Upload
salibagustavo
View
237
Download
0
Embed Size (px)
Citation preview
7/27/2019 Muscle Flaps
1/87
Muscle Flaps
Trefor Nodwell MD CM
Dr. D. Lalonde, FRCSCDr. W. Parkhill, FRCSC
7/27/2019 Muscle Flaps
2/87
Outline
Review Basic Anatomical and Physiologic Review
Reconstructive Goals & Principles
Classification Schemes with examples
Muscle Flaps Only Common Examples
Type/Pattern of CirculationApplications
Anatomy and Elevation
7/27/2019 Muscle Flaps
3/87
Outline
Precautions/Pitfalls
Brief overview of Less Common (but applicable)flaps
Discussion
7/27/2019 Muscle Flaps
4/87
The Basics - Anatomy
Motor nerves are always accompanied byvascular pedicles
Pedicles
Dominantcan sustain entire muscle on its own
Minormaintains only a portion of the muscle
Segmentalnourishes small segment of the muscle
Allows for a classification scheme
7/27/2019 Muscle Flaps
5/87
The Basics- Physiology
Arc of Rotation
Standard
extent of reach of the muscle based onits dominant pedicle
Reverse (distally based)restricted by secondarypedicles
7/27/2019 Muscle Flaps
6/87
The Basics- Physiology
Choke arteries
Small caliber vessels allowing bidirectional flow
Oscillating veins No valves, allows reversal of flow
Perforators
Vessels pass through muscle to supply overlying skin Identified preoperatively
7/27/2019 Muscle Flaps
7/87
The Basics
Balance reconstructive needs and sacrifice ofnormal function
Reconstructive Ladder versus Triangle
Defect analysis
Location
Size
Physical Components
Environmenthost factors
7/27/2019 Muscle Flaps
8/87
The basicsGoals & Principles
Safety - successful wound coverage
Identify and protect pedicle
Conservative skin territories
Tension- at pedicle or inset site
Form- normal shape or contour
Restoration at defect
Preservation at donor site
7/27/2019 Muscle Flaps
9/87
The basicsGoals & Principles
Functionstability of closure, specializedfunctions.
Hair growth
Sensibility
Skeletal Support
Locomotion (or animation)
7/27/2019 Muscle Flaps
10/87
Classification
7/27/2019 Muscle Flaps
11/87
Classification
According to mode of innervation (Taylor) Type Isingle unbranched nerve enters muscle.
Type II- Single nerve, branches prior to entering. Type IIIMultiple branches from same nerve trunk.
Type IVMultiple branches from different nerve trunks.
Affects suitability for functioning muscle transfer
7/27/2019 Muscle Flaps
12/87
Classification
Vascular Supply(Mathes and Nahai, PRS, 1981)
Type ISingle vascular pedicle
Type II
Dominant pedicle, minor pedicle(s) Type IIIDual dominant pedicles
Type IVSegmental Pedicles
Type VDominant pedicle with secondary segmental pedicles
7/27/2019 Muscle Flaps
13/87
ExamplesType I
Single Vascular Pedicle
Tensor fascia Lata
Gastrocnemius
Genioglossus Stylogossus
Anconeus
First Dorsal Interosseus
Abductor Digiti Minimi(hand)
Abductor Pollicis Brevis Vastus Lateralis
7/27/2019 Muscle Flaps
14/87
ExamplesType II
Dominant VascularPedicle and MinorPedicles
Gracilis Trapezius
Soleus
Rectus femoris
Coracobrachialis
Biceps Femoris
Triceps
SCM Platysma
Brachioradialis
Abductor digiti minimi
(foot)
7/27/2019 Muscle Flaps
15/87
ExamplesType III
Two Dominant Pedicles
Gluteus Maximus
Rectus abdominus
Serratus Temporalis
Pectoralis Minor
Intercostal
Orbicularis oris
7/27/2019 Muscle Flaps
16/87
ExamplesType IV
Segmental Pedicles
Sartorius
Tibialis Anterior
External Oblique Extensor Hallucis Longus
Flexor digitorum longus
Flexor hallucis longus
7/27/2019 Muscle Flaps
17/87
ExamplesType V
Single Dominant andsecondary segmentalpedicles.
