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
23 Inferior Gluteal Artery Perforator Flap
23.6 Core Surgical Techniques inFlap
Dissection
The ap design should allow adequate closure of the resulting donor site; in some cases undermining of the superior
and inferior borders will be required to ensure a tension-free
closure.
Once the ap is raised and medially mobilized, it is crucial to secure the de-epithelialized superior edge of the ap
to the anterior surface of the sacrum. The surgeon should be
vigilant in ensuring that the sacral venous plexus is not damaged at this stage; this can lead to hemorrhage which is difcult to control.
The de-epithelialized medial edge then should be secured
to the lateral pelvic outlet to ensure a complete seal of the
pelvic cavity to avoid herniation of pelvic contents. This is
done with 0’Vicryl suture.
In addition to the aforementioned ap drains, a nonsuction pelvic drain is used. This is placed through the
opposite buttock in case of unilateral IGAPs and through
the inferior border of a ap if bilateral IGAPs have been
used.
The authors also utilize this ap for reconstruction of
vaginal defects in addition to closing the perineal wound.
When a posterior vaginal reconstruction only is required,
the defect is measured, and a template created. The template is transferred to the medial edge of the IGAP, and that
portion of skin is preserved when de-epithelializing the
ap. This area is then inset using parachute suture technique to close the vaginal defect. Care must be taken in
deciding where the de-epithelialization commences on the
ap as well as its width as this will dictate the vaginal
diameter, thereby reducing the risk of subsequent stenosis
but must still allow a tension- free midline closure of the
perineal defect.
229
Fig. 23.5 Unilateral IGAP ap perforators, marked with handheld
Doppler
23.7 Clinical Scenario
Unilateral IGAP ap marked for closure of perineal defect
following abdominoperineal excision (APE) for rectal cancer (Fig.23.5). The perforators are marked with a handheld
Doppler. The ap is elevated and two perforators dissected
along their course to achieve adequate medial advancement
(Fig.23.6). The ap is inset by using 0’Vicryl for anchoring sutures to the sacrum and the pelvic walls. Dermal and
skin closure is carried out with dissolvable sutures
(Fig.23.7).
Fig. 23.6 Perforator dissection complete and ap elevated, this ap
can be rotated at 90 degrees to allow closure of the defect if required
Fig. 23.7 Unilateral IGAP ap inset into perineal defect
230
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
M. Mughal and P. Roblin
23.8 Summary
Bilateral IGAPs provide enough bulk in our experience, in
dealing with extensive defects resulting from total pelvic
exenteration (TPE) with high sacrectomies. It is documented
that gluteal fasciocutaneous aps provide sufcient tissue
for even signicant sacrectomy defects over 2000 cm3 in
volume [3].
The IGAP is a robust ap, which is technically simple and
reproducible. It has minimal donor site complications and
postoperative pain. The constant anatomy allows ease in
planning and design, and in the modern era of minimally
invasive surgery, i.e., robotic and laparoscopic resections, it
remains a compatible local option for perineal
reconstruction.
23.9 Pearls andPitfalls
Pearls
• The surgeon needs to ensure that the ap raise is in
the subfascial plane, dividing the fascia completely
facilitates medial mobilization and in patients with
laxity of tissue planes, the medial mobilization of
the ap can be achieved without dissecting the
pedicle.
• Medial edge should also be raised in the subfascial
plane to aid advancement.
• The middle one third of the ap will contain the
maximum number of perforators. Care must be
taken not to elevate this area unless perforator dissection is planned.
• In patients with less buttock laxity, undermining of
the superior and inferior aspect will be required to
aid closure of the donor site.
• One advantage of the V-Y pattern is that in the event
of wound dehiscence, the ap can be readvanced to
close the defect.
23.10 Selected Readings
• Mughal M, etal. Reconstruction of perineal defects. Ann
R Coll Surg Engl. 2013;95(8):539–44.
• Overview of principles of perineal reconstruction with
management options.
