Kỹ Thuật Thực Hành Trong Phẫu Thuật Ghép Vạt Da

643
Fig. 23.32  Procedure 18: Image from X-ray immediately after
surgery
Fig. 23.33  Procedure 19: A continuous suction drain is inserted in the
donor site, and the wound closed
Vascularized Fibula Graft to Forearm (Level of Difficulty: 4)

644
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)
Information
Vascular pedicle Digital artery of foot or dorsal metatarsal artery and cutaneous vein
Indication In cases where the entire PIP joint of the finger is destroyed, and the joint construction is also destroyed and
an artificial joint cannot be utilized. In cases where only the head of the proximal phalanx is destroyed, a costal carti-
lage graft is indicated, and where the extensor tendons or collateral ligaments have been retained, an artificial joint will
provide better range of movement.
From observation of results over many years, the average range of movement for a PIP joint from the toe is between
30° and 40°.

23  Transplantation of Bone and Joints

645
Operation Procedures
Fig. 23.34  Procedure 1: Transfer of the great toe has been conducted
with respect to an amputation of the right thumb. Transplantation of the
PIP joint of the second toe is planned with respect to the destruction of
the PIP joint of the middle finger
Fig. 23.35  Procedure 2: Destruction of the PIP of the middle finger
can be seen
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)

646
Fig. 23.36  Procedure 3: From a dorsal incision, appearance of the
removed extensor tendon and PIP joint
Fig. 23.37  Procedure 4: Flap is designed above the PIP joint of the
second toe
23  Transplantation of Bone and Joints

647
Fig. 23.38  Procedure 5: The flap with dorsal metatarsal artery as the
vascular pedicle, and PIP joint containing skin flap with extensor ten-
don attached is harvested
Note  The skin flap is cut with cutaneous veins attached, then the
extensor tendon is severed distally/proximally, after which the PIP joint
is severed proximally and distally with a bone saw.
For the vascular pedicle, the digital artery heading to the second toe
from the dorsal metatarsal artery is identified and cut at the distal posi-
tion, and then elevated together with the PIP joint.
Fig. 23.39  Procedure 6: The harvested flap. The joint, extensor tendon
and skin flap are removed as one, and the dorsal metatarsal artery (or
plantar artery) and cutaneous veins under the skin flap are removed as
the vascular pedicle
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)

648
Fig. 23.40  Procedure 7: The joint is fixed proximally and distally with
Kirschner wire, the extensor tendon sutured proximally and distally.
Anastomosis of the arterial pedicle is conducted to the digital artery,
and of the cutaneous vein to the dorsal cutaneous vein. The monitoring
flap is sutured
Fig. 23.41  Procedure 8: It is possible to retain the second toe, however
in consideration of problems that can occur post-operation it is prefer-
able to remove it
Note  In this case it was severed from the MP joint.
23  Transplantation of Bone and Joints

649
Fig. 23.42  Procedure 9: X-ray image 2 months after surgery
Fig. 23.43  Procedure 10: Appearance 1 year later
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)

650
Fig. 23.44  Procedure 11: X-ray image 1 year after surgery
23  Transplantation of Bone and Joints

651
a
b
Fig. 23.45  (a, b) Procedure 12: After 1 year, greater than 60° range of
movement could be obtained passively for the transplanted joint, but
only 35° autonomously
Fig. 23.46  Procedure 13: Appearance of foot. The great toe of the
right foot was transferred to the thumb, and the PIP joint of the toe on
the left foot was transferred to the PIP joint of the middle finger. Patient
experiences no problems walking
PIP Joint Transfer from Second Toe (Level of Difficulty: 4)

652
Vascularized Bone Graft from Radius (Level of Difficulty: 3)
Information
Vascular pedicle Branch from radial artery
Size Required bone chip with vascular pedicle is approximately 5 × 8 mm
Indication Scaphoid non-union or scaphoid fracture delayed union, Kienbock’s disease
Advantage High bone healing rate and short fixing period (around 4–6 weeks)
Caution Normally transfer of a pedicled bone chip is conducted by passing beneath the extensor tendon, but some are
of the opinion that doing so places pressure on the vascular pedicle and they prefer to pass it over the extensor
tendon.

