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Page 2 of 6 Moores et al. Plast Aesthet Res 2018;5:44 I http://dx.doi.org/10.20517/2347-9264.2018.32

a case where a pedicled omental flap reached well below the inguinal ligament to provide circumfrential
coverage of a vascular bypass graft.

CASE REPORT
A 46 year-old male with past medical history significant for obesity, type-two diabetes, and ventricular
bigeminy presented to outside emergency care with recurrent chest pain consistent with acute coronary
syndrome. Cardiac biomarkers were negative, however the recurrent nature and severity of symptoms
generated enough concern that the patient was taken for cardiac catheterization, whereupon no significant
stenosis was discovered. The patient was diagnosed with likely upper GI pain and discharged to home.

In subsequent follow-up a common femoral pseudoaneurysm was diagnosed as a complication of cardiac
catheterization and the patient was taken for open repair by the vascular surgery service. At the time of
pseudoaneurism repair a large arteriotomy was discovered that required circumferential common femoral
artery excision and interposition poly tetra fluoro ethylene (PTFE) graft repair. Two days later the patient
was taken back to the operating room with a floridly infected PTFE graft and underwent graft excision and
cryo-vein reconstruction. At this time plastic surgery was consulted and we performed a pedicled rectus
femoris muscle flap for soft-tissue coverage.

Further complications ensued: six months later the patient was noted to have a large retroperitoneal hematoma
as a result of graft rupture. This was rapidly treated with retroperitoneal washout by the vascular surgery
service. A covered stent was placed across the new vascular defect that covered the take-off of the ipsilateral
deep inferior epigastric artery, which would prove to complicate reconstructive options going forward.

The wound again underwent serial debridement and antibiotic bead therapy under the care of the vascular
service with plastic surgical consultation. During this time plans for definitive reconstruction of both the
vascular pathology as well as soft tissue coverage were made. Vascular surgery planned to perform open
excision of the covered ilio-femoral stent and replace this with a new cryovein conduit.

Following vascular reconstruction, plastic surgery was presented with two wounds. The first a chronic, and
serially debrided groin wound with indwelling vascular bypass graft. The second, a midline laparotomy [Figure 1].

Lengthy discussion was held regarding the method of soft tissue coverage. Because the take-off of the
deep inferior epigastric artery was stented across, an ipsilateral pedicled rectus abdominus muscle was not
available. The patient had already undergone pedicled rectus femoris transposition, and the plastic surgery
service was concerned that additional muscular flaps from the same leg would result in prohibitive disability,
especially as the patient previously had an ipsilateral femoral and iliac vein deep vein thrombosis (DVT).
Additionally, most of the pedicles for local flap options were “in the zone of injury” of multiple operative
debridements and a lengthy period of local infection and inflammation.

Free tissue transfer was also discussed, including free latissimus dorsi and free contralateral antero-lateral
thigh (ALT), however, the patient’s clinical condition after prolonged ICU care was seen as potentially
prohibitive of these measures.

The plastic surgery service elected to perform pedicled omental flap coverage. Plastic surgery was able to
mobilize the patient’s omentum based on the right gastroepiploc artery by dividing the left gastroepiploic
artery and serially dividing the arcades to the greater curve of the stomach to within 8 cm of the pylorus.
The omentum was unfurled by dividing the entirety of its attachment to the transverse colon and by
separating the inner and outer lamellae. Following this dissection, the omentum easily reached below the
base of the groin incision to the middle third of the thigh [Figure 2]. The anatomic course of the ilio-femoral