Practical Plastic Surgery

Table 50.1. Local and distant flaps commonly used for abdominal wall reconstruction

Component Separation

The components separation procedure, also known as the “separation of parts,” involves the longitudinal release of the medial edge of the external oblique aponeurosis and occasionally the release of the posterior rectus fascia. This procedure is especially useful for closing large midline musculofascial defects up to 30 cm transversely. It can also be performed as a salvage procedure when defects recur or prosthetic materials become exposed or infected. It allows medial advancement of the anterior rectus fascia and the internal oblique and provides dynamic support of the abdominal wall.

After entering the abdomen, dissection along the semilunar lines if achieved via 6 cm transverse incisions located at the inferior aspect of the rib cage. These lateral incisions allow for preservation of the abdominal skin blood flow. The muscle and fascia of the external oblique are then incised 1 cm lateral to the semilunar line. This incision is extended superiorly to the costal margin and inferiorly to the inguinal ligament. This release allows for approximation of the rectus sheaths at the midline. Drains are left at each semilunar line and at the midline.

Postoperative Considerations

Complications related to abdominal wall reconstruction are manifold and depend partly on the indication. Urgent abodominal wall reconstruction using simple cutaneous flaps or absorbable mesh are associated with a high rate of ventral hernia formation. Repair of ventral hernias with permanent mesh may be complicated by mesh extrusion, infection, enterocutaneous fistula and hernia recurrence.

Pearls and Pitfalls

1.Think of abdominal wall reconstruction as the solution to two related problems: How to deal with the structural support and how to deal with the skin.

2.Preservation of skin blood flow decreases local wound complications.

3.Often, complex abdominal wounds with infected mesh and fistulae can be excised “en bloc”, allowing for the reconstruction to be performed with noninflamed tissues. In such cases, the best repair discards the most tissue.

4.Leaving the skin open to be managed with NPWT after repair of the abdominal wall is an effective management strategy in the obese patient with contaminated wounds.

Suggested Reading

1.Mathes SJ, Steinwald PM, Foster RD et al. Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg 2000; 232(4):586-96.

2.Ramirez OM, Ruas E, Dellon AL.“Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990; 86(3):519-26.

3.Rohrich RJ, Lowe JB, Hackney FL et al. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 2000; 105(1):202-16.

4.Stone HH, Fabian TC, Turkleson ML, Jurkiewicz MJ. Management of acute full-thickness losses of the abdominal wall. Ann Surg 1981; 193(5):612-8.

5.Szczerba SR, Dumanian GA. Definitive surgical treatment of infected or exposed ven-

Table 51.1. Options for vaginal reconstruction

testicles. In the interim, they may be replaced back into the neoscrotum to maintain spermatogenesis. Skin loss on the penis can be managed using a nonexpanded meshed 51 STSG, being sure to tumesce the penis prior to grafting in order to prevent constric-

tion during subsequent erection. The graft is arranged such that the mesh slits are transversely oriented. The suture lines between grafts should be made obliquely or in a zigzag pattern to prevent unidirectional scar contraction.

Defects of the Penis

The three aims of penile reconstruction are to create the ability to urinate normally, restore sexual function and achieve acceptable cosmesis. In order to meet these demands, the reconstructed phallus must have sufficient rigidity and sensation. The radial forearm free flap is a versatile flap that can be used for this purpose. The antebrachial cutaneous nerve can be anastomosed to the pudendal nerve to achieve sensation. The “cricket bat” phalloplasty employs a narrow “handle” of skin to recreate the urethra inside of the attached “blade” of skin that recreates the phallus itself. The use of a prosthesis is required to attain rigidity; this is best inserted as a second procedure, after protective sensation has developed. The free fibula osteocutaneous flap, based on the perineal artery, has the potential advantage of rigidity without a prosthesis. The lateral sural cutaneous nerve is used to achieve sensation. Urethral reconstruction is performed using skin grafts.

Reconstruction of the Pelvic Floor and Perineum

Pelvic defects may involve the pelvic floor, the perineum, or both. The choice of reconstruction depends on the relative involvement of each of these structures. Three solutions for flap reconstruction of these defects are presented in Table 51.2.

When a pelvic floor defect exists with minimal perineal soft tissue loss, the omentum or mesh can be used. The omentum brings with it excellent blood flow and immunologic properties. It can fill small cavities in the pelvis but may be too elastic to

provide durable suspension of the viscera. The rectus abdominis muscle flap or de-epithelialized posterior thigh flaps can also be used for pelvic defects in this setting.

If a large perineal defect coexists with loss of the pelvic floor, bulky flaps such as the oblique rectus abdominis myocutaneous (ORAM) flap can be used to restore the pelvic floor while filling pelvic dead space and providing a large skin island. The ORAM, based on the deep inferior epigastric artery, employs a skin flap based on periumbilical perforators that extends superolaterally to the anterior axillary line toward the tip of the ipsilateral scapula. The skin paddle can be up to 7 cm wide.

Finally, free tissue transfer using large flaps such as the anterolateral thigh flap may be necessary for extremely large defects or patients who have few local flap options because of radiation or prior surgeries. Vein grafts to the vascular pedicle are often required.

Pearls and Pitfalls

•When adjuvant radiation therapy is planned, it is important to exclude the small bowel from the pelvis in order to prevent radiation enteritis. The ORAM flap is an excellent solution as it is a large soft tissue flap that can be raised with little muscle loss.