23  Transplantation of Bone and Joints

653
Operation Procedures
Fig. 23.47  Procedure 1: First, an incision is made diagonally above the
scaphoid of the dorsal radial side of the wrist. The scaphoid can be seen
between the second and third compartment, and a 5 × 8 mm hole is
opened in the scaphoid non-union area using a drill, while confirming
under radioscopy
Note  It is difficult to open up the scaphoid non-union area using an
approach from the dorsal side of the wrist, so surgery is performed by
gradually bending the wrist.
Fig. 23.48  Procedure 2: The incision is continued proximally. The
extensor retinaculum is cut while paying attention to the dorsal branch
of the radial nerve. Opening up the first and second compartments, it is
possible to see the nutrient vessels traveling above the periosteum of the
distal end of the radius. A bone flap of around 5 × 8 mm is designed that
will enable a vascular pedicle of around 3–4 cm to be secured
Fig. 23.49  Procedure 3: An incision is made in the periosteum sur-
rounding the vascular pedicle and a large pedicle flap secured. Using a
small chisel, the bone chip is harvested, being careful that it isn’t
detached from the periosteum
Vascularized Bone Graft from Radius (Level of Difficulty: 3)

654
Fig. 23.50  Procedure 4: The area beneath the extensor tendon is
detached and the bone chip transferred and inserted into the hole opened
in the scaphoid. It is then sutured to the surrounding periosteum using
an absorbable suture. Under radioscopy, a steel rod of less than 1 mm
diameter is inserted to fix the bone flap in place. After the wound is
closed, the hand is fixed with a thumb spica cast
23  Transplantation of Bone and Joints

655
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_24
Fat Graft
Basic Principles
The abdomen, the scapular region and the inguinal region are the most common areas used
for fat that can be harvested as transplant tissue with a vascular pedicle. All of these can be
harvested as skin fl aps and the skin part can be de-epithelized.
Augmentation can also be used for the fascia fl ap, however can be diffi cult as the sur-
geon cannot know during surgery how much the swelling will go down post-operation.
Selectable Flaps and Surgical Procedures
• Groin fl ap • Scapular fl ap • Abdominal fl ap • Anterolateral thigh fl ap
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
24

656
Free Vascularized Groin Fat Graft (Level of Diffi culty: 4)
Information
Vascular pedicle Superfi cial circumfl ex iliac blood vessel (at distal end branches into the superfi cial branch and deep
branch, and superfi cial branch enters the fl ap). Length is 1.5–2 cm.
Size The width is around 10–15 cm centered around the inguinal ligament, and the length is up to about 25–30 cm, two
times the length from the femoral artery to the anterior superior iliac spine
Advantage Donor site can be sutured closed primarily and isn’t obvious. Skin fl ap is comparatively thin, and large skin
fl ap can be harvested.
Disadvantage Often variations in the path of the superfi cial circumfl ex iliac artery. The vascular pedicle is short and
thin (0.5 mm). Fat tissue in the medial side of the fl ap (medial side of the femoral artery) is thick
Caution When detaching the medial side of the anterior superior iliac spine, if going too deep, the lateral cutaneous
nerve of the thigh can be damaged, so care is required.
24 Fat Graft

657
Operation Procedures
Fig. 24.1 Procedure 1: Painful atrophy of the subcutaneous tissue
present following bruising to the right medial lower leg
Fig. 24.2 Procedure 2: An inguinal fl ap is designed in the inguinal
region
Free Vascularized Groin Fat Graft (Level of Diffi culty: 4)

658
Fig. 24.3 Procedure 3: The superfi cial circumfl ex iliac artery is
detached and identifi ed from where it branches off from femoral blood
vessels. (Elevated skin fl ap →( thick arrow ), artery→( medium arrow ),
vein → ( narrow arrow ))
Fig. 24.4 Procedure 4: The fascial fat fl ap is elevated from the distal
end of the fl ap. For the area distal of the anterior superior iliac spine, the
fl ap is dissected with fat, and for the area proximal, the fl ap is dissected
under the sartorius muscle fascia


24 Fat Graft

659
Fig. 24.5 Procedure 5: The harvested inguinal fl ap. As much of the
peripheral fat was included as possible
Fig. 24.6 Procedure 6: The posterial tibial blood vessels are identifi ed
in the graft bed

Free Vascularized Groin Fat Graft (Level of Diffi culty: 4)

660
Fig. 24.7 Procedure 7: End-to-side anastomosis is conducted for
the arteries and side-to-side anastomosis for the veins
Fig. 24.8 Procedure 8: A bolster suture is conducted to spread
the transplanted fat over a wide area to prevent formation of a bump
Note Unless suffi cient dissection is performed of the pocket in which
the fat fl ap is inserted, then an uneven deformation will form after sur-
gery, so care is required.

