RECONSTRUCTIVE SURGERY
The Combined Pedicled Anterolateral Thigh and Vastus Lateralis Flap as Filler for Complex Perineal Defects Pietro G. di Summa, MD, PhD,* Mathias Tremp, MD,Þ Moritz Meyer zu Schwabedissen, MD,Þ Dirk J. Schaefer, MD,Þ Daniel F. Kalbermatten, MD, PhD, MPhil,Þ and Wassim Raffoul, MD* Abstract: Extensive defects of the pelvis and genitoperineal region are a reconstructive challenge. We discuss a consecutive series of 25 reconstructions with the pedicled anterolateral thigh (ALT) flap including muscle part of the vastus lateralis (VL) in 23 patients from October 1999 to September 2012. Only surface defects larger than 100 cm2 and reconstructions by composite ALT + VL were included in this retrospective analysis. Of the 23 patients, 19 underwent oncologic resection, whereas 4 cases presented Fournier gangrene. Three patients did not reach 6 months of follow-up and were excluded from further data analysis. Among the remaining 20 patients (22 reconstructions), average follow-up period was 14 months (range, 10Y18 months). Patient’s average age was 60 years. Average size of the defect was 182 cm2. Postoperative complications included 1 (4.5%) flap necrosis out of 22 raised flaps, 1 partial flap necrosis after venous congestion, and 2 cases where a complementary reconstructive procedure was performed due to remaining defect or partial flap failure. In 6 cases, peripheral wound dehiscence (27%) was treated by debridement followed by split-thickness skin graft or advancement local flaps. Defect size was significantly related to postoperative complications and increased hospital stay, especially in those patients who underwent preoperative radiotherapy. At the end of the follow-up period, a long-term and satisfactory coverage was obtained in all patients without functional deficits. This consecutive series of composite ALT + VL flap shows that, in case of extended defects, the flap provides an excellent and adjustable muscle mass, is reliable with minimal donor-site morbidity, and can even be designed as a sensate flap. Key Words: composite ALT flap, perineal reconstruction, complex defects (Ann Plast Surg 2015;75: 66Y73)
T
he anterolateral thigh (ALT) flap, first described in 1984 by Song et al,1 is a reliable flap for soft tissue reconstruction with a large skin flap based on musculocutaneous or fasciocutaneous perforators that can be safely harvested and provides tissue to fill large defects.2Y4 It has been successfully used as a free flap for defect reconstruction in the head and neck region5Y7 as well as for lower and upper extremities.8,9 The flap possesses the qualities of pliability with an excellent blood supply, minimal donor-site morbidity, and ease of suspension and fixation.4 Pedicled ALT flaps were successfully used to repair defects of the groin, internal pelvis, and genitoperineal region.8 However, for larger and deeper defects, the ALT flap alone may not be reliable enough and only few reports or short series exist in the literature
Received May 12, 2013, and accepted for publication, after revision, August 1, 2013. From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne, Lausanne; and †Department of Plastic, Reconstructive and Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Conflicts of interest and sources of funding: none declared. Reprints: Pietro Giovanni di Summa, MD, PhD, Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Rue du Bugnon 46, 1006 Lausanne, Switzerland. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7501-0066 DOI: 10.1097/SAP.0b013e3182a884c8
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concerning the clinical application of this flap for complex locoregional reconstruction.8,10,11 In a recent study, ALT perforator flaps combined with vastus lateralis (VL) muscle proved valuable as a musculocutaneous flap for defect closure in the head and neck area.12 In our study, the ALT flap combined with partial VL muscle has been chosen for complex perineal reconstruction because of its low morbidity13 and similar tissue thickness to the lost ones (‘‘replace like with like’’).14 We reviewed our experience in the surgical management of complex perineal defects, considering only reconstructions by pedicled ALT composite flaps in defects with surface larger than 100 cm2. The influence of age, defect size, type of defect (tumoral vs infectious), and preoperative radiotherapy (RT) on surgical outcomes was analyzed and discussed.
PATIENTS AND METHODS Between October 1999 and September 2012, approximately 250 patients were admitted to the Centre Hospitalier Universitaire Vaudois and transferred to our plastic surgery unit for reconstruction of perineum defects. According to defect size and location, multiple reconstructive procedures were performed, including simple debridement associated with split-thickness skin grafts (STSG), local advancement flaps, gracilis myocutaneous flaps, vertical rectus abdominis myocutaneous (VRAM) flaps, or ALT flaps. In this study, we retrospectively reviewed only the cases where pedicled ALT flaps were raised as composite flaps to cover complex abdominal and perineal defects. Inclusion criteria were soft tissue defects with a surface of more than 100 cm2 after surgical excision (abdominoperineal amputation, pelvic exenteration, and massive perineal debridements) and the inclusion of VL muscle and/or tensor fasciae latae within the ALT flap. Retrospective investigation was conducted on medical records (operatory reports, hospital dismission letter, and outpatient clinic follow-up consultations) obtained from the hospital computerized database and patient’s medical charts. In total, 23 patients (16 women and 7 men) were included in the study (Table 1). Three patients (patients 2, 7, and 9) died prematurely (4 months postoperatively) due to cancer-related reasons and were excluded from data analysis. Among the remaining 20 patients, ages ranged from 24 to 81 years (mean, 60; median, 64.5). Postoperative complications were defined as major or minor according to previous literature.11 Major complications included partial or total flap loss, major wound dehiscence (involving more than one third of the incision length), and persistent dead space requiring a supplementary reconstructive procedure during follow-up period. Minor complications included minor dehiscence (involving less than one third of the incision length), which healed after debridement and STSG or local flap advancement or wounds that had a persistent dehiscence after 4 weeks. The average length of follow-up was 14 months (range, 10Y18 months). The study was approved by the local ethic committee.
Surgical Technique After placing in a lithotomy position, design and dissection of the fasciocutaneous flap with the VL muscle was performed as described earlier.12,15 The skin flap was defined around the marked perforators and according to the size of defect. First, a medial exploring incision Annals of Plastic Surgery
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was made down to the fascia over the rectus femoris muscle. Next, the subfascial dissection was continued laterally toward the intramuscular septum between the VL and rectus femoris muscles, identifying the septocutaneous or muscular perforators, as well as the lateral circumflex femoral vessels by Doppler probe. Then, the dissection was performed as a musculocutaneous ALT + VL flap and adjusted according to the size of defect (Fig. 1), including the tensor fasciae latae if necessary. The vascular pedicle was dissected from distal to proximal until its origin from the deep femoral vessels, preserving the motor innervation to the remaining VL muscle and the femoral cutaneous nerve within the flap. After completion of flap harvesting, the single pedicled ALT f lap with the partial VL muscle was passed under the rectus femoris muscle before being transferred to cover the perineal defect through a subcutaneous channel. If required, the vaginal and urethral cuffs were brought out through the hole to create a vaginal and urinary introitus (Fig. 2). Donor site was either closed directly or by using STSG. Extirpative surgery was carried out by colorectal surgeons, gynecologists, or urologists, whereas the flap reconstruction was performed by plastic surgeons from our unit.
Statistical Analysis Patient ages, defect sizes, operative time, time to healing, and hospital stay were statistically analyzed (GraphPad Prism 5.0; San Diego, Calif ). Linear and logistic regressions or contingency W2 test (depending whether the variables were continuous or binary) was used to detect potential relationships between independent (age, defect size, RT, and type of defect) and dependent (complications, time to healing, and hospital stay) variables (StataCorp LP, College Station, Tex). Statistical significance was considered for P values less than 0.05.