Latissimus Dorsi Fibula
Pectoralis Major
Internal oblique
7/27/2019 Muscle Flaps
18/87
Common Examples
Each reviewed in terms ofApplications
FeaturesLocation, size, origin, insertion
Classification Nerve supplymotor and sensory
Function
Anatomy
vascularArc of rotation
Elevation
7/27/2019 Muscle Flaps
19/87
Tensor Fascia Lata
7/27/2019 Muscle Flaps
20/87
Tensor Fascia Lata - Type I
Applications- Coverage of lower abdominal wall,perineum, ischium and sacrum. Free flap.
Small thin, flat. 5X15cm.
OriginASIS and crest. Behind sartorius
InsertionIliotibial tract of Fascia Lata.
Innervation Superior Gluteal
T12 and lateral femoral cutaneous
7/27/2019 Muscle Flaps
21/87
Tensor Fascia Lata - Type I
Function - flexes and abducts the thigh
Vascular AnatomyAscending branch lateral circumflex femoral (off
Profunda femoris) Pedicle: length7cm, Diameter 2-3mm
Arc of Rotation
Anterior
abdominal wall, groin, perineum Posteriorgreater trochanter, ischium, perineum,
sacrum.
7/27/2019 Muscle Flaps
22/87
Tensor Fascia Lata - Type I
Musculocutaneous
V-Y advancement
Fasciocutaneous Precautions
Distal end less reliable (consider delay)
Donor site closure
possible thigh compartmentsyndrome
Donor site often requires grafting
7/27/2019 Muscle Flaps
23/87
Gastrocnemius - Type I
7/27/2019 Muscle Flaps
24/87
Gastrocnemius - Type I
Applicationscoverage of inferior thigh, knee,contralateral leg.
Locationsuperficial posterior calf. Medial andlateral heads. 20X 8 cm.
Originsmedial and lateral femoral condyles
Insertioncalcaneus via Achilles tendon
7/27/2019 Muscle Flaps
25/87
Gastrocnemius - Type I
Pedicles Major - Medial and
Lateral sural arteries
Minorpaired
anastomotic sural vessels\
Innervation Tibial nerve
Saphenous (medial), Sural
(lateral)
Functionplantarflexion of the foot.
7/27/2019 Muscle Flaps
26/87
Gastrocnemius - Type I
Vascular Anatomy - medial and lateral muscles
Arc of rotation - Medial
Standard - suprapatellar thigh, knee, upper 1/3 tibia.
Extendedby 5-8cm
Distally basedmiddle third of leg.
V- Y advancement to Achilles
7/27/2019 Muscle Flaps
27/87
Gastrocnemius - Type I
Skin territories
Vertical and transverse islands. 10 X 23 cm
Elevation Supine or lateral decubitus position. Stocking seam incision
Pedicles in popliteal fossa entering deep surface, near
origins superior to popliteal crease Popliteal vein and tibial nervesuperficial to
popliteal artery
7/27/2019 Muscle Flaps
28/87
Gastrocnemius - Type I
Precautions
Preserve soleus
Tourniquet recommendedavoid nerve injury
Standard flap leaves better scar
Preoperative angiography
Relative contraindication
recent DVT
7/27/2019 Muscle Flaps
29/87
GracilisType II
7/27/2019 Muscle Flaps
30/87
GracilisType II
Applications
groin, perineum, abdomen,ischium. Vaginal reconstruction. Facialreanimation.
Location
medial thigh. Pubis to medial kneeThin, flat 6X24 cm.
Adductor longus and sartorius anteriorly
Semimembranosus posteriorly. OriginPubic symphysis
InsertionMedial Tibial condyle
7/27/2019 Muscle Flaps
31/87
GracilisType II
Innervation
Motoranterior branch of obturator
Sensoryanterior femoral cutaneous (L2-3).
