Vastus lateralis myocutaneous Br. J. Surg. 1990, Vol. 77, November, 12751 277

N. Waterhouse and flap for reconstruction of defects C. Healy* around the groin and pelvis Department of Plastic Surgery, St. Bartholomew‘s Hospital and the 1 ondon Hospital, Whitechapel and the *Department of Plastic Surgery, University College and Middlesex School of Medicine, 1 ondon, UK Correspondence to: Mr C. Healy, Department of Plastic Surgery, University College Hospital, G o w e r Street, London WC1 6AU. UK

We present our experience using the vastus lateralis myocutaneous f lap for the repair of defects around the groin and pelvis. It is a relatively new technique, with many advantages over other flaps used in this area, though it has limitations. The history, anatomy and surgical technique of raising the flap are described and clinical cases are discussed. The importance of patient selection is highlighted. Keywords: Pelvic and groin defects, vastus lateralis myocutaneous flap

The reconstruction of large defects around the groin and pelvis (principally pressure sores) has been greatly facilitated by the development of local myocutaneous flaps. This paper presents our experience of the relatively new vastus lateralis myocutaneous flap, the use of which has not as yet been reported in this country. The repair of trochanteric pressure sores using the vastus lateralis muscle flap was described in 1977 by Minami et a1.l. In 1982 Bovet et a/.’ described the vastus lateralis myocutaneous flap and reported favourable results in similar cases. Drimmer and Krasna’ reported its use in treating decubiti involving the greater trochanter, the ischium and the posterior thigh. The quadriceps musculocutaneous flap, incorporating the vastus lateralis muscle, was described by Larson and Liang in 19834, for the repair of hemipelvectomy defects.

Anatomy The vastus lateralis is the largest of the quadriceps group of muscles, accounting for the major portion of thigh bulk. It functions as a knee extensor and also contributes to the lateral stability of the knee joint. It arises from the posterolateral aspect of the upper femur. Anteromedially, it is adjacent to and continuous with the rectus femoris muscle. The aponeurotic deep surface of the vastus lateralis moves freely over the underlying vastus intermedius muscle. A flat tendon arises on the deep surface of the lower part of the muscle and inserts into the superolateral aspect of the patella and the lateral condyle of the tibia. Innervation is by a branch of the posterior division of the femoral nerve, and its main artery is a large descending branch of the lateral circumflex artery (Figure I). These form a neurovascular bundle which lies a hand’s breadth below the greater trochanter. Selective injection studies by Zuffrey et uL5 show the vascular cutaneous territory, supplied via fasciocutaneous branches, extending along the distal two-thirds of the thigh as far as the patella. This observation has been confirmed, in our own dissections and those of Swartz et ~ 1 . ~ .

Surgical technique The axis of the vastus lateralis myocutaneous flap is a line drawn on the skin between the anterior superior iliac spine and the upper lateral aspect of the patella (Figure 2). marking the plane of dissection between the vastus lateralis and rectus femoris muscles. The primary defect having been debrided, the islanded skin paddle is outlined, beginning inferiorly above the patella with two-thirds of the width anterior to the axis of the flap. This ensures that the skin paddle overlies the vastus lateralis muscle, leaving the fascia lata undisturbed. To allow direct closure of the donor site, the maximum flap width is about 6 cm; the length may extend to 12cm. Starting high in the thigh, the incision runs along the axis of the flap. The vastus lateralis muscle is identified and, by using blunt dissection, the plane between it and rectus femoris is mobilized. The neurovascular pedicle enters the vastus lateralis medially and runs on the undersurface of the muscle for all of its length. Having identified it at the beginning of the dissection it is protected from inadvertent division in the upper part of the thigh. The small communicating vessels between the muscles are divided as the dissection proceeds. The lateral side of the muscle can be dissected with impunity.

Using sharp dissection, working downward from the greater trochanter, the vastus lateralis is separated from it and the vastus intermedius. The surgeon’s linger may then be used to push the vastus intermedius apart from the edge of the vastus lateralis, freeing the muscle flap with its isolated skin paddle. When raised, the flap has a wide arc of rotation

Figure I A diagram shonring ihe sartorius (S) and the rectus,femnris ( R F ) muscles rui onlay to recieal rhe laieral circumfles artery branches io ihe UUSIUS Iaierolis muscle ( V I . vosius iniermedius; VL. vastus Iateroli.~; VM, UUSIUS mediulis and A L. adducior lonyus)

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Vastus lateralis myocutaneous flap: N. Waterhouse and C. Healy

Figure 2 (P) with the skin paddle outlined, two-thirds of which lie anterior to the axis (GT, greater trochanter)

The axis of the vastus lateralis myocutaneous flap marked, running from the anterior superior iliac spine (ASIS) to the upper lateral patella

