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Soft Tissue Reconstruction Includes Preoperative Strategy, Microsurgery

Johns Hopkins Orthopaedic Surgery
May 18, 2015 Soft Tissue Reconstruction Includes Preoperative Strategy, Microsurgery

Gene Deune readies a microscope for surgery. When not in surgery, Deune teaches residents and speaks at meetings like the World Society for Reconstructive Microsurgery. Top, left, a biceps flap constructed by Deune. Bottom, left, five years later, the biceps is disease-free and the arm is functional.

When planning their approach for soft tissue sarcomas in the extremities, surgical oncologists at Johns Hopkins must think beyond simply removing the cancer. They also think about the defect left behind and any potential loss of function.

That’s where Gene Deune comes in. An internationally recognized expert in microsurgery and soft tissue reconstruction for the extremities, Deune uses microsurgical techniques for vascular, nerve, muscle and tissue reconstruction to preserve or restore limb form and function in patients with upper and lower extremity sarcomas. He also trains surgical residents who carry the techniques beyond Johns Hopkins.

Working closely with the orthopaedic oncology surgeons before the operation, Deune tries to anticipate the possible defect and what reconstruction will be needed once the sarcoma is resected.

If the defect cannot be closed, then reconstruction may require a skin graft, rotational flap or tissue free flap — procedures that may take an additional six to eight hours. If the patient had preoperative radiation, a rotational or a soft-tissue free flap with nonradiated tissue can be beneficial.

“The flap not only allows the wound to heal,” says Deune, “it also re-establishes the contour, which helps restore the patient’s self-image.”

When function is expected to be decreased or eliminated by the sarcoma resection in an upper extremity, Deune needs to reconstruct with tendon transfers or innervated muscle flaps. For example, when the biceps is removed along with the cancer, Deune uses either an innervated latissimus dorsi muscle rotational flap or an innervated gracilis muscle free flap to restore elbow flexion.

The incision for the gracilis, he says, “is typically where the interior seam of your pants runs, from the knee to the groin. I include a small piece of skin attached to the gracilis to monitor the blood flow going into the flap during the postoperative period. The skin also allows for a tensionless closure of the incisions in the arm.”

Prior to the gracilis harvest, Deune dissects and identifies the thoracoacromial vessels at the lateral clavicle. He then transfers the gracilis to the arm and microsurgically connects the artery, vein and nerve. After he is confident there is strong blood flow into the gracilis, he secures it to the clavicle at the shoulder level and then weaves the tendinous end of the gracilis to the remnant of the biceps tendon at the elbow end, making sure the correct tension is re-established. Finally, he closes the skin and places the arm and elbow in a splint. If the nerve successfully regrows into the gracilis, the muscle can show signs of activity in a few months.

“The gracilis flap promotes healing at the surgical site and provides functional restoration,” says Deune. “Elbow flexion generally is not as strong as before, but patients can usually lift 5 to 10 pounds and are happy that they have a functioning arm.” 

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