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Ann Thorac Surg 2002;74:1038-1042
© 2002 The Society of Thoracic Surgeons

Original article: general thoracic

Free deepithelialized anterolateral thigh myocutaneous flaps for chronic intractable empyema with bronchopleural fistula

Feng-chou Tsai, MDa, Hung-chi Chen, MD, FACS*a, Samuel Huan-tang Chen, MDa, Bruno Coessens, MDa, Hui-ping Liu, MDb, Yi-cheng Wu, MDb, Ping-chang Lin, MDb

a Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
b Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Accepted for publication June 5, 2002.

* Address reprint requests to Dr Chen, Department of Plastic Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsin St, Kweishan, Taoyuan, Taiwan
e-mail: plastytsai{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Free deepithelialized anterolateral thigh (DALT) flaps have been used for treatment of chronic intractable empyema with bronchopleural fistula at Chang Gung Memorial Hospital since 1997.

Methods. Twelve patients with chronic empyema were treated at Chang Gung Memorial Hospital from January 1997 to January 2001. Their age ranged from 31 to 70 years (mean age 48.6 years). Left-sided involvement was predominant (left to right ratio = 9: 3). All patients had bronchopleural fistula, and all were cured. The average numbers of previous thoracotomy were 5.4. The ipsilateral DALT flaps were harvested with primary closure of donor site.

Results. At a mean follow-up of 1 year, no recurrence was noted. All flaps survived well. The average hospital stay was 25.8 days. Complications after reconstruction included chrondritis, partial muscle necrosis, and wound dehiscence (1 patient each). There was no donor site morbidity.

Conclusions. Free DALT flaps can be selected according to different situations during surgery as long as they meet the following requirements: (1) tissue of sufficient volume and good blood supply, and (2) closure of the bronchial leak. Based on this retrospective study, use of free DALT flaps with technical refinement is a reliable method for treatment of chronic intractable empyema combined with bronchopleural fistula.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Management of empyema requires obliteration of pleural space, often in the early stage simply by tube thoracostomy, but as the infection becomes chronic and intractable open drainage may be necessary, especially when multiple innoculation, inaccessible collections and sepsis are present [1]. Over the years, three different methods of obliterating pleural space have evolved: (1) thoracoplasty, (2) sterilization of space with antimicrobial solutions, and (3) autogenous tissue (eg, decortication and muscle flaps) [2]. Successful management is possible with resection of the destroyed lung, closure of bronchopleural fistula, and obliteration of residual pleural space. Autologous muscle or myodermal flaps can be used to efficiently treat both of the aforementioned conditions like the "tissue glue or dermal plug" without obvious morbidity relating to donor and recipient site.

Myodermal flaps are reserved for patients with the following indications: (1) chronic intractable empyema; (2) large residual empyema, (3) multiple pleural, costal, and myoplastic procedures with failures and loss of local groups, (4) desire to avoid disfiguring thoracoplasty, (5) persistent bronchopleural fistula, and (6) failure of free muscle flaps for bronchopleural fistula [3–5]. Unfortunately the fragile feature of muscle is not suitable for the suture to the infected bronchial stump; therefore the new method is developed for solution of this technical problem.

The anterolateral thigh (ALT) flap supplied by the lateral femoral circumflex system was first introduced by Song and colleagues [6] in 1984 and was developed for clinical applications by Koshima and colleagues in 1993 [7, 8]. To harvest the ALT flap safely and reliably, a thorough understanding of the anatomic variations of the perforators and the operative technique was introduced by Kimata and colleagues [9, 10]. The lateral femoral circumflex system originating from the deep femoral artery travels along the intermuscular space between rectus femoris, vastus medialis and vastus lateralis muscle. The vastus lateralis muscle and skin over the lateral thigh should be included for the use of myocutaneous flap. This flap provides the adequate volume and long pedicle for obliteration of dead space and microsurgical anastomosis in empyema.

