|Year : 2021 | Volume
| Issue : 2 | Page : 146-148
Tensor fascia lata flap: A lifeboat for unresolved bladder exstrophy defect
Sameer Sharad Mahakalkar1, Vishal Mago1, Ashok Rijhwani2, Manish Gupta2
1 Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Pediatric Surgery, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||16-Apr-2020|
|Date of Acceptance||15-May-2020|
|Date of Web Publication||26-Mar-2021|
Dr. Sameer Sharad Mahakalkar
Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
Bladder exstrophy is a rare lower urinary tract malformation that occurs less frequently in women than in men. A case of 11-year girl, who presented with the residual bladder exstrophy along with lower abdominal defect secondary to previously operated bladder exstrophy. Anterior osteotomy and abdominal rectus muscle and musculocutaneous flaps are commonly used options for closure of the defect. Due to extensive scarring and atrophic abdominal recti and late presentation, local reconstructive options were exhausted. Hence, the tensor fascia lata flap was used for the defect closure. In the following report, we discuss our experience with this procedure.
Keywords: Abdomen defect, bladder exstrophy, tensor fascia lata flap
|How to cite this article:|
Mahakalkar SS, Mago V, Rijhwani A, Gupta M. Tensor fascia lata flap: A lifeboat for unresolved bladder exstrophy defect. Turk J Plast Surg 2021;29:146-8
| Introduction|| |
The various techniques for the repair of the bladder exstrophy have till now been extensively described. Reconstruction of the abdomen and bladder are both integral parts of the procedure and failure of either can result in suboptimal outcomes. Options ranging from the pelvic osteotomies, rectus abdominis flaps to fasciocutaneous flaps such as the groin and hypogastric have been described. Osteotomies and abdominal rectus are routinely practiced. However, the late presentation and the previously scarred territory posed unique challenges due to scarcity of local tissue for the reconstruction, necessitating the use of an autogenous resilient coverage in the form of tensor fascia lata (TFL) flap.
| Case Report|| |
A 11-year-old girl presented to our center with unresolved vesical exstrophy and a lower abdominal defect. She underwent repair of exstrophy in the neonatal period for which bilateral osteotomies were also performed. However, by 2 years of age, she developed multiple vesical calculi and urosepsis. Thus, calculi were extracted by open approach; however, the closure could not be achieved and bladder was draining as congenital bladder exstrophy. The patient could not undergo closure procedure as she was lost to the primary surgeons' follow-up and presented to our center 9 years later.
The girl presented to us in acute renal failure and signs of urosepsis. She had a midline broad lower abdominal scar with bilateral oblique groin scars of the previous osteotomies. The large exstrophy defect was present over the mons pubis and the anterior labial commissure was laid widely apart. Investigations revealed bilateral impacted vesicoureteral calculi. She recovered after bilateral nephrostomies. The bladder plate and ureters were opened and calculi were extracted. Due to the delayed presentation, bladder augmentation with sigmoid colon and appendicovesicostomy (Mitrofanoff procedure) for continence was planned with flap coverage for the abdominal defect in the same sitting, after consent from patient's parents.
The bladder mobilization and augmentation created a defect of 15 cm × 12 cm was created in the lower abdominal wall. Abdominal recti of both sides were found to be atrophic. Hence, TFL flap 35 cm × 12 cm was raised from the right thigh. The pedicle (the transverse branch of the lateral circumflex femoral artery) was traced 6 cm below the ASIS (anterior superior iliac spine) by a vascular doppler [Figure 1]a and [Figure 1]b. With a distal incision, the TFL muscle was identified and tagged to the skin paddle. The rest of the flap was raised and the flap was rotated to the defect. The abdominal skin and subcutaneous tissue underlying the flap was excised to accommodate the flap within the abdominal contour. Double-layered closure was done, with TFL muscle was sutured to abdominal recti with 2-0 polypropylene sutures and skin paddle to the abdominal wall. Thus, minimizing herniation. The secondary flap defect was grafted.
|Figure 1: (a) Exstrophy defect with abdominal scaring (b) Flap marking with pedicle|
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On 4th postoperative day, purulent discharge ensued from the drains and suture line and 2 cm distal tip necrosed which was followed by urinary leakage [Figure 2]. Antibiotics were stepped up as per the culture. Once the inflammation settled, re-exploration was performed. Underlying the TFL muscle was found healthy. The necrosed portion of the flap was debrided and the defect was closed without tension by the advancement of the redundant flap. The scars healed well and the further course was uneventful.
The patient was followed up to 6 months and has not developed any herniation [Figure 3]a and [Figure 3]b.
|Figure 3: (a) Well-healed scar and donor area (b) Mons bulge with patent vaginal orifice|
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| Discussion|| |
The current techniques for the repair of the bladder exstrophy have evolved through a long period, however, still there are controversies regarding the methods of repair and even the steps of surgery in various procedures. Abdominal wall closure can be a difficult problem in failed exstrophy repair, crucial to the success of the entire surgery. Several techniques have been described, with osteotomies forming the main crus to aid closure taking advantage of the skeletal pliability in the early pediatric age. With delayed presentation, skeletal rigidity makes rules out this method of reconstruction. Pelvic osteotomies are also known to have immediate or late postoperative morbidities.
Yet another option that has been described in the literature is the mobilization of abdominal recti., Rectus fascial flaps have been used in abdominal closure. This method provides a better aesthetic and scar less reconstruction. Due to the bulk of the muscles, being brought to the midline, the elevation of the mons area, which is lacking in the typical exstrophy patient is also created. However, when wide diastasis and atrophy of the rectal muscles are present, as happened in our case, fistulas and at times gapping with reopening of the bladder along with abdominal herniation is common in early and late postoperative periods, respectively.
Groin flaps and hypogastric flaps also have been reported. Major disadvantages, these being fasciocutaneous flaps, lack muscular and deep fascial layer. Hence, without underlying recti, herniation is ominous. To avert this, polypropylene mesh is commonly used for reconstruction. However, mesh repair is greatly prone to infection in surgeries with bowel. Taking into consideration the previous osteotomy scarring, need for fascial or muscular support, dimensions of our defect, and high incidence of infection, usage of this option was not prudent.
Thus, a need for autogenous and resilient flap was realized. TFL has been used as a workhorse flap for lower abdominal reconstruction. TFL flap is a myofasciocutaneous flap that has been first described by Wangensteen in 1934 for abdominal wall reconstruction. A strong fascial layer, its reach to the lower abdomen has made it an attractive option for reconstruction of these challenging defects. Various authors have claimed that as the flap is transferred with its intact motor nerve supply to the muscle, the muscle retains its tone, which is transmitted to the fascia, making it an ideal method for abdominal wall reconstruction. In so far as the vascularity of the TFL flap is concerned, tip necrosis, as happened in our case, has been reported both in pedicled and free TFL flap. Nahai et al. claimed that the flap could be safely made as large as 15 cm × 40 cm, and could be raised within 5 cm from the knee. Despite its advantages, obvious scarring of the donor site is the only main downside with its usage.
| Conclusion|| |
The TFL flap is a versatile flap with a large fasciocutaneous skin paddle. The main advantage being its musculofascial layer that provides a resilient repair. The only morbidity of this flap lies in thigh scarring which is worse if a skin graft is used, especially in females. Although flap proved an easy, reliable, and effective method for the reconstruction, in this case, its use should be only be reserved for difficult and compound defects as described above.
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]