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Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap
670
British Journal
sensation when diagonally opposite incisions in different quadrants of the breast are used and breast reductions are performed using a variety of pedicles. As regards the overlap between the branches coming from the lateral and the anterior cutaneous nerves, Jaspar noted that there was no cross-over across the nipple line. It is difficult to understand why the milk line in the breast region should be a watershed line for the cutaneous nerve branches. If such were the case, a nipple and areola retained on a purely vertical pedicle would always be numb; the clinical evidence is to the contrary Yours faithfully,
N. S. Sarhadi MBBS, MS(Cal), MNAMS, FRCS(Glas), Registrar in Plastic Surgery, Canniesburn Glasgow, UK.
Hospital,
J. Shaw Dunn BSc, MBChB, PhD, FRCS(Glas), Senior Lecturer in Anatomy, Department University of Glasgow, Glasgow, UK.
of Anatomy,
D. S. Soutar MCh, FRCS(Ed), FRCS(Glas), Consultant Plastic Surgeon, Canniesburn Bearsden, Glasgow G61 lQL, UK.
Hospital,
of Plastic Surgery
muscle to a bipedicled vascular delay procedure. This resulted in not only significantly increased distal muscle perfusion but also significantly improved distal muscle function.2,3 We have further demonstrated that the increased perfusion and function of vascularly delayed LDM was permanent by recording these significantly improved parameters 2 weeks following the end of the vascular delay period.4 This work has resulted in the clinical application of the vascular delay procedure to the LDM prior to cardiomyoplasty in selected centres in both the USA and Europe. Utilising the rodent LDM model we have demonstrated increased distal muscle flap survival after acute flap elevation by subjecting the muscle to sequential short periods of ischaemia and reperfusion, a phenomenon known as ischaemic preconditioning. 5,6 We were unable to demonstrate increased muscle perfusion of preconditioned muscle, despite increased survival, suggesting altered metabolism rather than increased perfusion as the mechanism for ischaemic preconditioning. We believe that Barron et al have presented a useful method to estimate blood flow in experimental muscle flaps and look forward to further papers from them in this field. Yours faithfully,
References 1. Jaspars JJP, Posma AN, Van Immerseel AAH, Gittenberger-de Groot AC. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg 1997; 50: 249959. 2. Sarhadi NS, Shaw Dunn J, Lee FD, Soutar DS. An anatomical study of the nerve supply of the breast, including the nipple and areola. Br J Plast Surg 1996; 49: 156-64. 3. Sarhadi NS, Shaw Dunn J, Soutar DS. A review of the nerve supply of the breast with special reference to the nipple and areola: Sir Astley Cooper revisited. Clin Anat 1997; 10: 283-8. 4. Sarhadi NS, Soutar DS. Nerve supply of the nipple: only from the fourth or from several intercostal nerves? A clinical experiment and an anatomical investigation. Eur J Plast Surg 1997; 20: 209-l 1.
Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap Sir, In their paper ‘Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap: the effect of mobilisation and electrical stimulation’, Barron et al’ make a number of observations. They state that mean perfusion of the distal muscle segment was significantly reduced by mobilisation whilst that of the proximal muscle segment was not, and that repeated stimulation of the mobilised flap resulted in a significantly greater hyperaemic response in the proximal muscle segments when compared to the distal ones. They rightly conclude that mobilisation of (the entire) latissimus dorsi muscle (LDM) causes distal muscle ischaemia, which results in decreased distal muscle function leading to distal atrophy and fibrosis. Our group in Louisville, Kentucky, USA, have published extensively on the same subject, have reached similar conclusion and have presented a solution now in use in clinical trials.2-7 Using the canine LDM-simulated cardiomyoplasty model we noted decreased distal muscle perfusion after flap elevation but have resolved this problem by subjecting the
S. M. Carroll FRCSI Senior Registrar in Plastic Surgery, Selly Oak Hospital, Birmingham, UK.
References 1. Barron DJ, Etherington PJE, Winlove CP, Pepper JR. Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap: the#effect of mobilisation and electrical stimulation. Br J Plast Surg 1997; 50: 43542. 2. Carroll SM, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay improves latissimus dorsi muscle perfusion and muscle function for use in cardiomyoplasty. Surg Forum 1995; Vol XLVI: 730-2. 3. Carroll SM, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay improves latissimus dorsi muscle perfusion and muscle function for use in cardiomyoplasty. Plast Reconstr Surg 1997; 99: 1329-37. 4. Carroll SM, Carroll CMA, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay of the latissimus dorsi muscle: An essential component of cardiomyoplasty. Ann Thorac Surg 1997; 63: 103440. 5. Carroll CMA, Carroll SM, Overgoor MLE, Tobin G, Barker JH. Acute ischaemic preconditioning of skeletal muscle prior to flap elevation augments muscle flap survival. Plast Reconstr Surg 1997; 100: 58-65. 6. Carroll CMA, Carroll SM, Overgoor MLE, Tobin G, Barker JH. Acute ischaemic preconditioning increases muscle flap survival. Surg Forum 1996; Vol XLVII: 73941. 7. Barker JH, van Alst VC, Keelan PC, et al. Vascular delay in skeletal muscle: a model for microcirculatory studies. Plast Reconstr Surg 1997; 100: 665-9.
Venous enhancement of a distally-based islanded fasciocutaneous flap Sir, Despite the obvious fasciocutaneous flaps described by Erdmann tip necrosis still act as
benefits of islanded distally-based in lower limb reconstruction as et al,’ the 7.6% failure rate and 10.6% a deterrent to some surgeons. In our
British Journal
sensation when diagonally opposite incisions in different quadrants of the breast are used and breast reductions are performed using a variety of pedicles. As regards the overlap between the branches coming from the lateral and the anterior cutaneous nerves, Jaspar noted that there was no cross-over across the nipple line. It is difficult to understand why the milk line in the breast region should be a watershed line for the cutaneous nerve branches. If such were the case, a nipple and areola retained on a purely vertical pedicle would always be numb; the clinical evidence is to the contrary Yours faithfully,
N. S. Sarhadi MBBS, MS(Cal), MNAMS, FRCS(Glas), Registrar in Plastic Surgery, Canniesburn Glasgow, UK.
Hospital,
J. Shaw Dunn BSc, MBChB, PhD, FRCS(Glas), Senior Lecturer in Anatomy, Department University of Glasgow, Glasgow, UK.
of Anatomy,
D. S. Soutar MCh, FRCS(Ed), FRCS(Glas), Consultant Plastic Surgeon, Canniesburn Bearsden, Glasgow G61 lQL, UK.
Hospital,
of Plastic Surgery
muscle to a bipedicled vascular delay procedure. This resulted in not only significantly increased distal muscle perfusion but also significantly improved distal muscle function.2,3 We have further demonstrated that the increased perfusion and function of vascularly delayed LDM was permanent by recording these significantly improved parameters 2 weeks following the end of the vascular delay period.4 This work has resulted in the clinical application of the vascular delay procedure to the LDM prior to cardiomyoplasty in selected centres in both the USA and Europe. Utilising the rodent LDM model we have demonstrated increased distal muscle flap survival after acute flap elevation by subjecting the muscle to sequential short periods of ischaemia and reperfusion, a phenomenon known as ischaemic preconditioning. 5,6 We were unable to demonstrate increased muscle perfusion of preconditioned muscle, despite increased survival, suggesting altered metabolism rather than increased perfusion as the mechanism for ischaemic preconditioning. We believe that Barron et al have presented a useful method to estimate blood flow in experimental muscle flaps and look forward to further papers from them in this field. Yours faithfully,
References 1. Jaspars JJP, Posma AN, Van Immerseel AAH, Gittenberger-de Groot AC. The cutaneous innervation of the female breast and nipple-areola complex: implications for surgery. Br J Plast Surg 1997; 50: 249959. 2. Sarhadi NS, Shaw Dunn J, Lee FD, Soutar DS. An anatomical study of the nerve supply of the breast, including the nipple and areola. Br J Plast Surg 1996; 49: 156-64. 3. Sarhadi NS, Shaw Dunn J, Soutar DS. A review of the nerve supply of the breast with special reference to the nipple and areola: Sir Astley Cooper revisited. Clin Anat 1997; 10: 283-8. 4. Sarhadi NS, Soutar DS. Nerve supply of the nipple: only from the fourth or from several intercostal nerves? A clinical experiment and an anatomical investigation. Eur J Plast Surg 1997; 20: 209-l 1.
Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap Sir, In their paper ‘Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap: the effect of mobilisation and electrical stimulation’, Barron et al’ make a number of observations. They state that mean perfusion of the distal muscle segment was significantly reduced by mobilisation whilst that of the proximal muscle segment was not, and that repeated stimulation of the mobilised flap resulted in a significantly greater hyperaemic response in the proximal muscle segments when compared to the distal ones. They rightly conclude that mobilisation of (the entire) latissimus dorsi muscle (LDM) causes distal muscle ischaemia, which results in decreased distal muscle function leading to distal atrophy and fibrosis. Our group in Louisville, Kentucky, USA, have published extensively on the same subject, have reached similar conclusion and have presented a solution now in use in clinical trials.2-7 Using the canine LDM-simulated cardiomyoplasty model we noted decreased distal muscle perfusion after flap elevation but have resolved this problem by subjecting the
S. M. Carroll FRCSI Senior Registrar in Plastic Surgery, Selly Oak Hospital, Birmingham, UK.
References 1. Barron DJ, Etherington PJE, Winlove CP, Pepper JR. Regional perfusion and oxygenation in the pedicled latissimus dorsi muscle flap: the#effect of mobilisation and electrical stimulation. Br J Plast Surg 1997; 50: 43542. 2. Carroll SM, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay improves latissimus dorsi muscle perfusion and muscle function for use in cardiomyoplasty. Surg Forum 1995; Vol XLVI: 730-2. 3. Carroll SM, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay improves latissimus dorsi muscle perfusion and muscle function for use in cardiomyoplasty. Plast Reconstr Surg 1997; 99: 1329-37. 4. Carroll SM, Carroll CMA, Heilman S, Stremel R, Tobin GR, Barker J. Vascular delay of the latissimus dorsi muscle: An essential component of cardiomyoplasty. Ann Thorac Surg 1997; 63: 103440. 5. Carroll CMA, Carroll SM, Overgoor MLE, Tobin G, Barker JH. Acute ischaemic preconditioning of skeletal muscle prior to flap elevation augments muscle flap survival. Plast Reconstr Surg 1997; 100: 58-65. 6. Carroll CMA, Carroll SM, Overgoor MLE, Tobin G, Barker JH. Acute ischaemic preconditioning increases muscle flap survival. Surg Forum 1996; Vol XLVII: 73941. 7. Barker JH, van Alst VC, Keelan PC, et al. Vascular delay in skeletal muscle: a model for microcirculatory studies. Plast Reconstr Surg 1997; 100: 665-9.
Venous enhancement of a distally-based islanded fasciocutaneous flap Sir, Despite the obvious fasciocutaneous flaps described by Erdmann tip necrosis still act as
benefits of islanded distally-based in lower limb reconstruction as et al,’ the 7.6% failure rate and 10.6% a deterrent to some surgeons. In our