Dickinson, Brian P.; Spoon, Daniel B.; Cordray, Tracy L.; Lazareff, Jorge; Wasson, Kristy; Bradley, James P.
Journal of Craniofacial Surgery. 17(4):707-713, July 2006.
Sunday, December 11, 2011
Coverage of Massive Brain and Skull Defects with Latismus Dorsi Free Flaps
Latissimus Free Flaps for Massive Brain and Craniofacial Skull Wounds
Large defects of the craniofacial skull that are created from cancers, trauma, radiation, or other causes, often require microvascular free tissue transfer to close the wounds. On the vertex of the skull, there is limited tissue to close even small wounds and the amount of tissue is often decreased even more significantly if the tissue mobility is affected by radiation. The transfer of free muscle allows the operative surgeon to 1) cover any open wounds and 2) obliterate dead space which can often cause recurrent or recalcitrant infections.
Massive wounds of the brain and skull require complete debridement of all devitalized, radiated, necrotic, and osteomyelitic bone to allow the wound to heal properly. After all of the necrotic and devitalized material has been debrided, then the microsurgeon can bring well vascularized tissue to the area to help heal the wound.
The latissimus dorsi offers the most optimal muscle to be transferred to the scalp as it has a broad surface area to cover the entire scalp. The size match of the thoracodorsal vessels also coincide well with the size match of the superfical temporal artery and vein to allow an appropriate size match. It is important for the operative surgeon to be prepared to harvest either the greater saphenous vein or the lesser saphenous vein in the lower extremity in case the superficial temporal vein is inadequate. In this case the venous anastamosis needs to be jumped to the external jugular vein in the neck. This should be marked out pre-operatively and no central venous lines placed on that side of the neck pre-operatively.
www.drbriandickinson.com
Sunday, November 20, 2011
Free Flaps to Poplitieal Artery-Anterior Tibial Artery Saphenous Vein Bypass Grafts
As the population ages, there are an increasing number of patients who have undergone vascular bypass procedures such as popliteal to anterior tibial bypasses with saphenous vein grafts. Often, in the aging population, the only patent blood vessel to the foot is the bypass graft. When these patients incur injuries or wounds to the most distal aspect of the lower extremity, planning free flap reconstruction can be quite challenging.
I have found that in those patients, magnetic resonance angiography and magnetic resonance venograms can be helpful to establishing a correct plan for the outflow of the microvascular anastomosis. In those cases when the saphenous vein has been used, the surgeon must rely on the venae comitantes of adjacent vessels to determine successful outflow.
I have encountered, that even when native arteries have been diseased, and new blood flow has been established via bypass grafts, the venae comitantes are still often of sufficient caliber. In that case it is important for the operating surgeon to determine the location of the bypass graft tract in relation to the defect, and then select an appropriate venae comitantes in the vicinity of the bypass graft.
Either a long and sufficient caliber leash on the venae comitantes should be mobilized, in addition a flap with a long venous leash that can easily be dissected free of the artery should be selected. I have found the rectus muscle to be an excellent muscle for these cases; In that, the muscle is long and wide allowing not only for adequate coverage, but also for greater margin of separation of vascular bypass and location of nearest venae comitantes.
When the rectus has been harvested, it is important for the surgical team to spend sufficient time and care with the deep inferior epigastric artery and vein to allow adequate mobilization between both vessels.
When there is a single vessel run-off to the lower extremity, I find it helpful to perform the arterial end-to-side anastomosis first so that the flap can be rotated to-and-fro. The vein can then be usually anastomosed so that it will not be kinked. If one anastomoses the vein first, the end-to-side arterial anastomosis is often more difficult as the vein anastomosis now prevents the to-and-fro motion of the flap.
When dissecting toward arterialized vein bypass grafts, I find it helpful to gain proximal and distal control with the vascular bull-dog clamps from the vascular set. One must be aware that there is often a significant amount of scar tissue present around these grafts as they have been tunneled from their proximal to distal locations. Once adequate control has been obtained, the operative surgeons need to spend sufficient time dissecting scar off the vessel before they reach lumen.
Once the muscle has been vascularized, the split thickness skin graft can be placed.
