Double Pedicled Perforator Flap Reconstruction for a Rare Cutaneous Squamous Cell Carcinoma on a Hypertrophic Lichen Planus Patient
--- CASE STUDY
Dr. Kong Chee Kwan Department of Plastic and Reconstructive Surgery, Hospital Kuala Lumpur, Malaysia.
Mdm (Dr) Normala Bte Hj Basiron
It is rare for a cutaneous lichen planus lesion to develop malignancy. We present a case report of a young man with chronic lichen planus who developed a squamous cell carcinoma over his right shin. Wide excision and right inguinal dissection were performed. The large defect exposing tibia bone were covered with a novel concept of a double pedicled perforator fasciocutaneous flap to reconstruct the defect. The knowledge of anatomy and understanding of the perforator concept offer single stage, safe, and aesthetically satisfying reconstruction of large skin defects following excision of tumours with minimal donor site morbidity.
Lichen planus is a mucocutaneous inflammatory disease of unknown aetiology. It is believed that lichen planus represents a cell-mediated immunological reaction within the affected tissues, however, the precise trigger for this being unknown 1. Lichen planus, typically arises in females of middle age but also affects males. The oral mucosa and skin are the most frequently involved areas2. According to population-based data from Sweden, the prevalence of cutaneous lichen planus among men is 0.3% while in women is 0.1%3. Meanwhile, the prevalence of oral lichen planus among men is 1.5% while among women is 2.3%4.
We present a case report of a novel concept of a fasciocutaneous flap with 2 independent perforators isolated to reconstruct the defect.
A 31-year-old male patient was diagnosed with multiple cutaneous lichen planus since 27 years ago by dermatologist in our hospital based on his clinical features and serial biopsies of the lesions. The most recent biopsy was taken over the right shin lesion in 2007 and it was reported as consistent with hypertrophic lichen planus. He never had history of oral or mucosal lichen planus. There was no family history of any skin disorder such as lichen planus and his Hepatitis C status was negative. All the while he was on treatment using topical and injection
corticosteroid and laser therapy by dermatologist at our center. Some of the lesions have healed but others remained.
In February 2012, he was referred to plastic and reconstructive surgery clinic with the history of a rapidly enlarging ulcerative lichen planus lesion on the anterior aspect of his right shin of 2 months duration (Fig 1). It was initially a violacious, papular lesion that never disappear despite treatments. Clinically, there were multiple palpable and mobile right inguinal lymph nodes. Besides the skin lesion and right groin lymphadenopathy, his general physical examination and systemic examinations did not reveal any abnormality. A wedge biopsy of the lesion was immediately performed which later revealed squamous cell carcinoma.
Figure 1: Rapidly enlarging and ulcerative lesion over right mid-shin Page 4
A wide excision down to tibia with surrounding 3 cm margin was carried out together with right inguinal dissection. The defect size was 14 x 5cm. After identifying the site of perforators by handheld Doppler ultrasound, the skin paddle medial to the defect was designed. Intra-operatively, we elevated the islanded fasciocutaneous flap based on 2 independent perforator vessels from posterior tibial artery. The first perforator was dissected through soleus muscle and the second perforator through gastrocnemius muscle (Fig 2). The perforator from soleus muscle was the dominant pedicle, situated 15cm proximal to medial malleolus. The patency of both perforators was confirmed by handheld Doppler ultrasound after skin closure. The flap skin had normal colour and turgor. The flap provided soft tissue cover over the exposed tibia. The surrounding muscle and donor site defect were covered with split thickness skin graft (Fig 3).
Perforator through gastrocnemius
Perforator through soleus
Figure 2: The double perforators arising from posterior tibial artery
Figure 3: The flap transposed over the tibia defect. Split thickness skin graft covered the surrounding muscle and donor site defect.
It is rare for this patient to develop lichen planus at the age of 4 years and then to develop squamous cell carcinoma over the lesion at 31 years old. Most of the age onset of lichen planus is at middle age and more commonly affecting females5.
There are guidelines on the management of oral but not on cutaneous lichen planus6. Corticosteroid therapy is the mainstay of treatment. However, there is limited evidence from randomized controlled trials as to the precise efficacy of Page 7
the various preparations that are in common usage. Management choices on the cutaneous lesions are based mainly on clinical experience. 7
There is no guideline specific to monitoring of cutaneous lichen planus lesions for malignancy changes. Based on UK National Institute for Health and Clinical Excellence “Referral guidelines for suspected cancer”, any non-healing lesions larger than 1 cm with a documented expansion over 8 weeks should be biopsied to exclude squamous cell carcinoma8.
For a long-standing oral lichen planus lesion, it has been reported the development of squamous cell carcinoma of the mouth at a rate of 0.5 - 2% over a 5-year period. Whether this reflects a common cause or that lichen planus is pre-malignant remains unclear and the association could be coincidental9. So far, there is no report on the rate of squamous cell carcinoma developed from cutaneous lichen planus. There have been only a small number of case reports on such patients10.
Squamous cell carcinoma can be an occasional complication of long standing chronic granulomas, chronic ulcers, osteomyelitic sinuses, old burn etc. A higher incidence of squamous cell carcinoma is also observed in immunosuppressed patients. Only a relatively small number of squamous cell carcinomas can arise without some previous exogenous cause11.
Large defects following wide resection of skin malignancies are a challenge for the reconstructive surgeon especially when anatomic structures like bones, nerves, blood vessels, or tendons
are exposed. Method chosen
reconstruction depends on the anatomical location, size, function and aesthetic outcome based on the reconstructive ladder12. As for our patient, there are few options available to close the right shin defect, ie. local pedicle flap, perforator, flap, tissue expansion and free flap.
Ideally, limb reconstruction should be planned taking into consideration of shortoperative times, minimal donor side morbidity, and optimal functional result by replacement of the missing tissue following the “like with like” principles. In 1917, Esser introduced the subcutaneous pedicle flap. Since then, there have been multiple modifications such as V-Y advancement flap, bipedicle flap and keystone flap. Such local pedicle flaps are easy to design and execute. However, there are restrictions such as limited mobility and resultant tension placed on the wound13.
An example of local pedicle flap is the keystone design island flap introduced by Felix C. Behan in 2003. It is a curvilinear shaped trapezoidal flap parallel with the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, and by V-Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic
results14. It was not chosen for our patient due to the large defect size, location at upper half of tibia and the skin texture was non-pliable.
The introduction of pedicled perforator flap techniques by Koshima and Soeda in 1989 sparked a major shift in the thought process of reconstructive surgery. The flaps harvested with only the perforating vessels and vascular pedicle without the muscle15. According to the Gent consensus, perforator flaps are composed of skin and subcutaneous fat being nourished by vessels (perforators) arising from the deep vascular system, which are reaching the surface by passing mostly through muscle and intermuscular septa. Since they are based on perforator vessels, dissection of these flaps leaves minimal donor side morbidity and they are easier for tailoring to fit perfectly into the defect16. Used either as transpositioned, V-Y advanced or rotated, such flaps were employed for coverage of a large array of complex defects.
One option of perforator flap is propeller flap, which was first described by Hyakusoku in 1991. It is a fasciocutaneous flap based on a central subcutaneous perforator, which once dissected, allowed a 90 to 180 degree rotation on it’s axis, to cover a tissue defect. The advantage is that the perforator vessels can withstand torsions up to 180 degree, thus giving the surgeon an almost unlimited flexibility in planning the reconstruction17. However, this type of flap was not suitable for our patient because of the longitudinal defect.
The advantages of tissue expansion were preservation of sensation and hair, absence of donor defect and good colour and texture match. However, it was not suitable, as it needed at least 2-stage surgery and waiting time to expand the donor site. Free flap would be a good option, however, it is technically demanding and requires prolonged operative time and microsurgical expertise18.
Therefore, in our patient, transpositional islanded pedicled perforator flap was chosen because of the large longitudinal defect size. Intra-operatively, we delineated 2 perforators to ensure sufficient vascularity of the long flap. After insetting the flap, it produced less of a dead space, allowing for more reliable wound healing. However, the donor site required split skin thickness grafting. The drawback is the incisions restrict future flap design, as compared with other alternatives such as a rotational flap. We present this case report because the usage of double pedicled perforator flap is seldom used and reported. The only such recent reports were to cover lumbosacral19 and flank20 defects.
Double pedicled perforator flaps provides a novel concept of perforator flaps. The knowledge of anatomy and understanding of the perforator concept offer single stage, safe, and aesthetically satisfying reconstruction of large skin defects following excision of tumours with minimal donor site morbidity.
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