Latissimus Dorsi Free Flap Research Articles

Factors affecting success of reconstruction of extremity injuries with microvascular free flaps

Objective One of the most challenging aspects of restoring form and function to an extremity affected by a traumatic event is repairing the extensive soft tissue defect. Some methods of repair are use of microvascular free flaps, pedicled perforator flaps, and skin grafting.1 The choice of reconstruction depends on many factors, including location/size, patient's comorbidities, and donor site limitations. The aim of this study was to review extremity soft tissue reconstructions that were performed by pedicled and free flap methods and to determine if any factors played a role in the outcome of treatment. Methods With institutional review board approval, a retrospective chart review was performed for cases in the Department of Oral and Maxillofacial Surgery involving extremity reconstruction procedures in the years 2010–2015. A data set was created in REDCap to record patient demographic characteristics, social habits, cause/site of injury, procedures performed, postoperative/post-discharge complications, and healing outcome. Statistical analysis was performed by using SPSS, SAS, and Excel software. A comparative analysis, by using Fisher's exact test, Pearson's χ2 test, and independentt tests, was performed. Results We identified 71 patients, 20 of whom were excluded because of repetition and/or other reconstruction. Of the 51 patients identified, 38 (74.5%) were males and 13 (25.5%) were females (mean age 41 years). Accident-related injuries included motorcycle, 13 (26.5%); car, 14 (28.6%); falls, 8 (15.7%); pedestrian–automobile collision, 8 (15.7%); and other causes. Lower extremities were affected in 49 of 51 cases. Reconstructions included radial forearm free flap (17), anterior lateral thigh flap (7), latissimus dorsi free flap (3), gastrocnemius pedicled flap (9), and other rotational flaps (15). Of 51 patients, 15 required readmissions—9 for wound dehiscence and 11 for infection (6 had both). Of the patients with poor wound care, 60% developed an infection, 72% of whom required readmission. No significant correlation between patient comorbidities and the rate of flap failure/readmission was noted. Conclusions Extensive extremity injuries caused by traumatic events often lead to soft tissue defects that require tissue rearrangement/free tissue transfer for repair. In evaluating patients with free flap/rotational flap reconstruction of these defects, we determined that readmissions mainly resulted from infection, most of which were correlated with poor wound care. To further address our hypothesis, we plan to review patients from 2016 to 2019 to evaluate if any other factors (i.e., orthopedic hardware) may play a role in the rate of infections.

The Muscle-Sparing Descending Branch Latissimus Dorsi Free Flap for Lower Extremity Reconstruction.

The muscle-sparing descending branch latissimus dorsi muscle (MSLD) flap is a versatile flap with numerous benefits. It is an often overlooked but useful option when considering free flap donors. In this article, the authors present the largest experience with the MSLD flap, with focus on its use in lower extremity reconstruction. Patients undergoing lower extremity reconstruction with the MSLD flap at a single institution from 2012 to 2017 were identified. Patient and wound characteristics, surgical details, complications, and outcomes were examined. Outcomes were compared to a cohort who underwent lower extremity reconstruction with other free muscle flaps during the same period. Thirty-six consecutive patients who underwent MSLD flap surgery were identified. Mean follow-up was 18.8 months. Mean body mass index was 29.2 kg/m and 56 percent were smokers. The most common wound causes were motor vehicle collision (46 percent) and fall (22 percent). The most common anatomical location was the distal third of the tibia (33 percent). Mean operative time was 380 minutes. Complications included three total losses (8 percent) and one partial loss (3 percent). No donor-site seromas were reported. Four patients required subsequent amputation for orthopedic issues (nonunion/pain). Patients receiving MSLD and other flaps had similar rates of amputation, donor- and recipient-site complications, and ambulation status (p > 0.05). The MSLD flap is a useful and reliable option for free flap reconstruction of the lower extremity. Advantages include an easily contourable flap, low revision rate, low complication rate, and the ability to harvest in supine position. In addition, the MSLD flap preserves donor function useful for rehabilitation and minimizes seroma risk. Therapeutic, III.

