Ann Thorac Surg 2004;77:1465-1466
© 2004 The Society of Thoracic Surgeons
How to do it
Simple technique for maximal thoracic muscle harvest
M. Blair Marshall, MDa,
Larry R. Kaiser, MDa,
John C. Kucharczuk, MDa*
a General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Accepted for publication June 25, 2003.
* Address reprint requests to Dr Marshall, Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 4 Silverstein Pavilion, 3400 Spruce St, Philadelphia, PA 19104, USA
e-mail: blair.marshall{at}uphs.upenn.edu
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Abstract
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We present a modification of technique for standard muscle flap harvest, the placement of cutaneous traction sutures. This technique allows for maximal dissection of the thoracic muscles even through minimal incisions. Through improved exposure and traction, complete dissection of the muscle bed can be performed and the tissue obtained maximized. Because more muscle bulk is obtained with this technique, the need for a second muscle may be prevented.
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Introduction
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Muscle flaps are the foundation of reconstruction in thoracic surgery. They are used in a number of complex clinical scenarios both for prevention and management of complications such as bronchopleural fistulas and residual spaces [1–3]. The latissimus dorsi and serratus anterior are the most commonly harvested muscles in these situations but the pectoralis major and other muscles are available for use as well. They have specific advantages in that they are proximal to their transposed location, have a reliable blood supply, and have ample bulk.
Both the latissimus dorsi and serratus anterior muscles have very broad origins making it difficult to optimally dissect these muscles to obtain maximum tissue bulk. This is particularly true as one moves toward less invasive approaches and smaller incisions.
Traditionally, retractors are used to elevate flaps along the superficial and deep borders of the muscle as they are dissected. The limitations of retractors become apparent during this dissection. As one progresses deeper, it becomes difficult to maintain tension at the deepest level of dissection. Visibility is compromised and the flap may be divided prematurely leaving significant muscle bulk behind. In order to perform cautery dissection, one must have adequate traction at the deepest level of dissection. Usually, a Deaver retractor is used but this becomes inefficient as the direction of force is no longer parallel to the line of tension. One eventually exceeds the limit of these retractors and is unable to adequately dissect the fascial beds further; this is particularly true for large patients.
We developed a simple technique, the placement of radial traction sutures, that greatly increase exposure and facilitates dissection. With this technique, one is readily able to dissect the latissimus from the lower thoracic spinous processes and iliac crest to its tendinous insertion on the humerus. This technique facilitates division of the humeral attachments, further increasing the amount of muscular tissue available to transpose into the chest even through limited incisions. The serratus anterior can be dissected similarly from its origin along the thoracic ribs, down to the eighth and ninth ribs, to its insertion on the scapula.
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Technique
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An appropriate standard incision is made for the planned procedure; we most commonly use a posterolateral skin incision or a vertical axillary incision. Interrupted heavy silk sutures are placed though the skin in a radial pattern out from the incision approximately every 10–15 cm (Figure 1).
The sutures are placed on clamps for traction. During the dissection, tension is maintained by pulling on the appropriate sutures and using a sponge stick to press down on the dissected muscle (Figure 2).
Continuing deeper in the plane of dissection, additional sutures are placed as necessary. This provides traction to facilitate the dissection. For the latissimus dorsi, the iliac crest, the spinous processes of the lower thoracic and lumbar vertebral bodies, and the humeral grove are the anatomic boundaries for harvest. Once the subcutaneous layer of the muscle has been dissected, the deep border can be developed. The muscle is separated from its attachments to the serratus. The neurovascular bundle from the thoracodorsal is identified and preserved. The branch to the serratus is ligated. At this point the tendinous insertion on the humerus may be divided proximal to the insertion of the vessels. This allows for full mobilization of the entire pedicle and transfer of maximal muscle bulk into the chest (Figure 3).
For the serratus anterior, it is the inferior aspect of the muscle where it attaches to the lower thoracic cage that is most commonly sacrificed. Again, use of this technique increases the exposure and tension at the level of the deepest portion of the dissection allowing for additional bulk to be harvested.
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Fig 1. Illustration demonstrating the location for placement of traction sutures. The continuous dashed lines represent the thoracotomy incision. The short lines represent the spacing of traction sutures along the bed of the latissimus dorsi muscle. Once placed, clamps can be used to put these sutures on traction facilitating dissection of the muscle from the attachments to the iliac crest, transverse processes, and humerus.
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Comment
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During the past year, the authors have used this technique in more than 20 patients requiring thoracic muscle flaps. This technique has allowed us to harvest muscle flaps with greater ease, speed, and efficiency especially in larger patients; by obtaining additional muscle bulk from each muscle dissected we have decreased our requirement of a second muscle.
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References
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- Cerfolio R.J. The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001;13:3-7.[Medline]
- Regnard J.F., Alifano M., Puyo P., Fares E., Magdeleinat P., Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection. J Thorac Cardiovasc Surg 2000;120:270-275.[Abstract/Free Full Text]
- Tseng Y.L., Wu M.H., Lin M.Y., Lai W.W. Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis. Eur J Cardiothoracic Surg 2000;18:666-670.[Abstract/Free Full Text]
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Abstract
Introduction
