Kỹ Thuật Thực Hành Trong Phẫu Thuật Ghép Vạt Da

342
Fig. 10.9  Procedure 3: The flap margin is cut and dissected above the
tendon sheath. Although not essential for the thumb, if it is possible to
remain the dorsal branch from the digital artery, it should be retained
Fig. 10.10  Procedure 4: The flap is advanced and Z plasty conducted
along the margin, with wire inserted from the fingertip, fixing the flap
in place. At the tip of the flap, a suture is made with both sides rotated,
creating a bulge at the finger tip from the resultant dog ear
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343
Fig. 10.11  Procedure 5: The nail bed is harvested from the great toe
Fig. 10.12  Procedure 6: The harvested nail bed is transplanted
onto the defect nail bed on the transferred flap and sutured using an
absorbable suture thread
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344
Fig. 10.13  Procedure 7: A tie-over bolster dressing is applied to the
nail bed
Fig. 10.14  Procedure 8: Regeneration of the nail is observed over a 6
month period. The nail bed forms a dry crust and eventually peels off
due to the formation of a normal nail. (Some photos reproduced from
“Injuries to distal finger area and nail/Trauma Cosmetic Surgery” by
Yuichi Hirase, edited by Masaki Ando, p.115–119, Kokuseido
Publishing, Tokyo, 2007; “Injuries to distal finger area (6) Treatment
Using Tissue Flaps” by Yuichi Hirase, MB Orthop 20: 81–87, 2007;
“Reconstruction of distal finger area using Graft-on flap method” by
Yuichi Hirase; The Japanese Journal of Plastic Surgery 50: 743–748,
2007)
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Tips
Why is extended volar advancement flap the first choice for volar reconstruction of the thumb?
For advancement flap of other fingers, the vascular pedicle runs parallel with the movement direction of the flap and
expansion of the blood vessel is limited. In the case of an extended volar advancement flap, the vascular pedicle enters
from the lateral ulnar side of the flap, so there is little expansion of the vascular pedicle due to advancement of the flap.
Therefore, the larger the flap, the greater the range of coverage from the stretching of the flap, and if a VY plasty is
conducted on the base flap, the flap movement distance as an island flap increases considerably. If a VY plasty is con-
ducted on an extended volar advancement flap, it is possible for the flap to move 3 cm.
In the photo the vascular pedicle of the flap can be seen bound by a blood vessel silicon band, and it enters the flap
from the lateral ulnar side.
Split-Thickness Nail Bed Graft and Digital Arterial Flap (Graft-on Flap Method) (Level of Difficulty: 3)

346
Distal Phalanx Amputation of Thumb: Wrap-­Around Flap (Level of Difficulty: 4)
Information
Indication When there is a dorsal oblique amputation at the level of the IP joint and there is sufficient skin on the volar
side. Arthrodesis is performed in cases of a defect IP joint.
Vascular pedicle First dorsal or plantar metatarsal artery and subcutaneous vein
Size The entire nail of the great toe is transplanted for the reconstruction of the thumb nail.
Anastomotic vessel For reconstruction of the thumb, anastomosis of the first dorsal metatarsal artery and radial artery
is conducted distal of the snuff box, and of the plantar metatarsal artery to the digital artery on the volar side.
Sensation reconstruction The plantar digital nerve is included when harvesting the flap and sutured to the digital
nerve. It is possible to include the deep peroneal nerve when harvesting the flap, but suturing is not necessary if there
is insufficient diameter of the dorsal branch of the radial nerve on the graft bed.

