Free Latissimus Dorsi Muscle Flap Research Articles

A Rare Case of Primary Sarcoma Arising Within Free Muscle Transfer

AbstractSoft tissue sarcomas are one of the rarest forms of cancer. We describe a unique case of a 35-year-old patient who sustained an open lower limb fracture requiring an intramedullary nail and free latissimus dorsi (LD) muscle flap reconstruction. He had a complex postoperative course including osteomyelitis, a refracture, and chronic pain. Eleven years following the injury, he presented with pain and localized swelling around the flap. Histological analysis confirmed a rhabdomyosarcoma within the LD muscle and he underwent a transfemoral amputation. He is now in remission and walks on a prosthesis pain-free.

36-year Follow-up on Scalp Reconstruction Using Free Latissimus Dorsi Muscle Flap, Skin Grafting, and Scalp Expansion.

Immediate coverage of a large area of exposed skull is the first step in reconstructing a major scalp loss. In the 1970s, the free omental flap was used for scalp reconstruction, replacing removal of the external table and skin grafting only. Introduction of flaps and expanders has revolutionized reconstruction of major scalp losses. A free muscle flap is used to cover the exposed skull. Skin graft covers the muscle flap, and next, the expanded scalp is used to restore the scalp to its original shape. In certain cases, a hair transplant could help create a more natural hairline. In this case, in 1987, a free latissimus dorsi muscle flap and skin grafting were used in a 27-year-old man with major scalp loss. The left latissimus dorsi muscle was harvested with its vascular pedicle intact. Left superficial temporal vessels were used as recipients. After complete healing of the free flap, scalp and forehead skin were expanded and used to restore the scalp to its preinjury shape. Coverage of the exposed parietal skull with free latissimus dorsi muscle flap and skin graft was successful. Then, scalp tissue surrounding the defect and forehead skin were expanded and used to restore the scalp to its original shape. This 36-year follow-up in a patient who had major scalp reconstruction using free latissimus dorsi muscle and skin grafting followed by scalp and forehead expansion shows that this method provides an excellent and reliable long-term coverage for such an injury.

Robotic-assisted harvesting of a latissimus dorsi muscle flap: a case report

Having established itself in various other areas of surgery as well as in urology, robotics is increasingly gaining importance in plastic surgery. The case presented in this manuscript describes the first published robotic-assisted harvesting of a latissimus dorsi muscle free flap in the German-speaking world. The aim is to increase the knowledge of robotics in plastic surgery and to support the introduction of robotic-assisted plastic surgery in Germany.

Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis.

Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

Latissimus dorsi muscle free flap for management of large complex wound

Background and objective: Dealing with a large complex wound is very challenging, and latissimus dorsi flap through history has been used as its very variable and flexible in the form of pedicle or free flap in the coverage of those large complex wounds as its large, well perfused, and flexible in configuration. The study aimed to evaluate the versatility of use and viability of latissimus dorsi free flap for coverage of large complex wounds in different parts of the body. Methods: A retrospective study was conducted from 2012 to 2019 in Erbil Rizgary teaching hospital, Rozhawa emergency hospital, and PAR private hospital, Kurdistan region, Iraq on 22 cases, (20) male (90.9%), and (2) female (9.1%), all with a large complex wound in different sites of the body that latissimus dorsi free flap in the form of myocutaneous mainly and only one with muscle free flap. Results: The complex large wounds ranged from (22*15 cm – 35*20 cm) indifferent sites of the body, (18) from the lower limb,(3) from the forearm and (1) from the scalp, from those 22 cases, we had 17 cases that survived totally(77.2%), and 5 failure cases (22.7%) those were from leg who associated with tibial bone fracture gestilo type 111B and C and large soft tissue defect with or without vascular injury, and in regard to flaps out of 22 cases 5 of them presented with total necrosis (55.6%), one case with partial necrosis(11.1%), and 3 cases with partial skin graft loss (33.33%), that managed conservatively, in all cases donor site closed primarily with few morbidities as happened in 5 cases (22.7%) like bleeding in 3 cases (60.0%) and stoppage needed operation theater, one case (20.0%) with seroma, and one with minor wound dehiscent (20.0%), that both managed conservatively. Conclusion: The latissimus dorsi myocutaneous free flap is the reliable, flexible and highly recommended for large soft tissue defect reconstruction in different sites of the body especially those associated with extensive bone damage.