RESULTS During the study period, 25 consecutive ALT composite flaps were used to repair extensive perineal wound defects in 23 patients (16 women and 7 men) (Table 1). Two patients (1 and 19) previously underwent a reconstruction by gracilis myocutaneous f lap, which turned out to be insufficient. Of the 23 patients, 19 (83%) underwent oncologic surgery (13 for primary tumor treatment and 6 for recurrent disease). Diagnosis included anal epidermoid carcinoma in 8 patients; rectum epidermoid carcinoma in 6 patients; vulvar melanoma in 2 patients (in 1 case associated to an ovarian cystadenocarcinoma); and vulvar, vaginal, and bladder epidermoid carcinoma in 1 patient each. In 1 patient, both tumor and infection were present as he developed a necrotizing fasciitis (Fournier gangrene) secondary to an anal epidermoid carcinoma. The remaining 4 patients underwent radical perineal debridement due to Fournier gangrene only. Reconstructions included 13 mixed perineal-pelvic defects and 10 perineal defects, eventually associated to inguinal, scrotal, or vulvar defects with different amounts of dead space. In 1 case, the defect was pelvic only including the lower abdominal wall. As previously mentioned, 3 patients (patients 2, 7, and 9) died prematurely and were excluded from further data analysis. Considering these remaining 20 patients, 14 (87%) of 16 patients with tumor diagnosis underwent RT or combined RT and chemotherapy (RT + CT). One patient only underwent CT because of melanoma diagnosis (patient 22). Total RT dose ranged from 40 to 108 Gy [65 (22) Gy; average (SD)]. Wound defects ranged from 112 to 396 cm2 [182 (71) cm2; average (SD), median 161 cm2]. Operative time ranged from 96 to 330 minutes [199 (54) minutes; average (SD)]. Only 1 (5%) of 20 patients (patient 3) had to be readmitted to hospital for surgical-related complications. Average time to complete healing (considering the total healing time, if the patient had to undergo a supplementary surgical procedure during the same hospital stay) ranged from 12 to 42 days [22 (10) days; average (SD)]. Finally, * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Combined ALT+VL Flap as Filler for Complex Defects
hospital stay varied from a minimum of 13 to a maximum of 80 days [35 (19) days; average (SD)].
Complications Twenty-two ALT + VL flaps were performed on the 20 patients included in the final data analysis (Table 1); 1 patient required an immediate double pedicled ALT procedure (Fig. 3) and in another patient the contralateral ALT flap needed to be harvested due to necrosis of the previous flap. This was the only flap necrosis encountered in our series [1 (4.5%) of a total of 22 raised flaps]. Among other major complications, 2 other patients needed a complementary reconstructive procedure due to remaining defect or partial flap failure (gracilis myocutaneous f lap was used in both cases). One patient presented a venous congestion due to pedicle kinking, which had to be revised. The peripheral necrosis was excised and covered by STSG. Other minor complications included 6 (30%) cases of minor peripheral flap dehiscence, which were treated by debridement followed by STSG or advancement local f laps, except in 1 case where the patient preferred a long-term conservative treatment. The remaining ALT composite flaps (50%) healed uneventfully or presented minimal local dehiscence, which healed spontaneously or after conservative treatment before stitches removal (3 weeks postoperative). Postoperative complications were analyzed according to age, defect size, RT, and original cause of the defect. The frequency distribution of the defect size has been represented, (Fig. 4). Both the average and the median value of the defect size (182 and 161 cm2, respectively) are contained in the first class (112 to 185 cm2). When considering defect surfaces’ frequency distribution, we could make a distinction among defects greater than 180 cm2 and less than or equal to 180 cm2 (this threshold corresponding to the approximated average defect size) when studying the complications (Table 2). The subgroup where the defect was greater than 180 cm2 represented 35% of our study population (7 of 20 patients). In this group, 3 patients developed major complications and 3 developed minor complications (a total of 85% rate of complications), whereas just 4 (30%) of 13 patients developed postoperative complications when the defect was less than or equal to 180 cm2. A W2 test showed a significant influence of defect size on postoperative complications (P = 0.019). Of the 14 patients who received preoperative RT or combined RT and CT (representing 70% of included patients), 4 developed major complications and 4 minor complications (total complications, 57%). In the subgroup which did not receive RT, just 2 (33%) of 6 patients developed complications. A W2 test could not detect a statistically significant difference among these groups (P = 0.329) (Table 2). Linear and logistic regressions were performed among variables: age and type of disease (oncological vs infectious) did not seem to affect significantly surgical outcomes (complications, time to complete healing, or time of hospital stay). The defect size alone was not correlated with the complete time to healing (P = 0.21), but was almost significantly correlated with the hospital stay (P = 0.05). In the same way, RT alone did not seem to inf luence significantly time to complete healing (P = 0.36) or time of hospital stay (P = 0.14). However, when combined together in a linear regression the two variables (defects sizes and preoperative RT), the cumulative inf luence on both time to healing and hospital stay became strongly significant (P = 0.087 for time to healing and P = 0.007 for hospital stay).
Flap Design All 26 ALT were prepared as composite flaps with different amount of VL muscle, according to the defects. In each patient, the muscular part was adjusted to the size of defect. The flap could be tailored to the defect including partial or full muscle mass (Fig. 1). If the defect could not be covered by a single ALT-VL flap, a double flap muscle mass was used (Fig. 3). Septocutaneous perforators were present in 4 (16%) of 25 flaps. In the remaining 22 flaps, musculocutaneous www.annalsplasticsurgery.com
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TABLE 1. Patient’s Age, Preoperative Treatment, Demolitive Procedure, Defect Location and Size, Reconstructive Procedure, Flap Type, and Outcomes (Eventual Complications, Time to Healing, and Total Hospital Stay) Patient Sex/Age, y 1
F/68
2* 3
Diagnosis
Preoperative RT-CT
F/51 F/41
Recurrent vulvar melanoma + ovarian cystadenocarcinoma Major dehiscence after previous procedure Vaginal epidermoid carcinoma Rectum epidermoid carcinoma
RT
RT CT + RT
4 5
F/64 M/24
Recurrent anal epidermoid carcinoma Fournier gangrene
CT + RT V
6 7* 8 9*
M/67 F/42 F/71 F/39
Fournier gangrene Anal epidermoid carcinoma Anal epidermoid carcinoma Anal epidermoid carcinoma
V RT CT + RT CT + RT
10 11
M/50 F/72
Anal epidermoid carcinoma Anal epidermoid carcinoma
CT + RT RT
12
M/61
13 14 15 16 17 18
F/70 M/43 M/65 F/64 M/77 F/81
Recurrent anal epidermoid carcinoma + Fournier gangrene Vulvar epidermoid carcinoma Fournier gangrene Rectum adenocarcinoma + perianal fistula Recurrent anal epidermoid carcinoma Rectum adenocarcinoma Rectum adenocarcinoma
19
F/68
20 21
RT RT V RT CT + RT RT RT
M/48 F/56
Recurrent rectum adenocarcinoma with rectovaginal; persistent perineal fistula Fournier gangrene with uretroscrotal necrosis Recurrent vulvar melanoma
RT V CT
22
77/F
Rectum adenocarcinoma
RT
23
37/F
Bladder epidermoid carcinoma
V
Demolitive/Oncologic Procedure
Defect Size, cm2
APR + cystectomy + vulvectomy (A + P)
128 (16 8)
Vulvectomy + lymphadenectomy (P + I) APR + hysterectomy + annexectomy+ cystectomy + (A + P) APR + posterior colpectomy (A + P) Perineal and scrotal defect after debridement (P + S) perineal and scrotal defect after debridement (P + S) APR (A + P) APR + hysterectomy + colpectomy (A + P) APR + hysterectomy + annexectomy + posterior colpectomy (A + P) Pelvic exenteration (A + P) APR + posterior colpectomy (A + P)
345 (23 15) 192 (16 12)
APR + ureterectomy (A + P)
160 (10 16)
Vulvectomy (P) Scrotal and perianal debridement (S + P) APR (A + P) APR + posterior colpectomy (A + P) Perineal debridement (P) APR + hysterectomy + annexectomy + posterior colpectomy (A + P) Perineal debridement and excision of perineal fistula (P) Perineal debridement and ureterectomy (P) Perineal debridement, external vulvectomy (P + I) Previous APR with chronic dehiscence (A + P) Subtotal cystectomy and inferior abdominal wall resection (A)
176 (15 diameter) 140 (14 10) 180 (18 10) 240 (16 15) 112 (14 8) 153 (7 diameter)
136 (17 8) 192 (24 8) 113 (6 diameter) 165 (15 11) 160 (16 10) 285 (19 15) 396 (22 18) 270 (18 15)
162 (18 9) 130 (13 10) 120 (12 10) 190 (19 10) 300 (10 30)
*Data for patients 2, 7, and 9 are presented for general information. However, the data have been removed from statistical analysis if follow-up was not completed. A indicates abdominal wall; APR, abdominoperineal resection; CT, chemotherapy; FL, fascia lata; I, inguinal; P, perineum; S, scrotum.
