Revisionary soft tissue reconstruction of posterior midline defects after spinal surgery-plastic reconstructive options including perforator flaps.

Background: Chronic prevertebral soft tissue defects with exposed metal hardware following spinal surgery represent a challenging complication. Frequently patients underwent multiple previous operations due to wound complications. Surrounding soft tissues are often compromised due to malperfusion, severe subcutaneous scarring, previous local advancement flaps and therefore impair stable wound closure.

Methods: Patients after spinal surgery who received complex soft tissue reconstructions between 2011 and 2015 were analyzed retrospectively. Patient`s age, risk factors, wound size, cause and defect location as well as complication rates were evaluated. A focus was set on therapeutic strategies and decision-making concerning reconstructive techniques.

Results: Fourteen patients receiving 27 pedicled and one free flap were included in the study. Patients mean age was 51.1 years, mean wound size was 144 cm. Defects were located in the lumbar spine [8], cervical spine [2] and thoracic spine [1], respectively. Three patients suffered from extensive defects affecting more than one area. Mean time of flap surgery was 213 minutes. Fifteen perforator-based flaps and 11 non-perforator (classic rotation-flaps), 1 pedicled and 1 free latissimus dorsi flap were used. In 9 patients (64.3%) different flaps had to be combined in a single-staged procedure due to large wounds. Implant material was removed completely in six patients (42.9%), whereas in five patients (35.7%) implants were replaced within the operation for soft tissue reconstruction. In three patients (21.4%) initial implant removal or replacement was not possible which leads to prolonged postoperative wound infections.

Conclusions: Most patients with exposed spinal hardware suffered from multiple comorbidities and showed a poor general condition. Due to the reduced soft tissue quality wound healing is significantly impaired. Exposed implant material should be replaced or removed when possible. Therefore, the complete armamentarium of plastic reconstructive techniques is required for wound closure. Today, perforator flaps play a prominent role due to the variability, excellent vascularization and sufficient subcutaneous filling capacities.