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
The Scapular Axis Flaps: An Expendable
Direct Cutaneous Perforator withMany
Options
DanielSaleh andJohnHenton
16
16.1 Introduction
The scapular axis provides an abundance of tissue options in
reconstruction. Both the scapular and parascapular aps
were described in 1982 by Dosantos and Nassif,
respectively.
These cutaneous aps are less favored than the nearby
latissimus dorsi, but they do offer versatility without sacricing a muscle unit.
Scapular axis aps can provide large skin/fasciocutaneous ap options and an osseous ap. The osseus component
which largely is the lateral border of the scapula receives a
nonpenetrating periosteal vascular (NPPV) supply [1]. Thus
for cortical reconstructions with little reliance on endosteal
blood supply, these units of bone can be very useful for an
array of applications.
Pedicled scapular and parascapular cutaneous aps are
commonly used for defects in the axilla or posterior trunk.
As free aps they are widely used in extremity reconstruction alongside the head and neck. These skin aps offer
excellent versatility for reconstructive needs, for large surface areas with acceptable donor morbidity, largely conned
to stretched scars. Moreover no motor units to regional musculature are affected by ap dissection, and parascapular ap
harvest can be performed in the supine position.
16.2 Anatomy
The scapular axis aps all derive from the subscapular artery,
which arises from the third part of the axillary artery. The
subscapular artery gives rise to the thoracodorsal artery and
the circumex scapular artery. The circumex scapular
passes through the triangular space where it becomes the
supercial circumex scapular artery (SCSA). The SCSA
D. Saleh (*) · J. Henton
Newcastle University Hospitals NHS foundation Trust,
Newcastle upon Tyne, UK
gives off several cutaneous branches including the transverse
branch (scapular ap) and the descending (parascapular
ap).
The scapula bone is enveloped by a plexus of communicating vessels. Several of these on the lateral edge of the
scapula are given off by the subscapular artery before it
becomes the SCSA.Scapula bone can therefore be taken as
a ap in isolation or combined with other aps in the scapular axis. Furthermore, if the subscapular artery is included,
aps based on the thoracodorsal artery may be taken on the
same pedicle (latissimus dorsi, scapular tip bone ap, and the
serratus).
Any of these can be taken in isolation or in combination
as chimeric aps. To include the thoracodorsal-based aps,
the teres minor needs disinsertion or sectioning; Fig. 16.5
depicts a raised latissimus dorsi and parascapular ap with
the intervening teres muscle still intact between the
pedicles.
Both the scapular and parascapular aps must incorporate
the skin overlying the triangular space to capture the SCSA
and its key branches.
If dissected back to the subscapular artery, a pedicle up to
7cm long with an arterial diameter of up to 4mm may be
obtained. There are usually two venae comitantes.
The scapular ap can be taken horizontally up to the midline of the back, although aps crossing the midline are possible especially if a delay procedure is used. Around 10cm
ap width in the vertical plane may be closed directly.
The parascapular ap can be up to 30cm long, and ap
width can vary between 15 and 25 cm for direct closure,
depending on the patient’s habitus. Larger aps can be harvested but require secondary closure. The osseus component
of the lateral scapular border can be 2–3 cm wide and
approximately 12cm long.
Anatomical variants: sometimes the circumex scapular
artery can arise directly from the axillary artery, and it is
important to recognize the midline is not a “boundary” for
these aps.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_16
165
166
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D. Saleh and J. Henton
16.3 Preoperative Investigation
Outpatient vascular assessment can be performed with handheld Doppler examination to conrm the presence and location of the SCSA cutaneous perforator in the skin over the
triangular space. It is also possible to trace the courses of the
transverse branch and the descending branches with the
Doppler to plan ap dimensions.
To locate the perforator, with the patient’s arm abducted,
feel for the point where there is an indentation between the
bulk of the superior border of the teres major and the inferior
border of the teres minor on the lateral edge of the scapular.
Cross-sectional computed tomography (CT) with contrast
will delineate the vascular anatomy, and while we routinely
do this, the recognized anatomical variations described
above may mean some would take benet from radiographic
anatomy.
