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Nicolas K. Case 3 (2023): Reconstruction of an extensive circumferential leg defect using a preconditioned bipedicular MS-2-TRAM Free Flap. Journal of Plastic, Breast & Reconstructive Surgery. 2023.
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Nicolas K1
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
BeforeAfterA 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.
The patient was transferred to the department of Plastic, Reconstructive and Microsurgery because of the formation of large areas of full thickness necrosis.
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.
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.
2
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. Marking the planned flaps (22x78cm). The flap was incised cranially and laterally and raised from lateral to medial up to the semilunar line. Caudally the incision was carried out to the lateral region of the SIEV.
3
Preparation of the thigh: Mobilization of the M. sartorius in a posterior direction, transection of the vastoadductoria membrane between the M. vastus medialis and M. adductor longus and exposure of the femoral arteria and vein up to 6 cm
Completion of the incision and preparation of the SIEV on both sides over a length of 8cm Raising of the flap by dissection from lateral to medial and preparation of all perforating vessels
Dissecting the vessels through the rectus abdominis muscle with a small muscle cuff on both sides (right: 3×5 cm, left 2x4cm)
6
Left pedicle: 1x arterial end to end anastomosis to the ant. tibial artery and 1x venous end to end anastomosis the accompanying vein with a 3.5mm coupler. Right pedicle: 1x arterial end to side anastomosis to the superf. femoral artery and 1x venous end to side anastomosis to the accompanying vein.
7
Hourly perfusion checks for 5 days postoperatively Coagulation management Delamination of Novosorb BTM and split skin grafting Mobilization (physiotherapy) Planning of follow-up treatment (rehabilitation)
