Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана
.pdf
15 Thoracodorsal Artery Perforator Flap
mapping. Although a very small number of perforators were
missed on the computed tomography images, the ones
missed were always smaller than the ones identied and did
not affect the validity of their study. However, the difculty
in interpreting the computed tomography images was greater
than with abdominal donors because the perforators were
smaller and the back occasionally has little subcutaneous
tissue.
15.4 Flap Design andMarkings
To harvest a thoracodorsal artery perforator ap, the patient
is placed in a supine position with the arm abducted and elevated. Redundant ank tissue is pinched to estimate the point
of primary closure of the donor site, and the anterior border
of the muscle is identied. The surface landmarks used are
the border of the pectoralis major muscle and the anterior
border of the latissimus dorsi muscle, along which the midportion is outlined. A parallel incision is made along the midportion between the anterior border of the latissimus dorsi
and pectoralis major muscles (Fig.15.2).
155
Fig. 15.2 Surface marking and ap design. The surface landmarks
used are the border of the pectoralis major muscle and the anterior border of the latissimus dorsi muscle, along which the midportion is outlined. A parallel incision is made along the midportion between the
anterior border of the latissimus dorsi and pectoralis major muscles
(PM pectoralis major, LD latissimus dorsi)
15.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Skin Traction
After skin incision, traction toward the surgeon is
applied to the skin ap, along with countertraction to the
muscle toward the chest, to avoid missing very small
latissimus dorsi perforators (Fig.15.3).
2. Finding the Latissimus Dorsi Muscle
Finding the anterior border of the latissimus dorsi
muscle is the quintessential step in successful ap harvest. Since the anterior border of the latissimus dorsi
muscle is easier to nd on the distal part, it is better to
elevate the ap from the distal part. After nding the anterior border, ap is raised while maintaining the suprafascial layer.
3. Finding Reliable Perforators.
There are numerous perforators along the anterior bor-
der of the latissimus dorsi muscle, and we try to include
reliable “pulsatile” perforators that enter to the skin paddles. If there are no visible perforators piercing the latissimus dorsi, reliable septocutaneous or direct cutaneous
perforators are often used instead.
Fig. 15.3 Skin traction. After skin incision, traction towards the surgeon is applied to the skin ap, along with counter-traction to the muscle towards the chest, to avoid missing very small latissimus dorsi
perforators
15.6 Core Surgical Techniques inFlap
Dissection
Once a suitable perforator is identied, we continue the dissection of the thoracodorsal artery branches using bipolar
electrocauterization while preserving the thoracodorsal
nerve. In the case of thoracodorsal perforator aps, branches
of the thoracodorsal vessel, the serratus anterior vessels, and
156
ab
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Y. H. Kim and L. S. Chang
the circumex scapular vessels are often ligated to achieve a
longer vascular pedicle. Once the pedicle dissection is complete, an outline that matches the defect is made, and the ap
is harvested from caudal to cephalad. Since the intramuscular dissection is important, the detailed technique is described
below:
1. Conventional Intramuscular Pedicle Dissection
Using the conventional method, further intramuscular
dissection is made following the perforator from the muscle entry point to the thoracodorsal vessels. The avascular
plane between the latissimus dorsi muscle and the fascia
of the serratus anterior muscle is dissected, and the subscapular arterial system including the serratus anterior
branch, the circumex scapular branches, and several
muscular branches from the thoracodorsal vessels is
located. Apart from the vessels that are harvested, other
vascular branches are ligated during proximal dissection
of the main pedicle. This dissection is performed immediately below the axillary vessels.
2. Modied Intramuscular Pedicle Dissection
The quality of the intramuscular dissection of the per-
forator is the key to success or failure. Intramuscular dissection requires great care until the diameter of the
perforator increases where it enters the descending or
transverse branch of a thoracodorsal vessel. We have
introduced a modied technique for intramuscular dissection that makes it easier and safer than the classical
method and decreases operative time.