Figure 3 sore as in case I , and the donor defect closed directly

The vastus lateralis myocutuneuusfkup tunnelled and inset in the defect remaining after the debridement of a trochanteric indolent pressure

Table 1 Details of patients in whom a vastus lateralis myocutaneous jlap has been used for reconstruction

Case Sex Age

1 F 28

2 M 44

3 F 61

4 M 65

5 M 50

Medical history

Paraplegic with trochanteric pressure sore Paraplegic with failed biceps femoris flap for an ischial pressure sore Trochanteric pressure sore following pneumonia Groin and iliac dissection including skin for nodal recurrence of penile cancer Paraplegic with ischial pressure sore after failed surgical and conservative treatment

Primary defect Postoperative stay Complications

7x7cm 10 days None

6x8cm 12 days None

8x8cm 18 days None

1 2 x 6 c m 21 days Lymphocele of groin required drainage

IOx6cm 16 days Donor site healed after 14 day delay

and can be subcutaneously tunnelled to reach the greater trochanter, the ischium or the groin. The flap is then sutured into the defect and the donor site is closed primarily (Figure 3 ) over a closed suction drain. Details of patients in whom we have used the flap are summarized in Table I .

Discussion A pressure sore, when excised, leaves a wound with the same characteristics as a compound injury elsewhere, i.e. a defect of skin and soft tissue, exposure of underlying bone and almost universal bacterial colonization and contamination. Godina’ has shown that success rates in the reconstruction of compound limb defects are higher when flaps that include muscle are used. Vascularized muscle allows prompt healing even in the presence of contaminated wounds. The vastus lateralis is an ideal myocutaneous flap in that it has a reliable vascular pedicle, is easy to dissect, has a wide arc of rotation and is an acceptable donor site. These qualities are not all fulfilled by the myocutaneous flaps more commonly used in the repair of defects around the groin and pelvis.

Though the traditional myocutaneous flap from the lateral thigh is the tensor fasciae latae flap, its reliability has been called into question. The cutaneous perfusion of the artery supplying

it extends only to the proximal half of the lateral thigh skin5. Therefore the distal extension of the tensor fasciae latae flap, when raised, is deprived of its normal arterial inflow coming medially from the fasciocutaneous arteries of the vastus lateralis, laterally from the posterior compartment septocutaneous branches and inferiorly from the superior lateral geniculate artery’.’. The random nature of its blood supply makes the distal portion of the tensor fasciae latae flap prone to inadequate perfusion and necrosis. In contrast the islanded vastus lateralis myocutaneous flap has many advantageous features; it has a potentially large muscle bulk, its arc of rotation is wide, its vascular pedicle is reliable and it produces a functionally and cosmetically acceptab!e donor site. Even after multiple attempts a t treatment of other pressure sores with other local flaps, because of its anatomical location the vastus lateralis segment needed for the myocutaneous flap is normally left undamaged. The vastus lateralis, separated from the fascia lata by loose areolar tissue, presents perforating vessels to the overlying skin at its anterior border above the knee. In its upper two-thirds, particularly laterally, there is a definite surgical plane between it and the vastus intermedius. The vastus lateralis neurovascular bundle is located in fatty areolar tissue, permitting easy dissection. The muscle also has vascular contributions from

1276 Br. J. Surg., Vol. 77, No. 11, November 1990

Vas tus lateralis myocu taneous flap: N . W a t e r h o u s e and C. Healy

distal perforators of the superficial femoral artery and the superior lateral beniculate artery, which act retrogradely allowing the muscle t o be raised distally to cover the knee joint6. As a muscle only flap, it has been described t o cover defects in a variety of location^'*^*^^. Although a very useful development, the muscle only flap has a disadvantage in that it requires cover with a split skin graft. This is avoided with the islanded vastus lateralis myocutaneous flap, which utilizes the same essential technique for freeing the vastus lateralis muscle and provides the same arc of rotation. Our decision to use this flap in an ambulant patient (case 4) was vindicated by his preservation of normal quadriceps function. Swartz et aL6 reported a similar outcome when the vastus lateralis was used as a distally based muscle flap. This series contains the first report of the use of the islanded vastus lateralis myocutaneous flap for repair of a groin defect. The inferiorly based rectus flap is ccimmonly used for such defects, but pre-existing abdominal wall scarring or respiratory disease may prohibit its use.

In conclusion, the islanded vastus lateralis myocutaneous flap is technically simple to raise, reliable in its vascular supply and has a wide arc of transposition. I ts donor site is closed directly, is cosmetically acceptable a n d has a low morbidity. This flap deserves wider application in both plastic and general surgery, with a possible role in the repair of perineal fistulas, groin dissection defects and perianal excisional defects in patients with Crohn’s disease.

Acknowledgements We would like to thank Mr C. M. Ward, Mr R. Sanders,

Case report

Mr P. J. Smith and Mr B. M. Jones for allowing us to report on their patients. Illustrations by Dr G . Alvarez.