• Niranjan NS, et al. Perforator aps for perineal reconstructions. Semin Plast Surg. 2006;20:133–44.
• Key paper describing the anatomy and technical aspects
of local ap reconstruction options in the perineum.
• Higgins JP, et al. Ischial pressure sore reconstruction
using an inferior gluteal artery perforator (IGAP) ap.
Brit Journ Plast Surg. 2002;55(1):83–5.
• Description of the inferior gluteal artery perforator ap
and its use in perineal reconstruction.
• Hainsworth A, etal. Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator aps. BJS. 2012;99:584–8. https://doi.org/10.1002/
bjs.7822.
• Clinical outcomes of Abdominoperineum excision recon-
struction with IGAP aps.
• Garvey PB, Rhines LD, Feng L, Gu X, Butler
CE. Reconstructive strategies for partial sacrectomy
defects based on surgical outcomes. Plastic and recon-
structive surgery. [Online] United States;
2011;127(1):190–199. Available from: https://doi.
org/10.1097/PRS.0b013e3181f95a19.
• Surgical outcomes of large pelvic exenterations and
reconstruction with IGAP aps.
References
1. Higgins JP, et al. Ischial pressure sore reconstruction using an
inferior gluteal artery perforator (IGAP) ap. Br J Plast Surg.
2002;55(1):83–5.
2. Mughal M, et al. Reconstruction of perineal defects. Ann R Coll
Surg Engl. 2013;95(8):539–44.
3. Garvey PB, Rhines LD, Feng L, Gu X, Butler CE.Reconstructive
strategies for partial sacrectomy defects based on surgical outcomes.
Plast Reconstr Surg. 2011;127(1):190–9. https://doi.org/10.1097/
PRS.0b013e3181f95a19.
Pitfalls
• Delayed wound healing is a common complication
especially in the midline due to pelvic collections.
In our experience the pelvic drain is kept in for at
least 2weeks postoperatively to aid drainage.
• Postoperative compliance for nursing side to side
for 48hours is important; in our experience patients
requiring prolonged intensive care admission after
surgery are at higher risk of wound healing
complications.
The Lumbar Artery Perforator Flap:
ATrue Alternative inAutologous Breast
Reconstruction
FilipB.J.L.Stillaert, PhillipBlondeel,
andKoenraadVan Landuyt
24
24.1 Introduction
The lumbar artery perforator (LAP) ap is designed around
the love-handle region and incorporates skin and an ample
amount of subcutaneous fat tissue. Its use in autologous
breast reconstruction was initially described in 2003 [1].
Obviously, autologous breast reconstructions are superior
to implant-based reconstructions as they yield long-term,
natural results and avoid complications related to implantbased surgery.
The reference in autologous breast reconstruction is the
deep inferior epigastric artery perforator ap (DIEP ap),
and alternatives such as the SGAP ap (superior gluteal
artery perforator), TMG ap (transverse myocutaneous gracilis), or PAP ap (profunda artery perforator) have been
reported. These substitutes are selected when the DIEP ap
is not suitable due to inadequate volume or compromised tissue after previous surgery.
Yet, none of these aps offer the convenience of the DIEP
ap. The SGAP ap was our second choice, but the rmness
of the gluteal fat can be an annoying hitch to shape an aesthetically pleasing breast. Differently, a great benet of the
LAP ap is the pliable and moldable fat tissue overlying the
gluteus medius muscle.
The LAP ap is an excellent choice in slender, “pearshaped” patients, as an alternative or surrogate for the DIEP
ap or in patients that prefer not to have an abdominal scar.
24.2 Anatomy
The four-paired lumbar arteries arise from the aorta and the
majority pass posterior to psoas major muscle. The upper
three lumbar arteries course between the quadratus lumborum muscle and the erector spinae muscle. The lumbar arteries arising from L4 run directly anterior to the quadratus
lumborum muscle. The arteries pierce the aponeurosis of the
transversus abdominis lateral to the erector spinae muscle or
have an intramuscular course through the erector spinae.