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Operation Procedures
Fig. 10.15  Procedure 1: First, a longitudinal incision is made in the
direction of the dorsum of the foot from the first web space. The vein in
the direction of the second toe is ligated, moving deeper detaching the
tissue. This enables confirmation of the first dorsal metatarsal artery
and deep peroneal nerve (in rare cases the first dorsal metatarsal artery
may be weak or lost). The first dorsal metatarsal artery is dissected
distally, and the first/second digital toe artery and the plantar metatarsal
artery branch off and are secured. The second digital toe artery is short
ligated and severed, and a slightly long section of the plantar metatarsal
artery is secured and ligated/severed. At the same time the parallel toe
nerve is also harvested. The bone cortex of the distal phalanx is divided
and included in the flap. At this time, take care not to damage the attach-
ment area of the long extensor tendon. The flap is elevated with two
subcutaneous veins included
Refer to Section of  “Nail Reconstruction/Digital arterial flap &
partial toe transfer” in Chap. 10
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348
Fig. 10.17  Procedure 3: Dissection is conducted proximally up to the
dorsal metatarsal artery (normally it is not necessary to dissect up to the
dorsal pedis artery)
Fig. 10.16  Procedure 2: As far as possible the fat surrounding the vas-
cular nerves is removed as they are detached. As a result, the flap
includes part of the distal phalanx, the two arteries of the dorsal and
plantar metatarsal arteries, and three nerves, which are the bilateral
digital toe nerves and deep peroneal nerves, and two subcutaneous
veins
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a
b
Fig. 10.18  (a, b) Procedure 4: The bone is wired in place and end-to-
end anastomosis is conducted of the dorsal metatarsal artery to the
radial artery. Anastomosis is conducted on the two subcutaneous veins.
If possible the deep peroneal nerve is sutured to the dorsal branch of the
radial nerve, however the dorsal branch of the radial nerve can at times
be too thin to perform a suture. If possible, an additional anastomosis is
conducted between the plantar metatarsal artery and digital toe artery
on the volar side, and the digital toe nerve is sutured to the finger nerve
Note  In this case, the IP joint could not be retained and arthrodesis was
conducted.
Distal Phalanx Amputation of Thumb: Wrap-Around Flap (Level of Difficulty: 4)

350
Digital Phalanx Amputation of Thumb: Volar Advancement Flap & Wrap-­around Flap
(Level of Difficulty: 4)
Information
Indication: In cases where the bone is amputated at the IP joint level, but only where the amputation is a transverse
amputation or a diagonal amputation toward the volar side, and there is a lack of skin on the volar side. For an amputa-
tion proximal to the IP joint, IP arthrodesis is conducted. Requirements are that there is no damage on the volar side
and a volar advancement flap can be created.
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Operation Procedures
Fig. 10.19  Procedure 1: The volar flap is designed extending to the
thumb volar thenar
Fig. 10.20  Procedure 2: The bilateral neurovascular bundle is left in
place, and the thumb volar flap is elevated
Digital Phalanx Amputation of Thumb: Volar Advancement Flap & Wrap-around Flap (Level of Difficulty: 4)

352
Fig. 10.21  Procedure 3: The thumb volar flap is advanced and the
volar fingertip is reconstructed
Fig. 10.22  Procedure 4: The wrap-around flap is designed
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Fig. 10.24  Procedure 6: The distal phalanx contained in the flap is
wired to the distal phalanx of the thumb at the graft site. The dorsal
metatarsal artery and subcutaneous vein are anastomosed to the radial
artery and subcutaneous veins distal to the snuff box. Skin is grafted
over the snuff box, making sure not to place pressure on the vascular
pedicle
Fig. 10.23  Procedure 5: The flap is elevated with the dorsal and plan-
tar metatarsal arteries, subcutaneous veins, lateral digital toe nerve and
part of the distal phalanx attached
Digital Phalanx Amputation of Thumb: Volar Advancement Flap & Wrap-around Flap (Level of Difficulty: 4)

354
Fig. 10.25  Procedure 7: Anastomosis of the plantar metatarsal artery
is conducted with the digital artery on the ulna side of the thumb, and
the lateral digital nerve of the great toe is sutured to the ulnar digital
nerve of the thumb
Fig. 10.26  Procedure 8: Artificial dermis was applied to the flap donor
site, and a skin graft conducted 2 weeks later. During that time the IP
joint was temporarily wired in place
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Tips
In cases where amputation occurs close to the IP joint of the thumb, the bone is fixed in a slightly bent position
In cases of amputation close to the IP joint of the thumb, in some cases fixing of the IP joint is unavoidable, but if
the MP joint has a normal range of motion, there is little restriction to the patient’s lifestyle. However, an effort should
be made to fix the bone in a slightly bent position (10–20°) so that it is easier to pinch objects. Care must be taken to
avoid hyperextension fixation of the IP joint.
Digital Phalanx Amputation of Thumb: Volar Advancement Flap & Wrap-around Flap (Level of Difficulty: 4)

