Plastic Elimination of Soft Tissue Defects of the Chest Wall Arising After Harvesting Free Revascularized Autotransplants

The dissertation is devoted to the study of methods for plastic closure of soft tissue defects of the posterolateral surface of the thoracic cage arising after harvesting microsurgical autotransplants. The work presents an analysis of indications for the application of various methods of local skin plastic surgery, investigates local complications, and develops optimal methodologies and techniques for closing donor site defects. Based on a comprehensive examination of 200 patients, the most effective methods for defect restoration using local tissues were identified.

Relevance. The method of microsurgical autotransplantation of free revascularized tissues is currently the most effective method in plastic and reconstructive surgery and surpasses the results of known methods of distant plastic surgery for the closure of large defects of various etiology and localization (Trofimov E.I. 2001, Mnilznov N.A. et al. 2003). Nevertheless, the question of achieving an optimal cosmetic and functional result not only in the recipient area but also in the donor area remains open.

The most commonly used microsurgical autotransplant is the thoracodorsal and scapular flap, which is associated with their universality (Krylov V.S. et al. 1982; Mplanov N.A. 1984; Trofimov E.I. 1985; Voskresenskiy M.N. et al., 1979). When harvesting these flaps, defects of sufficiently large size arise on the posterolateral surface of the back, the closure of which is often problematic, which very often leads to gross scar changes and functional complications (Rzaev D.O. 1991). Thus, the problem of closing the donor defect, which is by its very nature iatrogenic, requires an adequate solution that will make it possible to avoid possible functional and aesthetic complications.

The insufficient study of the full complex of factors influencing the consequences of harvesting a thoracodorsal and scapular tissue complex on clinical material requires, at the present level of development of plastic and reconstructive microsurgery, closer attention to this problem.

Functional and aesthetic impairments in the donor area after harvesting a tissue complex are the result of the action of local and general factors.

In the first case, these are the consequences of partial or complete excision of the latissimus dorsi muscle with the skin-fat layer from the motor and cover systems of the human body, which gives rise to certain, and in some cases significant problems in closing the donor defect, and thus aesthetically rough scars, often fused with surrounding tissues, appear, limiting the motor function of the adjacent upper extremity in the postoperative period.

In the second case, the consequences are often caused by an inadequate approach, namely the tactic of ignoring (except in emergency indications) the optimal possibilities of the donor area and the social characteristics of the patient in favor of functional, plastic, and sometimes aesthetic goals of treatment — without a preliminary analysis of the consequences of harvesting.

A comprehensive study of the causes of complications in the donor area after harvesting a tissue complex and the development of an optimal approach to donor possibilities appears, in light of the above, highly relevant.

Objective of the study: to determine the influence of the method of closure of soft tissue defects arising after harvesting microsurgical autotransplants from the posterolateral surface of the thoracic cage on the development of immediate and late local complications.

Tasks:

To give an assessment of soft tissue defects arising as a result of harvesting microsurgical autotransplants from the posterolateral surface of the thoracic cage.

2. To determine the indications for the use of various methods of local skin plastic surgery for the closure of soft tissue defects of the posterolateral surface of the thoracic cage.

3. To give an analysis of local complications developing after plastic closure of soft tissue defects of the posterolateral surface of the thoracic cage.

4. To conduct a comparative analysis of the results of applying various methods of local skin plastic surgery for the closure of soft tissue defects of the posterolateral surface of the thoracic cage arising after harvesting microsurgical autotransplants.

5. To determine the optimal methodology and technique of skin plastic surgery for the closure of soft tissue defects of the posterolateral surface of the thoracic cage.

Results.

An analysis of the results of autotransplantation of the musculocutaneous thoracodorsal, fasciocutaneous scapular flap, as well as muscular flaps based on the serratus anterior muscle and latissimus dorsi muscle, performed in the Department of Plastic and Reconstructive Microsurgery of the State Institution "Russian National Research Center of Surgery" named after Academician B.V. Petrovsky of the Russian Academy of Medical Sciences, was conducted with a retrospective archival study of the entire period of patient treatment. In order to determine the features and develop optimal methods of local skin plastic surgery of the donor defect, clinical and active examination with archival study of the medical histories of 200 patients was used.

To identify functional, social, and aesthetic complications after harvesting microsurgical autotransplants, active examination of 25 patients and a general questionnaire survey of 108 patients, not including the actively examined, was carried out.

As a result of the conducted research, indications for the use of methods of local skin plastic surgery for the elimination of iatrogenic defects of the posterolateral surface of the thoracic cage arising as a result of harvesting microsurgical autotransplants were identified and analyzed in detail. An optimal methodology and technique of skin plastic surgery in the donor area after harvesting microsurgical autotransplants was also developed. Based on this, a number of important practical conclusions were made.

The scientific novelty of the work lies in the fact that for the first time on a large archival and clinical material, an analysis of the causes of the development of immediate, as well as functional and aesthetic complications in the donor area after harvesting a tissue complex was conducted, and based on detailed examination, the most optimal methods for closing donor defects and forms of autotransplants were identified for the first time.

The data on the consequences of flap harvesting made it possible to develop and successfully test optimal methods for closing donor defects through skin plastic surgery using local tissues.

Practical Significance

A comprehensive examination of patients with soft tissue defects of the posterolateral surface of the thoracic cage after the application of microsurgical autotransplants was conducted.

In the work, the indications for the use of methods of local skin plastic surgery for the closure of iatrogenic defects of the posterolateral surface of the thoracic cage arising as a result of harvesting microsurgical autotransplants were identified and studied in detail.

The most optimal methodology and technique of skin plastic surgery in the donor area was determined.

The results obtained in the work can be used in the work of departments and centers of plastic and aesthetic surgery.

Implementation of the Results of the Work into Practice

The scientific provisions and recommendations contained in the dissertation were implemented in the practical activities of the Department of Restorative Microsurgery of the State Institution "Russian National Research Center of Surgery" named after Academician B.V. Petrovsky of the Russian Academy of Medical Sciences.

Presentation of the Work. The dissertation presentation was made at the scientific conference of the Department of Restorative Microsurgery of the State Institution "Russian National Research Center of Surgery" of the Russian Academy of Medical Sciences on June 16, 2006.

Five publications were published on the topic of the dissertation.