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_5208_Библиотеки_им_академика_М_И_Перельмана
.pdf
110
A. A. Ong and F. Sokoya
fascia lata, and branches into an anterior and posterior segment to supply the
skin [4].
If the vastus lateralis muscle is to be included in the ALT ap, the motor nerve
for the vastus lateralis muscle can be harvested as well for a functional reconstruction. The vastus lateralis muscle is innervated by a branch of the posterior division
of the femoral nerve and travels in close proximity with the vascular pedicle. Prior
to the descending branch of the LCFA enters the vastus lateralis muscle, the motor
nerve turns laterally and sends branches to innervate the undersurface of the vastus
lateralis.
Indications/Contraindications
Due to the versality of donor site tissue, including skin, fascia, and/or muscle, the
ALT ap lends itself to the reconstruction of a variety of head and neck defects. In
the oral cavity, the ALT ap can be used for the full range of tongue reconstruction:
as a thin cutaneous perforator ap for partial glossectomy defects or as a myocutaneous ap including the vastus lateralis muscle for the reconstruction of near-total
or total glossectomy defects. In cases which require dead space obliteration such as
orbital exenteration defects, the myocutaneous ALT ap with vastus lateralis muscle
can also be used. For through-and-through defects requiring the reconstruction of
intraoral lining and external fascial skin, the ALT can be harvested with multiple
skin paddles with separate perforator vessels, or de-epithelialized to create separate
skin islands with a single perforator vessel [5, 6]. Additionally, as a ap which can
provide signicant bulk, the ALT ap can be used in total parotidectomy defects to
restore facial form and volume. Finally, the tubed ALT ap has been described for
esophageal reconstruction.
Relative contraindications of the ALT ap include thick hair-bearing skin of the
upper thigh requiring signicant postoperative grooming when used for reconstruction intraorally and inexperience with perforator ap dissection. In addition, the
thickness of the ap may be disadvantageous for reconstruction of certain defects,
providing unnecessary bulk at the recipient site.
Preoperative Planning
During the preoperative evaluation, the surgeon should pay careful attention to
patient’s knee range of motion. Due to the location of the vascular pedicle through
the vastus lateralis muscle, intramuscular dissection or even harvest of the vastus
lateralis may cause increased risk of functional impairment of the knee postoperatively; however, many regain preoperative functionality [7, 8].
Unlike the peroneal artery which supplies the bula free ap, the LCFA is rarely
affected by atherosclerotic disease, and angiography is seldom required preoperatively. However, angiography can be obtained if there is concern for signicant
atherosclerosis or previous injury or operations of the upper thigh.
t.me/Dr_Mouayyad_AlbtousH
7 Anterolateral Thigh Free Flap
111
The recipient site should be heavily considered when deciding on the use of the
ALT ap. Male patients may have thick hair overlying the lateral thigh, which is not
ideal for certain recipient sites such as the oral cavity. This can be addressed with
laser removal of hair preoperatively, or frequent shaving of the ap after reconstruction. In addition, in obese patients, the ALT ap may be excessively thick requiring
primary thinning or secondary debulking procedures to achieve optimal outcomes.
Instrument/Equipment Set
A hand-held Doppler can be used preoperatively to identify the approximate location of the cutaneous perforators prior to the initial incision. A typical soft tissue
instrument set can be used for the dissection. When beginning the initial dissection,
skin hooks can be utilized to retract the rectus femoris medially and the ap laterally
to provide better exposure to the intermuscular septum. Alternatively, Allis clamps
can be placed on the fascia to provide counter traction for exposure of the intermuscular septum. During perforator dissection, surgical clips are used to isolate the
cutaneous perforator as it is traced back to the lateral LCFA.Microvascular anastomosis is performed using an operative microscope. Arterial anastomosis is performed with 8.0 or 9.0 nylon sutures, while venous anastomosis is performed with
an appropriately sized venous coupler. If there are concerns with the integrity of the
ap intraoperatively, near-infrared angiography can be used to determine the quality
of perfusion throughout the ap. Although no single monitoring technique is widely
accepted, a handheld Doppler or an implantable Doppler can be used postoperatively to monitor ap perfusion on the oor.