356
Digital Arterial Flap and Partial Toe Transfer (Level of Difficulty: 4)
Information
Digital flap: For the long fingers, an oblique triangular flap or Heuston’s flap is often selected, while for the thumb, a
volar advancement flap is often selected. The partial toe flap is elevated with the necessary amount of nail, as well as
the digital toe artery, digital toe nerve and subcutaneous vein, with small bone fragment attached.
Advantages: It is possible to reduce the size of the nail flap harvested from the foot by combining it with the digital
flap created in the finger, preventing damage to the plantar weight-bearing region. The reduced damage to the foot
leads to a faster recovery. Because it is possible to reconstruct the fingertip using two flaps, there is sufficient amount
of tissue and the reconstructed fingertip doesn’t become too thin.
Disadvantages: It is a requirement that the digital arterial flap can be elevated within the finger. If it is not possible,
then a twisted wrap-around flap is indicated, however the technique is complicated.
Caution: Of the two digital arteries, one is used for the digital artery flap, so in order to retain blood circulation of
the finger, it is desirable that the anastomosis position is distal to the PIP joint. In the case of performing anastomosis
proximal to the digital base, it is safer to transfer the digital artery of the neighboring finger and then perform
anastomosis.
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Operation Procedures
Refer to Section of  “Reconstruction of the fingertip/Oblique triangular
flap modification” in Chap. 8
Note  At the same time, the opposing digital artery distal to the PIP
joint in the center of the middle phalanx is prepared as the anastomotic
artery. In the case that the anastomotic site is proximal to the finger
base, the digital artery of the neighboring finger is detached and trans-
ferred for use in order to preserve the circulation of the finger.
Fig. 10.28  Procedure 2: The oblique triangular flap is elevated and
transferred to the fingertip
Fig. 10.27  Procedure 1: The oblique triangular flap is designed
Digital Arterial Flap and Partial Toe Transfer (Level of Difficulty: 4)

358
Note  In consideration of combining with the flap on the finger, a zig-
zag pattern is used along the margin.
Fig. 10.29  Procedure 3: The flap is designed with the necessary
amount of soft tissue and nail on the lateral great toe
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359
Fig. 10.31  Procedure 5: The distal phalanx is divided from the toe tip,
with 1/3 of the bone attached to the flap
Fig. 10.30  Procedure 4: The digital toe artery (or dorsal/plantar meta-
tarsal artery), digital toe nerve, and subcutaneous veins of the flap are
secured, proceeding from the first web space
Note  In this situation, pay attention not to break the bone in the area
that connects with the nail matrix. In the case that it is difficult to attach
to the flap, it is possible to harvest by amputating up to the IP joint,
however it is necessary to remove the projecting portion of the distal
end of the proximal phalanx bone, return the collateral ligament to its
original position and suture the surrounding area.
For the attachment section of the extensor pollicis longus muscle
tendon, be careful not to sever the tendon.
Digital Arterial Flap and Partial Toe Transfer (Level of Difficulty: 4)

360
Fig. 10.32  Procedure 6: The nail flap with short pedicle artery, vein
and nerve attached is harvested
Fig. 10.33  Procedure 7: The distal phalanx is wired in place. The nail
flap and the finger flap are combined and sutured. At this point, anasto-
mosis is conducted between the digital toe artery and the finger artery at
the PIP joint region, and the digital toe nerve sutured to the finger nerve
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361
Fig. 10.34  Procedure 8: A mattress suture is conducted between the
finger flap and the nail flap, and a perionychium created. Using a subcu-
taneous tunnel, the artery on the skin flap is anastomosed to the subcu-
taneous artery at the dorsal base of the finger
Fig. 10.35  Procedure 9: Artificial dermis is attached to the flap donor
site. The surface film is peeled back after 1 week, and if granulation
tissue is prepared, then a skin graft is performed under local anesthesia
2–3 weeks later
Note  If there is a skin defect, a skin graft is added.
Digital Arterial Flap and Partial Toe Transfer (Level of Difficulty: 4)

362
Tips
Conduct skin graft after granulation tissue becomes prepared in the artificial dermis
If granulation tissue is sufficiently prepared in the artificial dermis before conducting the skin graft, then depressive
deformity that was previously seen in cases involving the IP joint of the great toe, almost completely disappears.