In the modied method, after a reliable perforator that
pierces the latissimus dorsi muscle is found, the perforator is marked using a vessel loop. The anterior border of
the latissimus dorsi muscle is detached from the serratus
anterior muscle and chest wall. The thoracodorsal vessels
are then dissected to the bifurcation point of the transverse and descending branches and followed proximally
to the axillary vessels. After that, the thoracodorsal vessel
branches are traced distally to their points of entry into
the muscle before intramuscular dissection.
With the latissimus dorsi muscle stretched in the anterior direction, transillumination makes it easy to trace a
perforator from its point of entry, past the muscle to the
branch of the thoracodorsal vessels. The point where the
perforator is illuminated at the inner portion of the latissimus dorsi is marked, and a cuff of muscle about 2cm
width is harvested intact by bipolar electrocautery
(Fig.15.4).
15.7 Clinical Scenario
A 73-year-old man with a history of diabetes presented with
necrosis of the right fth toe and a 5×6cm2 sized ulcer over
the dorsum of the right foot, with exposure of the tendon
(Fig.15.5a). Preoperative CT angiography showed segmental occlusion of the anterior tibial artery, posterior tibial
artery, and peroneal arteries of the right lower limb
(Fig. 15.5b). Percutaneous angioplasty was performed.
Fig. 15.4 Various showcases
of modied method of
intramuscular dissection.
(a–c) Modied method of
intramuscular dissection of a
thoracodorsal artery
perforator ap. The pedicle
incorporated a small muscle
cuff during intramuscular
dissection using bipolar
cauterization
c
15 Thoracodorsal Artery Perforator Flap
a b c
157
d
f
Fig. 15.5 Case. (a) A 73-year-old male with diabetes presented with
necrosis of the right fth toe and a 5×6cm2 sized deep ulcer exposing
extensor tendon. (b) Preoperative CT angiography showed segmental
occlusion of the anterior tibial artery, posterior tibial artery, and peroneal arteries of the right lower limb. (c, d) 8×5cm2 sized thoracodorsal
artery perforator had an 18 cm pedicle with an eccentrically located
e
perforator. (e) The thoracodorsal vessels were anastomosed to the anterior tibial vessels above the ankle in an end-to-side manner. (f) The ap
survived completely and there was no recurrence of ulcer during 2years
of follow up. Without additional debulking surgery, the patient has no
difculty putting on shoes
However, only the anterior tibial artery was successfully
cleared above the ankle. One week after revascularization,
debridement of the dorsal foot was performed with ray
amputation of the fth toe. The defect was reconstructed
using an 8×5cm2 sized thoracodorsal artery perforator free
ap. The length of the pedicle reached 18cm to reach above
the ankle, and the perforator was positioned eccentrically to
the ap to secure the long pedicle (Fig.15.5c, d). The thoracodorsal vessels were anastomosed to the anterior tibial vessels above the ankle in an end-to-side manner (Fig.15.5e).
The ap survived completely and there was no recurrence of
ulcer during 2years of follow-up. Without additional debulking surgery, the patient has no difculty putting on shoes
(Fig.15.5f).
158
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
15.8 Pearls andPitfalls
Pearls
• How to Product a Long Vascular Pedicle
When CT angiography reveals no suitable recipient
vessels near a defect, the long vascular pedicle technique is used in order to approach above the ankle
level to seek reliable recipient vessels.
– Choose a Distally Located Perforator
To obtain a long vascular pedicle, a distally
located perforator from the descending branches
of the thoracodorsal vessels should be selected.
Proximal perforators from descending branches
or perforators from transverse branches are not
good candidates.
– Make the Perforator in the Eccentric Position of
the Flap
If a much longer vascular pedicle is required, we
position the perforator close to the margin of the
ap and design the ap eccentrically. The actual
pedicle length can be affected by the ap size
and the entry point of the perforator to the skin
ap. Assuming that the pedicle is harvested with
the same length, the ap where the perforator is
located in the center has a shorter length of the
actual pedicle than located in the edge by the
size of the skin ap. Perforators can be located
eccentrically using the free-style ap harvesting
technique as described by Wei FC. A reliable
perforator is rst located, and the ap is designed
around it such that it can be elevated safely and
the location of the perforator can be controlled.
