Latissimus Dorsi Free Flap Research Articles

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of seven cases

The purpose of this paper is to review the results of free latissimus dorsi transfer for scalp and cranial reconstruction in the case of large defects with exposed brain tissue, cranial bone without periosteal cover, and dura, which cannot be reconstructed with local flaps or skin grafts. Free latissimus dorsi transfer was carried out in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after long-standing osteitis, two tissue breakdown after irradiation, one defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was performed with a muscle flap (1) or a myocutaneous flap (6) in combination with a split-thickness skin mesh (1:1.5) graft in a single-stage procedure. In a retrospective clinical study, the following criteria were evaluated: (1) flap healing, (2) aesthetic result, and (3) complications. All flaps healed primarily, and all wounds remained closed without any signs of infection. Complete wound healing was achieved after 4 to 8 weeks, depending on the “take” of the skin grafts. Secondary skin grafting was necessary in two patients, while revision of the donor site was necessary in two patients. From an aesthetic point of view, four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patients judged the result as good or acceptable. Besides the free omentum flap, the free latissimus dorsi transfer is the only option for cover of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression, we use a myocutaneous flap. The skin island must be removed secondarily. In patients where no bone reconstruction is possible or planned, the de-epithelialized skin paddle can be used for correction of a contour defect.

Combined Method for Treating Severe Recurrent Post Burn Flexion Contracture of the Knee Joint: Free Flap and Ilizarov Apparatus

Post-burn severe recurrent flexion contracture of the knee joint is an extremely difficult reconstructive problem. The dense popliteal scar includes contracted neurovascular bundles, hamstring tendons, and sometimes extra-articular heterotopic ossification. Surgical release and skin grafting are often inadequate and doomed to failure. The authors presented their approach to this difficult problem, which includes surgical release of the scar, limited by the length of the neurovascular bundle; free latissimus dorsi flap transfer; and application of the Ilizarov apparatus. The knee joint is straightened gradually over the following weeks.

Free Latissimus Dorsi Flap Transfer for Scalp and Cranium Reconstruction

Free Latissimus Dorsi Flap Transfer for Scalp and Cranium Reconstruction

Combined Iliazarov and Free Flap for Severe Recurrent Flexion–Contracture Release

This article discusses the treatment of recurrent flexion-contracture of the knee after circumferential burns involving the entire limb. A two-team approach to surgery is used: the orthopedic team widely excises the scar tissue and releases tendons, muscles, and adjacent soft tissue that limit joint movement. The microsurgery team covers the exposed popliteal neurovascular elements with a latissimus dorsi free flap. However, full range of the knee is still limited by the short neurovascular bundle. Therefore, the orthopedic team applies a circular hinged Iliazarov external-fixator-frame to achieve gradual correction, until full range of the knee is achieved. Intensive physiotherapy and continuing use of extension splints for additional 6 months until the scars are deemed stable compliment the treatment regimen and prevent the recurrence of contractures. Between the years 2002 and 2003, we treated four patients (totaling five knee joints) with recurrent severe flexion-contractures after circumferential burns of the entire lower extremity. A significant limitation was caused by the abnormal scarring, which left the patients confined to a wheelchair. In all our patients, previous attempts to release the flexion-contracture failed. With the aforementioned technique, within 3 months after the procedure, all patients were able to walk. We encountered one major complication (ie, drop foot). At follow-up, all patients enjoyed a full range of motion and were able to walk. The strength of our approach comes from combining a free muscle flap with an Iliazarov external fixation and a detailed postoperative rehabilitation plan.

Use of Microvascular Free Flaps in the Reconstruction of the Anterior and Middle Skull Base

Different reconstruction techniques of the anterior and middle skull base as consequence of a defect after surgical treatment of neoplastic pathologies are described in the literature. The aim of the present study is to present our experience regarding the use of microvascular free flaps for reconstruction of the anterior or middle skull base after large defects caused by removal of malignant neoplasms. From 2000 to 2004, in the Department of Maxillo-Facial Surgery of the University of Rome "La Sapienza" and "Tor Vergata," 13 surgical procedures for reconstruction of anterior and middle skull base defects by free flaps were performed in 11 patients. Data on patient demographics, histopathology, location and size of defect, type of reconstruction, and postoperative complications were obtained from medical record charts. A safe soft tissue closure of the intracranial space was achieved in all patients. Defect repair was accomplished by revascularized transfer of rectus abdominis flaps in seven cases, latissimus dorsi muscle flaps in two patients, radial forearm flap in one case, and fibula flap in one case. There were two total flap losses; the secondary defect repair was accomplished in both cases by revascularized transfer of latissimus dorsi muscle flap. No donor site complications were observed in all the flaps. The mean operation time was 85 hours; patients were hospitalized for a mean period of 14 days. The method of choice for the reconstruction of anterior or middle skull base defect should be based upon careful evaluation of the single case and, particularly, the localization and entity of the residual defect. For defects that require large amounts of soft tissue, the latissimus dorsi free flap and the rectus abdominis free flap are the best appropriate choices for reconstructive procedures for anterior and middle skull base tumors.