Maxillary Reconstruction With a Rib-attached Free Latissimus Dorsi Muscle Flap.

In defect reconstruction after maxillary tumor resection, filling the dead space created by resection and reconstruction of surrounding areas are crucial for good cosmetic outcomes. Although various procedures have been described in the literature, most are complex and require advanced surgical skills. Therefore, in this study, the authors aimed to identify a simple procedure for successful reconstruction with minimal bone fixation. Three patients who underwent total maxillectomy and reconstruction using the rib-attached free latissimus dorsi flap at Keio University Hospital between 2012 and 2014 were included and followed up with for a minimum of 5 years. After total maxillectomy, the authors used a free latissimus dorsi flap with a portion of the rib to fill the dead space and reconstructed the orbit, nasal cavity, and oral cavity.The authors performed a rigid reconstruction of the zygomatic ridge using only 2-point plate fixations of the ribs at the outer orbit and anterior nasal spine. Patients were followed up for ≥5 years, and the flap successfully survived in all cases. There was an issue with rib fixation in 1 case; however, all patients were highly satisfied with the procedure's cosmetic results.

Reconstruction of Scalp and Forehead Defects: Options and Strategies.

Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2,and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases ofskin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area.Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.

Facial reanimation using free partial latissimus dorsi muscle transfer: Single versus dual innervation method

The aim of the present study was to analyze the consequences of partial free latissimus dorsi muscle flap with nerve splitting technique (Partial LD transfer) for facial reanimation and compare outcomes according to innervation method (singer versus dual innervation).Patients with complete unilateral facial paralysis underwent either the single (ipsilateral masseteric nerve only) or dual (ipsilateral masseteric nerve plus contralateral buccal branch of the facial nerve) nerve innervation method for facial reanimation. An assessment was carried out to compare the outcomes between the single and dual innervation.Total of 21 patients were involved in this study. In the single innervation group, 7 out of 8 patients developed a voluntary smile. However, none were able to achieve a spontaneous smile. On the other hand, 9 out of 13 patients developed a voluntary smile and 3 out of 13 patients achieved a spontaneous smile. The mean increases of smile excursion assessed by Emotrics software and Terzis grades showed no significant differences between two groups.Within the limitations of the study it seems that partial LD transfer approach utilizing the dual innervation method has a positive effect on achieving a spontaneous smile and could be a valuable option for facial reanimation.

Clinical application of three-dimensional printed preformed titanium mesh combined with free latissimus dorsi muscle flap in the treatment of squamous cell carcinoma with skull defect in the vertex