CT is helpful in patients where a virtually planned osseous ap is desired. This allows clear three-dimensional (3D)
reconstruction of the scapula and the desired osseous component for the purpose of intraoperative jigs to perform accurate osteotomies. In such cases we do add the contrast
component to the CT examination to assess the vascular
pedicles.
ned to the lateral border of the scapula and is best
incorporated into a parascapular skin ap.
Depending on the complexity of the reconstructive effort,
variable components of the thoracodorsal axis can also be
incorporated into these aps.
16.5 Positioning
The best positioning in our experience is lateral or “lazy”
supine with a soft bolster across the posterior-inferior costal
margin on the ipsilateral side (Fig.16.1).
The key to positioning is allowing movement of the
shoulder girdle. Irrespective of whether the patient is lateral
or lazy supine, we prep the skin down to the elbow and sterile wrap the hand and forearm to lie in a sterile trough assembled at 90 degrees to the operating table (Fig. 16.2). This
allows easy movement of the arm and shoulder to open up
the triangular space and ease pedicle visualization and dissection depending on the components of the ap.
16.4 Flap Design, Markings,
andPositioning
Flaps can be individual, conjoined, or chimerized. We
describe below raising of individual parascapular and scapular aps. The obliquely oriented parascapular ap is sometimes referred to as the “inframammary extended circumex
scapular ap” or IMECC.For the purpose of this description,
we describe a conventional parascapular ap, but the skin
markings can be obliquely oriented from the posterior axillary fold toward the pectoral crease and chest if needed/
desired.
These aps are generally hairless in females and many
males, but lack good cutaneous nerves to allow for coaptation to restore sensibility. The osseous component is con-
Fig. 16.1 An example of supine positioning with a small bolster under
the ipsilateral hemitrunk lying approximately parallel with the posterior
costal margin. The green markings show a small scapular ap can easily
be raised in this position across the midline. The red cross hatches
showing the lateral border portion of an osseus ap. All red markings
depict Dopplered vessels in the operative position
16 The Scapular Axis Flaps: An Expendable Direct Cutaneous Perforator withMany Options
Fig. 16.2 The positioning of
the forearm and arm allows
shoulder girdle movements to
allow uid raising and
exposure of the triangular
space. A dual team limb
reconstruction and osseocutaneous parascapular ap
being harvested in the supine
position. The forearm is
sterile wrapped and placed in
a sterile trough when needed
167
16.6 Flap Markings
It is our experience that marking the patient in the planned
operative position is preferred. We advise positioning as
above, so, for example, placing the patient in the lateral
decubitus position with the ipsilateral arm abducted to 90°
and supported by a colleague by the bedside will allow accurate marking presurgery. The scapula is very mobile and
given the mobility of the truncal skin on the ank and back–
vascular anatomy and Doppler signal can vary.
Mark the scapular outline and the scapular spine. The
main pedicle emerges from the triangular space above the
teres major. It is difcult to clinically isolate and clearly
identify the teres major in many patients. Thus, we draw a
line parallel to the lateral scapular border limited to its
cranio- caudal axis (Fig.16.3) and also a similar line running
from the scapular spine to the inferior tip of the scapula. At
approximately the midpoint of these lines at the lateral scapular border—the Doppler signal of the main pedicle can be
found as it emerges above the teres major. Here the vascular
signal can be followed for either branch. In general the parascapular ap branch runs roughly parallel to the lateral scapular border with the arm abducted to 90°; similarly the
scapular branch runs parallel to the scapular spine. Given the
variability in patient positioning and mobility of the truncal
skin, we prefer to follow the vascular signal with a Doppler
in the primary operative position.
Fig. 16.3 Two parallel lines on the lateral border, from the spine to tip,
and upper border to tip of the scapular and their respective midpoints.
Around this midpoint the exit of the main pedicle from the triangular
space can be Dopplered
Figure 16.1 highlights the markings with a green scapular
ap outlined, the red cross hatch delineating the lateral border osseous component and the parascapular branch running
immediately lateral to the lateral scapular border. These vessels were all Dopplered.
168
ab
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
D. Saleh and J. Henton
16.7 Flap Elevation: AStep-by-Step Guide
16.7.1 Scapular Flap
Our preference is to medially expose the vessels and therefore raise the ap from medial to lateral.