perforators passing through the VL muscle were identified and carefully preserved during muscle harvesting (Fig. 5). In 5 (20%) cases, we included the fascia latae in the harvesting of the f lap to reconstruct the urethra by tubulization (patients 12 and 20), posterior vagina wall (patient 9), and posterior and inferior abdominal wall (patients 22 and 23, respectively). The lateral femoral cutaneous nerve was preserved in 4 (16%) flaps. Sensory evaluation was qualitative (touch and protection sensibility) and successful in all cases. However, quantitative analysis was not performed.
Donor Sites and Aesthetic Outcomes Donor site was generally closed primarily after harvesting. In 2 (8%) cases of 25 raised flaps, STSG was used to complete the partial closure. All donor sites healed uneventfully with no functional impairment of the limb and normal walking abilities. From the aesthetic point of view, no patients complained of relative skin color mismatch. In 1 case (patient 21), we performed a flap defatting due to excessive 68
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bulkiness at the same time of the secondary closure for peripheral flap dehiscence.
DISCUSSION In this study, we present a consecutive series of 25 extended ALT pedicled f laps raised with VL muscle to cover complex and deep perineal defects in 23 patients. We observed 1 case of flap necrosis: this occurred after an initial venous congestion at postoperative day 1. Flap revising seemed to be ineffective and a new ALT flap from the contralateral thigh had to be performed 2 weeks after the initial operation. This patient indeed presented many risk factors to the procedure. He was a heavy smoker (100 pack/y, cigarette consumption) and had undergone RT and CT due to anal carcinoma, which was complicated by a rectal-bladder fistula eventually leading to Fournier gangrene. Two other cases (patients 3 and 11) needed a complementary reconstructive procedure with gracilis pedicled muscle flaps because of persistent * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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Reconstructive Procedure
Operative Time, min
Combined ALT+VL Flap as Filler for Complex Defects
Outcome
Donor Site
Time to Hospital Healing, d Stay, d
ALT myocutaneous flap + VL
190
Peripheral dehiscence, direct closure after debridement Primary closure
30
42
ALT myocutaneous flap + VL ALT myocutaneous flap + VL
180 240
Primary closure + STSG Primary closure
90 21
119 24
ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL + FL Double ALT myocutaneous flap + VL ALT myocutaneous flap + VL
180 190 190 170 330 190
Peripheral dehiscence, direct closure after debridement Remaining defect covered by double gracilis muscular flap Favorable Peripheral dehiscence, direct closure after debridement
Primary closure Primary closure Primary closure Favorable Primary closure Peripheral dehiscence, direct closure after debridement Primary closure Peripheral dehiscence, direct closure after debridement Partial closure + STSG
20 25 14 21 30 30
29 30 21 36 50 65
230
Venous sufferance of one of the flaps, revision + STSG for peripheral necrosis Major dehiscence requiring second reconstructive procedure by gracilis myocutaneous flap
Partial closure + STSG
42
80
Primary closure
26
67
Primary closure
38
61
Primary Primary Primary Primary Primary Primary
closure closure closure closure closure closure
14 21 14 14 14 13
29 36 19 18 21 15
240
ALT myocutaneous flap + VL + FL
255
ALT myocutaneous flap + VL ALT myocutaneous flap + VL + STSG ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL
150 212 158 180 192 150
Flap necrosis requiring second reconstructive procedure by contralateral ALT myocutaneous flap + TFL + VL Favorable Favorable Favorable Peripheral dehiscence, long-term conservative treatment Favorable Favorable
ALT myocutaneous flap + VL
210
Favorable
Primary closure
14
48
ALT myocutaneous flap + VL + FL ALT fasciocutaneous flap + VL
273 200
Favorable Peripheral dehiscence covered by local pudendal flap
Primary closure Primary closure
12 30
13 38
ALT myocutaneous flap + VL + FL
96
Peripheral dehiscence covered by local pudendal flap
Primary closure
40
43
ALT myocutaneous flap + VL+ FL
120
Favorable
Primary closure
12
14
intrapelvic dead space (developed at 4 and 2 months postoperatively). Finally, a venous congestion occurred in 1 case (patient 10) at postoperative day 4 due to excessive tension on the vascular pedicle. Flap revision and superficial necrosis debridement and STSG allowed f lap recovery. As previously mentioned, we registered 6 (30%) cases of minor wound dehiscence of the 20 patients who completed follow-up, accounting for a total complications rate of 50%, which compares similarly to previous published reports on perineal reconstruction, with complication rates ranging from 10% to 57%.16 However, previous series on perineal reconstruction often included limited number of patients,8 different type of reconstructions,11 and smaller or just infectionrelated defects.16 Our study included only important defects (surface 9 100 cm2) and coverage by ALT + VL muscle and eventually fascia lata when abdominal wall, posterior vaginal wall, or urethra had to be reconstructed after pelvic exenteration. In our series, the size of wound defect was related to the risk of complications, with defects greater than 180 cm2 accounting for 75% of total major complications and 50% of * 2014 Wolters Kluwer Health, Inc. All rights reserved.
total minor complications. As predicted, the size of the defect was also related in a direct way to the time of hospital stay (as this last is generally lengthened with complications). All major complications and 66% of minor complications occurred on an irradiated tissue field, suggesting the negative effect of preoperative irradiation.17 Similar to previous reports, the effect of RT alone did not reach statistical significance also with respect to the small sample size of patients who did not receive RT.11 However, when combining together the effects of defect sizes and RT on surgical outcomes, we could show a strong correlation on time to complete healing and a significant influence on time of hospital stay. Even if muscle parts of the VL were taken in the myocutaneous f lap transfer, the functional impairment of the thigh was minimal. This minimal functional impairment goes in line with the literature.18 Complex perineal defects after radical resection often result in large wounds requiring stable and durable soft tissue reconstructions. Despite advances in reconstructive surgery, the repair of large pelvic and genitoperineal wound defects remains a challenging task. Providing www.annalsplasticsurgery.com
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FIGURE 1. The ALT-VL f lap can be harvested with different amounts of the VL muscle adjusting the volume according to the perineal defect (AYD).