Transplantation of lobulated free latissimus dorsi flap for repairing irregular soft tissue defect of shank

Objective To investigate the feasibility and clinical effects of lobulated free latissimus dorsi flap in repairing severe shank trauma with irregular soft tissue defect. Methods Eight patients with soft tissue defect of shank due to trauma were treated from February, 2013 to November, 2018, which were 5 males and 3 females. All wounds were irregular. The size of soft tissue defect ranged from 11.0 cm×15.0 cm to 15.0 cm×23.0 cm, with different degrees exposure of deep tissue such as bone and tendon. Five cases out of 8 were infected wound, 3 cases of which had internal fixation bracket exposed. Five infected wounds were firstly treated with negative pressure after debridement, then repaired with flap transplantation until the infection were completely controlled. Other wounds were repaired directly after debridement. The free lobulated latissimus dorsi flap was designed and applied to repair the irregular soft tissue defect of shank. The lobulated latissimus dorsi flap with the outer branch of the thoracodorsal artery ranged from 14.0 cm×7.0 cm to 24.0 cm×8.5 cm. The lobulated latissimus dorsi flap with the inner branch of the thoracodorsal artery ranged from 10.0 cm×5.0 cm to 15.0 cm×7.0 cm. When cutting the flap, the branch vessels should be protected to insure the continuity of the thoracodorsal artery. After spliced the 2 lobulated flaps, the thoracodorsal arteriovenous was anastomosed with the recipient region arteriovenous. All the donor sites were sutured directly. All patients were followed-up by outpatient and telephone regularly. Results Seven flaps survived well. Only 1 case of partial necrosis appeared at the distal edge of the lobulated flap and healed after wound care. All patients were followed-up from 3 to 30 months, averaged of 14 months. The texture of flap was flexible and the appearance was well. Only a linear scar was left in the donor site. The shoulder joint retained good mobility. Conclusion The lobulated latissimus dorsi flap has rich blood supply, concealed donor area and high survival rate after transplantation, which can flexibly repair the irregular soft tissue defect of the shank, and effectively prettify the appearance of the recipient area. This strategy has little effect on the appearance and function of the donor area, and worthy of promoting in clinic. Key words: Lobulated, latissimus dorsi flap; Transplantation; Shank; Microsurgical technique

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects

ObjectiveManagement of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases. Patients and methodsThirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6–33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months. ResultsAll the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs. ConclusionSkin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.

AV loop free flap: an interdisciplinary approach for perineal and sacral defect reconstruction after radical oncological exenteration and radiation in a colorectal cancer patient

BackgroundThe free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF.Case presentationWe describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region.ConclusionWe recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.

Laçage de lambeau libre de grand dorsal dans le cadre des soins locaux d’un lambeau en nourrice du cuir chevelu

Surgical treatment of large and multiple lesions of irradiated scalp may require subtotal scalp exeresis and reconstruction in two-stage free flap surgery: harvesting and placing the flap first, then scalp removing and defect covering in a second step. This strategy raises the question of how to care the flap between the two surgeries. We report an original technique of free latissimus dorsi flap lacing. A 70-year-old male, afflicted with familial cylindromatosis and treated by brachytherapy 18years ago, received a free latissimus dorsi myocutaneous flap in two-stage surgery, allowing 25×25cm pathological scalp exeresis. During first step, suture clips were fixed in two rows around the future scalp defect, in order to be used as anchors for the flap lacing. Braided wire were chosen for a better steerability, and to prevent knots untightening. Thus, the flap were placed in "anatomical" place, next to the scalp, pending secondary procedure. This situation permitted to avoid flap or pedicle compression or plication, and to ease flap care. The wires were tighten as shoelaces, allowing them to be undone and done as desired. The two-stage free latissimus dorsi flap reconstruction of scalp large defect permitted us to assess the flap reliability before final reconstruction. The lacing solution allowed us regular local care and convenient flap handling, while favoriting its optimal placing next to its future location.

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.

Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. Between January 2007 and May 2017, 129 female transsexuals, aged 20-53years (mean 24years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. The mean follow-up period was 43months (ranged from 13 to 137months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6cm in length and 12.4cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7cm (mean 15.8cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.

33 - Microsurgical musculocutaneous latissimus dorsi free flap as an option for phalloplasty in female transsexuals

33 - Microsurgical musculocutaneous latissimus dorsi free flap as an option for phalloplasty in female transsexuals

94 - Musculocutaneous latissimus dorsi free flap as an option for phallic reconstruction in transmen

94 - Musculocutaneous latissimus dorsi free flap as an option for phallic reconstruction in transmen

Defect reconstruction of the trochanter major after necrotizing fasciitis and multiple operations using an arteriovenous loop and latissimus dorsi free flap

Necrotizing fasciitis (NF) is a severe soft tissue infection which has to be treated with a radical debridement as the key element. In the further course often large tissue defects occur, so that a long-term stable defect reconstruction plays a crucial role after any successful debridement. The reconstruction can include split skin grafting or local and free flaps. Here we present a case of a 41-year-old male patient with a NF in the trochanter major region after spondylodesis and spinal cord stimulation (SCS) device implantation. After multiple operations including local and free flaps we performed a defect reconstruction using an arteriovenous (AV) loop and subsequent free latissimus dorsi transplantation leading to no further operations. This complex reconstruction can be considered as the final stage of any reconstruction latter.