The concept of deepithelialization is first applied to the field of free flaps for the stability of bronchial seal-off. In this article, techniques and advantages of use of free deepithelialized (myodermal) flaps in intractable cases are highlighted.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
From January 1997 to January 2001, 12 patients with chronic intractable empyema underwent free DALT flaps at Chang Gung Memorial Hospital in Taiwan. All patients were male, with a mean age of 48.6 years (range 31–70 years). Left-sided involvement was predominant. (left to right ratio 9:3). The average number of previous procedures including tube thoracostomy, thoracotomy, decortication, and lobectomy was 5.4 (Table 1). Under general anesthesia, one-lung ventilation was used to prevent intraoperative interference of lung movement. Adequate debridement was performed by a chest surgeon, with ipsilateral free DALT flap harvest performed by the plastic surgeon. The surgical table can be adjusted intraoperatively for the convenience of operative process. The methods used to estimate the volume of the residual space were preoperative chest roentgenography and preoperative computed tomography. After estimating the size of the residual defect, the appropriate size of free flaps was selected.


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  		Table 1. Previous Treatments

 
After perforators were identified with a pencil Doppler probe in the middle point from the anterior superior iliac spine to the superolateral border of the patella over the ipsilateral thigh, the initial incision was made 3 cm medial to this straight line (Fig 1A). The fascia was incised to identify the perforators emitting from the branches of lateral circumflex femoral system (Fig 1B). Retrograde intramuscular dissection was performed along the direction of musculocutaneous perforators. Because there are no superficial branches from these perforators according to the anatomical study, the dissection was made faster by the transection of muscle just around the perforators (Fig 1C). The muscle cuff was depicted along the axis of the descending branch of lateral circumflex femoral artery (LCFA) according to the need of volume of the flap. The flap included the deepitheliazed skin, subcutaneous tissue, fascia, and muscle. The motor nerve was cut out for denervation of the function of the vastus lateralis muscle. The descending branch of the lateral circumflex femoral system was easily discovered after retracting the RF medially. The total pedicle (length about 6 cm) was dissected delicately. The diameter of artery and vein was 2.5 mm and 3 mm, respectively. The deepithelialization procedure was then performed on the donor thigh using scissors to remove the epidermis. The thickness of residual dermis is about 0.3 cm for preservation of the intact blood supply of subdermal plexus.



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  		Fig 1. (A) The initial incision is made 3 cm medial to the straight imaginary line from the anterior superior iliac spine to the superolateral border of the patella. (B) The myocutaneous perforators emit from the branches of lateral circumflex femoral system and pierce the fascia. (C) Retrograde intramuscular dissection is performed along the direction of musculocutaneous perforators with the transection of muscle just around the perforators. (D) The myocutaneous flap before deepithelialization. (E) The flap is put on the uppermost portion of dead space in the lesion site. (F) Donor site can be primarily closed without difficulty if width of cutaneous part is less than 7 cm.

 
The recipient vessels were prepared in the upper thorax (thoracodorsal vessels [TDV] were preferred due to its proximity and adequate vessel size). If the previous thoracotomy caused the thoracodorsal vessels to be injured, the internal mammary vessels (IMV) were the second choice. The orifice of cavity was created to allow insertion of free flaps by removing 6- to 8-cm segments of at least two successive ribs while preserving the pedicled intercostal muscles to increase the total muscle volume.

Free DALT flaps were harvested and denervated to allow progressive atrophy in the future. The pedicle was left as long as possible for the convenience of inset and microsurgical anastomosis. Free flaps were then inserted to the uppermost portion of the empyema cavity. If a bronchopleural fistula existed, the myodermal flaps were inserted into the stump to obliterate the fistula tract (Fig 1D and E). Two layers of horizontal mattress sutures were used to secure the sealing of opening of the fistula. Care was necessarily taken to avoid kinking or twisting of vessels before microsurgical anastomosis and wound closure. A temporary drain for a residual air leak was inserted into the surface of bronchial stump and then removed after neovascularization of the free flap; the oblique tract could be obliterated by compression of the flap. The donor site was primarily closed (Fig 1F). Postoperatively the patient had been put in the lateral decubitus or supine position to avoid compression of vessels for at least 1 week. Specific antibiotics were used according to wound culture for at least 2 weeks. The intensive respiratory care places an important role in the management of these patients including assisted mechanical ventilation, chest care, and sedation for at least 5 days.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
The 12 patients studied have no recurrence of empyema and bronchopleural fistula after free DALT flap transposition. The flap survived well without reexploration of vessels due to venous and arterial thrombosis, hematoma, total flap necrosis or infection. The recipient vessels were ipsilateral thoracodorsal (10 patients) and internal mammary vessels (2 patients). All donor sites were primarily closed. Average operative time was 7 hours. No obvious functional disability, including walking and jumping, was found. The average hospital stay was 25.8 days. Complications after reconstruction include chondritis, partial muscle necrosis, and wound disruption (1 patient each). After an average of 1.5 years of outpatient follow-up, all chronic problems and the above-mentioned complications were resolved.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Chronic empyema is generally regarded as an entity that presents difficult management. Not only is the infection difficult to control, but the residual space easily redevelops. The difficulty in obliteration of infective dead space and bronchopleural fistula are two main causes of failure for treatment of chronic intractable empyema.

