British Journal of Plastic Surgery (1992), 45, 3X-41 0 1992 The Trustees of British Association of Plastic Surgeons

Delayed debulking of free muscle flaps for aesthetic contouring debulking of free muscle flaps

R. P. Choydary and R. X. Murphy

The Allentown Hospital-Lehigh Valley Hospital Center, Division of Plastic Surgery, Allentown, Pennsylvania, USA

SUMMARY. Although denervated muscle and myocutaneous free flaps atrophy over a period of time, when used for surface coverage they may remain bulky, resulting in a less than optimal aesthetic result. With the availability of a number of donor sites, soft tissue defects can often be reconstructed with like tissue in a single stage. Even though the goal of all plastic surgeons is to achieve a good cosmetic result, special circumstances might dictate that need take precedence over form. We have had six cases where a bulky muscle was used to achieve well vascular&d coverage. After wound closure had been successfully accomplished, a secondary debulking procedure was performed safely for a final acceptable aesthetic result.

The advancement of microvascular free tissue trans- fers has enabled reconstructive surgeons to achieve difficult wound closure with a 95% success rate (Shaw, 1983). With the choice of over 60 available free flap donor sites, both functional and aesthetic considera- tions become important when selecting an appropriate flap for transfer. Whether tissue is required to resurface a wound, to cover a fracture site, to cure an osteomyelitis, or to reconstruct a composite defect created by extirpation of malignant disease, the importance of form as well as function should not be overlooked (Berger and Bargamann, 1989). However, there are situations where aesthetic considerations, at least temporarily, will have to be ignored as the requirements of a specific wound take precedence. In a potentially contaminated wound, for example, most reconstructive surgeons will prefer a muscle or myocutaneous flap to a fasciocutaneous flap even with the muscle flap’s inherent drawback of being bulky (Chang and Mathes, 1982; Calderon et al., 1986).

Over a period of time a denervated muscle flap will atrophy and will gradually contour better to fit a defect (Bailey and Godfrey, 1982). Unfortunately, in clinical practice there are situations where, even after a prolonged period of time, the atrophied muscle is still bulky enough to foster complaints. It is in this group of very carefully selected patients that we have employed the technique of delayed debulking in order to contour these flaps better.

Materials and methods

Between January of 1986 and December of 1988, six free muscle tissue transfers performed met the criteria for secondary debulking. These criteria were, simply, an unacceptable contour and an elapsed period of time of at least 6 months from the initial free flap surgery (Table 1). At a second procedure, any residual skin paddle and subcutaneous tissue was debrided and then

Table 1 Patient data

Recipient Patient Donor muscle site Needforfiee tissue transfer Result and debtdking

1 RW LD with skin Right ankle Osteomyelitis of talus/calcaneus Flap and graft healed well; patient paddle ambulates wearing no shoes

2 JD LD with skin Right leg Osteomyelitis Healed satisfactorily. Patient can wear tight paddle fitting clothes

3 HF LD Left ankle Soft tissue loss with exposed ankle joint Continues satisfactory ambulating with regular shoes

4 WD LD with skin Right leg Shotgun blast injury with compound Healed well paddle cornminuted facture proximal tibia with a

large soft tissue defect

5 RS LD wtih skin Left leg Grade III B fracture left tibia Healed satisfactorily paddle

6 DL LD Left foot Loss of full thickness skin with exposed Satisfactorily ambulating, participates in all tendons-and bones school gym activities

38

Delayed Debulking of Free Muscle Flaps for Aesthetic Contouring Debulking of Free Muscle Flaps 39

Fig. 1

figure I-Intraoperative view of layered debulking

the free flaps were sculpted using a Humbey knife to excise excess muscle in a direction parallel to the muscle fibres and axial vessels (Fig. 1). A split thickness skin graft was applied to complete wound closure. Representative case reports are presented.

