Pedicled Latissimus Dorsi Flap Research Articles

Adjuvant combined ozone therapy for extensive wound over tibia

Disinfectant and antibacterial properties of ozone are utilized in the treatment of nonhealing or ischemic wounds. We present here a case of 59 years old woman with compartment syndrome following surgical treatment of stress fracture of proximal tibia with extensively infected wound and exposed tibia to about 4/5 of its extent. The knee joint was also infected with active pus draining from a medial wound. At presentation the patient had already taken treatment for 15 days in the form of repeated wound debridements and parenteral antibiotics, which failed to heal the wound and she was advised amputation. Topical ozone therapy twice daily and ozone autohemotherapy once daily were given to the patient along with daily dressings and parenteral antibiotics. Within 5 days, the wound was healthy enough for spilt thickness skin graft to provide biological dressing to the exposed tibia bone. Topical ozone therapy was continued for further 5 days till the knee wound healed. On the 15th day, implant removal, intramedullary nailing, and latissimus dorsi pedicle flap were performed. Both the bone and the soft tissue healed without further complications and at 20 months follow-up, the patient was walking independently with minimal disability.

Analyse médico-économique du lambeau libre de DIEP en reconstruction mammaire

We postulate that the absence of a CPT code for DIEP (deep inferior epigastric perforator) free flap in breast reconstruction is in part responsible for the delayed adoption of this modern technique in France. In order to provide data to our regulating health agency, we determined the cost of this technique compared to a gold standard. We performed a cost-identification study, comparing costs of DIEP free flap versus latissimus dorsi pedicled flap with implant (LD+I) in secondary breast reconstruction following irradiation. Over a 12-month period, direct medical and non-medical costs as well as indirect costs were recorded in both groups (DIEP and LD+I). In an academic department funded by the national health system, total cost of a secondary breast reconstruction by DIEP free flap was 10,671 ± 3005€ (n=57) versus 8218 ± 2049€ (n=18) for the LD+I group (P<0.05). Mean OR occupation time was 390 ± 64minutes for DIEP versus 283 ± 44minutes for LD+I (P<0.05). Mean hospital stay was 6 ± 2 days for DIEP versus 5 ± 2 days for LD+I (P>0.05). DIEP free flap technique offers a long lasting breast reconstruction at an reasonable expense compared to the LD+I (+22%). Furthermore, in an academic department, collaboration of two microsurgeons during DIEP flaps allows OR times to drop significantly and become competitive with LD+I.

Reconstruction of the Anterior Chest for Radiation Ulcer and Radiation Sarcoma with Contralateral Pedicled Latissimus Dorsi Flap

Reconstruction of the Anterior Chest for Radiation Ulcer and Radiation Sarcoma with Contralateral Pedicled Latissimus Dorsi Flap

Does the Latissimus dorsi insert on the iliac crest in man? Anatomic and ontogenic study

The Latissimus dorsi muscle is usually considered as inserted on the iliac crest, but it is separated from it by the thoracolumbar fascia. In our experience based on the harvesting of pedicled Latissimus dorsi flaps to cover cervicofacial loss of substances, we have found that in some cases, the muscular fibers of the anterior border of the muscle are directly inserted on the iliac crest. In these cases, the harvesting of the flap could be more distal. To determine whether this direct muscular insertion is frequent or not, we performed dissections on 30 fresh cadavers of the lower insertion of the Latissimus dorsi muscle, and 6 dissections of human fetuses to study the ontogeny of these insertions. The Latissimus dorsi muscle presented direct muscular insertions on the iliac crest in 13.33% of cases. The fetal dissections showed that before 30 weeks of development, the anterior part of the muscle was directly inserted on the iliac crest, and after it was separated from it by the thoracolumbar fascia. Although the harvesting of the Latissimus dorsi in continuity with the thoracolumbar fascia has been described in pedicled flaps, it is usually considered that it is impossible to harvest Latissimus dorsi musculocutaneous flaps in contact with the iliac crest, because there are no perforating vessels from the thoracolumbar fascia to the skin. According to our results, in some cases, it could be possible to harvest a pedicled musculo-cutaneous LD flap more distal that it is usually described.

Reconstruction complexe de la région mammaire après traumatisme thoracique grave par arme à feu

This case report is of a 47-year-old woman who suffered a ballistic chest trauma with severe left hemothorax and heart wound. She was treated in emergency for the collapse by heart surgery. Then the coverage for her soft thorax tissue loss was done by an ipsilateral musculocutaneous latissimus dorsi pedicled flap. The patient was subsequently addressed to our team for a repair, especially for reconstruction of the left breast. Initially, rehabilitation of aesthetics units breast was achieved through the realization of an abdominal advancement flap, and breast volume was restored by several sessions of lipomodeling. The surgical alternatives were very limited for this post-traumatic complex breast reconstruction. Due to ballistic trauma, no reliable recipient vessels allowed a microsurgical solution, and the ipsilateral latissimus dorsi was used for the coverage. In conclusion, the restoration of the aesthetics units with lipomodeling has achieved a very good result in this extreme thoracomammary region repair.