FIGURE 2. A 51-year-old female patient with a local aggressive squamous cell cancer of the vagina/vulva. The combined ALT f lap with VL muscle was harvested based on a single perforator and adjusted to the small sized defect (A). The solid line shows the outline of the f lap (B). Defect of perineum after resection of the tumor with the patient in the lithotomy position (C). Postoperative view after defect closure (D). 70
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Combined ALT+VL Flap as Filler for Complex Defects
FIGURE 3. Intraoperative view (A) after wide tumor resection of a 50-year-old male patient with a local progressive squamous cell cancer of the anorectum. Split-thickness skin graft was necessary for donor-site closure (B). A bilateral ALT f lap with VL muscle was isolated for the coverage of this massive defect (C). Postoperative view after defect closure (D).
stable soft tissue coverage and vascularized muscle is indicated in body areas where RT is required or is prone to infections and contamination.19 Muscle flaps such as the rectus abdominis flap, pedicled gracilis myocutaneous f lap, gluteus maximus flap, and inferior gluteal f lap have been reported to repair defects of perineum.20Y22 However, they present a limited range of orientation with the vascular pedicle and may have a significant donor-site morbidity.10,23 Although many reports described the use of free ALT in head and neck region as well as for upper and lower extremity,24Y27 only a few studies exist in the scientific literature about the use of an extended ALT flap for complex regional and perineal reconstruction. In our experience, the composite ALT-VL flap resulted particularly useful in pelvic and inferior abdominal wall defects because it offers different tissues for resurfacing deep and large size defects. Moreover, the fascia of the tensor fasciae latae can be incorporated within the composite flap and has been used in reconstruction of large abdominal wall hernia defects.8 This flap is particularly adapted in the important defects cited in this study, when patients present not
only a deep cavity but also a large superficial area with need of external coverage. Here, The ALT-VL f lap can be used as filler (muscle part) and ideal surface cover (cutaneous palette). Moreover, indications become stronger when patients underwent laparotomies that could preclude the use of VRAM flaps. The long pedicle offers the possibility to reach deep pelvic defects, and we found the fascia lata extremely useful to reconstruct inferior and posterior abdominal wall. In a recent detailed retrospective series, thigh flaps showed higher complication rates when compared to VRAM flaps in pelvic and perineal defects.11 Our series compares favorably with the cited paper, presenting lower incidence of similarly defined major and minor complications in thigh flaps. This is probably due to the exclusive use of the composite ALT + VL flap in our study, instead of other thigh f laps used in the cited publication (as gracilis or posterior thigh). Even if caution is applied in comparing with a different study, we believe that composite ALT + VL f laps are not inferior to VRAM flaps even in challenging perineal-pelvic defects, considering also the longer pedicle
TABLE 2. Postoperative Complications
FIGURE 4. Frequency distribution of the defect size. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Defect 9 180 cm2 Defect e 180 cm2 RT No RT Oncological Infectious
Absolute Number (% of Total Population)
No. Major
No. Minor
Total No. Complications
7 (35) 13 (65) 14 (70) 6 (30) 16 (80) 4 (20)
3 1 4 V 4 V
3 3 4 2 5 1
6 4 8 2 9 1
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FIGURE 5. The VL muscle can be included as either a fixed muscle plomb or mobile perforator feeded muscle plomb (A and B). The f lap can be further subclassified as a 2-perforator or 1-perforator f lap (C and D).
and the larger skin paddle. In our series, enough tissue volume could be transferred in the pelvis without hernias or bulges at follow-up. Limitations of this study must be acknowledged and include its retrospective and uncontrolled design. Moreover, the 25 presented cases are distributed during the long period. However, inclusion criteria were selected to target on composite ALT reconstructions only and extensive defects (9100 cm2), reducing the overall number. We associated a fasciocutaneous flap (ALT) with variable muscle portion (VL), according to surface area and filler volume needed. Flap design was adapted to extensive defects requiring partial, full muscle portions, or double ALT f laps. Further refinement can be done with either a fixed or mobile perforator-feeded muscle part. We believe that indications of tailoring of this composite flap may be useful for the reconstructive surgeon when dealing with complex defect and need of ideal flap coverage.
CONCLUSIONS In this retrospective series, we were able to show that the combined ALT flap with part of the VL muscle is a feasible and safe option for complex pelvic and genitoperineal reconstruction. This flap is adjustable; provides a large cutaneous island with a reliable blood supply and adequate muscle portion for deep perineal defects; and provides durable soft tissue coverage making adjuvant RT feasible. It even can be considered for immediate reconstruction of soft tissue defects in its neighboring area and can be transferred as a sensate flap. In addition, donor-site morbidity is minimal. ACKNOWLEDGMENT The authors thank Dr Federico Turatti for the useful advices in data analysis and presentation, Carol De Simio for the graphic illustrations, and Mrs Sandrine Kung for the help in patients’ database managing.
2. Koshima I, Fukuda H, Utunomiya R, et al. The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg. 1989;42:260Y262. 3. Zhou G, Qiao Q, Chen GY, et al. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg. 1991;44:91Y96. 4. Jin X, Teng L, Xu J, et al. Anterolateral thigh adipofascial flap for the restoration of facial contour deformities. Microsurgery. 2010;30:368Y375. 5. Lai CL, Ou KW, Chiu WK, et al. Reconstruction of the complete loss of upper and lower lips with a chimeric anterolateral thigh flap: a case report. Microsurgery. 2012;32:60Y63. 6. Tan NC, Yeh MC, Shih HS, et al. Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation. Microsurgery. 2011;31:524Y528. 7. Tsuchiya S, Nakatsuka T, Sakuraba M. One-sided soft palatal reconstruction with an anterolateral thigh fasciocutaneous flap: report of two cases. Microsurgery. 2011;31:150Y154. 8. Ng RW, Chan JY, Mok V, et al. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg. 2008;61:158Y164. 9. Demirtas Y, Kelahmetoglu O, Cifci M, et al. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery. 2010;30:24Y31. 10. Wang X, Qiao Q, Burd A, et al. Perineum reconstruction with pedicled anterolateral thigh fasciocutaneous flap. Ann Plast Surg. 2006;56:151Y155. 11. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175Y183. 12. Posch NA, Mureau MA, Flood SJ, et al. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg. 2005;58:1095Y1103. 13. Mureau MA, Posch NA, Meeuwis CA, et al. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome. Plast Reconstr Surg. 2005;115:1077Y1086. 14. Tos P, Innocenti M, Artiaco S, et al. Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol. 2011;12:93Y99. 15. Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap: a versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg. 2010;64:458Y461.
REFERENCES
16. Chen SY, Fu JP, Chen TM, et al. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstr Aesthet Surg. 2011;64:528Y534.
1. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37:149Y159.
17. Miles WK, Chang DW, Kroll SS, et al. Reconstruction of large sacral defects following total sacrectomy. Plast Reconstr Surg. 2000;105:2387Y2394.
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Annals of Plastic Surgery
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18. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg. 2001;107:1766Y1771. 19. Momeni A, Kalash Z, Stark GB, et al. The use of the anterolateral thigh flap for microsurgical reconstruction of distal extremities after oncosurgical resection of soft-tissue sarcomas. J Plast Reconstr Aesthet Surg. 2011; 64:643Y648. 20. Burke TW, Morris M, Roh MS, et al. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol. 1995;57:221Y225. 21. Loree TR, Hempling RE, Eltabbakh GH, et al. The inferior gluteal flap in the difficult vulvar and perineal reconstruction. Gynecol Oncol. 1997; 66:429Y434. 22. Goi T, Koneri K, Katayama K, et al. Modified gluteus maximus V-Y advancement flap for reconstruction of perineal defects after resection of intrapelvic recurrent rectal cancer: report of a case. Surg Today. 2003;33:626Y629.
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Combined ALT+VL Flap as Filler for Complex Defects
23. Baumann DP, Butler CE. Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg. 2010; 126:1573Y1580. 24. Cavadas PC, Sanz-Jimenez-Rico JR. Use of the extended-pedicle vastus lateralis free flap for lower extremity reconstruction. Plast Reconstr Surg. 2005;115:1070Y1076. 25. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg. 2000;53:30Y36. 26. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg. 1997;123:1325Y1331. 27. Ozkan O, Coskunfirat OK, Ozgentas HE. The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities. Ann Plast Surg. 2004;53:455Y461.