Function
thigh adductor.
7/27/2019 Muscle Flaps
32/87
GracilisType II
Vascular Anatomy
Dominant
Ascending branch of medial circumflex femoral.
Length6 cm, Diameter1.6 mm.
Minor
one or two branches of superficial femoral
Length2 cm, Diameter0.5 mm
7/27/2019 Muscle Flaps
33/87
GracilisType II
Arc of Rotation
Standardgroin perineum vagina, anus and ischium
Distalrequires delay, arc to knee.
Skin territory
Pubis to junction of middle and lower third betweenrectus anteriorly and biceps posteriorly.
16X18cm
7/27/2019 Muscle Flaps
34/87
GracilisType II
Flap Elevation Draw line from Symphysis to medial femoral
condylecut 3cm posterior to this.
Pedicle location
10cm inferior to pubic tubercle.Retract the adductor longus to expose.
Muscle superficial to adductor magnus
Medial to adductor longus
Anterior to semimembranosus
7/27/2019 Muscle Flaps
35/87
GracilisType II
Precautions
Selective arteriography if prior vascular surgery
Confirm skin island position often
Special case-
Functional muscle transplant
Mark muscle resting length with sutures prior to
disinsertion Dissect out obturator nerve
Vaginal reconstructionpaired flaps
7/27/2019 Muscle Flaps
36/87
TrapeziusType II
7/27/2019 Muscle Flaps
37/87
TrapeziusType II
Applications
Skull, head and neck, Oral cavity,posterior trunk and shoulder. Mandible facialreanimation.
Location
large, flat, triangular. Superficial. 34 X 18 cm Originexternal occipital protuberance, medial third of
sup. nuchal line, ligamentum nuchae, spinous processesof C7 to T12
Insertionlateral third of clavicle, spine of scapula,acromion.
7/27/2019 Muscle Flaps
38/87
TrapeziusType II
Vascular anatomy
DominantTransverse cervical artery
Length 4 cm, diameter 1.8 mm
Minor Branch of Occipital artery
Length 3 cm, diameter 1mm Dorsal Scapular artery
Length 4 cm, diameter 1.6mm.
7/27/2019 Muscle Flaps
39/87
TrapeziusType II
Innervation
MotorCN XI (spinal accessory)
Sensory - #rd and 4th cervical nerves, intercostals
Function
Rotates scapula, elevates shoulder during abductionand flexion of arms
7/27/2019 Muscle Flaps
40/87
TrapeziusType II
Arc of Rotation
StandardPosterior skull, cervical and thoracicvertebral column, midface and neck.
Reverse
midline of trunk
Skin territory
20 X 8 cm.
7/27/2019 Muscle Flaps
41/87
TrapeziusType II
Elevation
Mark midline, scapular border, midportion ofscapula. Midpoint between scapular tip and PSIS
Position prone or lateral decubitus
Pedicle
Vertical flap - vertical component TCA. Deep surface of
middle fibers, over superior rhomboid Lateral flapascending branch of TCA identified in
posterior neck
7/27/2019 Muscle Flaps
42/87
TrapeziusType II
Vertical Flap
7/27/2019 Muscle Flaps
43/87
TrapeziusType II
Precautions
Preserve superior fibers
Selective ateriography if radiated or radical neck
dissection.
Use Doppler to identify segmental vessels in reverseflap
Shoulder immobilization post op to avoid tension onclosure.