Mark the ellipse desired and to directly close by pinch. A
relatively avascular plane exists in the suprafascial plane.
Incise all the markings except the lateral quarter until the
vascular pedicle is visualized. This avoids being compromised by variable anatomy whereby the medial aspect of the
ellipse does not include the vessel.
The sharp dissection with monopolar cautery proceeds
over the trapezius, infraspinatus (and possibly rhomboid
major), and teres minor.
Once over the surface of the teres minor, it is common to
see the pedicle in the subcutaneous tissue. The dissection can
now proceed subfascially using a blade or Jameson scissor
dissection, as this makes it easier to include the brofatty
tissue around the pedicle as the triangular space is approached.
The remainder of the ap can now be incised knowing the
vasculature is within the ap tissue.
Once the vessel and surrounding fat is released from the
most lateral surface of the teres minor, move the arm into the
trough (or across the anterior trunk), and retract the teres
minor with a Czerny retractor medially. This opens the triangular space and will allow accurate ligation of the many
small venous branches draining the surrounding musculature. As more tissue is released, a Norfolk-Norwich selfretainer can be placed between the teres minor and the long
head of triceps to allow dissection of the pedicle with the
surrounding anatomy relatively static.
Larger-caliber arterial vessels an also be ligated and the
pedicle dissected to the desired point.
16.7.2 Parascapular Flap
This ap is similar to the scapular ap and is preferred often
because it provides a larger skin paddle, with ease of patient
positioning.
Once the ap markings are complete, incise the distal
three quarters of the ap to preserve the proximal part, which
can be incised once the vessels are visualized at the entry
point to the ap.
The ap is lifted in the suprafascial plane, using monopolar cautery, over the latissimus dorsi until the teres major
muscle comes into view. The dissection then proceeds in the
subfascial plane which will also bring the teres minor into
view medially. At this juncture it is common to see the vessels across the free upper edge of the teres major as the brofatty tissue comes into the surgical eld. A Travers
self-retainer can be placed between the teres minor and
major to better identify side branches going to the lateral
scapula and muscles.
The dissection follows the free edge of the teres major
gradually advancing the dissection well into the triangular
space. Figure 16.4 demonstrates a retracted teres major
exposing the length of the pedicle in the triangular space.
16.7.3 Osseus Flaps
Either skin ap can be incorporated into taking the lateral
border of the scapular for an osteocutaneous reconstruction.
The major difference in technique arises once entering the
triangular space. The medial vessels, which are numerous,
running from the main pedicle to the lateral border of the
scapula must be preserved. Thus, the main release of the
pedicle occurs primarily on its lateral aspect. Once the lateral
Fig. 16.4 (a, b) Teres major retracted and the pedicle dissection complete in a parascapular ap
16 The Scapular Axis Flaps: An Expendable Direct Cutaneous Perforator withMany Options
pedicle dissection is complete, all that should be tethering
the skin ap to the triangular space is the soft tissue (small
vessel) attachments to the scapula.
Reect the skin ap laterally, and incise the musculature
(infraspinatus), along the desired length of the scapula border– this does not typically include the bone cranial (superior) to the scapular spine. Similarly it is advisable to avoid
taking the tip of the scapula with this pedicle as it has separate axial blood supply from the thoracodorsal axis; therefore if desired additional pedicle dissection would be
required.
Once the muscle is incised, lift the periosteum from
medial to lateral but not to denude the bone ap portion.
Our preference is to use a sagittal saw for a uniform stepwise bone cut which allows control once through the deep
cortical aspect of the bone. Once the cuts are complete, an
Obwegeser elevator can be passed on the deep surface of
bone to “lever” it free from the subscapularis bers which
are now the only soft tissue attachments remaining.
16.8 Pearls andPitfalls
169
Be wary of the venous branches that require ligation
once in the triangular space. Typically these aps have
two venae draining the tissue, and so one must be cau-
tious as to not ligate a main vein of the ap. There can
be variability in our experience in the venous
anatomy.
Once the axial vessels come into view in the “fast”
phase of raising the ap, switch to more delicate dis-
section with scissors.
