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
17 Thoracoacromial Artery Flap: Pectoralis Major Muscle Flap
175
Fig. 17.12 Dening the border of the pectoralis major. Allis forceps
hold the muscle up to free it from the underlying chest wall once it is
free from the cutaneous plane
retraction with a Deaver is essential here. Care is taken to
preserve the feeding vessels to the muscle.
Step 4
Two Allis forceps are attached to the leading edge of the
muscle adjacent to the wound, and traction is placed on the
freed up muscle by an assistant. Movement and ap reach
can be increased by releasing the tendinous insertion of the
muscle. Access to this is most safely achieved through a separate incision in the anterior axillary line; however some surgeons prefer to approach this through the sternal wound
(Fig.17.13).
Step 5
The process is repeated as necessary on the contralateral pectoralis major muscle (if available).
Step 6
Both pectoralis muscles are advanced. The leading edge of
the muscle to be used to ll the dead space is sutured in
place with parachuted 2/0 PDS mattress sutures. The second muscle ap is then double-breasted over the buried ap
for security with 2/0 PDS.Mediastinal and subcutaneous
16Ch drains are placed bilaterally. This double breasting of
Fig. 17.13 Mobilisation of the pectoralis major: demonstrating the
advancement of the completely released muscle
Fig. 17.14 Double-breasting of the pectoralis major muscles: this
serves to reinforce the stability of the sternum and eliminate residual
dead space
the pectoralis aps provides some sternal stability
(Fig.17.14).
Step 7
The skin wound is nally closed in layers to achieve a sound
and watertight closure. Topical negative pressure dressing
application can help splint these wounds (Fig.17.15).
176
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 17.15 Closure of median sternotomy: the skin incision close well
and judicious use of drains is recommended
17.6 Core Surgical Techniques inFlap
Dissection
Step 1 Flap Design
Preserve the rst two intercostal vessels when designing the
skin paddle in case a deltopectoral ap is required in the
event of ap failure—the ‘defensive approach’ described by
MacGregor.
Many cutaneous paddles have been described, and they
have the most reliable vasculature when located over muscle.
In female patients, the skin paddle can be located at the
infra-mammary crease—this may be inferior to the pectoralis major, and the blood supply is no longer axial and should
be considered as random pattern with a 1:1 length-to-width
ratio.
Step 2 Supercial Muscle Flap Dissection
Monopolar diathermy and a lighted retractor permit swift
dissection of the supercial muscle surface.
Steps 3, 4, 5 Flap Elevation
The distal extent of the ap can be elevated with monopolar
diathermy. Dissecting scissors or bipolar provide more cautious dissection near the pedicle.
J. A. Dunne et al.
Rotation-advancement muscle aps for sternal defects
may be challenging to visualise and dissect at the lateral
edge. A separate skin incision over the tendon may facilitate
its division at the inter-tubercular groove.
Step 6
Additional length for transfer to the neck may be gained by
dividing the muscle origin at the clavicle and isolating the
ap on the pedicle alone. In addition, excising a cuff of muscle so the upturned ap is applied directly to the clavicle
without an intervening muscular bridge can increase length.
Passing the ap deep to the clavicle can increase length
by up to 4 cm, allowing caution for adjacent vascular
structures.
17.7 Clinical Scenario
Clinical Scenario A Head and neck salvage
Surgeon: Jeremy Rawlins Dariush Nikkhah
A 54-year-old man with failed free anterolateral thigh ap
to right mandibular SCC secondary to thrombus. Following
ap debridement, vessels, bone and nerves lie exposed. The
pectoralis major ap is ideal for this salvage operation where
microsurgical options have failed and a robust myocutaneous
ap with a reliable blood supply is required.
Clinical Scenario B Sternal mediastinitis
Surgeon: Dariush Nikkhah
A 74-year-old diabetic male with sternal wound breakdown 10 days following coronary artery bypass grafting
where both internal mammary arteries had been harvested.
Following preoperative optimisation and debridement by the
cardiothoracic team, sternal wires had been removed, and
there is a soft tissue defect comprising the skin, fat, and
mediastinum, and the pericardium is exposed beneath.
Advancement of bilateral pectoralis major aps is appropriate in such a scenario.
17.8 Pearls andPitfalls
Pearls
• The larger the skin paddle harvested, the higher the
likelihood of skin survival.
