背阔肌皮瓣Word格式.docx

背阔肌皮瓣Word格式.docx

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解剖 

ANATOMY

Themuscletakesoriginontheiliaccrestinferiorlyandthethoracolumbarfasciaposteriorlynearthemidline. 

Itinsertsintothehumeruswhereitactsasahumeraladductorandinternalrotator. 

Theposterioraxillaryfoldismadeupofthemostsuperioraspectofthemusclethatbeginstonarrowbeforeitformsthetendonofinsertion. 

Thenervesupplyisviathethoracodorsalnerve,abranchoftheposteriorcordofthebrachialplexus. 

Lesionsof 

C-7 

willaffectlatissimusfunction. 

Thenervecloselyaccompaniesthethoracodorsalartery.Thelatissimusmusclebloodsupplyisviathesubscapularartery,abranchoftheaxillaryartery.

起点：

下6个胸椎棘突，腰背筋膜，髂嵴，下3-4个肋骨；

以肌腱形式止于肱骨结节间沟底；

功能：

伸展、内收、内旋肱骨，攀爬时拉起肢体，并可辅助吸气。

神经支配：

臂丛神经后束分支--胸背神经（C7）；

血供：

肩胛下动脉分支--胸背动脉。

Thesubscapularsendsoffacircumflexscapularbranchposteriorlyandthendistributesaserratusbranchbeforeitentersthesubstanceofthemuscleonitsundersurface. 

肩胛下动脉首先发出旋肩胛动脉然后分出前锯肌肌支，最后进入背阔肌并走行于肌肉下方。

（见图1）

Thesubscapulararterycanbefrom2to5millimetersinsize,whilethethoracodorsalarteryrangesfrom1to3millimeters. 

Thevenaecommitansisusuallyslightlylarger.

肩胛下动脉直径为2-5mm，胸背动脉为1-3mm，其伴行静脉一般比动脉稍粗大。

Themuscleisalsosuppliedbyperforatorsfromthethoracicintercostalandlumbararteriesthatallowittobeusedasapedicledflapthatcanresurfaceposteriordefects. 

Thesevesselsarequitesmallwithshortleashesandnottypicallyusedformicrosurgicalreconstruction.

背阔肌通过交通支与肋间动脉和腰动脉连续，通过交通支可以将背阔肌向下方旋转修复骶尾部皮肤缺损，但由于其血管较细小，供应范围少，不是典型的外科重建选择皮瓣。

手术步骤 

OPERATIVEPROCEDURE

Thepatientisplacedinthelateraldecubituspositiononabeanbag,withanaxillaryrollplacedinthedependentaxilla. 

Theipsilateralarmispreppedcompletelyandleftintheoperativefield,allowingittobefreelymovedaboutthefield. 

FormostoftheprocedureitiskeptabductedandrestingonawellpaddedsterileMayostandplacedanterosuperiorlytothepatient. 

Thelatissimusborderisoutlinedwithamarkingpen. 

Theincisionisthenmarkedextendingfromtheaxillaortheposterioraxillaryfold,theninferiorlyandmediallyoverthelatissimusmuscle.Thelengthofmuscleneededwilldictatetheincisionlength.Alternatively,ifaskinpaddleisnecessary,itismarkedovertheflap.ApencilDopplercanbeusedtoensurethepresenceofaperforatorintheskinpaddle.

患者取健侧卧位，患侧在上，并用支架固定，身体同侧上臂及手完全消毒，以便术中移动；

手术过程中需要保持肩外展，标记背阔肌边界，切口起自腋窝或腋窝后壁，向下、向背阔肌中间部位延伸，如果需要带皮肤转移，则需如下图虚线示切取方法，可以用多普勒测定皮支穿出点。

Thepatientismarkedinthelateraldecubituspositionfortheextentofthemuscle,skinincisionandpossibleskinpaddle.

Thesuperioredgeofthelatissimusisidentifiedattheinferiorangleofthescapula.Theserratusmusclecanbeidentifiedeasilywiththisapproach.

在肩胛骨下角找到背阔肌上缘，此处很容易明确其与前锯肌间隙。

Thepocketisdissected

Thesuperioredgeofthelatissimus,belowtheinferiorangleofthescapulaisthenelevated.Thisareolarplaneiseasytodissect,andanylargecaliberperforatorscanbeligatedanddivided.Thedissectionisthendirectedtowardthemidline,andtheinsertionsofthemusclenearthemidlineofthebackisdivided.Thedissectionproceedsinferiorlyfreeingthemedialmuscleinsertion.

从背阔肌上缘，肩胛骨下方将背阔肌掀起，并钝性分离。

Thesuperioredgeofthemuscleiselevated

Whentheinferiorportionofthemuscleisreached,theattachmentplanehereisnotclearandmusclebecreatedwiththeelectrocautery.Afterthemedialandinferiormuscleisreleased,thedissectionproceedunderneaththemuscletowardtheaxilla.Theplanebecomesverythinandareolarandeasytodissect.

在肌肉下方分离，向远端根据需要显露肌肉，如需重建肌肉，则在远端带部分腰背筋膜以便进行缝合修复。

Themuscleisfreedofmedialandinferiorattachments

Thevesselstothelatissimusandserratusbecomeclearasthea