When ligating the venous branches in the triangular
space, attempt to preserve the length of one additional
branch in case of ap drainage problems (Fig. 16.5
ligated side branch of good caliber).
When using the osseus ap, re-tensioning the subscap-
ularis and infraspinatus muscles is important. We pre-
fer to place 2mm drill holes in the neo-lateral border
of the scapula and use a 2.0 Ethibond suture passed
through the now free edge of the infraspinatus, through
the hole, and through the deeper free edge of subscapu-
laris to then be tied.
When combining thoracodorsal aps and scapular
aps, release the teres muscle to allow conjoined pedi-
cle dissection (Fig.16.5).
Fig. 16.5 A latissimus dorsi and parascapular ap raised with the
intervening teres minor still intact which requires sectioning or disinsertion to chimerize
16.9 Clinical Example
A 47-year-old woman was involved in a cycling accident and
denuded the soft tissues of the dorsomedial foot and sustained
a midfoot fracture dislocation (Fig.16.6). Following osteosynthesis soft reconstruction was performed. The patient
desired a discrete donor site, and given the dimensions were
felt to exceed those appropriate for a groin ap, a scapular
ap was advocated to allow the scar to be concealed by
underwear and clothing.
The ap was raised in the lateral position allowing access
to the foot for osteosynthesis and reconstruction. A skin ap
was preferred in this patient because it was felt by the orthopedic team skeletal revision was a risk given the severity of
the midfoot injury, and so having a skin ap would more
easily permit reaccessing the midfoot if ever needed
(Fig.16.7).
170
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 16.6 A left foot injury in a 47-year-old woman
D. Saleh and J. Henton
16.10 Selected Readings
• Tang AL, Bearelly S, Mannion K.The expanding role of
scapular free-aps. Curr Opin Otolaryngol Head Neck
Surg. 2017;25:411–5.
• Mayou BJ, Whitby D, Jones BM.The scapular ap– an
anatomical and clinical study. Br J Plast Surg.
1982;35:8–13.
• Klinkenberg M, Fischer S, Kremer T, Hernekamp F,
Lehnhardt M, Daigeler A. Comparison of anterolateral
thigh, lateral arm, and parascapular free aps with regard
to donor-site morbidity and aesthetic and functional out-
comes. Plast Reconstr Surg. 2013;131:293–302.
• Izadi D, Paget JTEH, Haj-Basheer M, Khan
UM.Fasciocutaneous aps of the subscapular artery axis
to reconstruct large extremity defects. J Plast Reconstr
Aesthet Surg. 2012;65:1357–62.
Reference
Fig. 16.7 Parascapular ap reconstruction of a dorsal and medial foot
defect following trauma
1. Sparks DS, Saleh DB, Rozen WM, Hutmacher DW, Schuetz MA,
Wagels M. Vascularised bone transfer: history, blood supply and
contemporary problems. JPRAS. 2017;70:1–11.
Thoracoacromial Artery Flap: Pectoralis
Major Muscle Flap
JonathanA.Dunne, IanC.C.King, DariushNikkhah,
andJeremyRawlins
17
17.1 Introduction
The pectoralis major ap was rst described by Hueston and
McConchte [1] in 1968 as a means of ensuring adequate blood
supply for a skin ap to reconstruct the chest wall; Brown etal.
further modied the use of the ap for sternal defects to make
the repair more robust [2]. Maruyama rst reported its use in
head and neck surgery in 1977 to reconstruct an oral cavity
defect [3], and it was subsequently popularised by Ariyan [4].
The ap comprises the pectoralis major muscle, with or without overlying skin, and can include the rib to reconstruct mandibular defects. It is most frequently used as a pedicled ap but
can also be utilised as a free ap and remains a workhorse ap
in head and neck reconstruction and is frequently used for sternal defects secondary to infection, tumours or trauma.
17.2 Anatomy
The pectoralis major is an anterior muscle of the pectoral
girdle with two origins. The clavicular head originates from
the antero-medial portion of the clavicle and sternal head
from the anterior manubrium, sternum, costal cartilages 1–6
and external oblique aponeurosis. The two heads converge as
one muscle, occasionally with a small gap, to form a tendon
inserting into the inter-tubercular groove. The medial and
lateral pectoral nerves innervate the muscle and are commonly divided during elevation of the ap.