• Additional length of skin paddle can be obtained
beyond the edge of the paddle as a random-pattern
ap, but this has higher risk of skin necrosis.
• The defensive approach for head and neck reconstruction denes a paddle of skin marked from the
second and third intercostal spaces bounded cranially along the clavicle, laterally by the deltopectoral
groove. This permits a deltopectoral ap to be
17 Thoracoacromial Artery Flap: Pectoralis Major Muscle Flap
raised if required as a lifeboat ap. Preservation of
this tissue necessitates subcutaneous tunnelling of
the myocutaneous ap to reach the clavicle.
• If access is particularly challenging or the skin
defect is signicant, the deltopectoral ap can be
raised concurrently for access and to allow soft tissue advancement for closure. This serves to delay
the deltopectoral ap for future use if required.
• Division of the clavicular pectoralis muscle bres
above the pedicle, division of the lateral thoracic
artery and/or splitting and removing the middle
one-third of the clavicle can increase ap reach.
177
Pitfalls
• Judicious use of Ligaclips to control chest wall muscle perforators is important to control bleeding.
• Adequate retraction using a Deaver is key to identifying and protecting the vessel on the underside of
the muscle.
• Division of the clavicle or passing the ap below
the clavicle increases operative time, morbidity and
complications.
• When insetting the ap into the neck, avoid overly
rotating, compressing or kinking the proximal ap,
taking particular care where the ap crosses the
clavicle.
17.9 Chimeric Thoracoacromial Pectoralis
Major Flap
The chimeric pectoralis major ap allows simultaneous
raise of a myocutaneous component and fasciocutaneous
ap [7] to allow versatility in the ap inset, especially in
pharyngeal circumferential defects (Fig. 17.16). It is
based both on the clavicular branch of the thoracoacromial artery and occasionally the fasciocutaneous perforators arising from the long thoracic artery laterally [8].
Freemean et al. demonstrated a rich anastomosis link
between thoracoacromial, internal mammary and when
present the lateral thoracic artery [5]. The rich muscle
vasculature allows myocutaneous ap elevation at any
axis longitudinal to the thoracoacromial artery branches
and a separate perforator-based fasciocutaneous skin ap
based on a cutaneous perforator.
Fig. 17.16 Circumferential hypopharyngeal and oesophageal defect following total laryngopharyngectomy requiring tubular ap reconstruction
Fig. 17.17 Surgical markings for the chimeric myocutaneous pectoralis major ap (B) and the perforator-based thoracoacromial ap (A)
The accompanying venae comitantes provide enough
venous drainage for the myocutaneous component; however,
the fasciocutaneous ap raising requires extra care to preserve venous drainage to the overlying skin paddle through
venous networks of the cephalic vein [5]. The thoracoacromial artery may require to be dissected allowing ease during
inset and the two skin components.
Design, Flap Dissection and Inset
• The surface markings according to the cutaneous perfora-
tors from the pectoral branch of TAA, using a handheld
Doppler. A 4-cm2 area around the located perforator was
drawn along the line joining the acromion to the xiphoid
process intersection with the perpendicular line drawn
from the midclavicular line (Fig.17.17).
178
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
• The chimeric TAAP ap raised from medial to lateral.
The fasciocutaneous perforator constantly arises from the
septum between the clavicular and the sternocostal heads
of PM muscle. The fasciocutaneous component dissection proceeds along the subfascial plane. The thoracoacromial pedicle with the two chimeric components could
be lengthened by superior retraction under the clavicle.
• During the dissection, the pectoral branch of the thoracoacromial pedicle is preserved to harvest the myocutaneous ap component (Fig.17.18). The two aps can then
pass under the clavicular head of the pectoralis major
muscle and through either a subcutaneous tunnel or even
under the clavicle bone, to allow inset in a pharyngoesophageal defect (Fig.17.19).
• A spiral inset conguration of the two skin paddles allows
slightly lengthening and less tension neo-pharyngeal
suturing.
• Both transverse (fasciocutaneous component) and the
vertical (myocutaneous component) could be primarily
closed.
J. A. Dunne et al.
Fig. 17.19 Chimeric pectoralis major myocutaneous ap and TAAP
ap inset to form the neo-oesophageal tube
Chimeric Pectoralis Major Flap (Figs. 17.16, 17.17,
17.18, and 17.19).
