Surgical Management of Marjolin Ulcer With the Anterolateral Thigh Free Flap: A Retrospective Analysis

MU is a malignant degeneration of traumatized skin that mostly occurs on a scar and clinically manifests as a local chronic ulcer. The pathology of MU is most commonly squamous cell carcinoma; a few cases of basal cell carcinoma and malignant melanoma have also been reported.¹ Extensive resection of the lesion by surgery has been the first choice for MU. It is more common in the lower limbs (43.7%), followed by the head, neck, upper limbs, trunk, and other regions.² Because the scar is relatively dense and lacks elasticity, it is often difficult to suture the scar directly after extended resection of the MU. Free skin grafts can be used to repair the postoperative wound of the MU in nonfunctional parts and without deep tissue exposure after extended resection. Smaller functional parts or wounds with exposed deep tissues can be repaired with pedicled flaps. Most patients do not recognize the early presentation of MU, which leads to late treatment, larger tissue defects, and deeper tissue exposure after extended surgical resection; consequently, free skin flaps are usually required for repair. The ALT free flap has been the most frequently used among the various free flaps, but few reports have described its use to repair wounds after resection of an MU.

This report analyzed the clinical data of patients with MUs that were repaired with ALT free flaps after expanded consultation through a single-center, nonrandomized, retrospective study. The purpose of this study, which, to the authors’ knowledge, represents the largest series of ALT free flaps to repair defects, was to provide evidence supporting a viable repair method for clinicians after extensive resection of MUs.

In this group of 15 patients, 2 patients had head defects. One measured 8 cm × 5.5 cm, and the other was 14 cm × 9.5 cm. One of these patients had cancer invading the skull and underwent dural repair after skull and dural resection. In 3 patients, the lesions were in the upper extremities and ranged in size from 9 cm × 6 cm to 14 cm × 5 cm. Lesions were located in the lower limbs in 10 patients, whose defects ranged in size from 8 cm × 7 cm to 21 cm × 13.5 cm. Preoperative tissue biopsy was performed to confirm the diagnosis in each case. The patients with head lesions were routinely examined by enhanced CT scan of the head before surgery, and there was no lymph node or organ metastasis. The patients with lesions in the upper extremities underwent ultrasonography of the axillary lymph nodes and cervical lymph nodes, and the patients with defects in the lower extremities underwent ultrasonography of the popliteal and inguinal lymph nodes. No abnormal lymph nodes were found (Table).

Ethical compliance

All photographs were taken and used with informed patient consent, and all physical and clinical examinations were approved by the Ethics Committee at the General Hospital of Western Theater Command. All clinical investigations were conducted according to the principles expressed in the Declaration of Helsinki.

Surgical technique

The principle of no-cancer operation was strictly observed. A 2-cm incision was made at the edge of the MU, which was sometimes extended into the deep fascia, muscle tissue, periosteum, and even bone according to the depth of cancer invasion. During the operation, the margin and base were routinely sent for frozen examination to ensure complete resection. After the MU was removed, the wound was repeatedly washed with sterile distilled water, and then the gloves and surgical equipment were replaced. The recipient vessels were explored and freed according to the adjacent location of the wound.

CT angiography and color Doppler ultrasonography were performed routinely before the operation. The flap was designed based on the defect and preoperative location of the marks. The connection between the ilium and the patella was marked, and a portable Doppler blood flow meter was used to measure the point where the first musculocutaneous artery of the descending branch of the lateral femoral circumflex artery passed through the skin near its midpoint. This point was the intersection of the upper one-third of the flap and the iliac-patellar line. According to the size and shape of the defect, the ALT flap was designed to extend 2 cm beyond the edges of the defect.

The initial incision was performed at the medial margin of the design, which continued into the subfascial plane. The intermuscular dissection between the rectus femoris and the vastus lateralis was continued until the perforators of the descending branch of the lateral femoral circumflex artery were found. Subsequently, the descending branch of the lateral femoral circumflex artery was dissected in a retrograde manner along the perforating vessel. Then, the outer edge of the flap was cut to the level of the subfascial plane, and the perforators were freed from the outside. The surrounding tissues were freed with meticulous protection of the vascular pedicle. The descending branch of the lateral femoral circumflex artery or its perforators and accompanying veins were severed until the surgeon was satisfied with the length of the vascular pedicle.

Arteries were anastomosed with 9-0 absorbable sutures, while veins were anastomosed with a venous stapler or 9-0 absorbable sutures, both of which were anastomosed end-to-end. The ratio of the anastomosed arteries to veins was 1:2 or 1:1. All donor sites were directly sutured.

Postoperative treatment

Based on the results of drug sensitivity or empirical medication, systemic antibiotics were given for 3 to 5 days, and treatments to promote anticoagulation (low molecular weight heparin calcium injected subcutaneously at 40 AXa IU/kg once daily), prevent vasospasm (30 mg of papaverine dripped intravitously every 8 hours), and improve flap microcirculation (use of a heat lamp) were routinely administered. To observe the blood supply of the flap, the dressing at the flap was left with an observation window. The dressing was changed once daily for the first 3 days after the operation and then once every 2 days thereafter. Usually, the drainage strip was removed on the second day after surgery. If a drainage tube was placed, it was removed when the drainage fluid volume was less than 10 mL. The sutures were removed 10 to 14 days after the operation. An oncologist would be consulted, who then decided whether to carry out radiotherapy or chemotherapy after confirming the results of the postoperative pathological classification.