7/27/2019 Muscle Flaps
44/87
SoleusType II
7/27/2019 Muscle Flaps
45/87
SoleusType II
Applications
coverage of middle third +/- lower thirdof leg
Location large, broad, bipennate, deep to gastroc. Medial and lateral
bellies. Fused proximally. 8X28 cm (Flap dimensions 7-12 cm)
Origin Lateral posterior head and body of fibula
Medial middle third of medial border of tibia Insertion
Calcaneus via Achilles tendon
7/27/2019 Muscle Flaps
46/87
SoleusType II
Innervation
Motorposterior tibial and medial popliteal nerves
Function- plantar flexion of the foot
7/27/2019 Muscle Flaps
47/87
SoleusType II
Vascular Anatomy
Dominant Proximal two branches of popliteal artery (Length 0.5-1 cm,
diameter 1-1.5mm)
Proximal two branches of posterior tibial artery (Length 1-2cm, diameter 1-2 mm) medial belly
Proximal two branches of peroneal artery (Length 1-2 cm,diameter 1-2 mm) lateral belly
Minor 3-4 segmental branches of posterior tibial (L 1-1.5 cm, D 0.5
1mm)
7/27/2019 Muscle Flaps
48/87
SoleusType II
Arc of rotation
Standardmiddle third of tibia
Distaldistal third of tibia, based on minorpedicles. (Distal hemisoleus, more reliable)
7/27/2019 Muscle Flaps
49/87
SoleusType II
Elevation
Landmarksmedial border of tibia, fibulalaterally. Extends below gastrocs and plantaris.
Pedicle
Deep surface (Post tib medial, peroneal laterally)
Minor segmentalsdistal medial border
7/27/2019 Muscle Flaps
50/87
SoleusType II
Standard Flap
Medial incision, transposed laterally.
Lateral approach
Hemisoleusmedial and lateral.
Pedicle length cannot be extended
7/27/2019 Muscle Flaps
51/87
SoleusType II
Precautions
Congenital adhesions
Distally based lateral hemisoleus has less reach than
medial.
7/27/2019 Muscle Flaps
52/87
Gluteus MaximusType III
7/27/2019 Muscle Flaps
53/87
Gluteus MaximusType III
Applications
Sacrum , Ischium, Trochanter,breast reconstruction.
Locationlarge, quadrilateral, most superficial.
24X24 cm
Origingluteal line of ilium and sacrum
InsertionGreater tuberosity of femur, iliotibialband.
7/27/2019 Muscle Flaps
54/87
Gluteus MaximusType III
Vascular Anatomy
Dominant
Superior gluteal artery (Length 3 cm, diameter 2.5 mm)
Inferior Gluteal artery (Length 3 cm, diameter 2.5 mm) Minor
First perforator of Profunda femoris (L 5 cm, D 1.5mm)
Intermuscular branches of lateral circumflex femoral (length1 cm, diameter, 0,6 mm)
7/27/2019 Muscle Flaps
55/87
Gluteus MaximusType III
Innervation
Motorinferior gluteal nerve (L5 to S1-2) via sciaticforamen at level of piriformis
Sensory
Posterior divisions of L1-3 laterally, S1-3medially)
Function
Extends and laterally rotates the thigh
7/27/2019 Muscle Flaps
56/87
Gluteus MaximusType III
Arc of Rotation
Standard
Axis edge of sacrum
Covers sacrum and ipsilateral ischium
Reverse (Inferior half)
Divide origin and inferior pedicle
To posterior lateral thigh
Segmental transposition
7/27/2019 Muscle Flaps
57/87
Gluteus MaximusType III
Elevation
Easily identified
Standard flap
Superior halfcover sacrum
Inferior halfcover ischium
7/27/2019 Muscle Flaps
58/87
Gluteus MaximusType III
Donor closure
Recommended, V-Y advancement may facilitate this.
Precautions
Not expendable
Denervation atrophy
Piriformiskey to division of midportion
Sciatic nerve
inferior flap
7/27/2019 Muscle Flaps
59/87
Rectus AbdominusType III
7/27/2019 Muscle Flaps
60/87
Rectus AbdominusType III
Applications
Thorax, abdomen, perineum,Breast, head and neck upper and lowerextremities.
Location
vertical, costal margin to pubis, longflat, three tendinous intersections.. Length 25X6cm.
