Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. the wound has healthy granulation tissue led to a significant decrease in complications related to muscle flap closure(17). But it may not be appropriate in some cases. Background: The pectoralis major muscle is a versatile flap used as an advancement or turnover flap for the treatment of deep sternal wound infection (DSWI) after median sternotomy. Often, muscle flaps are used for defects where skin grafting or local flaps would not adequately address the defect, or where skin grafting or local flaps have previously failed. One or two myocutaneous perforators must be saved if The issues that would negatively impact free flap success should be assessed. 2 The incidence of sternal wound infections or mediastinitis is approximately 1–5% following open heart surgery 3 and will typically increase length of hospitalization by 20 days and increase the cost by three times compared to an uncomplicated postoperative course. Key Highlights Lower extremity soft-tissue reconstruction techniques using local muscle and perforator workhorse flaps Bone salvage and restoration techniques, including vascularized bone grafts Diabetic foot management with in-depth ... is applied with the foot and ankle in neutral dorsiflexion (Fig. When this occurs, a variety of flaps may be used, and you may separately report the flap. Mathes SJ, McCraw JB, Vasconez LO. One can also use a combination of the turnover pectoralis flap on the side in which the IMA has not been harvested and a unipedicled rotational advancement flap on the ipsilateral side. Care must be About Local Flaps. The disadvantage of the turnover flap is that the muscle is harvested on its non-dominant blood supply and if a midline sternotomy is needed again, the muscle may be damaged. dermal, 5-0 Monocryl deep dermal, 5-0 Monocryl as subcuticular. The humeral insertion must first be divided. the wound has healthy granulation tissue led to a significant decrease in complications related to muscle flap closure(17). Bilateral-pectoral major muscle advancement flap combined with Vacuum-assisted closure therapy for the treatment of deep sternal wound infections after cardiac surgery can shorten the hospital stays and few complications. They remain attached to their original site and retain their blood supply. A comprehensive reference covering all facets of the management and treatment of mutilating injuries of the hand. Borders of the pectoralis (see Figure 4.2): The thoracoacromial artery arises from the midpoint of the clavicle and courses medially. After the pectoral flaps have been raised, suture them in the midline with figure-of-eight sutures (strong monofilament such as 0-0 Prolene®; Ethicon, Somerville, NJ). heavily fused bilaminar myofascia (Fig. The decreased durability of a skin graft over muscle relative to a skin flap in the first few weeks after surgery can be a drawback. Appropriate resuscitation with blood or fluids. No specialized equipment other than routine surgical instruments are needed to raise an LD muscle flap. – Zone of injury may be larger than anticipated and may include rotated muscle – More muscle tissue available in free flaps Pollak, A et.al. Guest editors Tirbod Fattahi and Rui Fernandes present the latest information on mandibular reconstruction. TY - JOUR. Functional reconstruction of muscle loss or absence in congenital conditions, Increase perfusion and resistance to infection. closed and dry. Deep median sternotomy wound infection is a significant source ofmorbidity after cardiac operations. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. The medial gastrocnemius myocutaneous flap. Open-heart surgery is usually performed through median sternotomy, as first described by Milton in 1897.1 A rare but serious complication associated with this approach is the development The muscle is elevated off the chest wall medial to lateral, taking care to ligate the intercostals and internal mammary perforators medially (Figure 4.9). 6. The plane between the deep side of the soleus and the deep flexor The myofascial flap variation carries no skin paddle and is utilized primarily to close small mucosal defects, to protect major vascular structures, and to support primary mucosal closure in a patient at increased risk of wound breakdown (prior radiation, diabetic, weight loss). This book is an open access book with CC BY 4.0 license. This comprehensive open access textbook provides a comprehensive coverage of principles and practice of oral and maxillofacial surgery. Debridement and closure are usually done in stages, with initial deep intraoperative cultures to guide long-term antibiotics. If further advancement is needed caudally, back cutting the superior medial aspect of the pectoralis muscle up to 6 cm maintains its blood supply. The rotating end of the turnover flap may be sutured in place at the adjacent costal cartilage and intercostal fascia. Like its predecessor, the book is essential reading for residents and a must for any professional performing reconstructive surgery. Common flaps for a laparotomy include 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk and 15756 Free muscle or myocutaneous flap with microvascular anastomosis. This inhibits optimal wound healing and can lead to seroma or bursa formation and an increased risk of recurrent ulceration. A rongeur and periosteal elevator allow for debridement of the affected sternum and cartilage. For instance, if a previous lower extremity gastrocnemius flap failed to adequately treat a complex open tibial wound, the surgeon should ascertain if poor vascular inflow to the leg compromised muscle perfusion. Pain and dysesthesias at the donor (c) Closure of muscle layer. A DSSI involves the fascial and muscle layers or organ spaces and pus in the deep incision, spontaneous dehiscence of the wound, an abscess diagnosed by computed tomography, or … Muscle flap coverage of exposed endoprostheses. Vascularized free muscle flaps are indicated