Annals of Burns and Fire Disasters - vol. XII - n° 4 - December 1999

ABDOMINAL WALL RECONSTRUCTION IN AN ELECTRICAL BURN WITH A MYOCUTANEOUS TENSOR FASCIAE LATAE ISLAND FLAP. CASE REPORT

Cavadas P.C.

La Fe University Hospital, Valencia, Spain

SUMMARY. High-voltage electrical injuries often cause full-thickness defects in the abdominal wall, which are difficult to reconstruct. A case is reported of periumbilical reconstruction using a tensor fasciae latae (TFL) myocutaneous flap in an 8-yr-old boy who had sustained severe electrical injuries. The operative procedure is described, in which a right TFL myocutancous island flap was used. The treatment described led to satisfactory results.

General considerations

Reconstruction of full-thickness defects in the abdominal wall is a difficult problem that is sometimes encountered in the treatment of high-voltage electrical injuries. In the acute situation of explosive exit wounds in the abdomen, with traumatic evisceration, it has been recommended that skin grafting should be performed in the granulating peritoneal surface, although reconstruction of a competent abdominal wall will later prove necessary.
Local cutaneous or fasciocutaneous flaps can be based medially on anterior midline perforators, laterally on intercostal perforators, cranially on superficial superior epigastric vessels, and caudally on superficial inferior epigastric vessels. Bogart et al. reported on the use of a bilateral groin flap to repair a large defect after desmoid tumour resection. Little et al. described a sensate upper quadrant flap based on intercostal bundles.
Farr described a thoracic myofascial flap for upper abdomen reconstruction. In 1934 Wargensteen first reported on the use of the tensor fasciae latae (TFL) myofascial flap for wide infrared umbilical defects. Wargensteen also stated that even in patients with very long femurs, the TFL is not long enough to reconstruct subcostal defects. Watson described the extended TFL up to the knee joint for the reconstruction of supraumbilical defects. The external oblique muscle flap was used by Hershey and Butcher for supraumbilical abdominal defects.
Boswick et al. described the extended latissimus dorsi flap and Houston et al. reported on its use in reconstruction of large incisional hernia. In 1977 Mathes and Boswick, using a previous work of Brown et al., described the use of a superiorly based rectus abdominis myocutaneous flap for upper abdominal defects. The inferiorly based rectus abdominis flap has been widely used for upper abdomen reconstruction. Taylor et al. described the extended rectus abdominis myocutaneous flap for abdominal wall reconstruction. Cormack and Quaba reported on the use of a bilobed extended rectus abdominis flap for massive abdominal reconstruction.
A clinical case is reported of periumbilical reconstruction with a TFL flap.

Case report

An 8-yr-old male had sustained a high-voltage electrical injury one yr before presentation, with left above-knee amputation, severe hand injuries, and a 13 x 9 em perisupraumbilical hernia. The hernia resulted from the exit wound, which was skingrafted directly over the peritoneum. There was heavy scarring in the upper abdomen.
The reconstruction of the hernia was performed with a right TFL myocutaneous island flap, after excision of the abdominal skin graft (Figs. 1-3).

Fig. 1 - Skin markings for the procedure, depicting the, defect, the tensor fasciae latae muscle, the skin island, and the lateral circumflex femoral vessels.

The supporting structure of the reconstruction was made up of vascularized fascia lata from the flap. The flap was completely elevated, disinserting the muscle from the anterior superior iliac spine.
Approximately one-quarter of the distal skin island was lost, although the fascia remained vital and accepted a skin graft after partial debridement. The final result was satisfactory in terms of the recovery of abdominal wall competence (Fig. 4).

Fig. 3 - Immediate post-operative result. The donor tensor fasciae latae area was skingrafted. Fig. 4 - Late post-operative result. The distal part was debrided and skin was grafted over the viable fascia.

Discussion and conclusion

Upper abdominal wall defects can be a difficult problem when both recti abdominis muscles are lost. In general the most widely accepted choices for this situation are either a laterosuperiorly based external oblique muscle flap or a TFL flap. In the case reported here, an external oblique muscle flap was ruled out because of heavy scarring in the upper abdomen, with probable injury of the muscle, and a TFL flap was therefore preferred. Although Watson has stated that the TFL flap, when extended up to the knee joint, permits reconstruction of the upper abdomen, opinions vary as regards the safety of this extension. In the case reported here, the distal. end of the flap was 4 cm above the knee joint. The distal skin (not fascia) necrosis could have been due to excessive tension, and could have been prevented by extending the flap ventrally instead of caudally. The end result was satisfactory.

RESUME. Les lésions causées par la haute tension peuvent provoquer des défauts à toute epaisseur de la paroi abdominale difficiles à reconstruire.'L'Auteur décrit un cas de reconstruction périombilicale avec l'emploi d'un lambeau myocutané du tensor fasciae latae (TFL), dans un enfant âgé de 8 ans qui avait subi de graves brûlures électriques. L'Auteut décrit la procédure chirurgicale, effectuée avec l'emploi d'un lambeau droit en îlot myocutané du TFL. Le traitement a donné des résultats satisfaisants.

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