Case Report

36 years old Malay man who has a recurrent dermatofibrosarcoma protuberans on the back at the level of the lumbo-sacral region was subjected on 10th of July 2008 for excision of the lesion with a safety margin of 2 – 3 cm, as shown in fig (1) and (2)

The defect measured 12 cm X 10 cm and was rhomboid shaped.

The general surgeon asked to wait until histopathologist gave us the needed informations about the safety margin excised. When he confirmed that the margins are free of any neoplastic cells we proceeded to cover the defect.

Figure 1

Figure 1: Defect after tumor excision of the tumor (dermatofibrosarcoma protuberans)

Figure 2

Figure 2

The author designed and mapped the defect and surrounding possible skin flaps.

He put the design as shown in figure (3 - 7) either to make (right thoraco-lumbar and left gluteal) or (left thoraco-lumbar and right gluteal) island flaps.

Technique

Incisions were done around the marked areas in Fig (4 and 7) and release of the fasciocutaneous flaps from the surrounding skin and mobilizing these flaps to meet at the center (Fig 5). Mild dissection of proximal ends of these flaps was done to become more mobile. Incision of the deep fascia was also done on both flaps with securing the bleeding vessels.

When the flaps became mobile enough, and met easily to fill the defect, the author started to undermine the upper and lower edges of the wound.

When the author became comfortable with the all flaps, he started to close the wound in layers with a suction drain below the flap Fig (8 and 9). The medial edges of the flaps are sutured to each other and fixed to the underlying tissue over the spine to close any possible dead space.

Figure 3

Figure 3: The defect

Figure 4

Figure 4: Mapping

Figure 5

Figure 5: Flap dissection

Figure 6

Figure 6: Closure complete

Figure 7

Figure 7: Defect and mapping

Post Operative

Results

Flaps are nicely healed and closure of the wound was complete

Figure 8

Figure 8: One week after operation with a drain in place

Figure 9

Figure 9

Figure 10

Figure 10: 11 days postoperative

Figure 11

Figure 11

Discussion

Perforator arterial supply to the skin from the underlying soft tissue as muscle or deep fascia are to be considered responsible for viability of the flap.(₆)

Design of the flap and dissection need to be based on allocation of the proper arterial supply from the underlying tissues.

With larger flaps the chance of viability and good blood supply will be more. Design of the flaps also should suits the size and shape of the defect. If the perforator artery is well known, the flap can be freed as a pedicle flap and moved up to 90°

Conclusion

Mr Felix C. Behan whom the author met in Lengkawi Malaysia 2008, said that this method is an excellent technique to replace free micro-vascular flaps.

Acknowledgement

Correspondence to

Dr Ahmed Hussein AER, plastic surgeon, Malaysia ahmedhusseinr@yahoo.com, ahmedhussein@salam.uitm.edu.my