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The Combined Pedicled Anterolateral Thigh and Vastus Lateralis Flap as Filler for Complex Perineal Defects Pietro G. di Summa, MD, PhD,* Mathias Tremp, MD,Þ Moritz Meyer zu Schwabedissen, MD,Þ Dirk J. Schaefer, MD,Þ Daniel F. Kalbermatten, MD, PhD, MPhil,Þ and Wassim Raffoul, MD* Abstract: Extensive defects of the pelvis and genitoperineal region are a reconstructive challenge. We discuss a consecutive series of 25 reconstructions with the pedicled anterolateral thigh (ALT) flap including muscle part of the vastus lateralis (VL) in 23 patients from October 1999 to September 2012. Only surface defects larger than 100 cm2 and reconstructions by composite ALT + VL were included in this retrospective analysis. Of the 23 patients, 19 underwent oncologic resection, whereas 4 cases presented Fournier gangrene. Three patients did not reach 6 months of follow-up and were excluded from further data analysis. Among the remaining 20 patients (22 reconstructions), average follow-up period was 14 months (range, 10Y18 months). Patient’s average age was 60 years. Average size of the defect was 182 cm2. Postoperative complications included 1 (4.5%) flap necrosis out of 22 raised flaps, 1 partial flap necrosis after venous congestion, and 2 cases where a complementary reconstructive procedure was performed due to remaining defect or partial flap failure. In 6 cases, peripheral wound dehiscence (27%) was treated by debridement followed by split-thickness skin graft or advancement local flaps. Defect size was significantly related to postoperative complications and increased hospital stay, especially in those patients who underwent preoperative radiotherapy. At the end of the follow-up period, a long-term and satisfactory coverage was obtained in all patients without functional deficits. This consecutive series of composite ALT + VL flap shows that, in case of extended defects, the flap provides an excellent and adjustable muscle mass, is reliable with minimal donor-site morbidity, and can even be designed as a sensate flap. Key Words: composite ALT flap, perineal reconstruction, complex defects (Ann Plast Surg 2015;75: 66Y73)
T
he anterolateral thigh (ALT) flap, first described in 1984 by Song et al,1 is a reliable flap for soft tissue reconstruction with a large skin flap based on musculocutaneous or fasciocutaneous perforators that can be safely harvested and provides tissue to fill large defects.2Y4 It has been successfully used as a free flap for defect reconstruction in the head and neck region5Y7 as well as for lower and upper extremities.8,9 The flap possesses the qualities of pliability with an excellent blood supply, minimal donor-site morbidity, and ease of suspension and fixation.4 Pedicled ALT flaps were successfully used to repair defects of the groin, internal pelvis, and genitoperineal region.8 However, for larger and deeper defects, the ALT flap alone may not be reliable enough and only few reports or short series exist in the literature
Received May 12, 2013, and accepted for publication, after revision, August 1, 2013. From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne, Lausanne; and †Department of Plastic, Reconstructive and Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland. Conflicts of interest and sources of funding: none declared. Reprints: Pietro Giovanni di Summa, MD, PhD, Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Rue du Bugnon 46, 1006 Lausanne, Switzerland. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7501-0066 DOI: 10.1097/SAP.0b013e3182a884c8
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concerning the clinical application of this flap for complex locoregional reconstruction.8,10,11 In a recent study, ALT perforator flaps combined with vastus lateralis (VL) muscle proved valuable as a musculocutaneous flap for defect closure in the head and neck area.12 In our study, the ALT flap combined with partial VL muscle has been chosen for complex perineal reconstruction because of its low morbidity13 and similar tissue thickness to the lost ones (‘‘replace like with like’’).14 We reviewed our experience in the surgical management of complex perineal defects, considering only reconstructions by pedicled ALT composite flaps in defects with surface larger than 100 cm2. The influence of age, defect size, type of defect (tumoral vs infectious), and preoperative radiotherapy (RT) on surgical outcomes was analyzed and discussed.
PATIENTS AND METHODS Between October 1999 and September 2012, approximately 250 patients were admitted to the Centre Hospitalier Universitaire Vaudois and transferred to our plastic surgery unit for reconstruction of perineum defects. According to defect size and location, multiple reconstructive procedures were performed, including simple debridement associated with split-thickness skin grafts (STSG), local advancement flaps, gracilis myocutaneous flaps, vertical rectus abdominis myocutaneous (VRAM) flaps, or ALT flaps. In this study, we retrospectively reviewed only the cases where pedicled ALT flaps were raised as composite flaps to cover complex abdominal and perineal defects. Inclusion criteria were soft tissue defects with a surface of more than 100 cm2 after surgical excision (abdominoperineal amputation, pelvic exenteration, and massive perineal debridements) and the inclusion of VL muscle and/or tensor fasciae latae within the ALT flap. Retrospective investigation was conducted on medical records (operatory reports, hospital dismission letter, and outpatient clinic follow-up consultations) obtained from the hospital computerized database and patient’s medical charts. In total, 23 patients (16 women and 7 men) were included in the study (Table 1). Three patients (patients 2, 7, and 9) died prematurely (4 months postoperatively) due to cancer-related reasons and were excluded from data analysis. Among the remaining 20 patients, ages ranged from 24 to 81 years (mean, 60; median, 64.5). Postoperative complications were defined as major or minor according to previous literature.11 Major complications included partial or total flap loss, major wound dehiscence (involving more than one third of the incision length), and persistent dead space requiring a supplementary reconstructive procedure during follow-up period. Minor complications included minor dehiscence (involving less than one third of the incision length), which healed after debridement and STSG or local flap advancement or wounds that had a persistent dehiscence after 4 weeks. The average length of follow-up was 14 months (range, 10Y18 months). The study was approved by the local ethic committee.
Surgical Technique After placing in a lithotomy position, design and dissection of the fasciocutaneous flap with the VL muscle was performed as described earlier.12,15 The skin flap was defined around the marked perforators and according to the size of defect. First, a medial exploring incision Annals of Plastic Surgery
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was made down to the fascia over the rectus femoris muscle. Next, the subfascial dissection was continued laterally toward the intramuscular septum between the VL and rectus femoris muscles, identifying the septocutaneous or muscular perforators, as well as the lateral circumflex femoral vessels by Doppler probe. Then, the dissection was performed as a musculocutaneous ALT + VL flap and adjusted according to the size of defect (Fig. 1), including the tensor fasciae latae if necessary. The vascular pedicle was dissected from distal to proximal until its origin from the deep femoral vessels, preserving the motor innervation to the remaining VL muscle and the femoral cutaneous nerve within the flap. After completion of flap harvesting, the single pedicled ALT f lap with the partial VL muscle was passed under the rectus femoris muscle before being transferred to cover the perineal defect through a subcutaneous channel. If required, the vaginal and urethral cuffs were brought out through the hole to create a vaginal and urinary introitus (Fig. 2). Donor site was either closed directly or by using STSG. Extirpative surgery was carried out by colorectal surgeons, gynecologists, or urologists, whereas the flap reconstruction was performed by plastic surgeons from our unit.
Statistical Analysis Patient ages, defect sizes, operative time, time to healing, and hospital stay were statistically analyzed (GraphPad Prism 5.0; San Diego, Calif ). Linear and logistic regressions or contingency W2 test (depending whether the variables were continuous or binary) was used to detect potential relationships between independent (age, defect size, RT, and type of defect) and dependent (complications, time to healing, and hospital stay) variables (StataCorp LP, College Station, Tex). Statistical significance was considered for P values less than 0.05.