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Fingernail Reconstruction: Twisted Wrap-Around (TWA) Flap (Level of Difficulty: 5)
Information
Vascular pedicle: Dorsal metatarsal artery (or plantar metatarsal artery), subcutaneous vein (in the case of two flaps,
one is secured for each flap)

Fingernail Reconstruction: Twisted Wrap-Around (TWA) Flap (Level of Difficulty: 5)

364
Operation Procedures
Fig. 10.36  Procedure 1: Fingertip amputation distal to DIP joint
Fig. 10.37  Procedure 2: Fingertip cut in cross shape
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365
Fig. 10.38  Procedure 3: Flap shape reflected in accordance with the
banana splitting method and the stump of the digital nerve exposed
Fig. 10.39  Procedure 4: The design for harvesting two wrap-around
flaps is created from the great toe and second toe. The nail is harvested
from the great toe, and the second flap is designed on the second toe for
combining with this
Fingernail Reconstruction: Twisted Wrap-Around (TWA) Flap (Level of Difficulty: 5)

366
Fig. 10.40  Procedure 5: The two flaps are elevated with the dorsal
metatarsal artery (or plantar metatarsal artery). Part of the distal pha-
lanx is attached to the nail flap side (great toe side), and a subcutaneous
vein and digital toe nerve included in each of the two flaps
Fig. 10.41  Procedure 6: The bone is wired in place. Anastomosis of
the dorsal metatarsal artery is conducted to the digital artery at the fin-
ger base. If possible, an additional anastomosis is conducted using the
plantar metatarsal artery on the contralateral distal end of the digital
artery. The digital toe nerves included in each of the flaps are sutured to
the bilateral digital nerves
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367
Fig. 10.43  Procedure 8: An artificial dermis is applied to the flap
donor site, and a skin graft is conducted 2–3 weeks later
Fig. 10.42  Procedure 7: The two flaps are combined, and the subcuta-
neous veins for each are anastomosed to the subcutaneous veins on the
dorsal side of the finger base via a subcutaneous tunnel
Fingernail Reconstruction: Twisted Wrap-Around (TWA) Flap (Level of Difficulty: 5)

368
Fig. 10.44  Procedure 9: Two months after the transplant, it is possible
to remove part of the soft tissue and conduct touch-up surgery
Note  Photo is 6 months after reconstruction.
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369
Tips
Curve deformity may remain on the great toe
Slight curve deformity may remain at the IP joint of the great toe. This does not cause a hindrance to daily lifestyle,
however it is necessary to explain this to patients in advance, especially those active in sports.

Fingernail Reconstruction: Twisted Wrap-Around (TWA) Flap (Level of Difficulty: 5)

370
Tips
Reconstruction of the whole finger using an extended TWA flap
Using an extended TWA flap combined with a dorsal pedis flap, it is also possible to reconstruct a whole finger.

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371
Vascularized Nail Bed Graft (Level of Difficulty: 4)
Information
Vascular pedicle Digital toe artery and subcutaneous vein
Indication In cases of amputation where more than 2/3 of the distal phalanx is lost, but the nail matrix remains intact.
A nail bed containing bone without the nail matrix is transplanted as vascularized tissue

Vascularized Nail Bed Graft (Level of Difficulty: 4)

372
Operation Procedures
Fig. 10.45  Procedure 1: Case of fingertip bone/soft tissue defect and
nail deformity due to nail bed defect
Fig. 10.46  Procedure 2: The design of the hemi pulp flap including the
nail bed and bone of the distal part of the great toe is created
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373
Fig. 10.47  Procedure 3: Flap containing vascularized pedicle with nail
bed and bone is harvested in accordance with the hemi pulp flap
procedure
Refer to Section of  “Fingertip reconstruction/Hemi pulp transfer”
in Chap. 8
Vascularized Nail Bed Graft (Level of Difficulty: 4)

