This video illustrates principles of reconstruction following four-quarter amputation. This patient presented with a locally advanced myosarcoma of the left shoulder extending into the axilla and chest wall. Following neoadjuvant radiation treatment, he was planned for resection with a four-quarter amputation and reconstruction of the skeletal and soft tissue components. An anterior medial approach was performed for this interscapulothoracic resection. It is paramount to have wide exposure for control of subclavian and axillary vessels and preservation of potential recipients. In this locally advanced tumor with neurovascular invasion, the remaining brachial plexus structures must be addressed during the reconstruction. The completed resection is composed of the entire upper extremity, including the left arm, scapula, lateral clavicle, upper six ribs, and chest wall musculature supplied by the axillary vascular axis. The final defect requiring reconstruction includes the anterior chest wall soft tissue and musculature overlying the lateral clavicle and ribs one through six, as well as the anterior segments of the pleura. Following resection, semi-rigid mesh and vascularized soft tissue coverage are required to protect the exposed neurovascular structures and to achieve stability of the residual hemithorax, medistinal, and pleural cavities. The primary aims of the reconstructive plan are to restore a dynamic, semi-rigid musculoskeletal structure and to provide neurovascular and visceral protection with soft tissue coverage that affords primary wound healing and minimal donor site morbidity. The anterior chest wall defect was reconstructed under tension with a composite bilayer of expanded polytetrafluoroethylene and polypropylene mesh. These images from a different case demonstrate indwelling catheters for anesthetic infiltration placed intraoperatively adjacent to the remaining brachial plexus stumps. The large soft tissue defect was reconstructed with both spare parts from the amputated limb and bilateral deep inferior pegastric perforator flaps. The fasciocutaneous extended radial forum flap was harvested from the resected specimen, and bilateral pedicled DIP flaps were harvested from the anterior abdomen. Inset of these large fasciocutaneous flaps allowed for the robust vascularized coverage of the great vessels, the buried brachial plexus remnants, the composite mesh, and allowed for primary wound healing of the recipient and donor sites. In some cases, the defect size allows for closure with spare parts alone. This patient illustrates a case of a primary oncologic resection with four-quarter amputation without neoadjuvant radiation. For this patient, the resected specimen provided an adequately sized extended radial forum free flap to provide adequate soft tissue coverage, along with the posterior regional soft tissue to obtain primary closure.

reconstructive surgery

myosarcoma

thoracic stabilization

vascularized soft tissue

flap techniques