for complex reconstruction of: The indications are numerous and varied, but most common for reconstruction of complex defects with exposed vital structures such as bone, tendon, nerve, vein graft or other major vessels. Preserve these muscles as they will be used as advancement flaps for sternal closure on top of the fixation system. Figure 4.11 Pectoralis myocutaneous rotation advancement flap for coverage of fistula postesophagectomy. For management of larger wounds with bone or tendon exposure, flaps may be required. should be preserved. resecting its tendinous attachments, resulting in a 2- to 3-cm increase if the gastrocnemius or the soleus muscle is used alone. Wound size was 13 x 8cm with 2 flaps, measuring 13 x 4 cm each and a 13cm layered plastic closure of the skin and subcutaneous tissue. anterior surface of the muscle to expand the size and the dimensions of For DSWI caused by cardiothoracic surgery, VAC has been widely proven to be more effec-tive than traditional treatments.12,13 The median sternal defect can be covered with multiple flaps or muscle flaps, like the free anterolateral thigh myocutaneous flap, Not only is the skin the largest organ by the surface area of the body, the integument has multiple essential functions such as preventing dehydration, acting as a first-line barrier to infection, permitting unrestricted movement of joints, as well as sustaining a normal profile and appearance. significant rotation of the muscle into the wound (Fig. Written from the surgeon’s perspective, this medical reference book features step-by-step guidance on performing the most updated developments and cutting edge approaches across the entire spectrum of dermatologic surgery. crisscross incisions made both anteriorly and posteriorly through its 46.22). The Third Edition features new chapters by the original experts who have made landmark contributions to the recent literature. Many chapters from the previous edition have been completely revised. The book is primarily aimed at trainee plastic, orthopaedic and trauma surgeons (particularly for expanding knowledge and examination revision) but would also appeal to established surgeons to improve patient care. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. The most common local flaps used for coverage of this area are abductor hallucis–abductor digiti minimi muscle flaps, extensor digitorum brevis muscle flap, lateral supramalleolar flap, and sural fasciocutaneous flap. When underlying treatable conditions that promote failure are corrected or addressed, the choice of muscle flap over other free flaps depends on surgeon preference and comfort, pedicle needs, wound dimensions, donor site morbidity, defect location and the need for future surgical treatment. The left IMA (LIMA) was used for the CABG, and the right IMA (RIMA) was damaged during debridement, so rather than a rectus abdominus flap, he will undergo a pedicled omental flap for coverage. A higher complication rate was found in wounds closed in delayed primary fashion (13 of 19 patients, 68 percent) than those reconstructed with muscle flaps (2 of 10 patients, 20 percent) (p = 0.021). neurovascular structures at all times. However, other studies show that delayed closure of the wound with muscle flaps, when systemic infection has subsided, decreases the rate … Pectoralis major insertions are divided, and the muscles are based on the secondary IMA blood supply and turned and inferiorly rotated in to fill sternal wound defects. attachment to the Achilles tendon. subcutaneous tissue (Fig. Several myocutaneous and fasciocutaneous flaps have been used for this purpose. difficult to ligate. DeArmond, and H.J. Disclosures Found inside – Page 1211This is applied to the wound bed . Fixation of the graft for 4 to 5 days prevents movement between the graft and the recipient bed . This usually results in graft acceptance . Myocutaneous Flaps Closure of large soft - tissue defects ... Fold the lateral portion of the muscle into the mediastinum while maintaining its vascular supply by means of perforators from the IMA and anterior intercostal arteries. FIVE STARS from Doody's Star Ratings™ A step-by-step manual on the use of reconstructive surgery flaps – from planning to execution Written by pioneering, world renowned flap surgeons, this is the quintessential manual on the use of ... Designed as an easy-to-use, practical guide to tumors of the eye, lids, and orbit, this Open Access book comprehensively addresses surgical treatment and management of diseases related to ophthalmic oncology. A thorough examination of the patient is crucial when planning either a gastrocnemius or … Variations of flap design can cover upper-third defects over a relatively wide arc of rotation, as long as … A pseudoraphe is encountered approximately three fourths of superficial coverage. Surgery in all cases included removal of necrotic bone and tension-free closure of the formed mandibular bone wound with local mucoperiosteal flaps (group 1) or double-layer closure with mylohyoid muscle and local mucoperiosteal flaps (group 2). Undermine the chest wall both superficial and deep to the pectoralis muscles. I believe that this book represents an enhancement in the knowledge and in the involvement of individuals dedicated to these areas of study. Identify at least three healthy ribs for the sternal fixation system. 9 If viable bone and cartilage remain in the setting of paradoxical chest wall movement and sternal instability, rigid sternal fixation can be a part of chest wall reconstruction. The use of local transposition muscle flaps as an adjunct in closing complex back wounds has been very successful in our experience. Written by expert surgeons and educators, Current Therapy in Oral and Maxillofacial Surgery covers the latest treatment strategies, surgical techniques, and potential complications in OMS. the surgeon working along the posterior midline while protecting the

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