Introduction: Surgical site infection after adult spine surgery is not uncommon. When conservative measures fail, wound debridement for dehiscence is often required, and plastic surgery input needed for subsequent reconstruction. Previously described techniques include myocutaneous flaps or perforator based fasciocutaneous flaps. These can be time-consuming and surgically challenging. We propose a simple and effective alternative flap.

Methods: Four patients with failed conservative management of infected midline posterior spinal wounds, underwent wound repair with a local islanded de-epithelialized double-breasted fasciocutaneous transposition flap, performed by joint input from the neurosurgical and plastic surgical teams.

Results: The flap was used to repair one wound in the cervical spine, one in the thoracic spine with underlying fixation, and two wounds in the lumbar-sacral spine, of which one had underlying fixation. In all patients, pre operatively the wounds were either dehiscent with exposed hardware, or had large defects, unsuitable for direct closure, following debridement. Follow-up ranged from 2 to 24 months. One patient died at two months post-operatively due to progression of underlying metastatic disease. All patients demonstrated good wound healing with no subsequent repeat surgery or removal of spinal fixation.

Conclusions: We demonstrate the importance of plastic surgical input with problematic spinal wounds, and successful management using a de-epithelialized fasciocutaneous flap that has not previously been described in repair of spinal wounds. This technique, which led in all cases to good wound healing and prevented removal of metalwork, has comparable efficacy but increased ease of use versus previous techniques.

Patient Care: Significant improvement to the management of spinal wound dehiscence with a simple and effective method of wound repair with resultant reduction of operative time and of inpatient stay by weeks or months by avoiding use of Vac dressings for prolonged periods.

Learning Objectives: To demonstrate the effectiveness of a relatively simple and novel technique employing a local islanded de-epithelialized double-breasted fasciocutaneous transposition flap, for the repair of non-irradiated spinal wounds.

References: 1. Bassewitz HL, Fischgrund JS, Herkowitz HN. Postoperative spine infections. Semin Spine Surg 2000;12:203–211 2. Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: A comparative study. Neurosurg 1981;8:422–425 3. Stolke D, Sollmann WP, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine 1989;14:56–59 4. Weinstein MA, McCabe JP, Cammisa FP Jr. Postoperative spinal wound infection : a review of 2,391 consecutive index procedures. J Spinal Disord 2000;13:422-426 5. Vicario C, De Juan J, Esclarin A, et al. Treatment of deep wound infections after spinal fusion with a vacuum-assisted device in patients with spinal cord injury. Acta Orthop Belg 2007;73:102-106 6. Mehbod AA, Ogilvie JW, Pinto MR, et al. Postoperative wound infections in adults after spinal fusion. Management with Vacuum Assisted wound closure. J Spinal Disord Tech 2005;18:14-17 7. Hallock GG. Reconstruction of Posterior Trunk Defects. Semin Plast Surg 2011;25:78–85 8. Netscher DT, Valkov PL. Reconstruction of Oncologic Torso Defects: Emphasis on Microvascular Reconstruction. Semin Surg Oncol 2000;19:255–263 9. Sharma RK, Nanda V, Makkar S, et al. De-epithelialised fasciocutaneous turnover flap: An alternative for defects in lower thigh and knee joint. Indian Journal of Plastic Surgery 2004; 37:40-43 10. Shaw AD, Ghosh SJ, Quaba AA. The island posterior calf fasciocutaneous flap: an alternative to the gastrocnemius muscle for cover of knee and tibial defects. Plast Reconstr Surg 1998;101:1529-36 11. Vranckx JJ, Hoore AD. Reconstruction of Perineum and Abdominal Wall. In: Danilla S, ed. Selected Topics in Plastic Reconstructive Surgery. InTech; 2012:141-160 12. Haas F, Weiglein AH, Schwarzl F, et al. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg 2004;113:1580–1590 13. Angrigiani C, Grilli D, Karanas YL, et al. The dorsal scapular island flap: an alternative for head, neck, and chest reconstruction. Plast Reconstr Surg 2003;111:67–78 14. Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg 1984;74:68–75 15. Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg 1987;40:1–10 16. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561–566 17. Serletti JM. Chest, abdomen, groin, and back. In: Wei FC, Mardini S, eds. Flaps and Reconstructive Surgery. Philadelphia,PA: Saunders; 2009:41–45