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Free LD flap for scalp reconstruction DR VIPIN V NAIR

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FOR LARGE SCALP WOUND

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Free LD flap for scalp reconstruction DR VIPIN V NAIR

  1. 1. DRVIPINV NAIR SR Plastic surgery PGIMER Chandigarh OPERATIVE SEMINAR 1
  2. 2.  Direct closure Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996;98:1159-66.
  3. 3.  Skin Grafting  pericraneum (periostium ) present  Local or regional flap reconstruction  Transposition  Rotation  Hatchet  Ghandasa Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996;98:1159-66.
  4. 4.  Prefer a free tissue transfer. Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast Reconstr Surg 1996;98:1159-66. •Latissimus dorsi (LD) •Combined LD and serratus •Omentum •Scapula •Rectus abdominis •Radial forearm •Iliac crest-internal oblique osteomyocutaneous flap •Multiterritory (scapular, parascapular, LD •and lateral thoracic) flap
  5. 5.  I will be discussing  FREE LD Flap for  LARGE Scalp defect  With intact skull bone
  6. 6.  Large available surface area  Ability to drape over a convex surface.  Pedicle is adequate in length to reach the superficial temporal vessels  Pedicle vessels are of ample diameter.  Donor site morbidity is minimal  Cosmetic appearance of the final reconstruction is excellent.
  7. 7.  Vessel size  STA 2.1 -2.5 mm  Occipital 1.9 -2.2 mm  Facial 2.4 -3 mm
  8. 8.  Type V muscle  Flat , broad  20 x 40 cm.  Extends from the  Posterior axilla to the midline of the back and inferiorly to the posterior portion of the iliac crest.  Posterior axillary fold 10
  9. 9.  Origin  Posterior iliac crest  Spinous processes of the lower 6 thoracic vertebrae.  lumbar and sacral vertebrae, and the thoracolumbar fascia  Adherent to the  External surface of the serratus anterior muscle  4 lowermost ribs.  Inserts  Anteriorly into the lesser tubercle and intertubercular groove of the humerus between the teres major and pectoralis major muscles.
  10. 10.  Diameter  Aretery 1.5 -1.9 mm  Vein 2.5 3.1 mm.  Extramuscular pedicle length 6 to 16 cm [average 9 cm]
  11. 11.  Adductor and medial rotator of the arm.  Pull the shoulder inferiorly and posteriorly.
  12. 12.  Absolute contraindications  POSTLATThoracotomy  Any previous deep laceration in of LD muscle causing vascular pedicle compromise  Conditions may make the flap less reliable.  Radiation to the chest or axilla  Previous axillary dissection
  13. 13.  Other muscles of the shoulder girdle are intact  Post neck dissection with sacrifice of the spinal accessory nerve  Bleeding tendencies coagulation problems  Patients who use crutches  Wheelchair bound  Professional skiers  Consider other options
  14. 14.  Basic investigations  Doppler flowmeter when in doubt to trace  Thoracodorsal artery from its origin at the subscapular artery to the point where it enters the latissimus dorsi muscle.  Keep patient warm  Preop night hydration  Correct anemia Flap: Overview, Anatomy, Contraindications http://emedicine.medscape.com/article/880878overview 5/122/7/2017
  15. 15.  Preoperative discussion  Risk of haematomas and seromas  Unsightly scar.  Risk of flap failure.
  16. 16.  First outline the anterior and superior edges of the latissimus dorsi muscle.  These boundaries are marked to indicate the extent of muscle that can be harvested. 19
  17. 17.  Correct anemia  Keep warm  Get coagulogram  Keep patient hydrated  Maintain good urine output
  18. 18. Types: a. compound loupes b. prismatic loupes (wide- angle loupes) - For anastomosis : 3.5x or 4.5x magnification Working distance : 25 to 50 cm
  19. 19. ► Most commonly used- Nylon and Prolene ► Size: 7-0 to 12-0 ► MICRONEEDLES : 3/8 circle taper- pointed needles with a diameter range of 30 to 150 micron are preferred
  20. 20. BIPOLAR COAGULATORWITH BOTH STANDARDTIPS AND MICROTIPS SMALL ABSORBENT CELLULOSE SPONGES  Instrument demagnetizing coil
  21. 21.  GA + ETT  FLEXOMETALIC TUBE 28
  22. 22.  Place the patient on his or her side  Lateral decubitus position  Operative side facing up  Shoulder abducted.  An axillary roll  Contralateral axilla.
