Correspondence and communications
Conflict of interest None declared.
References 1. Hasegawa M, Torii S, Katoh H, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93: 1012e20. 2. Baumeister SP, Spierer R, Erdmann D, et al. A relalistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003;112:129e40. 3. Erdmann D, Sudin BM, Moquin KJ, et al. Delay in unipedicle TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2003;110:762e7. 4. Foran M, Schreiber J, Christy M, et al. The modified reverse sural artery flap lower extremity reconstruction. J Trauma 2008;64:139e43. 5. Tsai J, Laio HT, Wang PF, et al. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery 2013;33:342e9.
John Heineman Wei F. Chen Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals & Clinics, Iowa, USA E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.007
1769 perforator that had the prominent and consistent Doppler signal was selected as the preferred supply for the flap. An elliptical flap was designed along the longitudinal axis of the limb, extending almost the full length of the arm. A thorough debridement of the ulcer was performed. Then an incision, facilitating exploration of the perforator, was made down to the deep fascia. Dissection was undertaken subfascially until the previously marked perforators were visualized. The pulsation of perforator was observed and verified its reliability. The flap was raised and the pedicle was skeletonized to allow a 180 clockwise rotation of the flap, without any kinking or tension. Then, the flap was inset and the donor site was primarily closed or skin grafted (Figure 2).
Discussion Medial arm flap is a desirable donor site for local reconstruction with available vascularized tissue and well-hidden scar. The recent anatomic study showed that perforators from either the brachial artery or superior collateral ulnar artery are present near the axilla.3 According to our clinical experiences, flap based on a pulsatile perforator can be safely harvested with entire medial arm skin.4 The perforator-based propeller design made the medial arm flap easily reach the lateral chest wall. Reconstruction of the chest wall radiation ulcer has high complication rates.2 Horsework flaps for chest wall reconstruction sometimes may fail, leaving the surgeons few reconstructive options. The perforator-based propeller flap of medial arm can provide sufficient coverage with minimal morbidities and may become the lifeboat to solve such a pressing problem. We present this technique as the first report of using the propeller medial arm flap for chest wall reconstruction. The propeller medial arm
Propeller medial arm flap: A plan “B” for reconstruction of radiation ulcer of the chest wall Dear Sir, Radiation-related wounds of the chest wall pose lifethreatening hazards to the patients, which require complete debridement followed by coverage of a wellvascularized flap.1 Regional muscle flap is the first reconstructive choice. However, the reconstruction is challenging with the high complication rates, thus surgeons should always have a “plan B” in mind.2 We suggest the propeller medial arm flap might be a good backup for the coverage of medium-sized radiation ulcer at the lateral chest wall.
Operative technique Before the surgery, a Doppler ultrasound probe was used to identify perforators in the medial arm region, adjacent to the potential defect on the chest wall (Figure 1). The
Figure 1 A 66-year-old female patient sustained a giant chest wall radiation ulcer after radical mastectomy. The ulcer was removed, and the resultant defect was sequentially repaired by a pedicle Latissimus dorsi myocutaneous flap and a pedicle island transverse rectus abdominus myocutaneous flap. Unfortunately, both the flaps suffered partial flap necrosis, resulting in a large non-healing wound on her lateral chest wall. Her physical and psychological conditions didn’t allow another aggressive procedure, including free tissue transfer or the omental flap. A thorough debridement was performed, creating a 13 cm 6 cm defect on her chest wall.
1770
Correspondence and communications ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.040
The use of intraoperative indocyanine green dye to aid excision of a lymphatic lesion Figure 2 The defect was successfully repaired with a 15 cm 6 cm propeller medial arm flap, based on a perforator with strong Doppler signal near the axilla originating from proximal brachial artery, The donor site was skin grafted to avoid excessive tension. Both the recipient and donor site healed uneventfully. This image showed the result 1 month after the surgery.
flap can be considered as a backup for reconstruction of the medium-sized radiation ulcer on the lateral chest wall.
Ethical approval N/A.
Funding None.
Conflict of interest statement The authors have no conflict of interest or any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
References 1. Granick MS, Larson DL, Solomon MP. Radiation-related wounds of the chest wall. Clin Plast Surg 1993;20:559e71. 2. Thorne CH. Grabb and Smith’s plastic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. 3. Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site. Surg Radiol Anat 2013;35:39e48. 4. Bin S, Yuanbo L, Ji J, Shan Z. Preexpanded pedicle medial arm flap: an alternative method of massive facial defect reconstruction. Aesthet Plast Surg 2011;35:946e52.
