Microsurgery. 2021 Oct 20; doi: 10.1002/micr.30827. Epub 2021 Oct 20.

The triple conjoined scapular-latissimus dorsi-groin flap for reconstruction of long lower extremity degloving injury: A case report.

Microsurgery

Francesco Amendola, Davide Spadoni, Jonathan Velazquez-Mujica, Loukas Platsas, Hung-Chi Chen

PMID: 34669226 DOI: 10.1002/micr.30827

Abstract

Since the introduction of the angiosome concept, many attempts have been made to push the dimensional limits of free tissue transfers. While initially limited by the boundaries of random vascularization of adjacent angiosomes, wider flaps were transferred by combining contiguous source vessels. Combined flaps, either chimeric or conjoined, represent nowadays the largest reconstructive options in the human body. This is the first report of a triple conjoined free flap with two vascular anastomoses, able to cover the anterior surface of the entire lower limb, representing the longest flap ever reported in history. A 43-year-old woman sustained a car accident as a pedestrian and presented with a massive circumferential degloving injury of the right lower limb. Femoral displaced shaft fracture and Gustilo type IIIb tibial fracture were diagnosed with emergent CT scan. A myocutaneous latissimus dorsi flap was planned, conjoined with the scapular flap to obtain a thick and large cover for the knee, and with a groin flap, to cover for the foot. Descending branch of lateral circumflex femoral artery and anterior tibial artery at the dorsum of the foot were selected as recipient vessels. Donor site was closed primarily. All flaps survived and no immediate nor late complications were reported. Follow up was 3 months. The triple conjoined flap can be considered a safe and useful reconstructive tool in severe degloving injuries of the lower limb, allowing the coverage of a large surface of the lesion with a single operation and without increasing the donor site morbidity.

© 2021 Wiley Periodicals LLC.

