Latissimus Dorsi Musculocutaneous Flap Research Articles

Intractable Bronchopleural Fistula After Lung Resection in Mycobacterial Infection; Surgical and Endoscopic Treatment With Fibrin Glue Application Followed by Latissimus Dorsi Musculocutaneous Flap Coverage: A Case Report

Postoperative bronchopleural fistula (BPF) is a challenging and complicated problem to cope with. Involving with multidisciplinary care team is essential for the best outcome. This report provides our experiences in intractable BPF after lung resection surgery which fail to completely heal after received surgical and endoscopic treatment. A 56-year-old female with no known underlying disease presented with nonmassive hemoptysis, productive cough, low-grade fever, and significant weight loss for 3 years. Her sputum consisted of Mycobacterium abscessus with multidrug resistant. Radiological examination revealed reticulonodular infiltration at middle lobe of the right lung and lingular lobe of the left lung, also a bronchiectatic change of both lungs. After 3 years of medical treatment, neither of her symptoms nor radiological findings improved. Therefore, a video-assisted thoracoscopic surgery (VATS) with middle lung lobectomy and lingulectomy was performed. After that, BPF at lingular stump occurred. Many surgical and endoscopic techniques followed by latissimus dorsi musculocutaneous flap along with vacuum dressing were introduced to encourage the complete healing of the BPF. One month later, the patient’s clinical was improved and endoscopic findings showed nearly complete healing of the BPF. In conclusion, surgical and endoscopic treatments combined with postoperative vacuum dressing encourage patient’s symptoms to be subsided.

Comparison of Ischemic Preconditioning and Systemic Piracetam for Prevention of Ischemia-Reperfusion Injury in Musculocutaneous Flaps.

Ischemia-reperfusion injury plays an important role in flap failure. Ischemic preconditioning technique is the only proven method for preventing ischemia-reperfusion injury, but it is not used widely in daily practice because of difficulties such as prolonging the operation time, need for surgical experience, and increasing the risk of complications. This study has been performed with the assumption that piracetam may be a simple and inexpensive alternative to the preconditioning technique due to its antioxidant, antiaggregant, rheological, anti-inflammatory, antiapoptotic, cytoprotective, and immune modulating effects. Thirty-two rats were divided into four groups and latissimus dorsi musculocutaneous flaps were raised. No extra procedure was applied, and no treatment was given to the control group. Four hours of ischemia was created by clamping the thoracodorsal pedicle in the second group. The animals in the third group were treated with 10 minutes of ischemia and reperfusion periods as a preconditioning procedure before the 4 hours of ischemia. Animals in the fourth group received systemic piracetam 30 minutes before and 6 days after reperfusion. Nitric oxide and myeloperoxidase levels in serum and tissue, acute inflammatory cell response, and vascular proliferation in tissue were examined at the postoperative 24th hour and 10th day. Myeloperoxidase activity in both preconditioning and piracetam groups, was significantly lower than the ischemia-reperfusion group. Acute inflammatory cell response was similarly decreased in both preconditioning and piracetam groups compared with ischemia-reperfusion group. Tissue measurements of nitric oxide were also significantly higher in both preconditioning and piracetam groups than in the ischemia-reperfusion group. However, vascular proliferation increased in the preconditioning group, while it did not show any significant change in the piracetam group. This study shows that systemic piracetam treatment provides protection against ischemia-reperfusion injury in musculocutaneous flaps and can offer a simple and inexpensive alternative to the preconditioning technique.

Dual Purpose of De-Epithelialized Latissimus Dorsi Musculocutaneous Flap for Treatment of Chronic Frontal Sinusitis and Frontal Bone Defect.

