Keywords: Hatchet flap, thoracic skin defect, malignant melanoma, reconstruction
Authors: Carolina Maria Helena Hilton, MD, Magnus Balslev Avnstorp, MD. Institution: Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark
Abstract
A 73-year-old man was diagnosed with a malignant melanoma on the left anterior chest wall. According to guidelines he was scheduled for re-excision in 20 mm and sentinel node procedure. The defect following re-excision was too large for primary closure. A Hatchet flap was designed, covering the defect, with a cosmetic and functionally acceptable result.
Patient medical history
A 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure.
Before and After
Patient examination
The skin examination showed a cicatrice on the left chest wall, close to the neck, measuring around 30 mm, where skin mobility was not sufficient for direct closure if excised with a 20 mm margin. A lymph node scintigraphy showed two sentinel nodes in the left axilla. The patient was taking acetylsalicylic acid which was continued according to Danish guidelines (from “Dansk selskab for Trombose og Haemostase” (the Danish society of Thrombosis and Hemostasis)) .
Pre-operative considerations
Direct closure would probably result in reduced neck mobility or at least uncomfortable stricture. Several options were considered. We decided that a Hatchet flap was a good solution for a local flap as the patient had a moderate amount of skin excess caudolaterally to the lesion.
The Hatchet flap is a procedure first described by Emmett in 1977(1). Hatchet flaps allows tissue rotation and advancement, thereby providing sufficient mobilization of tissue with minimal tension on closure as compared to a transposition flap which was also considered(2,3). A skin transplant was not considered as good an option due to post-operative stricture and the thickness of the defect.
Drawing of the re-excision
The cicatrice was marked, and a surgical margin of 20 mm was drawn.
Flap drawing
The Hatchet flap was designed with the back-cut area placed as shown as not to displace the nipple. The flap was drawn x 2-3 times the width of the defect size.
Re-excision
The tumor was excised with a 20 mm margin to the muscular fascia. Hereafter the crescent-formed flap inscison was made.
Raising the flap
The flap was raised in the plane above the muscle fascia, frequently testing if sufficient mobility was achieved while trying to minimize the length of the back-cut. While raising the flap perforators were spared.
Testing mobility of flap
Closing by nylon sutures
Due to the size of the surgical area and the fact that the patient was taking acetylsalicylic acid a glove-drain was placed, and the patient was given a single dose intravenous Cefuroxime 1,5 g. The flap was sutured with a monofilament absorbable suture 3-0 (Maxon, Medtronic, USA) in the subcutaneous fascia, 3-0 absorbable uncolored polyfilament dermal inverted sutures and 3-0 absorbable monofilament intracutaneously (and non-absorbable colored monofilament suture for the drain).
3 months follow-up
At three months postoperatively, the patient was satisfied with the cosmetic result and had no physical complaints.
Pearls
A Hatchet flap is useful for covering defects in the thoracic area as it allows tissue rotation and advancement. It is a good option for using excess skin on a larger area and to distribute skin traction
Pitfalls
There is a risk of displacing the breast nipple when the hatchet flap is used in the thoracic anterior upper area.
Post-operative plan
The patient stayed overnight in hospital due to the applied glove drain. The patient was discharged the following day after removal of the drain. No further antibiotic treatment was required. The patient was instructed to avoid compression of the flap and advised not to engage in strenuous physical activities, such as sports or housework for 14 days. Paracetamol as needed (1 g, maximum four times daily) was prescribed for analgesia.
The patient was seen in the outpatient clinic eight days later for histology results. There were no metastases to the sentinel nodes. Therefore, he was classified as clinical stage 1B. According to guidelines the patient will be monitored clinically yearly for five years including a final control of the flap three months after surgery.
References
- 1. The closure of defects by using adjacent triangular flaps with subcutaneous pedicles. Emmett AJ. doi: 10.1097/00006534-197701000-00008.
- 2. Random pattern hatchet flap as a reconstructive tool in the treatment of pressure sores: clinical experience with 36 patients. M J Alfeehan 1, Ma-A Aljodah 2, M Z Al-Zajrawee 3, A A Marzook 2 1University of Anbar, Anbar, Iraq 2University of Baghdad, Iraq 3University of Kufa, Najaf, Iraq doi: 10.1308/rcsann.2020.7077.
- 3. Long-Term Comparison of Esthetic Outcomes Between Hatchet and Transposition Flaps in Facial-Defect Reconstruction.Taegyu Lee1, Junhyung King1, Woonhyeok Jeong1 , Taehee Jo1 , Jaehoon Choi2 , Sang Woo Park3 Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 56 Dalseong-ro Jung-gu, Daegu, 41931, Republic of Korea1, Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 56 Dalseong-ro Jung-gu, Daegu, 41931, Republic of Korea. psjchoi@dsmc.or.kr2, Department of Plastic and Reconstructive Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea3. doi: 10.1007/s00266-024-04053-7