A total laryngopharyngectomy defect with a 10-cm pha-
ryngeal circumferential defect in a 58-year-old male was
reconstructed with the chimeric pectoralis major regional
ap. The bilobe ap was raised using the thoracoacromial
fasciocutaneous (transverse) component and the myocutaneous (vertical) component.
Fig. 17.18 Both the myocutaneous pectoralis major ap and the TAAP
ap dissected and islanded on the thoracoacromial pedicle
17.10 Selected Readings
• Hueston JT, McConchie IH.A compound pectoral ap.
Aust N Z J Surg. 1968;38(1):61–3.
Description of including the pectoralis major in chest
ap for repair of large chest wall defects, including
medial ends of clavicles and sternum.
• Brown RG, Fleming WH, Jurkiewicz MJ.An island ap
of the pectoralis major muscle. Br J Plast Surg.
1977;30:161–5.
Case report describing the use of bilateral pectoralis
major muscles for sternal reconstruction. Both aps were
advanced with division of the tendinous insertion and lateral thoracic arteries and were double-breasted for reinforced closure. The skin was tacked to the muscle and the
remaining defect grafted.
• Maruyama Y, Fujino T, Aoyagi F, etal. One stage reconstruction of oral cavity by use of pectoralis major myocutaneous island ap. Keio J Med. 1978;27:47–52.
Describes the transfer of the ap through a midline
section of the clavicle for oral cavity reconstruction using
the pedicled pectoralis major ap for a one-stage reconstruction of the oral defect.
• Ariyan S.The pectoralis major myocutaneous ap. A versatile ap for reconstruction in the head and neck. Plast
Reconstr Surg. 1979;63:73–81.
Seminal paper widely credited (incorrectly) as describ-
ing the pectoralis major myocutaneous ap rst. Ariyan
17 Thoracoacromial Artery Flap: Pectoralis Major Muscle Flap
179
describes the anatomical landmarks based on cadaveric
dissection. He further describes the pectoralis major
myocutaneous ap as having a combined skin-muscle
pedicle and discusses modications such as islanding the
ap by dividing the clavicular muscular attachments.
• McGregor IA. 1980 Fundamental techniques of plastic
surgery, 7th ed. Edinburgh: Churchill Livingstone.
Describes the use of a combined pectoralis major myocutaneous ap and deltopectoral ap in intra-oral
reconstruction.
• McGregor IA.A “defensive” approach to the island pectoralis major myocutaneous ap. Br J Plast Surg.
1981;34:435–7.
Proposes the preservation of the deltopectoral ap
during the elevation of the pectoralis major ap, advocating the raising of this ap as an islanded ap and utilising
a subcutaneous tunnel for ap dissection and delivery.
• Palmer JH, Batchelor AG.The functional pectoralis major
musculocutaneous island ap in head and neck reconstruction. Plast Reconstr Surg. 1990; 85(3):363–7. https://
doi.org/10.1097/00006534- 199003000- 00004.
Describes a modication of islanding the pectoralis
major myocutaneous ap to maintain maximal donor-site
function, facilitate closure of the donor site defect,
increase pedicle length and the arc of rotation, reduce
pedicle bulk and improve cosmesis.
Acknowledgements We thank Georgios Patanis, Dajiang Song and
Zan Li for writing this case scenario section.
References
1. Hueston JT, McConchie IH.A compound pectoral ap. Aust N Z J
Surg. 1968;38(1):61–3.
2. Brown RG, Fleming WH, Jurkiewicz MJ.An island ap of the pectoralis major muscle. Br J Plast Surg. 1977;30:161–5.
3. Maruyama Y, Fujino T, Aoyagi F, et al. One stage reconstruction
of oral cavity by use of pectoralis major myocutaneous island ap.
Keio J Med. 1978;27:47–52.
4. Ariyan S. The pectoralis major myocutaneous ap. A versatile
ap for reconstruction in the head and neck. Plast Reconstr Surg.
1979;63:73–81.
5. Freeman JL, Walker EP, Wilson JS, Shaw HJ.The vascular anatomy of the pectoralis major myocutaneous ap. Br J Plast Surg.
1981;34:3–10.
6. McGregor IA.A “defensive” approach to the island pectoralis major
myocutaneous ap. Br J Plast Surg. 1981;34:435–7.
7. Zhang YX, Li Z, Grassetti L, etal. A new option with the pedicle
thoracoacromial artery perforator ap for hypopharyngeal reconstructions. Laryngoscope. 2015;126:1315.
