FOR LARGE SCALP WOUND

1. DRVIPINV NAIR
SR Plastic surgery
PGIMER Chandigarh
OPERATIVE SEMINAR
1

3.  Direct closure
Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base reconstruction. Plast
Reconstr Surg 1996;98:1159-66.

4.  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.

5.  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

6.  I will be discussing
 FREE LD Flap for
 LARGE Scalp defect
 With intact skull bone

7.  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.

9.  Vessel size
 STA
2.1 -2.5 mm
 Occipital
1.9 -2.2 mm
 Facial
2.4 -3 mm

10.  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

11.  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.

12.  Diameter
 Aretery 1.5 -1.9 mm
 Vein 2.5 3.1 mm.
 Extramuscular pedicle
length 6 to 16 cm
[average 9 cm]

14.  Adductor and medial
rotator of the arm.
 Pull the shoulder
inferiorly and
posteriorly.

15.  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

16.  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

17.  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

18.  Preoperative
discussion
 Risk of haematomas
and seromas
 Unsightly scar.
 Risk of flap failure.

19.  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

21.  Correct anemia
 Keep warm
 Get coagulogram
 Keep patient hydrated
 Maintain good urine
output

23. Types:
a. compound loupes
b. prismatic loupes (wide-
angle
loupes)
- For anastomosis :
3.5x or 4.5x magnification
Working distance : 25 to 50 cm

26. ► 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

27. BIPOLAR COAGULATORWITH BOTH
STANDARDTIPS AND MICROTIPS
SMALL ABSORBENT
CELLULOSE SPONGES
 Instrument
demagnetizing coil

28.  GA + ETT
 FLEXOMETALIC
TUBE
28

29.  Place the patient on his or
her side
 Lateral decubitus position
 Operative side facing up
 Shoulder abducted.
 An axillary roll
 Contralateral axilla.

30.  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

31.  Take care to pad any
firm spots to minimise
risks of pressure
necrosis
 Place a pillow between
the knees, which
should be slightly bent

32.  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

34.  Prep the back up to the spine and include
ipsilateral arm

35.  Put a stocking
over the arm
and secure it to
the drapes

36.  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

37.  Design a lazy-S shaped
incision a few centimetres
behind the anterior edge
of the muscle

38.  Incise the skin and
subcutaneous tissue

39.  Extend the incision down
to the muscle

40.  Raise the anterior flap
until the anterior edge of
the latissimus dorsi
muscle is identified

41.  Now raise the flap
posteriorly
 Superiorly identify
latissimus dorsi
intersperses with the
fibres of the teres major
muscle

42.  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

43.  Dissect the latissimus
dorsi muscle off the
thoracic wall using
blunt finger dissection

44.  Superiorly dissection
plane consists of loose
areolar tissue which
makes it easy to strip
the latissimus dorsi
from the underlying
tissues

45.  By doing this
manoeuvre, the
pedicle should become
visible as it enters the
muscle on its deep
aspect, superiorly

46.  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

47.  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

48.  Continue upward along
the spinous processes
until the entire muscle
is released.
 Ensure good
haemostasis as you
encounter the lumbar
and intercoastal
perforators

49.  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

50.  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

51.  To maximise the
length of the
pedicle, the
artery can be
traced to the
axillary artery

52.  Divide the pedicle and
harvest the flap once
donor vessels have
been prepared

53.  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

58. 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

59. ►COMFORTABLE POSITION
►PATIENCE
►GOOD PLANNING
►ADEQUATE EXPOSURE

62. *Avoid grasping the ends
of the vessels to be
anastomosed
*Grasp only a small
quntity of loose
periadventitia

63. ►Inspect under high power for signs of damage
►Debride until no signs of vessel damage
►Strong pulsatile flow of blood after adequate
debridement

64. ►Mechanical dilatation
►Hydro distention of the vein graft
►Pharmacologic measures
► Papaverine
►2 % Plain Lignocain
► Moist gauge soaked in warm saline

65. ►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

66. ►Not too tight or too
loose sutures
►Too tight sutures-
Avoided by a small
“suture circle” at
the end of three ties

67. 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

68. ►Hemostasis - must
*Vascular clips
*Bipolar coagulator
*Torniquet
►Avoid perivascular hematoma
►Irrigation

69. ►Plane of dissection
►Retract the sheath by gentle pulling and
remove it
►Vessels branches
►Background
►Moist field

70. Resection to normal vessels:
- Resect proximal to
areas with microscopic signs
of vessel damage with fine,
straight, sharp scissors in a
single motion

71. Demonstration of forward pulsatile flow prior
to clamping

72. Double approximating
clamp
Tips of the jaws should
Project just beyond the
vessel for maximal grip

75. ►Resect sufficient
periadventitia, flush
with the underlying end
to expose 2-3 mm of the
vessel wall for suturing

77. ►Irrigate the lumen with
solution of
heparinized saline
100 units / ml solution

78. ►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)

83. ►Make sure that the
posterior wall is not
accidentally cought
For last 2-3 sutures:
Modified
Harshina
technique

84. ►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

85. ►Veins are thinner, flatter
and more difficult to
anastomose
►Use ringer’s solution to
float or irrigate the
vessel
►Deeper bites
►More sutures

86. ►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

87. BACK-WALL FIRST
( ONE-WAY UP)TECHNIQUE
SAFEST
Entire inside of the anastomosis
can be visualized until the
very last few sutures are
placed

88. 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

89. 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

92. ►Return of colour
►Capillary oozing and venous bleeding from
the revascularized tissue
►Direct inspection under the microscope

93. ►Traumatic
►Performed
as gently and
infrequently as
possible

94.  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

98.  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

99.  Proper patient positioning
to
 Avoid compression of the flap
or pedicle.
 Head elevated 45 to 70
degrees
 Head maintained in neutral
position
99

100.  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

101. ►Oxygen administation
►Bed rest for 3 to 5 days
►Warm room
►Fluid administration for good
hydration
►DEXTRAN 40 25 ml /hr

102. ►Adequate analgesia
►Limitation of visitors and
telephone calls to decrease the
emotional stress
►Prohibition of smoking,
caffeine and chocolate because
they may cause
vasoconstriction

103.  Important physical signs
 Quality of capillary filling
 Bleeding from a cut edge
 Tissue turgor

104. ARTERIAL PROBLEM
 Pale
 Cool
 Without capillary refill
 Abrasion no bleeding
VENOUS PROBLEM
 Rigid
 Blue
 Rapid refill
 Abrasion brisk, dark
bleeding

106. 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

107. (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.)

108.  DIFFICULTY IN
POSTOP
MONITORING
108

109.  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

110. 110

111. 111