Hirase - Practical Techniques in Flap Surgery

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Springer Japan 2017

Yuichi Hirase Practical Techniques in Flap Surgery 10.1007/978-4-431-56045-6_1

1. Reconstruction of Upper Arm and Medial and Lateral Elbow

Yuichi Hirase 1

(1)

Yotsuya Medical Cube, Chiyoda-ku, Tokyo, Japan

Basic Principles

Exposure of blood vessels or nerves of the medial elbow, or exposure of the bone of the lateral elbow must be covered using a skin flap. Although a number of either normal flow or reverse flow vascularized flaps can be created in the elbow region, in many cases blood vessel damage is also present, and there are often restrictions on the size of the flap, so focusing only on the upper arm can make surgery more difficult. In spite of large dissection, a vascularized latissimus dorsi flap is stable and practical.

With skin graft using negative pressure wound therapy, because the elbow is not required to be fixed in place, there is less chance of contracture occurring, and even when graft conditions are poor, there is a high ratio of the graft taking, making it extremely practical.

Selectable Flaps and Surgical Procedures

Pedicled latissimus dorsi musculocutaneous flap Skin graft pressure method using negative pressure wound therapy

The difficulty level of each surgical procedure is shown subsequent to the procedure title (e.g., Level of Difficulty: 2). The levels range from 1 to 5, with level 1 indicating a preliminary level and level 5 indicating a very advanced level.

1.1 Pedicled Latissimus Dorsi Musculocutaneous Flap (Level of Difficulty: 3)

Information

Vascular pedicle thoracodorsal blood vessel (the circumflex scapular artery is ligated and detachment continued up to the subscapular blood vessels)

Size (muscle flap) width of 40 cm and length of 40 cm; if thoracolumbar fascia is included, it is possible to harvest the entire 60 cm length

Advantage Good circulation, vascular pedicle is large and long, technique is comparatively easy. Can freely design skin on muscle flap

Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus dorsi muscle causes bulkiness preventing it from being used as a musculocutaneous flap, and therefore a skin graft is required (1.5 times mesh skin graft)

Caution The muscle head is also cut, creating a complete muscle island flap. Do not use an electrical scalpel after cutting the muscle ends. The space following removal of the latissimus dorsi muscle can cause a painful seroma, so several continuous suction drains should be put in place.

1.1.1 Operation Procedures

Fig. 1.1

( a , b ) Procedure 1: Restriction in range of movement in the elbow joint due to advanced scar contraction of medial elbow. Scar resection expects skin defect on medial elbow due to elbow extension

Fig. 1.2

Procedure 2: After resecting the scar and conducting joint mobilization surgery it was possible to extend the elbow, however a skin defect and exposure of the medial nerves and blood vessels were present

Fig. 1.3

Procedure 3: A latissimus dorsi musculocutaneous flap is elevated. The distal end of the muscle is cut, and a complete island musculocutaneous flap with only a neuro vascular pedicle is created

Note

The vascular intima can be damaged if an electric scalpel is used after creation of the island musculocutaneous flap by cutting the proximal end of the muscle, so care is required. If a skin flap is required, it is possible to elevate a latissimus dorsi muscle flap that has an island the same size as the distance from the axillary fossa to the skin defect of the elbow, however it is often bulky.

Refer to Section of

Reconstruction of Achilles tendon area/Free latissimus dorsi musculocutaneous flap (serratus anterior musculocutaneous flap) in Chap.

Fig. 1.4

Procedure 4: The elevated latissimus dorsi musculocutaneous flap is transferred to the elbow via the subcutaneous pocket of the upper arm

Fig. 1.5

Procedure 5: The skin defect area is covered with the muscle flap. A bolster suture is done to pull the flap into the subcutaneous layer

Fig. 1.6

Procedure 6: A split-thickness skin graft is conducted on top of the muscle flap. A tie-over bolster dressing is applied

Fig. 1.7

( a , b ) Procedure 7: After surgery the range of motion of the elbow has improved and full extension became possible

Tips

Can also be used for covering bone exposure of the lateral elbow

For use on the lateral elbow, if the flap is transferred with a skin island attached, it is appropriate for covering and protecting the olecranon.

Column

Form ever follows function LH Sullivan

During the reconstruction following the Great Fire of Chicago, sky rise buildings began to emerge as a means of effectively utilizing space. The pioneers of that movement were the architects known as the Chicago School which included names such as William Holabird, Dankmar Adler and Frank Lloyd Wright, a famous architect in his own right.

One of the key figures in this Chicago group was Louis Sullivan. Sullivan asserted that both form and function were equally important. This expression comes from the architectural world, but it is just as important for a reconstructive surgeon. When asked whether to choose form or function the only answer is to choose both. That is because form is also a part of function.

However, what is important is that it is not that function always follows form, but that form always follows function. In other words, it is always form that follows, and even though they go together, function is always one step ahead. Whether it be the human body, or the home or office where we live, when it boils down to it, the answer is function. If architecture aims for ease of use and with good form also, then reconstructive surgery aims for good form, little pain and ease of use, but if we take this one step further, it becomes no pain, ease of use, and if there is good form even better. This order must never be confused.

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