|Year : 2020 | Volume
| Issue : 1 | Page : 14-18
Pedicled thoracoumbilical flap coverage for wounds around elbow: A versatile option
Mohd Altaf Mir1, Fahad Khurram2, Dinesh Kumar3
1 Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Mohri, Haryana, India
2 Department of Burns, Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
3 Department of Surgery, Adesh Medical College, Mohri, Haryana, India
|Date of Submission||19-Nov-2018|
|Date of Acceptance||15-Jan-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Mohd Altaf Mir
Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Mohri, Haryana - 136 135
Source of Support: None, Conflict of Interest: None
Background: To evaluate the reliability of pedicled thoracoumbilical flap for reconstruction of soft-tissue defects around the elbow. Materials and Methods: This was a prospective study undertaken between September 2017 and November 2018, in division of plastic and reconstructive surgery of our institution. Patients with soft-tissue defect of the elbow referred from the division of orthopedic surgery were included. Those with a scarring in the region of thoracoabdominal flap were excluded. A detailed history and examination were recorded. An informed consent was taken from every patient. Anteroposterior and lateral radiographs of the elbow were taken in all cases. Pedicled thoracoumbilical flaps were raised in all patients for the coverage of soft-tissue defects around elbow. Pedicle division and final inset were done after 4 weeks in all cases. All patients were followed up regularly. Results: A total of 5 patients with soft-tissue defect around the elbow were referred to our division from the division of orthopedic surgery. All patients were male with a mean age of 33 ± 6.67 years (25–40 years). The injuries were common in labor class, and the most common etiology being fall from height in three out of five cases. The right elbow was often injured (three out of five cases). In all patients, the wounds were of Gustilo Anderson grade IIIB. In one case, the implant was exposed (case 3). The mean defect size was 45.75 ± 6.29 cm2, and the mean flap size was 171.85 ± 13.12 cm2. No complications were seen in our case series. Conclusion: The pedicled thoraco-umbilical flap is technically simple and versatile option for the coverage of soft-tissue defect around elbow since it is vascularity is predictable.
Keywords: Coverage, elbow wound, thoracoumbilical flap
|How to cite this article:|
Mir MA, Khurram F, Kumar D. Pedicled thoracoumbilical flap coverage for wounds around elbow: A versatile option. Turk J Plast Surg 2020;28:14-8
| Introduction|| |
The management of soft-tissue defects about the elbow is a challenge to a plastic surgeon. There are many treatment options, and appropriate management requires careful consideration of all alternatives among the reconstructive ladder. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, local or distant one-stage muscle or myocutaneous transposition, distant pedicle flaps, and microvascular free tissue transfer.
Life-threatening injuries or other medical illness may preclude immediate lengthy complex reconstruction. Extensive crushed injury and prior surgical scars may exclude many local flap options. A thorough assessment of the extremities vascular status should be performed before the flap reconstruction. A handheld Doppler device is useful in planning axial flaps in such cases.
The vascular anatomy of the paraumbilical region is well known. The skin island of the thoracoumbilical flap is supplied by paraumbilical perforators from the deep inferior epigastric vessels. The largest perforator is located at approximately 2 cm lateral to the umbilicus, and directs toward the inferior angle of the scapula, anastomoses with the posterior intercostal artery. The course of paraumbilical musculocutaneous perforator vessels in the deep subcutaneous fat and then superficial to the scarpa fascia., The course of these perforators is parallel to the skin, where they started to divide and form subdermal plexus. These perforators also anastomosing with the superficial vessels in the abdominal wall.,
Traumatic defects require thorough debridement and irrigation, but often may be closed within 24 h of injury, with salutary results. In contrast, complex wounds resulting from high-energy injury and contaminated wounds may require serial debridement and a delay to allow adequate assessment of tissue viability.,
We present an excellent outcome of our cases managed with the pedicled thoraco-umbilical flap in terms of flap survival and adequacy of coverage.
| Materials and Methods|| |
This was a prospective study undertaken between September 2017 and November 2018 in division of plastic and reconstructive surgery of our institution. The study has been approved by Departmental Ethics Committee and has therefore been performed in accordance with ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Patients with soft-tissue defect around elbow referred from the division of orthopedic surgery were included. Those with a scarring in the region of thoracoabdominal flap were excluded. A detailed history and examination were recorded. An informed consent was taken from every patient. Anteroposterior and lateral radiographs of the elbow were taken in all cases. Pedicled thoraco-umbilical flaps were raised in all patients for the coverage of soft-tissue defects around the elbow. Pedicle division and final inset were done after 4 weeks in all cases. All patients were followed up regularly. The data obtained were analyzed by one-way analysis of variance using IBM SPSS 23 version of statistical tool (Armonk, NY: IBM Corp).
