Floor plan - 2013 Annual Meeting - American Association for Hand ...

Modified Tibial Turn-up Fillet flap for Repair of Extensive Composite Defects of the Thigh
Institution where the work was prepared: The University of Texas, M. D. Anderson Cancer, Houston, TX, USA
Yoav Barnea; Sackler Faculty of Medicine, Tel-Aviv University; Patrick Lin, MD; The University of Texas, M. D. Anderson
Cancer; Gregory Reece, MD; MD Anderson Cancer Center
INTRODUCTION:
Management of sarcomas in the proximal, posterior thigh region can be quite challenging, especially for recurrent disease and tissues compromised
by previous treatment. Conventional treatment for massive soft tissue loss is hemipelvectomy or hip disarticulation with an anterior
flap. The modified tibial turn-up fillet flap offers an alternative to high amputation and is a novel means for reconstructing the lower limb.
PATIENT & METHODS:
We present a case report of a 58-year-old male who previously underwent numerous wide excisions and flap reconstructions for multiple
recurrences of malignant fibrous histiocytoma of his left posterior upper thigh. He had received extensive radiation therapy. The current
tumor recurrence required a radical composite resection of the femur, sciatic nerve, and the soft tissues of the posterior upper thigh
and inferior gluteal area (total area, 1000 cm2). Instead of performing a hip disarticulation, the lower limb was reconstructed using a
modified tibial turn-up fillet flap. The leg and foot of the affected extremity were filleted from the popliteal fossa to the metatarsal-digital
joints and only the tibia with all the soft tissue attached was preserved. The flap was vascularized by the popliteal vessels. After trimming
the ends, the distal tibia was turned up to the hip, converting the medial malleolus to a neo-greater trochanter. The gluteal tendons
were sewn to the deltoid ligament of the medial malleolus laterally and the Achilles tendon posteriorly. The iliopsoas tendon was
reattached to the fibular periosteum anteriorly. A total hip joint prosthesis with a constrained acetabular liner was used to reconstruct
the hip. The skin of the sole of foot was inset to cover the inferior gluteal and the ischial areas. The proximal tibia became the distal end
of the stump and the leg skin covered the posterior side of the thigh.
RESULTS:
Ten months postoperatively, he had a well-healed stump with durable sensate skin covering the ischium. He could actively flex and
abduct the left hip 30 degrees but relied on gravity for hip extension. An above-knee-amputation prosthesis with microprocessor-controlled
knee joint (C-Leg, Otto Bock) provided stable ambulation.
CONCLUSION:
The modified tibial turn-up fillet flap is a novel reconstructive option for patients who require composite resection of the proximal thigh
that is too extensive for free flap coverage. The method offers distinct advantages over hip disarticulation, i.e., better cosmesis and
patient self-image and the technique provides a sensate, functional stump permitting ambulation with a prosthetic leg.
Partial Breast Reconstruction with Free Autologous Tissue Transfers
Institution where the work was prepared: University of Manitoba, Winnipeg, Canada
Edward Wayne Buchel; Thomas E.J. Hayakawa; University of Manitoba
PURPOSE:
Lumpectomy and radiation therapy is the standard of care for treatment of early stage breast cancer. Cosmetic results vary significantly
depending on the lumpectomy size, location and the development of a significant seroma pre-radiation. Cosmetic results on many of these
patients are suboptimal resulting in the patient requesting reconstruction surgery to obtain better symmetry and individual breast shape.
We present our initial experience with perforator flap reconstruction of partial breast defects post lumpectomy and radiation treatment.
METHODS:
A retrospective chart review was completed on all patients undergoing a partial breast reconstruction using autologous tissue transfers.
RESULTS:
The review of the University of Manitoba Micorsurgical Data base revealed 48??? Free perforator flap breast reconstructions. Twelve
patient underwent partial breast reconstruction. Eight even were completed using the Deep Inferior Epigastric artery Perforator flap
while the remaining four were completed using the Superficial Inferior Epigastric Artery flap. There were no flap failures. Three patients
required secondary revisions for flap debulking and one patient need revision of the nipple and areola complex.
CONCLUSIONS:
Partial breast defects are common problems facing patients post lumpectomy and radiation therapy. Typically, symmetry is obtained by
reducing the contralateral breast, tissue rearrangements of the affected breast or an combination of both. Implant reconstructions have
also been completed with varying degrees of success. Pedicled flaps form the lateral chest and back have been advocated for laterally
placed lumpectomy defects. The use of free perforator flap transfers allows the reconstructive surgeon to replace lost or scarred skin,
while filling the irradiated lumpectomy defects in any position on the chest wall. The long pedicle allows easy access to the IMA vessels
for the anastomosis and the perforator anatomy allow the flap to be thinned and shaped to fit the lumpectomy defect. Abdominal
donor morbidity is limited and cosmetics can be excellent. Our patients are now offered the option of breast volume and shape restoration
in addition to the option for only breast symmetry.
Learning Objectives:
Review the reconstructive option for partial breast reconstruction. Highlight the technique of autologous tissue transfer for partial breast
defects.
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