Serratus Flap with Rib

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Serratus Flap with Rib

Jesse Selber MD Assistant Professor

Department of Plas5c Surgery MD Anderson Cancer Center

Houston, Texas

(2)

Outline

Serratus Anterior Flap

•  INDICATIONS

•  ANATOMY

•  FLAP DISSECTION

•  CLINICAL

EXAMPLES WITH PEARLS

•  COMPLICATIONS

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Serratus Anterior Flap -‐ Indica9ons

Mandible reconstruc5on (Alterna5ve to ﬁbula)

–  When skin is not needed

–  Pt is high performance runner –  No radia5on needed

Midface reconstruc5on

–  Zygoma

–  Orbital ﬂoor

–  Upper dental arch

–  With facial reanima5on

Flap may include fascia, muscle, rib and skin

Poten5al for chimeric ﬂaps oﬀ the

subscapular axis

(4)

Serratus Anterior Flap -‐ Anatomy

•  Origin is ribs 1 -‐ 9 on a line from anterior axillary fold to the anterior superior iliac spine.

•  Inserts on medial border (slips 1-‐4) and medial 5p (slips 5-‐8) of scapula

•  Long Pedicle (up to 15 cm)

(5)

Serratus Anterior Flap -‐ Anatomy

•  Motor Innerva5on: Long thoracic nerve (slightly

posterior to midaxillary line)

•  Blood Supply –

–  Lateral thoracic supplies superior 4 slips

–  thoracodorsal vessel supplies the inferior slips (single branch 72%, two branches 24%)

•  Blood supply to the underlying rib is through muscular

inser5on via periosteum

–  Muscular footprint is

small and anterior

(6)

•  Posi5on supine or lateral

•  Mark anterior border of la5ssimus muscle and line from anterior

axillary fold to ASIS

•  Curvilinear incision from axilla between the two lines

•  Reﬂect the la5ssimus dorsi to

expose the serratus muscle, nerve and pedicle

•  Select slips to be harvested

•  Elevate pedicle away from upper slips and long thoracic nerve

Serratus Flap – Flap Dissec9on

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•  To include bone: the desired rib or ribs are selected (usually 6^th or 7^th rib),

•  Inser5on on scapular 5p is divided

•  Origin on rib is iden5ﬁed, osteotomy site anterior to the origin is marked.

•  Inferior and superior border of rib is

iden5ﬁed and dissec5on is carried sharply onto rib.

•  Subperiosteal dissec5on on posterior surface of the rib, leaving intercostal neurovascular bundle and posterior periosteum and pleura down

•  anterior and posterior osteotomies are performed and the ﬂap is elevated

Serratus Flap – Flap Dissec9on

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•  Pedicle dissec5on proceeds proximally un5l desired length and diameter

•  Lateral thoracic nerve above the

harvested ﬂap and thoracodorsal nerve are spared

•  Dissec5on may be taken up to axillary vessels including subscapular vessels for maximal length (up to 15cm, arterial diameter up to 4mm)

Serratus Flap – Flap Dissec9on

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Case 1: Serratus with rib

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Case 2: Serratus w rib

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Serratus -‐ Pearls

•  Harvest lower 3 slips only to avoid winging

•  Subscapular system ideal for chimeric ﬂaps (LD, Serratus, scapula, rib, scapular, parascapular etc.)

•  Good alterna5ve to the ﬁbula when skin is not needed, or pa5ent needs to run hard

•  Pedicle overlies the muscle – unique to this ﬂap

•  Subperiosteal dissec5on on posterior surface

•  Detect and repair pneumothorax

•  Footprint of muscle on bone is small – do not disrupt

•  Assure adequate 5ssue availability to cover anterior osteotomy site of rib ader ﬂap inset as muscle origin will be at edge of osteotomy

•  Avoid long thoracic nerve injury

•  Inconspicuous donor site

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SGAP/IGAP FLAPS FOR BREAST RECONSTRUCTION

Donald P. Baumann MD Assistant Professor

Department of Plas5c Surgery MD Anderson Cancer Center

Houston, Texas

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SGAP FLAP

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SGAP

Superior Gluteal Artery Perforator Flap

“Firm-‐rounder” breast Prone or lateral posi5on When other op5ons not

possible or pa5ent preference

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SGAP:

Flap Design

•  Landmarks:

•  First/Second third of line between Posterior

Superior Iliac Spine to Greater Trochanter

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SGAP: Flap Design

Dellacroce et al 2005, Guerra 2004

• Center Flap over Perforators which travel Superior & Lateral

• Oblique or Horizontal Flap Design

• Pedicle may be Medial or Lateral,

Lateral pedicle Longer

(26)

Preopera9ve Planning

CT angiography

Perforator mapping Laterality

Skin paddle design

Opera5ve sequence/posi5oning

(27)

SGAP

Very thin

Does not want implant

“cork-‐screw” posi5on for simultaneous mastectomy and ﬂap harves5ng

(28)

SGAP

Preserve all perforators

before deciding which one to keep

Lateral perforator will give longer pedicle length

(29)

SGAP

Micro in lateral posi5on to allow for simultaneous donor site closure

Supine posi5on for insekng and shaping of the breast

(30)

Mul5ple abdominal scars Does not want implant

Courtesy of David Chang, MD

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4 weeks postop.

