The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
6. Zalunardo MP, Zollinger A, Spahn DR, et al. Effects of intravenous and oral clonidine on hemodynamic and plasma-catecholamine response due to endotracheal intubation. J Clin Anesth 1997;9:143Y147 7. Zalunardo MP, Serafino D, Szelloe P, et al. Preoperative clonidine blunts hyperadrenergic and hyperdynamic responses to prolonged tourniquet pressure during general anesthesia. Anesth Analg 2002;94:615Y618 8. Marchal JM, Go´mez-Luque A, Martos-Crespo F, et al. Clonidine decreases intraoperative bleeding in middle ear microsurgery. Acta Anaesthesiol Scand 2001;45:627Y633 9. Toivonen J, Kaukinen S. Clonidine premedication: a useful adjunct in producing deliberate hypotension. Acta Anaesthesiol Scand 1990;34:653Y657 10. Ishiyama T, Kashimoto S, Oguchi T, et al. The effects of clonidine premedication on the blood pressure and tachycardiac responses to ephedrine in elderly and young patients during propofol anesthesia. Anesth Analg 2003;96:136Y141 11. Jabalameli M, Hashemi M, Soltani H, et al. Oral clonidine premedication decreases intraoperative bleeding in patients undergoing endoscopic sinus surgery. J Res Med Sci 2005;1:25Y30 12. Yokota S, Komatsu T, Yano K, et al. Effect of oral clonidine premedication on hemodynamic response during sedated nasal fiberoptic intubation. Nagoya J Med Sci 1998;61:47Y52 13. Mohseni M, Ebneshahidi A. The effect of oral clonidine premedication on blood loss and the quality of the surgical field during endoscopic sinus surgery: a placebo-controlled clinical trial. J Anesth 2011;25:614Y617 14. Woodcock TE, Millard RK, Dixon J, et al. Clonidine premedication for isoflurane-induced hypotension. Sympathoadrenal responses and a computer-controlled assessment of the vapour requirement. Br J Anaesth 1988;60:388Y394 15. Ganter MT, Hofer KC, Spahn DR, et al. The effect of clonidine on perioperative blood coagulation. J Clin Anesth 2005;17:456Y462 16. Mahla E, Lang T, Vicenzi MN, et al. Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth Analg 2001;92:572Y577
Extensive Scalp Reconstruction After Repeated Failure of Free Tissue Transfer With a Pedicled Latissimus Dorsi Flap Woo Shik Jeong, MD,* Jong Lyel Roh, MD, PhD,Þ Eun Key Kim, MD, PhD* Abstract: Extensive scalp defects after surgical ablation often require free tissue transfer. However, if free tissue transfer cannot be used, pedicled flaps derived from distant tissue could provide an alternative method of achieving scalp coverage. The latissimus dorsi From the *Departments of Plastic Surgery and † Otolaryngology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea. Received November 18, 2013. Accepted for publication December 27, 2013. Address correspondence and reprint requests to Dr Eun Key Kim, Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000671
Brief Clinical Studies
(LD) flap is commonly used as free flap; however, it can also cover a defect from the occiput to the vertex as pedicled flap with complete division of humeral insertion and exposure of pedicle. Here, we report a case of extensive scalp defect covered with a pedicled LD flap after repeated failure of free flaps. Flap survived completely after complete division of the pedicle on postoperative day 25, although the defect bed contained alloplastic material. Key Words: Reconstruction, scalp, latissimus dorsi, flap
F
or the management of extensive scalp defects, there are many options, including tissue expansion, skin grafts (with or without artificial dermal grafts), local or distant flaps, and free tissue transfer. Several factors, including a defect size of over 200 cm2, the compromised beds such as the skull or alloplastic materials,1 and remoteness from the regional donor site,2 hinder the achievement of a satisfactory reconstruction. Extensive defect with such hindering factors can be best reconstructed with free tissue transfer. However, distant flaps could be considered when free flap is not available for some reason. This article presents our experience with the use of a distant pedicled latissimus dorsi (LD) flap for the treatment of an extensive scalp defect after the repeated failure of free tissue transfer.