  23. 23.  Once intubated and all lines tubes and ECG leads taped and secured  Rotate patient about 30-45 degrees to facilitate exposure of the back which will be used for the harvest  Expose the back up to the spinous processes
  24. 24.  Take care to pad any firm spots to minimise risks of pressure necrosis  Place a pillow between the knees, which should be slightly bent
  25. 25.  Gently bend the contralateral arm with padding placed between the arm and the chest  Properly secure the patient to the bed with belts and tape so that the bed can be tilted and the patient remains secure
  26. 26.  Prep the back up to the spine and include ipsilateral arm
  27. 27.  Put a stocking over the arm and secure it to the drapes
  28. 28.  Identify the anterior edge of the latissimus dorsi  Identify the posterior axillary fold  The posterior axillary fold consist of teres major and the latissimus dorsi
  29. 29.  Design a lazy-S shaped incision a few centimetres behind the anterior edge of the muscle
  30. 30.  Incise the skin and subcutaneous tissue
  31. 31.  Extend the incision down to the muscle
  32. 32.  Raise the anterior flap until the anterior edge of the latissimus dorsi muscle is identified
  33. 33.  Now raise the flap posteriorly  Superiorly identify latissimus dorsi intersperses with the fibres of the teres major muscle
  34. 34.  Once these landmarks have been identified the entire surface of the muscle is exposed using electrocautery  There are no major structures in this area that can be injured
  35. 35.  Dissect the latissimus dorsi muscle off the thoracic wall using blunt finger dissection
  36. 36.  Superiorly dissection plane consists of loose areolar tissue which makes it easy to strip the latissimus dorsi from the underlying tissues
  37. 37.  By doing this manoeuvre, the pedicle should become visible as it enters the muscle on its deep aspect, superiorly
  38. 38.  Having identified the pedicle, dissect the muscle off the thoracic wall in a proximal-to- distal fashion  Be sure to control small perforating vessels that enter the muscle from the thoracic wall
  39. 39.  Once the whole muscle is exposed as well as separated from the thoracic wall, the muscle is divided inferiorly  Once the inferomedial point is reached continue to free it medially along the spine
  40. 40.  Continue upward along the spinous processes until the entire muscle is released.  Ensure good haemostasis as you encounter the lumbar and intercoastal perforators
  41. 41.  Superiorly the most medial aspect of the muscle may be obscured by the inferior aspect of trapezius muscle  Delay dividing the humeral attachment of the latissimus dorsi until very late thus avoiding traction injury to the vessels
  42. 42.  The pedicle is now easily visualised  Commence dissection of the pedicle  Expose the thoracodorsal artery as far proximally as needed for adequate vessel length  Having someone lift the arm perpendicularly to the floor greatly facilitates the axillary exposure at this stage
  43. 43.  To maximise the length of the pedicle, the artery can be traced to the axillary artery
  44. 44.  Divide the pedicle and harvest the flap once donor vessels have been prepared
  45. 45.  Before dividing the vessels, the thoraco-dorsal nerve which runs with the pedicle has to be divided  Before closing the defect, assure excellent haemostasis  Insert 2 large suction drains left in situ for 2 weeks  Close the skin in layers  Sutures removed at 2 weeks
  46. 46. DONOR  Thoracodorsal artery and vena commitans  Aretery 1.5 -1.9 mm  Vein 2.5 3.1 mm. RECIPIENT Artery  STA 2.1 -2.5 mm  Occipital 1.9 -2.2 mm  Facial 2.4 -3 mm Veins  Occipital  Facial  STV  Posterior Auricular
  47. 47. ►COMFORTABLE POSITION ►PATIENCE ►GOOD PLANNING ►ADEQUATE EXPOSURE
  48. 48. *Avoid grasping the ends of the vessels to be anastomosed *Grasp only a small quntity of loose periadventitia
  49. 49. ►Inspect under high power for signs of damage ►Debride until no signs of vessel damage ►Strong pulsatile flow of blood after adequate debridement
  50. 50. ►Mechanical dilatation ►Hydro distention of the vein graft ►Pharmacologic measures ► Papaverine ►2 % Plain Lignocain ► Moist gauge soaked in warm saline
  51. 51. ►Apply an adjustable approximating clamp to bring the vessel end together for convenient suturing ►Never apply clamp with excess tension ►Avoid any kinking or twisting of the vessels distal to the anastomosis
  52. 52. ►Not too tight or too loose sutures ►Too tight sutures- Avoided by a small “suture circle” at the end of three ties
  53. 53. APPROPRIATE SUTURE SPACING: -Goal is to achieve an ultimately leak- free anastomosis with as few sutures as possible RECHEK OF ANASTOMOSIS: -All anastomosis are rechecked prior to the final skin closure