8. Zhang YX, Yongjie H, Messmer C, etal. Thoracoacromial artery
perforator ap: anatomical basis and clinical applications. Plast
Reconstr Surg. 2013;131:759e–70e.
Transverse Cervical Artery Flap -
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Supraclavicular Flap
PedroCiudad, JusteKaciulyte, GeorgiosPatanis,
andHung-ChiChen
18
18.1 Introduction
The supraclavicular region represents a fetching donor site
for several aps for its cutaneous features and easy-to-hide
location. In 1842, Mutter [1] was the rst to introduce a random shoulder-based ap for a neck burn contracture. A century later, in 1958, Kirschbaum [2] described the acromial or
“in charretera” ap, as the ornamental military patch placed
on shoulders. The “in charretera” fasciocutaneous ap was
renamed as cervicohumeral ap by Mathes and Vasconez
[3], who were the rst to study the supraclavicular region’s
vascular anatomy in 1970.
Lamberty etal. [4] followed this lead and in 1979 reported
the supraclavicular artery being a branch of the transverse
cervical artery in most cases, and they described the supraclavicular artery ap as an axial ap. Nevertheless, the ap’s
popularity witnessed a quick fall as the use of excessively
long tissues’ portions led to frequent distal necrosis.
Almost 20years had to pass until Pallua etal. [5] gave
new revival to the ap, by reporting its successful use in cervicomental scar contractures treatment in 1997. Since then,
it has been used as a pedicled fasciocutaneous ap mostly, in
various cervicofacial district reconstructions.
P. Ciudad (*)
Department of Plastic, Reconstructive and Burn Surgery,
Arzobispo Loayza National Hospital, Lima, Peru
Academic Department of Surgery, Federico Villarreal National
University, Lima, Peru
J. Kaciulyte
Department of Surgery “P.Valdoni”, Unit of Plastic and
Reconstructive Surgery, Sapienza University of Rome, Policlinico
Umberto I, Rome, Italy
G. Patanis
Department of Plastic Surgery, Emergency Care and Trauma
Division (ECAT), The Royal London Hospital, Barts Health NHS
Trust, London, UK
H.-C. Chen
Division of Plastic Surgery, China Medical University Hospital,
Taichung, Taiwan
The rst to introduce the idea of free muscle perforator
aps’ harvest from the supraclavicular region were Mizerney
etal. [6] and Cordova etal. [7] in 1995 and 2008, respectively. Finally, in 2012 Becker described supraclavicular
lymph node transfer technique for limb lymphedema management [8].
18.2 Anatomy
The transverse cervical artery (TCA) and the supraclavicular
artery are the main vessels of the supraclavicular region.
They are both found in the lateral triangle of the neck which
is delimitated by the anterior clavicular part inferiorly, the
sternocleidomastoid muscle anteriorly, and the trapezius
muscle posteriorly.
After its origin from the subclavian artery, the TCA runs
posteriorly and laterally passing under the omohyoid muscle,
toward the trapezius muscle. In this path, TCA passes supercially to the scalene muscles and the brachial plexus and
traverses the bro-adipose tissue of the supraclavicular fossa.
Close to the trapezius muscle, the TCA splits into its two
nal branches, supercial and deep. One or two committing
veins travel alongside the TCA.
The supraclavicular artery emerges from the TCA after its
passage under the omohyoid muscle, at the middle third of the
clavicle in 90% of cases and at the lateral third in the other 10%
[9]. This origin from the TCA has been observed from 62.9%
to 100% of cases, according to various anatomical studies [10].
In the remaining cases, it arises from the suprascapular artery.
During its course, the supraclavicular artery presents a diameter of 1–1.5mm and it divides into two branches [11]. The main
lateral deltoid branch passes through the deep fascia while running laterally over the cap of the shoulder, toward the acromioclavicular joint and the deltoid muscle. It supplies the overlying
skin from the neck to upper chest, including the shoulder and
the deltoid region. One or two committing veins travel alongside toward the external jugular vein (EJV). The anterior thoracic branch directs to the anterior thoracic region.
© 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_18
181
182
Finally, the venous drainage of the supraclavicular area is
provided by the supercial cervical vein (SCV) too. The
SCV emerges anteriorly from the trapezius muscle and stays
under the supercial cervical fascia while coursing parallel
to the clavicle. After receiving perforators from the overlying
skin, the SCV reaches the EJV.