The procedure is done under general anesthesia. A sand bag is placed under the lower ribs on the same side. The paraumblical vertical line 2 cm lateral to the umbilicus is marked. The vascular axis of the flap is marked as a line extending superiorly and laterally from a point 2 cm lateral from the umbilicus to the tip of the scapula. The two vertical lines corresponding to mid- and posterior-axillary lines are marked. Elasticity of the skin is assessed by pinching the skin and hence, width of the flap is decided. The flap is raised from distal to proximal (axillary lines to the paraumblical line). It is elevated in the subscarpa plane to include the subdermal plexus as well as the less important vessels within the fat and the flimsy fascia. The dissection should cease 2–2.5 cm medial to the lateral border of the rectus muscle or at any point of time, if the flap is adequate in length. However, if more length of the flap is required, then the dissection continues medially, the rectus muscle is divided, and the flap is thus based on the inferior epigastric artery only. The donor site is closed primarily with the help of undermining of surrounding tissue. The arm is immobilized on the patient's side with the help of adhesives and a pillow may be placed underneath the elbow. The flap division and final inset are performed 3 weeks after the primary operation.
| Results|| |
A total of 5 patients with soft-tissue defect around the elbow were referred to our division from the division of orthopedic surgery. All patients were male with a mean age of 33 ± 6.67 years (25–40 years). The injuries were common in labor class, and the most common etiology being fall from height in three out of five cases. The right elbow was often injured (three out of five cases). In all patients, the wounds were of Gustilo Anderson grade IIIB. In one case, the implant was exposed (case 3), the mean defect size was 45.75 ± 60.29 cm2, and mean flap size was 171.85 ± 13.12 cm2. No complications were seen in our case series. The clinical profile of patients is summarized in [Table 1].
|Table 1: Summary of clinical profile of patients managed with pedicled thoracoumbilical flaps|
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We represent here two case of soft-tissue defect coverage of elbow with pedicled thoraco-umbilical flap; the case 3 and 5 [Table 1].
A 27-year-old male laborer presented to orthopedician for management of postvehicular accident Gustilo Anderson grade IIIB fracture of the left olecranon. Subsequently, the patient developed ulcer left elbow posteriorly with exposed implant. The ulcer margins were debrided and actual defect measuring 7 cm × 6.5 (45.5) cm. The coverage with pedicled ipsilateral thoracoumbilical flap measuring 8 cm × 22 (176) cm was achieved. The flap pedicle was divided 3 weeks after primary operation, and the final inset of flap 3 days of flap division. The patient was followed up weekly and flap condition and elbow function assessed and found satisfactory [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Intraoperative photograph of planning for coverage of wound with exposed implant around posterior elbow (case 3)|
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|Figure 2: Postoperative photograph on 10th-postoperative day showing healthy flap (case 3)|
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|Figure 3: Follow-up photograph showing the adequate coverage of elbow wound (case 3)|
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A 40-year-old male mason presented to orthopedician for the management of post fall from height Gustilo Anderson grade IIIB fracture of the right olecranon and closed fracture of radius. The patient had wound right elbow posteromedial aspect with exposed olecranon. The wound margins were debrided and actual defect measuring 6 cm × 7.5 (46) cm. The coverage with pedicled ipsilateral thoracoumbilical flap measuring 7 cm × 23 (161) cm was achieved. The flap pedicle was divided and inset 3 weeks after primary operation. The patient was followed up weekly and flap condition and elbow function assessed and found satisfactory [Figure 4], [Figure 5], [Figure 6].
