Ann Thorac Surg 1999;67:866-869
© 1999 The Society of Thoracic Surgeons
How To Do It
Microvascular vastus lateralis muscle flap for chronic empyema associated with a large cavity
Hung-chi Chen, MDa,b,
Eric Santamaria, MDa,b,
Hern-hsin Chen, MDa,b,
Ming-huei Chenga,b,
Chau-hsiung Chang, MDa,b,
Yueh-bih Tang, MDa,b
a Department of Surgery, Chang Gung Hospital, Taipei, Taiwan
b Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
Accepted for publication August 17, 1998.
Address reprint requests to Dr Tang, 6F-1, 28, Hang-chow North Road, Taipei, Taiwan
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Abstract
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Thoracic empyema can be disabling and may need microvascular free flaps in some intractable cases. After repeated failure of conventional thoracic surgical procedures, 2 patients with empyema were treated with microvascular free vastus lateralis muscle flaps for obliteration of the large empyema cavity. The reconstruction was successful in wound closure and eradication of infection. The donor site morbidity was minimal, and the patients resumed normal daily activities. Microvascular vastus lateralis muscle flap is the best option if free flaps are required for reconstruction of empyema.
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Introduction
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Thoracic empyema remains a common disease and is associated with substantial morbidity [1]. The use of local or extrathoracic muscle flaps for treatment of this entity has been accepted more frequently in the recent years, including the use of free muscle flaps, as we originally proposed several years ago [2]. Selection of the adequate muscle to be transferred depends on the size of the residual cavity and, secondarily, on the patient’s position during operation. The flap must be versatile, simple, speedy, and safe to raise, with minimal donor site morbidity. The vastus lateralis muscle can provide a large bulk for obliteration of a huge intrathoracic dead space and is easy to harvest. It represents a good alternative for reconstruction of this difficult problem, as described in the following cases.
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Technique
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Surgical anatomy
The vastus lateralis muscle flap is reserved for those patients who have the following indications: (1) chronicity; (2) large residual empyema (with or without bronchopleural fistula); (3) multiple pleural, costal, and myoplastic procedures with failures and loss of local muscle groups; and (4) patients who wish to avoid disfiguring thoracoplasty.
The vastus lateralis is one of the muscles in the quadriceps femoris group. Its origin is mainly at the greater trochanter and is inserted distally at the tibial tuberosity by joining the patella common ligament (Fig 1). Its vascular supply is provided by the descending branch of the lateral circumflex femoral artery from the deep femoral artery. The descending branch gives three main branches at regular intervals, entering the muscle medially, under the rectus femoris muscle. The proximal branch has the largest diameter(2.0 mm) and was used as the main pedicle in continuity with the descending artery (2.0- to 2.5-mm diameter), together with the two accompanying veins. More comprehensive anatomic descriptions, including variations in the vascular supply have been presented elsewhere [3, 4].
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Fig 1. Vastus lateralis muscle insertion and arterial anatomy. The main branch of the descending branch of the lateral circumflex femoral artery enters the muscle between 12 and 15 cm below the great trochanter. The dashed line indicates the skin incision (A = superior anterior iliac spine; B = lateral border of the patella.)
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Operative technique
The skin incision is marked as a line between the anterior superior iliac spine and the lateral border of the patella. With the patient in the lateral decubitus position (used generally for thoracotomy), the incision is started approximately 5.0 cm below the greater trochanter and is extended 3.0 cm proximal to the superior border of the patella. The anterior fascia is divided; then the rectus femoris and vastus lateralis muscles are identified. The flap is raised in an upward direction. The main branch of the descending artery usually enters the muscle between 12 and 15 cm below the greater trochanter. All other branches from the descending artery and some branches directly from the superficial femoral artery entering the muscle distally can be ligated. Proximally the main pedicle is isolated. The rest of the muscle can be raised proximally to the origin. The motor nerve is localized 2.0 to 3.0 cm proximal to the main branch of the descending artery. When this vessel is dissected together with the descending artery, a 4.0- to 6.0-cm pedicle length can be obtained.
The muscle flap can be transferred to the chest with microsurgical technique, using the thoracodorsal artery and vein as the recipient vessels. The large volume of the muscle can obliterate the empyema space and close the bronchopleural fistula at the same time. Because the pedicle is long, with a large diameter, the vascular anastomosis is easy and safe. It can even be carried out with loupes instead of an operating microscope. Postoperatively, the vessels are prevented from compression by proper positioning of the patient. With correct surgical technique, the wound should be able to heal within 2 weeks.
Case reports
Patient 1
A 64-year-old man experienced an episode of empyema in the left chest, associated with a 20 x 15-cm calcified tumor mass. He had been treated for pulmonary tuberculosis 5 years previously. A thoracotomy for resection of the mass, together with decortication of the lung and evacuation of the empyema cavity, was performed. The final pathologic study of the tumor revealed a fibrous mesothelioma. One month later, the patient experienced recurrence of the empyema. Thereafter, thoracotomy with decortication and open drainage was performed twice by thoracic surgeons, but all failed. The chest x-ray film revealed the presence of a huge cavity (21 x 16 cm) in the left chest. A new thoracotomy was planned for empyema evacuation and decortication by the thoracic surgeon, followed by obliteration with muscular tissue by plastic surgeon. Because the local flaps had been divided previously and a large muscle was required, it was decided to use a vastus lateralis muscle free flap.