A 26-year-old woman underwent excision of a painful cystic lesion in the talus of the right foot. The patient’s postopera-

tive course was complicated by staphylococcal osteomyelitis. Repeated bone debridements, appropriate antibiotic therapy and a local adductor hallucis muscle flap failed to control the infection. Radical bone and soft tissue debridement was performed and the wound was then resurfaced with a free latissimus dorsi muscle flap (with a cutaneous paddle for monitoring). The osteomyelitis subsequently resolved. Xow- ever, the flap remained bulky and the patient could not wear regular shoes. Debuiking was performed and the hap was skin grafted. The flap healed satisfactorily (Fig. 2). The patient now ambulates wearing shoes.

case 2

A 36-year-old man sustained a fracture sf the lower one- third of the tibia. This was treated with open reduction and internal fixation. Three months later, the patient developed osteomyelitis. The plate and screws were removed. We required hospitalisation for local wound care and intra- venous antibiotics on two occasions. Due to the persistence of osteomyelitis, soft tissues and bone were thoroughly debrided and covered with a latissimus dorsi muscle free flap. Six months later the bone healed. However, the flap remained bulky. Debulking was done and the surface of the muscle was skm grafted. The patient is ambulatory. The flap has healed satisfactorily (Fig. 3).

A 14year-old boy had his left foot caught in the wheels of an all terrain vehicle. The soft tissues of the dorsum of the foot were completely avulsed, as were some extensor tendons. Tarsal and metatarsal bones were exposed. Gravel was embedded in the soft tissue and bone. After severai thorough

Figme 2-(A) Latissimus dorsi flap to right ankle-flap remained bulky and oedematous (B) Intraoperative view after debulking just prior to skin grafting. (C, D) Well healed flap with acceptable aesthetic contouring.

40 British Journal of Plastic Surgery

Fig. 3

Figure 3-(A) Chronic open wound of the lower tibia after multiple debridements. (B) Extensive debridement of bone and soft tissues followed by latissimus dorsi free flap. Flap remains bulky. (C)Three months after layered debulking and skin grafting.

debridements, the defect was covered with a latissimus dorsi free flap and skin graft. One year later, the patient still could not wear shoes because the flap remained bulky. The flap

was debulked and skin grafted. The flap healed well and the patient is actively participating in all gym activities at school (Fig. 4).

Fig. 4

Figure 4-(A) Avulsive injury to the dorsum of the left foot; gravel deeply embedded in the wound. (B) Appearance of the wound after multiple debridement just prior to free flap coverage. (C) Latissimus dorsi free flap with skin graft remains bulky. (D) Final appearance after debulking and skin grafting.

Delayed Debulking of Free Muscle Flaps for Aesthetic Contouring Debulking of Free Muscle Flaps 41

Discussion

As our experience with free tissue transfers has increased, our sophistication with selection of donor sites has improved. For surface defects either a fasciocutaneous or fascial flap with a split thickness skin graft is used with increasing frequency. However, in a contaminated or infected wound or for the treatment of osteomyelitis, we prefer a muscle flap (Mathes et al., 1982, 1983; Weiland et al., 1984) A well vascularised free muscle transfer is also a good source of neovascularisation to facilitate healing of a fracture site.

Bailey and Godfrey (1982) pointed out that a free muscle flap is much less bulky than its free myocuta- neous equivalent and that the denervated muscle in either flap will atrophy significantly in 6-12 months. Zook et al., in their 1986 report on flap surgery in lower extremity wounds, noted that free flaps were occasionally too bulky and that up to one-third of latissimus dorsi myocutaneous free flaps would require defatting. To achieve the most acceptable aesthetic result, therefore, our logical choice for soft tissue coverage in lower extremities with Type III fractures is a free muscle flap resurfaced with a split thickness skin graft (Gustillo et al., 1987). Occasionally, as in these reported cases, the muscle remains bulky and interferes with the patient’s self-image and ability to wear tight fitting clothes and shoes.

In 1981, Bartlett et al. raised the possibility of transferring a thinned latissimus dorsi muscle. Further study of the anatomy of the thoracodorsal neurovas- cular pedicle within the latissimus muscle by Rowsell et al, (1986a) documented the feasibility of the approach. In a 1986 case report, Rowsell et al. described their experience with using a thinned latissimus dorsi, muscle flap and split thickness skin graft to resurface a forehead/scalp deficit in a 21-year- old male.