Recurrent Localized Fibrous Tumor of the Pleura

Localized fibrous tumors of the pleura are rare. They are often asymptomatic and may have symptoms based on size, bronchial invasion, or hormone production, or a combination of these. Complete resection offers the best chance of cure. However, recurrence is reported in a significant number of patients and can often be treated by repeated resection, albeit with increasing difficulty. We present a case in which delayed recurrence occurred after excision of such a tumor. This required a chest-wall resection and reconstruction after which a second recurrence occurred. Further thoracotomy including a latissimus dorsi free flap procedure was needed for a third-time recurrence.

Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children

Objective Total phalloplasty is rarely performed in children due to the mutilation involved and the dilemma concerning neophallic size in children. We present a musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children with difficult psychological problems. Materials and methods Total phalloplasty was performed in eight boys aged between 10 and 15 years. Indications were small penis after failed epispadias repair (4), micropenis (3) and intersexuality (1). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethroplasty was performed in five patients using buccal mucosa, while in the remaining three a Mitrofanoff channel had been created previously. An inflatable penile prosthesis was implanted in two cases after puberty. Results Follow-up was from 6 to 53 months (mean: 29 months). Penile size varied from 13 to 16 cm in length and from 10 to 12 cm in circumference. No flap necrosis, either partial or total, was noted. The donor site healed acceptably in four cases while in the remaining four moderate scarring occurred. Function of the penile prostheses is satisfactory. Psychological status is significantly improved in all children. Conclusion Phalloplasty in childhood is indicated to prevent profound psychological problems related to body dysmorphia. The musculocutaneous latissimus dorsi flap is a possible choice for phalloplasty in children that enables good neophallic size as in adults. We recommend this surgery to be performed before puberty to ensure optimal psychosexual pubertal development.

Use of cross-leg latissimus dorsi free flap for repair of extensive lower leg electrical injury in a child

Extensive electrical injury to the distal part of the lower extremity presents a difficult reconstruction problem to the plastic surgeon. The amputation rate of the lower extremity in patients with high-voltage electrical injuries is reported as 40% [1]. Providing vascularized tissue to the injured area has been advocated as a method to improve outcome in electrical injuries [1]. The usefulness and reliability of muscle flaps diminish in the distal third of the leg. Early reconstruction with microvascular tissue transfers became the method of choice especially for large soft tissue defects due to condition of patient, microsurgical skill of surgeon and availability of suitable recipient vessels in defect area. Microvascular surgery in children is safe and carries a high success rate which was reported by Parry et al. [2]. Cross-leg free flaps have been described for reconstruction of leg defects in cases of trauma with no suitable recipient vessels in the vicinity of the defect. Vascular pedicle of the free flap can be temporarily anastomised to the recipient vessels in the contralateral leg and then divided after adequate neovascularisation of the flap occurs from the recipient bed. We present a 7-year-old child who sustained a high voltage burn to his right upper extremity and bilateral lower extremities. A pedicled latissimus dorsi flap was used to

Transfer of Innervated Split Latissimus Dorsi Free Musculocutaneous Flap for Flexion and Extension of the Fingers

A severe form of Volkmann contracture is associated with loss of flexor and extensor compartment muscles. An 11-year-old boy with Volkmann contracture was admitted to our clinics with flexion contracture of the wrist joint and total loss of flexor and extensor muscle functions. Split latissimus dorsi free flap was used for reconstruction. The muscle was split based on the branching of thoracodorsal nerve and artery within the muscle so that each part of the muscle is nourished and innervated by a branch of thoracodorsal nerve and artery. No complication has occurred, and the patient can now grasp objects, although he cannot achieve full range of motion of the fingers. We performed a single muscle transfer for reconstruction of both the extensor and flexor compartments in severe form of Volkmann contracture and omitted the use of a second muscle transfer, thus greatly decreasing the operative time, cost, and morbidity.

Entrapment der A. tibialis anterior in einer distalen Tibiafraktur nach intramedullärer Nagelung

We present a patient with a closed displaced distal tibia fracture with entrapment of the anterior tibial vessels in the fracture after tibial nailing. This complication was initially not recognised. After several debridements of the forefoot on the same side due to open metatarsal fractures and severe soft tissue injury, a free latissimus dorsi flap was used for covering the dorsum pedis. Preoperative angiography showed occlusion of the anterior tibial artery at the fracture line which was interpreted as a secondary occlusion due to an intima lesion of the vessel after injury. The entrapment in the fracture line was recognised intra-operatively during the preparation of the anterior tibial vessel.

Combined reconstruction of complex defects of the chest wall

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex) mesh, and Marlex mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.

Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.

Scalp reconstruction with free flaps using the external carotid artery and internal jugular vein as the recipient vessels without the need for interpositional vein grafts or arterio-venous loops

The technique of lengthening of the pedicles of the rectus abdominus and latissimus dorsi free flaps are described in five patients. Lengthening of these pedicles allowed scalp reconstruction using the external carotid artery and internal jugular vein as the recipient vessels without the need for interpositional vein grafts or arterio-venous loops. Post-operative recovery was uneventful in all cases.

Patellar Tendon Reconstruction Using a Free Latissimus Dorsi Flap Following Resection of a Prepatellar Myxofibrosarcoma: Case Report

The authors' experience indicates that good functional results are achievable in cases with wide resection of the knee extensor mechanism. They report a low-grade myxoid fibrosarcoma patient in whom a one-stage functional reconstruction was carried out by transfer of a free latissimus dorsi flap without secondary surgical procedures.

Hemispheric brain volume replacement with free latissimus dorsi flap as first step in skull reconstruction

Large skull defects lead to progressive depression deformities, with resulting neurological deficits. Thus, cranioplasty with various materials is considered the first choice in therapy to restore cerebral function. A 31-year-old female presented with a massive left-sided hemispheric substance defect involving bone and brain tissue. Computed tomography showed a substantial convex defect involving the absence of calvarial bone as well as more than half of the left hemisphere of the brain, with a profound midline shift and a compression of the ventricular system. There was a severe problem due to multiple deep-skin ulcerations at the depression margin, prone to skin perforation with a probability of intracranial infection. In a first step, a free myocutaneous latissimus dorsi flap was transplanted for volume replacement of the hemispheric brain defect, and 4 months later, artificial bone substitute was implanted in order to prevent progressive vault depression deformity. Healing was uneventful, and the patient showed definite neurological improvement postoperatively. Free tissue transfer can be a valuable option in addition to cranioplasty in the treatment of large bony defects of the skull. Besides providing stable coverage for the reconstructed bone or its substitute, it can also serve as a volume replacement.

Neurovascular musculocutaneous latissimus dorsi free-flap transfer for reconstruction of a major cheek defect with facial palsy in a 14-month-old child

This report deals with a female infant 14 months old at time of surgery. Three weeks before admission, she suffered a direct blow to the left cheek by hitting a table. Within 24 h, she developed a hematoma involving the whole cheek. Ten days later, she developed an eschar on the cheek and was referred to us. Three weeks after the initial trauma, the damaged tissues were debrided, including the skin, subcutaneous tissue, and muscle. The buccal mucosa remained intact. Facial palsy involving the territory of the buccal and mandibular branches was already evident at 3 weeks, as well as facial asymmetry. Consequently, a free musculocutaneous neurovascular latissimus dorsi free flap was proposed to restore the volume, shape, and function of the left half of the face. We present the surgical technique and the results 3.5 years later.

Advantages of Using Intercostal Vessels as the Recipients for Free Flaps Covering Lumbar Defects

Anatomic conditions in the lumbar region can complicate procedures for covering defects. In particular, a free flap is often required when the defect is large, in which case suitable recipient vessels must be found to insure revascularization. This report concerns a 50-year-old woman with multiple basal-cell carcinomas in the lumbar radiodermatitis zone, who underwent a large resection from D10 to S2. The defect was repaired using a free latissimus dorsi flap revascularized by microvascular anastomosis to the 8(th) intercostal pedicle. The advantages of using these recipient vessels are then considered relative to reports in the literature.

Reconstruction of soft tissue defects around the knee joint with free latissimus dorsi flap

Reconstruction of soft tissue defects around the knee joint with free latissimus dorsi flap

Microvascular reconstruction of a giant encephalocele defect in a 10-week-old infant

Microvascular reconstruction of a cranial defect in a 10-week-old infant, which is the youngest case in the literature, is reported. A latissimus dorsi free muscle flap was transferred to cover the defect and a split thickness skin graft was placed over the muscle flap. Despite the successful flap transfer in this case, microvascular reconstruction in an infant has its own risks and infants should be discussed as a separate entity apart from the other pediatric patients.

Bilateral latissimus dorsi flaps for the reconstruction of extensive scalp defects

The reconstruction of large scalp defects is occasionally required. Several methods of scalp reconstruction have previously been described. This paper presents the authors' experience with two patients in whom traditional methods were not sufficient and in whom bilateral latissimus dorsi free flaps were required. To evaluate the effectiveness of a new technique in reconstructing extensive scalp defects. Two case histories are presented. These include the rationale for the choice of reconstruction used as well as a discussion on the technical features of the surgery. Reconstruction was effective in both cases. However, one patient died in the early postoperative period from a pulmonary embolus. Bilateral latissimus flaps can be safely and effectively used in closing massive scalp defects in selected cases.