Advantages of Using the Intercostal Vessels as Recipient Sites for Free Flaps Covering Lumbar Defects

Repair of defects in the lumbar region is still a delicate problem for the surgeon, requiring mastery of the techniques of reconstructive surgery. Microsurgery plays a major role in the treatment of large defects. However, the difficulty of any microsurgical act in this region is complicated by the need to search for potential recipient vessels.

Case report. A 50-year-old woman was seen as an outpatient in November, 2002 for occurrence of multiple basal cell carcinomas in a lumbar radiodermatitis area (22x10 cm). She had presented with an ependymoma of the cauda equina in 1985 requiring resection with L1-S1 laminectomy and complementary external radiotherapy.

A large resection of the radiodermatitis zone was performed to avoid major risk of degeneration of the entire region. The resected area was to be filled with a free left latissimus dorsi flap, and the revascularization of this flap was to be ensured by a double arterial and venous bypass (performed with a right greater saphenous vein graft) connected to the thoracodorsal vessels.

After resection of the radiodermatitis zone, dura mater was exposed along the entire upper part of the L1-S1 laminectomy. The latissimus dorsi pedicle was of small caliber (1.3 mm). The diameter of the right greater saphenous vein was much greater (4.5 mm). This major incongruence between the two vessels made any attempt at arterial and venous microanastomosis risky. This led then to a search for local recipient vessels of suitable diameter. The 8th intercostal pedicle was investigated at the level of the anterior axillary line, and dissection was continued from front to back until congruent vessels were obtained, whose mobilization avoided any curvature. A termino-terminal arterial and venous microanastomosis was then performed.

A thin split-thickness graft was utilized on day 6, and the patient was discharged on day 22. Histopathologicl studies showed five foci of superficial basal cell carcinomas, with deep lateral excision lines in the non-tumor area. Healing was complete after 6 months of follow-up. The patient has no functional difficulties in everyday life and experiences no pain when pressure is applied to the lumbar region.

This case was unique and does not allow precise definition of the circumstances for utilization of the intercostal pedicle as a recipient vessel. However, the advantages of this procedure, as described, suggest that it could be a useful addition to the therapeutic arsenal for the repair of lumbar defects by free flaps.