Treating frontal sinusitis refractory to endoscopic sinus surgery and complicating frontal bone defect remains a challenge. One surgical option determined is free flap transfer, which has the versatility to accommodate adequate sinus obliteration and reconstruct skin and bone defects. After successful free flap transfer, forehead recessus deformity can emerge as an esthetic problem for patients waiting for cranioplasty. Hence, the authors examine three cases in which they performed free latissimus dorsi musculocutaneous (LDM) flaps for chronic frontal sinusitis with frontal bone defect. All LDM flaps survived without complications, and all patients achieved passable forehead contours without cranioplasty and with no occurrence of infection. In our procedure, the muscle portion of the LDM flap was used to obliterate the frontal sinus, which is similar to conventional free LDM flap. Conversely, our procedure also uses the de-epithelialized skin paddle of the LDM flap filled with the frontal bone defect, which is distinct from conventional free LDM flap. Thus, preventing postoperative forehead recessus deformity has been the identified as primary advantage of our procedure. The use of the free de-epithelialized LDM flap transfer fulfills two goals: controlling chronic frontal sinusitis and restoring a passable forehead contour.

Acute compartment syndrome secondary to anterolateral thigh flap harvesting in a pediatric patient

Introduction:The anterolateral thigh (ALT) flap is the most popularly used flap for major soft tissue reconstruction. Although it is widely used, acute compartment syndrome (ACS) in pediatric patients has rarely been reported in the literature. We herein reported a case of ACS in a 6-year-old girl after ALT flap harvest with direct closure of the donor site.Patient concerns:A 6-year-old girl was admitted to the Second Hospital of Jilin University with crush injury on the palmar aspect of the right hand and wrist.Diagnosis:Examination showed soft tissue defect of the hand and wrist, damage on the thenar muscles, lightly crushed flexor tendons, crushed median nerve, and ulnar artery thrombosis.Interventions:The defect was closed with an ipsilateral ALT flap measuring 9 cm in length by 6 cm in width.Outcomes:After debridement was performed 3 times, the majority of the rectus femoris and lateral femoris were removed. Secondary closure by skin grafting was performed 2 weeks later. Three days after the procedure, necrotic tissues were noted on the edges of the wound. The diagnosis of ACS of the right was made. A second exploration was decided, and an extensive anterior compartment fasciotomy was performed. After 6 weeks of vacuum sealing drainage therapy, the defect was closed with a free latissimus dorsi musculocutaneous flap. At 4 months of follow-up, the right thigh wound had healed. At 6 months of follow-up, quadriceps muscle weakness remained. At 1 year of follow-up, the patient's mobility had been significantly improved, but diminished sensation remained on the lateral aspect of the thigh.Conclusion:ACS can occur after ALT flap harvesting in pediatric patients and should be recognized as early as possible to avoid devastating complications.

Elbow flexion reconstruction after arm-sparing excision for high-grade triton sarcoma: a case report

BackgroundSoft tissue sarcomas affecting the root of an upper extremity raise the question of limb amputation depending on their location, size, and malignancy. Malignant triton tumors are a rare subtype of neurofibrosarcomas that have been poorly reported in the literature. We report the case of a challenging reconstruction of the upper extremity using a pedicled latissimus dorsal flap.Case presentationA 25-year-old Occidental man was referred to our sarcoma unit for the management of a large, high-grade malignant peripheral nerve sheath tumor with no regional or distant extension and very fast progression. He was treated first by concomitant neoadjuvant radiotherapy and chemotherapy. Carcinologic excision was performed “en bloc” including the skin, the tumor, and the flexor muscles of our patient’s elbow. Coverage of the skin defect and elbow flexion restoration were achieved by using a homolateral pedicled musculocutaneous latissimus dorsi flap. Histological analysis showed an R0 resection. The reconstruction process recovered a complete bending of his elbow. He is still in remission at 26 months follow-up.ConclusionsA malignant triton tumor is a rare, aggressive, and high-grade sarcoma. It was successfully treated and this case report describes an effective treatment modality. Reconstructive surgery, allowing large, complete tumor removal, is indispensable after neoadjuvant chemotherapy and radiotherapy.