A maximum actual pedicle length was achieved
with this technique in our hands. Pedicle length
can often be extended from 15cm to 20 cm by
this modication (Fig. 15.6). Concerns about
perfusion in aps where the perforator is eccentric have been demonstrated in our previous
study that if the perforator is reliable, sufcient
Y. H. Kim and L. S. Chang
perfusion is provided. However, the ap should
be harvested parallel to the anterior border of the
latissimus dorsi muscle because vascular networks and the subdermal plexus are connected
parallel to the latissimus dorsi muscle according
to the perforasome theory.
• How to Manage Multiple Defect?
When multiple or distant defects require reconstruction simultaneously, a chimeric pattern ap is
harvested (Fig.15.7). After nding reliable perforator, the subscapular arterial system including the
serratus anterior branch, the circumex scapular
vessel branches, and several muscular branches
from the thoracodorsal vessels can be located in the
avascular plane under the latissimus dorsi muscle.
The other branches of the thoracodorsal vessels
such as the transverse branch can be harvested
together with the latissimus dorsi muscle, and the
serratus anterior branch and muscle can also be harvested, if required. The skin paddle is rst inset into
the defect and xed in position, and then the latissimus dorsi or serratus anterior muscle components
are carefully positioned over the remaining defect
avoiding twisting or kinking the pedicle.
• How to Harvest a Thin Flap?
Suprafascial dissection is the norm for raising perforator aps. However, elevation along the supercial fascial layer between the supercial and deep
adipose tissue can provide a thin ap (Fig.15.8).
Preserving the linking vessels and orienting the ap
in the direction of linking vessels make it possible
to harvest long and thin aps. In addition, the ap
can be thinned further by defatting procedure with
sharp Metzenbaum scissors until the supercial fat
tissue is all removed except around the perforator.
Great care should be taken to avoid injury to perforators and subdermal plexus. These superthin aps
can be used for head and neck resurfacing and are
often used for nger and toe resurfacing.
15 Thoracodorsal Artery Perforator Flap
abc
d
f
159
e
Fig. 15.6 TDAP free ap with long pedicle. (a) A 20-year-old male
suffered capillary malformation on his right hemiface. (b) A severe pigmented lesion was removed and supercial temporal vessels were
selected as recipient site. Required pedicle length was more than 18cm.
(c, d) A distal perforator from the lateral thoracic region was selected
and the perforator was eccentrically located. So we harvested a TDAp
ap with a pedicle of more than 18cm in length. (e) Immediate postoperative view showing good color match with contours. (f) Long-term
follow-up view
160
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Y. H. Kim and L. S. Chang
Fig. 15.7 TDAP free ap
with chimeric pattern. (a)
Post cranioplasty infection
with skin loss. (b) Radical
debridement and dead tissues
were removed. (c) TDAp
chimeric ap including a skin
paddle and latissimus dorsi
muscle ap. (d) The skin
paddle was resurfaced to the
scalp defects, and the
latissimus dorsi muscle was
used for dead space
obliteration of temple region.
(e) Long-term follow-up view
shows no recurrence of
infection
a
b
c
d
e
15 Thoracodorsal Artery Perforator Flap
ab
161
Fig. 15.8 Thin TDAP ap. (a) Suprafascial dissection is the norm for
raising perforator aps. Dissection in the plane between the supercial
and deep adipose layers provides a very thin ap. (b) The ap is thinned
Pitfalls
• To Avoid Missing Perforator
– Traction
Traction of both sides of the skin of the incisional margin helps perforators to stand out.
Perforators naturally run vertically toward the
skin, but following a surgical access incision,
they “lie down,” so traction perpendicular to the
skin plane makes them easier to nd.
– Dissection Plane
If the dissection is started in the supercial fat
layer, perforators are likely missed. Initial dissection for nding perforators should start in the
suprafascial layer of the latissimus dorsi muscle.
A sharp vertical dissection is performed down to
the plane of the deep fascia until a pulsating perforator is detected. This dissection should run
from distal to proximal.