RESULTS During the study period, 25 consecutive ALT composite flaps were used to repair extensive perineal wound defects in 23 patients (16 women and 7 men) (Table 1). Two patients (1 and 19) previously underwent a reconstruction by gracilis myocutaneous f lap, which turned out to be insufficient. Of the 23 patients, 19 (83%) underwent oncologic surgery (13 for primary tumor treatment and 6 for recurrent disease). Diagnosis included anal epidermoid carcinoma in 8 patients; rectum epidermoid carcinoma in 6 patients; vulvar melanoma in 2 patients (in 1 case associated to an ovarian cystadenocarcinoma); and vulvar, vaginal, and bladder epidermoid carcinoma in 1 patient each. In 1 patient, both tumor and infection were present as he developed a necrotizing fasciitis (Fournier gangrene) secondary to an anal epidermoid carcinoma. The remaining 4 patients underwent radical perineal debridement due to Fournier gangrene only. Reconstructions included 13 mixed perineal-pelvic defects and 10 perineal defects, eventually associated to inguinal, scrotal, or vulvar defects with different amounts of dead space. In 1 case, the defect was pelvic only including the lower abdominal wall. As previously mentioned, 3 patients (patients 2, 7, and 9) died prematurely and were excluded from further data analysis. Considering these remaining 20 patients, 14 (87%) of 16 patients with tumor diagnosis underwent RT or combined RT and chemotherapy (RT + CT). One patient only underwent CT because of melanoma diagnosis (patient 22). Total RT dose ranged from 40 to 108 Gy [65 (22) Gy; average (SD)]. Wound defects ranged from 112 to 396 cm2 [182 (71) cm2; average (SD), median 161 cm2]. Operative time ranged from 96 to 330 minutes [199 (54) minutes; average (SD)]. Only 1 (5%) of 20 patients (patient 3) had to be readmitted to hospital for surgical-related complications. Average time to complete healing (considering the total healing time, if the patient had to undergo a supplementary surgical procedure during the same hospital stay) ranged from 12 to 42 days [22 (10) days; average (SD)]. Finally, * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Combined ALT+VL Flap as Filler for Complex Defects
hospital stay varied from a minimum of 13 to a maximum of 80 days [35 (19) days; average (SD)].
Complications Twenty-two ALT + VL flaps were performed on the 20 patients included in the final data analysis (Table 1); 1 patient required an immediate double pedicled ALT procedure (Fig. 3) and in another patient the contralateral ALT flap needed to be harvested due to necrosis of the previous flap. This was the only flap necrosis encountered in our series [1 (4.5%) of a total of 22 raised flaps]. Among other major complications, 2 other patients needed a complementary reconstructive procedure due to remaining defect or partial flap failure (gracilis myocutaneous f lap was used in both cases). One patient presented a venous congestion due to pedicle kinking, which had to be revised. The peripheral necrosis was excised and covered by STSG. Other minor complications included 6 (30%) cases of minor peripheral flap dehiscence, which were treated by debridement followed by STSG or advancement local f laps, except in 1 case where the patient preferred a long-term conservative treatment. The remaining ALT composite flaps (50%) healed uneventfully or presented minimal local dehiscence, which healed spontaneously or after conservative treatment before stitches removal (3 weeks postoperative). Postoperative complications were analyzed according to age, defect size, RT, and original cause of the defect. The frequency distribution of the defect size has been represented, (Fig. 4). Both the average and the median value of the defect size (182 and 161 cm2, respectively) are contained in the first class (112 to 185 cm2). When considering defect surfaces’ frequency distribution, we could make a distinction among defects greater than 180 cm2 and less than or equal to 180 cm2 (this threshold corresponding to the approximated average defect size) when studying the complications (Table 2). The subgroup where the defect was greater than 180 cm2 represented 35% of our study population (7 of 20 patients). In this group, 3 patients developed major complications and 3 developed minor complications (a total of 85% rate of complications), whereas just 4 (30%) of 13 patients developed postoperative complications when the defect was less than or equal to 180 cm2. A W2 test showed a significant influence of defect size on postoperative complications (P = 0.019). Of the 14 patients who received preoperative RT or combined RT and CT (representing 70% of included patients), 4 developed major complications and 4 minor complications (total complications, 57%). In the subgroup which did not receive RT, just 2 (33%) of 6 patients developed complications. A W2 test could not detect a statistically significant difference among these groups (P = 0.329) (Table 2). Linear and logistic regressions were performed among variables: age and type of disease (oncological vs infectious) did not seem to affect significantly surgical outcomes (complications, time to complete healing, or time of hospital stay). The defect size alone was not correlated with the complete time to healing (P = 0.21), but was almost significantly correlated with the hospital stay (P = 0.05). In the same way, RT alone did not seem to inf luence significantly time to complete healing (P = 0.36) or time of hospital stay (P = 0.14). However, when combined together in a linear regression the two variables (defects sizes and preoperative RT), the cumulative inf luence on both time to healing and hospital stay became strongly significant (P = 0.087 for time to healing and P = 0.007 for hospital stay).
Flap Design All 26 ALT were prepared as composite flaps with different amount of VL muscle, according to the defects. In each patient, the muscular part was adjusted to the size of defect. The flap could be tailored to the defect including partial or full muscle mass (Fig. 1). If the defect could not be covered by a single ALT-VL flap, a double flap muscle mass was used (Fig. 3). Septocutaneous perforators were present in 4 (16%) of 25 flaps. In the remaining 22 flaps, musculocutaneous www.annalsplasticsurgery.com
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TABLE 1. Patient’s Age, Preoperative Treatment, Demolitive Procedure, Defect Location and Size, Reconstructive Procedure, Flap Type, and Outcomes (Eventual Complications, Time to Healing, and Total Hospital Stay) Patient Sex/Age, y 1
F/68
2* 3
Diagnosis
Preoperative RT-CT
F/51 F/41
Recurrent vulvar melanoma + ovarian cystadenocarcinoma Major dehiscence after previous procedure Vaginal epidermoid carcinoma Rectum epidermoid carcinoma
RT
RT CT + RT
4 5
F/64 M/24
Recurrent anal epidermoid carcinoma Fournier gangrene
CT + RT V
6 7* 8 9*
M/67 F/42 F/71 F/39
Fournier gangrene Anal epidermoid carcinoma Anal epidermoid carcinoma Anal epidermoid carcinoma
V RT CT + RT CT + RT
10 11
M/50 F/72
Anal epidermoid carcinoma Anal epidermoid carcinoma
CT + RT RT
12
M/61
13 14 15 16 17 18
F/70 M/43 M/65 F/64 M/77 F/81
Recurrent anal epidermoid carcinoma + Fournier gangrene Vulvar epidermoid carcinoma Fournier gangrene Rectum adenocarcinoma + perianal fistula Recurrent anal epidermoid carcinoma Rectum adenocarcinoma Rectum adenocarcinoma
19
F/68
20 21
RT RT V RT CT + RT RT RT
M/48 F/56
Recurrent rectum adenocarcinoma with rectovaginal; persistent perineal fistula Fournier gangrene with uretroscrotal necrosis Recurrent vulvar melanoma
RT V CT
22
77/F
Rectum adenocarcinoma
RT
23
37/F
Bladder epidermoid carcinoma
V
Demolitive/Oncologic Procedure
Defect Size, cm2
APR + cystectomy + vulvectomy (A + P)
128 (16 8)
Vulvectomy + lymphadenectomy (P + I) APR + hysterectomy + annexectomy+ cystectomy + (A + P) APR + posterior colpectomy (A + P) Perineal and scrotal defect after debridement (P + S) perineal and scrotal defect after debridement (P + S) APR (A + P) APR + hysterectomy + colpectomy (A + P) APR + hysterectomy + annexectomy + posterior colpectomy (A + P) Pelvic exenteration (A + P) APR + posterior colpectomy (A + P)
345 (23 15) 192 (16 12)
APR + ureterectomy (A + P)
160 (10 16)
Vulvectomy (P) Scrotal and perianal debridement (S + P) APR (A + P) APR + posterior colpectomy (A + P) Perineal debridement (P) APR + hysterectomy + annexectomy + posterior colpectomy (A + P) Perineal debridement and excision of perineal fistula (P) Perineal debridement and ureterectomy (P) Perineal debridement, external vulvectomy (P + I) Previous APR with chronic dehiscence (A + P) Subtotal cystectomy and inferior abdominal wall resection (A)
176 (15 diameter) 140 (14 10) 180 (18 10) 240 (16 15) 112 (14 8) 153 (7 diameter)
136 (17 8) 192 (24 8) 113 (6 diameter) 165 (15 11) 160 (16 10) 285 (19 15) 396 (22 18) 270 (18 15)
162 (18 9) 130 (13 10) 120 (12 10) 190 (19 10) 300 (10 30)
*Data for patients 2, 7, and 9 are presented for general information. However, the data have been removed from statistical analysis if follow-up was not completed. A indicates abdominal wall; APR, abdominoperineal resection; CT, chemotherapy; FL, fascia lata; I, inguinal; P, perineum; S, scrotum.