18.3 Preoperative Investigation
Doppler exam represents the most frequent preoperative
investigation in supraclavicular ap planning [12]. The exam
can easily locate the emergence of supraclavicular artery in
the lateral neck triangle. Moreover, it may be useful intraoperatively, to follow the ap’s pedicle during its harvest.
Computed tomography angiography (CTA) is considered
a valid preoperative exam to study the vascular regional system, for cases of free ap planning in particular [13].
These two most used techniques have been compared to
triplex ultrasound, magnetic resonance angiography, digital
subtraction angiography, and indocyanine green (ICG)
angiography in a study on preoperative supraclavicular
mapping capacity by Sheriff etal. [14] Despite that handheld Doppler showed perforators in 80% of cases, CTA
results were considered the best of the series, as it identied
60% of perforators and it traced the supraclavicular artery’s
course in 45% of cases. For the ICG showed similar mapping efcacy, it was named as a feasible alternative to CTA,
with the advantage of no radiation-related risks. ICG exam
has proven its validity intraoperatively, even in conrming
ap’s blood perfusion and being predictive for ap’s survival [15].
Before supraclavicular lymph node harvest, ICG is used
to reverse mapping upper limb’s lymph ow and to identify
the sentinel lymph nodes to be spared [16].
P. Ciudad et al.
Fig. 18.1 Anatomical landmarks of the transverse cervical arterybased ap correspond to the lateral triangle of the neck with the clavicle
(CL) inferiorly, the sternocleidomastoid muscle (SM) anteriorly, and
the medial border of the trapezius muscle (TM) posteriorly
18.4 Flap Design andMarkings
The best exposure is obtained with the patient in supine position with a shoulder roll placed to create neck hyperextension. The left side should be avoided in order to prevent risk
of iatrogenic injury to the thoracic duct. The anatomical
landmarks of the pedicle’s origin correspond to the lateral
triangle of the neck: the clavicle inferiorly, the sternocleidomastoid (SCM) muscle anteriorly, and the medial border of
the trapezius muscle posteriorly (Fig. 18.1). Lymph node
harvest is performed within these triangle borders. In fasciocutaneous aps, skin paddle is drawn along an axis traced
from the center of the triangle toward the acromioclavicular
joint and the deltoid muscle. With no pre-expansion, maximum ap’s measures are about 30× 10 cm, with possible
primary closure [17].
Fig. 18.2 After skin incision and dissection up to the platysma muscle,
the EJV is identied (proximal and distal blue laces) and ligated proximally and distally
18.5 Flap Raise/Elevation: AStep-by-Step
Guide
In right neck’s lateral triangle, skin incision deepens up to
the platysma muscle close to the lateral border of the
SCM.The EJV is identied and ligated proximally and distally (Fig.18.2).
After EJV ligation, dissection continues medially until
the TCA with its committing veins are visualized (Fig.18.3).
18 Transverse Cervical Artery Flap - Supraclavicular Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 18.3 After EJV ligation (double blue laces), dissection is carried
out deeper and medially until the TCA (red lace) with its committing
veins (single blue lace) are visualized
Fig. 18.4 The supraclavicular lymph node ap appears ready for harvest, together with its pedicle that consists in TCA (red lace) and one
committing vein (blue lace)
TCA and its veins form the ap’s pedicle that is followed
toward the trapezius muscle direction. Care is taken to
preserve lymph nodes that surround the TCA in a broadipose tissue envelope (Fig.18.4).
18.6 Core Surgical Techniques inFlap
Dissection
1. Surgery is performed under general anesthesia, with the
patient in supine position and neck hyperextension,
183
thanks to a shoulder roll to favor right side exposure. The
anatomical landmarks to identify are those of the lateral
triangle of the neck: the clavicle inferiorly, the SCM
anteriorly, and the medial border of the trapezius muscle
posteriorly. Handheld preoperative Doppler exam may
show the exact location of the anterior perforating
branch of the supraclavicular artery.
2. Fasciocutaneous paddle dissection is started from the
lateral-distal edge. The vessels run within the subcutaneous plane, so rising can be carried out above the
muscle fascia to the clavicle, with no risk to harm the
pedicle. When required, the clavicle’s periosteum
may be included to perform a chimeric osteocutaneous ap.