All free ALT flaps survived after the extensive resection of the 15 MUs in this group. One patient underwent a second operation 8 hours after the operation because of the pressure of a blood clot resulting from bleeding of the wound on the vascular pedicle. All donor incisions healed primarily without infection and hematoma. All patients were followed up for 1 to 32 months (mean, 18 months). None of the flaps were necrotic, and the patients were satisfied with the treatment effect. Herein, the authors report 2 cases from this series: 1 of a patient with the greatest surgical risk, and another who had the largest defect repaired by bilateral ALT flaps.

Case 1

A 71-year-old female was hospitalized for 6 months because of an overhead MU in which the pathological examination showed squamous cell carcinoma (Figure 1A). Head CT and MRI showed osteolytic bone destruction of the left parietal bone. Fortunately, no brain metastasis or malignant lymph nodes were found. Scalp lesions were present, and part of the skull and dura were enlarged and removed under general anesthesia in collaboration with neurosurgeons until the margins were negative in the intraoperative frozen pathological examination. The final defect area was 15 cm × 10.5 cm (Figure 1B), and the dura mater defect was repaired by an artificial corresponding dura mater (Beijing TianXinFu Medical Instrument Co Ltd) that was 8 cm × 6 cm. The skull defect could not be repaired in a single procedure, as neurosurgeons recommended that skull repair be considered at a later stage; therefore, a right ALT flap measuring 16 cm × 11.5 cm was designed (Figure 1C). The donor and recipient areas were not repaired with skin grafts but healed during the first stage with no long-term complications (Figure 1D-F).

Case 2

A 54-year-old male was admitted with a mass on the anterior tibial region first noted 2 years before presentation to the authors’ hospital. The mass was approximately 15 cm × 8 cm and irregular, and the surface was ulcerated and uneven (Figure 2A). The calf was examined by enhanced CT, which showed that the bone was without metastasis. Color Doppler ultrasonography showed that the popliteal and inguinal lymph nodes were without metastasis. The lesion was extensively resected under general anesthesia until the margins were clean on frozen pathological examination during the operation, and the surgery resulted in a 20 cm × 13 cm defect in the anterior tibial region (Figure 2B). Because postoperative radiotherapy was required and the patient declined to have the donor site repaired by skin grafting, bilateral ALT flaps were repaired by series anastomosis. The size of the right ALT flap was 23 cm × 8.5 cm, and the left flap was 22 cm × 7 cm (Figure 2C, D). There were 2 perforators on the left side and 1 on the right after freeing the bilateral ALT perforator flaps. To avoid damaging the skin flap vascular perforation as much as possible, one end of the descending branch of the right lateral circumflex femoral artery was anastomosed with the descending branch of the left lateral circumflex femoral artery, and the other end was anastomosed with the anterior tibial artery to form a series (Figure 2E, Figure 3). The resulting flap looked similar to an ALT flow-through flap. The donor and recipient areas were sutured directly and healed at the first stage. Postoperative radiotherapy was recommended for the patient, but he refused. Unfortunately, the patient did not go to the outpatient clinic after discharge from the hospital and lost contact after a phone follow-up at 1 month due to living in a remote mountainous area (Figure 2F).

MU is an uncommon, aggressive malignancy on the skin and body surface that was first described by French scholar Jean Nicolas Marjolin in 1828.¹ Although the pathogenesis is complicated and unclear, it is characterized by repeated ulcerations, erosions, and prolonged nonhealing, which is most common in scars after burns. The first choice to treat MUs has been extended resection, usually more than 2 cm away from the edge.³ To ensure that there is no residual cancer at the resection margin, it is necessary to mark the margin and base of the excised cancer during the operation and then perform a rapid intraoperative frozen pathological examination. Based on the results of the intraoperative frozen pathological examination, the authors of the current study determined whether to perform further extended resection until the final pathological result was negative.

It has been reported that complete removal of an MU lesion with Mohs surgery could preserve the normal tissue to the greatest extent.⁴ Since the enlarged resection of the lesion often leads to larger skin and soft tissue defects, the repair of the defect after resection is the key to the treatment of MU.

Although surgery is the main treatment method, it is not suitable for all patients with MUs (eg, patients who decline to undergo surgery or are unable to tolerate surgery, or in cases where distant metastases have developed secondary to MU); treatment approach must be decided after consultation with a medical oncologist. Meanwhile, MUs with lymph node metastasis, a diameter greater than 10 cm, poor differentiation, or those that have invaded the bone or have distant metastasis need to be treated with radiotherapy after extended resection.³ It should be noted that excessive radiotherapy of wounds is not recommended in patients with MUs who have undergone extended resection, especially in elderly patients, because it can lead to delayed wound healing and even new ulcers.