Flap Design/Surgical Technique/Ducic Pearls
In the operating room, the patient is generally placed in the supine position. The
anterior superior iliac spine and superolateral aspect of the patella are identied, and
a line is drawn connecting these points with the midpoint of the line being marked.
Figure7.3 illustrates these markings. A handheld Doppler can be used to identify
the general location of the cutaneous perforators. Once the cutaneous perforator is
identied, the ap is marked out based on the size of the recipient defect while centered on the cutaneous perforator. A ap measuring up to 8cm in width allows for
primary closure of the donor site. The length of the ap is determined by the recipient’s defect size with a maximum length of 40cm which can be harvested [9]. The
ap design can also be modied after visualization of the size and quality of the
cutaneous perforators intraoperatively.
After marking the ap, the medial incision is made rst through the skin and
subcutaneous tissue down to the fascia over the rectus femoris muscle. Depending
on the recipient defect needs, the ap can be harvested in either a subfascial or a
suprafascial plane. The subfascial dissection allows for easier identication of the
intermuscular septum and the perforator vessels. The length of intermuscular
t.me/Dr_Mouayyad_AlbtousH
112
A. A. Ong and F. Sokoya
To p
Superior
ASIS
X
Fig. 7.3 Position of the cutaneous perforators
5cm
x
A
1.5
x
B
Bottom
5cm
x
C
Inferior
AP line
49 cm
septum is exposed, and the rectus femoris muscle is retracted medially to expose the
descending branch of the LCFA.Septocutaneous perforators occur in approximately
10% of cases and can be traced back to the descending branch of the LCFA [10]. In
cases with musculocutaneous perforator, an intramuscular dissection is executed
and followed in a retrograde fashion to the descending branch of the LCFA. Fine
tenotomy or Metzenbaum scissors are used to separate the muscle bers from the
perforator vessels. Any branching vessels that are identied are either cauterized
with a ne bipolar tip or ligated. Once the descending branch of the LCFA is
reached, the main pedicle is dissected until the adequate pedicle length is achieved.
Care should be taken to identify and preserve the motor nerve to the vastus lateralis
muscle along the course of the main pedicle. After conrmation of intact perforator
vessels, the ap design is nalized. The posterior incision is made to complete ap
harvest and taken to the vastus lateralis fascia if a subfascial dissection is performed.
Carefully note the location of the pedicle as undue traction may injure the pedicle.
The recipient vessels are prepared prior to pedicle division. Of note, a portion of, or
the entire vastus lateralis musculature may be harvested with the free ap by dividing the muscle inferiorly and superiorly. This is helpful if additional bulk is needed
at the recipient site. This technique also allows for expedited harvest of the ALT ap
as time is saved by obviating the need for perforator dissection.
In most cases, the ALT donor site can be closed primarily as long as the width of
the harvested ap is less than 8cm. Defects that are wider require closure with a
split-thickness skin graft. If a split-thickness skin graft is used, knee immobilization
t.me/Dr_Mouayyad_AlbtousH
7 Anterolateral Thigh Free Flap
113
is preferred to allow for optimal skin graft take. Depending on the surgeon’s preference, a closed-suction drain can be placed between the vastus lateralis and rectus
femoris muscles to minimize seroma and hematoma formation.
Postoperative Management
Flap monitoring to ensure ap viability is instituted immediately postoperatively
and based on the surgeon’s and institution’s preference. Hourly ap monitoring is
continued for the rst 72h postoperatively, either in the intensive care unit or in the
specialized step-down unit. No specic pharmacologic therapies are required postoperatively; this is determined by the surgeon’s preference. Our postoperative pharmacologic therapy includes the use of heparin and aspirin. For head and neck
reconstruction, patients are positioned with the head of the bed elevated at 30°, and
the neck is inspected to avoid compression by wires, intravenous lines, or tracheostomy straps, which may lead to pedicle compromise. If a closed-suction drain was
placed, it can be removed once the output has decreased to ≤30mL over 24h.
