SENSATE ANTEROLATERAL THIGH PERFORATOR FLAP FOR ISCHIATIC SORES RECONSTRUCTION IN MENINGOMYELOCELE PATIENTS FABIO SANTANELLI DI POMPEO, M.D., Ph.D.,* BENEDETTO LONGO, M.D., Ph.D., MARCO PAGNONI, M.D., and ROSARIA LAPORTA, M.D.
Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap’s vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the C 2014 Wiley Periodicals, Inc. Microsurgery 35:279–283, 2015. middle third of the anterolateral thigh. V
Meningomyelocele
is a developmental congenital disorder presenting as an incomplete closure of the embryonic neural tube, with vertebral malformation and consequential protrusion of the spinal cord with the meninges and cerebrospinal fluid in a small and delicate sac. The deformity can be localized at a lumbar or sacral level and according its location, it determines a spectrum of deficiencies with functional lower limb impairment up to paralysis and complete loss of sensation. The decrease of epicritic, proprioceptive, and protopathic sensitivity is the major cause of pressure sores in meningomyelocele patients, increasing the risk for mechanical and thermal skin damage, while the impairment of autonomic innervation causes an alteration in tissues’ homeostasis and healing process. The limitation in motility and the inability of these patients to monitor the pressure applied on insensate areas while sitting on a wheelchair, are the principal factors responsible for the onset of ischial and sacral pressure ulcerations.1,2 Conservative treatments as nutritional support, frequent changes in sitting-position and local wound care are very useful tools, however, chair-fast patients, as those Plastic Surgery Unit, NESMOS department, Sant’Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Italy Disclosure: We, hereby certify, that to the best of our knowledge no financial support or benefits have been received by author or any co-author, by any member of our immediate family or any individual or entity with whom or with which we have a significant relationship from any commercial source which is related directly or indirectly to the scientific work which is reported on in the article. *Correspondence to: Fabio Santanelli di Pompeo, M.D., Ph.D., Azienda Ospedaliera Sant’Andrea – U.O.D. Chirurgia Plastica, Via di Grottarossa 1035–1039, 00189 Rome, Italy. E-mail: [email protected] Received 9 May 2014; Revision accepted 6 September 2014; Accepted 8 September 2014 Published online 20 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22330 Ó 2014 Wiley Periodicals, Inc.
affected by meningomyelocele, have still a tendency to develop recurrent ulcerations which require a correct surgical approach. While a multitude of procedures for patients undergoing pressure sore flap reconstruction have been suggested, there is a paucity of specific protocols for spinal cord-injured patients with their injury below L2. The goal of their surgical treatment is to raise a predictably vascularized sensate flap and inset it with minimal tension. Different options have been considered in case of ischiatic pressure sore repair, including the tensor fasciae latae flap, the gluteal flap, and posterior thigh V-Y perforator flaps.3,4 However, in meningomyelocele patients with their injury below L2 these flaps are not available as sensate flaps, then tissue from the anterior thigh with conserved sensory perception becomes an ideal choice. Although previous authors reported the use of vastus lateralis myocutaneous flap for ischiatic sores, the incorporation of the lateral cutaneous femoral nerve (LCFN) to provide sensory perception at the ischiatic area has not been reported yet.5–8 Moreover, most of their spinal cordinjured patients were paraplegic, thus not ambulatory, not suffering functional impairment because of the sacrifice of the vastus lateralis muscle, and no sensitive perception on the anterior thigh. As meningomyelocele patients are ambulatory with preserved anterior thigh sensory function, the use of a sensate anterolateral thigh perforator flap may be an ideal choice for ischiatic sores reconstruction in this patients population. Purpose of this article is to present our preliminary experience on the novel use of the sensate pedicled anterolateral thigh (ALT) perforator flap for ischiatic sores reconstruction in patients affected by mid-lumbar or lower level (L3 to S4) meningomyelocele, with conserved thigh sensitivity.
