Case 3 (2023): Reconstruction of an extensive circumferential leg defect using a preconditioned bipedicular MS-2-TRAM Free Flap

Nicolas K

Journal of Plastic, Breast & Reconstructive Surgery·Begutachtete Open-Access-Fallberichte aus der ChirurgiePeer-Review · Open Access

Case 3 (2023): Reconstruction of an extensive circumferential leg defect using a preconditioned bipedicular MS-2-TRAM Free Flap · JPBRS

Fallbericht

Case 3 (2023): Reconstruction of an extensive circumferential leg defect using a preconditioned bipedicular MS-2-TRAM Free Flap

Nicolas K¹

¹Ewerbeck, MD, BG Ludwigshafen, Germany

Veröffentlicht 2. April 2023144 Aufrufe5 Min. Lesezeit

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Zusammenfassung

Wichtigste Lernpunkte

Pearls

During recovery the patient was expected to need the help of crutches for mobilization. Therefore the latissimus dorsi flap was not our first choice. Significant skin access was available at the patient’s abdomen measuring 78×22 cm. The whole flap would be needed to cover the defect and the exposed structures. Recipient vessels would be required at the leg matching the pedicles of the abdominal flap.
In order to ensure perfusion throughout the whole flap dimensions, ischemic preconditioning of the abdominal flap was done as an initial step 10 day prior to the final surgery

Pitfalls

Classic free flaps to cover large body areas are usually sacrificing major muscles e.g. the combined latissimus dorsi and parascapular flap. During recovery the patient was expected to need the help of crutches for mobilization. Therefore the latissimus dorsi flap was not our first choice. The whole flap would be needed to cover the defect and the exposed structures. Recipient vessels would be required at the leg matching the pedicles of the abdominal flap.
CT angiography of the abdominal perforators and the leg to ensure good vascularity. Otherwise an AV-loop would be needed.
Patient information and consent: Risk of partial or total free flap loss, donor-site complication (seroma, haematoma, bulging, hernia, abdominal wall insufficiency, loss of strength), monitoring of the flap.

Patient history

A 49-year-old woman was involved as a pedestrian in a car accident and overrun by a truck. At arrival in our A&E department she suffered from multiple abrasions and large hematomas on the left thigh and lower leg. The trauma CT scan showed no fractures and no further injuries. The initial surgical treatment was performed by the trauma surgeons including debridement of multiple tension blisters and drainage of hematoseromas. After 2 weeks of further conservative treatment the patient was transferred to the department of Plastic, Reconstructive and Microsurgery because of the formation of large areas of full thickness necrosis.

Examination

The patient was transferred to the department of Plastic, Reconstructive and Microsurgery because of the formation of large areas of full thickness necrosis.

Radical full thickness necrectomy was performed and continuous negative pressure dressings were applied. The result was a circumferential defect stretching from the upper thigh to the proximal lower leg measuring approximately 70cm in length with exposure of the knee, the patella and proximal tibia.

Pre-operative considerations

Soft tissue reconstruction with the need to cover the exposed structures was necessary. Furthermore the contour of the leg should be restored preventing later scar formation with consecutive impairment of the mobility.

Proposed treatment Plan: -CT angiography of the abdominal perforators and the leg to ensure good vascularity. Otherwise an AV-loop would be needed. -Ischemic preconditioning of the abdominal flap to secure perfusion of the most distal flap areas. -All areas that cannot be covered with the abdominal flap should be treated with a dermis substitute (Novosorb BTM)
Classic free flaps to cover large body areas are usually sacrificing major muscles e.g. the combined latissimus dorsi and parascapular flap. During recovery the patient was expected to need the help of crutches for mobilization. Therefore the latissimus dorsi flap was not our first choice. Significant skin access was available at the patient’s abdomen measuring 78×22 cm. The whole flap would be needed to cover the defect and the exposed structures. Recipient vessels would be required at the leg matching the pedicles of the abdominal flap.
Preoperative imaging: -MR Angio of the leg: vascular status = normal vascularity with a three-vessel supply on the left lower leg was found. -CT Angio: abdominal wall perforator display

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Case 3 (2023): Reconstruction of an extensive circumferential leg defect using a preconditioned bipedicular MS-2-TRAM Free Flap

Zusammenfassung

Wichtigste Lernpunkte

Patient history

Examination

Pre-operative considerations

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Schritt 1 — Debridement and Decision Making

Schritt 2 — Ischemic preconditioning

Schritt 3 — Transplantation of the flap – Preparation of the lower leg and thigh

Schritt 4 — Transplantation of the flap – Preparation of the abdomen

Schritt 5 — Transplantation of the flap – Preparation of the abdomen

Schritt 6 — Transplantation of the flap – Positioning of the flap on the ventral left extremity

Schritt 7 — Transplantation of the flap – Applying Novosorb BTM to the dorsal aspect of the leg

Schritt 8 — Follow-up

Post-operative plan

Pearls

Pitfalls