Objective: To explore the clinical effects of three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation in the treatment of wounds with skull defect after radical surgery of squamous cell carcinoma in the vertex. Methods: A retrospective observational study was conducted. From January 2010 to December 2019, 5 patients with squamous cell carcinoma in the vertex accompanied with skull invasion who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of the Second Affiliated Hospital of Air Force Medical University, including four males and one female, aged 50 to 65 years. The original lesion areas ranged from 5 cm×4 cm to 15 cm×8 cm. The titanium mesh was prefabricated via three-dimensional technic based on the result the scope of skull resection predicted with computerized tomography three-dimensional reconstruction before surgery. During the first stage, the soft tissue defect area of scalp (8 cm×7 cm to 18 cm×11 cm) after tumor enlargement resection was repaired with the preformed titanium mesh, and the titanium mesh was covered with latissimus dorsi muscle flap, with area of 10 cm×9 cm to 20 cm×13 cm. The thoracodorsal artery/vein was anastomosed with the superficial temporal artery/vein on one side. The muscle ends in the donor site were sutured together or performed with transfixion, and then the skin on the back were covered back to the donor site. On the 10th day after the first-stage surgery, the second-stage surgery was performed. The thin intermediate thickness skin graft was taken from the anterolateral thigh to cover the latissimus dorsi muscle flap. The duration and intraoperative blood loss of first-stage surgery were recorded. The postoperative muscle flap survival after the first-stage surgery and skin graft survival after the second-stage surgery was observed. The occurrence of complications, head appearance, and recurrence of tumor were followed up. Results: The average first-stage surgery duration of patients was 12.1 h, and the intraoperative blood loss was not more than 1 200 mL. The muscle flaps in the first-stage surgery and the skin grafts in the second-stage surgery all survived well. During the follow-up of 6-18 months, no complications such as exposure of titanium mesh or infection occurred, with good shape in the recipient sites in the vertex, and no recurrence of tumor. Conclusions: Three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation and intermediate thickness skin graft cover is an effective and reliable method for repairing the wound with skull defect after extended resection of squamous cell carcinoma in the vertex. This method can cover the wound effectively as well as promote both recipient and donor sites to obtain good function and appearance.

40 years of microvascular reconstruction with latissimus dorsi muscle free flap

Introduction: The first use of the latissimus dorsi as a myocutaneous flap was described as early as the end of the 19th century, in the coverage of an extensive defect following radical mastectomy (Tansini 1895). Subsequently, the surgical procedure was forgotten and later re-introduced as a pedicled flap for breast reconstruction (Olivari 1976). Olivari prompted the microsurgical team from Ljubljana to perform a free muscle transfer (Godina 1978). The first emergency free flap transfer in Ljubljana was performed in 1979.Patients and Methods: Latissimus dorsi flap can be used as a muscle or musculocutaneous flap, in a pedicle or a free form. The procedure of reconstructing large tibial defects always proceeded as a two-team procedure simultaneously. For the continuity of the axial blood flow of the tibia, M. Godina developed end-to-side anastomosis.Results: Using latissimus dorsi free flap for reconstruction of tibial defects the first statistics by M. Godina from 134 patients showed a 0.75% flap loss rate and 1.5% infection rate; an average healing time of 6.8 months and a bed rest period estimated at 27 days. In the case of delayed reconstruction, the author reported an infection rate of 17.5%.Conclusions: Due to clinical experience, good results and a new doctrine of the Ljubljana School of microsurgery played a historical role in the reconstruction of the tibia with a muscular microvascular muscle flap.

Extracorporeal lung support for tracheoesophageal fistula surgical repair with free flap

Tracheoesophageal fistula results in persistent leakage of saliva into the trachea, prevents oral feeding, and predisposes to aspiration pneumonia. Large fistula closure may require a free flap to cover the defect. When the defect involves the tracheal area between the neck and the mediastinum, a tubeless field for optimal exposure can be advantageous. This article reports the use of veno-venous extracorporeal lung support, a known safe and efficient technique to support the patient’s respiratory function, for this purpose. The typical veno-venous extracorporeal lung support setting includes a femoro-jugular bypass. The patient cases reported here had characteristics that precluded the use of the jugular vein, such as neck radiation dermatitis, previous radical neck dissection, and poor accessibility. Therefore a more rarely described femoro-femoral approach was used. The cases of three patients with persistent tracheoesophageal fistula who had free flap surgeries (two bi-paddled radial forearm free flap and one latissimus dorsi muscle free flap) assisted by femoro-femoral veno-venous extracorporeal lung support are reported.

