Microsurgical reconstruction of large scalp defects after malignant tumors removal with latissimus dorsi flap – Nguyen Hong Ha

Journal of military pharmaco-medicine n o 1-2019 188 MICROSURGICAL RECONSTRUCTION OF LARGE SCALP DEFECTS AFTER MALIGNANT TUMORS REMOVAL WITH LATISSIMUS DORSI FLAP Nguyen Hong Ha1; Tran Xuan Thach1; Vu Trung Truc1 Bui Mai Anh1; Ngo Manh Hung1 SUMAMRY Introduction: Scalp defects after large malignant tumor removal are always a challenge for plastic surgeons and neurosurgeons. Large defects with exposed calvarium and dura mater must be covered by flaps that are thick, good vitality and large enough. Free latissimus dorsi flap was used and reported by many authors. However, they only focused on reconstruction for defects in thoracic region and extremity. Subjects and methods: The retrospective study was conducted on 4 patients. All had large tumors in the scalp or with the trespass possibility on scalp and dura mater. They were put under treatment and reconstructive surgery from 2012 to 2018. Results: 4 latissimus dorsi flaps were used. All the cases of skin - muscle flap were in good vitality and had good results in function, anatomy and aesthetics. Two patients were not required for calvarium reconstruction with artificial materials. Conclusion: Treatment for scalp defects after large malignant tumors requires a multi-specialty combination between neurosurgery, plastic surgery, anesthesiology and oncology. Using free latissimus dorsi flap to reconstruct scalp defects has many advantages and brings good results in anatomy, function and aesthetics. * Keywords: Latissimus dorsi flap; Scalp malignant tumor; Scalp tissue defects. INTRODUCTION Scalp defects after large malignant tumor removal are always a challenge for plastic surgeons and neurosurgeons and are common lesions in trauma, post- tumor surgery, scalp scar, etc. If large defects with exposed calvarium and dura mater are not treated, there will be serious affect the anatomy, function and aesthetics of the patient. The requirement for reconstruction is to have flaps that are thick, good vitality and large enough. Throughout clinical use and literature review, we relized that latissimus dorsi flap microsurgeon exhibits a number of advantages in covering large scalp lesions. In 1896, latissimus dorsi flap was first presented in the literature by Tansini, and in 1906, he succeeded in using latissimus dorsi flap to cover the thoracic defects [4, 5]. For a long time after that, the latissimus dorsi flap was not studied and applied. In 1976, Olivani N and Mull B studied the use of latissimus dorsi flap in thoracic surgery [5]. Also in 1976, Baudet J was the first to successfully use free latissimus dorsi flap for the recovery of software of lower extremities [1]. 1. Vietduc Hospital Corresponding author: Nguyen Hong Ha (nhadr4@gmail.com) Date received: 20/10/2018 Date accepted: 15/12/2018 Journal of military pharmaco-medicine n o 1-2019 189 In Vietnam, many authors have used latissimus dorsi flap to cover the defects in thoracic, axillary and lower extremity regions [2, 3, 5], etc. However, in our current understanding, the use of latissimus dorsi flap to cover the scalp defects has not been reported. From 2012 to 2018, at the Department of Maxilofacial-Plastic and Aesthetic Surgery of Viedduc Hospital, we performed 4 cases of reconstructive surgery for scalp defects after removal of large malignant tumor using free latissimus dorsi flap. Total results were satisfied. Purposes of this article are: To review literatures, indication and advantages of this flap in scalp reconstruction. SUBJECTS AND METHODS The research was conducted on 4 patients. All had large tumors in the scalp or with the trespass possibility on scalp and dura mater. They were put under treatment and reconstructive surgery of the scalp using free latissimus dorsi flap at the Department of Maxilofacial- Plastic and Aesthetic Surgery of Vietduc Hospital from 2012 to 2018. * Latissimus dorsi muscle surgery [1, 2]: The latissimus dorsi muscle is a broad, flat, triangular muscle, covering most parts of the lower back, twisting forward and turning upward to the upper end of the humerus and muscle covered by a small portion of the trapezius muscle. The source of the muscle consists