|Figure 5: Intraoperative photograph of thoracoumbilical flap raised and inset to cover the right elbow wound (case 5)|
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|Figure 6: Postoperative photograph of healthy flap at 3 weeks after final inset (case 5)|
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| Discussion|| |
Reconstruction of soft-tissue defects around the elbow is a challenge to the reconstructive surgeon. The soft-tissue defects around the elbow may be post trauma, tumor extirpation, infections, and radiations. Various reconstructive options ranging from skin grafts to free flaps are available., Local flaps such as lateral arm, proximally based radial forearm, proximallybased posterior interosseus, and brachioradialis muscle flaps can be used for smaller defects whenever nerve, vessels, tendon, bone, or joint are exposed., These local flaps providing skin coverage with similar color and texture. However, local flaps are limited in size and availability of tissue. Sometimes, local flap harvest from the ipsilateral limb is unwarranted in view of concomitant traumatic damage to the vessels. The loco regional flaps such as scapular and parascapular flaps have a limited arc of rotation. The pedicled thoraco-umbilical flap based on the paraumbilical perforator is versatile for the coverage of large and complex defects of the forearm including around the elbow. Pedicled thoraco-umbilical flap can provide coverage of defects up to 20 cm.,
The basis for the thoracoumbilical flap is the radiating nature of the dominant periumbilical perforators originating from the deep inferior epigastric artery. The flap is designed with its base in the umbilical region and its axis orientated along the major interconnections with the intercostal system, is an axial flap providing coverage to the soft-tissue defects in the upper extremity, especially to the elbow. It was first described by Taylor et al. The best flap appeared to be one planned along the axis between the umbilicus and the inferior angle. By including a disc of anterior rectus sheath together with underlying muscle, the para umbilical perforators could be preserved. Dissection of the vascular pedicle toward the groin, with or without the rectus muscle, permitted the skin flap to rotate through a wide arc. In 1984, Taylor et al. described their clinical experience with 18 patients treated with thoracoumbilical flap based on the deep inferior epigastric vessels.
In study done by Yilmaz et al., majority (72.7%) of the patients were females (8/11) which is contrary to our observation while as male preponderance (70/83) and (21/23) has also been observed by Mishra and Sharma and Demirseren etal respectively. However, our observation of 100% male preponderance may be attributed to social composition of our population where more often men is performing outdoor work and hence is more prone to the trauma.
Mishra and Sharma found the patients of 4–56 years of age were injured with young preponderance under 40 years of age (61/83) while as Demirseren et al. observed the involvement of age group between 12 and 54 years with mean age of 36.2 years. Our results are in concordance with the observations of both the authors.
Mishra and Sharma observed vehicular accident as common etiology of elbow trauma (28/83). However, in our study fall from the height was common etiology for elbow injury since our cases were mostly from labor class.
In study of Mishra and Sharma (33/83) defects were <100 cm2, (39/83) were 100–200 cm2, and (11/83) were ≥200 cm2. However, the mean defect size observed in our study was 43.80 ± 4.37 cm2 (ranging: 36–46 cm2). The defect size is larger in their cases because, most of their cases had forearm defects while as our cases had soft-tissue defects around the elbow alone.
The flap size vary from 101 to 400 cm2 in cases of Mishra and Sharma, 4 cm × 6 cm–14 cm × 34 cm in study cases of Demirseren et al., up to 5 × 14 cm2 in cases of Yilmaz et al., and 10 × 8 cm2–30 × 14 cm2 in cases of Zanget al. However, in our study, the flap size vary from 7 cm × 23 (161) cm to 7 cm × 21.5 (192.5) cm with the mean flap size of 171.85 ± 13.12 cm2. Zang et al. used prexpanded thoracoumbilical flaps for the coverage of extensive forearm soft-tissue defects and hence, used larger sized flaps with 100% (25/25) success. Demirseren et al. also observed 100% (23/23) success while as Mishra and Sharma observed 97% (81/83) success. Our results are also in concordance with the observations of these studies. However, our study is strictly about the coverage of soft-tissue defect around the elbow and studies (6, 17, 18, and 19) discussed have dealt with the coverage of soft-tissue defect of forearm.
This flap option has several disadvantages, including the residual donor site scar and the need to attach the patient's arm to their abdomen for 3 weeks. The immobilization of the extremity for a period of time may lead to joint stiffness. The pressure and temperature precautions must be emphasized in view of insensate nature of thoracoumbilical flap.
However, the judicious use of pedicled thoracoabdominal flaps has several significant advantages. The flaps can be based anteriorly or posteriorly to accommodate soft-tissue wounds anywhere around the elbow. The flap dimensions can be adjusted to cover defects of small to significant size. These fasciocutaneous flaps are relatively thick and durable and therefore, can withstand joint motion and prosthetic wear. Finally, these flaps can be employed during scar revision or as definitive initial soft-tissue coverage of wounds.
| Conclusion|| |
The pedicled thoracoumbilical flap is technically simple and versatile option for the coverage of soft-tissue defect around the elbow since its' vascularity is predictable.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]