– Distinguish the Thoracodorsal Perforators from
the Intercostal Perforators
Once a reliable musculocutaneous perforator is
identied, it is rst traced distally to establish its
point of entry to the fat and skin. Some perforators follow a horizontal course above the fascia
for a few centimeters before piercing the overlying fat. Intercostal perforators in the distal area
are often regarded as thoracodorsal musculocu-
further by monopolar electrocautery, with the ap held under tension
with skin hooks, and with special care at the entrance of the perforator
into the skin envelope
taneous perforators. If we follow and dissect an
intercostal perforator, we waste a lot of time as
its short length and small diameter make it
unsuitable as a ap perforator. Intercostal perforators run distally unlike thoracodorsal perforators, which run proximally. So you can
distinguish a few dissection of intramuscular
dissection of the latissimus dorsi.
• Exceptional Situation Without Reliable Perforator
If the thoracodorsal artery perforator is small or not
reliable, there are several reliable alternatives. In
one approach, a small portion of muscle around
bifurcation point of the transverse and descending
branch can be harvested with the skin paddle in
what we call the muscle-sparing technique. Another
option is to combine latissimus dorsi muscle aps
with skin grafts because thinner aps can be
achieved with this approach. However, if we need
skin ap, this method is not suitable. Finally, most
surgeons look for other perforators. Fortunately,
another dominant nourishing artery, such as the
intercostal artery, is often available. In such situations we tend to nd reliable perforators in the
intercostal area (ninth to eleventh intercostal
grooves), which enables us to harvest lateral intercostal artery perforator (LICAP) aps. Deep dissection is performed to obtain suitable vessels for
anastomosis. In our experience the maximal pedicle
length is approximately 5cm (Fig.15.9).
162
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
abc
Y. H. Kim and L. S. Chang
Fig. 15.9 Lateral intercostal artery perforator (LICAP) ap. (a) Black
triangular arrow shows the thoracodorsal artery perforator and the
white triangular arrow shows the lateral intercostal artery perforator
(LICA p). (b, c) The initial plan was TDAP ap resurfacing; unfortu-
Fig. 15.10 Degloving injury to the forearm, radius, and ulna xed with
plate
nately there were no suitable reliable thoracodorsal perforators in the
lateral thoracic region, but there was a reliable perforator in the distal
region. We dissected into the rib cage and harvested a LICAP ap with
a pedicle of 5cm length instead of a TDAP ap
Fig. 15.11 Perforator dissection through the latissimus dorsi muscle
Case Scenario B: TDAP Flap for Extremity Reconstruction
Dariush Nikkhah Consultant Plastic Surgeon Royal Free
Hospital
Jeremy Rawlins Consultant Plastic Surgeon Royal Perth
Hospital
A 27-year-old man was struck by a lorry while on his
motorbike. He sustained open fractures of his radius and ulna
and soft tissue loss of his right forearm. After surgical debridement and xation, an immediate free ap was planned for coverage (Fig. 15.10). The patient was placed supine and the most
dominant perforator was marked with handheld Doppler. A 9
by 25 cm thoracodorsal artery perforator ap was raised, and
the main perforator was dissected through the anterior border
of the latissimus dorsi muscle (Fig. 15.11). The ap was anastomosed end to side to the brachial artery and two veins were
repaired end to end with venous couplers. The donor site was
closed primarily, and the patient made a full recovery and had
an excellent outcome at 3 months with full function of his
right extremity (Figs. 15.12 and 15.13).
Fig. 15.12 Extremity outcome at 3 months
15 Thoracodorsal Artery Perforator Flap
Fig. 15.13 Donor site outcome at 3 months
15.9 Selected Readings
• Koshima I, Soeda S.Inferior epigastric artery skin aps
without rectus abdominis muscle. Br J Plast Surg.
1989;42:645–8.
The author harvested inferior epigastric artery skin
ap without the rectus abdominis muscle, pedicled on the
muscle perforators and the proximal inferior deep epigastric artery. They suggested the possibility of a perforator
ap by showing that a large ap without muscle could
survive on only a single muscle perforator.
