Combined latissimus dorsi and gluteal artery flap 529

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

4. Cady B, Brooke-Cowden GL. Repair of massive abdominal wall defects: combined use of pneumoperitoneum and Marlex mesh. Surg Clin North Am 1976; 56: 559-70.

5. Caldironi MW, Romano M, Bozza F, et al. Progressive pneu~ moperitoneum in the management of giant incisional hernias: a study of 41 patients. Br J Surg 1990; 77: 306-7.

6. Kyle SM, Lovie M J, Dowle CS. Massive inguinal hernia. Br J Hosp Med 1990; 43: 383-4.

7. Forrest J. Repair of massive inguinal hernia: with pneumoperi- toneum and without using prosthetic mesh. Arch Surg 1979; 114: 1087-8.

8. Udwadia TE. Stomach strangulated in inguinal hernia presenting with hematemesis. Int Surg 1984; 69: 177-9.

9. Weitzenfeld MB, Brown BT, Morillo G, Block NL. Scrotal kidney and ureter: an unusual hernia. J Urol 1980; 123: 437-8.

10. Serpell JW, Polglase AL, Anstee EJ. Giant inguinal hernia. Aust N ZJ Surg 1988; 58: 831-4.

11. Merrett ND, Waterworth MW, Green ME Repair of giant inguino- scrotal inguinal hernia using marlex mesh and scrotal skin flaps. Aust N Z J Surg 1994; 64: 380-3.

12. Read RC. Bilaterality and the prosthetic repair of large recurrent inguinal hernias. Am J Surg 1979; 138: 788-93.

13. Wantz GE, Ascher E. Prosthetic incisional hernioplasty: indica- tions and results. In: Schumpelick V, Kingsnorth AN, eds. Incisional Hernia. Berlin, London: Springer, 1999:303-11.

14. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fascia lata musculocutaneous flap. Ann Plast Surg 1978; 1: 372-9.

15. Nahai F, Hill HL, Hester TR. Experiences with the tensor fascia lata flap. Plast Reconstr Surg 1979; 63: 788-99.

16. Williams JK, Carlson GW, deChalain T, Howell R, Coleman JJ. Role of tensor fasciae latae in abdominal wall reconstruction. Hast Reconstr Surg 1998; 101: 713-18.

17. O'Hare PM, Leonard AG, Brennen MD. Experience with the ten- sor fasciae latae free flap. Br J Plast Surg 1983; 36: 98-104.

18. Wangensteen OH. Repair of recurrent and difficult hernias and other large defects of the abdominal wall employing the iliotib- ial tract of fascia lata as a pedicled flap. Surg Gynecol Obstet 1934; 59: 766-80.

19. Disa JJ, Goldberg NH, Carlton JM, Robertson BC, Slezak S. Restoring abdominal wall integrity in contaminated tissue-defi- cient wounds using autologous fascia grafts. Hast Reconstr Surg 1998; 101: 979-86.

20. Depuydt K, Boeckx W, D'Hoore A. The pedicled tensor fasciae latae flap as a salvage procedure for an infected abdominal mesh. Plast Reconstr Surg 1998; 102: 187-90.

21. Safak T, Klebuc MJA, Ke~ik A, Shenaq SM. The subcutaneous pedi- cle tensor fascia lata flap. Plast Reconstr Surg 1996; 97: 765-74.

The Authors

Felicity V. Mehendale MS (Gen Surg, Bombay) FRCS(Plast), Cleft Fellow St Andrew's Centre for Plastic Surgery, Broomfleld Hospital, Essex CM1 7ET and Great Ormond Street Hospital for Children, London WC1N 3JH, UK.

Previously, Specialist Registrar in Plastic Surgery, Derriford Hospital, Plymouth PL6 8DH, UK.