The pectoralis major muscle ap is a Mathes and Nahai type
V ap, with a dominant vascular pedicle and multiple minor
pedicles. The major vascular supply is from the pectoral branch
of the thoracoacromial artery. The pectoral branch emerges
from the main trunk lateral to the pectoralis minor, lying deep
to the pectoralis major, and traverses deep to it before emerging
medial to its tendon and piercing the clavipectoral fascia. It
runs on the muscle’s deep surface in a distinct fascial plane,
before dividing into muscular and cutaneous perforators.
The clavicular branch of the thoracoacromial artery
almost exclusively supplies the clavicular head of the pectoralis major. Minor segmental supply is from the internal
mammary artery perforators through intercostal spaces 1–3
medially and the long thoracic artery laterally. A cadaveric
study by Freemean demonstrated a rich anastomosis between
major and minor pedicles, with signicant vascular contributions by all pedicles to the muscle, which in turn supplies the
skin paddle via perforators [5]. The rich vasculature allows
ap elevation on a major or minor pedicle. Accompanying
venae comitantes provide venous drainage from the muscle,
and an overlying skin paddle has drainage into the cephalic
vein. A skin paddle extending inferior to the muscle has a
random blood supply, as opposed to axial vasculature.
J. A. Dunne (*)
Imperial College Healthcare NHS Trust, London, UK
I. C. C. King
Queen Victoria Hospital NHS Foundation Trust,
East Grinstead, UK
D. Nikkhah
Department of Plastic, Reconstructive and Aesthetic Surgery,
Royal Free Hospital, London, UK
J. Rawlins
Department of Plastic Surgery, Royal Perth Hospital,
Perth, WA, Australia
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_17
17.3 Preoperative Investigation
Clinical assessment is the mainstay of preoperative work-up
for the pectoralis major ap, and determining the requirements of the defect is imperative in ap planning. For head
and neck reconstruction, the necessity of a skin paddle must
be considered with the knowledge it will create a bulkier
ap. In addition, in female patients in particular, a skin paddle may carry increased donor site morbidity with breast distortion. Chest wall defects may be reconstructed with an
171
172
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
advancement-rotation ap based on the pectoral branch, or a
turnover ap vascularised by the internal mammary artery
perforators. Consideration of previous cardiac surgery,
which may have utilised the ipsilateral internal mammary
vessels, should be considered and will preclude use of a turnover ap.
17.4 Flap Design andMarkings
The surface marking of the pectoral branch of the thoracoacromial artery is from the midpoint of the clavicle descending
inferiorly and continued as a line bisecting it from the acromioclavicular joint to the xiphoid process. The internal
mammary artery perforators emerge from intercostal spaces
one to three, 1 to 2cm lateral to the sternum with the second
perforator usually the largest.
The boundaries of the muscle are the clavicle superiorly,
sternum medially and anterior axillary fold laterally.
Mediastinal defects are commonly reconstructed without a
skin paddle, with overlying skin closed directly or with a
split-thickness skin graft. A unilateral pectoralis major muscle ap will cover most sternal defects, although may struggle to cover the xiphoid process. Options include a
contralateral turnover ap or a different ap such as omentum or rectus abdominis aps.
A number of skin paddle designs have been reported, and
a paramedian skin paddle is frequently used in head and neck
reconstruction, beginning inferior to the second intercostal
space to permit use of a deltopectoral ap as a backup,
acknowledging the defensive approach proposed by
MacGregor [6].
17.5 Flap Raise/Elevation: AStep-by-Step
Guide
17.5.1 Head andNeck Reconstruction
Step 1 Flap Design
Mark the surface anatomy of the vascular pedicle and the
skin incision.
A paramedian skin ap overlying muscle is frequently
used. The arc of rotation from the inferior border of the clavicle to the distal edge of the skin paddle should be measured
and be equal to or greater than the distance from the inferior
clavicle and the distal edge of the defect (Figs.17.1 and 17.2).
Step 2
The skin paddle should be incised down to the muscle fascia
and undermining avoided, as it may damage musculocutaneous perforators. The pedicle lies deep to the muscle, and
therefore the supercial surface of the pectoralis major
J. A. Dunne et al.
Fig. 17.1 Markings: note the necrotic free ap on the right neck.
