Case 4 (2023): Extensive scalp reconstruction using a free myocutaneus lattisimus dorsi flap

Felix Strübing

Journal of Plastic, Breast & Reconstructive Surgery·Rapports de cas chirurgicaux en libre accès, évalués par les pairsÉvalué par les pairs · Libre accès

Case 4 (2023): Extensive scalp reconstruction using a free myocutaneus lattisimus dorsi flap · JPBRS

Rapport de cas

Case 4 (2023): Extensive scalp reconstruction using a free myocutaneus lattisimus dorsi flap

Felix Strübing

Publié 2 avril 2023151 vues5 min de lecture

Exporter :RIS BibTeX

Résumé

Points clés à retenir

Conseils pratiques

Precise preoperative planning can ease the operative flow and save operating time.
A skin paddle extending anteriorly beyond the muscle may be raised to extend the lattisimus dorsi flap.
Intraoperative ICG angiography may prevent partial flap loss due to hypoperfusion of distal parts of the flap.
Place large drains at the donor site and remove only if

Écueils

If possible, delay the reconstruction until clear surgical margins have been confirmed.
Meticulous dissection of the recipient vessels is crucial.

Patient history

A 57-year-old male patient presented with an ambiguous lesion on his scalp. Sixteen years prior, he had sustained a work-related scalping injury when his long hair became entangled in a machine. Although a replantation of the scalp was attempted, it ultimately failed. A soft tissue defect measuring approximately 25 x 6 cm resulted, and reconstruction was performed using split-thickness skin grafting. In the years following the procedure, the skin graft area progressively thinned, leading to an increased susceptibility to superficial lesions. Furthermore, an ulcer developed on the parietal scalp, raising concerns about potential malignancy.

Examination

Large parts of the scalp have been reconstructed using split thickness skin grafts. The skin was extremely thin and non-pliable. On the parietal aspect of the scalp, centrally located in the skin grafted area, a hypergranulating ulcer five centimeters in diameter was found.

Pre-operative considerations

Skin lesions, such as the grafted area in this patient or actinic keratosis commonly observed in elderly individuals, have the potential to develop into squamous cell carcinomas (SCCs) at multiple sites. Consequently, it is imperative to discuss the complete removal of the lesion and soft-tissue reconstruction employing a large flap.

Proposed treatment plan:
1. Excise the suspicious lesion and obtain histological confirmation, ensuring clear surgical margins.
2. In the event of malignancy, excise the entire area at risk of developing further SCCs and apply temporary negative pressure wound therapy.
3. Reconstruct the scalp using an expansive free myocutaneous latissimus dorsi flap.
4. If the free myocutaneous latissimus dorsi flap would not suffice for a complete reconstruction, a conjoined free myocutaneous latissimus dorsi and anterior lateral thigh flap would be backuo strategy. The entire planning had been discussed with the patient, including the possible extension of the surgery.
Patient information: Risk of partial or total free flap loss, donor-site complications (seroma, hematoma, wound breakdown, loss of strength), hourly monitoring of the flap for 48 hours. The reconstruction might be bulky at first but will thin due to denervation of the muscle.