Origin
crest of pubis, symphysis
Insertion5th to 7th ribs
7/27/2019 Muscle Flaps
61/87
Rectus AbdominusType III
Innervation
Motorsegmental 7th to 12th intercostal nerves
Sensory7th to 12th intercostal nerves
Function
Flexes vertebral column, tenses abdominal wall.
7/27/2019 Muscle Flaps
62/87
Rectus AbdominusType III
Vascular anatomy
Dominant
Superior epigastric (L 2cm, D 1.8 mm)
Inferior epigastric (L 5 cm, D 2.5 mm)
Minor
Subcostal and 6-7 intercostal arteries
7/27/2019 Muscle Flaps
63/87
Rectus AbdominusType III
Arc of rotation
Standardtwo
Superior epigastricAnterior thorax
Inferior epigastric
Groin Perineum and inferiortrunk
Skin territory
Vertical standard or island
Transverse ipsilateral or TRAM
7/27/2019 Muscle Flaps
64/87
Rectus AbdominusType III
Elevation
Landmarkscostal margins to pubic ramus
Easily palpable
Leg raising maneuver
Standard muscle flapnumerous modifications
Donor closure Critical to prevent herniation
Avoid tension on pedicle base
7/27/2019 Muscle Flaps
65/87
Rectus AbdominusType III
Precautions
Previous abdominal surgery - Kocher, Pfannenstiel
Prior LIMA/RIMA surgery
Segmental flap elevation may not preserve function
Marlex mesh reinforcement
Direct donor site closure preferred.
7/27/2019 Muscle Flaps
66/87
Serratus AnteriorType III
7/27/2019 Muscle Flaps
67/87
Serratus AnteriorType III
Applications
head and neck, Thorax, axilla,posterior trunk, breast reconstruction and freetissue transfer
Thin, broad, multidigitated. 15X20cm.
Originouter surface upper nine ribs
Insertionventral surface of medial border ofscapula.
7/27/2019 Muscle Flaps
68/87
Serratus AnteriorType III
Innervation
MotorLong thoracic N. (C5-7 roots)
SensoryT2-4 segmental intercostals
Function
pulls medial border of scapulaanteriorly. Prevents winging.
7/27/2019 Muscle Flaps
69/87
Serratus AnteriorType III
Vascular anatomy
Dominant
Lateral thoracic (L 6-8 cm, D 2-2.5 mm)
Branches of Thoracodorsal (L 6-8 cm, D 2-2.5 mm)enters posterior to Lat. Thoracic.
7/27/2019 Muscle Flaps
70/87
Serratus AnteriorType III
Arc of rotation
Standard - chest wall, shoulder, axilla, back.
Extendeddivide one of the two pedicles.
Combined Serratus-Latissimus dorsi flap.
7/27/2019 Muscle Flaps
71/87
Serratus AnteriorType III
Elevation - Standard
Mark Lat. dorsi and Pec. major
Scapular tip
Elevate skin flaps anteriorly and posteriorly
Pedicles
Lateral Thoracic
upper 3-5 slips, deep to pecThoracodorsal6 cm lateral and below LT pedicle
7/27/2019 Muscle Flaps
72/87
Serratus AnteriorType III
Identify lower 3-4 slips (on TD pedicle)
Identify Nerves
Lateral thoracicsuperficially, at 6th rib with TD
pedicle
Long Thoracic
Divide vessels to latissimus.
Donor site closed primarily.
7/27/2019 Muscle Flaps
73/87
Serratus AnteriorType III
Precautions
Identify thoracodorsal pedicle early to speeddissection
Prevent winging
3-4 segments, preventdenervation.
Tunnelingpotential for vascular compromise.
7/27/2019 Muscle Flaps
74/87
Latissimus DorsiType V
7/27/2019 Muscle Flaps
75/87
Latissimus DorsiType V
Applications
among the most varied
Locationlarge flat, triangular, postero-inferiortrunk. Deep to trapezius. 25X35cm.
Origin
aponeurosis to thoraco lumbar fascia,T7-12 spinous processes, sacrum, post iliac crest
Insertionscapular tip. Intertubercular groove
of humerous.