Incidence and Reconstruction of Chronic Radiation-Induced Chest Wall Ulceration in Postoperative Breast Cancer Patients

Background: Breast cancer patients who receive radiotherapy for postoperative tumor control are exposed to the possibility of adverse effects including osteoradionecrosis and ulceration. The purpose of this study is to explore reconstruction of ulcers according to their characteristics, and also to investigate the incidence of skin ulcers in patients who had undergone radiotherapy after modified radical mastectomy (MRM).Methods: Data of patients who underwent radiation therapy after MRM from 1979 to 2003 were collected. Demographics and radiation details were analyzed along with their reconstruction outcomes and pathologic characteristics. Effects of surgical debridement and reconstruction strategies for success were also assessed.Results: A total of 113 patients had radiotherapy after MRM in our institution, out of which nine patients (7.96%) developed ulcerations in the chest wall. Eleven patients underwent reconstructive surgery, including the nine patients who developed chest wall ulcerations and an additional two patients from other hospitals. Seven patients had thoracoepigastric flaps while three had latissimus dorsi musculocutaneous flaps and one had a perforator flap. The average initial wound size was 5.77 cm<sup>2</sup>, and this average was enlarged by 23.6 times after debridement. There was no reconstructive failure in any of the patients. Fibrosis, necrosis with ulceration, and dystrophic calcification were common pathological findings. Dystrophic calcification was found in seven of 11 cases. Additionally, ossification with bone formation was noted in three of seven cases with dystrophic calcification.Conclusion: A thorough preparation of the wound bed and reconstruction with flaps appropriate for the defect can successfully treat chronic radiation-induced ulceration.

Less Invasive Management of Tissue Deficits for Deep Sternal Wound Infections.

Background:The frequency of sternomyelitis after cardiovascular surgery has been reported to be 0.4% -5%.Methods:The treatment method used for 47 patients (29 male and 18 female) who developed sternomyelitis after sternotomy with tissue defects in the chest was examined retrospectively.Results:Of the original conditions, the most frequent was coronary artery disease undergoing bypass grafting (22 cases, 46.8%), followed by acute aortic dissection (10 cases, 21.3%). The number of times debridement was performed was: once, 35 cases; twice, 11 cases; 7 times, 1 case; and unknown, 2 cases. The most frequent time of occurrence of sternomyelitis was within 2 weeks after surgery (12 patients, 25.5%). A residual internal thoracic artery remained on both sides in 28 cases (59.6%), and only on the right side in 17 cases (36.2%); there was no remaining one in 2 cases (4.2%). The reconstruction method was a pectoralis major musculocutaneous flap in 31 cases (66.0%), internal mammary artery perforator flap in 7 cases (14.9%), rectus abdominis musculocutaneous flap in 4 cases (8.5%), omentum transplant in 3 cases (6.4%), superior epigastric artery perforator flap in 2 cases (4.3%), external abdominal oblique muscle flap in 1 case (2.1%), and latissimus dorsi musculocutaneous flap in 1 case (2.1%). The internal mammary artery perforator flap and the superior epigastric artery perforator flap have been effective treatment.Conclusions:In 47 patients, our method of treatment for tissue defects of the chest wall after sternal osteomyelitis was examined, and an algorithm using less invasive management was proposed.

Volumetric change of the latissimus dorsi muscle after postoperative radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap.

BackgroundThis study aimed to determine the magnitude of volume reduction of the latissimus dorsi (LD) muscle after treatment using only postoperative radiotherapy (PORTx) in patients who underwent immediate breast reconstruction using an extended LD musculocutaneous (eLDMC) flap after partial mastectomy.MethodsWe retrospectively reviewed 28 patients who underwent partial mastectomy and an eLDMC flap, received only PORTx, and underwent chest computed tomography (CT) 7 to 10 days after surgery and 18±4 months after the end of radiotherapy, from March 2011 to June 2016. The motor nerve to the LD was resected in all patients. One plastic surgeon performed the procedures, and the follow-up period was at least 36 months (mean, 46.6 months). The author obtained LD measurements from axial CT views, and the measurements were verified by an experienced radiologist. The threshold for statistical significance was set at P<0.05.ResultsA statistically significant decrease in the LD volume was found after the end of PORTx (range, 61.19%–80.82%; mean, 69.04%) in comparison to the measurements obtained 7 to 10 days postoperatively (P<0.05). All cases were observed clinically for over 3 years.ConclusionsThe size of an eLDMC flap should be determined considering an average LD reduction of 69% after PORTx. Particular care should be taken in determining the size of an eLDMC flap if the LD is thick or if it occupies a large portion of the flap.