24 Fat Graft

661
Column
For what, for whom
An event that happened 20 years ago:
After telling a middle-aged man in the emergency ward that he would need to be hospitalized for about one week,
he replied in a faint voice that he couldn’t stay in hospital. His right thumb had been amputated from the base of the
nail. At the time I had successfully re-attached a number of fi ngers, but I didn’t have a case of an amputation as distal
as the base of the nail.
“If you aren’t hospitalized then I won’t be able to reattach your fi nger. If there is something that needs to be done,
you can get your family to take care of it.”
I walked out of the emergency ward without looking him in the face and began negotiating with the operating room
staff. That was because I needed to get the understanding of the head nurse and the anesthesiologist in charge of the
operating room to use the operating room outside normal hours.
My supervisor came to look in on me during the surgery. Although it is something I could do now without raising
a sweat, at the time I hadn’t the knowledge or the skill to reattach the vein in the fi ngertip, and I barely managed to
attach a single thin artery. I can still clearly remember the freshly fallen snow piled up on the sidewalk as I walked
outside the hospital toward the pharmacy as the sun was rising the next morning.
For the next 4 days I slept at the hospital, letting blood out of the fi nger every few hours, battling congestion of the
reattached fi nger. At that time there weren’t any medical leeches, so all I could do was prick it with a needle to let the
blood out, and then cover the fi nger with a saline gauze dressing containing heparin.
It was on the morning of the third day when the patient asked me with downcast eyes whether he could return home
for a few hours. I reacted angrily, telling him that this was the most crucial time, and I probably added a sermon about
the importance of the thumb to the hand. He never told me the reason, but afterwards the nurse found out that he wanted
to feed his bird.
The fi nger fi nally took. Several weeks later when he visited as an outpatient, I probably felt a little exalted to see my
fi rst successful case of a reattachment from the base of the nail. But when I asked him how his bird was, he simply gave
a vague expression and never answered. As I watched him leave the examination room without expressing a word of
gratitude, it occurred to me that he must live alone. The photo of that valuable reattachment case is now lost somewhere
and I haven’t tried to fi nd it.
Since I’ve reached his age my thinking has changed. Now, I’d probably forgive him if he were to choose his bird
over his thumb.
Free Vascularized Groin Fat Graft (Level of Diffi culty: 4)

663
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_25
Muscle Graft
Basic Principles
Free muscle graft is indicated for reconstruction in cases where the muscle has been lost or
has become paralyzed in the forearm or face. However, if tendon transfer can be conducted
for reconstructing the function of the arm, a free muscle graft is not the fi rst option.
Muscles consist of pennate muscles that have a large contractile force but short contrac-
tion length (for example rectus femoris muscle) and fusiform muscles that have long muscle
fi bers and a long sliding distance (gracilis muscle, pectoralis major muscle, latissimus dorsi
etc.). Of these two, fusiform muscles with the long sliding distance are suitable for recon-
struction of the fl exor muscles of the forearm, and the gracilis muscle which possesses
tendon characteristics is the fi rst option.
Selectable Flaps and Surgical Procedures
• Gracilis muscle • Latissimus dorsi muscle • Serratus anterior muscle
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
25

664
Free Vascularized Gracilis Muscle Graft (Level of Diffi culty: 4)
Information
Vascular pedicle Medial circumfl ex femoral artery
Nerve Anterior branch of obturator nerve (It runs 2 cm forward to the vascular pedicle)
Advantage As long as the muscle can be identifi ed, detachment is simple, and the vascular pedicle is suffi ciently thick
Disadvantage The blood fl ow to the skin above the muscle is supplied by the muscle, however the distal 1/3 is supplied
by the sartorius muscle and the border is not distinct
Caution Where a musculocutaneous fl ap is desired, design the fl ap with the hip joint in the fully open extended posi-
tion. If designed with the hip joint or knee joint in the bent position, the design will be forward of the desired area,
which can lead to necrosis of the skin area, so care is required.