perforators passing through the VL muscle were identified and carefully preserved during muscle harvesting (Fig. 5). In 5 (20%) cases, we included the fascia latae in the harvesting of the f lap to reconstruct the urethra by tubulization (patients 12 and 20), posterior vagina wall (patient 9), and posterior and inferior abdominal wall (patients 22 and 23, respectively). The lateral femoral cutaneous nerve was preserved in 4 (16%) flaps. Sensory evaluation was qualitative (touch and protection sensibility) and successful in all cases. However, quantitative analysis was not performed.
Donor Sites and Aesthetic Outcomes Donor site was generally closed primarily after harvesting. In 2 (8%) cases of 25 raised flaps, STSG was used to complete the partial closure. All donor sites healed uneventfully with no functional impairment of the limb and normal walking abilities. From the aesthetic point of view, no patients complained of relative skin color mismatch. In 1 case (patient 21), we performed a flap defatting due to excessive 68
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bulkiness at the same time of the secondary closure for peripheral flap dehiscence.
DISCUSSION In this study, we present a consecutive series of 25 extended ALT pedicled f laps raised with VL muscle to cover complex and deep perineal defects in 23 patients. We observed 1 case of flap necrosis: this occurred after an initial venous congestion at postoperative day 1. Flap revising seemed to be ineffective and a new ALT flap from the contralateral thigh had to be performed 2 weeks after the initial operation. This patient indeed presented many risk factors to the procedure. He was a heavy smoker (100 pack/y, cigarette consumption) and had undergone RT and CT due to anal carcinoma, which was complicated by a rectal-bladder fistula eventually leading to Fournier gangrene. Two other cases (patients 3 and 11) needed a complementary reconstructive procedure with gracilis pedicled muscle flaps because of persistent * 2014 Wolters Kluwer Health, Inc. All rights reserved.
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Reconstructive Procedure
Operative Time, min
Combined ALT+VL Flap as Filler for Complex Defects
Outcome
Donor Site
Time to Hospital Healing, d Stay, d
ALT myocutaneous flap + VL
190
Peripheral dehiscence, direct closure after debridement Primary closure
30
42
ALT myocutaneous flap + VL ALT myocutaneous flap + VL
180 240
Primary closure + STSG Primary closure
90 21
119 24
ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL + FL Double ALT myocutaneous flap + VL ALT myocutaneous flap + VL
180 190 190 170 330 190
Peripheral dehiscence, direct closure after debridement Remaining defect covered by double gracilis muscular flap Favorable Peripheral dehiscence, direct closure after debridement
Primary closure Primary closure Primary closure Favorable Primary closure Peripheral dehiscence, direct closure after debridement Primary closure Peripheral dehiscence, direct closure after debridement Partial closure + STSG
20 25 14 21 30 30
29 30 21 36 50 65
230
Venous sufferance of one of the flaps, revision + STSG for peripheral necrosis Major dehiscence requiring second reconstructive procedure by gracilis myocutaneous flap
Partial closure + STSG
42
80
Primary closure
26
67
Primary closure
38
61
Primary Primary Primary Primary Primary Primary
closure closure closure closure closure closure
14 21 14 14 14 13
29 36 19 18 21 15
240
ALT myocutaneous flap + VL + FL
255
ALT myocutaneous flap + VL ALT myocutaneous flap + VL + STSG ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL ALT myocutaneous flap + VL
150 212 158 180 192 150
Flap necrosis requiring second reconstructive procedure by contralateral ALT myocutaneous flap + TFL + VL Favorable Favorable Favorable Peripheral dehiscence, long-term conservative treatment Favorable Favorable
ALT myocutaneous flap + VL
210
Favorable
Primary closure
14
48
ALT myocutaneous flap + VL + FL ALT fasciocutaneous flap + VL
273 200
Favorable Peripheral dehiscence covered by local pudendal flap
Primary closure Primary closure
12 30
13 38
ALT myocutaneous flap + VL + FL
96
Peripheral dehiscence covered by local pudendal flap
Primary closure
40
43
ALT myocutaneous flap + VL+ FL
120
Favorable
Primary closure
12
14
intrapelvic dead space (developed at 4 and 2 months postoperatively). Finally, a venous congestion occurred in 1 case (patient 10) at postoperative day 4 due to excessive tension on the vascular pedicle. Flap revision and superficial necrosis debridement and STSG allowed f lap recovery. As previously mentioned, we registered 6 (30%) cases of minor wound dehiscence of the 20 patients who completed follow-up, accounting for a total complications rate of 50%, which compares similarly to previous published reports on perineal reconstruction, with complication rates ranging from 10% to 57%.16 However, previous series on perineal reconstruction often included limited number of patients,8 different type of reconstructions,11 and smaller or just infectionrelated defects.16 Our study included only important defects (surface 9 100 cm2) and coverage by ALT + VL muscle and eventually fascia lata when abdominal wall, posterior vaginal wall, or urethra had to be reconstructed after pelvic exenteration. In our series, the size of wound defect was related to the risk of complications, with defects greater than 180 cm2 accounting for 75% of total major complications and 50% of * 2014 Wolters Kluwer Health, Inc. All rights reserved.
total minor complications. As predicted, the size of the defect was also related in a direct way to the time of hospital stay (as this last is generally lengthened with complications). All major complications and 66% of minor complications occurred on an irradiated tissue field, suggesting the negative effect of preoperative irradiation.17 Similar to previous reports, the effect of RT alone did not reach statistical significance also with respect to the small sample size of patients who did not receive RT.11 However, when combining together the effects of defect sizes and RT on surgical outcomes, we could show a strong correlation on time to complete healing and a significant influence on time of hospital stay. Even if muscle parts of the VL were taken in the myocutaneous f lap transfer, the functional impairment of the thigh was minimal. This minimal functional impairment goes in line with the literature.18 Complex perineal defects after radical resection often result in large wounds requiring stable and durable soft tissue reconstructions. Despite advances in reconstructive surgery, the repair of large pelvic and genitoperineal wound defects remains a challenging task. Providing www.annalsplasticsurgery.com
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FIGURE 1. The ALT-VL f lap can be harvested with different amounts of the VL muscle adjusting the volume according to the perineal defect (AYD).