280
Santanelli di Pompeo et al. Table 1. Patient and Operative Data
Case
Sex (age, years)
Defect location
Flap size (cm)
Perforators number (Typea)
Overall operative time (minutes)
1 2
M (24) M (25)
Right Ischium Left Ischium
8x9 8x8.5
2 (M,M) 1 (S)
250 190
3 4 5
F (19) M (21) M (22)
Right Ischium Left Ischium Left Ischium
6x10.5 7x7.5 8x7
2 (M,S) 1 (S) 1 (S)
225 180 215
Complications MWD at donor site -
Follow-up (months)
Sore recurrence
36 31
No No
26 24 12
No No No
a
M, Muscolocutaneous; S, Septocutaneous; MWD, Minor wound dehiscence
PATIENTS AND METHODS
Between May 2011 and September 2013, five meningomyelocele patients (four male, one female), with mean age of 22.2 years (range, 19–25), reporting chronic ischial sores were addressed to debridement and reconstruction of the defect with a sensate pedicled ALT flap. Patients’ demographics are shown in Table 1. Pre-operatively, with a 5-cm insulated 22-Gauge needle, ultrasound-guided block of the LCFN was performed injecting 6 mL of 1.5% plain lidocaine.9 The contours of the anesthetized area, representing the LCFN territory of distribution, were delineated. Subsequently, within this area epicritic and proprioceptive sensitivity testing was performed, assessing pressure thresholds of static and moving one and two-point discrimination with the Pressure-Specified Sensory Device (Sensory Management Services, LLC, Baltimore, Md.), in order to measure skin sensitivity and to appropriately draw the flap. Surgical Procedure
Peri-operative antibiotic therapy was administered to all patients after wound culture testing. With patient positioned in lateral decubitus and hip elevated and flexed, a radical debridement of the ulcer was performed using methylene blue staining, until healthy vascularized tissue was obtained. Flap was harvested suprafascially, starting the incision at its superior margin, to locate and dissect the LCFN up to the anterosuperior iliac spine. Dissection proceeded then from medial to lateral towards the intermuscular septum between rectus femoris and vastus lateralis muscles, to identify the perforators and dissect flap pedicle towards its origin from the lateral circumflex femoral artery (LFCA).10 A tunnel from the anterior to the posterior thigh compartment was created through the intermuscular space between vastus intermedius and vastus medialis muscles, then penetrating through the vastus medialis’ femoral origin, adjacent to the linea aspera of the femur, and through the intermuscular space between pectineus muscle cranially and adductor longus caudally. Finally, the passageway was completed penetrating through the Microsurgery DOI 10.1002/micr
adductors brevis and magnus and the gluteus maximus muscles, spreading the fibers as to maintain their longitudinal integrity.5 The flap was folded on itself to protect the neurovascular pedicle, was transposed to the ischial defect taking care not to injure the sciatic nerve, and then sutured in place after positioning of a closed suction drain. Donor site was closed primarily in all cases. All patients were placed prone or in lateral decubitus on an air-fluidized bed with the lower limbs extended and adducted. Early assisted ambulation on postoperative day one allowed for urinary catheter removal and prevention of urinary disorders in patients that already suffer from neurogenic bladder.11 Neurosensory Analysis
Postoperative measurement of cutaneous pressure thresholds was performed by PSSD for static and moving one-point and two-point discrimination at minimum 12months follow-up at flap’s midpoint to assess the persistence of sensation on the reconstructed area. RESULTS
Mean overall operative time was 212 minutes (range, 180–250 minutes), and average flap size was 7.4 x 8.5 cm (range, 6 x 10.5–8 x 9 cm). Donor-site defect was closed primarily in all cases (Table 1). After average 4 days of initial swelling all flaps flattened at the level of the surrounding skin; no immediate or late complications were observed, except for one case with minor wound dehiscence at donor site. All patients presented cutaneous sensitivity at donor site and, although reduced, showed persistence of sensation at the reconstructed area (Table 2). Mean follow-up was 26.4 months (range, 12–39 months). Case Report
A 22-year-old man with sacral meningomyelocele (S2), neurogenic bladder and marked spasticity of the lower extremities presented with a history of recurrent ischiatic sore previously reconstructed with posterior thigh and gluteal fasciocutaeous flaps. Clinical examination revealed a 5
ALT Flap for Ischiatic Sores Reconstruction
281
Table 2. Pre-operative and Postoperative Pressure Thresholds Type of examination 1. One-point static discrimination (g/mm2) 2. Two-point static discrimination (g/mm2) 3. One-point moving discrimination (g/mm2) 4. Two-point moving discrimination (g/mm2) 5. Heat-cold perception 6. Pain perception
Preoperative (Thigh)
Postoperativec (Ischiatic region)
8.861.14
15.862.43
4.162.31a
11.763.67b
3.160.97
10.563.04
3.8 62.25a
10.963.59b
Yes Yes
Yes Yes
a
Mean detectable distance of tip probes was 15.1 mm (range, 13.5–18.7). Mean detectable distance of tip probes was 19.6 mm (range, 15.3–22.8). Mean follow up of 26.4 months (range, 12–39 months).