The ALT ap has a low complication rate, which can include seroma, hematoma,
wound dehiscence, infection, and neuroma [7]. The majority of patients regain their
preoperative level of function, even with the division of the motor nerve to the vastus lateralis muscle or harvesting of the vastus lateralis muscle.
References
1. Song YG, Chen GZ, Song YL.The free thigh ap: a new free ap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37(2):149–59.
2. Sokoya M, Deleyiannis FW.A triple pedicle, near-total thigh ap supercharged with the owthrough technique. Eplasty. 2016;16:e4.
3. Yu P, Selber J. Perforator patterns of the anteromedial thigh ap. Plast Reconstr Surg.
2011;128(3):151e–7e.
4. Ribuffo D, Cigna E, Gargano F, Spalvieri C, Scuderi N.The innervated anterolateral thigh ap:
anatomical study and clinical implications. Plast Reconstr Surg. 2005;115(2):464–70.
5. Lawson BR, Moreno MA.Head and neck reconstruction with chimeric anterolateral thigh
free ap: indications, outcomes, and technical considerations. Otolaryngol Head Neck Surg.
2016;154(1):59–65.
6. Sun G, Lu M, Hu Q, Tang E.Reconstruction of extensive through-and-through cheek defects
with free anterolateral thigh ap. J Craniofac Surg. 2014;25(1):e31–8.
7. Hanasono MM, Skoracki RJ, Yu P.A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free ap harvest in 220 patients. Plast Reconstr
Surg. 2010;125(1):209–14.
8. Weise H, Naros A, Blumenstock G, Krimmel M, Hoefert S, Kluba S, etal. Donor site morbidity of the anterolateral thigh ap. J Craniomaxillofac Surg. 2017;45(12):2105–8.
9. Chen HC, Tang YB. Anterolateral thigh ap: an ideal soft tissue ap. Clin Plast Surg.
2003;30(3):383–401.
10. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH.Have we found an ideal soft-tissue ap?
An experience with 672 anterolateral thigh aps. Plast Reconstr Surg. 2002;109(7):2219–26;
discussion 27–30.
t.me/Dr_Mouayyad_AlbtousH
t.me/Dr_Mouayyad_AlbtousH
Free Rectus Flap Reconstruction
AuroraG.Vincent andSpenceer R.Anderson
Introduction
The abdominal rectus free ap (ARFF) is a well-known vascularized free tissue ap
utilized among reconstructive surgeons [1–4]. The ARFF was rst described in
1980 [3] and later popularized by Hartrampf in 1982 [5], ultimately becoming a
workhorse ap for a diverse array of reconstructive needs. The ARFF is often the
head and neck reconstructive ap of choice for wounds that require bulky tissue for
adequate reconstruction. The ARFF offers consistent ap anatomy, ease of technical
elevation, up to 15cm of pedicle length, as well as the opportunity for a well-hidden
donor site scar [5, 6]. Herein, we review the ARFF including preoperative planning
needs, patient candidacy, intraoperative technique, postoperative monitoring, and
donor site management.
8
Operative Steps
Preoperative Considerations
The ARFF is a useful ap when a larger tissue bulk is needed for head and neck
reconstruction. It is worth considering in patients with a normal or low BMI.However,
A. G. Vincent (*)
Eisenhower Army Medical Center, Fort Gordon, GA, USA
e-mail: aurora.g.vincent.mil@health.mil
S. R. Anderson
Division of Plastic and Reconstructive Surgery, Wright State University Boonshoft School of
Medicine, Dayton, OH, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_8
t.me/Dr_Mouayyad_AlbtousH
115
116
A. G. Vincent and S. R. Anderson
it is often not appropriate in patients who are overweight or obese, as excess subcutaneous adiposity creates too much tissue bulk in those cases. The ARFF is ideal for
reconstruction of total glossectomy defects and obliteration of deep wounds (such
as maxillectomy defects that included overlying skin excision, exenteration defects,
etc.) Patients should be queried about and examined for previous abdominal surgeries and scars. Ports for many laparoscopic procedures are often outside the dissection area for a rectus ap, so having had these procedures does not disqualify a
patient from undergoing ARFF harvest. Previous open abdominal surgery, however,
may have compromised the ap pedicle.
