Trunk Reconstruction with Free Fasciocutaneous Flaps Using Intra-Abdominal Donor Vessels

Resection of large and recurrent cancers of the chest and trunk presents difficult reconstructive problems. The defect size and frequent radiation requirement limit local reconstructive options. Free tissue transfers are well-established but frequently require the use of vein grafts to lengthen donor vessels. Intra-abdominal vessels are ideally positioned as recipient vessels for these chest and trunk reconstructions.

Patients with cancer involving the chest or trunk, requiring resection and radiation, were evaluated for reconstruction. All required a full-thickness chest-wall and/or trunk-wall resection. None were suitable for free tissue reconstruction without the use of vein grafts. Patients underwent resection and intraoperative radiation as needed. Free anterolateral thigh flaps were used with the incorporation of the tensor fasciae latae. In 3 cases, the right gastroepiploic vessel was dissected off the greater curvature of the stomach and used as the donor vessel for central abdominal- and chest-wall defects. In 2 cases, a splenectomy was performed and the splenic vessels were used for reconstruction of the left lateral chest, diaphragm, and left lateral abdominal-wall defects. In 3 cases, omental vessels were used for defects involving the mid abdomen.

All 7 cases could be reconstructed with the use of intra-abdominal vessels alone. No vein grafts were needed due to the proximity of the donor vessels to the defects. In one case in which the splenic vessels were used, significant venous congestion occurred on postoperative day 5. This was coincident with patient hypotension and resolved with fluid resuscitation. In all cases, the arterial signal was significantly compromised when the systolic blood pressure decreased, and immediately returned or improved with fluid resuscitation.

Reconstruction of trunk and chest-wall defects can pose difficult problems, if no donor vessels are available for free tissue transfer. These full-thickness defects allow easy exposure of intra-abdominal vessels that can be used effectively for free tissue transfers. The gastroepiploic system, splenic vessels, and omental vessels are the most easily used. Defect location dictates which vessel is most appropriate. The most significant concern related to these vessels is the degree of vasoactivity they possess. In all cases, postoperative hypotension significantly decreased the Doppler signal strength on the flap. This potentially could increase the rate of thrombosis and flap failure, if not addressed promptly.