|Year : 2015 | Volume
| Issue : 2 | Page : 54-58
Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint
Nilamani Mohanty, Bibhuti Bhusan Nayak
Department of Plastic Surgery, Shrirama Chandra Bhanj Medical College, Cuttack, Odisha, India
|Date of Web Publication||10-Mar-2016|
At- Nadiasahas Pur, Po- Balichandra Pur, Cuttack - 754 205, Odisha
Source of Support: None, Conflict of Interest: None
Marjolin's ulcer is a rare and often aggressive cutaneous malignancy that arises in previously traumatized or chronically inflamed skin, particularly after burns. Treatment modalities of Marjolin's ulcers include wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy. Wide local excision, together with skin grafting, is usually considered appropriate in the treatment of Marjolin's ulcers. For lesions that are located at critical places skin grafting cannot be done because either the excised bed will not take the graft or skin grafting can be done but due to the unstable nature is often avoided preferring a flap cover. Defects over the knee is challenging especially when the defect is quiet large and the surrounding skin is scarred and unhealthy. In such situations neither any local fasciocutaneous flap nor muscle flap is possible, the only option left are in the form of free tissue transfer. But if this type of situation can be managed by transferring tissue from the upper part of the thigh in the form of pedicled flap then other complex reconstructions can be avoided. We describe a case of a 45-year-old male with Marjolin's ulcer over the post burn scar of right knee for 5 years duration with no regional or distant metastasis managed with wide local excision and cover with reverse vastus lateralis musculocutaneous flap. The post op outcome is uneventful with better patient satisfaction.
Keywords: Knee defect, Marjolin's ulcer, vastus lateralis flap
|How to cite this article:|
Mohanty N, Nayak BB. Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint. Nigerian J Plast Surg 2015;11:54-8
|How to cite this URL:|
Mohanty N, Nayak BB. Reverse vastus lateralis musculocutaneous flap for Marjolin's ulcer over the knee joint. Nigerian J Plast Surg [serial online] 2015 [cited 2020 Dec 3];11:54-8. Available from: https://www.njps.org/text.asp?2015/11/2/54/178457
| Introduction|| |
The term “Marjolin's ulcer” was named after French surgeon, Jean Nicolas Marjolin, who first described the condition in 1828.,, But it was Dupuytren who noted it as a malignancy. In 1923, Da Costa first coined the expression “Marjolin's ulcer” to describe malignant transformation in burn wound and scars. It is a rare and often aggressive cutaneous malignancy and has a 1–2% incidence in all burn scars. The latency period from the time of injury to the onset of malignant transformation averages 36 years. Marjolin's ulcers with short latency period have been described in the literature., Studies from Western countries have shown that the average age at diagnosis is in the fifth decade of life with a range of 18–84 years, and men are three times more frequently affected than women. The youngest patient with this condition in India is a 13-year-old male. Most lesions occur on the extremities (60%), with ulcers on the head and face occurring less frequently (30%) and least frequently (10%) on the trunk. Marjolin's ulcers histopathologically present as squamous cell carcinoma in 75–96% of cases. Other histological types, such as basal cell carcinomas, melanoma, osteogenic sarcoma, fibrosarcoma, and liposarcoma, have also been reported., These are very aggressive tumors that necessitate a well-thought-out treatment plan to optimize care and assure patient survival. Early diagnosis and prompt surgical intervention is mandatory in Marjolin's ulcers as they may invade vital structures. Treatment modalities of Marjolin's ulcers include wide local excision, block dissection of the regional nodes, amputation in advanced lesions of limbs, radiotherapy, and chemotherapy given either as neo or adjuvant therapy. Wide local excision (surgical margin of at least 2 cm), together with skin grafting, primarily is usually considered appropriate in the treatment of Marjolin's ulcers.,, Lesions that are located at critical places, flap cover is usually preferred because of the unstable skin grafts. Defects over the knee is always challenging, especially when the defect is quiet large and local tissue is unhealthy. In such situations neither any local fasciocutaneous flap nor muscle flap is possible, the only option left are in the form of free tissue transfer. But if this type of situation can be managed by transferring tissue from the upper part of the thigh in the form of pedicled flap then other complex reconstructions can be avoided.
| Case Report|| |
A 45-year-male presented with an ulcerated growth over the previously burnt right knee of 5 years duration [Figure 1]. He had sustained thermal flame burn to the right lower limb 30 years previously, which was managed conservatively without skin grafting. Since last 10 years, he had recurrent ulceration and healing of the scar over the right knee. He had difficulty in walking on the affected leg, unable to fully flex the knee. Since last 5 years he developed ulceration over the same site that did not heal with conservative treatment. There is no history of pain, unusual bleeding from the ulcer, and significant weight loss.