Mengqing Zang Lingling Guo Yuanbo Liu Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China E-mail address: [email protected]
Dear Sir, Excision of lymphatic malformations is a notoriously problematic procedure. Due to difficulty in assessing the lesion margins, incomplete excision rates and reoccurrence rates can be frequent.1 We would like to outline a new, simple, intra-operative technique, which we have used to achieve complete excision of a lymphatic lesion. Indocynanine green is a cynanine dye with near infra-red fluorescence.2 Its preferential uptake by lymphatics has made it an invaluable tool in the assessment of lymph channels, particularly in the assessment of lymphoedema.3 We have used these properties, in combination with the Photodynamic Eye (PDE) camera (Hamamatsu Photonics Co., Japan), a near infra-red imaging system, to help visualise a lesion intra-operatively. This allowed us to identify and delineate a lymphatic lesion, and thereby assess clearance at the time of excision. This technique was used to excise a 6 4 cm lymphatic lesion on the peroneal aspect of a 33-year-old woman’s right lower leg. The lesion had reoccurred following incomplete excision in childhood, now causing paraesthesia in the distribution of the superficial peroneal nerve. Prior to the operation, 0.5 ml of indocyanine green dye was injected into the ipsilateral first web space of the patient’s foot. The lesion was approached anteriorly via the old biopsy scar; an indication of the extent of the lesion was obtained by PDE fluoroscopy. The lesion was then excised down to the deep fascia, lifting it off the superficial peroneal nerve. The PDE camera was used to confirm a diseasefree plane between the excised lesion and the superficial peroneal nerve, thus allowing sparing of the nerve. A small, discrete residual lesion in the mid-incision dermal area that was not visible macroscopically was also identified using the PDE camera (Figures 1 and 2). This was then excised and complete excision confirmed by repeat fluoroscopy. Histological results of both specimens confirmed a lymphatic malformation. The use of dyes to mark anatomical and pathological structures, aiding dissection and excision is well described. However, to our knowledge, the use of indocyanine green dye to identify and so aid the dissection and excision of a lymphatic malformation is a new technique. The technique importantly enables: 1. Initial identification of the extent of an otherwise amorphous, indistinct lesion.
Conflict of interest None declared.
References 1. Hasegawa M, Torii S, Katoh H, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93: 1012e20. 2. Baumeister SP, Spierer R, Erdmann D, et al. A relalistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003;112:129e40. 3. Erdmann D, Sudin BM, Moquin KJ, et al. Delay in unipedicle TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2003;110:762e7. 4. Foran M, Schreiber J, Christy M, et al. The modified reverse sural artery flap lower extremity reconstruction. J Trauma 2008;64:139e43. 5. Tsai J, Laio HT, Wang PF, et al. Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: patient selection and surgical refinement. Microsurgery 2013;33:342e9.
John Heineman Wei F. Chen Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals & Clinics, Iowa, USA E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.007
1769 perforator that had the prominent and consistent Doppler signal was selected as the preferred supply for the flap. An elliptical flap was designed along the longitudinal axis of the limb, extending almost the full length of the arm. A thorough debridement of the ulcer was performed. Then an incision, facilitating exploration of the perforator, was made down to the deep fascia. Dissection was undertaken subfascially until the previously marked perforators were visualized. The pulsation of perforator was observed and verified its reliability. The flap was raised and the pedicle was skeletonized to allow a 180 clockwise rotation of the flap, without any kinking or tension. Then, the flap was inset and the donor site was primarily closed or skin grafted (Figure 2).
Discussion Medial arm flap is a desirable donor site for local reconstruction with available vascularized tissue and well-hidden scar. The recent anatomic study showed that perforators from either the brachial artery or superior collateral ulnar artery are present near the axilla.3 According to our clinical experiences, flap based on a pulsatile perforator can be safely harvested with entire medial arm skin.4 The perforator-based propeller design made the medial arm flap easily reach the lateral chest wall. Reconstruction of the chest wall radiation ulcer has high complication rates.2 Horsework flaps for chest wall reconstruction sometimes may fail, leaving the surgeons few reconstructive options. The perforator-based propeller flap of medial arm can provide sufficient coverage with minimal morbidities and may become the lifeboat to solve such a pressing problem. We present this technique as the first report of using the propeller medial arm flap for chest wall reconstruction. The propeller medial arm
Propeller medial arm flap: A plan “B” for reconstruction of radiation ulcer of the chest wall Dear Sir, Radiation-related wounds of the chest wall pose lifethreatening hazards to the patients, which require complete debridement followed by coverage of a wellvascularized flap.1 Regional muscle flap is the first reconstructive choice. However, the reconstruction is challenging with the high complication rates, thus surgeons should always have a “plan B” in mind.2 We suggest the propeller medial arm flap might be a good backup for the coverage of medium-sized radiation ulcer at the lateral chest wall.