7/27/2019 Muscle Flaps
76/87
Latissimus DorsiType V
Vascular anatomy
Dominant
Thoraco dorsal artery (L 8 cm, D 2.5mm)
Secondary Segmental
Lateral Row (L2-3cm, D 2.5 mm)
Medial Row (L 1-2 cm, D 0.5 mm)
7/27/2019 Muscle Flaps
77/87
Latissimus DorsiType V
Innervation
MotorThoracodorsal (C6-8)enters withdominant pedicle
Sensory
Lateral intercostal cutaneous nerves(divided)
Functionadducts, extends and rotates the
humorous
7/27/2019 Muscle Flaps
78/87
Latissimus DorsiType V
Arc of Rotation Standard
Axis at posterior axilla
Posterior
neck, occiput, parietal skull.Anteriorhemi thorax, sternum, mid face, upper
abdomen.
Extended 5-10 cm more
Reverseoff segmentals
T
7/27/2019 Muscle Flaps
79/87
Latissimus DorsiType V
Elevation -Standard muscle flap
Posterior axillary incision 5-10cm
Pediclein posterior axilla deep to muscle. 10-15 cm below insertion.
Proceed from inferior/medial to superior/lateral
Divide insertion only after pedicle is isolated
Donor site closuredirect 5-7cm.
L i i D i T V
7/27/2019 Muscle Flaps
80/87
Latissimus DorsiType V
Precautions
Relative contraindication contra-lateral shouldergirdle is paralyzed
Denervated muscle is difficult to dissect Do not divide branch to serratus until subscapular-
thoracodorsal system is identified.
Adhesions with serratus Identify segmental vessels prior to reverse
transposition.
P li M j T V
7/27/2019 Muscle Flaps
81/87
Pectoralis MajorType V
P li M j T V
7/27/2019 Muscle Flaps
82/87
Pectoralis MajorType V
Applications Coverage, Reconstruction,Functional transfer, Free flap.
Locationflat, fan shaped. 15X23 cm.
Origin
Medial clavicle, anterior sternum, upperseven costal cartilages, ext. oblique aponeurosis.
InsertionLateral lip of bicipital groove.
P li M j T V
7/27/2019 Muscle Flaps
83/87
Pectoralis MajorType V
Vascular Anatomy
Dominant
Pectoral branch of Thoracoacromial artery (L 4cm. D 2-2.5
mm) Minor
Pectoral branch of lateral thoracic (L 3-4 cm, D 1-2 mm)
Minor Segmental
Internal mammary perforators (L 1-2 cm, D 1-2mm)
Intercostal perforators, 5-7th (L 1-2 cm, D
7/27/2019 Muscle Flaps
84/87
Pectoralis MajorType V
Innervation Motor
Lateral (Superior) Pectoral nerve deep surface near
dominant pedicle. Medial (Inferior) Pectoral nervevia pec minor to
posterolateral pec major.
Sensory 2-7th intercostal nerves
Functionarm adduction and medial rotation.
P li M j T V
7/27/2019 Muscle Flaps
85/87
Pectoralis MajorType V
Arc of rotation
Standard
Head and neck, sternal defects
Extended
3-5 cmInferior orbital rim, intrathoracic cavity
Reverse (turn over)
Sternum and mediastinum
P li M j T V
7/27/2019 Muscle Flaps
86/87
Pectoralis MajorType V
Elevation Standard (Thoraco acromial pedicle)
Midline incision elevate skin flaps then muscle
Identify pedicle
deep surface, junction of middleand lateral thirds of clavicle.
Minor pedicles cauterized.
Incise origin
island muscle flap
P li M j T V
7/27/2019 Muscle Flaps
87/87
Pectoralis MajorType V
Precautions Less reliable as vascularized bone flap (5th-6th rib)
Bulky in head and neck reconstruction
Donor deformity (loss of axillary fold)
minimizedwith segmental transpositions.