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•  Right breast ca •  DIEP ﬂap, 3/07

Courtesy of David Chang, MD

(33)

Led prophylac5c mastectomy SGAP ﬂap, 2/08

(34)

Vascular Anastomosis End to End to IMV & IMA perforator in ICS 3

Large Volume ﬂap

(35)

2 month follow up

(36)

SAL of abdomen Does not want implant

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3 month follow up

(38)

IGAP FLAP

IGAP longer pedicle than SGAP

Lower gluteal fat soder and more pliable than upper gluteal fat

Donor site less deforming, contour preserved

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IGAP vs. Inferior Gluteal Flap

More straighnorward harvest Longer vascular pedicle

Improved Donor site:

–  Less sensory disturbance than IG

–  Fewer Contour

deformi5es than IG

Allen et al 2005

(40)

Pre-‐Opera9ve Doppler Assessment

Pre-‐Op Doppler (Hand Held) Doppler Duplex to Verify Tests appeared Concordant Variability Right vs. Led

Courtesy of Elisabeth Beahm, MD

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Posi9oning for Gluteal Flaps

Lateral Decubitus Ipsilateral Flap

Simultaneous Harvest &

Mastectomy

Codner & Nahai 1994

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IGAP: Flap Design

Donor scar must lie in Gluteal crease

Scar will be visible laterally

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IGAP Flap Harvest

Skin Incision: Conserva5ve

Fat beveled circumferen5ally-‐avoid

overzealous lateral-‐ inferior resec5on

Largest Vessels, Longest length: Very Lateral vascular pedicle

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IGAP Flap in Situ

Long vascular pedicle with coalesced VCs

–  Pedicle Artery 1.2 mm –  Pedicle vein 3.5 mm

(45)

Note large volume ﬂap

(46)

Early Post Op Result

Subsequently IMF Lowered w/ Placement of

Contralateral Implant

(47)

IGAP Donor site

(48)

48 yo TE XRT

Prior SAL abdomen

Courtesy of Pierre Chevray, MD, PhD

(49)

IGAP Pedicle

–  Long: 13+ cm –  Vein: 3.5 mm

–  Arterial perforator: 1 mm Arterial anastomosis to IMA perf

(50)

Right IGAP Flap 200 cc silicone 10 mo f/u

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Maximizing Outcomes of GAP Donor Sites

Ideal SGAP Donor:

–  Upper Buqock Fat distribu5on –  Close Transversely/ obliquely pay

aqen5on to contour

–  Be aware of limita5ons of ﬂap shape and volume for breast (“Lemon Wedge”)

(52)

Maximizing Outcomes of GAP Donor Sites

Ideal IGAP Donor:

–  Lower Buqock Fat distribu5on –  Place scar in crease

(53)

Summary: IGAP vs. SGAP

–  IGAP Pros:

•  Longer vascular pedicle than SGAP

•  Larger ﬂap volume than SGAP

•  Less challenging ﬂap dissec5on

–  IGAP Cons:

•  Less longitudinal experience than SGAP

•  Higher poten5al for sensory disturbances than SGAP

•  Lower, poten5ally visible donor scar

(54)

Perforators from the IGA & SGA*

Blondeel, et al 2005 Cormack & Lamberty 1993

*

More Perforators from IGA

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Summary: Gluteal Flaps

SGAP/ IGAP vs. SG/IG Myocutaneous ﬂaps:

–  Less morbidity

–  Longer vascular pedicle

Compared to the Lower Abdominal ﬂaps:

–  Second 5er approach –  More complex to harvest

–  Limited volume and quality of 5ssue

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Conclusions: GAP Flaps

GAP ﬂaps best suited to smaller, non-‐ pto5c breasts and immediate reconstruc5on.

Careful donor site design is impera5ve: Consider primary area pa5ent’s fat deposi5on for harvest IGAP vs. SGAP.

An5cipate a higher revision rate and secondary procedures for donor and recipient sites and contralateral breast compared to lower abdominal ﬂaps for breast reconstruc5on.

Serratus Flap with Rib