Summary of Surgical Flap Classification and Applications
Surgical Flap Classification & Applications for Students
Introduction
Reconstruction of the thorax and mediastinum addresses defects after infection, tumor resection, trauma, or radiation. These reconstructions restore chest wall stability, obliterate dead space, protect intrathoracic organs, and promote wound healing. This guide focuses on practical choices of regional and distant tissues used for mediastinal and chest wall reconstruction, indications, advantages, and limitations.
Definition: Mediastinal reconstruction is the surgical restoration of the central thoracic compartment (mediastinum) and adjacent chest wall to obliterate infected or dead spaces and to re-establish protection and structural support for intrathoracic organs.
Key anatomical and clinical considerations
- Prior surgeries (median sternotomy, thoracotomy) and use of the internal mammary artery (IMA) for coronary bypass alter flap choices and perfusion.
- Infection after median sternotomy, although infrequent (reported incidence ~0.4% to 6.9%), carries high morbidity and mortality; early flap coverage reduces complications.
- Choose flaps that reliably fill dead space, reach the defect, and bring healthy vascularized tissue into contaminated wounds.
Common reconstructive options for mediastinum and anterior chest
Pectoralis major
- Primary regional muscle for mediastinal and anterior chest coverage. Use when feasible for midline sternal defects.
- Vascular supply: thoracoacromial pedicle for standard transposition; perforators from the internal mammary vessels permit a turnover design.
- Techniques:
- Standard pedicled transposition based on the thoracoacromial artery.
- Turnover (reverse) flap based on segmental perforators from the internal mammary vessels.
- Modified turnover that preserves the lateral one-third of the muscle (maintains anterior axillary fold and some function).
- Clinical notes:
- Can be used unilaterally or bilaterally depending on defect size.
- Often first-line for sternal wound infections after median sternotomy.
Definition: Turnover flap is a flap design in which the muscle is rotated over its long axis to fill a dead space while preserving segmental blood supply from perforators.
Rectus abdominis
- Reliable source for inferior mediastinal or lower sternal coverage and for filling large dead spaces.
- Its use depends on the status of the internal mammary arteries because the superior epigastric artery is the continuation of the internal mammary artery below the sternum.
- Clinical considerations:
- If the internal mammary artery was harvested for coronary bypass, perfusion to a superiorly based rectus flap on that side may be compromised; collateral circulation often suffices but must be assessed.
- Can be used as a muscle or musculocutaneous flap to provide bulk and reach inferior mediastinum.
Omentum
- Useful when chest wall muscles are unavailable or inadequate, especially for contaminated fields where well-vascularized tissue is needed to control infection.
- Can be based on the right or left gastroepiploic vessels.
- Considerations:
- Risk of contaminating the peritoneal cavity means it is generally reserved for cases where pectoralis and rectus are not options.
- Laparoscopic harvest reduces abdominal wall morbidity.
Latissimus dorsi
- Valuable alternative for upper mediastinal or extensive anterior chest wall defects.
- Advantages:
- Large surface area and bulk; donor site remote from infected anterior chest.
- Can be transferred pedicled or as a free microvascular flap.
- Disadvantages:
- Harvest from the back is less convenient in some settings.
- Prior thoracotomy may compromise pedicle reliability but does not absolutely preclude use; portions of the muscle can remain viable depending on prior incisions.
- Special designs:
- Upper third (thoracodorsal pedicle) for superior anterolateral defects.
- Lower two-thirds as a reverse latissimus flap based on paraspinal perforators for inferolateral or posterior defec
Zaregistruj se pro celé shrnutíAlready have an account? Sign in
Thorax Mediastinum Reconstruction
Klíčové pojmy: Pectoralis major is first-line for sternal-mediastinal coverage, Turnover pectoralis flaps use internal mammary perforators when needed, Rectus abdominis depends on intact superior epigastric circulation (IMA status), Omentum reserved when chest wall muscles are unavailable or contaminated, Latissimus dorsi offers large bulk and can be pedicled or free, Reverse latissimus design uses paraspinal perforators for inferolateral defects, Use mesh or prosthesis for skeletal stability when ribs are resected, Early muscle flap transposition reduces morbidity in sternal wound infections, Serratus anterior is useful for bronchopleural fistula closure and posterior defects, Prior thoracotomy or IMA harvest alters flap selection and perfusion assessment, Laparoscopic omental harvest reduces abdominal wall morbidity, Combine structural support and vascularized soft tissue for large chest wall defects