b c
Figure 2. (Left) Pre-operative markings of the ALT perforator flap. (Right) Intra-operative view. The yellow vessel loop identifies the LCFN and the red vessel loop identifies the perforator on which the ALT flap was based. The vessel clamp identifies the common branch of two previously dissected distal perforators converging into the profunda femoris artery.
R
Figure 1. Preoperative view showing a 5 x 5-cm IV stage serous exudative open wound with bone involvement on left ischiatic area.
x 5-cm IV stage serous exudative open wound with bone involvement on left ischiatic area (Fig. 1). Microbiological examination showed no bacterial contamination, and a radiograph of the pelvis confirmed the absence of left ischial osteomyelitis. Pre-operative sensory assessment of the left LCFN territory of distribution showed the following values: 7.4 g/mm2 for one-point static; 4.6 g/mm2 for two-point static; 4.2 g/mm2 for one-point moving; 3.4 g/ mm2 for two-point moving. Under general anesthesia, following administration of pre-operative antibiotic prophylaxis of a first-generation cephalosporin (cafazolin, 1 g intravenously), the patient underwent wide wound debridement that resulted in a soft tissue defect of 7 x 7 cm over the left ischial tuberosity. As described above, an 8 x 7-cm pedicled sensate ALT perforator flap based on three perforators was raised. As two distal perforators converged into a common branch originated from the profunda femoris artery, they were ligated and the flap was harvested on the
cranial perforator. A blue single-use ScanlanV vascular tunneler sheath (Scanlan Medical Instruments, St. Paul, Minnesota) between the rectus femoris and the vastus lateralis muscles was used to identify the intermuscular passageway, through which the flap was transferred to the recipient site to reconstruct the ischial defect (Figs. 2, 3). Healing was uneventful, the patient started walking with assistance on day 1 after surgery, and no recurrence was observed at 1-year follow-up (Fig. 4). Neurosensory analysis performed at 12 months from surgery confirmed the presence of sensitive perception on the transferred skin paddle: 12.4 g/mm2 for one-point static; 7.3 g/mm2 for two-point static; 7.1 g/ mm2 for one-point moving; 6.4 g/mm2 for two-point moving. DISCUSSION
The management of ischial ulcers in chair-fast patients is quite intricate because of their tendency to develop recurrent ulcerations, which make conservative treatments not resolutive, hence requiring a surgical definitive approach. Many loco-regional flaps have been used for this issue, but as recidivation rates often exceed 50%, proper flap selection according to the need for adequate bulk, vascularization and sensory recovery is fundamental.6,12–15 Tissue expansion has already been described by Neves et al.; while in 2001, Thomson et al. reported their experience in reconstruction of recurrent Microsurgery DOI 10.1002/micr
282
Santanelli di Pompeo et al.
Figure 3. Intra-operative view of the vascular pedicle (blue vessel loop) and LCFN (yellow vessel loop) passing through the intramuscular passageway after flap transposition to the ischial defect.
Figure 4. Postoperative view showing the anterolateral thigh perforator flap transposed into the ischial defect.