CLINICAL REPORT A 62-year-old female patient presented with an 11 cm 10 cm 8 cmYsized mass on the scalp, which progressively enlarged over 2 months (Fig. 1). A biopsy confirmed the presence of a malignant vascular neoplasm consistent with angiosarcoma. In November 2012, the patient underwent a wide excision, modified radical neck dissection of the right neck, suboccipital lymph node resection, and a cranioplasty with alloplastic material (polymethylmethacrylate, PMMA). The extent of the scalp defect was 20 cm 18 cm (Fig. 2). As the patient’s body mass index was 30 kg/m2 and she had marked skin redundancy in her trunk with rather thin thighs, the transverse rectus abdominis myocutaneous (TRAM) free flap was chosen instead of the anterolateral thigh free flap. The TRAM flap was elevated and the pedicle vessels were anastomosed with the right superficial temporal artery and vein in the preauricular area. Three days after the operation, the flap gradually became ischemic and the entire flap was eventually lost. Fifteen days after the operation, a left LD muscle flap with a split-thickness skin graft (STSG) was elevated and anastomosed with the left superficial temporal artery and vein. However, ischemic change and flap loss occurred again 3 days after the operation. No specific abnormality was found in a hypercoagulability blood test. After the repeated failure of free tissue transfer, the safety and reliability of operation became the priority of reconstruction and the patient wanted to avoid another free tissue
FIGURE 1. A 62-year-old female patient presented with an 11 cm 10 cm 8 cmYsized mass on the scalp, which progressively enlarged over 2 months.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1103
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 3, May 2014
FIGURE 2. After a wide excision and cranioplasty with alloplastic material, the scalp defect measured 20 cm 18 cm.
FIGURE 4. The flap was completely separated and survived perfectly without any complications.
transfer if alternative options were available. Out of necessity, a right LD flap was selected as a distant pedicled flap and the LD flap was elevated with complete division of humeral insertion of the LD muscle. To provide sufficient coverage of the vertex area, complete exposure of the pedicle and skin graft to pedicle for preventing dehydration was also necessary (Fig. 3). After the operation, the patient’s right arm was kept attached to the right ear to release tension of pedicle until the flap was divided. The division of the pedicle was held daily 21 days after the operation and was completely separated 4 days after starting the division. Although the scalp defect bed contained alloplastic material (PMMA), the flap survived perfectly without any complications (Fig. 4).
transfer. A composite latissimus dorsi and serratus anterior and rib free flap (LD-SA/rib) can be an alternative procedure.7 Nevertheless, if free tissue transfer cannot be used for whatever reason, pedicled flaps derived from distant tissue could provide an alternative method of scalp coverage. The trapezius flap, superficial cervical artery flap, and LD flap are the most commonly available flaps used as muscle or musculocutaneous compartments that can be transferred on a reliable vascular pedicle.8Y10 Trapezius muscle is superficial, flat, triangular, and approximately 34 18 cm2 in dimension. When based on the deep branch of the transverse cervical artery, trapezius musculocutaneous flap has been successfully used for 1-stage closure of complicated wounds. However, the trapezius flap may be limited in its ability to cover hard-to-reach wounds of the posterior neck and occiput.8 Superficial cervical artery flap is situated 6 to 7 cm apart from the transverse process of the seventh cervical vertebra and large enough to cover large defects with its wide arc of rotation. To further increase flexibility of flap rotation and decrease the possibility of some functional loss to trapezius, superficial cervical artery island flaps can be used for large soft tissue reconstruction of occipital and parotid region.9 The LD flap is commonly used as free flap; however, it can also cover defects of head and neck as pedicled flap. It has a very long dominant vascular pedicle based on the thoracodorsal vessels, which allows it to reach virtually any region in head, neck, and scalp, and support thin and large skin islands, as 35 12 cm2.10 In our current case, to extend the mobility of the flap transfer, a complete division of the humeral insertion of LD muscle was carried out. However, with this alone, the flap did not reach the defect and the pedicle of the flap was also skeletonized. STSG was performed on the pedicle after complete exposure to prevent dehydration. The right arm was maintained in a fixed position beside the right ear, enabling full coverage of the defect from the occiput to the vertex. Although the scalp defect bed contained alloplastic material, the angiogenesis around the flap margin allowed the flap to survive perfectly after complete division of the pedicle on postoperative day 25. In reconstruction of a large scalp defect, when free flaps are not available for some reasons or more simple and less time-consuming procedure is required, the pedicled LD flap could be considered as an alternative reconstructive procedure.
