Flap course Day1 -The lateral arm flap

Flap course Day1

Omdurman teaching hospital

Upper limb & anterior trunk

 The lateral arm flap

Skin, fat and fascia. A portion of the humerus can be used to make this an osteocutaneous flap.
Innervation: posterior cutaneous nerve of the forearm.
Blood supply: posterior radial collateral artery.
Artery: Small caliber, often less than 1.5 mm.
Vein(s): The venae are typically paired and the dominant is similar in size to the artery..
Pedicle length: Short. It does not reach proximal to the proximal edge of the flap unless the flap is designed very distally.

Marking the flap outline. The axis of the flap lies over the lateral intermuscular septum. The more distal the flap is made, the thinner the skin. It can be based very distally, as a lateral forearm flap.

 The axis of the humerus is marked from the deltoid insertion to the lateral epicondyle. The lateral arm flap is designed with its longitudinal axis on this marking. The skin of the arm is pinched to judge the maximum with of the flap is a large paddle is needed. Usually, four to five centimeters are the widest a flap can be. The flap can be quite long however, from the deltoid insertion to distal to the lateral epicondyle. Alternatively, a lateral forearm flap can be marked using the distal think skin around the lateral epicondyle, as shown in the diagram.

 

The flap is supplied by the radial collateral artery. It originates from the brachial artery and wraps posteriorly around the humerus, descending on the lateral aspect of the humerus and then branching into an anterior and posterior segments. The posterior branch supplies the lateral arm and lateral forearm flaps.

Anatomy of the lateral arm flap. The radial nerve travels across the proximal base of the flap. It sends a sensory branch with the pedicle of the flap that supplies the distal lateral arm.

 

Posterior flap elevation is performed first. The flap is elevated deep to the muscular fascia. The fascial is peeled anteriorly until the septum is encountered.

The anterior aspect of the flap is then elevated until the septum, and then the flap can be raised from distal to proximal. The septal attachment to the humerus is released as the flap is elevated.

The lateral arm flap has long been the workhorse of microvascular surgeons in the cover of small and moderate-sized defects, especially in the head, neck, and the extremities. Its versatility, however, has always been restricted by its small skin paddle

The lateral Arm Osteocutaneous Flap The lateral arm flap can also be harvested as an osteocutaneous flap. The wedge of bone with periosteal cuff is harvested under the septum and septal pedicle. A narrow portion of bone approximately 1 to 1.5 centimeters wide can be harvested.

Flap course Day1 - Deltopectoral flap

Flap course Day1

Omdurman teaching hospital

Upper limb & anterior trunk

Deltopectoral flap

Deltopectoral Flap, was developed by Bakamjian as an axial-pattern skin flap, and its blood supply depends on perforating branches from the internal mammary artery. The main blood supply of the deltopectoral flap is provided by the second and third intercostal arteries. Deltoid portion is random.

 Indications

1. Carotid coverage after pharyngocutaneous fistula formation
2. for cervical and neck reconstructions
3. Hypopharyngeal reconstruction
4. Sternum reconstructions
5. Oral cavity & floor of the mouth
6. Paired Deltopectoral Flap was prescribed for lower lip reconstruction. 

Contraindications

1. For most cases, other flaps are a better choice.
2. Prior chest wall surgery or injury (eg, radical mastectomy, pacemaker)
3. Prior cardiac surgery with use of internal mammary artery for bypass

Consent Inclusions

1. Chest wall and neck scar
2. Possible need for skin grafting to shoulder
3. Bleeding, infection
4. Flap failure (distal necrosis possible)

 

To prevent injury to the perforators, flap elevation should remain lateral to a vertical line approximately 2 cm from the sternal border. The vessels provide an axial blood supply to the proximal two thirds of the flap; the remaining third is random in distribution. The elevation of this flap below the pectoralis fascia protects the subdermal network of vasculature for the random distribution. A delay technique may be valuable.

Interesting  Classification of sternal wounds: Pairolero and Arnold have based their classification of sternal wounds on timing of presentation of infection; this classification divides wounds into 3 categories.This classification system does not indicate the type of reconstruction necessary for management of each type of sternal wound. Type II and III wounds are typically referred to plastic surgeons for reconstruction.

• Type I: Type I wounds occur in the first few days postoperatively, contain early wound separation with or without sternal instability, and are characterized by serosanguineous drainage without cellulitis, osteomyelitis, or costochondritis.
• Type II: Type II wounds occur within the first few weeks and are characterized by drainage, cellulitis, mediastinal suppuration, and positive cultures. Type II wounds are characterized by fulminant mediastinitis.
• Type III: Type III wounds occur months to years after surgery and are characterized by the presence of chronic draining sinus tracts, localized cellulites, osteomyelitis, or retained foreign bodies. Mediastinitis is a rare complication of type III wounds.