25 Muscle Graft

665
Operation Procedures
Fig. 25.1 Procedure 1: An epithelioid sarcoma is present on the left
medial forearm. 8 years have passed since onset and four resections
have been conducted
Fig. 25.2 Procedure 2: Excluding the pronator teres muscle and fl exor
carpi ulnaris muscle, all of the fl exor muscle groups are removed from
the head to the attachment area, and the median nerve resected up to
5 cm from the margin of the tumor. A total of 8 cm of the median nerve
is lost


Free Vascularized Gracilis Muscle Graft (Level of Diffi culty: 4)

666
Fig. 25.3 Procedure 3: The full length (33 cm) sural nerve with the
peroneal artery as the vascular pedicle is harvested from the lower leg
together with the fi bula fl ap
Fig. 25.4 Procedure 4: The pedicled sural nerve is transferred to the
forearm and cut into 3 sections and transplanted to the median nerve
defect area as a cable graft. Side-to-side anastomosis is conducted of
the peroneal blood vessels to the anterior interosseous blood vessels
25 Muscle Graft

667
Fig. 25.5 Procedure 5: A 10 × 18 cm gracilis muscle containing skin is
harvested from the left medial thigh
Fig. 25.6 Procedure 6: The distal part of the gracilis muscle was
sutured to the fl exor tendons at the carpal tunnel and the proximal part
was sutured to the periosteum of the ulna bone near at the cubital joint.
The medial circumfl ex femoral artery and vein were anastomosed to the
radial artery ad vein and the obturator nerve was sutured to the branch
of median nerve
Note The line connecting the pubic tubercle to the medial condyle of
tibia when the hip joint and knee joint are extended is the center axis of
the gracilis muscle, however the adductor longus muscle is the fi rst to
appear directly beneath the subcutaneous tissue, so it is easy to make an
error. When the incision is continued distally, the sartorius muscle is
seen running diagonally, and when this is pulled forward, the gracilis
muscle can be seen behind it.
Note Photos in the Information box of the front page shows the fi nal
condition at 10 years after surgery.
(Photos partially reproduced from Hirase Y, Kojima T, et al.
Epithelioid sarcoma of the arm: Three treatment cases. Japanese Society
for Surgery of the Hand . 1996, 12:919–921; Kinoshita Y, Hirase Y.
Reconstruction of arm following tumor resection: Reconstructive sur-
gery following tumor resection.- Recent advancements Tai, Y (editing),
Kokuseido Tokyo 1996; 145–153)
Free Vascularized Gracilis Muscle Graft (Level of Diffi culty: 4)

668
Tips
Design the skin fl ap with the hip joint and knee joint extended.
When the hip joint and knee joint are extended, the gracilis muscle is tight and straight and it is possible to design
the skin fl ap correctly over the skin. However, if the hip joint or knee joint is bent, the gracilis muscle slackens and
moves downward. If the skin fl ap is marked out in this position it is too far forward of the correct position.
This is the reason why problems often occur with skin fl aps of the gracilis muscle.


25 Muscle Graft

669
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6
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Chapter 11: Mediastinitis, Pyothorax,
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Chapter 13: Gluteal, Sacral, Trochanteric Region
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Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh fl ap. A reliable
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Chapter 14: Patella Region
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Chapter 15: Anterior Lower Leg Region
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mius rotational fl ap for treatment of chronic knee extensor mecha-
nism defi ciency in patients with and without total knee arthroplasty.
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Kuokkanen HO, Tukiainen EJ, Asko-Seljavaara S. Radical excision and
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Mathes SJ, Alpert BS, Chang N. Use of the muscle fl ap in chronic
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Willcox TM, Smith AA, Beauchamp C, et al. Functional free latissimus
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Chapter 16: Distal 1/3 of Lower Leg
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Barwick WJ, Goodkind DJ, Serafi n D. The free scapular fl ap. Plast
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Gilbert A, Teot L. The free scapular fl ap. Plast Reconstr Surg.
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Hallock GG. Anatomic basis of the gastrocnemius perforator-based
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Hamilton SG, Morrison WA. The scapular free fl ap. Br J Plast Surg.
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artery fl ap. Plast Reconstr Surg. 1994;93:1012–20.
Hing DN, Buncke HJ, Alpert BS. Application of the extensor digitorum
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Huisinga RL, Houpt P, Dijkstra R, et al. The distally based sural artery
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Kojima T. Resurfacing exposed bone of the lower leg using muscle fl ap
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Kojima T, Kohno T, Ito T. Muscle fl ap with simultaneous mesh skin
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Landi A, Sorangi O, Monteleone M. The extensor digitorum brevis
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Chapter 18 and 19: Calcaneal, Plantar Region
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plantar fl ap to cover the defects of the plantar foot, posterior heel,
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Chapter 20: Dorsum and Amputated Foot Stump
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Chapter 21: Dorsum of Toe
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Chapter 22: Nerve Graft & Nerve Transfer
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Chapter 23: Transplantation of Bone & Joint
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Chapter 24: Fat Graft
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contour deformities. Plast Reconstr Surg. 2000;106:10–5.
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Chapter 25: Muscle Graft
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