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Plasty of Achilles region with propeller tendon-fasciocutaneous peroneal artery perforator flap after radical excision of a neglected squamous cell carcinoma.

Introduction

Squamous cell carcinoma (SCC) is one of the most common forms of the skin cancer that originates from the epithelium [1, 2]. Cutaneous SCC develops more frequently in chronically injured or long-standing skin diseases, for example in burn patients or in osteomyelitis. In most instances, this type of SCC is more aggressive locally, invading the surrounding anatomical structures earlier, with higher chances for recurrence and increased metastatic potential [3]. The clinical presentations of the chronic ulcers and squamous cell carcinomas can vary, but at the same time they can coexist [4, 5].

The aim is to report a clinical case of a post-oncological reconstruction after a 20-years non-healing ulceration of a large defect at Achilles level. The reconstruction was performed with tendon-fasciocutaneous peroneal artery perforator flap, in a propeller manner translation, with good function of the limb with minimum recovery time.

Case report

A 57 year-old man with diabetes type II for 10 years was admitted to our department with an ulcerated tumor of 5x10 cm at the Achilles level with functional impotence, developed on a non-healing ulcer at the Achilles level after 20 year-old car accident (Figure 1).

Preoperatively, the cutaneous arteries were evaluated using a hand-held Doppler (Figure 1) and the reconstruction plan was designed to include posterior calf skin and advance it in propeller fashion to cover the post-excisional defect (Figure 2). The patient agreed to the proposed treatment.

The tumor was removed along with minimum 1 cm healthy tissue circumferentially and 1 cm deep margin even in the bone, resulting in a 3 cm deep bony defect with absence of overlying Achilles tendon. Multiple specimens were harvested for frozen section evaluation.

Calf skin was incised according to the preoperative plan (Figure 3). Fascia was included together with distal medial half of the Achilles tendon for reconstruction of the 11 cm tendon defect (Figure 4). The flap was harvested on peroneal perforator vessels marked on the skin (Figure 1). The composite tendon-fasciocutaneous flap was rotated 180 o to the distal region and inset.

The tendon included in the flap reconstructed the gap of the distal Achilles tendon overlying the calcaneus, the skin island covered the defect and donor site defect was skin grafted.

The patient underwent large excision of the tumor and the complex defect including soft tissue, tendon and bone was reconstructed using flap from calf area. The frozen sections identified no cancer in the resection margins after the excision. The final pathological examination confirmed squamous cell carcinoma on the background of chronic inflammation; the bone tissue presented necrosis (Figure 5). The excision margins were free of cancer cells.

The postoperative period was uneventful, with survival of the entire flap. The ankle joint function was restored to dorsal flexion -10[degrees], plantar flexion -25[degrees], the patients was ambulating normally, without pain (Figure 6).

Discussion

Our case report is about a diabetic patient with squamous cell carcinoma developed on a chronic inflammatory wound persisting for 20 years following a car accident. Malignant transformation from chronic wounds is notorious, with up to 25% of cancers being linked to inflammation or infection, either viral or bacterial. Moreover, many authors report that epidermal cells are highly susceptible to malignant transformation and cancer progression to metastatic disease status [6-9].

Following SCC treatment protocols, the patient underwent wide excision with minimum 1 cm macroscopic circumferential and deep margins which resulted in a complex defect involving bone, tendon and soft tissue.

Reconstruction of complex defects of Achilles region is challenging and aims to achieve soft tissue stable coverage, restoration of limbs' form and function and pleasing cosmetic effect in a minimum recovery timeframe. Of course, ambulation is the most important function therefore it should not be impeded by a bulky flap [10].

The main reconstruction options of Achilles region are the free tissue transfer and the loco-regional flaps, with the latter being increasingly used with the recent progress of perforator flaps. Traditional free muscle flaps are latissimus dorsi and gracillis while fasciocutaneous flaps, while the most frequently used are the lateral arm and the anterolateral thigh flap. The choice depends mostly of patients' needs in terms of defect size, composition, comorbidities but equally on surgeons' preference and expertise [11, 12].