ulcers defects using fasciocutaneous sensate flaps with random vascular pattern from anterolateral/anteromedial thigh, on four patients affected by meningomyelocele.16,17 More consistent approaches include the use of musculocutaneous and fasciocutaneous flaps with each having pros and cons. Myocutaneous flaps (e.g. rectus Microsurgery DOI 10.1002/micr
abdominis flap, semitendinous and semimenbranous flaps, and gluteal flap) have significant bulk and robust vascularization.18–20 On the downside, muscle is not an ideal option in ambulatory patients. Fasciocutaneous flaps (e.g. anterolateral thigh perforator flap, gluteal perforator flap, gracilis perforator flap, and profunda femoris perforator flap) have good blood supply, sufficient bulk and allow for muscular function preservation.21,22 However, they may become less useful when filling of a wound with significant depth is required. Nowadays, thanks to advances in perforator flaps, the basic rule to rob Peter to pay Paul23 should be updated to only with as less morbidity as possible for Peter, leading us to conceive a pedicled sensate ALT perforator flap as an ideal solution, as protective sensitivity to the anterolateral thigh region is usually preserved in lower lombar and sacral meningomyelocele patients. The ALT flap has widely demonstrated its versatility and reliability, and the LCFN can be incorporated into the flap to provide sensation to reconstructed area.24–27 It has already been used for the coverage of pressure sores as a pedicled island flap including a cuff of vastus lateralis muscle,5–7,28 however, to the best of our knowledge, without sensitive innervation. Indeed, all cases reported in literature are on paraplegic patients, in which including sensitive branches within the flap would have been worthless. Moreover, while in such patients the inclusion of vastus lateralis muscle has no relevant functional drawback; in meningomyelocele patients it is wise to spare lower limb muscles to preserve deambulation as much as possible. The direct intermuscular passageway allows to both reduce the distance between the ischial defect and the LCFN and LCFA origins, and to use the more reliable skin from the middle third of the anterolateral thigh instead of the distal third. Intra-operative delicate manipulation of perforators and correct positioning of the flap’s vascular pedicle into the intermuscular tunnel to prevent pedicle torsion is recommended to avoid spasm, while postoperative prevention of adductor muscles contraction is kept by lower limb adduction with the patient placed prone or in lateral decubitus on an air-fluidized bed. While reduced, if compared to pre-operative anterolateral thigh measurements, the preserved flap sensitivity restores patient’s ability to monitor the pressure applied to the buttock, and together with the instructions on the correct skin care and pressure-release measures, may improve prevention of recidivating ulcerations. CONCLUSIONS
Despite the limited number of patients, the sensate anterolateral thigh perforator flap may be considered an ideal solution for ischial pressure sore reconstruction in
ALT Flap for Ischiatic Sores Reconstruction
meningomyelocele patients in which pressure consciousness is essential for the prevention of sore recurrence.
REFERENCES 1. Henderson J, Price SH, Brandstater ME, Mendac BR. Efficacy of three measures to relieve pressure in seated persons with spinal cord injury. Arch Phys Med Rehabil 1994;75:535–539. 2. Thomson HG. The recurrent neurotrophic buttock ulcer in the meningomyelocele paraplegic: A sensate flap solution. Plast Reconstr Surg 2001;108:1192–1196. 3. Bauer J, Phillips LG. MOC-PSSM CME Article: Pressure sores. Plast Reconstr Surg 2008;121:1–10. 4. Hupkens P, Ozturk E, Wittens S, Hoevenaren IS, Kooloos JG, Ulrich DJ. Posterior thigh perforator flaps: An anatomical study to localize and classify posterior thigh perforators. Microsurgery 2013; 33:376–382. 5. Lee JT, Cheng LF, Lin CM, Wang CH, Huang CC, Chien SH. A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores. J Plast Reconstr Aesthet Surg 2007;60:1060– 1066. 6. Kua EH, Wong CH, Ng SW, Tan KC. The island pedicled anterolateral thigh (pALT) flap via the lateral subcutaneous tunnel for recurrent ischial ulcers. J Plast Reconstr Aesthet Surg 2011;64:21–23. 7. Moullot P, Philandrianos C, Casanova D. Resurfacing of an ischial and trochanteric recurrent pressure sore by a pedicled fasciocutaneous anterolateral thigh flap. Ann Chir Plast Esthet 2013. doi: 10.1016/j.anplas.2013.06.004. [Epub ahead of print]. 8. Hsu H, Chien SH, Wang CH, Cheng LF, Lin CH, Wu MS, Huang CC, Lee JT. Expanding the applications of the pedicled anterolateral thigh and vastus lateralis myocutaneous flaps. Ann Plast Surg 2012; 69:643–649. 9. Corujo A, Franco CD, Williams JM. The sensory territory of the lateral cutaneous nerve of the thigh as determined by anatomic dissections and ultrasound-guided blocks. Reg Anesth Pain Med 2012;37: 561–564. 10. Santanelli F, Berlin O, Fogdestam I. The combined tensor fasciae latae/rectus femoris musculocutaneous flap: A possibility for major soft tissue reconstruction in the groin, hip, gluteal, perineal, and lower abdominal regions. Ann Plast Surg 1993;31:168–174. 11. Swartz D, Stephenson E. The neurogenic bladder in spinal cord injury. Can Med Assoc J 1957;76:462–465. 12. Foster RD, Anthony JP, Mathes SJ, Hoffman WY. Ischial pressure sore coverage: a rationale for flap selection. Br J Plast Surg 1997; 50:374–379.
