SEMRA KARŞIDAĞ, Arzu AKÇAL, Gürsel TURGUT, Kemal UĞURLU, Lütfü BAŞ

Lower extremity soft tissue reconstruction with free flap based on subscapular artery

Amaç: Çalışmamızda subskapüler vasküler sistemden hazırlanan serbest şeplerle yapılan alt ekstremite yumuşak doku rekonstrüksiyonlarımızın değerlendirilmesi amaçlandı. Çalışma planı: Ocak 1998 - Aralık 2008 tarihleri arasında alt ekstremite defekti ile başvuran hastaların 51’ine subskapüler vasküler sistemden beslenen şeplerle onarım uygulandı. Yaş ortalaması 26 olan hastaların 16’sı kadın, 35’i erkekti. Defektlerin %37'si krus, %19’u ayak tabanı, %16'sı topuk ve %14’ü ayak dorsali yerleşimliydi. Hastaların %80.5’inde trafik kazasına, %13.5’inde yanığa bağlı doku defekti mevcuttu. Bulgular: Hastaların %53’üne serbest latissimus dorsi kas şebi ile onarım, %21’ine serbest serratus kas ve/veya fasya şebi ile onarım, %14’üne serbest paraskapüler fasyokutan şep, %12’sine serbest kombine latissimus kas ile serratus kas ve/veya fasya şebi ile onarım uygulandı. Hastaları n %80’inin anastomozları posterior tibial arter ve yandaş ven ve/veya ayak dorsal venlerine gerçekleştirildi. Ondört hastada uç-uca anastomoz gerçekleştirilirken, 35 hastada uç-yan anastomoz uygulandı. Altı hastaya karşı bacaktan anastomozlu serbest şep uygulandı. Bunlardan 4’ünde çapraz latissimus, 1 hastaya çapraz serratus ve 1 hastaya da çapraz kombine serratus ve latissimus şepleri uygulandı. Anastomoz karşı bacak tibialis posterior arteriyle uç-yan olarak gerçekleştirildi. Çapraz anastomozlar 4 hafta sonra ayrıldı. Erken dönemde 4 hastada venöz, 1 hastada arteryel ve venöz tıkanıklık saptandı. Anastomozlar tekrarlandı. 2 hastada parsiyel nekroz gözlendi. Hastaların izlem periyodu ortalama 61 aydır. 4 hastada geç dönemde basıya bağlı ülseratif lezyonlar gelişti. Hastaların lezyonları debridman ve primer sütür veya kısmi kalınlıklı deri grefti ile onarıldı. Çıkarımlar: Uzun ve yeterli çapta pedikülü, iyi vaskülaritesi, az donör alan morbiditesi ve komplike defektlerin onarımında kombine kullanıma imkan vermesi sebebi ile, subskapüler vasküler sistemden hazırlanan şeplerle alt ekstremite rekonstrüksiyonu güvenli ve başarılı bir seçenektir. Ayrıca, uygun alıcı damar yokluğunda tek veya kombine karşı bacak (cross-leg) serbest şepler, başarılı onarım sağlamaktadır.

Subskapüler vasküler sistemden hazırlanan serbest fleplerle alt ekstremite yumuşak doku rekonstrüksiyonu

Objective: The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery. Methods: Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects. Results: Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-toend anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts. Conclusion: The subscapular vascular system based flaps have an optimal vascularity once they are prepared with adequate pedicles, causing minimal donor site morbidity. These flaps are a safe and effective alternative in lower extremity reconstruction. On the other hand, in the absence of appropriate recipient vessels, single or combined cross-leg free flaps may provide successful repair.

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