374
Fig. 10.49  Procedure 5: Growth of the nail is observed for the next
6 months
Fig. 10.48  Procedure 4: Bone is wired into place and nail bed area is
sutured using an absorbable suture. Anastomosis is conducted of the
digital toe artery to the digital artery and subcutaneous vein to the digi-
tal dorsal subcutaneous vein, and the digital toe nerve is sutured to the
digital nerve
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© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_11
Reconstruction of Mediastinitis/
Pyothorax/Abdominal Incisional Hernia
Selectable Flaps for Mediastinitis / Pyothorax
• Pectoralis major muscle fl ap
• Rectus abdominis muscle fl ap
• Latissimus dorsi musculocutaneous fl ap
Selectable Methods for Abdominal Hernia Reconstruction
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.
11

Components
Separation
Method
Hernia is located medially;
less than 15cm wide
One side of rectus
abdominis muscle lost
Hernia is
located laterally
Hernia is located
in the center but is
greater than 15cm wide
External oblique
turn-over fascial
flap method
Tensor fascia
lata flap method

376
Mediastinitis: Pectoralis Major Muscle Flap (Level of Diffi culty: 2)
Information
Vascular pedicle Thoraco-acrominal artery, Lateral thoracic artery
Indication In cases where the range of osteomyelitis of the sternum is narrow, and amount of defect bone in the center
of the sternum following debridement is comparatively superfi cial.


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

377
Operation Procedures
Fig. 11.1 Procedure 1: Subcutaneous fi stula that developed after heart
surgery. Small amount of gentian violet is injected into the fi stula to dye
the fi stula area
Fig. 11.2 Procedure 2: The stained area is then completely debrided. If
the necrotic section of the fi stula and sternum is small, and the tissue
vessels are not large, then a pectoralis major muscle transfer is
indicated
Note If there is a large tissue defect, then a latissimus dorsi musculo-
cutaneous fl ap is indicated, and if the defect is deep, then a rectus
abdominis muscle fl ap transfer is indicated.
Mediastinitis: Pectoralis Major Muscle Flap (Level of Diffi culty: 2)

378
Fig. 11.3 Procedure 3: The section of pectoralis major muscle attached
to the sternum is carefully and broadly detached and the full length of
the muscle margin of pectoralis major is completely removed. A mat-
tress suture is performed to both sides to incorporate the fl ap into the
tissue defect area. By repeating uniformly for the whole length and con-
ducting several layers of suturing, the fl ap gradually fi lls the tissue
defect area
Fig. 11.4 Procedure 4: A continuous suction drain is inserted subcuta-
neously above the fl ap, and the wound closed


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

379
Tips
Make sure to conduct suffi cient debridement of the infectious wound
Dyeing by injecting gentian violet into the fi stula is essential to make sure suffi cient debridement is conducted of
infectious wounds.


Mediastinitis: Pectoralis Major Muscle Flap (Level of Diffi culty: 2)

380
Mediastinitis: Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Right superior epigastric artery and internal thoracic artery
Size Full length of rectus abdominis muscle
Indication For fi lling the lost tissue following debridement of infectious sternum in lower part of chest.
Disadvantage Often insuffi cient amount of tissue to cover/fi ll upper chest in vicinity of sternoclavicular joint. In such
cases a pectoralis major muscle fl ap or latissimus dorsi muscle fl ap transfer is also carried out.
Caution In many cases involving heart surgery, the left internal thoracic artery has already been used, so elevate the
right internal thoracic artery for use as the muscle fl ap pedicle.


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

381
Operation Procedures
Fig. 11.5 Procedure 1: A subcutaneous fi stula was recognized in the
vicinity of the hypochondrium following heart surgery
Fig. 11.6 Procedure 2: Gentian violet is injected from the fi stula to dye
the area, and the fi stula is completely debrided


Mediastinitis: Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)

382
Fig. 11.8 Procedure 4: The left internal thoracic artery had already
been used in heart surgery so the rectus abdominis muscle fl ap with
monitoring skin was raised from the right side. The rectus abdominis
muscle is severed toward the periphery with suffi cient length in consid-
eration of the overlap margin, and the deep inferior epigastric blood
vessels running along the rear of the fl ap ligated and cut. The fl ap is
rotated to the proximal side
Fig. 11.7 Procedure 3: Although the range of the fi stula is narrow, it is
deep, so fi lling using a rectus abdominis muscle fl ap is planned, and a
longitudinal incision extended to the abdominal region
Note If the skin fl ap is not attached, the muscle fl ap is turned over to
the proximal side.