The methods for obliteration of dead space and BPF include (1) rib resection drainage and open thoracic window, (2) space collapse (thoracoplasty) [11–13], (3) space sterilization, and (4) space-filling methods (autogenous tissue obliteration). These have inspired us to design more effective procedures.

Eloesser flap use and thoracoplasty prompt us to use all tissues near the window that increase the total volume for closure of space, such as combined methods (free muscle flaps plus pedicled muscle flaps). Therefore, limited thoracoplasty confines resection to only a portion of a few ribs, combined with other space reduction techniques (primarily intrathoracic transposition of extrathoracic skeletal muscle such as the intercostal, serratus anterior and pectoralis major muscles).

Use of the Clagett procedure in the treatment of postpneumonectomy empyema has produced satisfactory results in the majority of patients [2]. The antimicrobial solution is used for the empyema cavity via irrigation or antibiotic-gauze wet dressings during operation in our department.

The two main causes of failure of decortication are (1) insufficient lung parenchyma (nothing can expand) especially after pneumonectomy and (2) pulmonary fibrosis (fibrothorax), which prevents expansion. Many patients with inadequate treatment were transferred to our medical center from other local hospital due to repeated decortication and debridement. Therefore, the modified procedures have stressed the following: (1) chest surgeon must extensively decorticate the fibrotic pleura and debris to increase the possibility of expansion before reconstruction, and (2) denervated myodermal flaps must be inserted as high as possible by obliteration due to muscle atrophy and diaphragm elevation.

Bronchopleural fistula usually follows pulmonary resection. The result of treatment of BPF depends on the number, length, and severity of bronchial fistulas. The more BPF, the worse the results. Direct surgical repair of chronic bronchopleural fistula may be achieved in most patients after adequate pleural drainage by suture closure and aggressive transposition of vascularized pedicle flaps [14–16]. Muscle flaps transposed intrathoracically are observed to revascularize ischemic bronchial segment. Poor tissue healing and high-pressure ventilation during operation makes infected bronchial stumps difficult to be sealed off. Indeed, the chronic empyema with multiple BPF is an absolute indication of myodermal flaps. The myodermal plug should be inserted into the bronchial stumps by pull-in sutures.

The muscle flaps have more capacity for bacterial clearance and oxygen tension than random flaps [17]. The free muscle flaps have more advantages than pedicled muscle flaps: (1) ease of inset of flap, (2) no waste of muscle outside thoracic cage such as pedicle muscle flap.

The size and pedicle of muscle flaps is determined by the following factors: (1) the debilitated or bedridden patient condition that causes muscle atrophy in the whole body, (2) severity of empyema, (3) type of procedures (decortication, lobectomy, pneumonectomy, etc) were performed, (4) preoperative lung function, which decides grade of lung expansion, and (5) whether the previous thoracotomy damaged the neighboring muscle and recipient vessels [18, 19].