Reconstruction of a Large Infected Midline Abdominal Wall Defect Using a Latissimus Dorsi Free Flap

Managing large infected midline abdominal defects are clinically challenging and technically demanding. The alloplastic materials, regional flaps, and component separation are usually infeasible because of the size, location, depth, and state of the defects. In these cases, the free flap is the only option with a large well-vascularized tissue that is free to inset regardless of the location. Herein, we report a case of 44-year-old man with a large infected midline abdominal wall defect who was completely treated with a latissimus dorsi myocutaeous free flap followed by negative pressure wound therapy.

Management of the total glossectomy defect with latissimus dorsi free flap

Radical surgical management of tongue cancer results in sever speech and swallowing disruption, impaired airway protection and life-threatening aspiration. Surgical objective of total glossectomy defect management is an adequate restoration of lingual mass and affected tissues of the floor of the mouth. Range of flaps are known to provide the adequate outcome, i. e. pediculed pectoralis major flap, anterolateral free thigh flap, rectus abdominis flap, radial free forearm flap and latissimus dorsi flap. In the current report, we present a case of glossectomy defect reconstruction with pediculed latissimus dorsi flap. Postoperative assessment of the transplant was made according to clinical criteria and viability of the flap was assessed via laser Doppler flowmetry. Signs of microcirculation improved starting from day 5 postoperatively, and were almost equal with donor site microcirculation signs on day 14. A sufficiently large mass of the transplant allowed to create a thickening over the epiglottis, as well as to close the defect in the oral cavity. The latissimus dorsi flap in the tongue reconstruction has a high potential: its use provides a relatively good quality of articulation, recovery of deglutition.

Tibia Adamantinoma Resection and Reconstruction with a Custom-Made Total Tibia Endoprosthesis: A Case Report with 8-Year Follow-Up

This case study describes a total tibia resection and reconstruction with a custom-made endoprosthetic replacement (EPR) and a long-term, 8-year follow-up. The patient underwent a total tibia adamantinoma resection in 2009. Reconstruction was performed with a custom-made total tibia EPR, where both the knee joint and ankle joint were reconstructed. Two muscle flaps, latissimus dorsi free flap and a pedicled medial gastrocnemius flap, were used for soft tissue reconstruction. The patient returned to normal life as a kindergarten teacher, without complications for eight years. This case demonstrated the importance of successful multidisciplinary teamwork in close collaboration with industry. In our best knowledge, no over 2 years of follow-up of total tibia replacement reports have been published.

Functional lower lip reconstruction with the partial latissimus dorsi muscle free flap without nerve coaptation.

The repair of extensive lower lip defects is difficult due to the presence of both functional and esthetic requirements. This report describes functional lip repair using the partial latissimus dorsi free flap without nerve coaptation. Reconstruction of the lower lip due to subtotal and total tissue defects was performed using latissimus dorsi free flap on twelve patients, between 2013 and 2017. The etiology was squamous cell carcinoma in six patients, malignant melanoma in one, firearm injury in three and microstomia in two. Following exposure of the lip defect, the partial latissumus dorsi muscle flap was harvested and transfered into the lower lip defect. The microvascular anastomoses was done and no nerve coaptation was performed. The muscle was covered with a skin graft taken from the thigh for mucosal and skin lining. Functional outcomes were assessed using physical examination, electromyography (EMG), electroneuromyography, cold/warm and pain sensation, two point discrimination (TPD), and Semmes Weinstein (SMW) tests. Postoperative course was uneventful for all of the flaps. Patients were followed for between fifteen months and four years (mean 28.2 months).Color match between the flap and the face and functional outcome was satisfactory. Reinnervation was detected at EMG in eleven patients undergoing surgery six months postoperatively.After 1 year, the patients demonstrated quite normal results of the test with SMW and TDP results. None of patients perceived both hot and cold sensation. The technique is an alternative option in lower lip reconstruction since it provides satisfactory functional and esthetic results despite absence of any neural coaptation.

Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps

When microsurgical transfers are required in posttraumatic lower limb reconstruction, surgeons must choose among many types of free flaps. Historically, surgeons have advocated muscular flaps for coverage of open lower extremity wounds, but fasciocutaneous free flaps are now often used with good results. This study aimed to compare the functional and aesthetic outcome of reconstruction by free muscular latissimus dorsi (LD) flap and free fasciocutaneous anterolateral thigh (ALT) flap used for soft tissue coverage of distal lower extremity open fractures. We performed a single-center, retrospective study of subjects with distal lower limb open fractures treated with LD flaps or ALT flaps between 2008 and 2014. Patients with limited follow-up or incomplete data were excluded from the analysis. Donor and recipient sites, early complications and long-term outcomes (functional and aesthetic) were studied and compared according to the type of flap. A total of 47 patients were included: 27 patients in the LD flap group and 20 patients in the ALT flap group. No significant difference was found regarding early and late complications and long-term functional outcomes (bone healing, infectious bone complications, flap healing). As for aesthetic outcome and donor-site morbidity, reconstruction using the ALT free flap had significantly better results (p < 0.05). In posttraumatic lower limb injury, either LD or ALT free flaps can be used for wound coverage with comparable long-term functional outcomes. The ALT flap provides better cosmetic results than LD.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases. Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap. All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications. The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Scapular tip and latissimus dorsi osteomyogenous free flap for the reconstruction of a maxillectomy defect: A minimally invasive transaxillary approach