Direction change in a distal bypass graft due to increased collateral perfusion after the free flap transfer: a case report

Distal bypass combined with a free flap is a frequent surgical option for ischemic ulcers of the lower extremities. Here, we describe a patient in whom there was a change in the direction of blood flow in a distal bypass graft. A 68-year-old male patient with an ischemic ulcer on his left heel was referred to our facility by a local dermatology clinic. Surgical revascularization was performed between the popliteal artery and the dorsalis pedis artery using an ipsilateral great saphenous vein as the graft vessel. The wound site did not heal postoperatively, so it was covered using a free latissimus dorsi muscle flap. At the same time, the thoracodorsal artery was anastomosed to the bypass graft in an end-to-side manner to serve as a nutrient vessel. Initially, blood flow into the thoracodorsal artery from the bypass graft was via the popliteal artery. However, after occlusion of the proximal anastomotic site of the bypass graft, blood flow into the thoracodorsal artery from the bypass graft was via the dorsalis pedis artery, which was the distal anastomotic site. The change in direction of blood flow might have been the result of an increase in blood flow in the collateral vessels in the ischemic lower leg, which eventually overwhelmed the blood flow in the bypass graft.

Outcome of latissimus dorsi free flap in-case of large scalp defect a single center study

Reconstruction of scalp and calvarial defects following trauma post burn and after tumor ablation frequently requires prosthetic cranioplasty and soft tissue coverage. Furthermore, patients often have advanced disease and receive perioperative radiotherapy following tumor ablation. We evaluated the outcome of scalp reconstruction in traumatic cases with a free Latissimus dorsi (LD) muscle flap in this setting. The aim of this study was to evaluate outcome of latissimus dorsi free flap in-case of large scalp defect. This prospective non-randomized study was conducted on 10 patients with scalp defects following trauma attended emergency unit and outpatient department of burn and plastic surgery, Dhaka medical college hospital (DMCH) in the period between July 2017 and June 2018. Durability of coverage, flap success, infection and overall satisfaction were studied. The age distribution of the study population shows highest number of patients (60%) were in middle (24-30 years) age group whereas lowest are in older group (30-50 years). The lowest age was 24 years and the highest age was 45 years. Highest number of patients (80%) were standard myocutanous type of flap whereas lowest were in (20.0%) were partial latissimus muscle flap. Outcome of the reconstruction (80.0%) were excellent 10% partial flap necrosis occur and total flap loss in 1 (10%) patient. The reconstruction of scalp defects continues to be a challenge for the reconstructive surgeon, who must achieve a satisfactory functional and aesthetic outcome.

A New Extraperitoneal Method for Entero-atmospheric Fistula Closure Using a Free Muscle Flap.

Summary:Treatment of an entero-atmospheric fistula (EAF) is challenging and associated with significant morbidity and mortality. For an EAF with protrusion of mucosa, chances for spontaneous closure are minimal. Standard surgical procedures may be associated with a high risk for complications in patients with a hostile abdomen. This article describes a new method for extraperitoneal closure of an EAF in a patient with a hostile abdomen. A free segmental latissimus dorsi musculocutaneous flap was harvested on its thoracodorsal pedicle, leaving the remaining muscle innervated. The flap was anastomosed to the internal mammary vessels. The muscle was sutured into the fistula opening using a parachute technique and temporarily immobilized with a negative wound pressure device. The skin of the flap was used for monitoring and later replaced by a skin graft. The postoperative course was uneventful. At 24 months follow-up, there were no signs of recurrences. The patient had no pain and had no defecation problems. Extraperitoneal closure of an EAF with a segmental free latissimus dorsi muscle flap sutured into the fistula opening with a parachute technique may be a new promising technique in patients where standard surgical procedures are associated with too high a risk for complications and where a local pedicled muscle flap is not available. The advantages of this method are that no laparotomy is required, the intestinal lumen is not reduced in diameter, and that no bowel resection is performed, which is a particular advantage in cases with a short bowel syndrome.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience.

BACKGROUNDSensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODSIn this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel.RESULTSOut of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group.CONCLUSIONLocoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

Latissimus Dorsi Muscle Flap for Scalp Reconstruction and Postoperative Ulceration Management.