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13. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272–278. 14. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119: 1259–1266. 15. Scuderi N, Scioli M, Santanelli F, Rubino C, Di Caprio G, Sposato G. Free nonsensory plantar flap in the treatment of trochanteric pressure ulcers. Plast Reconstr Surg 1996;98:909–910. 16. Neves RI, Kahler SH, Banducci DR, Manders EK. Tissue expansion of sensate skin for pressure sores. Ann Plast Surg 1992;23:433–437. 17. Thomson HG, Azhar Ali M, Healy H. The recurrent neurotrophic buttock ulcer in the meningomyelocele paraplegic: A sensate flap solution. Plast Reconstr Surg 2001;108:1192–1196. 18. Kuo P-J, Chew K-Y, Kuo Y-R, Lin P-Y. Comparison of outcomes of pressure sore reconstructions among perforator flaps, peroforatorbased rotation fasciocutaneous flaps, and musculocutaneous flaps. Microsurgery 2014;34:547–553. 19. Gaster RS, Bhatt KA, Shelton AA, Lee GK. Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels. Microsurgery 2012;32:388–392. 20. Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction. Microsurgery 2013;33:32–38. 21. Ayestaray B, Proske YM. Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap. Microsurgery 2015;35:64–67. 22. Kim CM, Yun IS, Lee DW, Lew DH, Rah DK, Lee WJ. Treatment of ischial pressure sores with both profunda femoris artery perforator flaps and muscle flaps. Arch Plast Surg 2014;41:387–393. 23. Neligan PC. Plastic Surgery. Elsevier-Saunders, 3rd ed. 2012. Vol. 1, p 367. 24. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219–2226. 25. Longo B, Paolini G, Belli E, Costantino B, Pagnoni M, Santanelli F. Wide excision and anterolateral thigh perforator flap reconstruction for dermatofibrosarcoma protuberans of the face. J Craniofac Surg 2013;24:e597–e599. 26. Longo B, Ferri G, Fiorillo A, Rubino C, Santanelli F. Bilobed perforator free flaps for combined hemitongue and floor-of-the-mouth defects. J Plast Reconstr Aesthet Surg 2013;66:1464–1469. 27. Longo B, Pagnoni M, Ferri G, Morello R, Santanelli F. The mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. Plast Reconstr Surg 2013;132:656–665. 28. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction. Plast Reconstr Surg 2002;109:610–616.
Microsurgery DOI 10.1002/micr
Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure-Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow-up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap’s vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the C 2014 Wiley Periodicals, Inc. Microsurgery 35:279–283, 2015. middle third of the anterolateral thigh. V
Meningomyelocele
is a developmental congenital disorder presenting as an incomplete closure of the embryonic neural tube, with vertebral malformation and consequential protrusion of the spinal cord with the meninges and cerebrospinal fluid in a small and delicate sac. The deformity can be localized at a lumbar or sacral level and according its location, it determines a spectrum of deficiencies with functional lower limb impairment up to paralysis and complete loss of sensation. The decrease of epicritic, proprioceptive, and protopathic sensitivity is the major cause of pressure sores in meningomyelocele patients, increasing the risk for mechanical and thermal skin damage, while the impairment of autonomic innervation causes an alteration in tissues’ homeostasis and healing process. The limitation in motility and the inability of these patients to monitor the pressure applied on insensate areas while sitting on a wheelchair, are the principal factors responsible for the onset of ischial and sacral pressure ulcerations.1,2 Conservative treatments as nutritional support, frequent changes in sitting-position and local wound care are very useful tools, however, chair-fast patients, as those Plastic Surgery Unit, NESMOS department, Sant’Andrea Hospital, School of Medicine and Psychology, “Sapienza” University of Rome, Italy Disclosure: We, hereby certify, that to the best of our knowledge no financial support or benefits have been received by author or any co-author, by any member of our immediate family or any individual or entity with whom or with which we have a significant relationship from any commercial source which is related directly or indirectly to the scientific work which is reported on in the article. *Correspondence to: Fabio Santanelli di Pompeo, M.D., Ph.D., Azienda Ospedaliera Sant’Andrea – U.O.D. Chirurgia Plastica, Via di Grottarossa 1035–1039, 00189 Rome, Italy. E-mail: [email protected] Received 9 May 2014; Revision accepted 6 September 2014; Accepted 8 September 2014 Published online 20 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22330 Ó 2014 Wiley Periodicals, Inc.