While the consistent anatomy of the axial thoraco- dorsal vascular, pedicle on the undersurface of the latissimus dorsi muscle allows the muscle to be safely and reliably sculpted by the operating surgeon at the time of free tissue transfer, we feel that this is not an appropriate course of action when dealing with the lower extremity. In reporting their experience with free flap surgery Percival et al. (1989) noted that, although it is an extremely reliable flap, the degree to which the latissimus muscle atrophies cannot be predicted when it is used for wound coverage in the lower extremity. These authors hypothesise that lymph accumulation can result in a persistently bulky flap. It is for this reason that we feel debulking of free tissue transfers should be delayed in the lower extremity. Only after allowing sufficient time for the flap to reach a stable plateau where no’ further atrophy is observed should the final aesthetic contouring be undertaken. Eayered debulking can then be reliably performed with tourniquet control and split thickness skin grafting after the tourniquet is released and haemos- tasis is achieved.

The case reports in this presentation represent a small percentage of our free muscle tissue transfers with an unaesthetic result. The latissimus dorsi flap

was utilised in these cases because of its constant anatomy, technical ease of dissection and minimal donor site morbidity. Should time and natural atrophy of the:se flaps not provide satisfactory contour, second- ary debulking, as illustrated by the cases contained in this report, can oiler a safe and predictable result.

It can be argued that there are better muscle donor sites to fit the defects in the illustrated cases. It is also possible that the flap could have been “thinned” at the time of insetting at the first operation, thus avoiding a second operation. The purpose of this presentation is to illustrate that if the flaps remain bulky they can safely be “contoured” to achieve a better aesthetic result.

References

Bailey, B. N. and Godfrey, A. M. (1982). Eatissimus dorsi muscle free flaps. British Journal of Plastic Surgery, 35,41.

IBntiett, S. P., May, J. W. and Yaremchuk, M. J. (1981). The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plastic and Reconstructive Surgery, 67,637.

Berger, A. and Bargarnanu, PI. J. (1989). Aesthetic aspects in reconstructive microsurgery. Aesthetic Plastic Surgery, 13, 115.

Calderon, W., Chang, N. and Matbes, S. J. (1986). Comparison of effects of bacterial inoculation in muscuiocutaneous and fascio- cutaneous flaps. Plastic and Reconstructive Surgery, 77,785.

Chang, N. aud Mat&, S. .I. (1982). Comparison of the effects of bacterial inoculation in musculocutaneous and random pattern daps. Plastic and Reconstructive Surgery, 7@, 1.

Gustillo, R. B., Groninger, R. ID. and Davis, T. (1987). Ciassitication of type III (severe) open fractures relative to treatment and results. Orthopedics, 10, 1781.

Matbes, S. J., Alpert, R. S. and Chaag, N. (1982). Use of muscle flaps in chronic osteomyelitis: experimental and clinical stttdy. Plastic and Reconstrmive Surgery, 69,815.

Matbes, S. J., Feng, L. J. and Hunt, T. K. (1983). Coverage of the infected wound. Annals of Plastic Surgery, 198,420.

Percival, N. J., Sykes, P. J. and Earley, M. J. (1989). Free flap surgery : the Welsh Regional Unit experience. British Joumal of Plastic Surgery, 42,435.

Rows& A. R., Eisenberg, h!., Da&s, D. M. and TayRorq G. 1. (1986a). The anatomy of the thoracodorsal artery within the latissimus dorsi muscle. British Journal ofPlastic Surgery, 39,206.

RowseM, A. R., Godfrey, A. M. and Richards, M. A. (1986b). The thinned latissimus dorsi free flap : a case report. British Journal of Plastic Surgery, 39,210.

Shaw, W. W. (1983). Microvascular free daps: the first decade. Clinics in Plastic Surgery, 10, 3.

Weiland, A. J., Moore, T. R. and Daniel, R. %. (1984). The efficacy of free tissue transfer in the treatment of osteomyelitis. Journalof Bone and:Joint Surgery (Am), 66, 181.

Zook, E. G., Russell, R. C. and Asaadi, M. (!986). A comparative study of free and pedicle flaps for lower extremity wounds. Annals of Plastic Surgery, B7,2P.

Raj P. Cbowdary, MD, FRCS (Glasg), FACS, Attending Plastic Surgeon.

Robert X. Murphy Jr, MD, Attending Plastic Surgeon.

The Allentown Hospital--Lehigh Valley IIospital Center, Allen- town, Pennsylvania, USA.

Requests for reprints to: Dr R. P. Chowdary, 1230 South Cedar Crest Boulevard, Suite 204, Allentown, PA 18103 USA.

Paper received 10 January 1991. Accepted 23 July 1991 after revision.