Karl O. Taams FCS(SA), MMed(Wits), Consultant Plastic Surgeon Andrew N. Kingsnorth, BSc(Hons), MBBS, MS, FRCS, FACS,

Professor of Surgery

Derriford Hospital, Derriford Road Plymouth PL6 8DH, UK.

Correspondence to Karl O. Taams.

Paper received 8 February 2000. Accepted 26 April 2000.

doi: 10.1054/bjps.2000.3358

Combined latissimus dorsi museuloeutaneous flap and free superior gluteal artery skin flap

K. Yano and Y. Matsuo

Department of Plastic Surgery, Kure National Hospital, Hiroshima, Japan

SUMMARY. We used a combined superior gluteal artery skin flap and latissimus dorsi musculocutaneous flap to repair a massive tissue defect of the upper limb. This combined flap has several advantages in that the length can be more than 60 cm, it can be used as an auxilliary muscle (latissimus dorsi) and it can also be used as a sensory flap. This combined flap is useful for covering massive skin defects. �9 2000 The British Association of Plastic Surgeons

Keywords: superior gluteal artery skin flap, latissimus dorsi musculocutaneous flap.

Surgical treatment of injuries to the upper extremities involves preservation of limb function where possible and reconstruction of tissue loss. We report a case of extensive necrosis of a left upper limb following a heat press injury.

It was felt impossible to preserve the hand because of massive necrosis. However, we aimed to preserve as much of the affected upper limb as possible in order to

allow future fitting of an artificial limb. This report presents our experience using a combined latissimus dorsi musculocutaneous flap and free superior gluteal artery skin flap for a massive tissue defect of the upper limb following radical resection of extensive necrotic tissue. This case report is the first description of the clinical use of a combined latissimus dorsi musculocu- taneous flap and free superior gluteal artery skin flap.

530 British Journal of Plastic Surgery

Figure 1--Heat press injury with massive necrosis of the flexor surface of the forearm and hand.

Figure 2--A combined flap of 60 cm in length and 10 cm in width at its widest point was designed from the left axilla to the buttock.

Case report

A 36-year-old man suffered a heat press injury to the left upper limb, which was caught in a heated roller for 90 min. Initial examination confirmed complete necrosis of the hand and massive necrosis of the flexor surface of the upper arm and forearm (Fig. 1). Angiography confirmed occlusion of the radial and ulnar arteries at the level of the wrist joint.

Debridement of necrotic tissue and upper limb reconstruc- tion using a combined flap was performed 2 weeks after the injury. The damage to the flexor aspect of the upper arm extended to the subcutaneous tissue and the biceps brachii muscle, which was excised to bleeding tissue. The proximal third of the radius and ulna were exposed as a result of this operation. On the extensor surface, tissue distal to the wrist was completely necrotic. Occlusion of the radial artery in the proximal forearm was noted although perfusion in the ulnar artery up to the wrist joint was satisfactory to allow the possibility of a microvascular anastomosis.

A combined flap of 60 cm in length and 10 cm width at the widest point was needed to cover the skin defect from the upper arm to the forearm and the exposed forearm bones (Fig. 2). A length of 35 cm of the proximal part of this flap was raised with the latissimus dorsi muscle as a musculocuta- neous flap and 25 cm of the distal part was raised as a free gluteal perforator-based fasciocutaneous flap and dissecting the gluteal perforator vessels the superior gluteal vessels were encountered and ligated (Fig. 3). Moreover, this flap also functions partially as a sensory flap supplied by the posterior primary rami of the upper three lumbar nerves.