The scar around the MU is relatively dense, and the defect after resection is often accompanied by exposure of deep tissue, which greatly increases the difficulty of repair. The principal methods of repair are autologous large skin transplantation and skin flap transplantation. Autologous large skin grafts are only suitable for those patients who have no deep tissue exposure and do not need postoperative radiotherapy. Flap repair is common in wounds that require postoperative radiotherapy, wounds that are in functional or weight-bearing areas, or wounds where the deep tissues, such as bones or tendons, are exposed. Smaller wounds can be repaired by direct suturing or translating adjacent flaps, which are relatively simple and safe. However, the area of repair for adjacent flaps is limited, and there is a risk of cancer implantation and metastasis.⁵ With the gradual maturity of microsurgery technology, free flap transplantation is increasingly favored by surgeons when repairing deep tissue exposure or large-area defects.^6-9

Flaps that have been consistently used to repair tissue defects after cancer resection include the latissimus dorsi flap, anterolateral femoral flap, gracilis myocutaneous flap, and inferior abdominal artery perforator flap.¹⁰ The latissimus dorsi flap is larger, and can repair larger tissue defects. However, it is also relatively thick, which often makes the flap look bloated after repair. At the same time, the donor site cannot be sutured directly and needs skin grafting, resulting in a large scar and unattractive appearance.¹¹

The ALT free flap is pedicled with the descending branch of the lateral femoral circumflex artery. It has the advantages of a long vascular pedicle, thick blood vessels, nonmajor blood vessels, large flap area, concealed location, sensory innervation, and little impact on the function of the donor area after the flap is freed. According to the needs of the wound, the ALT flap can be used to repair tissue defects with other tissues in parallel or in succession; the ALT flap can also be made into ultrathin flaps, fascial flaps, myocutaneous flaps, or lobulated flaps, among others. As a result, it has become one of the most commonly used free flaps.^12,13 It has been reported that the fascia lata carried by the ALT flap is an ideal alternative material for repairing dural defects^14,15 and can also be used to repair tendon tissues, such as the Achilles tendon. Meanwhile, for tissue defects in the hands or feet with high sensory function requirements, preparing the sensory skin flap containing the lateral femoral cutaneous nerve plays a non-negligible role in reconstructing the protective sensation of the skin.¹⁶

In the current case series, it should be noted that the first principle in the treatment of MUs is complete resection. It is meaningless to reconstruct the wound without confirming that the cancer is obliterated. Xiao et al¹⁷ reported on complications that arose in patients with MUs involving the dural sagittal sinus area. Due to fear of uncontrollable bleeding, only electrocautery was used to burn the surface of the dura mater, and postoperative adjuvant radiotherapy was used; however, the patients developed intracranial tumor metastasis within a short period.¹⁷

The second principle in treating MUs is the rational use of antibiotics. MUs are mostly skin squamous cell carcinomas, and the lesions may be accompanied by ulceration in which local bacterial cultures are mostly positive. In a randomized, controlled trial reported by Mücke et al,¹⁸ most patients received appropriate antibiotics (based on sensitivity) for more than 1 week prior to surgery. This was different from the current study. No signs of systemic infection were detected, anti-infective indicators were checked before surgery, and no preoperative antibiotics were used in the current study. Disinfection and dressing changes were only performed once a day using hydrogen peroxide and iodophor. In the group that received intraoperative and postoperative appropriate antibiotics (based on sensitivity tests) for 3 to 5 days, no postoperative infection occurred. The authors of the current study are of the opinion that systemic antibiotic therapy can be considered if there is a systemic infection before the operation. Systemic antibiotic treatment can also be chosen preoperatively for those patients with obvious periwound inflammation and poor results after local dressing change; otherwise, antibiotic treatment is not accessible. Unfortunately, this finding needs to be confirmed by further research because there were only a few patients in this group, and it was a retrospective analysis.

The third principle is that to maximize success, the flap should be cut and anastomosed with the vessel. CT angiography and color Doppler ultrasonography should be performed before the operation to comprehensively evaluate the position of the perforating branches and main arteries; this not only ensures the blood supply of each leaf flap and improves the success rate of the operation, but also shortens the time of flap removal.¹⁹ To increase the blood reflux of the flap, the 2 accompanying veins of the descending branch of the lateral femoral circumflex artery may be anastomosed with the veins of the recipient area if the conditions permit. To reduce the incidence of flap necrosis after surgery, torsion and compression of the vascular pedicle should be avoided during the operation, and the vascular anastomosis technique should be improved. The blood supply of the flap should be observed diligently after the operation, and any vascular crisis should be investigated and managed promptly.

The main limitation of this study is that it is neither a multicenter nor a prospective, randomized, controlled study. In addition, the number of patients was small, and the observation of 1 patient with a follow-up time of only 1 month showed no functional recovery. Multicenter, randomized, controlled trials are necessary for further clinical assessment of this method.

In short, wound repair is an important part of the treatment of MUs. Appropriate repair methods should be flexibly selected according to such factors as tissue defects, patient wishes, and postoperative radiotherapy. The free ALT flap has a certain clinical application and value in repairing wounds after extensive resection owing to its relatively constant vascular anatomy, convenient extraction, and reduced risk of damage to the surgical donor site.