In our patient, because of the long history of diabetes and chronic wound, we looked for a solution to avoid diabetic angiopathy complications and the probable complications linked to microsurgery, to spare the main vessels of the leg and to avoid long operating hours. A loco-regional fascial flap could be a simple and safe alternative for a free flap, provided it should be thin, pliable and have a sufficient amount to cover the defect while concomitantly reconstructing the tendon defect [13].

Perforator flaps rose as an alternative to free tissue transfer in patients in whom the complications toll is high: comorbidities including peripheral vascular disease, thrombosis and ischemia, loss of major vessels of the limb to microsurgery or extensive trauma or multiple surgeries, partial or total flap loss. Moreover, they are thin when compared to muscle or musculo-cutaneous flaps; they are based on short, small-caliber side-branches of the main vessel and not on main vessel itself, therefore produce less donor-site morbidity. The distal vessels perforator flaps are the solutions for defects located in distal two-thirds of the calf including Achilles area and the heel [14-16].

Over the free flaps, the peroneal artery perforator flap has notable advantages making it a suitable option for distal leg defects: reliable, versatile design, composition, size and mobility of the flap, shorter operating time, less bleeding and thrombosis, calf muscle and peroneal vessel sparing while providing adequate blood perfusion to the flap [17, 18].

Conclusions

The composite tendon-fasciocutaneous peroneal perforator flap can be used distally in pedicled propeller fashion to reconstruct defects of the calf and calcaneus in oncologic cases. It provides good functional reconstruction and aesthetically pleasing results with minimum recovery time. We do recommend the use of the flap in the armamentarium of reconstruction ladder for distal calf area.

DOI: 10.22551/2018.20.0503.10136

Competing interests

The authors have no conflict of interests to declare.

Patient consent

Written informed consent was obtained from the patient's legal guardians for publication of this case.

References

[1.] Nagy V. Principii de cancerologie generala. Curs pentru student Cluj-Napoca: Editura Medicala Universitara Iuliu Hafeganu, 2007; 37-47.

[2.] Stephens FO, Aigner KR. Basics of oncology. Springer, Heidelberg, London, New York, 2009; 49-64.

[3.] Kirsner RS, Spencer J, Falanga V, Garland LE, Kerdel FA. Squamous cell carcinoma arising in osteomyelitis and chronic wounds. Treatment with Mohs micrographic surgery vs amputation. Dermatol Surg 1996; 22(12):1015-1018.

[4.] Cassarino DS, Derienzo DP, Barr RJ. Cutaneous squamous cell carcinoma: a comprehensive clinicopathologic classification. Part one. J Cutan Pathol 2006; 33(3):191-206.

[5.] Enoch S, Miller DR, Price PE, Harding KG. Early diagnosis is vital in the management of squamous cell carcinomas associated with chronic non healing ulcers: a case series and review of the literature. Int Wound J 2004; 1(3): 165-175.

[6.] Tang L, Wang K. Chronic inflammation in skin malignancies. J Mol Signal 2016; 11:2.

[7.] Hussain SP, Harris CC. Inflammation and cancer: an ancient link with novel potential. Int J Cancer 2007; 121:2373-2380.

[8.] Mantovani A, Allavena P, Sica A, Balkwill F. Cancer-related inflammation. Nature 2008; 454:436-444.

[9.] Aggarwal BB, Gehlot P. Inflammation and cancer: how friendly is the relationship for cancer patients? Curr Opin Pharmacol 2009; 9:351-369.

[10.] Chalmers R, Tare M, Niranjan N. Vascularized Achilles tendon graft reconstruction--by the tendon for the tendon. J Plast Reconstr Aesthet Surg 2010; 63:273-276.

