Case 2 (2024): Perforator-based soft tissue reconstruction around the knee, utilizing a D-POP ALT flap
Abdullah Najib Maalouf1, Peter Sinkjær Kenney (MD1, PhD)1
- 1Vejle Sygehus & Aarhus University Hospital, Denmark
Abstract
A 73-year-old woman presented with malignant melanoma (pT2b-tumour) on her left thigh, located approximately 10 cm above the knee. The excision procedure aimed to remove the melanoma with a margin of 20 mm and perform sentinel node biopsy according to the protocols from Danish Melanoma Group (DMG). The patient had chronic obstructive lung disease, hypertension, hypercholesterolemia, ulcerative col
BeforeAfterA 73-year-old woman presented with malignant melanoma (pT2b-tumour) on her left thigh, located approximately 10 cm above the knee. The excision procedure aimed to remove the melanoma with a margin of 20 mm and perform sentinel node biopsy according to the protocols from Danish Melanoma Group (DMG). The patient had chronic obstructive lung disease, hypertension, hypercholesterolemia, ulcerative colitis, and migraine. Additionally, the patient smoked 10 cigarettes per day.
Two perforators were identified with doppler, of which the most distant is the basis for the D-POP ALT flap.
2
The soft tissue defect resulting after re-excision was located on the anterolateral part of the left thigh measured 45×45 mm in size. Flap harvest was commenced above the fascia. By the use of the handheld Doppler the signal from the perforator was closely monitored.
3
The perforator can be dissected intramuscularly or intraseptally to enable sufficient flap mobilization and unrestricted propeller technique. In this case it was not necessary to dissect subfascially. Subsequently, the flap was rotated 90 degrees into the defect, while the donor site was closed directly. Suturing the flap was done using interrupted deep dermal sutures with 4-0 Vicryl followed by a running dermal suture with 4-0 Nylon. Some surgeons add Nitroglycerine ointment to further support the permeability in the flap, but it is not a standardized requirement.
4
On this stage of the process meticulous precautions must be taken in order to avoid adding pressure on the flap, since this could jeopardize the flap’s vitality and thereby risk flap loss. Upon inspection, slight bruising and some swelling was seen. Flap was viable. No actions taken.
5
Upon the visit in our outpatient clinic, the results were satisfying with no signs of infection, pain or any complaints from the patient. The flap was viable. Nylon was removed.
6The patient had no functional limitations and she indicated that she had full range of motion without limitation as prior to surgery. Furthermore, there were no complaints in regards to pain or aesthetics. The patient indicated sensational disturbances in the area around the flap, but stressed that it did not affect her quality of life.
The patient was admitted for the first 24 hours with no specific scheme for monitoring the flap. The patient was recommended to avoid flexing the knee beyond 60 degrees for the first few weeks. Furthermore, the patient was instructed to avoid pressure on the flap until removal of the sutures. The patients underwent a standard follow-up 10-14 days after the surgery. Generally, no further controls are required, except in unique cases where the surgeon schedules a 3 months follow-up after the surgery.
How to cite this article
Abdullah Najib Maalouf, Peter Sinkjær Kenney (MD, PhD). Case 2 (2024): Perforator-based soft tissue reconstruction around the knee, utilizing a D-POP ALT flap. Journal of Plastic, Breast & Reconstructive Surgery. 2024.
Open access. © 2024 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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