During operation, the patient was placed in the right lateral decubitus position. After the thoracic surgeons removed the necrotic tissue, two teams worked simultaneously, the first preparing the recipient vessels in the upper thorax and the second elevating the muscle flap on the left thigh. A 30 x 12 x 6-cm muscle flap was harvested and was used to obliterate the entire empyma cavity. The ipsilateral thoracodorsal vessels were used as recipient vessels for vascular anastomosis. Warm ischemia time was 1 hour, and the operation lasted 3 hours. The donor site was closed primarily. The outcome of the patient was satisfactory. No recurrence of empyema was observed. After 16 months of follow-up, the chest x-ray film and computed tomographic scan showed adequate obliteration of the previous dead space. The patient was able to resume all daily activities, including walking upstairs (Fig 2).
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Fig 2. (A) Preoperative chest radiograph showing empyema on the left side associated with a large cavity. All mediastinal structures were shifted to the right side. (B) Chest radiograph at 16 months. The left lung has reexpanded, and the previous dead space has been filled with the muscle flap. (C) At 16 months of follow-up, no chest wall deformity or recurrence of infection is observed.
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Patient 2
A 71-year-old woman had a 10-year history of empyema in the right chest. She had undergone decortication and myoplasty performed by thoracic surgeons on two different occasions. The local muscles were used in a third attempt to obliterate the empyema 1 year earlier. This operation was also performed by a thoracic surgeon. However, the empyema recurred 1 month later. The purulent discharge was persistent, and a huge cavity measuring 10 x 13 x 5 cm was observed. After conservative treatment for 11 months, no improvement was seen. A 40 x 10 x 5-cm muscle flap was used to fill the entire cavity. The flap survived well, and the outcome was uneventful. No recurrence of thoracic infection was noted. The chest x-ray film after 12 months of follow-up showed soft tissue (muscle flap) occupying the previous cavity.
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Comment
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In the acute phase (exudative and fibrinopurulent stages), empyema is usually treated successfully with closed-tube drainage and systemic antibiotics or with pleurodesis in refractory cases. In the chronic phase (organizing stage), when the lung is no longer expandable, decortication, or Clagett’s procedure, can achieve expansion of the lung and recovery [5, 6]. Failure with such treatments or recurrence is usually associated with a bronchopleural fistula and the presence of a persistent dead space with continuous infection, especially after pneumonectomy. Furthermore, these procedures are associated with considerable morbidity and marked cosmetic deformity. In this situation, obliteration of the empyema space is required, and for this purpose several local flaps can be used. Muscle or omental tissue is used because it provides a source of reliable vascularized tissue that enhances eradication of the infection, allowing complete obliteration of the dead space, and promotes wound healing followed by gradual lung expansion [2]. Different regional muscles can be used, depending on the location and size of the empyema cavity. When local muscles are not available, because of previous division or resection or when they are not large enough to obliterate a large intrathoracic cavity, microvascular free tissue transfer is the next and probably last treatment option, as we proposed previously [2]. Because the muscle is transferred without its motor nerve, subsequent muscle atrophy develops during the healing process, and the lung gradually reexpands in the following months.
Selection of the ideal muscle to be transferred in this situation depends mainly on the size of the defect and, secondarily, on the patient’s position during operation. For a microvascular free flap to be versatile, it should be simple, easy, and safe to elevate, with minimal donor site morbidity. Originally the latisimus dorsi, combined with the anterior serratus muscle on the opposite chest, was used as our first option. Some of the shortcomings associated with the contralateral latisimus dorsi muscle are that a smaller muscle bulk is harvested, and the patient needs to be repositioned once or twice during operation for dissection of the recipient vessels and the free flap. The free rectus abdominis muscle has also been used but has the same disadvantages. The distant location of the vastus lateralis muscle is strategic to allow two surgical teams to work simultaneously. A large bulk is provided that may be tailored to obliterate a large dead space and can be easily fixed around the entire defect. Removal of the vastus lateralis muscle from the thigh causes no obvious dysfunction [4], particularly in elderly patients in whom leg strength is not so important, and daily activities may be continued. In summary, free muscle flap transfer for treatment of chronic empyema provides reliable, successful results in a one-stage procedure with minimal morbidity.
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References
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Weissberg D., Rafaely Y. Pleural empyema: a 24-year experience. Ann Thorac Surg 1996;62:1026.[Abstract/Free Full Text]
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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.[Medline]
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Mathes S.J., Nahai F. Vascular anatomy of muscles: classification and application. In: Mathes S.J., Nahai F., eds. Clinical application for muscle and musculocutaneous flaps. St. Louis, MO: Mosby, 1982:78-79.
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Wolff K.D., Grundmann A. The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg 1992;89:469.[Medline]
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Mandal A.K., Thadepalli H. Treatment of spontaneous bacterial empyema thoracis. J Thorac Cardiovasc Surg 1987;94:414.[Abstract]
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Barker W.L. Thoracoplasty. Chest Surg Clin North Am 1994;4:593.[Medline]
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Abstract
Introduction