On examination, there was an ulcerated growth of size 8×6 cm 2 over the right knee joint surface irregular with patches of slough and unhealthy granulation with nodules of variable sizes ranging from 1.5 cm×1.5 cm to 0.5 cm×1 cm, margins irregular, edges raised and everted at places, base indurated and the ulcer was fixed to the underlying structure. There was presence of foul smelling scanty serous discharge from the ulcer. The surrounding skin from the lower third of thigh to the upper 2/3 of the leg was badly scarred. There was severe restriction of knee flexion but the movement, sensation, and vascularity of rest of the foot was normal. There was insignificant bilateral superficial inguinal nodal enlargement and no clinical findings suggestive of distant metastasis noted. On work-up, scrap cytology of the lesion showed moderately differentiated squamous cell carcinoma, and other investigations, such as hematologic profile, kidney function tests, ultrasonography of abdomen and pelvis, and x-ray chest, were normal. Fine-needle aspiration cytology (FNAC) of the inguinal nodes showed reactive hyperplasia and no malignant cells. X-ray of the knee revealed normal joint architecture, with no bony erosion; computed tomography (CT) scan of the knee joint was not done as the patient was not affording for the same.
Surgical anatomy of reverse ALT flap
The blood supply to the vastus lateralis muscle is principally from the descending branch of the lateral circumflex femoral (DLCF) artery. The additional blood supply to the muscle is contributed by the branches of the superior lateral genicular artery that anastomose with the descending branch of the lateral circumflex femoral artery, which is the basis of the reverse flap. The lateral superior genicular artery (LSGA) originates from the popliteal artery. It travels superolaterally and gives branches to the knee joint, vastus lateralis, and biceps femoris. It runs in the intermuscular space between the vastus lateralis and biceps femoris. Then, it penetrates through the deep fascia proximal to the knee joint just above the lateral condyle of the femur and terminates as a skin perforator in this region. The cutaneous perforators of the LSGA penetrate through the deep fascia 5 cm proximal to the femoral condyle. The terminal branches of these perforators anastomose with musculocutaneous/septocutaneous perforators of the lateral circumflex femoral artery and perforator of profunda femoris and popliteal artery.
Preoperatively with the patient in standing position the marking was done with a permanent skin marker, a line was drawn from the anterior superior iliac spine to the superolateral border of the patella along the anterolateral aspect of the thigh. Using a handheld Doppler, cutaneous perforator was marked around the lower part of this line.
Under spinal anesthesia, the patient was kept in supine position, both the lower limbs were prepared and draped. First of all wide local excision done in the form of excising 3 cm of normal skin surrounding the ulcer and also removing the underlying periosteum with the lesion. The resultant defect was 11×9 cm 2 in size, Planning in reverse was done as in pedicled flaps, the skin paddle size was measured as per the size of the defect, the pivot point was kept about 10 cm above the superior border of patella that was 4 cm above the Doppler located perforator. Dissection was performed proximodistally in the subfascial plane and intermuscular septum between rectus femoris and vastus lateralis, and the descending branch of the lateral circumflex femoral vessel and its cutaneous perforator were observed. The superior border of the muscle was divided and the skin island was divided from all sides and was tacked to the muscle to prevent any shearing. The muscle was also freed from other muscles up to the pivot point and finally it was only attached proximally with the DLCF vascular pedicle and distally with intact skin and muscle. The DLCF pedicle is then clamped with a microvascular clamp and the circulation of the skin paddle was observed for 10 min. No noticeable change in the color of blood oozing from the skin edges was noted, though the rate of bleeding declined to some extent than when the DLCF pedicle was not clamped. Then the DLCF pedicle was tied and divided, and the flap was rotated to cover the defect over intact bridge of skin like interpolation flap. The skin edges of the flap were sutured all around except at the lateral aspect where the muscle is sutured to the defect and then nonadherent paraffin gauze dressing was done. The flap was monitored for venous congestion and vascular compromise, but no eventuality was noted. Regular alternate day dressing was done till a smooth granulation was noted over the muscle [Figure 2]. The division and final inset of the flap was done at 4 weeks, with split thickness skin grafting of the residual raw area at the lateral aspect of skin paddle and at the muscle donor site in the upper part of the thigh [Figure 3].
|Figure 2: Photograph after inset of the flap to the defect and development of healthy granulation tissue over the muscle|
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|Figure 3: Fifth day post op photograph after division and final inset of the flap showing healthy flap and SSG|
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| Discussion|| |
The aim of the coverage of soft-tissue defect around the knee joint is to provide an aesthetically acceptable appearance and to maintain the function of the joint.