•When an abdomino-perineal resection is planned, the right ORAM can be harvested through a paramedian incision which is then used to access the abdomen.

Suggested Reading

1.Achauer BM, Braly P, Berman ML et al. Immediate vaginal reconstruction following resection for malignancy using the gluteal thigh flap. Gynecol Oncol 1984; 19(1):79-89.

2.Black PC, Friedrich JB, Engrav LH et al. Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss. J Urol 2004; 172(3):976-9.

3.Friedman J, Dinh T, Potochny J. Reconstruction of the perineum. Semin Surg Oncol 2000; 19(3):282-93.

4.Giampapa V, Keller A, Shaw WW et al. Pelvic floor reconstruction using the rectus abdominis muscle flap. Ann Plast Surg 1984; 13(1):56-9.

5.Kusiak JF, Rosenblum NG. Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft. Plast Reconstr Surg 1996; 97(4):775-81.

6.Lee MJ, Dumanian GA. The oblique rectus abdominis musculocutaneous flap: Revisited clinical applications. Plast Reconstr Surg 2004; 114(2):367-73.

7.McCraw JB, Massey FM, Shanklin KD et al. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 1976; 58(2):176-83.

8.Semple JL, Boyd JB, Farrow GA et al. The “cricket bat” flap: A one-stage free forearm flap phalloplasty. Plast Reconstr Surg 1991; 88(3):514-9.

9.Sengezer M, Ozturk S, Deveci M et al. Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients. Plast Reconstr Surg 2004; 114(2):439-50.

10.Tobin GR, Pursell SH, Day Jr TG. Refinements in vaginal reconstruction using rectus abdominis flaps. Clin Plast Surg 1990; 17(4):705-12.

11.Vincent MP, Horton CE, Devine Jr CJ. An evaluation of skin grafts for reconstruction of the penis and scrotum. Clin Plast Surg 1988; 15(3):411-24.

Table 52.1. The Mangled Extremity Score (MESS)

Note: Amputation should be considered for any patient with a score above 7.

This increased pressure is usually due to direct local trauma or ischemia and reperfusion seen with proximal vascular occlusion. Compartment syndrome occurs in up to 10% of open tibial fractures.

There are four fascial compartments in the leg: anterior, lateral, superficial posterior and deep posterior (Table 52.2). A high index of suspicion is the single most important factor in recognition of compartment syndrome, especially in the obtunded patient.

In awake patients, the classic “5 Ps,” pain, paresthesia, paresis, pressure and 52 pulselessness suggest the diagnosis. Pain out of proportion to the injury is probably the

most useful symptom; paresthesias and pulselessness are usually late findings. Measurement of compartment pressures is more accurate than the history and physical exam. A compartment pressure greater than 30-35 mm Hg or a pressure within 30 mm Hg of the diastolic blood pressure are indications for fasciotomy. Clinical suspicion may also warrant fasciotomy even in the setting of a normal compartment pressure.

Fasciotomy is performed using two incisions, each of which releases two compartments. The anterior and lateral compartments are released using a longitudinal incision over the anterior intramuscular septum. A second incision posteromedially releases the superficial and deep posterior compartments.

Table 52.2. The compartments of the leg

Nerve Injuries

Nerve injuries in the lower extremity are often more challenging than in the upper extremity because of the force involved in lower extremity trauma and the fact that most injuries are relatively proximal. When a complete motor and sensory deficit exists, there is likely to be complete transection or severe traction injury. Partial neurologic deficits related to penetrating trauma suggest partial transection. Progressive neurologic dysfunction, meanwhile, may indicate the presence of compartment syndrome, ischemia, or an expanding hematoma. Exploration should be considered in any of these cases. Partial deficits related to blunt trauma may improve spontaneously and may warrant a delay in exploration. Immediate repair should be performed when a sharp transection of the nerve is found without major contamination or nearby soft tissue injury. Traction and crush injuries may benefit from the use of vascularized nerve grafts.

Reconstructive Options

The operative approach to the traumatized extremity should proceed in the following order:

•Examination (often under anesthesia)

•Debridement

•Fracture fixation

•Vascular repair

•Tendon repair

•Nerve repair

Hip and Proximal Femur

The thigh can typically be reconstructed using local or pedicle flaps. Common workhorses for thigh reconstruction include the vastus lateralis and gracilis. Fasciocutaneous flaps in the region include tensor fascia lata, medial thigh, rectus femoris and lateral posterior thigh. Finally, the inferior-based rectus abdominis with our without a skin paddle can reach the thigh.

Knee

The medial or lateral gastrocnemius flap is useful for coverage of ipsilateral and inferior defects around the knee. Other pedicle flap options include the distally-based vastus lateralis or vastus medialis. A wide variety of fasciocutaneous flaps, including the saphenous, sural, V-Y retroposition, posterior thigh and lateral genicular flap may be used for small defects. In some cases, free-tissue transfer may be warranted.

Proximal Tibia

The medial or lateral gastrocnemius flaps are most commonly used to reconstruct soft tissues about the proximal tibia. Alternatively, the saphenous or lateral/ medial fasciocutaneous flaps may be used alone or in combination with the gastrocnemius muscle flap.

Middle Tibia

Free flaps are commonly necessary to cover defects of the middle tibia. The soleus muscle flap can be used to cover a variety of wounds in the middle tibia. Smaller