓣具有血管恒定,切取制备容易,组织量较丰富,具有较广的适应证,是同期修复舌癌术后舌和口底联合缺损的比较满意的方法,值得推广应用。     

颞肌蒂下颌骨瓣联合前臂皮瓣一期修复腭上颌缺损

目的 探讨颞肌蒂下颌骨瓣与游离前臂皮瓣联合修复腭上颌缺损的临床疗效. 方法 2008年3月至2011年3月,共收治恶性肿瘤切除后腭上颌缺损9例,其中男6例,女3例,年龄34～68岁,平均57岁.根据Browm上颌骨缺损分类,其中Ⅱ B类8例,Ⅱ C类1例.均采用颞肌蒂下颌骨瓣与游离前臂皮瓣联合修复. 结果 9例移植的骨瓣及皮瓣均成活.随访期10～24个月,平均随访期14个月,除1例软骨肉瘤病例术后复发外,其余病例的面部外形和功能均恢复满意,供区未见并发症.结论 应用颞肌蒂下颌骨瓣与游离前臂皮瓣联合修复腭上颌缺损具有操作简单易行、安全可靠和并发症少等优点,是修复上颌骨缺损的较理想术式.     

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.