Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Reconstructive Surgery in the Tropics
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8. The flap is then passed gently through the subcutaneous tunnel without
tension on the vascular pedicle and without shearing forces between the
skin and muscle or rotation. It is then sutured in place with interrupted
sutures.
9. The expanded split thickness skin grafts are applied to the donor area of
the back after decreasing the size by circumferential suture.
10.The restored function and appearance of this myocutaneus flap is not
mitigate by the posterior back and chest scarring.
11.The nerve to the latissimus dorsi muscle may be divided if atrophy of the
muscle is desired.
12.If the myocutaneus flap is being used for breast or chest reconstruction,
primary closure of the donor area can be carried out
13.If the muscle alone is being used to replace the function of the biceps
muscle, the nerve is carefully preserved.
Intercostal Flap (Fig. 30)
This flap is based on several intercostal arteries. It is used especially if a full
thickness chest wall defect results after tumor excision and a good cover of fascia lata
or prefabricated mesh is needed. Usually this will be secured from below the defect,
and the donor area will have split thickness skin graft applied as illustrated.
Superficial Epigastric Artery Flap (Fig. 31)
Although this flap is most commonly considered a random flap, it is based on
the superficial epigastric artery and vein which supplies a large area of skin and
subcutaneous tissue just superior to the inguinal ligament and lateral to the midline
of the lower abdominal wall. The superficial epigastric artery and vein are the large
vessels seen at the time of open inguinal hernia repair. The flap can be almost 5
inches in width and 10 inches in length. It is. It is especially useful for the coverage
of the dorsum of the hand.
1. The flap is elevated starting distally at the level of the umbilicus. Working
proximally, the skin and both layer of subcutaneous tissue are elevated
from the rectus abdominal muscle fascia with special care. Spread in a
vertical direction with a blunt nosed scissors dissector as approach is made
to the inguinal ligament.
Figure 30. Intercostal flap from immediately
below defect. Split thickness skin
graft on donor area.
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