Once the vessels perforate the thoracolumbar fascia, they
immediately branch into smaller vessels to supply the subcutaneous fat. Perforators arising from the fourth lumbar artery
follow a more septocutaneous course and emerge between
the erector spinae muscles and the quadratus lumborum
(Fig.24.1).
Filip B. J. L. Stillaert (*) · P. Blondeel · K. Van Landuyt
Department of Plastic and Reconstructive Surgery, University
Hospital Gent, Ghent, East Flanders, Belgium
e-mail: Filip.stillaert@ugent.be; Phillip.blondeel@ugent.be;
Koenraad.vanlanduyt@ugent.be
© 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_24
Fig. 24.1 CT scan showing the anatomy of the lower back region. The
lumbar artery perforator L4 has a septocutaneous course and runs posteriorly to the psoas major muscle (PM). It then travels in between the
quadratus lumborum muscle (QL) and the erector spinae muscle (ESM)
and pierces the thoracolumbar fascia
231
232
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
F. B. J. L. Stillaert et al.
Fig. 24.2 The cluneal nerves innervate the upper part of the buttock
region. These nerves are included in the LAP ap dissection and can be
used to restore the sensibility of the newly reconstructed breast
Anatomical studies revealed an average of 5± 2 lumbar
artery perforators [2–5]. The mean diameter of the lumbar
artery and vein perforator ranges between 2.1 and
2.8±0.3mm [2, 4]. It is generally accepted that the lower
lumbar vessels give off more and larger perforators with a
dominancy of L3 and L4 perforators in more than 90 percent
of the patients [2]. The mean point of perforation of the lumbar fascia is at an average distance of 7.5cm from the midline [2, 5] (Fig.24.2). This length is measured from a bird’s
eye view (CT scan ndings). The real anatomical distance
will be at 8–9cm seen the convex shape of the erector spinae
muscle.
The superior cluneal nerves innervate the skin of the
upper part of the buttock region (Fig.24.2). They are the rst
structures that are encountered intraoperatively and pierce
the thoracolumbar fascia. The nerves can be incorporated in
the LAP ap to restore breast sensation.
Fig. 24.3 A 33-year-old, slender patient with a medical history of
bilateral mastectomy. Insufcient abdominal tissue excludes the use of
a DIEP ap to perform an autologous breast reconstruction
24.3 Preoperative Investigation
The ideal case for a breast reconstruction with a LAP ap is
a slender patient with a pear-shaped body morphology that
presents with surplus tissue in the love-handle region
(Figs.24.3 and 24.4). Medical history should exclude clotting diseases, smoking habits, allergy, lower spine surgery, or
lower spine conditions.
A preoperative computed tomography (CT) angiography
is performed of the lumbar and thoracic region (Fig.24.5).
This examination is performed in prone position and
visualizes the size, branching pattern, pedicle length, patency,
exact anatomical course, and position of the lumbar
perforators.
It also displays the available donor tissue in the lovehandle region. Permeability of the deep inferior epigastric
vascular pedicle should be investigated whenever a previous
breast reconstruction with a DIEP ap has been performed.
Perforators are marked by the radiologist using a grid system
with the midline being the Y-axis and the iliac crest being the
X-axis.
24 The Lumbar Artery Perforator Flap: ATrue Alternative inAutologous Breast Reconstruction
24.4 Flap Design andMarkings
The LAP ap is designed around the excess tissue in the
love-handle region (Fig.24.2). The initial markings are made
in a standing position. Markings include the midline, the
superior border of the iliac crest, and a vertical line drawn at
7.5 cm from the midline (Fig. 24.6). The skin island is
designed around the perforator and the ap design starts
medially at approximately 2cm from the midline. A pinch
test is performed to evaluate for a tension-free closure of the
donor site. It is obvious that a primary reconstruction requires
a smaller skin paddle compared to secondary
reconstructions.