Flap Features
1. Vascular Supply: The arterial supply is derived from the deep inferior epigastric
artery and its perforators. The venous outow is via the venae comitantes.
2. Bulk: Signicant bulk suitable for total glossectomy defect reconstruction or
deep wound obliteration. Flap includes muscle, subcutaneous adipose tissue,
and overlying skin. If a thinner bulk is necessary and a thinner ap (such as a
radial forearm ap) is not available, then the ARFF can be raised as a deep inferior epigastric perforator ap that includes only skin and subcutaneous tissue.
This technique requires perforator dissection through the rectus muscle.
3. Innervation: Thoracoabdominal nerve. Harvested ap is insensate.
Steps ofHarvest
1. Prep the abdomen from the palpable inferior edge of the ribs to the iliac crest.
Typically, prep can end, medially, just superior to where pubic hair begins; it
should not need to be trimmed or prepped into the eld.
2. Mark a box, roughly 6×6cm, centered vertically at the umbilicus, with its
medial edge just lateral to the umbilicus (Fig.8.1). Releasing incisions can be
marked extending superiorly and inferiorly, 2–3cm lateral to the umbilicus.
The superior extension should extend to the edge of the rectus muscle, just
below the rib margin. The inferior incision should extend to where the anterior
and posterior rectus fascia combine. Typically, this location can be visualized or
palpated.
(a) The shape of the ap can be altered from a square, as desired, given the
wound location, function, and size. In general, a 6×6cm square is a good
starting point and is typically a sufcient size for a total glossectomy defect.
The ap should not be made of a signicantly smaller size, or there is an
increased risk of damaging or excluding arterial perforators important for
ap survival.
(b) Note: There is no need to doppler out the location of perforating vessels.
Arterial perforators are reliably located 2–3cm lateral to the umbilicus.
t.me/Dr_Mouayyad_AlbtousH
Pubic symphysis
8 Free Rectus Flap Reconstruction
Fig. 8.1 Rectus free ap
initial markings
Linea alba
Umbilicus
117
Inferior
ribs
ASIS
Thus, if making a 6×6-cm ap centered at the umbilicus, the perforating
vessels will be in the center.
3. Incise along all markings; the authors prefer to make initial incisions with a
#15, then carry incisions deeper with spatula-tipped insulated Bovie to the anterior surface of the anterior rectus sheath. Dissection should be carried deeply
perpendicular to the anterior surface of the anterior rectus sheath. Of note, if the
dissection drifts away from the perpendicular, it may risk damage to perforating
arteries.
4. Laterally, dissection should extend along the supercial surface of the anterior
rectus sheath until the rectus line is identied. This dissection can be completed
rapidly with bovie, as it is not near any vascular structures of note.
5. Secure the skin paddle to the underlying anterior rectus sheath along the edges
of the ap with multiple 3-0 vicryl sutures. This step is performed to prevent
accidental shear of the skin paddle off the underlying muscle with future manipulation of the ap. Of note, if the ap is going to end up in the mouth or pharynx, then the sutures do not have to be buried. If the ap will end up on the skin,
then the sutures should be buried.
t.me/Dr_Mouayyad_AlbtousH
118
A. G. Vincent and S. R. Anderson
6. Incise the anterior rectus fascia and rectus muscle at the lateral edge of the ap.
If necessary for visualization, the superior cut can also be made, but the inferior
aspect of the ap should be left along to preserve the pedicle. Extend this incision deeply through the rectus muscle until the posterior rectus sheath is
encountered. Again, be mindful of dissection perpendicular to the abdominal
fascia. If the incision drifts medially, then injury to the ap perforators can
occur. If the incision drifts laterally, the rectus line may be encountered and the
posterior fascia perforated. If a small perforation in the posterior fascia is created, repair it with 3-0 vicryl and oversew with 2-0 PDS.
