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Thieme: an Illustrated Handbook of Flap-Raising Techniques

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Thieme: an Illustrated Handbook of Flap-Raising Techniques 4 Part 1 Flaps of the Upper Extremity Chapter 1 dyle are palpated and marked. A straight line is The Deltoid Fasciocutaneous Flap marked to connect these two landmarks. The groove between the posterior border of the del- toid muscle and the long head of triceps is pal- pated and marked. The intersection of these two lines denotes approximately the location of the vascular pedicle, as it emerges from under- The deltoid free flap is a neurovascular fascio- neath the deltoid muscle. This point may be cutaneous tissue, providing relatively thin sen- studied with a hand-held Doppler and marked sate tissue for use in soft-tissue reconstruction. if required. The deltoid fasciocutaneous flap was first de- Depending on the recipient area, the patient scribed anatomically and applied clinically by is positioned either supine, with the donor Franklin.1 Since then, the deltoid flap has been shoulder sufficiently padded with a stack of widely studied and applied.2–5 This flap is sup- towels, or in the lateral decubitus position. Myo- plied by a perforating branch of the posterior relaxants are required in muscular individuals, circumflex humeral artery and receives sensa- so as to ease retraction of the posterior border tion by means of the lateral brachial cutaneous of the deltoid muscle, especially if a long vascu- nerve and an inferior branch of the axillary lar pedicle is required for reconstruction. nerve. This anatomy is a constant feature, thus making the flap reliable. The ideal free deltoid Neurovascular Anatomy flap will be thin, hairless, of an adequate size, and capable of sensory reinnervation. These A large portion of the fasciocutaneous territory characteristics of the flap make it an attractive overlying the deltoid muscle is nourished by option for reconstructing defects of the orofa- the posterior circumflex humeral artery with its cial region. However, in adipose individuals, the paired venae comitantes (Fig. 1.1). The sensory fat tissue might add to the bulk of the flap. innervation of this skin area is through the lat- eral brachial cutaneous nerve, which is the ter- minal sensory branch of the axillary nerve, a Preparation musculocutaneous nerve arising from the pos- The course of the neurovascular pedicle is de- terior cord. This nerve accompanies the vascu- terminedandmarkedbeforesurgeryasfollows. lar pedicle, passing behind the humerus and With the patient in sitting or standing position, emerging from the quadrangular space, which the acromion and the lateral humeral epicon- is bordered by the teres major muscle below, Fig. 1.1 Anatomical basis of the deltoid Cutaneous branch Vascular pedicle of flap of (beneath the deep fascia) flap. axillary nerve Posterior circumflex humeral artery Long head of triceps Quadrangular space Teres minor Teres major aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Deltoid Fasciocutaneous Flap 5 Fig. 1.2 Planning markings of Acromioclavicular Anterior margin of flap the deltoid flap. joint Lateral epicondyle Posterior border of deltoid Vascular pedicle teres minor muscle above, long head of triceps lavicular junction with lateral epicondyle.3 The medially, and the lateral head of triceps later- intersection of the first two lines denotes the ally. The vascular pedicle gives off branches to point where the vascular pedicle emerges to the deltoid muscles before its emergence. The the surface behind the deltoid muscle; whereas nerve, as already mentioned, is a musculocu- the third line should ideally be the anterior bor- taneous nerve and provides motor innervation der of the planned skin flap. Any variation in to the deltoid muscle. The neurovascular pedi- the point of emergence of the vascular pedicle cle emerges at the posteroinferior border of the canbemarkedbeforesurgeryusingahand- deltoid muscle, turns cranially after its emer- held Doppler. gence, and supplies the skin overlying the pos- The anterior border of the marked skin flap terolateral aspect of the deltoid muscle. Thus a is incised first, extending it along the inferior safe flap will be carved behind the line connect- border as required. The deep fascia overlying ing the acromioclavicular joint and the lateral the deltoid muscle is sharply cut and the flap is epicondyle, with an adducted and internally elevated in a plane underneath the fascia. Dis- rotated arm (Fig. 1.2). section proceeds toward the vascular pedicle, which is visualized in the under surface of the flap, after partially raising it (Fig. 1.3). An occa- Incisions and Dissection sional perforator from the deltoid muscle With the patient’s arm adducted and internally should be coagulated and divided. The neuro- rotated, three