Latissimus Dorsi-Myocutaneous Flap in the Repair of Titanium Mesh Exposure and Scalp Defect After Cranioplasty.

Titanium mesh was widely used for cranium defect repair but associated with high complication rates. In this study, the authors describe a method using latissimus dorsi-myocutaneous flap in the repair of titanium mesh exposure and scalp defect after cranioplasty, and the plate retaining is also achieved. Fifteen patients from April 2012 to May 2016 underwent this procedure, the age ranged from 32 to 62 years and 47 years old on average, and all the patient had plate exposure combined with surgical site infection and variation of scalp defect. All the patients had fully flap survive, and follow up ranged from 6 months to 24 months, 1 patient had titanium mesh re-expose and received additional operation to remove the plate. The free latissimus dorsi musculocutaneous flap could supply large size of bulky tissue coverage with good blood supply and strong anti-infection ability. This method was an option for retaining the titanium mesh and repairing the exposure for the mild infection with small size scalp defect patient.

The Utility of Disposable Negative Pressure Wound Therapy (PICO) in Wound Healing of Latissimus Dorsi Musculocutaneous Flap Donor Sites

Background: Among treatments aiming to solve surgical wound complications, negative pressure wound therapy (NPWT) is considered an innovative method. NPWT can promote wound healing, protect the wound from infection and reduce the tension on suture sites. At the same time, the large machine required in the therapy led to some inconvenience. The PICO system has recently been developed as a simple pocket-sized NPWT device. By comparing the time required for healing of the wound, incidence of wound complications, duration of hospital stays, and dressing costs, we attempted to confirm the utility of PICO for managing latissimus dorsi musculocutaneous flap donor sites.Methods: PICO was used on nine donor sites of patients who had undergone breast reconstruction using latissimus dorsi musculocutaneous flaps. PICO was applied immediately after operation and removed on the 9th day. In the control group, daily conventional dressings were administered commensurate with the condition of the wounds. We defined the wound healing time to the point when no more dressing was needed. For the costs of dressing, only costs incurred on the donor sites were included.Results: Wound healing was proven to be faster in the PICO group (P=0.035) versus the control group, and no complications were observed in the PICO group. Also, the cost of PICO was lower compared to the costs incurred by the conventional dressing method (P&lt;0.001).Conclusion: We suggest that PICO can reduce wound complications on areas where anatomical movement could lead to tension, while also reducing dressing costs.

Axillary Reconstruction Using a Pedicled Thoracodorsal Artery Perforator Flap Including Latissimus Dorsi Muscle Strip

For axillary reconstruction, most reconstructive surgeons use the latissimus dorsi flap because of its usefulness and reliability. However, the latissimus dorsi musculocutaneous flap poses complications such as donor site morbidity and poor aesthetic results. Moreover, the thoracodorsal artery perforator (TDAP) flap, without muscle, presents difficulties for the delicate procedure of dissecting the perforators separately. Therefore, we propose the use of a pedicled TDAP flap including a latissimus dorsi muscle strip for axillary reconstruction, as it is believed to be easier and safer to perform.

Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections.

The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair. The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center. All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated. Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology. Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.

A Case of Dermatofibrosarcoma Protuberans of the Breast Followed by Secondary Breast Reconstruction Using Latissimus Dorsi Musculocutaneous Flap and Silastic Implant

A Case of Dermatofibrosarcoma Protuberans of the Breast Followed by Secondary Breast Reconstruction Using Latissimus Dorsi Musculocutaneous Flap and Silastic Implant

Strategies for innervation of the neophallus

A fundamental goal of phalloplasty includes the construction of a sensate neophallus. Both tactile and erogenous sensation are important for protective sensation (including retention of implantable penile prosthesis) as well as sexual satisfaction. This article will describe the sensory innervation of flaps commonly used for phalloplasty including the radial forearm flap, anterolateral thigh flap, and musculocutaneous latissimus dorsi flap. The sensory innervation of the perineum and external genitalia will be reviewed as a basis for selecting recipient nerves. Additionally, surgical techniques, such as neurorrhaphy, will be discussed. Finally, outcome data, although limited, will be assessed.

