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.
8.
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]
13.
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
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
20.
21. Correct anemia
Keep warm
Get coagulogram
Keep patient hydrated
Maintain good urine
output
22.
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
24.
25.
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
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
33.
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
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
54.
55.
56.
57.
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
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
70. Resection to normal vessels:
- Resect proximal to
areas with microscopic signs
of vessel damage with fine,
straight, sharp scissors in a
single motion
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)
79.
80.
81.
82.
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
90.
91.
92. ►Return of colour
►Capillary oozing and venous bleeding from
the revascularized tissue
►Direct inspection under the microscope
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
95.
96.
97.
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
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
105.
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
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
The intramuscular thoracodorsal artery reliably divides into vertical and transverse branches, which allows the flap to be divided into 2 separate muscle and skin paddles. The greatest density of myocutaneous perforators lies anteriorly along the border of the muscle, which is the ideal location for skin paddle harvest. Because these perforators are not routinely identified during harvest, a general rule is that very small skin paddles risk compromised vascular supply. If a small skin paddle must be fashioned, harvesting additional subcutaneous tissue around the skin in an attempt to maintain additional perforators is wise.