DISCUSSION Angiosarcoma is a rare malignant tumor accounting for less than 2% of all soft tissue sarcomas and usually affects the face and scalp regions. It is derived from the endothelial cells that occur in any region including the skin. Angiosarcomas have a high recurrence rate and approximately 50% of cases have local or distant metastases at the time of diagnosis. Overall prognosis is poor with reported 5-year survival of 12% to 43%. Although wide surgical excision is the treatment of choice, angiosarcomas are notoriously difficult to treat, most commonly due to multifocal nature and local spread pattern of these tumors.3 In previously reported algorithms for oncologic scalp reconstruction, surgical treatment can be selected depending on defect size and localization.4 Primary closure for wounds can be difficult even with undermining in large defects. Skin grafts are only an option if pericranium or, even better, galea remains after tumor excision. Secondary expansion or serial excisions were also not suitable for too large defect and immediate coverage. Local flaps, which are designed as single or multiple transposition procedures, are the first-line option for functional and aesthetic restoration because the vascular supply of the scalp is rich and reliable.5 However, when the defects reach over 8 cm in diameter, local scalp flaps are not suitable and free tissue transfers should be considered due to the limited pliability.6 In case of extensive composite defects of bone and soft tissue, it should be reconstructed with microvascular free tissue
REFERENCES
FIGURE 3. After the repeated failure of free tissue transfer, a distant pedicled flap with right latissimus dorsi muscle was transferred to the defect and a split-thickness skin graft was performed.
1104
1. Furnas H, Lineaweaver WC, Alpert BS, et al. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431Y444 2. Halvorson EG, Cordeiro PG, Disa JJ, et al. Superficial temporal recipient vessels in microvascular orbit and scalp reconstruction of oncologic defects. J Reconstr Microsurg 2009;25:383Y387 3. Gonzalez MJ, Koehler MM, Satter EK. Angiosarcoma of the scalp: a case report and review of current and novel therapeutic regimens. Dermatol Surg 2009;35:679Y684 4. Niklas I, Matthias CZ, Vincenzo P, et al. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg 2010;126:450Y459
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
5. Mueller CK, Bader RD, Ewald C, et al. Scalp defect repair: a comparative analysis of different surgical techniques. Ann Plast Surg 2012;68:594Y598 6. Beasley NJ, Gilbert RW, Gullane PJ, et al. Scalp and forehead reconstruction using free revascularized tissue transfer. Arch Facial Plast Surg 2004;6:16Y20 7. Trignano E, Fallico N, Nitto A, et al. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173Y183 8. Lynch JR, Hansen JE, Chaffoo R, et al. The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg 2002;109:444Y450 9. Sun CF, Li RW, Liu FY. Superficial cervical artery island flap for large soft-tissue reconstruction of occipital and parotid region after tumor resection. J Craniofac Surg 2011;22:259Y260 10. Robson MC, Zachary LS, Schmidt DR, et al. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989;83:438Y442
Brief Clinical Studies
FIGURE 1. Perioperative image of the laryngeal face of the epiglottis via direct laryngoscopy.
with AIDS). This tumor is multifocal and manifests most frequently in mucocutaneous sites; oropharyngeal mucosa; lymph nodes; and visceral organs, most notably the respiratory and gastrointestinal tracts. Laryngeal involvement is considered to be unusual.2,3 Almost all reported cases of this location are patients with advanced AIDS. In a review by Patrikidou and colleagues, only approximately 5% of nonAIDS KSs were located in the larynx.2
CLINICAL REPORT
Classic Mediterranean Type of Epiglottic Kaposi Sarcoma Irfan Kucuk, MD, Basak Caypinar, MD, Asli Sahin Yilmaz, Murat Hakan Karabulut, MD, Cagatay Oysu Abstract: Kaposi sarcoma is a malignant, multifocal, vascular, and low-grade tumor that mostly occurs in mucocutaneous sites. Kaposi sarcoma is usually associated with acquired immunodeficiency syndrome and involves lymphatic nodes and visceral organs. In this report, an 81-year-old man with epiglottic Kaposi sarcoma who screened negative for human immunodeficiency virus is presented. Key Words: Kaposi sarcoma, non-AIDS, epiglottic, supraglottic
K
aposi sarcoma (KS) is an angiogenic tumor. Histopathologically, it is characterized by endothelium-lined vascular spaces and spindle-shaped cells. It is usually encountered in immunocompromised subjects with acquired immunodeficiency syndrome (AIDS) or those who underwent organ transplantation.2 In this clinical report, we present a patient with classic Mediterranean-type KS that is not associated with immunosuppression. Kaposi sarcoma was first described by Moritz Kaposi in 1872.2 Four epidemiologic types of KS have been described: classic (sporadic, mainly in elderly patients of European, Jewish, and Mediterranean descent), human herpes virus-8 African-descent KS (endemic, mainly in Sub-Saharan Africa), iatrogenic (associated with immunosuppression and, principally, renal transplantation), and epidemic (associated From the Umraniye Education and Treatment Hospital, Istanbul, Turkey. Received November 25, 2013. Accepted for publication January 2, 2014. Address correspondence and reprint requests to Basak Caypinar, MD, Umraniye Education and Treatment Hospital, No:1 Umraniye, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000701
A type I classic Mediterranean KS case is reported here. Our patient was a male 81-year-old who presented with severe hoarseness that has been present for a few months. On physical examination, dysphagia and a feel of foreign material in the throat were noted. He had no history of synchronous cutaneous lesions. The patient screened negative for human immunodeficiency virus 1 (HIV-1), HIV-2, hepatitis B virus, and hepatitis C virus. He screened positive for immunoglobulin G antibody for cytomegalovirus. A reddishblue mass, vascular in appearance, involving the laryngeal face of the epiglottis and protruding into the laryngeal space, was detected on endoscopic examination (Fig. 1). Figure 1 shows KS on the laryngeal face of the epiglottis. It was approximately 1 cm in diameter, well capsulated, and firm. The mass was removed entirely via direct laryngoscopy. The patient’s postoperative course was uneventful, and he was discharged 1 day after the operation. With regard to histopathology, squamous epithelium sections of epiglottic surface were regular, and there were short bundles of spindle-shaped cells, which were pleomorphic and mitotic. Between these cells, there were vascular interstitial ducts
FIGURE 2. H-E, 40, of spindle-shaped cells, which were pleomorphic and mitotic; between them, there were vascular ducts.
FIGURE 3. H-E, 100, of spindle-shaped cells, which were pleomorphic and mitotic; between them, there were vascular ducts.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1105
& Volume 25, Number 3, May 2014
6. Zalunardo MP, Zollinger A, Spahn DR, et al. Effects of intravenous and oral clonidine on hemodynamic and plasma-catecholamine response due to endotracheal intubation. J Clin Anesth 1997;9:143Y147 7. Zalunardo MP, Serafino D, Szelloe P, et al. Preoperative clonidine blunts hyperadrenergic and hyperdynamic responses to prolonged tourniquet pressure during general anesthesia. Anesth Analg 2002;94:615Y618 8. Marchal JM, Go´mez-Luque A, Martos-Crespo F, et al. Clonidine decreases intraoperative bleeding in middle ear microsurgery. Acta Anaesthesiol Scand 2001;45:627Y633 9. Toivonen J, Kaukinen S. Clonidine premedication: a useful adjunct in producing deliberate hypotension. Acta Anaesthesiol Scand 1990;34:653Y657 10. Ishiyama T, Kashimoto S, Oguchi T, et al. The effects of clonidine premedication on the blood pressure and tachycardiac responses to ephedrine in elderly and young patients during propofol anesthesia. Anesth Analg 2003;96:136Y141 11. Jabalameli M, Hashemi M, Soltani H, et al. Oral clonidine premedication decreases intraoperative bleeding in patients undergoing endoscopic sinus surgery. J Res Med Sci 2005;1:25Y30 12. Yokota S, Komatsu T, Yano K, et al. Effect of oral clonidine premedication on hemodynamic response during sedated nasal fiberoptic intubation. Nagoya J Med Sci 1998;61:47Y52 13. Mohseni M, Ebneshahidi A. The effect of oral clonidine premedication on blood loss and the quality of the surgical field during endoscopic sinus surgery: a placebo-controlled clinical trial. J Anesth 2011;25:614Y617 14. Woodcock TE, Millard RK, Dixon J, et al. Clonidine premedication for isoflurane-induced hypotension. Sympathoadrenal responses and a computer-controlled assessment of the vapour requirement. Br J Anaesth 1988;60:388Y394 15. Ganter MT, Hofer KC, Spahn DR, et al. The effect of clonidine on perioperative blood coagulation. J Clin Anesth 2005;17:456Y462 16. Mahla E, Lang T, Vicenzi MN, et al. Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth Analg 2001;92:572Y577
Extensive Scalp Reconstruction After Repeated Failure of Free Tissue Transfer With a Pedicled Latissimus Dorsi Flap Woo Shik Jeong, MD,* Jong Lyel Roh, MD, PhD,Þ Eun Key Kim, MD, PhD* Abstract: Extensive scalp defects after surgical ablation often require free tissue transfer. However, if free tissue transfer cannot be used, pedicled flaps derived from distant tissue could provide an alternative method of achieving scalp coverage. The latissimus dorsi From the *Departments of Plastic Surgery and † Otolaryngology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea. Received November 18, 2013. Accepted for publication December 27, 2013. Address correspondence and reprint requests to Dr Eun Key Kim, Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000671
Brief Clinical Studies
(LD) flap is commonly used as free flap; however, it can also cover a defect from the occiput to the vertex as pedicled flap with complete division of humeral insertion and exposure of pedicle. Here, we report a case of extensive scalp defect covered with a pedicled LD flap after repeated failure of free flaps. Flap survived completely after complete division of the pedicle on postoperative day 25, although the defect bed contained alloplastic material. Key Words: Reconstruction, scalp, latissimus dorsi, flap
F
or the management of extensive scalp defects, there are many options, including tissue expansion, skin grafts (with or without artificial dermal grafts), local or distant flaps, and free tissue transfer. Several factors, including a defect size of over 200 cm2, the compromised beds such as the skull or alloplastic materials,1 and remoteness from the regional donor site,2 hinder the achievement of a satisfactory reconstruction. Extensive defect with such hindering factors can be best reconstructed with free tissue transfer. However, distant flaps could be considered when free flap is not available for some reason. This article presents our experience with the use of a distant pedicled latissimus dorsi (LD) flap for the treatment of an extensive scalp defect after the repeated failure of free tissue transfer.
CLINICAL REPORT A 62-year-old female patient presented with an 11 cm 10 cm 8 cmYsized mass on the scalp, which progressively enlarged over 2 months (Fig. 1). A biopsy confirmed the presence of a malignant vascular neoplasm consistent with angiosarcoma. In November 2012, the patient underwent a wide excision, modified radical neck dissection of the right neck, suboccipital lymph node resection, and a cranioplasty with alloplastic material (polymethylmethacrylate, PMMA). The extent of the scalp defect was 20 cm 18 cm (Fig. 2). As the patient’s body mass index was 30 kg/m2 and she had marked skin redundancy in her trunk with rather thin thighs, the transverse rectus abdominis myocutaneous (TRAM) free flap was chosen instead of the anterolateral thigh free flap. The TRAM flap was elevated and the pedicle vessels were anastomosed with the right superficial temporal artery and vein in the preauricular area. Three days after the operation, the flap gradually became ischemic and the entire flap was eventually lost. Fifteen days after the operation, a left LD muscle flap with a split-thickness skin graft (STSG) was elevated and anastomosed with the left superficial temporal artery and vein. However, ischemic change and flap loss occurred again 3 days after the operation. No specific abnormality was found in a hypercoagulability blood test. After the repeated failure of free tissue transfer, the safety and reliability of operation became the priority of reconstruction and the patient wanted to avoid another free tissue
FIGURE 1. A 62-year-old female patient presented with an 11 cm 10 cm 8 cmYsized mass on the scalp, which progressively enlarged over 2 months.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1103
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 3, May 2014
FIGURE 2. After a wide excision and cranioplasty with alloplastic material, the scalp defect measured 20 cm 18 cm.
FIGURE 4. The flap was completely separated and survived perfectly without any complications.
transfer if alternative options were available. Out of necessity, a right LD flap was selected as a distant pedicled flap and the LD flap was elevated with complete division of humeral insertion of the LD muscle. To provide sufficient coverage of the vertex area, complete exposure of the pedicle and skin graft to pedicle for preventing dehydration was also necessary (Fig. 3). After the operation, the patient’s right arm was kept attached to the right ear to release tension of pedicle until the flap was divided. The division of the pedicle was held daily 21 days after the operation and was completely separated 4 days after starting the division. Although the scalp defect bed contained alloplastic material (PMMA), the flap survived perfectly without any complications (Fig. 4).
transfer. A composite latissimus dorsi and serratus anterior and rib free flap (LD-SA/rib) can be an alternative procedure.7 Nevertheless, if free tissue transfer cannot be used for whatever reason, pedicled flaps derived from distant tissue could provide an alternative method of scalp coverage. The trapezius flap, superficial cervical artery flap, and LD flap are the most commonly available flaps used as muscle or musculocutaneous compartments that can be transferred on a reliable vascular pedicle.8Y10 Trapezius muscle is superficial, flat, triangular, and approximately 34 18 cm2 in dimension. When based on the deep branch of the transverse cervical artery, trapezius musculocutaneous flap has been successfully used for 1-stage closure of complicated wounds. However, the trapezius flap may be limited in its ability to cover hard-to-reach wounds of the posterior neck and occiput.8 Superficial cervical artery flap is situated 6 to 7 cm apart from the transverse process of the seventh cervical vertebra and large enough to cover large defects with its wide arc of rotation. To further increase flexibility of flap rotation and decrease the possibility of some functional loss to trapezius, superficial cervical artery island flaps can be used for large soft tissue reconstruction of occipital and parotid region.9 The LD flap is commonly used as free flap; however, it can also cover defects of head and neck as pedicled flap. It has a very long dominant vascular pedicle based on the thoracodorsal vessels, which allows it to reach virtually any region in head, neck, and scalp, and support thin and large skin islands, as 35 12 cm2.10 In our current case, to extend the mobility of the flap transfer, a complete division of the humeral insertion of LD muscle was carried out. However, with this alone, the flap did not reach the defect and the pedicle of the flap was also skeletonized. STSG was performed on the pedicle after complete exposure to prevent dehydration. The right arm was maintained in a fixed position beside the right ear, enabling full coverage of the defect from the occiput to the vertex. Although the scalp defect bed contained alloplastic material, the angiogenesis around the flap margin allowed the flap to survive perfectly after complete division of the pedicle on postoperative day 25. In reconstruction of a large scalp defect, when free flaps are not available for some reasons or more simple and less time-consuming procedure is required, the pedicled LD flap could be considered as an alternative reconstructive procedure.
DISCUSSION Angiosarcoma is a rare malignant tumor accounting for less than 2% of all soft tissue sarcomas and usually affects the face and scalp regions. It is derived from the endothelial cells that occur in any region including the skin. Angiosarcomas have a high recurrence rate and approximately 50% of cases have local or distant metastases at the time of diagnosis. Overall prognosis is poor with reported 5-year survival of 12% to 43%. Although wide surgical excision is the treatment of choice, angiosarcomas are notoriously difficult to treat, most commonly due to multifocal nature and local spread pattern of these tumors.3 In previously reported algorithms for oncologic scalp reconstruction, surgical treatment can be selected depending on defect size and localization.4 Primary closure for wounds can be difficult even with undermining in large defects. Skin grafts are only an option if pericranium or, even better, galea remains after tumor excision. Secondary expansion or serial excisions were also not suitable for too large defect and immediate coverage. Local flaps, which are designed as single or multiple transposition procedures, are the first-line option for functional and aesthetic restoration because the vascular supply of the scalp is rich and reliable.5 However, when the defects reach over 8 cm in diameter, local scalp flaps are not suitable and free tissue transfers should be considered due to the limited pliability.6 In case of extensive composite defects of bone and soft tissue, it should be reconstructed with microvascular free tissue
REFERENCES
FIGURE 3. After the repeated failure of free tissue transfer, a distant pedicled flap with right latissimus dorsi muscle was transferred to the defect and a split-thickness skin graft was performed.
1104
1. Furnas H, Lineaweaver WC, Alpert BS, et al. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431Y444 2. Halvorson EG, Cordeiro PG, Disa JJ, et al. Superficial temporal recipient vessels in microvascular orbit and scalp reconstruction of oncologic defects. J Reconstr Microsurg 2009;25:383Y387 3. Gonzalez MJ, Koehler MM, Satter EK. Angiosarcoma of the scalp: a case report and review of current and novel therapeutic regimens. Dermatol Surg 2009;35:679Y684 4. Niklas I, Matthias CZ, Vincenzo P, et al. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg 2010;126:450Y459
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
5. Mueller CK, Bader RD, Ewald C, et al. Scalp defect repair: a comparative analysis of different surgical techniques. Ann Plast Surg 2012;68:594Y598 6. Beasley NJ, Gilbert RW, Gullane PJ, et al. Scalp and forehead reconstruction using free revascularized tissue transfer. Arch Facial Plast Surg 2004;6:16Y20 7. Trignano E, Fallico N, Nitto A, et al. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173Y183 8. Lynch JR, Hansen JE, Chaffoo R, et al. The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg 2002;109:444Y450 9. Sun CF, Li RW, Liu FY. Superficial cervical artery island flap for large soft-tissue reconstruction of occipital and parotid region after tumor resection. J Craniofac Surg 2011;22:259Y260 10. Robson MC, Zachary LS, Schmidt DR, et al. Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plast Reconstr Surg 1989;83:438Y442
Brief Clinical Studies
FIGURE 1. Perioperative image of the laryngeal face of the epiglottis via direct laryngoscopy.
with AIDS). This tumor is multifocal and manifests most frequently in mucocutaneous sites; oropharyngeal mucosa; lymph nodes; and visceral organs, most notably the respiratory and gastrointestinal tracts. Laryngeal involvement is considered to be unusual.2,3 Almost all reported cases of this location are patients with advanced AIDS. In a review by Patrikidou and colleagues, only approximately 5% of nonAIDS KSs were located in the larynx.2
CLINICAL REPORT
Classic Mediterranean Type of Epiglottic Kaposi Sarcoma Irfan Kucuk, MD, Basak Caypinar, MD, Asli Sahin Yilmaz, Murat Hakan Karabulut, MD, Cagatay Oysu Abstract: Kaposi sarcoma is a malignant, multifocal, vascular, and low-grade tumor that mostly occurs in mucocutaneous sites. Kaposi sarcoma is usually associated with acquired immunodeficiency syndrome and involves lymphatic nodes and visceral organs. In this report, an 81-year-old man with epiglottic Kaposi sarcoma who screened negative for human immunodeficiency virus is presented. Key Words: Kaposi sarcoma, non-AIDS, epiglottic, supraglottic
K
aposi sarcoma (KS) is an angiogenic tumor. Histopathologically, it is characterized by endothelium-lined vascular spaces and spindle-shaped cells. It is usually encountered in immunocompromised subjects with acquired immunodeficiency syndrome (AIDS) or those who underwent organ transplantation.2 In this clinical report, we present a patient with classic Mediterranean-type KS that is not associated with immunosuppression. Kaposi sarcoma was first described by Moritz Kaposi in 1872.2 Four epidemiologic types of KS have been described: classic (sporadic, mainly in elderly patients of European, Jewish, and Mediterranean descent), human herpes virus-8 African-descent KS (endemic, mainly in Sub-Saharan Africa), iatrogenic (associated with immunosuppression and, principally, renal transplantation), and epidemic (associated From the Umraniye Education and Treatment Hospital, Istanbul, Turkey. Received November 25, 2013. Accepted for publication January 2, 2014. Address correspondence and reprint requests to Basak Caypinar, MD, Umraniye Education and Treatment Hospital, No:1 Umraniye, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000701
A type I classic Mediterranean KS case is reported here. Our patient was a male 81-year-old who presented with severe hoarseness that has been present for a few months. On physical examination, dysphagia and a feel of foreign material in the throat were noted. He had no history of synchronous cutaneous lesions. The patient screened negative for human immunodeficiency virus 1 (HIV-1), HIV-2, hepatitis B virus, and hepatitis C virus. He screened positive for immunoglobulin G antibody for cytomegalovirus. A reddishblue mass, vascular in appearance, involving the laryngeal face of the epiglottis and protruding into the laryngeal space, was detected on endoscopic examination (Fig. 1). Figure 1 shows KS on the laryngeal face of the epiglottis. It was approximately 1 cm in diameter, well capsulated, and firm. The mass was removed entirely via direct laryngoscopy. The patient’s postoperative course was uneventful, and he was discharged 1 day after the operation. With regard to histopathology, squamous epithelium sections of epiglottic surface were regular, and there were short bundles of spindle-shaped cells, which were pleomorphic and mitotic. Between these cells, there were vascular interstitial ducts
FIGURE 2. H-E, 40, of spindle-shaped cells, which were pleomorphic and mitotic; between them, there were vascular ducts.
FIGURE 3. H-E, 100, of spindle-shaped cells, which were pleomorphic and mitotic; between them, there were vascular ducts.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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