Arch Hand Microsurg.  2022 Dec;27(4):345-353. 10.12790/ahm.22.0056.

Resurfacing defects from mycobacterial skin and soft tissue infections using thoracodorsal artery perforator free flaps

• Wang H
• Lee YM
• Kim YH

• KMID: 2536223
• DOI: http://doi.org/10.12790/ahm.22.0056

Abstract

Purpose
Skin and soft tissue infections (SSTIs) caused by mycobacteria are rare and difficult to diagnose and treat. Furthermore, systematic treatment protocols for mycobacterial SSTIs have not been established. This study introduces a strategy with radical resection and resurfacing using thoracodorsal artery perforator (TDAP) free flaps.
Methods
From December 2013 to February 2022, 13 patients with mycobacterial SSTIs underwent radical resection and reconstruction using TDAP free flaps. Exact mapping of the lesion extent was performed preoperatively with magnetic resonance imaging. When the extent was limited to soft tissue, resection and reconstruction were performed in a single stage. However, in cases with bone or joint involvement, two-stage reconstruction was applied with radical resection and negative-pressure wound therapy followed by resurfacing with a flap. Complex defects formed after resection were filled with a musculocutaneous or chimeric flap. All patients were administered antimycobacterial medications.
Results
Mycobacterial infection recurred in one patient; therefore, a total of 14 cases of reconstruction were performed. Reconstruction was performed with a TDAP free flap alone in 10 cases, with a chimeric flap in three cases, and with a musculocutaneous flap in one case. The flaps ranged in size from 7×5 cm2 to 25×12 cm2 (mean, 97.2 cm2). The mycobacterial species identified were Mycobacterium tuberculosis (n=8) and nontuberculous mycobacteria (n=5).
Conclusion
For mycobacterial SSTIs, radical resection followed by resurfacing and reconstruction using TDAP free flaps can be an effective surgical treatment strategy.

Keyword

infections; Soft tissue infections; Free tissue flaps

Figure

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  Fig. 1. (A) A patient with tuberculous osteomyelitis on the right distal tibia. A preoperative photograph shows the previous operative wound with recurrent dehiscence. (B) Coronal view of preoperative T1-weighted magnetic resonance imaging (MRI). (C) Sagittal view of preoperative T1-weighted MRI. An intramedullary abscess measuring approximately 6×2×2 cm was identified. (D) A thoracodorsal artery perforator (TDAP) chimeric flap containing a 6×11-cm skin paddle and 1.5×5-cm serratus anterior (SA) fascial component was harvested. (E) The harvested TDAP chimeric flap is prepared for inset, covering the previously fixed plate containing an SA fascial component. (F) Immediate postoperative photograph of reconstruction using a TDAP chimeric flap. (G) One-year postoperative follow-up photograph shows no problems, including recurrence. (H) Anteroposterior view of the 1-year postoperative follow-up X-ray. (I) Lateral view of the 1-year postoperative follow-up X-ray, showing no remaining osteomyelitis, while the previously fixed plate remained in place.

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  Fig. 2. (A) A patient with tuberculous arthritis of the left knee joint. A preoperative photograph shows a defect measuring approximately 2×2 cm aligned with the healed wound from previously attempted closure. (B) Sagittal view of preoperative T1-weighted magnetic resonance imaging (MRI). An abscess with ill-defined septa was identified on the semimembranous bursa. (C) A 12×8-cm thoracodorsal artery perforator (TDAP) flap was harvested. (D) Immediate postoperative photograph of reconstruction using a TDAP flap. (E) Broad swelling was observed on the left thigh, adjacent to the prior arthritis region. (F) Coronal view of follow-up T1-weighted MRI shows an approximately 9×7×25-cm abscess arising from the suprapatellar bursa, superiorly extending along the vastus medialis and vastus intermedius muscle. (G) Intraoperative photograph shows whitish necrotic debris in the abscess. (H) The wound was cleared with application of negative-pressure wound therapy. (I) A TDAP chimeric flap containing a 25×12-cm skin paddle and a 10×3-cm serratus anterior muscular component was harvested. (J) Immediate postoperative photograph of reconstruction using a TDAP chimeric flap on the thigh. (K) Partial distal flap necrosis was found after 2 weeks but healed without additional surgery. (L, M) Fifteen-month postoperative follow-up photographs show no problems, including recurrence, in the thigh and popliteal region.

Reference

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