3. At the clavicle level, intraoperative handheld Doppler or
direct visual exam may show the pedicle within the subcutaneous tissues of the ap. The supraclavicular artery
and its committing veins are followed including a soft
tissue cuff, to their origin from the transverse cervical
vessels. After omohyoid muscle visualization, it has to
be preserved with its cephalic reection. In this way,
between the reected omohyoid muscle and the scalenus
muscles, TCA can be identied within the adipose tissue
of the supraclavicular fossa. The TCA is transected posteriorly and followed anteriorly to obtain a vessel diameter of almost 1.5mm.
4. When feasible, the SCV should be included in the ap in
order to supercharge its venous drainage and prevent
congestion. The SCV runs supercially from the trapezius muscle in the deltopectoral fossa toward the
EJV.The dissection is performed in retrograde direction,
after the main pedicle identication.
5. The dissection is slightly different when supraclavicular
lymph nodes are harvested. A 4-cmS-shaped incision is
performed 1.5cm above the clavicle, within the lateral
neck triangle.
6. Sub-platysmal aps are raised to the triangle anatomical
landmarks and the dissection deepens at the lateral border of the SCM.Particular care is taken to identify and
preserve the EJV.
7. The dissection continues until the omohyoid muscle is
identied and reected cephalad and the TCA with its
committing veins are visualized and followed in a plane
above the scalene muscles, toward the trapezius muscle
direction. Care is taken to preserve a consistent broadipose tissue surrounding the TCA, thus including the
lymph nodes.
8. The SCV is constantly supercial and posterolateral to
the TCA.It should be preserved and included in the ap,
together with the EJV that is ligated proximally and
distally.
9. The bro-adipose tissue harvested can be crossed by a
prominent cutaneous sensory nerve. As the majority of
184
bc
a
de
P. Ciudad et al.
Fig. 18.5 (a) Nasal bone and tip, part of the lateral walls and septum,
and both soft triangles loss consequent to squamous cell carcinoma
resection. (b) Intraoperative picture that shows the donor site from
which the SOC free ap with a skin paddle of 6 x 4cm has been har-
the lymph nodes are deeper, the nerve can be spared usually. Nevertheless, there can be cases in which a lymph
node may be present supercially to the nerve. If the
supercial lymph node has to be included in the ap, the
nerve can be accurately divided and re-anastomosed
immediately after.
10. The donor site is closed primarily, with multilayer
stitches and performing z-plasty technique. A suction
drain is placed to avoid hematoma and seroma.
vested. (c) SOC free ap with a skin paddle of 6×4cm and a clavicle’s
corticoperiosteal segment of 3 × 0.4 cm, ready for the inset. (d)
Postoperative picture taken 6days after surgery. (e) Postoperative picture taken 5months after reconstructive and revision surgeries
18.7 Clinical Scenario
18.7.1 Supraclavicular Osteocutaneous (SOC)
Free Flap
A 62-year-old female presented with ulcerated 1.5×1 cm
squamous cell carcinoma of the nasal dorsum.
Wide local excision was performed and resulted in nasal
bone and tip, part of the lateral walls and septum, and both
soft triangles resection (Fig.18.5a). Immediate reconstruc-
abc
18 Transverse Cervical Artery Flap - Supraclavicular Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
185
tion was achieved with SOC free ap with a skin paddle of
18.7.2 Supraclavicular Vascularized Lymph
6 × 4 cm and a clavicle’s corticoperiosteal segment of
3×0.4cm (Fig.18.5b, c).
TCA and its committing vein were anastomosed to the
left facial vessels with vein graft interposition (Fig.18.5d).
No postoperative complications occurred, and ap debulking procedures were carried out at 10weeks and 4months
postoperatively (Fig.18.5e).
e
Here we present a case of right lower limb I stage lymphedema according to the International Society of Lymphology
(ISL) (Fig.18.6a). A 48-year-old female presented it after
ablative surgery for cervical cancer and groin lymph node
dissection, performed 1.5years before.
Node Transfer (VLNT)
d
Fig. 18.6 (a) Right lower limb lymphedema assessed as stage I accord-
ing to ISL, subsequent to groin lymph node dissection surgery.
Intraoperative pictures of VLN ap harvest from the right supraclavicular region (b): the lymph nodes were harvested together with the TCA,
one committing vein, and the EJV (c). Postoperative pictures at
6months after surgery that show circumference reduction rates achieved
with the VLNT (d) and the lymph ow improvement at lymphoscintigraphy exam (e)
Соседние файлы в папке Библиотека им академика М.И. Перельмана