• Abgrigiani C, Grilli D, Siebert J.Latissimus dorsi musculocutaneous ap without muscle. Plast Reconstr Surg.
1995;96:1608–14.
The possibility of raising the cutaneous island of the
latissimus dorsi musculocutaneous ap without muscle
based on only one cutaneous perforator is presented in
this paper. An anatomic study performed in 40 fresh
cadaver specimens demonstrated that the vertical intramuscular branch of the thoracodorsal artery gives off two
to three cutaneous branches (perforators) that are consistently present.
163
• Kim JT. Two options for perforator aps in the ank
donor site: Latissimus dorsi and thoracodorsal perforator
aps. Plast Reconstr Surg. 2005;115:755–63.
The author summarized the confused nomenclature of
the perforator ap in the lateral ank area. The difference
between latissimus dorsi perforator ap and thoracodorsal perforator ap was explained, and its clinical application was reported.
• Mun GH, Kim HJ, Cha MK, Kim WY.Impact of perforator mapping using multidetector row computed tomographic angiography on free thoracodorsal artery
perforator ap transfer. Plast Reconstr Surg.
2008;122:1079–88.
Preoperative perforator mapping of thoracodorsal
artery perforator ap was performed using multidetectorrow computed tomographic angiography. The computed
tomographic ndings were compared with the acoustic
Doppler owmetric and intraoperative ndings.
Perforator mapping with preoperative multidetector-row
computed tomographic angiography is valuable for both
planning and executing thoracodorsal artery perforator
ap transfer.
• Colohan S, Wong C, Lakhiani C, Cheng A, Maia M,
Arbique G, Saint-Cyr M. The free descending branch
muscle sparing latissimus dorsi ap: vascular anatomy
and clinical applications. Plast Reconstr Surg.
2012;130:776e–87e.
The authors investigate the vascular anatomy of the
muscle- sparing variant and describe its application as a
free ap based on the descending branch of the thoracodorsal artery. Computed tomography angiography
demonstrated perfusion of the latissimus dorsi muscle by
the transverse and descending branches, with overlap of
vascular territories via cross-linking vessels. In the clinical study, the free muscle-sparing latissimus dorsi ap
provided excellent coverage with no ap complications or
seroma.
• Kim SW, Youn S, Kim JT, Kim YH.A modied method
for harvesting thoracodorsal artery perforator aps in a
simple and time-saving approach. Microsurgery.
2016;36:642–6.
The authors propose a modied method for harvesting
the thoracodorsal perforator ap during lower extremity
reconstruction and compare it with the conventional
method. Using the modied method for ap harvest, a
reliable perforator was found, and a cuff of muscle was
left around the perforator without intramuscular dissection. When the modied method was used, total operating
time was reduced from 311 to 272min.
• Kim YH, Lee HE, Lee JH, Kim JT, Kim S.Reliability of
eccentric position of the pedicle instead of central posi-
164
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Y. H. Kim and L. S. Chang
tion in a thoracodorsal artery perforator ap. Microsurgery.
2017;37:44–8.
The aim of this study was to compare the safety and
reliability of thoracodorsal artery perforator aps harvested with centrally or eccentrically located perforators.
There have been concerns regarding ap perfusion and
distal vascularity in eccentrically located perforators.
However, authors suggest that both eccentric and central
perforators are safe options in thoracodorsal artery perforator ap.
• Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich
RJ.The perforasome theory: vascular anatomy and clini-
cal implications. Plast Reconstr Surg.
2009;124:1529–44.
The authors investigated the three-dimensional and
four- dimensional arterial vascular territory of a single
perforator, termed a “perforasome,” in major clinically
relevant areas of the body. A vascular anatomy study was
performed using 40 fresh cadavers. Each perforasome is
linked with adjacent perforasomes by means of two main
mechanisms that include both direct and indirect linking
vessels. Every clinically signicant perforator has the
potential to become either a pedicle or free perforator
ap.
Соседние файлы в папке Библиотека им академика М.И. Перельмана