Figure 1 A 59-year-old man with cellulitis of right leg withthe start of necrosis on anterolateral free flap site 15 monthspost surgery.

420 Correspondence and communications

recurrence and the previous pretrichial incision has beencompletely hidden by newly grown hair.

Endoscopic techniques have allowed operations to beperformed with remote scars placed in less visible loca-tions. The advantages of endoscopic techniques are hiddenscars and the opportunity for complete resection allowingminimal analgesia and decreased risk of recurrence.1,5 Thisis a distinct advantage over piece meal excision2,3 with scarplaced conspicuously over the lesion. Moreover piece mealexcision has the risk of leaving residual tumour that maylead to recurrence.

Distinct advantage with the technique described here isthat there is no need for sophisticated equipment whichincrease learning time & cost. The scar in the pretrichialregion is bevelled to allow preservation of hair follicleswhich will grow through the scar. The zig-zag patternincreases the wound length to improve exposure.

The key step is the careful elevation of the subcuta-neous plane under direct vision to preserve a uniformthickness of the subcutaneous tissue. This minimises thedamage to the overlying skin which is associated with postinflammatory hyperpigmentation and contour irregularity.In the initial post-op period, there is some redundancy ofthe soft tissue on the lipoma which spontaneously contractsin 2e3 months. Hence there is no actual skin excess. Theplacement of the incision more anteriorly in the hairlinerather than more posterior in the hair bearing scalp as usedin endoscopic brow access discounts the technical difficultyof passing the instruments over the frontal bone curvature,providing a more vertical and easier access to the foreheadlipoma.

The technique described enables the complete removalof forehead lipomas with good aesthetic outcome withoutthe need for demanding endoscopic techniques (Figure 2).This method can be used as an alternative technique toreduce the cost of expensive instruments as well as oper-ative time.

Conflict of interest

None.

Funding

None.

References

1. Lin SD, Lee SS, Chang KP, et al. Endoscopic excision of benigntumors in the forehead and brow.Ann Plast Surg 2001 Jan;46:1e4.

2. Gupta S, Pandhi R, Kumar B . ‘Pot-lid’ technique for aestheticremoval of small lipoma on the face. Int J Dermatology 2001;40:420e4.

3. Chandwarkar RY, Rodriguez P, Roussalis J, et al. Minimal-scarsegmental extraction of lipomas: study of 122 consecutiveprocedures. Dermatol Surg 2005;31:59e64.

4. Funayama E, Minakawa H, Oyama A. Forehead lipoma resectionvia a small remote incision using a surgical raspatory. J Am AcadDermatol 2007 Mar;56:458e9.

5. Meningaud JP, Pitak-Arnnop P, Rigolet A, et al. Endoscopicexcision of forehead lipomas. Int J Oral Maxillofac Surg 2006Oct;35:951e3.

Lim Kim ZhuanHnin Hnin Hlaing

Lee Shu JinDivision of Plastic,

Reconstructive and Aesthetic Surgery,Department of Surgery

National University Hospital Singapore,5 Lower Kent Ridge Road,

Singapore 119074E-mail address: surv14@nus.edu.sg

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.07.025

Delayed autologous freeanterolateral thigh flap failure

Flap reconstruction following excision of large tumours isa common plastic surgical procedure. Failure of the flapmost often happens within the seven days of surgery andmonitoring is not required beyond 3e4 days.1,2 We reporta case of a 59-year-old gentleman who had an anterolateralthigh free flap for a grade II leiomyosarcoma and radio-therapy, who had flap failure 16 months, post surgery.

A 59-year-old self employed heavy goods vehicle driverwas referred to the sarcoma service from the generalsurgeons after having a lower limb swelling biopsied at thetime of an elective hernia repair in February 2008. This was

Correspondence and communications 421

demonstrated to be a grade II leiomyosarcoma. He had nosignificant past medical history or allergies, was a smokerwith a 12 pack year history.