  54. 54. ►Hemostasis - must *Vascular clips *Bipolar coagulator *Torniquet ►Avoid perivascular hematoma ►Irrigation
  55. 55. ►Plane of dissection ►Retract the sheath by gentle pulling and remove it ►Vessels branches ►Background ►Moist field
  56. 56. Resection to normal vessels: - Resect proximal to areas with microscopic signs of vessel damage with fine, straight, sharp scissors in a single motion
  57. 57. Demonstration of forward pulsatile flow prior to clamping
  58. 58. Double approximating clamp Tips of the jaws should Project just beyond the vessel for maximal grip
  59. 59. ►Resect sufficient periadventitia, flush with the underlying end to expose 2-3 mm of the vessel wall for suturing
  60. 60. ►Irrigate the lumen with solution of heparinized saline 100 units / ml solution
  61. 61. ►Pass the needle at right angles to the wall at a distance from the margin slightly greater than the thickness of the vessel wall ►( 1-2 times for arteries, 2-3 times for veins)
  62. 62. ►Make sure that the posterior wall is not accidentally cought For last 2-3 sutures: Modified Harshina technique
  63. 63. ►For thick walled arteries and large diameter collapsible veins- use 180 degree halving method ►First suture at 150 degree position and second suture at -30 degree
  64. 64. ►Veins are thinner, flatter and more difficult to anastomose ►Use ringer’s solution to float or irrigate the vessel ►Deeper bites ►More sutures
  65. 65. ►The distal clamp is released first ►If any major leak, reapply the clamp, irrigate and insert additional superficial thickness sutures ►Now release both the clamps ►Usually small amount of blood leaks from anastomosis, but stops after a few min with sponges
  66. 66. BACK-WALL FIRST ( ONE-WAY UP)TECHNIQUE SAFEST Entire inside of the anastomosis can be visualized until the very last few sutures are placed
  67. 67. When free flap, digit or vein graft is fixed fo mobile vessel, it can be flipped to expose the back-wall for repair, as rotation is not possible
  68. 68. ACCEPTABLE PATENCY RATES 92% FOR ARTERIES 84% FORVEINS ►Advantages: Quicker and more hemostatic DISADVANTAGES ►Potential for creating purse-string constriction at the site of anastomosis ► Entrapment of the suture material in the clamp ► Breakage of the suture
  69. 69. ►Return of colour ►Capillary oozing and venous bleeding from the revascularized tissue ►Direct inspection under the microscope
  70. 70. ►Traumatic ►Performed as gently and infrequently as possible
  71. 71.  Use background to help visualize suture  Demagnetize instruments, if needed  May reclamp vessels for repair after 15 minutes of flow  Reclamp both arterial and venous vessels when revising venous anastomosis  Support your hands and hold instruments like a pencil
  72. 72.  Need for vein grafts  Wound dehiscence with bone or cranioplasty exposure  Contour irregularities of scalp-flap junction  Bulk at the muscle origin  Cranial bone not good and completely infected
  73. 73.  Proper patient positioning to  Avoid compression of the flap or pedicle.  Head elevated 45 to 70 degrees  Head maintained in neutral position 99
  74. 74.  Encouraged to mobilise the arm postoperatively.  Drains left in place until the output has diminished.  24-hour output  25 mL per drain for 2 consecutive days
  75. 75. ►Oxygen administation ►Bed rest for 3 to 5 days ►Warm room ►Fluid administration for good hydration ►DEXTRAN 40 25 ml /hr
  76. 76. ►Adequate analgesia ►Limitation of visitors and telephone calls to decrease the emotional stress ►Prohibition of smoking, caffeine and chocolate because they may cause vasoconstriction
  77. 77.  Important physical signs  Quality of capillary filling  Bleeding from a cut edge  Tissue turgor
  78. 78. ARTERIAL PROBLEM  Pale  Cool  Without capillary refill  Abrasion no bleeding VENOUS PROBLEM  Rigid  Blue  Rapid refill  Abrasion brisk, dark bleeding
  79. 79. Early  Flap failure  Post op side bleeds  Dehiscence  Distal necrosis of flap  Donor site necrosis  Post op infections Late  Donor site scar  Bulky medial portion  Bulky flap 106
  80. 80. (J Hand Surg 2010;35A:1105–1110. © 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) 107 (J Hand Surg 2010;35A:1105–1110. © 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)
  81. 81.  DIFFICULTY IN POSTOP MONITORING 108
  82. 82.  LD free flap cover is a  Stable  Safe  Reliable cover for large scalp defect  Low complication rates  Better cosmetic outcome  Easy to practice and ideal for beginers
  83. 83. 110
  84. 84. 111

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