The ap is redesigned with the patient in prone position
and marked more inferiorly due to the change in position
(Fig. 24.7). The location of the perforator is conrmed by
Doppler examination, and usually the L4 perforator is
233
Fig. 24.4 The patient has a typical pear-shaped body morphology with
excess tissue in the love-handle region. She is a good candidate for a
bilateral, autologous breast reconstruction with a LAP ap. A bilateral
LAP procedure is performed in a two-staged approach with an interval
of 6weeks
Fig. 24.5 The CT scan of the patient mentioned in Figs.24.2 and 24.3
shows acceptable lumbar artery perforators to perform a LAP ap
breast reconstruction. Notice the ample amount of subcutaneous tissue
in the love-handle region compared to the subcutaneous abdominal
tissue
Fig. 24.6 The ap is designed in the lower back region and includes
skin and subcutaneous fat tissue of the love-handle region. The midline
is marked and a vertical line at 7.5 cm from the midline is drawn.
Additional markings include the superior border of the posterior iliac
crest and the presumed position of the nal scar. The lateral border of
the erector spinae muscle is marked (ESM)
234
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 24.7 The ap is redesigned more inferiorly with the patient in
prone position (interrupted line)
F. B. J. L. Stillaert et al.
24.5 Flap Raise/Elevation: AStep-by-Step
Guide
24.5.1 Supine Position
24.5.1.1 Mastectomy andRecipient Vessels
(Fig.24.10)
The mastectomy is performed in primary cases with dissection of the recipient, parasternal mammary vessels. In secondary cases the skin inferiorly to the mastectomy scar is
undermined and not desepidermised. This will recover part
of the original skin envelope and minimizes the surface of
the skin island of the LAP ap. Whenever feasible the mammary vessels are isolated through an intercostal approach
without resection of the costochondral cartilage.
Fig. 24.8 The location of the perforator is conrmed with Doppler
examination and marked
Fig. 24.9 Usually the L4 perforator is located where the lateral border
of the erector spinae muscle meets the superior border of the iliac crest
located at the point where the vertical line meets the superior
iliac crest (lateral border of the erector spinae muscle)
(Figs.24.8 and 24.9).
Fig. 24.10 Postoperative result of a bilateral breast reconstruction
with the LAP ap (patient presented in Fig.24.3). The skin inferiorly to
the mastectomy scar has been recovered in order to minimize the surface of the skin island of the LAP ap
24 The Lumbar Artery Perforator Flap: ATrue Alternative inAutologous Breast Reconstruction
a
b
Fig. 24.11 A vascular interposition graft is harvested through a small
incision in the groin region. The deep epigastric artery and vein are suitable vessels to lengthen the perforator. This facilitates ap inset, avoids
traction on the anastomosis with the recipient vessels, and overcomes
the size discrepancy between the perforator and the recipient (mammary vessels). Usually, the vascular interposition graft has a length of
approximately 7cm
235
24.5.1.2 Vascular Interposition Graft
(Fig.24.11)
Meanwhile, the deep inferior epigastric artery and vein are
harvested through a small incision in the inguinal region.
The pedicle is divided as distal as possible in order to deal
with the vessel discrepancy between the perforator and vascular graft. The graft is kept aside in a sterile heparin gauze.
The convenience of harvesting the interposition graft at this
stage is that the anastomosis with the perforator can be completed during the time when the patient is repositioned in
supine position after ap harvest.
24.5.2 Prone Position
24.5.2.1 Flap Harvest fromMedial toLateral
(Figs.24.12, 24.13, 24.14, 24.15, 24.16,
24.17, and24.18)
The patient is installed in prone position for ap harvest.
Flap margins are inltrated with a xylocaine 1%-adrenaline
solution to minimize intraoperative bleeding.
The ap is incised completely, and beveling is performed
superiorly and more extensively in the inferior part of the
ap to include the fat overlying the gluteus medius muscle.