[11.] Sabapathy SR, Venkataramani H, Latheef L, Bhardwaj P. Reconstruction of segmental defects of Achilles tendon: Is it a must in infected complex defects? Indian J Plast Surg 2013; 46:121-123.

[12.] Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr Surg 1988; 81:579-589.

[13.] Upton J, Tracy MB, Steven LS, et al. Fascial flap coverage of Achilles tendon defects. Plast Reconstr Surg 1995; 95:1056-1061.

[14.] Lin CT, Chen CY, Chang SC. Bipedicled flap reconstruction of soft tissue defect with Achilles tendon exposure. J Med Sci 2014; 34:129-132.

[15.] Michlits W, Gruber S, Windhofer C, Macheiner P, Walsh M, Papp C. Reconstruction of soft tissue defects overlying the Achilles tendon using the super extended abductor hallucis muscle flap. J Trauma 2008; 65:1459-1462.

[16.] Baj A, Ali Youssef D, Monteverdi R, et al. Recontruction of partial maxillary defects with the double-barrel fibula free flap. Acta Otorhinolaryngol Ital 2010; 30:299-302.

[17.] Vaienti L, Marchesi A, Palitta G, Gazzola R, Parodi PC, Leone F. Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds. Strateg Trauma Limb Reconstr 2013; 8:111-115.

[18.] Cheng L, Yang X, Chen T, Li Z. Peroneal artery perforator flap for the treatment of chronic lower extremity wounds. J Orthop Surg Res 2017; 12:170.

Viorica Mihaluta * (1), Alina Stoian (1), Rodica Iordachescu (2), Elena Pavlovschi (1), Adrian Cociug3, Eleonora Bors1, Snejana Smolenschi (4), Grigore Verega (1)

(1) "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chicinau, Republic of Moldova; (2) IMSP Institute of Emergency Medicine, Plastic Surgery and Reconstructive Microsurgery Department, Chicinau, Republic of Moldova; (3) The Human Research Tissue Bank, Chicinau, Republic of Moldova; (4) Department of Plastic Surgery, Regional Institute of Oncology, Iasi, Romania

Received: July 2018; Accepted after review: September 2018; Published: September 2018.

* Corresponding author: Viorica Mihaluta, "Nicolae Testemitanu" State University of Medicine and Pharmacy, 165, Stefan cel Mare si Sfant Bd. MD-2004, Chicinau, Republic of Moldova

Email: mihalutaviorica@yahoo.com

Caption: Fig. 1. Preoperative images: a) posterior-anterior view of the Achilles level with markings of the skin projection of peroneal artery perforators on Doppler examination; b) lateral view.

Caption: Fig. 2. Drawing the incision patterns. The size of the flap is 12x10 cm.

Caption: Fig. 3. The image of the radical resection of the: a) distal Achilles tendon and soft tissue defect; b) bone-tissue defect of 3 cm.

Caption: Fig. 4. The composite fasciocutaneous and tendon flap harvested, pedicled on the perforator vessels. Tendon graft is showed in the ruler.

Caption: Fig. 5. A) Squamous cell carcinoma: Thickening of the epidermis with papillomatosis (a), epidermal detachment and ulceration (b), carcinomatous infiltration surrounded by inflammatory infiltrate (c) and intradermal keratin pearls (HE, x40); B) Neoplastic islands with cellular atypia (a), cells with increased mitotic activity (b), inflammatory infiltrate (c) and keratin pearl formation (d) (HE, x100).

Caption: Fig. 6. a) Plantar flexion -25[degrees]; b) Dorsal flexion -10[degrees]; c) Achilles region aspect one month postoperatively with acceptable contouring of the flap inset in the defect and of the skin graft intake.
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Title Annotation:Case report
Author:Mihaluta, Viorica; Stoian, Alina; Iordachescu, Rodica; Pavlovschi, Elena; Cociug, Adrian; Bors, Eleo
Publication:Archive of Clinical Cases
Article Type:Clinical report
Date:Sep 1, 2018
Words:1786
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