affected by meningomyelocele, have still a tendency to develop recurrent ulcerations which require a correct surgical approach. While a multitude of procedures for patients undergoing pressure sore flap reconstruction have been suggested, there is a paucity of specific protocols for spinal cord-injured patients with their injury below L2. The goal of their surgical treatment is to raise a predictably vascularized sensate flap and inset it with minimal tension. Different options have been considered in case of ischiatic pressure sore repair, including the tensor fasciae latae flap, the gluteal flap, and posterior thigh V-Y perforator flaps.3,4 However, in meningomyelocele patients with their injury below L2 these flaps are not available as sensate flaps, then tissue from the anterior thigh with conserved sensory perception becomes an ideal choice. Although previous authors reported the use of vastus lateralis myocutaneous flap for ischiatic sores, the incorporation of the lateral cutaneous femoral nerve (LCFN) to provide sensory perception at the ischiatic area has not been reported yet.5–8 Moreover, most of their spinal cordinjured patients were paraplegic, thus not ambulatory, not suffering functional impairment because of the sacrifice of the vastus lateralis muscle, and no sensitive perception on the anterior thigh. As meningomyelocele patients are ambulatory with preserved anterior thigh sensory function, the use of a sensate anterolateral thigh perforator flap may be an ideal choice for ischiatic sores reconstruction in this patients population. Purpose of this article is to present our preliminary experience on the novel use of the sensate pedicled anterolateral thigh (ALT) perforator flap for ischiatic sores reconstruction in patients affected by mid-lumbar or lower level (L3 to S4) meningomyelocele, with conserved thigh sensitivity.
280
Santanelli di Pompeo et al. Table 1. Patient and Operative Data
Case
Sex (age, years)
Defect location
Flap size (cm)
Perforators number (Typea)
Overall operative time (minutes)
1 2
M (24) M (25)
Right Ischium Left Ischium
8x9 8x8.5
2 (M,M) 1 (S)
250 190
3 4 5
F (19) M (21) M (22)
Right Ischium Left Ischium Left Ischium
6x10.5 7x7.5 8x7
2 (M,S) 1 (S) 1 (S)
225 180 215
Complications MWD at donor site -
Follow-up (months)
Sore recurrence
36 31
No No
26 24 12
No No No
a
M, Muscolocutaneous; S, Septocutaneous; MWD, Minor wound dehiscence
PATIENTS AND METHODS
Between May 2011 and September 2013, five meningomyelocele patients (four male, one female), with mean age of 22.2 years (range, 19–25), reporting chronic ischial sores were addressed to debridement and reconstruction of the defect with a sensate pedicled ALT flap. Patients’ demographics are shown in Table 1. Pre-operatively, with a 5-cm insulated 22-Gauge needle, ultrasound-guided block of the LCFN was performed injecting 6 mL of 1.5% plain lidocaine.9 The contours of the anesthetized area, representing the LCFN territory of distribution, were delineated. Subsequently, within this area epicritic and proprioceptive sensitivity testing was performed, assessing pressure thresholds of static and moving one and two-point discrimination with the Pressure-Specified Sensory Device (Sensory Management Services, LLC, Baltimore, Md.), in order to measure skin sensitivity and to appropriately draw the flap. Surgical Procedure