The proximal part of the latissimus dorsi muscle was passed through a subcutaneous tunnel in the axilla to trans- pose the flap to the defect, and the distal part of the latis- simus dorsi muscle was fixed to the bicipital aponeurosis. The latissimus dorsi muscle assisted in elbow flexion. Exposure of the ulnar artery and vein distally allowed anastomosis to the detached superior gluteal vessels. The distal part of the flap was well vascularised following the anastomoses. The poste- rior primary rami of the upper three lumbar nerves were anastomosed to the superficial branch of the radial nerve. The full-length combined superior gluteal artery skin flap

Figure 3~Combined flap as viewed from the skin surface. The superior gluteal vessels can be seen in the distal part of the flap.

and latissimus dorsi musculocutaneous flap fitted into the defect well, running the entire length of the upper limb. The donor site was closed partly by direct suture (chest/buttock region) and by split thickness skin grafting in the lumbar region. Although the flap perfusion postoperatively was sat- isfactory, necrotic material and exudate discharged from the forearm wound 10 days following surgery. Further necrosis of both flexor and extensor muscles of the forearm originally preserved required further resection and again at 3 weeks. Subsequently the wound healed fully and the flap survived completely.

The range of motion at the elbow joint was recorded -10 to 120 ~ (extension, flexion) 2 years postoperatively (Fig. 4 A,B). A return of sensation to the flap became apparent 3 months following surgery. The mean touch-pressure thresh- old in the flap was 3.22 log10 force (1 mg) by means of Semmes-Weinstein monofilaments. The mean pain threshold in the flap was 2 g with an algesiometer, and the temperature test proved positive with a Sammi thermo-esthesiometer which was set at 60 ~ for testing hot perception and 0 ~ for

Combined latissimus dorsi and gluteal artery flap 531

Figure 5---Appearance of the donor site.

Figure 4--(A) The range of motion of elbow joint recovered to 10 degrees of extension and (B) 120 degrees of flexion, 2 years postoperatively. Figure 6~54 months following surgery with artificial limb fitted.

testing cold perception. The donor site defect can be seen in Figure 5. The patient had an artificial limb made and uses it in daily life (Fig. 6).

Discussion

Heat-press injury combines thermal and compression elements which compound each other. With an ordi- nary burn, it is preferable to perform the surgical debridement as soon as possible. However, in the case of a heat-press injury, it is difficult to determine the period and the depth of the debridement as the dam- age to the tissue progresses over time. In this case, the debridement and the reconstruction were performed 2 weeks post-injury, but after that it was still necessary to perform two further debridements. It was very difficult to accurately judge the extent of deep tissue damage. Therefore, in the case of a heat-press injury, it is difficult to use a skin graft as damage to tissues is progressive so it is desirable to cover wounds using a flap with good circulation and durable skin.

In the case of upper limb amputation, it is helpful to preserve as much length as possible to facilitate fitting an artificial limb. An extremely long flap may be needed in this situation to cover soft tissues and bone. No single flap has such a long length (60 cm), so a combined flap was used to cover the skin defect.

The long combined flaps that have been reported previously were a combination of the latissimus dorsi musculocutaneous flap and the groin flap, 1 a combina- tion of the lateral intercostal flap and the rectus abdo- minis musculocutaneous flap, 2 or a combination of the latissimus dorsi musculocutaneous flap and the rectus abdominis musculocutaneous flap?

The combined flap that we are reporting on this occasion was able to attain a total length of about 60 cm, and the circulation was so good that bleeding was observed at the centre of the flap.

The rotational arc of this combined flap extends to the entire area of the upper extremity and the entire head and neck region. The reach of this combined flap, with the pivot point at the superior gluteal vessels, extends to the lumbosacral region and the ipsilateral area of the thigh.

532 British Journal of Plastic Surgery

I f this combined flap is used for the reconstruction of the upper extremity, it is possible to reconstruct the flexor muscles of the upper a rm and to use it as an auxiliary muscle for flexing the elbow through the latissimus dorsi muscle. Furthermore, it is possible to innervate the flap if the posterior pr imary rami of the upper three lumbar nerves are anastomosed to the recipient sensory nerves.

One drawback of this flap is that the closure of the donor site at the lumbar region is difficult to suture directly and a skin graft is needed. The other drawback is that it is necessary to change the position of the patient during the operation.