Gracilis Free Flaps for Coverage of Achilles Tendon Wounds
It is quite common these days to see defects of the lower extremity in the region of the Achilles tendon. These wound locations are becoming increasingly more common as the population ages, is more active, and is more affected by the possibility of peripheral vascular disease.
When patients have wounds with exposed tendon it is very painful. Often wounds in the location of tendons appear to have pain out of proportion to the depth, size, and condition of surrounding skin or adjacent structures. To put it simply, wounds with exposed tendons are painful!
It is not until these wounds are covered that the patient reports relief from pain and are able to ambulate properly again.
There are many different options for covering wounds in the distal third of the lower extremity. Depending on the location, depth, structures that are exposed, and location of quality nearby recipient vessel, I often choose among the following free flaps: 1) Rectus Abdominus, 2) Gracilis, 3) Radial Forearm, 4) Latisimus, and 5)Serratus.
The gracilis free flap offers an excellent advantage in some cases in that the surgery is confined to one surgical site and there is minimal donor site morbidity associated with the flap harvest.The gracilis muscle inserts proximally onto the pubic symphysis while the distal insertion is the medial condyle of the tibia. The blood supply of the gracilis is from the ascending branch of the medial femoral circumflex femoral artery and vein.
These blood vessels are often an appropriate size match for the posterior tibial vessels deep distal in the lower extremity.
Sunday, September 25, 2011
Free Rectus Muscle Flap to Scalp with Saphenous Vein Graft to External Jugular
Radiation is often a necessary adjuvant in the treatment of many cancers. While radiation is often necessary in cancer therapy, the radiation can also cause damage to normal healthy tissue and prevent wound healing.
When radiation is used on the head, not only can it cause injury to the skin and subcutaneous tissue, it can also cause damage to the underlying bone. When the bone develops osteoradionecrosis, it can often cause wounds to recur or simply become non-healing. When the bone is removed, often a titanium mesh or bone cement is used to cover the brain.
Usually there is not enough tissue on the scalp to close these defects, therefore free tissue transfer and microsurgery is necessary to bring in healthy tissue to the area to close the wounds.
The rectus muscle is a nice muscle to use in this scenario as there is a long pedicle leash and a muscle with a large surface area. Occasionally the superficial temporal artery is of good quality and the vein may be small. In this case we have found that the saphenous vein can be an effective vein graft from the flap to the external jugular. We find that in the past many have not advocated the use of vein grafts. However, often is more advantageous to use a vein graft to a more suitable outflow than to rely on a marginal vein in the vicinity of the wound.
www.drbriandickinson.com
Saturday, September 24, 2011
Latisimus Flap for Closure of Complex Posterior Trunk Radiation Wounds
Radiation is often a necessary adjuvant in the treatment of many cancers. While radiation is often necessary in cancer therapy, the radiation can also cause damage to normal healthy tissue and prevent wound healing.
Closure of the radiated wound is often one of the most challenging problems the Plastic & Reconstructive Surgeon can face. The key to closing radiated wounds is adequate debridement. Often adequate debridement can create a much larger wound that the original and often much larger than anticipated by both patient and surgeon.
After adequate debridement has been performed, the next important step in reconstruction is to make sure that healthy tissue is brought into the area affected to allow wound closure. In some cases, tissue from an adjacent area of the body can be used, occasionally regional tissue may be used, and in some cases distant tissue is used to be brought into the area to allow wound closure. When tissue from a remote area of the body is used, this is called free tissue transfer or microsurgical anastomosis.
In this case a large posterior trunk wound was present after successful cancer removal and successful radiation therapy. The wound was thoroughly debrided to relatively healthy tissue. A wound VAC was then placed on the posterior trunk to promote blood perfusion and as a bridge to determine the final wound size and plan reconstruction.
In this case, a latisimus myocutaneous flap was used to bring both muscle to cover exposed bone and skin to fill a defect. A small skin graft was placed on the latisimus muscle to prevent too tight of a wound closure. The skin graft however contracts over time and can often eventually be excised and the wound closed with one skin paddle.
Monday, May 2, 2011
Lower Extremity Flap Surgery. Journal of Reconstructive Microsurgery Publication
Subscribe to:
Posts (Atom)