Operative technique Before the surgery, a Doppler ultrasound probe was used to identify perforators in the medial arm region, adjacent to the potential defect on the chest wall (Figure 1). The
Figure 1 A 66-year-old female patient sustained a giant chest wall radiation ulcer after radical mastectomy. The ulcer was removed, and the resultant defect was sequentially repaired by a pedicle Latissimus dorsi myocutaneous flap and a pedicle island transverse rectus abdominus myocutaneous flap. Unfortunately, both the flaps suffered partial flap necrosis, resulting in a large non-healing wound on her lateral chest wall. Her physical and psychological conditions didn’t allow another aggressive procedure, including free tissue transfer or the omental flap. A thorough debridement was performed, creating a 13 cm 6 cm defect on her chest wall.
1770
Correspondence and communications ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.040
The use of intraoperative indocyanine green dye to aid excision of a lymphatic lesion Figure 2 The defect was successfully repaired with a 15 cm 6 cm propeller medial arm flap, based on a perforator with strong Doppler signal near the axilla originating from proximal brachial artery, The donor site was skin grafted to avoid excessive tension. Both the recipient and donor site healed uneventfully. This image showed the result 1 month after the surgery.
flap can be considered as a backup for reconstruction of the medium-sized radiation ulcer on the lateral chest wall.
Ethical approval N/A.
Funding None.
Conflict of interest statement The authors have no conflict of interest or any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
References 1. Granick MS, Larson DL, Solomon MP. Radiation-related wounds of the chest wall. Clin Plast Surg 1993;20:559e71. 2. Thorne CH. Grabb and Smith’s plastic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. 3. Perignon D, Havet E, Sinna R. Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site. Surg Radiol Anat 2013;35:39e48. 4. Bin S, Yuanbo L, Ji J, Shan Z. Preexpanded pedicle medial arm flap: an alternative method of massive facial defect reconstruction. Aesthet Plast Surg 2011;35:946e52.
Mengqing Zang Lingling Guo Yuanbo Liu Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Beijing, China E-mail address: [email protected]
Dear Sir, Excision of lymphatic malformations is a notoriously problematic procedure. Due to difficulty in assessing the lesion margins, incomplete excision rates and reoccurrence rates can be frequent.1 We would like to outline a new, simple, intra-operative technique, which we have used to achieve complete excision of a lymphatic lesion. Indocynanine green is a cynanine dye with near infra-red fluorescence.2 Its preferential uptake by lymphatics has made it an invaluable tool in the assessment of lymph channels, particularly in the assessment of lymphoedema.3 We have used these properties, in combination with the Photodynamic Eye (PDE) camera (Hamamatsu Photonics Co., Japan), a near infra-red imaging system, to help visualise a lesion intra-operatively. This allowed us to identify and delineate a lymphatic lesion, and thereby assess clearance at the time of excision. This technique was used to excise a 6 4 cm lymphatic lesion on the peroneal aspect of a 33-year-old woman’s right lower leg. The lesion had reoccurred following incomplete excision in childhood, now causing paraesthesia in the distribution of the superficial peroneal nerve. Prior to the operation, 0.5 ml of indocyanine green dye was injected into the ipsilateral first web space of the patient’s foot. The lesion was approached anteriorly via the old biopsy scar; an indication of the extent of the lesion was obtained by PDE fluoroscopy. The lesion was then excised down to the deep fascia, lifting it off the superficial peroneal nerve. The PDE camera was used to confirm a diseasefree plane between the excised lesion and the superficial peroneal nerve, thus allowing sparing of the nerve. A small, discrete residual lesion in the mid-incision dermal area that was not visible macroscopically was also identified using the PDE camera (Figures 1 and 2). This was then excised and complete excision confirmed by repeat fluoroscopy. Histological results of both specimens confirmed a lymphatic malformation. The use of dyes to mark anatomical and pathological structures, aiding dissection and excision is well described. However, to our knowledge, the use of indocyanine green dye to identify and so aid the dissection and excision of a lymphatic malformation is a new technique. The technique importantly enables: 1. Initial identification of the extent of an otherwise amorphous, indistinct lesion.