Metachronous melanoma in breast reconstruction patients

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.

Anterior Chest Wall Reconstruction with a Low Skin Paddle Pedicled Latissimus Dorsi Flap: A Novel Flap Design

Anterior Chest Wall Reconstruction with a Low Skin Paddle Pedicled Latissimus Dorsi Flap: A Novel Flap Design

Immediate latissimus dorsi pedicle flap reconstruction following the removal of an eight kilogram giant phyllodes tumour of the breast: a case report

IntroductionPhyllodes tumors account for less than 1% of breast tumors in women, and giant phyllodes tumors are those that are larger than 10 cm in diameter. Removal of such large tumors places a huge burden on the surgeon to reconstruct a breast that is aesthetically acceptable by the patient. We report what may be the largest giant phyllodes tumor and, most likely, the first latissimus dorsi flap used to cover such a large defect caused by the resection.Case presentationWe report the case of a 36-year-old Malaysian woman who presented with a three-year history of gradually increasing swelling of the left breast, with skin changes. Examination revealed a huge, globular, lobulated mass measuring 400 mm by 350 mm. The patient had a mastectomy with an immediate latissimus dorsi pedicled myocutaneous flap reconstruction. The breast weighed 8.27 kg, and ex vivo, the tumor measured 280 mm by 250 mm by 180 mm. Histopathologic analysis confirmed the diagnosis as a giant phyllodes tumor. At 12-month follow-up, the patient reports no complications and is satisfied with the aesthetic outcome.ConclusionGiant phyllodes tumors are very rare tumors that can reach up to 40 cm in diameter. Reconstruction of such a defect is a great challenge, and we report what we believe is the first latissimus dorsi flap to cover successfully a defect of approximately 400 mm by 350 mm.

Six Cases of Reconstruction with Latissimus Dorsi Pedicled Flap for Head and Neck Defects in the Era of Free Flap Reconstruction

Received October 16, 2010 Revised January 4, 2011 Accepted January 12, 2011 Address for correspondence J. Hun Hah, MD Department of Otorhinolaryngology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea Tel +82-2-2072-0215 Fax +82-2-745-2387 E-mail jhunhah@snu.ac.kr Reconstruction with free flaps has become the choice of reconstruction for most patients with head and neck defects. However, pedicled flaps, such as pectoralis major pedicled flap and latissimus dorsi pedicled flap (LDPF), can also be used instead in selected patients. We performed LDPFs in 6 patients from November 2007 to September 2009. Five of the patients were females with either vascular diseases or large skin defects, or they were highrisk old patients. One male patient received LDPF as a salvage after tongue reconstruction with a free flap failed. Various types of head and neck defects were effectively managed with LDPF without complications. LDPF can be one option for head and neck reconstruction especially in patients who may hve high risk in undergoing free flap reconstruction. Korean J Otorhinolaryngol-Head Neck Surg 2011;54:174-8 Key WordsZZLatissimus dorsi flap ᆞPectoralis major myocutaneous flap ᆞPedicled flap ᆞ Free flap reconstruction.

A rare case of fungal osteomyelitis of the ribs requiring surgical reconstruction

I report a rare case of fungal osteomyelitis of ribs in a 23 year old male who presented with multiple discharging sinuses on the right side of the chest. The patient did not respond to medical management with fluconazole and ultimately surgical treatment in the form of excision of affected ribs and reconstruction with a pedicled myocutaneous latissimus dorsi flap had to be done. Fungal osteomyelitis although uncommon must always be thought of when treating a case of osteomyelitis of the ribs.