References 1.

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Minami RT, Hentz VR, Vistnes LM. Use of vastus lateralis muscle flap for repair of trochanteric pressure sores. PIast Reconstr Surg 1977; 60: 3648. Bovet JL, Nassif TM, Guimberteau JC, Baudet J. The vastus lateralis musculocutaneous flap in the repair of trochanteric pressure sores: Technique and indications. PIast Reconstr Surg 1982; 69: 830-4. Drimmer MA, Krasna MJ. The vastus lateralis myocutaneous flap. Plast Reconstr Surg 1987; 79: 560-4. Larson DL, Liang MD. The quadriceps musculocutaneous flap: a reliable, sensate flap for the hemipelvectomy defect. Plast Reconstr Surg 1983; 12: 347-53. Zufferey J, Doerfl J, Krupp S. The anatomical basis for delaying the musculocutaneous tensor fascia lata flap with distal a extension. Eur J PIast Surg 1988; 11: 109-16. Swartz WM, Ramasastry SS, McGill JR, Noonan JD. Distally based vastus lateralis muscle flap for coverage of wounds about the knee. PIast Reconstr Surg 1987; 80: 255-63. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78: 285-92. Cormack GC, Lamberty BGH. The blood supply of thigh skin. Plast Reconstr Surg 1985; 75: 342-54. Dowden RV, McCraw JB. The vastus lateralis muscle flap: Technique and applications. Ann PIust Surg 1980; 4: 3969. Jamra FNA, Afeiche N, Sumrani NB. The use of a vastus lateralis muscle flap to repair a gluteal defect. Br J PIust Surg 1983; 36: 319-22.

Paper accepted 20 April 1990

Br. J. Surg . 1990, Vol. 77, November, 1277-1278

Massive gastrointestinal haemorrhage due to ileal varices

P. Lewis, B. F. Warren and D. C. C. Bartolo

Department of Surgery, Southmead Hospital, Bristol BS 10 5NB. UK Correspondence to: Mr P. Lewis, Department of Surgery, Llandough Hospital, Penarth, South Glarnorgan CF6 1 XX, UK

Bleeding from ‘ectopic’ varices outside the gastro-oesophageal region is an uncommon complication of portal hypertension. However, awareness of the condition and its characteristic presentation can enable diagnostic and therapeutic procedures to be performed rapidly with an increased likelihood of a successful outcome. This report describes a patient with massive haemorrhage from ileal varices; the management of this unusual cause of gastrointestinal bleeding is discussed.

Case report A 72-year-old woman with alcoholic cirrhosis was admitted with hepatic encephalopathy precipitated by gastrointestinal bleeding demonstrated by the passage of dark red blood per anum. During the previous year she had required two courses of injection sclerotherapy for bleeding oesophageal varices and had also been admitted with a bleeding duodenal ulcer which responded to conservative treatment. Physical examination revealed stigmata of chronic liver disease and an old lower mid-line scar from a hysterectomy 10 years previously.

Endoscopy demonstrated oesophageal varices and a healed duodenal ulcer but no blood in the upper gastrointestinal tract. The patient was initially considered by a medical gastroenterologist to be too ill for surgery. However, with continued bleeding per anum emergency angiography was performed. The venous phase of a selective superior mesenteric angiogram revealed venous pooling in the pelvis and two large mesenteric veins (Figure I). Despite these findings embolization was performed because of a suspicious blush in the ileocolic territory during the arterial phase. This failed to control the haemorrhage and, despite the patient’s poor condition, a laparotomy was urgently undertaken.

The main operative findings were an adhesion between the ileum and the lateral pelvic wall in the region ofan enormously dilated ovarian vein stump and a distal segment of ischaemic small intestine which was thought to have been caused by the radiological embolization. When the intestine was dissected free, large venous lacunae were discovered in the wall of the adherent ileum with two linger-sized veins in the adjacent mesentery. The bleeding ovarian vein was oversewn and a limited ileocolic resection performed with end-to-end anastomosis.

Opening the resected small bowel revealed a 5 mm raised erythematous area of the mucosa. Close inspection of this lesion showed a sentinel flap of mucosa overlying a slit which communicated with large vascular spaces in the mucosa and submucosa. These spaces led into vascular lacunae in the external muscle coat and serosa which drained into several thick walled vessels. Histological sections demonstrated that the walls of the mucosal vascular spaces were lined by smooth muscle broken up by collagen and elastic tissue. Furthermore, the walls of the draining vessels had features of ‘arterialization’ with areas of intimal thickening and elastic reduplication.

The patient made a satisfactory recovery and was alive and well at follow-up 2 months later.

Discussion ‘Ectopic’ varices are estimated to occur in approximately 1-3 per cent of patients with cirrhosis’. They occur predominantly in the digestive tract and a t enterostomies, the most common site being a t an ileostomy, in which case the liver

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