The patient had a wider excision of the biopsy site fromthe right leg and the skin defect was closed with a freeautologous anterolateral thigh flap three weeks after theinitial surgery.

There were no immediate post-operative complicationsand the patient was discharged from hospital on day sixpost operation.

Three months later 34 cycles of radiotherapy 50 Gy in 25fractions were given over six weeks from May to June 2008.

Regular follow ups in the sarcoma clinic and clinicalexaminations were unremarkable and surveillance CT andMRI scans showed no evidence of recurrence of themalignancy.

In June 2009, 15 months following his wider excision andALT free flap and 12 months after completing his course ofradiotherapy he presented to the department witherythema over the flap site which started after a scratchwhile gardening a week before (Figure 1). Investigationsshowed no evidence of a collection, or DVT and withIntravenous antibiotics (IV) the cellulites subsided.

Over the following twenty-seven days only the areaoccupied by the previous free tissue transfer becamenecrotic (Figure 2). Recurrent wound swabs taken over thisperiod only demonstrated mixed growth of coliforms andGram-negative bacilli. The wound was negative to MRSAand other organisms. To the best of our knowledge thepatient was complaint with treatment, he had no psychi-atric/deliberate self harm history and denied tamperingwith his wounds that would explain the occurrence of thisorganism.

Figure 2 Same patient with loss of anterolateral free flap 18months post surgery.

The wound was debrided and a negative pressure wounddressing was applied. Histology of the necrotic arearevealed no evidence of recurrent leiomyosarcoma. Twomonths post debridement and intensive IV antibiotictherapy the wound still appeared indurated and slougy. Thepatient was closely followed up in the outpaients depart-ment managed conservatively with dressings and the woundstarted to show signs of healing. Repeat wound culturesduring this period demonstrated only moderate growth ofcolioforms.

Six months after the initial debridement the defect wasskin grafted. This healed with no further complications.

This flap had an uneventful immediate post-operativecourse and survived full cycle of radiotherapy. A normallynon pathological skin breach set off a series of events withthe flap that lead to its unpredicted very late failure. Aliterature search yielded very few other reported cases ofsuch late complete flap failure. A possible theory could bethat surgery and radiation therapy results in scar tissueformation and disruption of lymphatics preventing theclearance of infectious organisms.

There are reports of heparin induced thrombocytopae-nia syndrome3 and Pyodrema gangrenosum4,5 as a cause offlap failure, however this patient neither received anyheparin and the histology showed no evidence of pyodermagrangrenosum in the biopsies.

Conflict of interest statement

We declare no conflict of interest (personal or financial) inthe publication of this paper.

References

1. Kroll SS, Schusterman MA, Reece G, et al. Timing of pediclethrombosis and flap loss after free-tissue transfer. Plast.Reconstr. Surg 1996;98:1230e3.

2. Bui DT, Cordeiro PG, Hu QY, et al. Free flap reexploration:indication, treatment, and outcomes in 1193 free flaps. PlastReconstr Surg 2007;119:2092e100.

3. Tremblay DM, Harris PG, Gagnon AR, et al. Heparin-inducedthrombocytopenia syndrome as a cause of flap failure: a reportof two cases. J Plast Reconstr Aesthet Surg 2008;61:78e83.

4. Rajapakse Y, Bunker CB, Ghattaura A, et al. Case report:pyoderma gangrenosum following deep inferior epigastricperforator free flap breast reconstruction. J Plast ReconstrAesthet Surg 2010;63:e395e6.

5. Jejurikar SS, Kuzon Jr WM, Cederna PS. Recurrence of pyodermagangrenosum within a chronic wound following microvascularfree-tissue transfer. J Reconstr Microsurg 2000;16:535e9.

W. BhatJ.D. WiperA.J. Platt

Castle Hill Hospital, Hull, HU16 5JQ, U.KE-mail address: wbhat@hotmail.com

ª 2010 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2010.06.021