Experience of angiosarcoma in the North of England Bone and Soft Tissue Tumour Service

Angiosarcomas are rare aggressive sarcomas of vascular endothelial origin. These tumours have the potential to be multicentric and are associated with high rates of local recurrence, which makes treatment challenging. The gold-standard is that these patients are managed in specialist centres by a multidisciplinary team. We present our experience of managing patients with angiosarcoma in the North of England Bone and Soft Tissue Tumour Service and a review of the literature. A prospectively collated electronic database was used to identify patients with angiosarcoma treated between 2000 and 2008, and an analysis performed of demographics, anatomical site, surgical excision and reconstruction, local disease recurrence and metastatic disease. Fifteen patients (ten female, five male, mean age 71 years) were identified. Eight patients developed tumours in a previously irradiated area, after a mean of 11 years. Six patients had metastatic disease at presentation. Fourteen patients underwent wide surgical excision of the tumour, of which nine required defect reconstruction (five free latissimus dorsi flaps, two free anterolateral thigh flaps, two pedicled latissimus dorsi flaps). One patient was treated with chemotherapy only. Five of 14 patients received adjuvant radiotherapy, and one received adjuvant chemotherapy. Two out of 14 patients developed local recurrence. Eight patients developed metastases, the majority of which were pulmonary. Estimated five-year survival was calculated as 33% in our patient cohort. Angiosarcomas are aggressive, difficult to treat tumours, which can occur secondary to a multitude of causes. Clinical suspicion, biopsy and early diagnosis are essential to allow optimum treatment, which currently consists of radical surgery, together with adjuvant radiotherapy and chemotherapy.

Objective improvement in upper limb lymphoedema following ipsilaterall latissimus dorsi pedicled flap breast reconstruction – a case series and review of literature

We present a series of three patients whose upper limb lymphoedema (following total oncologic mastectomy and level III axillary clearance) resolved significantly after ipsilateral pedicled latissimus dorsi (LD) flap breast reconstruction. A retrospective review of the medical records of patients who had undergone oncologic mastectomy and level III axillary clearance with subsequent LD pedicled flap reconstruction was carried out. Individuals who had undergone review and treatment by the lymphoedema service were identified and patients with incomplete pre- or post-operative records were excluded. A minimum follow-up period of 2 years of conservative therapy, as well as 2 years post-operatively was undertaken. The rate of improvement of lymphoedema following conservative therapy was, on average, 0.095 mL/week and reached a plateau at 2-year follow-up. Following latissimus dorsi flap breast reconstruction, the rate of improvement in lymphoedema increased in all three cases, with an average improvement of 2.55 mL/week and remained sustained in the follow-up period. Pedicled myocutaneous flap reconstruction of the ipsilateral breast proved to be a useful treatment for upper limb lymphoedema in our series. This adds an important dimension to the assessment and treatment of patients with upper limb oedema resulting from mastectomy and axillary clearance.

Selection of Myocutaneous Flaps for Reconstruction Following Oncologic Resection of Sarcoma

The use of myocutaneous flaps for reconstruction following sarcoma resection is an important surgical technique. In this study, we discuss the issues surrounding proper selection of myocutaneous flaps following wide resection. A total of 59 patients underwent tumor resection and immediate reconstruction. In 26 patients, the tumor location was in the trunk and reconstructed mainly with pedicled latissimus dorsi and tensor fascia lata flaps. Functional muscle transfers were used for extremity reconstruction in 25 patients. Reinnervation was observed for 23 muscles after a mean period of 5.7 months. At final follow-up, primary wound healing was satisfactory in all surviving patients without severe complications. For sarcoma within the trunk, a pedicle latissimus dorsi flap is most suitable. The tensor fascia lata flap is best indicated for lower buttock or abdominal wall sarcomas. For extremity sarcomas, functional latissimus dorsi or gracilis muscle flaps produce good outcomes for restoration of motor function as well as wound healing.

EComment: Vacuum-assisted closure in thoracic surgery - an alternative to pedicled latissimus dorsi flap?

eComment: Vacuum-assisted closure in thoracic surgery - an alternative to pedicled latissimus dorsi flap?