Peri-operative antibiotic therapy was administered to all patients after wound culture testing. With patient positioned in lateral decubitus and hip elevated and flexed, a radical debridement of the ulcer was performed using methylene blue staining, until healthy vascularized tissue was obtained. Flap was harvested suprafascially, starting the incision at its superior margin, to locate and dissect the LCFN up to the anterosuperior iliac spine. Dissection proceeded then from medial to lateral towards the intermuscular septum between rectus femoris and vastus lateralis muscles, to identify the perforators and dissect flap pedicle towards its origin from the lateral circumflex femoral artery (LFCA).10 A tunnel from the anterior to the posterior thigh compartment was created through the intermuscular space between vastus intermedius and vastus medialis muscles, then penetrating through the vastus medialis’ femoral origin, adjacent to the linea aspera of the femur, and through the intermuscular space between pectineus muscle cranially and adductor longus caudally. Finally, the passageway was completed penetrating through the Microsurgery DOI 10.1002/micr
adductors brevis and magnus and the gluteus maximus muscles, spreading the fibers as to maintain their longitudinal integrity.5 The flap was folded on itself to protect the neurovascular pedicle, was transposed to the ischial defect taking care not to injure the sciatic nerve, and then sutured in place after positioning of a closed suction drain. Donor site was closed primarily in all cases. All patients were placed prone or in lateral decubitus on an air-fluidized bed with the lower limbs extended and adducted. Early assisted ambulation on postoperative day one allowed for urinary catheter removal and prevention of urinary disorders in patients that already suffer from neurogenic bladder.11 Neurosensory Analysis
Postoperative measurement of cutaneous pressure thresholds was performed by PSSD for static and moving one-point and two-point discrimination at minimum 12months follow-up at flap’s midpoint to assess the persistence of sensation on the reconstructed area. RESULTS
Mean overall operative time was 212 minutes (range, 180–250 minutes), and average flap size was 7.4 x 8.5 cm (range, 6 x 10.5–8 x 9 cm). Donor-site defect was closed primarily in all cases (Table 1). After average 4 days of initial swelling all flaps flattened at the level of the surrounding skin; no immediate or late complications were observed, except for one case with minor wound dehiscence at donor site. All patients presented cutaneous sensitivity at donor site and, although reduced, showed persistence of sensation at the reconstructed area (Table 2). Mean follow-up was 26.4 months (range, 12–39 months). Case Report
A 22-year-old man with sacral meningomyelocele (S2), neurogenic bladder and marked spasticity of the lower extremities presented with a history of recurrent ischiatic sore previously reconstructed with posterior thigh and gluteal fasciocutaeous flaps. Clinical examination revealed a 5
ALT Flap for Ischiatic Sores Reconstruction
281
Table 2. Pre-operative and Postoperative Pressure Thresholds Type of examination 1. One-point static discrimination (g/mm2) 2. Two-point static discrimination (g/mm2) 3. One-point moving discrimination (g/mm2) 4. Two-point moving discrimination (g/mm2) 5. Heat-cold perception 6. Pain perception
Preoperative (Thigh)
Postoperativec (Ischiatic region)
8.861.14
15.862.43
4.162.31a
11.763.67b
3.160.97
10.563.04
3.8 62.25a
10.963.59b
Yes Yes
Yes Yes
a
Mean detectable distance of tip probes was 15.1 mm (range, 13.5–18.7). Mean detectable distance of tip probes was 19.6 mm (range, 15.3–22.8). Mean follow up of 26.4 months (range, 12–39 months).
b c
Figure 2. (Left) Pre-operative markings of the ALT perforator flap. (Right) Intra-operative view. The yellow vessel loop identifies the LCFN and the red vessel loop identifies the perforator on which the ALT flap was based. The vessel clamp identifies the common branch of two previously dissected distal perforators converging into the profunda femoris artery.
R
Figure 1. Preoperative view showing a 5 x 5-cm IV stage serous exudative open wound with bone involvement on left ischiatic area.
