Arch Hand Microsurg.  2023 Sep;28(3):205-209. 10.12790/ahm.23.0022.

Bilateral anterolateral thigh free flap in a flow-through chimeric pattern for a extensively large defect reconstruction: a case of an elderly patient under spinal-epidural anesthesia

• Cha HG
• Kim DG
• Nam SM
• Choi CY

• KMID: 2545532
• DOI: http://doi.org/10.12790/ahm.23.0022

Abstract

An 83-year-old male patient presented with a Marjolin’s ulcer on his lower leg, which developed 60 years after a bomb blast injury. The lesion was a 24×12-cm2 chronic ulcer located circumferentially around the mid-third lower leg. Considering the patient’s age, vessel status, and the extent of the defect after wide excision, which included a section of the tibia, reconstruction utilizing bilateral anterolateral thigh free flaps in a flow-through pattern under spinal-epidural anesthesia was planned. The operative time was 9 hours, and the patient fully recovered without any complications. The patient was able to walk without any orthosis, and no evidence of recurrence was found during a 3-year postoperative follow-up period.

Keyword

Marjolin’s ulcer; Lower extremity; Reconstruction; Large defects; Free flap

Figure

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  Fig. 1. Preoperative clinical photograph of a very large Marjolin’s ulcer on the left lower leg of the patient that developed due to a bomb blast injury 60 years ago.

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  Fig. 2. (A) An immediate postoperative photograph of bilateral anterolateral thigh free flap reconstruction in a flow-through pattern. (B) Postoperative computed tomography angiography showing the anastomosis site on the posterior tibial artery (white arrow), the turbocharged site of the first anterolateral thigh (ALT) flap (blue arrow), and the anastomosis site of the first and second ALT flaps (yellow arrow).

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  Fig. 3. Clinical photograph of the patient at 3 years postoperatively.

Reference

References

1. Copcu E. Marjolin's ulcer: a preventable complication of burns? Plast Reconstr Surg. 2009; 124:156e–164e.

2. Copcu E, Aktas A, Sişman N, Oztan Y. Thirty-one cases of Marjolin's ulcer. Clin Exp Dermatol. 2003; 28:138–41.

3. Sharma S, Das N, Gupta V, Bera S, Bisht N. Lower extremity Marjolin's ulcer reconstruction with free anterolateral thigh flap: a case series of 11 patients. Cureus. 2020; 12:e11392.

4. Ozkan O, Ozgentaş HE, Dikici MB. Flow-through, functioning, free musculocutaneous flap transfer for restoration of a mangled extremity. J Reconstr Microsurg. 2005; 21:167–72.

5. Brandt K, Khouri RK, Upton J. Free flaps as flow-through vascular conduits for simultaneous coverage and revascularization of the hand or digit. Plast Reconstr Surg. 1996; 98:321–7.

6. Chick LR, Walton RL, Reus W, Colen L, Sasmor M. Free flaps in the elderly. Plast Reconstr Surg. 1992; 90:87–94.

7. Djokovic JL, Hedley-Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA. 1979; 242:2301–6.

8. Davis N, Lee M, Lin AY, et al. Postoperative cognitive function following general versus regional anesthesia: a systematic review. J Neurosurg Anesthesiol. 2014; 26:369–76.

9. Ehsani R, Djalali Motlagh S, Zaman B, Sehat Kashani S, Ghodraty MR. Effect of general versus spinal anesthesia on postoperative delirium and early cognitive dysfunction in elderly patients. Anesth Pain Med. 2020; 10:e101815.

10. Weber S, Bennett CR, Jones NF. Improvement in blood flow during lower extremity microsurgical free tissue transfer associated with epidural anesthesia. Anesth Analg. 1988; 67:703–5.