FIGURE 2. A 51-year-old female patient with a local aggressive squamous cell cancer of the vagina/vulva. The combined ALT f lap with VL muscle was harvested based on a single perforator and adjusted to the small sized defect (A). The solid line shows the outline of the f lap (B). Defect of perineum after resection of the tumor with the patient in the lithotomy position (C). Postoperative view after defect closure (D). 70
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Combined ALT+VL Flap as Filler for Complex Defects
FIGURE 3. Intraoperative view (A) after wide tumor resection of a 50-year-old male patient with a local progressive squamous cell cancer of the anorectum. Split-thickness skin graft was necessary for donor-site closure (B). A bilateral ALT f lap with VL muscle was isolated for the coverage of this massive defect (C). Postoperative view after defect closure (D).
stable soft tissue coverage and vascularized muscle is indicated in body areas where RT is required or is prone to infections and contamination.19 Muscle flaps such as the rectus abdominis flap, pedicled gracilis myocutaneous f lap, gluteus maximus flap, and inferior gluteal f lap have been reported to repair defects of perineum.20Y22 However, they present a limited range of orientation with the vascular pedicle and may have a significant donor-site morbidity.10,23 Although many reports described the use of free ALT in head and neck region as well as for upper and lower extremity,24Y27 only a few studies exist in the scientific literature about the use of an extended ALT flap for complex regional and perineal reconstruction. In our experience, the composite ALT-VL flap resulted particularly useful in pelvic and inferior abdominal wall defects because it offers different tissues for resurfacing deep and large size defects. Moreover, the fascia of the tensor fasciae latae can be incorporated within the composite flap and has been used in reconstruction of large abdominal wall hernia defects.8 This flap is particularly adapted in the important defects cited in this study, when patients present not
only a deep cavity but also a large superficial area with need of external coverage. Here, The ALT-VL f lap can be used as filler (muscle part) and ideal surface cover (cutaneous palette). Moreover, indications become stronger when patients underwent laparotomies that could preclude the use of VRAM flaps. The long pedicle offers the possibility to reach deep pelvic defects, and we found the fascia lata extremely useful to reconstruct inferior and posterior abdominal wall. In a recent detailed retrospective series, thigh flaps showed higher complication rates when compared to VRAM flaps in pelvic and perineal defects.11 Our series compares favorably with the cited paper, presenting lower incidence of similarly defined major and minor complications in thigh flaps. This is probably due to the exclusive use of the composite ALT + VL flap in our study, instead of other thigh f laps used in the cited publication (as gracilis or posterior thigh). Even if caution is applied in comparing with a different study, we believe that composite ALT + VL f laps are not inferior to VRAM flaps even in challenging perineal-pelvic defects, considering also the longer pedicle
TABLE 2. Postoperative Complications
FIGURE 4. Frequency distribution of the defect size. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
Defect 9 180 cm2 Defect e 180 cm2 RT No RT Oncological Infectious
Absolute Number (% of Total Population)
No. Major
No. Minor
Total No. Complications
7 (35) 13 (65) 14 (70) 6 (30) 16 (80) 4 (20)
3 1 4 V 4 V
3 3 4 2 5 1
6 4 8 2 9 1
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Annals of Plastic Surgery
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FIGURE 5. The VL muscle can be included as either a fixed muscle plomb or mobile perforator feeded muscle plomb (A and B). The f lap can be further subclassified as a 2-perforator or 1-perforator f lap (C and D).
and the larger skin paddle. In our series, enough tissue volume could be transferred in the pelvis without hernias or bulges at follow-up. Limitations of this study must be acknowledged and include its retrospective and uncontrolled design. Moreover, the 25 presented cases are distributed during the long period. However, inclusion criteria were selected to target on composite ALT reconstructions only and extensive defects (9100 cm2), reducing the overall number. We associated a fasciocutaneous flap (ALT) with variable muscle portion (VL), according to surface area and filler volume needed. Flap design was adapted to extensive defects requiring partial, full muscle portions, or double ALT f laps. Further refinement can be done with either a fixed or mobile perforator-feeded muscle part. We believe that indications of tailoring of this composite flap may be useful for the reconstructive surgeon when dealing with complex defect and need of ideal flap coverage.
CONCLUSIONS In this retrospective series, we were able to show that the combined ALT flap with part of the VL muscle is a feasible and safe option for complex pelvic and genitoperineal reconstruction. This flap is adjustable; provides a large cutaneous island with a reliable blood supply and adequate muscle portion for deep perineal defects; and provides durable soft tissue coverage making adjuvant RT feasible. It even can be considered for immediate reconstruction of soft tissue defects in its neighboring area and can be transferred as a sensate flap. In addition, donor-site morbidity is minimal. ACKNOWLEDGMENT The authors thank Dr Federico Turatti for the useful advices in data analysis and presentation, Carol De Simio for the graphic illustrations, and Mrs Sandrine Kung for the help in patients’ database managing.
2. Koshima I, Fukuda H, Utunomiya R, et al. The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg. 1989;42:260Y262. 3. Zhou G, Qiao Q, Chen GY, et al. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg. 1991;44:91Y96. 4. Jin X, Teng L, Xu J, et al. Anterolateral thigh adipofascial flap for the restoration of facial contour deformities. Microsurgery. 2010;30:368Y375. 5. Lai CL, Ou KW, Chiu WK, et al. Reconstruction of the complete loss of upper and lower lips with a chimeric anterolateral thigh flap: a case report. Microsurgery. 2012;32:60Y63. 6. Tan NC, Yeh MC, Shih HS, et al. Single free anterolateral thigh flap for simultaneous reconstruction of composite hypopharyngeal and external neck skin defect after head and neck cancer ablation. Microsurgery. 2011;31:524Y528. 7. Tsuchiya S, Nakatsuka T, Sakuraba M. One-sided soft palatal reconstruction with an anterolateral thigh fasciocutaneous flap: report of two cases. Microsurgery. 2011;31:150Y154. 8. Ng RW, Chan JY, Mok V, et al. Clinical use of a pedicled anterolateral thigh flap. J Plast Reconstr Aesthet Surg. 2008;61:158Y164. 9. Demirtas Y, Kelahmetoglu O, Cifci M, et al. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery. 2010;30:24Y31. 10. Wang X, Qiao Q, Burd A, et al. Perineum reconstruction with pedicled anterolateral thigh fasciocutaneous flap. Ann Plast Surg. 2006;56:151Y155. 11. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175Y183. 12. Posch NA, Mureau MA, Flood SJ, et al. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg. 2005;58:1095Y1103. 13. Mureau MA, Posch NA, Meeuwis CA, et al. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome. Plast Reconstr Surg. 2005;115:1077Y1086. 14. Tos P, Innocenti M, Artiaco S, et al. Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol. 2011;12:93Y99. 15. Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap: a versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg. 2010;64:458Y461.
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Annals of Plastic Surgery
& Volume 75, Number 1, July 2015
18. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg. 2001;107:1766Y1771. 19. Momeni A, Kalash Z, Stark GB, et al. The use of the anterolateral thigh flap for microsurgical reconstruction of distal extremities after oncosurgical resection of soft-tissue sarcomas. J Plast Reconstr Aesthet Surg. 2011; 64:643Y648. 20. Burke TW, Morris M, Roh MS, et al. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol. 1995;57:221Y225. 21. Loree TR, Hempling RE, Eltabbakh GH, et al. The inferior gluteal flap in the difficult vulvar and perineal reconstruction. Gynecol Oncol. 1997; 66:429Y434. 22. Goi T, Koneri K, Katayama K, et al. Modified gluteus maximus V-Y advancement flap for reconstruction of perineal defects after resection of intrapelvic recurrent rectal cancer: report of a case. Surg Today. 2003;33:626Y629.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Combined ALT+VL Flap as Filler for Complex Defects
23. Baumann DP, Butler CE. Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg. 2010; 126:1573Y1580. 24. Cavadas PC, Sanz-Jimenez-Rico JR. Use of the extended-pedicle vastus lateralis free flap for lower extremity reconstruction. Plast Reconstr Surg. 2005;115:1070Y1076. 25. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg. 2000;53:30Y36. 26. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg. 1997;123:1325Y1331. 27. Ozkan O, Coskunfirat OK, Ozgentas HE. The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities. Ann Plast Surg. 2004;53:455Y461.
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