Dissection starts from medial to lateral on top of the thoracolumbar fascia and continues over the concave contour of
the erector spinae muscle. The superior border of the iliac
crest is palpated and acts a reference point during the
dissection.
The superior cluneal nerves are visualized and perforate
the thoracolumbar fascia medially to the perforators. They
can be used to restore breast sensation.
Fig. 24.12 (a–b) Dissection is performed in prone position and runs
from medial to lateral on top of the thoracolumbar fascia. The subcutaneous tissue layer in the medial part of the ap is less voluminous compared to the lateral part. This facilitates dissection and exposure. The
thoracolumbar fascia runs over the erector spinae muscle and the quadratus lumborum muscle. In between those two muscles, the fascia consists of two layers which could be confusing during dissection
Fig. 24.13 The ap is completely incised circumferentially to allow
for maximal exposure during dissection
The thoracolumbar fascia is incised and the cluneal nerve
is isolated. Lateral to the cluneal nerve, the perforator is visualized: L4 runs adjacent to the upper margin of the iliac crest,
and often L3 can be incorporated as well (can be used as a
backup in case of damage to L4).
The perforator is progressively dissected out, and all side
branches are carefully clipped to obtain maximal hemostasis.
The dissection proceeds until a length of approximately
4–5cm is obtained with an artery that has a suitable diam-
236
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
F. B. J. L. Stillaert et al.
Fig. 24.14 Flap harvest starts at the medial side with the patient in
prone position. The medial part has a thin subcutaneous layer and provides better exposure compared to a lateral approach. Dissection continues over the thoracolumbar fascia, and the superior border of the iliac
crest is palpated (blue interrupted line). The iliac crest margin is a guidance as the L4 perforator will pierce the thoracolumbar fascia near this
border at the lateral border of the erector spinae muscle. The rst anatomical structures that are encountered are the superior cluneal nerves
(*) that pierce the thoracolumbar fascia. These nerves are included in
the ap and used for later anastomosis to the intercostal nerve
Fig. 24.16 The thoracolumbar fascia is incised, and the perforator is
isolated. One can observe the L4 perforator that runs against the superior border of the iliac crest
Fig. 24.17 Lateral dissection often reveals the descending branch of
the iliohypogastric nerve
Fig. 24.15 Flap harvest starts at the medial side with the patient in
prone position. A medial to lateral dissection provides better surgical
exposure. Dissection is continued over the thoracolumbar fascia and
continued to the lateral border of the erector spinae muscle
Fig. 24.18 Intraoperative view on the donor site and incision in the
thoracolumbar fascia
24 The Lumbar Artery Perforator Flap: ATrue Alternative inAutologous Breast Reconstruction
237
eter to perform the anastomosis with the interposition graft.
One should avoid a dissection toward the processus spinosus
in order to avoid nerve damage.
Finally, the LAP ap is fully freed and includes the fat
tissue overlying the gluteus medius muscle which has a
unique, soft, and moldable consistency. In the lateral region
of the ap, one should try to avoid damage to the iliohypogastric nerve (lateral cutaneous branch).
The incision in the thoracolumbar fascia is closed with a
running Prolene 2/0 suture. Drains are inserted and the donor
site is closed with Vicryl 2/0 tacking sutures. Subcutaneous
sutures with Vicryl 3/0 close the donor site and the skin is
closed with a running Monocryl 4/0 suture.
24.5.3 Supine Position
The patient is repositioned in supine position to perform the
actual breast reconstruction. Meanwhile, the anastomosis
between the vascular interposition graft and the perforator is
carried out on a side table.
24.5.3.1 Anastomosis Between thePerforator
oftheLAP Flap andtheVascular
Interposition Graft (Fig.24.19)
The ap is transferred to a side table, and an end-to-end
anastomosis is performed with an Ethilon 10/0 suture
between the perforator and the vascular interposition graft.
This is an important step in the procedure and requires specic attention: the anastomosis should be perfect as it will be
difcult to place additional sutures once the ap has been
anastomosed to the recipient vessels.