References

1. Bigdeli, A. K., Thomas, B., Falkner, F., Radu, C. A., Gazyakan, E., & Kneser, U. (2020). Microsurgical reconstruction of extensive lower extremity defects with the conjoined parascapular and latissimus dorsi free flap. Microsurgery, 40, 639-648. https://doi.org/10.1002/micr.30640 - PubMed
2. Bigdeli, A. K., Thomas, B., Schmidt, V. J., Kotsougiani, D., Hernekamp, F. J., Hirche, C., Kneser, U., & Gazyakan, E. (2018). The conjoined parascapular and latissimus dorsi free flap for reconstruction of extensive knee defects. Microsurgery, 38, 867-875. https://doi.org/10.1002/micr.30361 - PubMed
3. Boonipat, T., Ji, L., Manrique, O. J., & Chen, H. C. (2019). Combined bipedicled latissimus dorsi and groin flap for anterior chest wall reconstruction. BML Case Reports, 12(5), 2018-2020. https://doi.org/10.1136/bcr-2018-227372 - PubMed
4. Caffee, H. H. (1998). Transfer of the scapular flap on a reverse latissimus muscle pedicle. Plastic and Reconstructive Surgery, 101, 85-89. https://doi.org/10.1097/00006534-199801000-00014 - PubMed
5. Chiang, Y. C., Chen, F. C., Hsieh, M. J., & Wei, F. C. (1997). Reconstruction of a large thoracoabdominal wall defect with a flow-through forearm flap and a latissimus dorsi-groin flap. Plastic and Reconstructive Surgery, 100, 1240-1244. https://doi.org/10.1097/00006534-199710000-00025 - PubMed
6. De Francesco, F., Busato, A., Mannucci, S., Zingaretti, N., Cottone, G., Amendola, F., De Francesco, M., Merigo, F., Riccio, V., Vaienti, L., Parodi, P. C., Sbarbati, A., & Riccio, M. (2020). Artificial dermal substitutes for tissue regeneration: Comparison of the clinical outcomes and histological findings of two templates. The Journal of International Medical Research, 48(8), 1-22. https://doi.org/10.1177/0300060520945508 - PubMed
7. Dzwierzynski, W. W., Sanger, J. R., Matloub, H. S., & Yousif, N. J. (1995). Combination latissimus dorsi and groin free flap with double microvascular transfer. Annals of Plastic Surgery, 34, 631-634. https://doi.org/10.1097/00000637-199506000-00011 - PubMed
8. Hallock, G. G. (2008). The combined parascapular fasciocutaneous and latissimus dorsi muscle conjoined free flap. Plastic and Reconstructive Surgery, 121(1), 101-107. https://doi.org/10.1097/01.prs.0000293859.60618.79 - PubMed
9. Hallock, G. G. (2011). The complete nomenclature for combined perforator flaps. Plastic and Reconstructive Surgery, 127(4), 1720-1729. https://doi.org/10.1097/PRS.0b013e31820a662b - PubMed
10. Harii, K., Iwaya, T., & Kawaguchi, N. (1981). Combination myocutaneous flap and microvascular free flap. Plastic and Reconstructive Surgery, 68(5), 700-710. https://doi.org/10.1097/00006534-198111000-00006 - PubMed
11. He, J., Qing, L., Wu, P., Zhou, Z., Yu, F., & Tang, J. (2021). Large wounds reconstruction of the lower extremity with combined latissimus dorsi musculocutaneous flap and flow-through anterolateral thigh perforator flap transfer. Microsurgery, 41(6), 533-542. https://doi.org/10.1002/micr.30754 - PubMed
12. Johansen, K., Daines, M., Howey, T., Helfet, D., & Hansen, S. T. (1990). Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma: Injury, Infection and Critical Care, 30, 568-573. https://doi.org/10.1097/00005373-199005000-00007 - PubMed
13. Karakawa, R., Yoshimatsu, H., Tanakura, K., Imai, T., Yano, T., & Sawaizumi, M. (2021). Triple-lobe combined latissimus dorsi and scapular flap for reconstruction of a large defect after sarcoma resection. Microsurgery, 41, 26-33. https://doi.org/10.1002/micr.30627 - PubMed
14. Katsaros, J., Gilbert, D., & Russell, R. (1983). The use of a combined latissimus dorsi-groin flap as a direct flap for reconstruction of the upper extremity. British Journal of Plastic Surgery, 36(1), 67-71. https://doi.org/10.1016/0007-1226(83)90015-2 - PubMed
15. Koshima, I., & Soeda, S. (1985). Repair of a wide defect of the lower leg with the combined scapular and parascapular flap. British Journal of Plastic Surgery, 38(4), 518-521. https://doi.org/10.1016/0007-1226(85)90013-X - PubMed
16. Koul, A. R., Nahar, S., Prabhu, J., Kale, S. M., & Kumar, P. (2011). Free boomerang-shaped extended rectus abdominis myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities. Indian Journal of Plastic Surgery, 44(3), 396-404. https://doi.org/10.4103/0970-0358.90808 - PubMed
17. Levin, L. S. (1993). The reconstructive ladder: An orthoplastic approach. The Orthopedic Clinics of North America, 24, 393-409. - PubMed
18. Nicoli, F., Orfaniotis, G., Lazzeri, D., Lim, S. Y., Kiranantawat, K., Chen, P. Y., Ciudad, P., Chilgar, R. M., Sapountzis, S., Sacak, B., & Chen, H. C. (2016). The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema. Microsurgery, 36, 689-694. https://doi.org/10.1002/micr.22515 - PubMed
19. Schirò, G. R., Sessa, S., Piccioli, A., & MacCauro, G. (2015). Primary amputation vs limb salvage in mangled extremity: A systematic review of the current scoring system. BMC Musculoskeletal Disorders, 16(1), 1-7. https://doi.org/10.1186/s12891-015-0832-7 - PubMed
20. Steinberger, Z., Therattil, P. J., & Levin, L. S. (2021). Orthoplastic approach to lower extremity reconstruction: An update. Clinics in Plastic Surgery, 48(2), 277-288. https://doi.org/10.1016/j.cps.2020.12.007 - PubMed
21. Vaienti, L., Cottone, G., Zaccaria, G., Rampino Cordaro, E., & Amendola, F. (2020). One-step approach for infections after Achilles tendon open repair: The distally based peroneus brevis muscle flap. The International Journal of Lower Extremity Wounds, (Epub ahead of print), 1-7. https://doi.org/10.1177/1534734620951540 - PubMed

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