References

Harii K, Iwaya T, Kawaguchi N. Combination myocutaneous flap and microvascular free flap. Plast Reconstr Surg 1981; 68: 700-10.

2. Tanaka I, Nakajima H, Kaneko T, et al. Chest wall reconstruc- tion by means of a combination of the lateral intercostal flap and the rectus abdominis myocutaneous flap. J Jpn Plast Reconstr Surg 1988; 10: 1025.

3. Gunji H, Ariga T, Ono I, et al. An electrical injury resulting in an extensive soft tissue defect of the chest wall: a case report. Jpn J Plast Reconstr Surg 1992; 35:1135-41.

The Authors

Kenji Yano MD, Director Yuld Matsuo MD, Senior Resident

Department of Plastic and Reconstructive Surgery, Kure National Hospital, 3-1 Aoyama-cho, Kure, Hiroshima, 737--0023, Japan.

Correspondence to Dr Kenji Yano.

Paper received 20 August 1999. Accepted 3 March 2000, after revision.

doi: 10.1054/bjps.2000.3359

The use of the photoplethysmograph to monitor the training of a cross-leg free flap prior to division

M. E. Jones, S. Withey, R. Grover and R J. Smith

Department of Plastic and Reconstructive Surgery, Mount Vernon Hospital, Northwood, Middlesex, UK

SUMMARY. The cross-leg free flap is an important, although rarely used, option in the reconstruction of lower limb trauma. We report the use of photoplethysmography in the assessment of such a flap's training and the time of pedicle division. �9 2000 The British Association of Plastic Surgeons

Keywords: cross-leg free flap, photoplethysmograph, neovascularisation, hyperaemia.

In certain severe cases of lower limb reconstruction requiring free tissue transfer, local vessels m a y be unavailable. This problem may only become apparent during the operation. I f the vasculature in the opposite lower limb is good and the size and the extent of the defect demands a free tissue transfer, then one option is the use of a cross-leg free flap.l6 Thus, this procedure is usually only indicated in legs with relative ischaemia. In such legs the neovascularisation of the flap may take up to 7 weeks.l,4,6 It therefore becomes important to be able to determine objectively whether or not a flap is revascularised from the local tissues. In this report we describe a reliable, reproducible method of re-training the flap and an objective assessment for the timing of pedicle division using the photoplethysmograph. 7

Case report

A 37-year-old male smoker sustained a fracture of his left talus and lower tibia following a fall. He was admitted to his local Orthopaedic Surgical Department and underwent open reduction and internal fixation of the talus and lower tibia. Further surgical debridement left a wound over the medial

malleolus and distal tibia. The surgical wound subsequently developed an area of skin necrosis, which required tissue cover (Fig. 1).

He was referred to our unit 2 weeks after the initial trauma with a swollen lower limb. At operation, 1 week after admis- sion, the posterior tibial vessels were identified and sur- rounded by perivascular oedema, the pulse in the posterior tibial artery was poor. Exposure of the anterior tibial artery revealed reduced flow due to spasm. The venae comitantes of the posterior tibial artery were thrombosed. The saphenous veins were also exposed and were in an equally poor state. These findings together with multiple venous cannulation sites in his arms precluded the use of long vein grafts, which would have been the choice for reconstruction. It was there- fore decided to perform a cross-leg free flap. The contralateral posterior tibial vessels were exposed and the flap's pedicular artery and two veins were anastomosed end to end to a radial forearm flap. In order to protect the pedicle a split skin graft was wrapped around it. At the end of the procedure an exter- nal fixator was applied to stabilise the legs (Fig. 2).

The flap was observed for 2 weeks allowing the initiation of neovascularisation and stabilisation of the skin graft covering the pedicle. At 15 days from surgery, flap 'training' in the form of pedicle clamping began. This was initially for 15 min four times a day and increased to 30 min four times daily after a further 5 days. Response to clamping was