7. Using a kitner, gently separate the posterior surface of the rectus muscle to be
included in the ap from the posterior rectus sheath. Of note, the vascular pedicle vessels run along the posterior surface of the muscle, so it is important to
be precise in separating the muscle from the fascia. Leaving muscular fascia
down risks damage to the pedicle, whereas lifting posterior sheath into the ap
risks sheath perforation and herniation of abdominal contents.
(a) A kitner is a useful tool for sweeping along the face of the posterior sheath;
it can neatly reveal the appropriate tissue plane, will not accidentally perforate the posterior sheath, and will not damage the pedicle vessels if it
bumps them.
8. Visualize the pedicle vessels along the deep surface of the ap.
9. Complete incisions through the rectus muscle around all sides of the ap, tak-
ing care to preserve the vascular pedicle as it travels inferiorly and taking care
not to separate the pedicle from the ap itself. Superiorly, the ap can be efciently released by using monopolar cautery to cut through rectus muscle onto
the surgeon’s underlying nger. Take care medially not to enter the umbilicus.
Inferior to the ap, the pedicle can be bluntly dissected away from overlying
muscle with Metzenbaum scissors (in a cold fashion without cautery), then protected with a nger placed between the vessels and the overlying muscle while
Bovie is used to rapidly separate that muscle.
(a) A nger is a useful insulating tool in this dissection, as it will not conduct
heat energy to the vessels. Monopolar cautery should be used cautiously or
not at all when in close proximity to the ap vessels, as aberrant heat spread
can injure vessels and compromise ap survival.
(b) Metzenbaum scissors are useful for releasing the ap vessels from overly-
ing muscle given their blunt tips. Appropriate spread will break weak, natural fascial attachments surrounding the vessels before breaking vessel walls
or causing excessive muscular bleeding. Dissection with sharper scissors
risks damage to vascular walls or bleeding from muscular tissue.
10. Dissect out the length of the pedicle inferiorly. Again, cold dissection with met-
zenbaum scissors allows efcient separation of tissue to proceed safely. After a
sufcient length of the pedicle is achieved, the pedicle and ap can be separated. The authors prefer ligating the inferior aspect of the vessels with surgical
clips, free silk ties, or a combination of the two. The pedicle vessels themselves
t.me/Dr_Mouayyad_AlbtousH
8 Free Rectus Flap Reconstruction
119
do not require clips or ties, and use of such may compromise the tip ends at the
time of reanastomosis. The authors do not advocate the use of any cautery near
the site of pedicle ligation, as it can cause vascular injury that may compromise
ap survival. Figure8.2 depicts a harvested ARFF before inset, and Fig.8.3
depicts a total glossectomy wound (a) reconstructed with an ARFF (b).
Steps ofClosure
1. Irrigate the wound with copious amounts of saline. This is an important step
before the closure of all surgical wounds, as it can greatly decrease the risk of
surgical wound infections.
2. Dissect laterally along the anterior rectus sheath to allow primary closure of
the wound.
3. Reapproximate the anterior rectus sheath. 2-0pds can be used in a running fashion for this reapproximation. A wide ribbon retractor (3–4cm width) should be
placed over the posterior rectus sheath, beneath the anterior rectus fascia, during
reapproximation to prevent accidental needle-violation of the posterior sheath.
4. Close the skin and subcutaneous tissue in layers. The skin can be tailored superiorly and inferiorly to where the ap was harvested to facilitate a straight-line
closure.
(a) The authors typically place two bulb-suction fully perforated 10F at drains
in the wound bed, to be removed 1 to 2weeks postoperatively. At minimum,
two layers of suture should be used.
(b) The authors prefer closure of subcutaneous tissues with multiple 3-0 inter-
rupted vicryl sutures, then skin closure with a running prolene as this allows
efcient and cosmetically acceptable wound closure.
5. Cover the wound with antibacterial ointment, telfa, and an abdominal binder.
Fig. 8.2 Harvested rectus
free ap
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана