|Year : 2020 | Volume
| Issue : 1 | Page : 53-56
Free forearm fillet flap for chest wall reconstruction after forequarter amputation and malignant peripheral nerve sheath tumor excision
Harrison R Ferlauto1, Alexander S Lauder2, Detlev Erdmann3
1 Duke University School of Medicine, Durham, NC, USA
2 Department of Orthopaedic Surgery, University of Colorado, School of Medicine, Aurora, CO, USA
3 Duke University Medical Center, Division of Plastic, Reconstructive, and Maxillofacial Surgery, Durham, NC, USA
|Date of Submission||11-Feb-2020|
|Date of Decision||11-Feb-2020|
|Date of Acceptance||18-Sep-2020|
|Date of Web Publication||21-May-2021|
Mr. Harrison R Ferlauto
BSE, Duke University School of Medicine, 8 Searle Center Drive, Durham, NC 27710
Source of Support: None, Conflict of Interest: None
Fillet flaps are useful for reconstructing large soft-tissue defects, especially in cases where the surgeon has available spare body parts that would otherwise be discarded. The use of free forearm fillet flaps to reconstruct large chest wall defects arising from traumatic extremity amputation or malignant tumor excision has been previously described. This report represents the first case of a free forearm fillet flap used to reconstruct an extensive chest wall defect after forequarter amputation and excision of a malignant peripheral nerve sheath tumor involving the brachial plexus.
Keywords: Chest wall defect, fillet flap, forequarter amputation, malignant peripheral nerve sheath tumor
|How to cite this article:|
Ferlauto HR, Lauder AS, Erdmann D. Free forearm fillet flap for chest wall reconstruction after forequarter amputation and malignant peripheral nerve sheath tumor excision. Duke Orthop J 2020;10:53-6
|How to cite this URL:|
Ferlauto HR, Lauder AS, Erdmann D. Free forearm fillet flap for chest wall reconstruction after forequarter amputation and malignant peripheral nerve sheath tumor excision. Duke Orthop J [serial online] 2020 [cited 2023 Feb 6];10:53-6. Available from: https://www.dukeorthojournal.com/text.asp?2020/10/1/53/316560
| Introduction|| |
A fillet flap is an axial pattern flap harvested from an amputated or otherwise nonfunctioning or nonsalvageable body part. Fillet flaps are advantageous because they limit donor site morbidity while at the same time provide sizable amounts of tissue for coverage of defects elsewhere on the body. Fillet flaps are classified into three types based on the nature of the donor site and three subtypes based on the nature of the flap itself [Table 1].
The use of a free forearm fillet flap to reconstruct a complex chest wall defect was first described by Schmidt et al. in 1987. Since then, free fillet flaps of the upper extremity have proven useful in reconstructing extensive chest wall defects arising from malignant tumor excision., Here, we present the first reported case of a free forearm fillet flap, Type B3, used to reconstruct a chest wall defect after forequarter amputation and excision of a malignant peripheral nerve sheath tumor (MPNST) involving the brachial plexus.
| Case Report|| |
A 44-year-old male with neurofibromatosis Type 1 presented to an outside neurosurgery center in 2016 complaining of neck pain that had gradually worsened over several years. He had a history of sarcoma resected from the left shoulder 12 years prior. Cross-sectional imaging revealed a mass in the left supraclavicular fossa, concerning for plexiform neurofibroma, and the patient was followed in the outpatient setting.
Two years later, the patient presented to our hospital's emergency department complaining of 3 months of progressively worsening dysphagia and left upper extremity weakness. On examination, there was deformity of the left supraclavicular soft tissue, along with loss of motor and sensory function in the entire left upper extremity [Figure 1]. Magnetic resonance imaging revealed a 15.0 cm × 14.0 cm × 14.5 cm mass in the left subclavicular, extrathoracic space extending through the thoracic inlet into the mediastinum [Figure 2]. The mass involved the C5-T1 nerve roots of the left brachial plexus and wrapped completely around the left subclavian artery. Histologic examination of a core needle biopsy demonstrated spindle cells that were Ki-67 and S-100 positive, confirming the diagnosis of MPNST. The patient subsequently received neoadjuvant radiation and left vertebral artery coil embolization.
|Figure 1: A 47-year-old male with malignant peripheral nerve sheath tumor involving the left brachial plexus|
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|Figure 2: Coronal T1 magnetic resonance imaging revealing a 15.0 cm × 14.0 cm × 14.5 cm mass in the left subclavicular extrathoracic space involving the C5-T1 nerve roots and extending through the thoracic inlet into the mediastinum|
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In 2018, the patient underwent tumor excision and left forequarter (interthoracoscapular) amputation, leaving behind a complex chest wall defect [Figure 3]. Reconstruction began by covering the exposed left lung with a porcine-derived acellular dermal matrix. On the back table, a Type B3 free forearm fillet flap was harvested from the amputated left upper extremity [Figure 4]. A longitudinal incision was made along the subcutaneous border of the ulna, down to bone. The carpus was amputated, and subperiosteal dissection was performed along the ulna and across the interosseous membrane to the radius. The dissection was extended proximally to the elbow, and the collateral ligaments were released, and elbow joint unhinged. The bony forearm complex was excised en bloc, and the distal stumps of the radial and ulnar arteries were ligated. Finally, the fillet flap was elevated off the distal humerus and excised at the level of the humeral diaphysis.
|Figure 3: Complex chest wall defect and exposed left lung after left forequarter amputation and malignant peripheral nerve sheath tumor excision (arrow points to the left subclavian artery)|
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|Figure 4: Harvesting the free forearm fillet flap from the amputated left upper extremity|
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The brachial vessels of the flap were then prepared for anastomosis to the left subclavian vessels and inferior thyroid vein [Figure 5]. However, a size mismatch between the chest vessels and flap vessels required partial suture closure of the subclavian artery and vein, effectively reducing the size of their lumina. The left subclavian artery was then connected to the brachial artery using 8-0 nylon. Similarly, the left subclavian vein was connected to the larger of the two venae comitantes of the brachial artery. A vein coupler was then used to connect the inferior thyroid vein to the cephalic vein. Perfusion of the flap was confirmed to be excellent, and the flap was inset and sutured in place over the left chest wall [Figure 6]. Both the patient and the flap were doing well at 4-week postoperative [Figure 7].
|Figure 5: Left forearm fillet flap (arrow points to the left brachial artery)|
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|Figure 6: Free forearm fillet flap after microsurgical anastomosis and inset over the left chest wall|
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| Discussion|| |
In the case of MPNST involving the brachial plexus, forequarter amputation and en bloc resection of the tumor is the current standard of care that provides patients with the best chance for long-term survival., Depending on the size and location of the tumor, an extended excision may result in a chest wall defect that is too large to be closed with local myocutaneous flaps. In these situations, a Type B fillet flap from the patient's amputated upper extremity is an excellent reconstructive option as it provides a large amount of healthy tissue without causing additional donor-site morbidity.
Type B fillet flaps can be either free or pedicled and can be harvested in a fasciocutaneous, myofasciocutaneous, or osteomyocutaneous fashion. Pedicled fillet flaps are advantageous because they do not require microvascular anastomosis, have no ischemia time, and allow for staging of procedures without compromising the flap's viability. However, data from Samant et al. suggest that patients reconstructed with pedicled fillet flaps develop more wound healing complications than those reconstructed with free fillet flaps. This observation is attributed to the fact that free fillet flap tissue is initially located far away from the primary tumor, thus avoiding damage from neoadjuvant radiation. This may imply that free fillet flaps are preferred to pedicled flaps in the setting of oncologic reconstruction surrounding the shoulder. However, this decision must be made in light of the established principles of the reconstructive ladder.
In the present case, we chose to harvest the fillet flap in a myofasciocutaneous fashion because the additional soft-tissue bulk was necessary to fill the large void overlying the dermal patch. Since the MPNST wrapped circumferentially around the left subclavian artery, we had to perform a very proximal ligation of the subclavian vessels. This eliminated the possibility of using a pedicled fillet flap and also resulted in a luminal diameter mismatch, which was overcome through surgical stenosis of the subclavian artery before microsurgical anastomosis with the brachial vessels. Overall, this case demonstrates the utility of free forearm fillet flaps in providing adequate soft-tissue coverage of large chest wall defects following excision of MPNSTs involving the brachial plexus.
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.
| References|| |
Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: Classification, indications, and analysis of their clinical value. Plast Reconstr Surg 2001;108:885-96.
Schmidt RG, Springfield DS, Dell PC. Chest wall reconstruction with a free extended forearm flap. A case report. J Reconstr Microsurg 1987;3:189-91.
Samant M, Chang EI, Petrungaro J, Ver Halen JP, Yu P, Skoracki RJ, et al
. Reconstruction of massive oncologic defects following extremity amputation: A 10-year experience. Ann Plast Surg 2012;68:467-71.
Ver Halen JP, Yu P, Skoracki RJ, Chang DW. Reconstruction of massive oncologic defects using free fillet flaps. Plast Reconstr Surg 2010;125:913-22.
Gachiani J, Kim D, Nelson A, Kline D. Surgical management of malignant peripheral nerve sheath tumors. Neurosurg Focus 2007;22:E13.
Lusk MD, Kline DG, Garcia CA. Tumors of the brachial plexus. Neurosurgery 1987;21:439-53.
Levin LS, Erdmann D, Germann G. The use of fillet flaps in upper extremity reconstruction. J Am Soc Surg Hand 2002;2:39-44.
Shah SA, Wong WH, Adhvaryu D. Rotational pedicle myocutaneous forearm fillet flap used to fill forequarter amputation defect: Indications and uses. J Hand Surg Am 2018;43:390.e1-000.
Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am 1993;24:393-409.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]