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

383
Refer to Section of “Reconstruction of mediastinitis, pyothorax,
abdominal incisional hernia/Abdominal incisional hernia: Components
Separation Method” in Chap. 11
Please also see the Tips “ Apply the Components Separation Method
to close up the donor site ”.
Fig. 11.9 Procedure 5: The tissue defect area beneath the fi stula is
fi lled using the muscle fl ap section, and the surrounding area sutured in
place
Fig. 11.10 Procedure 6: The entire length of the bilateral external
oblique muscle is cut longitudinally in accordance with the components
separation method, and the medial margin of the affected external
oblique muscle sutured to the unaffected contralateral rectus abdominis
muscle, and the donor site closed


Mediastinitis: Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)

384
Fig. 11.11 Procedure 7: A continuous suction drain is inserted subcu-
taneously in the chest/abdomen region, and the wound closed

11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

385
Tips
Apply the Components Separation Method to close up the donor site
When closing the donor site after removing the rectus abdominis muscle, historically, various methods have been
utilized for preventing a post-operative hernia. However application of the Components Separation Method is the pre-
ferred surgical procedure for reconstructing abdominal incisional hernia.
By broadly detaching the subcutaneous abdominal wall, and cutting the entire length of the bilateral external oblique
muscle longitudinally, it is easy to maneuver the contralateral rectus abdominis muscle toward the center. The unaf-
fected contralateral rectus abdominis muscle is sutured to the affected external oblique muscle. A tight suture is con-
ducted using a non-absorbable suture.


Mediastinitis: Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)

386
Mediastinitis: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Blood vessel Thoracodorsal artery (the circumfl ex scapular artery is ligated, and detachment conducted up to the sub-
scapular artery)
Size (muscle fl ap) 40 cm wide, 40 cm long; if including up to lumbosacral fascia, it is possible to remove full length
of up to 60 cm
Advantage Good circulation, vascular pedicle is thick and long, technique is comparatively easy. Can freely design
skin on muscle fl ap
Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus
dorsi muscle cause bulkiness preventing it from being used as a musculocutaneous fl ap, and therefore a skin graft is
required (1.5 times mesh skin graft)
Caution The muscle ends are also cut, creating a complete muscle island fl ap. Do not use an electrical scalpel after
cutting the muscle ends. The space following removal of the latissimus dorsi muscle can cause a painful seroma, so
several continuous suction drains should be put in place.


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

387
Operation Procedures
Fig. 11.13 Procedure 2: Gentian violet is injected from 2 locations in
the fi stula
Fig. 11.12 Procedure 1. Contrast radiography of fi stula prior to sur-
gery. The fi stula reaches to the substernum space, but doesn’t extend to
the pericardium. (Case photos reproduced from Reconstruction of tho-
racic wall/Treatment of mediastinitis post-thoracotomy by Yuichi
Hirase et al. Operation 57: 1158–1162, 2003)


Mediastinitis: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)

388
Fig. 11.14 Procedure 3: Debridement is carried out. A deep osteomy-
elitis of sternum, part of which extended to the pericardium surface is
recognized. The wound is packed with gauze, sealed using adhesive
drape, and position changed to the lateral recumbent position
Fig. 11.15 Procedure 4: The muscle ends of the latissimus dorsi mus-
cle are cut, creating a muscle island fl ap with a complete neuro vascular
pedicle. A drain is inserted and the donor area closed off. The muscle
fl ap is placed in the subcutaneous tunnel created in the direction of the
precordial region. Position changed back to supine position


11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia

389
Fig. 11.17 Procedure 6: The site is fi lled using the latissimus dorsi
muscle so as to wrap up the infectious pericardium surface
Fig. 11.16 Procedure 5: The latissimus dorsi muscle fl ap is transferred
to the anterior chest through the precordial subcutaneous tunnel


Mediastinitis: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)

390
Fig. 11.18 Procedure 7: The muscle fl ap is sutured to the surrounding
area, a continuous suction drain inserted and the site closed

11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia