Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas

Jue Wang; Peiru Min; Luca Grassetti; Davide Lazzeri; Yi Xin Zhang; Fabio Nicoli; Marco Innocenti; Matteo Torresetti; L. Scott Levin; Paolo Persichetti

doi:10.1055/s-0035-1556078

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg 2015; 31(09): 621-630
DOI: 10.1055/s-0035-1556078

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas

Authors

Jue Wang^*

¹Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China
Peiru Min^*

¹Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China
Luca Grassetti^*

²Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, University Hospital of Ancona, Ancona, Italy
Davide Lazzeri

³Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy
Yi Xin Zhang

¹Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China
Fabio Nicoli

³Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy
Marco Innocenti

⁴Reconstructive Microsurgery Unit, Hospital of Florence, Florence, Italy
Matteo Torresetti

²Department of Plastic and Reconstructive Surgery, Marche Polytechnic University Medical School, University Hospital of Ancona, Ancona, Italy
L. Scott Levin

⁵Department of Orthopedic Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
Paolo Persichetti

⁶Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University, Rome, Italy

Abstract

Background We present the clinical application of the sixth internal mammary artery perforator (IMAP) and superior epigastric artery perforator (SEAP) flaps for the treatment of defects resulting from the excision of large lower sternal and upper abdominal keloids. Perforator selection and flap design were based solely on preoperative multidetector-row computed tomographic angiography (MDCTA) of the areas adjacent to the soft tissue defects.

Methods Between January 2009 and June 2014, 15 patients with large, unstable keloids subject to recurrent inflammation and infections and with a history of multiple failed treatments underwent surgical excision and early postoperative radiation therapy. The defects were located in the upper abdomen (n = 6) or lower sternum (n = 9). All patients underwent preoperative MDCTA for perforator localization.

Results A total of 15 patients underwent keloid removal followed by IMAP (n = 10) and SEAP (n = 6) flap coverage combined with early postoperative low-dose radiation therapy (350 cGy/5 fractions/5 days or 400 cGy/4 fractions/4 days). Flap sizes ranged from 9 × 5 to 17 × 6 cm. Only one IMAP flap developed a 2 × 2 cm tip necrosis, which was managed with dressing changes. The remaining flaps healed uneventfully with no keloid recurrence at 23.4 months. In all cases, the perforator location determined by preoperative MDCTA was precisely consistent with the intraoperative findings.

Conclusion The sixth IMAP and SEAP flaps combined with early postoperative radiation therapy provided a valid and feasible approach for the surgical treatment of large keloids in the lower sternal and upper abdominal. MDCTA enabled detailed preoperative assessment of the perforators, facilitating both flap design and dissection, and saving operating time. Although longer follow-up is required, these preliminary results are encouraging.

Keywords

internal mammary artery perforator - superior epigastric artery perforator - keloid - pedicle propeller flap - computed tomographic angiography

Volltext

Referenzen

References
1 Halim AS, Emami A, Salahshourifar I, Kannan TP. Keloid scarring: understanding the genetic basis, advances, and prospects. Arch Plast Surg 2012; 39 (3) 184-189
2 Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg 2009; 23 (3) 178-184
3 Brissett AE, Sherris DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg 2001; 17 (4) 263-272
4 de Almeida OM, Braz JC, Jorgetti C, de Lemos RG, Neves RI. Treatment of extensive sternum keloid scar with surgical removal and immediate reconstruction with skin flaps from a combined mammaplasty. Plast Reconstr Surg 2000; 105 (7) 2452-2454
5 Manuskiatti W, Wanitphakdeedecha R, Fitzpatrick RE. Effect of pulse width of a 595-nm flashlamp-pumped pulsed dye laser on the treatment response of keloidal and hypertrophic sternotomy scars. Dermatol Surg 2007; 33 (2) 152-161
6 Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med 2011; 17 (1-2) 113-125
7 Mustoe TA, Cooter RD, Gold MH , et al; International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110 (2) 560-571
8 Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg 2010; 125 (2) 557-568
9 Murakami M, Hyakusoku H, Ogawa R. The multilobed propeller flap method. Plast Reconstr Surg 2005; 116 (2) 599-604
10 Lazzeri D, Huemer GM, Nicoli F , et al. Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review. Arch Plast Surg 2013; 40 (1) 44-50
11 Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007; 120 (1) 1e-5e
12 Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009; 62 (9) 1127-1134
13 Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deep superior epigastric artery perforator ‘propeller’ flap for abdominal wall reconstruction: A case report. J Plast Reconstr Aesthet Surg 2010; 63 (7) 1223-1226
14 Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-cavity reconstruction after oncologic rib resection. Microsurgery 2011; 31 (4) 335-336
15 Oni G, Sharma R, Rao R, Unger J, Saint-Cyr M. Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage. J Plast Reconstr Aesthet Surg 2011; 64 (8) 1104-1107
16 Paes EC, Schellekens PP, Hage JJ, van der Wal MB, Bleys RL, Kon M. A cadaver study of the vascular territories of dominant and nondominant internal mammary artery perforators. Ann Plast Surg 2011; 67 (1) 68-72
17 Schmidt M, Aszmann OC, Beck H, Frey M. The anatomic basis of the internal mammary artery perforator flap: a cadaver study. J Plast Reconstr Aesthet Surg 2010; 63 (2) 191-196
18 Ono S, Chung KC, Hayashi H, Ogawa R, Takami Y, Hyakusoku H. Application of multidetector-row computed tomography in propeller flap planning. Plast Reconstr Surg 2011; 127 (2) 703-711
19 Wong C, Saint-Cyr M, Rasko Y , et al. Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg 2009; 124 (6) 1759-1769
20 Economides NG, Ferrell TH. Neck resurfacing with free tram flap. Microsurgery 1992; 13 (5) 240-242
21 de Almeida OM, Braz JC, Jorgetti C, de Lemos RG, Neves RI. Treatment of extensive sternum keloid scar with surgical removal and immediate reconstruction with skin flaps from a combined mammaplasty. Plast Reconstr Surg 2000; 105 (7) 2452-2454
22 Ogawa R, Akaishi S, Huang C , et al. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nippon Med Sch 2011; 78 (2) 68-76
23 Chen Y, Chhabra N, Liu YC, Zender CA. Lateral arm microvascular free tissue reconstruction of a large neck keloid. Am J Otolaryngol 2014; 35 (4) 514-516
24 Bayat A, Bock O, Mrowietz U, Ollier WE, Ferguson MW. Genetic susceptibility to keloid disease and hypertrophic scarring: transforming growth factor beta1 common polymorphisms and plasma levels. Plast Reconstr Surg 2003; 111 (2) 535-543 , discussion 544–546
25 Chin MS, Ogawa R, Lancerotto L , et al. In vivo acceleration of skin growth using a servo-controlled stretching device. Tissue Eng Part C Methods 2010; 16 (3) 397-405
26 Chin MS, Lancerotto L, Helm DL , et al. Analysis of neuropeptides in stretched skin. Plast Reconstr Surg 2009; 124 (1) 102-113
27 Aoki M, Akaishi S, Ono S, Iwakiri I, Ogawa R, Hyakusoku H. Usefulness and problems of flap surgery for keloids. Scar Management. 2010; 4: 108-111
28 Berman B, Flores F. Recurrence rates of excised keloids treated with postoperative triamcinolone acetonide injections or interferon alfa-2b injections. J Am Acad Dermatol 1997; 37 (5 Pt 1) 755-757
29 Li W, Wang Y, Wang X, Liu Z. A keloid edge precut, preradiotherapy method in large keloid skin graft treatment. Dermatol Surg 2014; 40 (1) 52-57
30 Clayman MA, Clayman SM, Mozingo DW. The use of collagen-glycosaminoglycan copolymer (Integra) for the repair of hypertrophic scars and keloids. J Burn Care Res 2006; 27 (3) 404-409
31 Chandawarkar RY, Piorkowski J, Amjad I, Deckers PJ. Combination therapy of a large, recurrent keloid. Dermatol Surg 2007; 33 (2) 229-235
32 Patel NP, Lawrence Cervino A. Keloid treatment: is there a role for acellular human dermis (Alloderm)?. J Plast Reconstr Aesthet Surg 2010; 63 (8) 1344-1348
33 Wang Y, Xu J, Wu H, Wang X, Wang Z. Recurrence of large subcutaneous keloids after tissue expansion: two case reports. J Plast Reconstr Aesthet Surg 2013; 66 (2) e58-e59
34 Jones K, Fuller CD, Luh JY , et al. Case report and summary of literature: giant perineal keloids treated with post-excisional radiotherapy. BMC Dermatol 2006; 6: 7
35 Kovalic JJ, Perez CA. Radiation therapy following keloidectomy: a 20-year experience. Int J Radiat Oncol Biol Phys 1989; 17 (1) 77-80
36 Botwood N, Lewanski C, Lowdell C. The risks of treating keloids with radiotherapy. Br J Radiol 1999; 72 (864) 1222-1224
37 Bilbey JH, Müller NL, Miller RR, Nelems B. Localized fibrous mesothelioma of pleura following external ionizing radiation therapy. Chest 1988; 94 (6) 1291-1292
38 Hamdi M, Craggs B, Stoel AM, Hendrickx B, Zeltzer A. Superior epigastric artery perforator flap: anatomy, clinical applications, and review of literature. J Reconstr Microsurg 2014; 30 (7) 475-482
39 Kim S, Choi TH, Liu W, Ogawa R, Suh JS, Mustoe TA. Update on scar management: guidelines for treating Asian patients. Plast Reconstr Surg 2013; 132 (6) 1580-1589