Song and colleagues [6] classified cutaneous perforators of free anterolateral thigh flaps into two types: septocutaneous and musculocutaneous perforators. Kimata and colleagues reported 74 cases with a total of 171 tiny cutaneous perforators (an average 2.31 per case) were found, musculocutaneous perforators (81.9%) were much more common than septocutaneous perforators (18.1%). The anatomy of this flap is constant and reliable for clinical use. Many advantages are provided by use of free DALT myodermal flaps, which are preferred for treatment of empyema in our department: (1) vastus lateralis muscle, the biggest muscle in the quadriceps muscle, can be combined with tensor fascia lata muscle or rectus femoris muscle to increase the volume (the vastus lateralis muscle has a volume of 17 x 38 x 3 cm and pedicle length of 12 cm); (2) it has a longer, sizable pedicle and constant, reliable anatomy; (3) the donor site can be primarily closed; (4) there is no obvious morbidity of donor site observed at long-term follow-up, and especially no obvious knee instability; and (5) the dermis (deepithelialization) part is more suitable for suture with infected bronchial stump. The surgeon should be attentive to any detail and pitfall of treatment. For example, the chest surgeon must avoid damage of the thoracodorsal vessels and local muscle groups during thoracotomy to reserve the recipient vessels for the microvascular anastomosis and coverage of residual space in the future. However the disadvantages of free DALT myodermal flaps are as follows: (1) the donor site is often covered with hair; (2) techniques are complicated that require long learning curves, including flap harvest and basic microvascular anastomosis; (3) split-thickness skin graft is necessary if skin size is larger than 9 cm; and (4) there is risk of microsurgical problems may occur that need intensive observation.

In the future, we believe that the technical development of free DALT flaps should be the armamentarium for intractable cases of chest empyema with bronchopleural fistula.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Delarue N.C. Empyema: principles of management—an old problem revisited. In: Deslauriers J., Lacquet L.K., eds. . International trends in general thoracic surgery. St Louis: Mosby, 1990:178-180.
  2. Clagett O.T., Geraci J.E. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963;45:141-144.
  3. Chen H.C., Tang Y.B., Noordhoff S.M., et al. Microvascular free muscle flaps for chronic empyema with bronchopleural fistula when the major local muscles have been divided: one stage operation with primary wound closure. Ann Plast Surg 1990;24:510-516.[Medline]
  4. Chen H.C., Santamaria E., Chen H.H., et al. Microvascular vastus lateralis muscle flap for chronic empyema associated with a large cavity. Ann Thorac Surg 1999;67:866-869.[Abstract/Free Full Text]
  5. Hammond D.C. Intrathoracic free flap. Plast Reconstr Surg 1993;91:1259-1264.[Medline]
  6. Song Y.G., Chen G.Z., Song Y.L., et al. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149-159.[Medline]
  7. Koshima I., Yamamoto H., Hosoda M. Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92:411-420.[Medline]
  8. Koshima I., Fukuda H., Yamamoto H. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92:421-428.[Medline]
  9. Kimata Y., Uchiyama K., Ebihara S. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123:1325-1331.[Medline]
  10. Kimata Y., Uchiyama K., Ebihara S., et al. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:1517-1523.[Medline]
  11. Robinson S. The treatment of chronic non-tuberculous empyema. Collect Pap Mayo Clin 1915;7:618-621.
  12. Robinson S. The treatment of chronic non-tuberculous empyema. Surg Gynecol Obstet 1916;22:557-560.
  13. Eloesser L. An operation for tuberculous empyema. Surg Gynecol Obstet 1935;60:1096-1098.
  14. Puskas J.D., Mathisen D.J., Grillo H.C., et al. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995;109:989-995.[Abstract]
  15. Pairolero P.C., Trastek V.F. Surgical management of chronic empyema: the role of thoracoplasty. Ann Thorac Surg 1990;50:689-690.[Medline]
  16. Pairolero P.C., Arnold P.G., et al. Intrathoracic transfer of flaps for fistulas, exposed prosthetic devices, and reinforcement of suture lines. Surg Clinic North Am 1989;69:1047-1059.
  17. Mathes S.J., Feng L.J., Hunt T.K., et al. Coverage of the infective wound. Ann Surg 1983;198:420-429.[Medline]
  18. Johnson W.C. Postoperative ventilatory performances: dependence upon surgical incisions. Ann Surg 1975;41:615-619.
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