Soft-tissue defects around the knees are common problems in the victims of trauma, postoperative wound, or after arthroplasty and excision of various lesions, which is usually associated with exposure of bone and implant. Coverage of these defects requires appropriate planning to keep the knee joint functioning. Local advancement or rotation flaps is useful only for very small defects around the knee joint. Moscatiello et al. used skin islands from the distal anteromedial aspect of the thighs of six patients at local perforator flaps in order to reconstruct the peripatellar region and upper leg soft-tissue defects. They concluded that the propeller distal anteromedial thigh perforator flap can reliably be transferred based on the only one adequate perforator vessel, but the disadvantage is that it becomes a microsurgical technique where the dissection of the pedicle is performed by using binocular magnifying glasses. This technique was not possible in our case as the lower third of thigh also burnt and scarred. Currently, various reconstructive options available are gastrocnemius flap, sural fasciocutaneous flap, and saphenous flap. These flaps are harvested from the leg and they are also involved and injured in the traumatisation process of the lower limb. Lu et al. first confirmed the presence of at least one supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle. This perforator arises from the saphenous branch of the descending genicular artery, which accompanies two venae comitantes. Inferiorly based anteromedial thigh fasciocutaneous flap can be taken from the anteromedial aspect of the thigh, which survives on supragenicular fasciocutaneous perforator. They performed their study on 11 patients with skin defects over the popliteal fossa, proximal 1/3 leg, and amputation stump below knee. Using distally based anteromedial thigh flaps, they successfully covered these defects and showed acceptable functional and cosmetic results in terms of movement at the knee joint and matching of skin paddle with the recipient site. Chou et al. described the distally based anteromedial thigh fasciocutaneous island flap for patellar soft-tissue reconstruction in seven patients. These island flaps were based on cutaneous feeders' vessels and perforator vessels in the muscle septum and deep fascia of the saphenous artery. In their series, all flaps survived uneventfully with only one having venous congestion.
In 1990, Hayashi and Maruyama  have reported the inferiorly based anterolateral thigh (ALT) fasciocutaneous flap based on the perforators of the LSGA for the reconstruction of defects around the knee, popliteal region, lower third of the thigh, and upper one-third of the leg. Due to variable pathway of its pedicle, this flap was not used widely at that time. Since its description, there are a few publications focusing on the clinical application of this flap., It was found in these publications that this flap can be very useful for soft-tissue coverage around the knee joints.
Zumiotti et al. performed an anatomical and histomorphometric study of the lateral genicular artery flap in 18 fresh cadavers, and the clinical results of knee reconstruction were demonstrated in four patients. They identified cutaneous perforator of the LSGA in all specimens at a mean distance up to the lateral condyle of the femur of 7.40 ± 2.77 cm and thus, they confirmed the constant location of the vascular pedicle. Al Moktader et al. performed inferiorly based thigh flap on 15 patients on the perforators of LSGA for the reconstruction of defects around the knee joint. They had excellent outcome in all cases except for one in which distal marginal flap necrosis was noticed that healed by debridement and dressings.
The inferiorly based thigh perforator flap (LSGAP flap) is closer to the knee or popliteal region than the distally based reverse flow vastus lateralis flap, making it more versatile for coverage of defects of these regions. But when the distal part of the thigh is scarred then reverse vastus lateralis flap is a reasonable option. Recently, the reverse-flow (distally based) ALT flap has been used for soft-tissue reconstruction around the knee,,,,,, and it has several advantages such as a long pedicle, a sufficient amount of tissue, possible composite transfer with fascia lata, and minimal donor site morbidity. However, this flap has a risk of venous congestion from the reverse blood flow and resistance of the venous valves.,, This might cause the development of flap failure. In the cases of flap-threatening venous congestion after the reconstruction of an oncologic defect of the knee with reverse-flow ALT island flap, a few authors have performed venous supercharge using the greater saphenous vein with a reliable vessel diameter and salvaged the flap successfully.
We have opted for reverse vastus lateralis musculocutaneous flap, as the surrounding skin at the lower third of the thigh is also scarred so no skin or fasciocutaneous flap was possible. The flap is also based on the same perforators as in reverse skin or fasciocutaneous flaps that also supply the vastus lateralis muscle. We have kept the pivot point at 10 cm above the superolateral border of patella that is about 4 cm above the mapped perforators and we have observed no venous compromise of the flap that is in contrast to other studies as the pivot point was further down.
| Conclusion|| |
Reverse vastus lateralis musculocutaneous flap is a very good option for covering a large knee defect especially when the surrounding skin of the lower third of the thigh and upper third of the leg is scarred. The flap is reliable and easy to execute and provides good cosmesis with minimal donor site morbidity.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]