背阔肌皮瓣.docx

背阔肌皮瓣.docx

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Thelatissimusdorsimuscleisthelargestmuscleinthebody,upto20by40centimeters,allowingcoverageofextremelylargewounds.Inspiteofitssize,nosignificantdonorfunctionaldeficitresultsfromremovalofthemuscle.Itisthelargestflapthatcanbeharvestedonasinglepredicle,andcanevenbecombinedwiththeserratus,scapularorparascapularflaps,tocreateaflapcomplexthatcancovermassivewounds.Inthenormalpopulationthemuscleisquitethin（lessthan1centimeterthick）,allowingittobedrapedoverirregularsurfaceswithease.Withtherectusmuscleandradialforearmflap,itrepresentsoneoftheworkhorseflapsinreconstructivemicrosurgery.Whenre-innervatedusingthethoracodorsalnerve,thelatissimuscanbeusedasafunctionalmuscle.

          背阔肌是身体面积较大肌肉支一，达到20*40cm，可以转移修复巨大创面，尽管其体积大，但对供区功能影响很小。

在普通人群其肌肉很薄（小于1cm）,可以修复不规则创面，也可以吻合胸背神经，作为功能肌皮瓣使用。

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