The purpose of this study was to propose a novel, minimally invasive transaxillary approach for harvesting the scapular tip and latissimus dorsi osteomyogenous free flap for the reconstruction of a maxillectomy defect. A retrospective case series study of 4 patients who underwent reconstruction using a scapular tip composite free flap through the transaxillary approach was conducted. The data (age, sex, pathology, previous treatment and adjuvant treatment) were collected and analysed. Total operation time, number of hospital days and the cosmetic and functional outcome of reconstruction were analysed. Two male and two female patients were enrolled in this study. The patients' ages ranged from 52 to 59 years. All the patients had maxillectomy defects, with at least a classification of Okay type II, which were successfully reconstructed using a scapular tip and latissimus dorsi free flap through a minimally invasive transaxillary approach. The entire operation time for the primary tumour surgery and reconstruction ranged from 6.2 to 12.1h (mean, 11.1h). The average length of the hospital stay was 13 days (range, 10-16 days). No major donor site morbidity was observed, and there was no graft failure that required revision or exploration surgery. The minimally invasive transaxillary approach for harvesting the scapular tip and latissimus dorsi osteomyogenous free flap for the reconstruction of maxillectomy defect is a promising approach for more favourable functional and aesthetic outcomes when compared to the use of other bone containing free flaps and the classic approach for harvesting scapular tip and latissimus dorsi free flap.

Use of the SurroSense Rx System for Sensory Substitution of the Insensate Plantar Foot Resurfaced With Latissimus Dorsi Muscle Free Flap and Skin Graft

Degloving injuries of the foot pose an important challenge to the reconstructive surgeon. Key features of reconstruction include sensibility, stability, and durability. Preservation of plantar sensibility is considered to be a critical factor in the evaluation of lower extremity trauma, with its absence once being considered an indication for amputation. However, recent studies show that outcomes following limb preservation are not as adversely affected by a lack of plantar sensation than was once thought. With the increasing practice pattern of attempting limb salvage in the face of impaired plantar sensation, methods and devices designed to provide patients with maximal protection for loss of protective sensation (LOPS) in the affected limb are critical. The authors present the innovative use of the SurroSense Rx smart insole system (Orpyx Medical Technologies Inc, Calgary, Canada) in the management of LOPS in a patient with a degloving injury of the foot that was reconstructed with a latissimus dorsi free flap and skin graft. To the authors’ knowledge, this is the first reported case of use of such a system following a traumatic injury to the lower extremity.

Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections.

Background:Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging.Methods:Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3).Results:The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred.Conclusions:The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds.

Giant adenoid basal cell carcinoma of the scalp with intracranial involvement—successful management strategies for a rare entity

Adenoid basal cell carcinoma (BCC) is a rare but aggressive histologic subtype of BCC. The aim of this report is to present our multidisciplinary management strategy and a literature review on this seldom reported entity. A 72-year-old female with fungating giant BCC of the scalp, ear, and bone underwent preoperative biopsy revealing adenoid histology with infiltrating and nodular components. The patient underwent radical resection of the biparietal and occipital scalp, auriculectomy and craniectomy with dural resection. Immediate reconstruction of the intracranial and bony defect was performed with dural substitute and a titanium cranioplasty. The soft tissue defect was reconstructed with a latissimus dorsi free flap and split thickness skin graft using the right superficial temporal artery and vein as recipient vessels. Adjuvant external beam radiation was initiated postoperatively. Nearly 2 years postoperatively, she presented mesh exposure necessitating secondary reconstruction with debridement, hardware removal, and an anterolateral thigh (ALT) free flap, followed by flap debulking. Four years following initial presentation, she remains disease-free. To our knowledge, this is the only reported case of a giant, locally invasive scalp BCC with the adenoid subtype treated with composite resection and single stage reconstruction. Using an aggressive multimodal management paradigm, treatment and surveillance of the rarely reported, giant, locally invasive scalp BCC with adenoid subtype can result in a durable disease-free response and a functional, esthetic reconstruction. Evidence-based medicine level.