of three parts: The attachment to processus spinosus vertebrae from the 4th thoracic vertebrae to the sacrum, the attachment to one third of the posterior iliac crest, and the attachment to the last four ribs of the ribcage. The function of the muscles is to close and rotate the arm in. When using the arm to lean, the body lifts up to climb, pull up, swing on tree, etc, while raising the four ribs up when breathing in. Blood supply for latissimus dorsi muscle includes a main pedicles which is a thoracodorsal artery and secondary pedicles separated from the intercostal arteries. The thoracodorsal artery is one of the two branches of the subscapular arteries. The nerve pedicle is located at the back and is 2 - 3 cm from the external border of the muscle. Before going into the muscles, intercostal arteries always spare a branch to support the costoscapularis and some branches for teres major muscle and external border of the shoulder blades. There is only one attendant vein that carries blood and ramifies just as the artery. The motor nerve of the latissimus dorsi muscle is the intercostal nerve, which is a pure motor nerve without any sensory fiber. * Surgical procedure: Surgical procedure is the simultaneous cooperation of neurosurgeon and plastic surgery. - The patient was endotracheal anaesthetized, lying on one side, the above flap location was also the location for the receiving artery dissection which was also the artery and vein of the shallow temporal. - The neurosurgery was carried out to remove the tumor, calvarium, dura mater and tumor in the brain. After that, the reconstruction of dura mater, calvarium by using artificial materials was conducted. Journal of military pharmaco-medicine n o 1-2019 190 - Plastic surgery: + The design of the flap is based on the anatomical markings: The insertion of the latissimus dorsi muscle at the upper part of hemerus, anterior crest of the latissimus dorsi muscle, processus spinosus vertebrae and iliac crest. From these anatomical markings, the boundary of the latissimus dorsi flap was drawn [1]. + The skin incision was based on the size of the flap to be taken and whether the flap was pure muscle flap or skin - muscle flap. In case of pure muscle flap only, the skin incision started from the curved point of the muscle tendon and went down to the back, away from the anterior crest of the muscle. In the case of skin-muscle flap, the skin incision went around the flap to be taken. The external incision could be pulled up for the conduction of pedicle dissection or dragged downward depending on the size of the flap to be taken. The flap was collected near the external border of muscle for this was the location where the skin - muscle perforaling veins were the most. + The two edges of the incision were detached. The detached layer was on the muscle latae and under skin latae to reveal the entire surface of the muscle. At the external border, the layers between the latissimus dorsi muscle and costoscapularis were detached with paying attention to protect the thoracodorsal pedicles. + The insertions of the muscles to the shoulder blade, spine, iliac crest, ribs, and finally the upper end of the hemerus were cut to remove the flap and close the flap location. + The flap was moved to cover the scalp defects, connect the pedicles to the receiving artery and vein of the shallow temporal with checking the condition of the blood supply and blood drainage. + The latissimus dorsi without flap was grafted with the skin taken from the thighs. After the surgery, the patient was treated with antibiotics, analgesics and heparin for 5 to 7 days. RESULTS Summary of injury characteristics and research results: 4 patients, aged 38 to 68 years. Monitoring period: 4 months to 6 years. Table 1: Patients Age Cause Size and location Flap and its size Result Complications Female 46 Basal cell of front and scalp with the trespass on calvarium and dura mater 15 x 11 cm, frontal temporal - left top Skin flap: 16 x 10 cm, entire latissimus dorsi muscle Good None Male 38 Basal cell of scalp with the trespass on calvarium and dura mater 18 x 16 cm, left top Skin flap: 16 x 5 cm, entire latissimus dorsi muscle Good None Journal of military pharmaco-medicine n o 1-2019 191 Male 68 Epithelium of scalp with the trespass on calvarium and dura mater 20 x 20 cm, Right top of Accipitotemporal Skin flap: 20 x 10 cm, entire latissimus dorsi muscle Good Hematoma at flap donnate location Male 60 Recurrent meningococcal meningitis with trespass on scalp 25 x 20 cm Accipitotemporal Skin flap: 22 x 10 cm, entire latissimus dorsi muscle Good None 2 patients were not required for calvarium reconstruction with artificial materials. 