lines are drawn1: a line connect- vascular pedicle is traced to the delto-tricipital ing the acromion and the lateral epicondyle,2 a groove and carefully isolated. Now the rest line along the groove between the posterior of the skin incision can be completed border of the deltoid muscle and the long head (Fig. 1.4). The posterior border of the deltoid of triceps, and a line connecting the acromioc- muscle is retracted to gain length of the vascu- Fig. 1.3 Dissection of the deltoid flap. Direction of dissection (in the subfascial plane) Neurovascular pedicle aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG 28 Part 2 Flaps of the Lower Extremity Chapter 7 TheTensorFasciaeLataeMuscleFlap The tensor fasciae latae muscle arises from the anterior part of the outer lip of the iliac crest and is invested in a double fascial layer. These fascial Fig. 7.1 Patient positioning for the harvest of the layers blend at the junction between the upper tensor fasciae latae flap. and the middle thirds of the lateral aspect of the thigh and course down as the ilio-tibial tract to Preparation insert into the lateral femoral condyle. The mus- cle flexes and rotates the femur internally. Ifnototherwisedictatedbythesitetoberecon- Themuscleisprovidedwithaconstant structed, the patient is positioned supine with blood supply through one reliable vascular ped- the hip and knee joints gently flexed. The thigh icle arising from the lateral circumflex femoral is rotated internally, so that its lateral aspect artery and its accompanying vein. The motor faces the surgeon (Fig. 7.1). The anterior supe- innervation is through the descending branch rior iliac spine and the iliac crest are palpated of the superior gluteal nerve. The overlying skin and marked. The line joining the lateral most has two sources of sensory innervation: (1) the aspect of the iliac crest and the lateral femoral cutaneous branch of the T12 segment (upper condylemarksthecourseoftheiliotibialtract. part), and (2) the lateral femoral cutaneous The position of the patient is determined by nerve (lower part). the area to be reconstructed. For instance, in us- Thetensorfasciaelataewasfirstdescribed ing the tensor fasciae latae muscle as a pedicled as a free musculocutaneous flap by Hill, Nahai, rotation flap for the reconstruction of decubitus and Vasconez in 1978.1,2 This musculocutaneous wounds, the patient may be positioned either unit can be transferred with motor as well as onthesideorinaproneposture. sensory innervation; there are ample and dif- ferent types of tissue that may be transferred Neurovascular Anatomy (Fig. 7.2) based on the vascular pedicle of this muscle.3–6 These properties make the tensor fasciae latae The vascular pedicle that nourishes the tensor muscle a very reliable workhorse for dealing fasciae latae muscle arises either from the lat- with various reconstructive challenges.4,6 eral circumflex femoral artery or, in some cases, Profunda femoris artery Fig. 7.2 Anatomical basis of the Lateral circumflex tensor faciae latae (TFL) flap. femoral artery Femoral artery Transverse and descending branches Ascending branch (vascular pedicle of TFL) Superior gluteal nerve (inferior branch) aus: Krishnan, An Illustrated Handbook (ISBN 9873131477613) @ 2008 Georg Thieme Verlag KG The Tensor Fasciae Latae Muscle Flap 29 Fig. 7.3 Planning markings of Point of entry of vascular pedicle Lateral femoral condyle thetensorfaciaelataeflap. Lateral cutaneous nerve of thigh Iliac crest ca. 4 cm 8 cm Lazy-S incision Skin flap Sensory branch of T12 directly from the profunda femoris artery as an points, 8 and 10 cm distal to the iliac crest and ascending branch. The pedicle enters the muscle along the anterior muscle border, are marked. belly ˚ 6–8 cm distal to the muscle’s origin from These represent the entry points of the vascular theiliaccrest.Theskinoverlyingthemuscleis pedicleandthelateralfemoralcutaneous richlyvascularizedbyaboutfourorfiveperfora- nerve, respectively. tor vessels arising from this vascular pedicle. The anterior border of the skin flap is incised The motor innervation is executed from the first, extending the incision in a lazy-S pattern dorsal aspect through the descending branch of proximally and distally as found necessary. Care the superior gluteal nerve. The sensory innerva- is taken to preserve the lateral femoral cutane- tion of the overlying skin is accomplished by ous nerve that appears along the incision. the cutaneous branch of T12 that enters the lat- After the anterior border of the tensor fas- eral thigh region after crossing the iliac crest, ciae latae muscle has been identified and dis- and by the lateral femoral cutaneous nerve that sected free, the muscle belly is retracted later- enters the anterior border of the lateral thigh ally and dorsally to reveal the entry point
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