24.5.3.2 Flap Transfer totheChest andFlap
Insertion (Figs.24.20 and24.21)
The LAP ap is transferred to the mastectomy site. An endto- end anastomosis is performed with an Ethilon 9/0 suture
in between the vascular interposition graft and the recipient
vessels (in most cases the parasternal mammary vessels in
the intercostal space III). An additional nerve anastomosis is
performed between the cluneal nerve and the intercostal
nerve with an Ethilon 9/0 suture. The ap is positioned to
shape the breast: the gluteal part with the moldable fat can be
positioned superiorly to achieve upper-pole fullness and
cleavage denition or can be positioned inferiorly to achieve
lower-pole fullness.
Fig. 24.21 The LAP ap is seen on the chest wall and has ideal volume and contours to reconstruct a breast. It has a conic shape. The gluteal fat can be positioned inferiorly to have lower-pole fullness or can
be positioned superiorly to have a well-dened cleavage. In this case
the gluteal fat is seen superiorly
Fig. 24.19 The mastectomy specimen is seen on the left side. The
LAP ap has the same shape and volume of the breast. A vascular interposition graft is anastomosed to the perforator to lengthen the pedicle,
avoid traction, and facilitate ap inset (arrow). Most of the volume of
LAP ap consists of gluteal fat overlying the gluteus medius muscle
Fig. 24.20 An intraoperative view on the anastomosis between the
vascular interposition graft and the mammary vessels. Notice the
tension- free appearance of the pedicle of the LAP ap. An additional
anastomosis is seen between the cluneal nerve and the intercostal nerve
(arrow)
238
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
F. B. J. L. Stillaert et al.
24.6 Core Surgical Techniques inFlap
Dissection
1. Harvest of the deep inferior epigastric pedicle as an inter-
position graft (Fig.24.22).
The vascular interposition graft plays a crucial role in
a breast reconstruction using the LAP ap. It lengthens
the vascular pedicle of the LAP ap, avoids tension on the
anastomosis with the recipient vessels, and overcomes
the discrepancy between the perforator and the recipient
vessels. It is important to harvest this interposition graft
as distal as possible to match vessel diameter between
perforator and graft.
2. Dissection proceeds from medial to lateral in prone position (Fig.24.23).
Instead of a lateral decubitus approach, we prefer to
perform ap harvest in prone position from medial to lateral. The advantage is a less voluminous tissue bulk on
the medial part of the LAP ap. A dissection from lateral
to medial in lateral decubitus position will result in a
more difcult approach and intraoperative view due to
the tissue in the lateral part of the LAP ap.
3. The perforator is located at the lateral border of the erector spinae muscle (Fig.24.12).
The CT scan measures the position of the perforator in
a bird eye’s view (normally 7.5–8cm) from the midline.
Remember that the contour of the erector spinae muscle
is a concave contour and the real location of the perforator will be at approximately 9cm. The border of the iliac
crest is also a good reference point to guide your
dissection.
4. The cluneal nerve.
The cluneal nerves are the rst identiable anatomical
structures to be encountered. They are located medially to
the perforator and should be included in the LAP ap.
They are anastomosed to the intercostal nerve to restore
sensation in the breast.
5. Do not proceed your dissection too deep until the proces-
sus spinosus.
The moment the artery of the perforator has an accept-
able diameter (2mm), the perforator can be clipped. A
Fig. 24.22 Our rst choice for an interposition graft is the deep inferior epigastric vessels. They are harvested through a small incision in
the inguinal region. Dissection should proceed as distal as possible to
overcome the vessel diameter discrepancy. Alternatives whenever they
are not available are the thoracodorsal vessels or the descending branch
of the lateral circumex femoral vessels
Fig. 24.23 The LAP ap is harvested in prone position and dissection
starts medial. The subcutaneous tissue bulk in this region is less voluminous compared to the lateral part and facilitates dissection and surgical
exposure
Соседние файлы в папке Библиотека им академика М.И. Перельмана