Markings for the pectoralis major myocutaneous ap don’t cross the
midline
Fig. 17.2 Defensive markings: preserving the upper intercostal perforators enables the deltopectoral ap to be protected in case of further
difculties with the reconstruction (a nal lifeboat). Note the design of
this ap goes just lateral to the deltopectoral groove where the blood
supply becomes random pattern rather than axial
should be dissected and exposed without concern. The skin
paddle may be tacked to the muscle to avoid damage due to
shear (Fig.17.3).
Step 3
The lateral border of the muscle is identied and the deep
surface of the muscle elevated from minimal attachments in
this region. The muscle is incised with cautery from its
medial and inferior origin, leaving the superior muscle intact.
Internal mammary artery perforators are cauterised when
dividing the muscle from its medial origin except when performing a turnover ap (Figs.17.3, 17.4, and 17.5).
Step 4
Continued ap elevation should leave the fascia on the deep
surface intact. With ongoing dissection of the ap away from
the pectoralis minor, the pedicle will be seen on the deep
surface of the muscle within the fascia. Branches of the
medial pectoral nerve and lateral thoracic artery traverse the
pectoralis minor and will be divided as they enter the deep
surface of the ap (Fig.17.6).
17 Thoracoacromial Artery Flap: Pectoralis Major Muscle Flap
173
Fig. 17.3 Identify inferior border of the pectoralis major muscle: this
allows the surgeon to adjust markings of the ap if required prior to
complete elevation. Dening boundaries is key
Fig. 17.4 Medial dissection: release from sternal attachments is key:
take care to carefully control the medial intercostal perforators if present; these can be large
Fig. 17.6 Medial release: carefully dissect the muscle from the chest
wall, taking care to look out for the pedicle which will appear on the
deep side of the pectoralis major muscle
Fig. 17.7 Lateral release: dividing the tendinous insertion is essential
to being able to mobilise this ap
Fig. 17.5 Lateral dissection: further dening the boundaries and insertion of the muscle, allowing visualisation of the released tissue and
donor sites
Step 5
Lateral to the pedicle, the insertion of the ap into the intertubercular groove is divided (Fig.17.7).
Step 6
Further muscular bres at the origin are released until adequate movement is achieved, which can necessitate islanding
the ap on the vascular pedicle (Fig.17.8).
The ap is passed superiorly via a wide subcutaneous tunnel into the neck, usually supercial to the clavicle, ensuring
there is no twisting of the pedicle (Figs.17.9 and 17.10).
174
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 17.8 Wide subcutaneous undermining: closure of the donor site is
dependent on wide undermining of the surrounding soft tissue
J. A. Dunne et al.
17.5.2 Sternal Reconstruction
The approach for the coverage of midline defects such as
those involving the sternum is slightly different from the
above. The movement required is less signicant and the
vector differs. The technique below is for an advancementrotation ap, not a turnover ap.
Step 1
Comprehensive debridement of the wound is vital, including
removal of metalwork and devitalised bone. Infected sternal
bone is soft, whereas bone which is viable is rm and makes
a characteristic clicking sound on debridement (Fig.17.11).
Step 2
The pectoralis major muscle can be accessed from the wound
edges and is dissected free from the subcutaneous tissue
plane. A lighted retractor is helpful for dissection in the subcutaneous plane (Fig.17.12).
Step 3
The muscle is then undermined and dissected from the chest
wall, taking care to control intercostal perforators with
Ligaclips. The muscle is elevated off the pectoralis minor:
Fig. 17.9 Flap turn-up: the ap can be tunnelled and turned through a
subcutaneous tunnel, positioning the ap in the position which puts
least tension on the pedicle and enables optimal skin ap placement
Fig. 17.10 Flap inset: the pectoralis major ap is sutured in place in
layers with care to ensure a drain is placed at the inferior aspect to allow
for swelling and any blood to escape as required
Fig. 17.11 Sternal dehiscence: note exposed wires, devitalised sternum and undebrided soft tissue along dehisced median sternotomy
incision
Соседние файлы в папке Библиотека им академика М.И. Перельмана