4 latissimus dorsi flaps were used. All the cases of skin - muscle flap were in good vitality and had good results in function, anatomy and aesthetics. Patient: Nguyen Tien H. - Recurrent meningococcal meningitis with trespass on scalp. - Removed meningococcal meningitis, reconstructed dura mater with fasciae latae, reconstructed calvarium with mesh titanium. - Reconstructed with latissimus dorsi flap. Journal of military pharmaco-medicine n o 1-2019 192 DISCUSSION The causes of scalp defects can be due to trauma, after the ablation of scalp tumors or tumors in the brain with the trespass on meninges and calvarium to the scalp. The surgery was a combination of neurosurgery and plastic surgery. In our study, three among the patients were after the surgical removal of cancer with the trespass on calvarium. One of the patients was after the surgery of expanding scalp and calvarium due to recurrent meningococcal meningitis with trespass on scalp. All the patients had their turmors and calvarium removed, calvarium and dura mater reconstructed by the neurosurgeons before being applied with flaps to cover their defects by the plastic surgeons. In scalp cancer with the trespass on calvarium, meninges or meningococcal meningitis with trespass on calvarium and scalp, the principle of surgical intervention in cancer, when removing the tumor, the scalp must be taken on a large scale and must be healthy and trespassed calvarium and dura mater must be removed [6, 7]. The two options that may be chosen to cover the defects produced by postoperative tumor on-site rotation flap and organizational flaps. The defects, which were very broad, and trepassing tumors cause ulcers, bleeding and infections, so we did not apply these options. Another reason for not choosing these flaps was that the time for preparation is long, which may take from 1 to 2 months and its complication is quite large. In the study, there was one patient with recurrent meningococcal meningitis that had calvarium reconstruction artificial material (titanium) and three patients with scalp cancer along with ulcers and infections. To be safe, we chose a skin - muscle flap method to reconstruct to cover. The free latissimus dorsi flap surgery allowed the patient to undergo only one surgery. This indication is also a priority for postoperative cancer patients with trespass on calvarium, meninges and meningitis and who continue to receive radiotherapy [7]. In 1972, McLean and Buncke first described scalp regeneration with free flaps [8]. Since then a lot of free flaps have been used as latissimus dorsi flaps, anterolateral thigh flaps, humeroradialis flaps, abdominal flaps, the upper clavicle flap, etc. Latissimus dorsi flap is one of the most common flaps in the reconstruction of head, face and neck due to its large size and wide coverage. Some authors use only the muscle flap and skin graft on the flap methods to ensure acceptable aesthetics [6, 7]. All patients in our study, because the defect is too big and can not be covered only by skin flap, we need used skin - muscle flap in combination with skin grafting. That is, we attached an appropriate skin flap on the muscle to ensure that it is able to directly close to the flap location, narrow the area to be grafted on the muscle flap and use this skin flap as a monitoring flap for the vitality of the flap after surgery. Another advantage of the latissimus dorsi flaps is that they have constant pedicles and their diameter is very convenient for vascular microsurgery. Long pedicles provide additional options for the receiving arteries and locations for Journal of military pharmaco-medicine n o 1-2019 193 vascular microsurgery [3, 4, 7]. Top defects occasionally have to be taken into account when venous grafting is necessary, especially, the receiving vein of head, face and neck area is usually small and thin [7]. However, in all four cases, we connected to the arteries and veins of superficial temporal of the anterior ear without the need for venous grafting. Postoperative treatment using anticoagulant has also been studied by several authors in the world, and it has been shown that, for free flaps transfer surgery with the preparation of vascular microsurgery, the use of anticoagulants is not necessary and there was no difference. Vascular microsurgery is the most important factor in determining the success of microsurgical flaps [9, 10]. However, three out of four patients after the surgery were given anticoagulant therapy with continuous heparin infusion from 5 to 7 days, then the patients were given with aspergic from 1 to 2 weeks. Among them, one patient we did not use heparin after the surgery but used only one dose during the surgery (50 mg/kg). That was the patient with recurrent meningococcal meningitis with trespass on scalp, whose meningioma, calvarium and scalp were put under extirpation by neurosurgeons. Because it is difficult to control the risk of bleeding in brain, we decided not to use anticoagulants after surgery. The results of all four cases in our study are in good vitality and good results. For scalp cancer patients, we always consult with cancer specialists to plan for chemotherapy or postoperative radiotherapy. In particular, patients who have been prescribed radiotherapy, the tumor extirpation and reconstruction with flaps that are thick, good vitality play an important role in minimizing radiological complications. There are two scalp cancer patients who are prescribed radiotherapy, so we did not use artificial materials to reconstruct skulls [6, 7]. In our sudy, we had one complications of hematoma. In literature, hematoma and fluid accumulation at flap location ranged from 9 - 80%, depending on the technique of flap surgery and flap closure [7, 11]. In our case, the hematoma at the flap location due to flap closure technique with the use of anticoagulation after surgery. We had to come back to surgery for stop bleeding and close the flap location. CONCLUSION Scalp defects are caused by a variety of causes and common. Treatment for scalp defects after large malignant tumors requires a multi-specialty combination between neurosurgery, plastic surgery, anesthesiology and oncology. Using free latissimus dorsi flap to reconstruct scalp defects has many advantages and brings good results in anatomy, function and aesthetics. REFERENCES 1. Nguyen Viet Tien. Latissimus Dorsi Flap with Nutrient Artery. Medical Pubishing House. 2011, pp.194 -217. 2. Le Van Doan. Anatomical study and clinical application of latissimus dorsi flap in the treatment of lower extremity. The Thesis of Doctor of Medicine. 2003. Journal of military pharmaco-medicine n o 1-2019 194 3. Nguyen Roan Tuat, Le Gia Vinh. The results of using latissimus dorsi flap in the reconstruction of thoranic defect. Journal of Practical Medicine. 2011, 715, pp.27-28. 4. Malktelow R.T. Latissimus dorsi. Microvascular reconstruction anatomy, application and surgical technique. Springer Verlag Berlin Heidelberg. New York, USA. 1986, p.45. 5. Baudel J, Guimbertean J, Nascimento E. Successful clinical transfer of two free thoracodorsal axillari flaps. Plast Reconstr Surg. 1976, 58, p.680. 6. Hussussian C.J, Reece G.P. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002, 109 (6), pp.1828- 1834. 7. Rochlin et al. Scalp reconstruction with free latissimus dorsi muscle. www.ePlasty.com. Interesting Case. 2013. 8. McLean Donald H. Buncke. Autotransplant of omentum to a large scalp defect with microsurgical revascularization. Plastic and Reconstructive Surgery. 1972, Vol. 49, Issue 3, pp.268-274. 9. Lek Veravuthipakorn, Apisit Veravuthipakorn. Microsurgical free flap and replantation without antithrombotic agents. J Med Assoc Thai. 2004, Vol. 87, No.6 10. Pan X.L, Chen G.X, Shao H.W, Han C.M, Zhang L.P et al. Effect of heparin on prevention of flap loss in microsurgical free flap transfer: A meta-analysis. PLoS ONE. 2014, 9(4): e95111. doi:10.1371/journal.pone.0095111. 11. Schwabegger A, Ninkovic M, Brenner E, Anderl H. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: Observations on cause and prevention. Ann Plast Surg. 1997, 38 (6), pp.594-597.