A Case of Using a Flap in Flap after the Free Latissimus Dorsi Musculocutaneous Flap Transfer

A Case of Using a Flap in Flap after the Free Latissimus Dorsi Musculocutaneous Flap Transfer

Preservation of bilateral elbow joints those were exposed and infected after severe heat press injuries using bilateral pedicled Latissimus Dorsi Musculocutaneous flaps. －A case report－

Preservation of bilateral elbow joints those were exposed and infected after severe heat press injuries using bilateral pedicled Latissimus Dorsi Musculocutaneous flaps. －A case report－

A case of chronic empyema with pulmonary fistula after right upper lobectomy effectively treated via plombage of a pedicled latissimus dorsi musculocutaneous flap

A case of chronic empyema with pulmonary fistula after right upper lobectomy effectively treated via plombage of a pedicled latissimus dorsi musculocutaneous flap

Volumetric changes of the latissimus dorsi muscle after postoperative chemotherapy in cases of immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap and implant.

This study aimed to evaluate the volume reduction of latissimus dorsi muscle in patients who underwent immediate breast reconstruction using extended latissimus dorsi musculocutaneous (eLDMC) flap with implant after skin/nipple sparing mastectomy (SSM/NSM) and postoperative chemotherapy (POCTx). We retrospectively reviewed clinical records of 19 patients who underwent this surgery with POCTx, and checked chest computer tomography (CT) at 7-10 days after surgery and 6-14 months after the end of chemotherapy, from May 2015 to October 2016. The motor nerve to latissimus dorsi muscle was severed in all patient. One plastic surgeon intervened and the follow up period was at least 18 months. Author obtained the area of latissimus dorsi muscle using the Picture Archiving and Communication System (PACS) in the axial view of the chest CT and it was verified by the experienced radiologist. The statistical test was performed (P<0.05). There was statistically decrease in latissimus dorsi muscle volume after the end of POCTx, range from 51.5-77.5%, average volume decrease was 62%, compared with latissimus dorsi muscle volume of the CT taken 7-10 days postoperatively (P<0.05). After a minimum follow-up period of 18 months, 14 of the 19 cases were satisfactory for both the surgeon and the patient. In 4 patients, breast volume was symmetrical when wearing bra, but the outline of the 90 cc implant was unfavorable. One patient had a smaller size of reconstructed breast than the other. The size of the implant should be determined considering that average latissimus dorsi muscle reduction is 62%. Especially, the size of the implant should be chosen carefully if latissimus dorsi muscle is thick or it occupies a large portion of the entire flap.

浅大腿動脈の再建を要した下腿の遊離広背筋皮弁移植の 1 例

浅大腿動脈の再建を要した下腿の遊離広背筋皮弁移植の 1 例

Large-to-Small End-to-Side Venous Anastomosis in Free Flap Transfer

BackgroundVessel size discrepancy is one of the major risk factors for anastomotic failure in free flap transfer. The situation becomes challenging for reconstructive microsurgeons when the recipient vein is much smaller than the flap vein. We investigated the feasibility of large-to-small end-to-side venous anastomosis for such cases. Materials and methodsThe subjects were 16 consecutive patients who underwent a free flap transfer for oncologic defects with a large-to-small end-to-side venous anastomosis. The larger flap vein was anastomosed to the side slit of the smaller recipient vein under an operating microscope. Surgical details and postoperative outcome were investigated retrospectively. ResultsAn anterolateral thigh flap was used in five patients, a superficial inferior epigastric artery flap in four, a thoracodorsal artery perforator flap in three, and a latissimus dorsi musculocutaneous flap and a fibular osteocutaneous flap in two patients each. The internal mammary vein and the anterior tibial vein were most frequently used as a recipient vein (four patients each), followed by the deep inferior epigastric vein (three patients). The extent of vessel size discrepancy ranged from 1.3- to 3.3-fold, and the mean discrepancy was 1.9-fold. No anastomotic failure occurred postoperatively, and the flap survived in all patients. ConclusionsLarge-to-small end-to-side venous anastomosis can be a versatile option when only a small vein is available as a recipient vein. Internal mammary, deep inferior epigastric, and anterior tibial veins are good candidates for this technique.