The latissimus dorsi muscle (LDM) flap has been widely accepted as the best choice for subtotal or total scalp reconstruction. Because of the unique anatomic and functional features of scalp, ulcerations formation would occur after reconstructive surgeries. in this study, we are presenting a patient with a large scalp defect successfully reconstructed by a latissimus dorsi muscle free flap. Ulcerations with skull exposure formed on the transplanted flap after the first surgery. They were subsequently repaired by flap recycling and tissue expansion techniques. An excellent reconstructive outcome was achieved at the 30-month follow-up after the last surgery and no further complication was found. This clinical report highlights the possibility of ulcer formation after scalp reconstructive surgeries and supports the use of recycle flaps and tissue expanders to manage postoperative ulcerations after latissimus dorsi muscle free flap transplantation.

Treatment of degloving injury of the hand using the free latissimus dorsi muscle flap: Long-term functional results

Treatment of degloving injury of the hand using the free latissimus dorsi muscle flap: Long-term functional results

Successful Microsurgical Reconstruction for Limb Salvage in a COVID-19-Positive Patient: A Case Report

Abstract Background Although the novel 2019 coronavirus (COVID-19) pandemic delayed elective microsurgical reconstruction cases, traumatic injuries requiring microsurgical reconstruction for limb salvage still presented to our hospital. Recent data suggests a link between COVID-19 and increased venous and arterial thromboembolic events, theoretically increasing the risk of microvascular anastomotic thrombosis and flap failure. Methods We provide a single case report of microsurgical limb salvage in a COVID-19-positive patient with a Gustilo IIIb open tibial-fibular fracture. Results A free latissimus dorsi muscle flap was used to successfully cover a Gustilo IIIb open tibial-fibular fracture with exposed orthopedic hardware and large soft tissue defect, with 5-month follow-up demonstrating a well-healed flap allowing for preserved ambulation. Conclusion Although there is a theoretical increased incidence of venous and arterial thrombotic microvascular failure in COVID-19-positive patients, microsurgical reconstruction is occasionally the lone option for salvage. Microsurgical reconstruction in this population must be carefully considered, meticulously executed, and closely monitored.

Free latissimus dorsi muscle flap for scalp reconstruction in elderly patients with a squamous cell carcinoma

Scalp defects resulting from the resection of a squamous cell carcinoma often require free tissue transfer. In these cases, a free latissimus dorsi muscle flap is a good possibility to cover scalp defects. Our aim was to evaluate the outcome of scalp coverage with free latissimus dorsi muscle flaps. This retrospective analysis included 4 patients aged over 70 years (7082), who underwent scalp reconstruction with a free latissimus dorsi muscle flap and a split-skin graft after the resection of a squamous cell carcinoma. Patient characteristics, histological findings, recurrence rate, postoperative radiotherapy, duration of operation and in-patient stay were recorded. All 4 patients had recurrent tumours and the follow-up period was 12-48 months. Histological findings demonstrated R0 resection in all patients. A PALACOS® bone was necessary in two patients and duraplasty in one. All free flaps healed without major complications. There was no flap loss; minor complications included seromas and wound dehiscence. One patient died during follow-up and two were no longer treatable due to tumour progression. One patient is still alive and has had no recurrence for 22 months. Free latissimus dorsi muscle flap is a reliable method to reconstruct large scalp defects, even in elderly patients, due to its low complication rate and good tissue vascularity. Despite R0 resection with partial resection of the skullcap and duraplasty, there is a high risk for local recurrence. A multidisciplinary approach is necessary to achieve the best therapy concept for each patient.

Salvage Procedure of a Lower Leg in a Contact Burn: Latissimus Dorsi Muscle Free Flap and Scalp Skin Graft

Salvage Procedure of a Lower Leg in a Contact Burn: Latissimus Dorsi Muscle Free Flap and Scalp Skin Graft