x 5-cm IV stage serous exudative open wound with bone involvement on left ischiatic area (Fig. 1). Microbiological examination showed no bacterial contamination, and a radiograph of the pelvis confirmed the absence of left ischial osteomyelitis. Pre-operative sensory assessment of the left LCFN territory of distribution showed the following values: 7.4 g/mm2 for one-point static; 4.6 g/mm2 for two-point static; 4.2 g/mm2 for one-point moving; 3.4 g/ mm2 for two-point moving. Under general anesthesia, following administration of pre-operative antibiotic prophylaxis of a first-generation cephalosporin (cafazolin, 1 g intravenously), the patient underwent wide wound debridement that resulted in a soft tissue defect of 7 x 7 cm over the left ischial tuberosity. As described above, an 8 x 7-cm pedicled sensate ALT perforator flap based on three perforators was raised. As two distal perforators converged into a common branch originated from the profunda femoris artery, they were ligated and the flap was harvested on the
cranial perforator. A blue single-use ScanlanV vascular tunneler sheath (Scanlan Medical Instruments, St. Paul, Minnesota) between the rectus femoris and the vastus lateralis muscles was used to identify the intermuscular passageway, through which the flap was transferred to the recipient site to reconstruct the ischial defect (Figs. 2, 3). Healing was uneventful, the patient started walking with assistance on day 1 after surgery, and no recurrence was observed at 1-year follow-up (Fig. 4). Neurosensory analysis performed at 12 months from surgery confirmed the presence of sensitive perception on the transferred skin paddle: 12.4 g/mm2 for one-point static; 7.3 g/mm2 for two-point static; 7.1 g/ mm2 for one-point moving; 6.4 g/mm2 for two-point moving. DISCUSSION
The management of ischial ulcers in chair-fast patients is quite intricate because of their tendency to develop recurrent ulcerations, which make conservative treatments not resolutive, hence requiring a surgical definitive approach. Many loco-regional flaps have been used for this issue, but as recidivation rates often exceed 50%, proper flap selection according to the need for adequate bulk, vascularization and sensory recovery is fundamental.6,12–15 Tissue expansion has already been described by Neves et al.; while in 2001, Thomson et al. reported their experience in reconstruction of recurrent Microsurgery DOI 10.1002/micr
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Santanelli di Pompeo et al.
Figure 3. Intra-operative view of the vascular pedicle (blue vessel loop) and LCFN (yellow vessel loop) passing through the intramuscular passageway after flap transposition to the ischial defect.
Figure 4. Postoperative view showing the anterolateral thigh perforator flap transposed into the ischial defect.
ulcers defects using fasciocutaneous sensate flaps with random vascular pattern from anterolateral/anteromedial thigh, on four patients affected by meningomyelocele.16,17 More consistent approaches include the use of musculocutaneous and fasciocutaneous flaps with each having pros and cons. Myocutaneous flaps (e.g. rectus Microsurgery DOI 10.1002/micr
abdominis flap, semitendinous and semimenbranous flaps, and gluteal flap) have significant bulk and robust vascularization.18–20 On the downside, muscle is not an ideal option in ambulatory patients. Fasciocutaneous flaps (e.g. anterolateral thigh perforator flap, gluteal perforator flap, gracilis perforator flap, and profunda femoris perforator flap) have good blood supply, sufficient bulk and allow for muscular function preservation.21,22 However, they may become less useful when filling of a wound with significant depth is required. Nowadays, thanks to advances in perforator flaps, the basic rule to rob Peter to pay Paul23 should be updated to only with as less morbidity as possible for Peter, leading us to conceive a pedicled sensate ALT perforator flap as an ideal solution, as protective sensitivity to the anterolateral thigh region is usually preserved in lower lombar and sacral meningomyelocele patients. The ALT flap has widely demonstrated its versatility and reliability, and the LCFN can be incorporated into the flap to provide sensation to reconstructed area.24–27 It has already been used for the coverage of pressure sores as a pedicled island flap including a cuff of vastus lateralis muscle,5–7,28 however, to the best of our knowledge, without sensitive innervation. Indeed, all cases reported in literature are on paraplegic patients, in which including sensitive branches within the flap would have been worthless. Moreover, while in such patients the inclusion of vastus lateralis muscle has no relevant functional drawback; in meningomyelocele patients it is wise to spare lower limb muscles to preserve deambulation as much as possible. The direct intermuscular passageway allows to both reduce the distance between the ischial defect and the LCFN and LCFA origins, and to use the more reliable skin from the middle third of the anterolateral thigh instead of the distal third. Intra-operative delicate manipulation of perforators and correct positioning of the flap’s vascular pedicle into the intermuscular tunnel to prevent pedicle torsion is recommended to avoid spasm, while postoperative prevention of adductor muscles contraction is kept by lower limb adduction with the patient placed prone or in lateral decubitus on an air-fluidized bed. While reduced, if compared to pre-operative anterolateral thigh measurements, the preserved flap sensitivity restores patient’s ability to monitor the pressure applied to the buttock, and together with the instructions on the correct skin care and pressure-release measures, may improve prevention of recidivating ulcerations. CONCLUSIONS
Despite the limited number of patients, the sensate anterolateral thigh perforator flap may be considered an ideal solution for ischial pressure sore reconstruction in
ALT Flap for Ischiatic Sores Reconstruction
meningomyelocele patients in which pressure consciousness is essential for the prevention of sore recurrence.
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Microsurgery DOI 10.1002/micr