Sweat Gland Carcinoma

Sir: Sweat gland carcinoma was first reported in 1865 but remains poorly understood due to its rarity, heterogeneity of subtypes, and confusing nomenclature. A 72-year-old man presented with a 15-cm ulcerated, firm, pedunculated lesion of his left axilla that had recently doubled in size after 20 years of relative indolence (Fig. 1). He reported no systemic signs of illness, weight loss, or functional impairment. The results of his neurovascular examination were normal and he had palpable axillary lymph nodes. A computed tomography scan showed no chest wall involvement or pulmonary metastasis. The core needle biopsy demonstrated a malignant epithelial neoplasm.Fig. 1.: A 15-cm ulcerated left axillary mass doubled in size over the previous year after 20 years of relative stability.The mass was excised with 1-cm margins, and axillary lymphadenectomy was performed, followed by a pedicled latissimus dorsi flap and skin graft reconstruction. Pathologic analysis confirmed “hidradenocarcinoma with preexisting hidradenoma” with negative margins. All 35 lymph nodes were negative for malignancy. Sweat gland carcinomas are rare, accounting for 0.005 percent of all malignant epithelial neoplasms.1 Lesions are typically a violaceous nodule, papule, or plaque, although other colors have been reported. Most occur in the head and neck, followed by the extremities; only occasionally do they appear on the trunk. Age at presentation ranges from 1 to 86 years, with most cases occurring in the fifth to seventh decades of life. These tumors overall occur equally in both sexes, although certain subtypes appear to have a predilection for males or females. Most sweat gland carcinomas grow slowly, with patients frequently having delayed presentation of 5 years or more. Rapid growth often occurs in a previously slow-growing lesion, possibly due to malignant degeneration of an originally benign tumor. Lymphatic metastasis typically occurs at a rate of 20 to 24 percent. Regional cutaneous metastasis and hematogenous spread have also been noted.2 Local recurrence occurs in 14 to 20 percent of cases.2 Most patients survive beyond 10 years and usually die of another cause, although notable exceptions of death within 6 months of diagnosis due to metastasis (to lymph node and lungs) have been reported.3 Controversy remains as to the most appropriate classification system. Table 1 outlines a system reported by Cruz that most readily accommodates the variety of names used in the literature.4Table 1: Modified Classification SystemWide local excision and evaluation of lymph node status via sentinel lymph node biopsy or regional lymphadenectomy are recommended. Radiotherapy is reserved for recurrence or metastatic lymph node involvement.2 Chemotherapy does not currently have a role in management, although administration of trastuzumab has been reported in a metastatic tumor with Her-2/neu gene amplification.5 As is typical for sweat gland carcinomas and for hidradenocarcinoma (malignant acrospiroma) in particular, this tumor manifested rapid growth and ulceration after two decades as an indolent, small lesion. Management of these tumors should include wide excision and evaluation for lymph node and pulmonary metastasis. Adjuvant radiation therapy is likely appropriate for cases with lymph node metastasis or high-grade tumors. DISCLOSURE The authors have no commercial associations or financial disclosures with regard to the article. ACKNOWLEDGMENT The authors thank Tiffany Sun, B.S., for her assistance in procurement of data for the article. J. Alan Chambers, M.D., M.P.H. Avron H. Lipschitz, M.D. Daniel Petrisor, D.M.D., M.D. Department of Surgery C. Alejandra Garcia-Mitchell, M.D. Department of Plastic Surgery Shelly Stepenaskie-Wolz, M.D. Department of Pathology University of Texas Southwestern Medical Center Dallas, Texas

Extension or combination of an autologous latissimus dorsi flap in breast reconstruction

The lateral thoracodorsal flap and the pedicled latissimus dorsi flap have been extensively described for breast reconstruction. In search of an alternative, non-microsurgical, autologous method of breast reconstruction we used both flaps combined to achieve adequate volume. The technique was used on three patients who had had a mastectomy at least two years previously. All flaps healed uneventfully with the appearance of an ordinary latissimus dorsi breast reconstruction. The method shows promising initial results and can be used as an alternative when reconstruction with autologous tissue is preferred.

Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience

Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience

Immediate breast reconstruction with latissimus dorsi flap and implant: audit of outcomes and patient satisfaction survey

A retrospective case-note study of immediate breast reconstruction using the pedicled latissimus dorsi flap with a silicone implant and a patient-satisfaction survey were carried out. Fifty-four reconstructions were performed in 52 patients between March 2001 and October 2006. Major complications included capsular contracture requiring capsulotomy (7.4%); minor complications included donor-site seroma (20.4%) and superficial wound problems (13%). The average score out of 10 for the appearance of the reconstructed breast whilst wearing a bra was 8.35; score for appearance whilst out of a bra was 7.0 and overall symmetry was 6.6. On the basis of the scores, 16 patients were grouped as excellent; 15 as good; seven as fair and two as poor. Significantly, more of the patients without a contralateral matching procedure graded their reconstruction as good or excellent (p=0.024). The pedicled latissimus dorsi flap with a silicone implant gives the majority of patients a satisfying reconstruction, without necessarily requiring a contralateral matching procedure, whilst minimising postoperative complications.

Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps – technique illustration and clinical outcomes

Reconstruction of large soft-tissue defects of an upper extremity is very challenging due to the unavailability of expendable local muscle. Appropriate soft-tissue restoration is an essential component of such reconstruction treatment protocols, and often requires a vascularised flap to protect the exposed neurovascular and musculotendinous structures. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilisation and expendability. Moreover, the flap provides well-vascularised tissue from a region far from the area of injury. This paper describes the technique for pedicle latissimus dorsi flap transfer and also reports the authors' experience of its application for the acute treatment of massive upper-extremity soft-tissue injuries. 20 patients with large soft-tissue defects over the upper extremity caused by trauma and infection underwent aggressive debridements and immediate soft-tissue reconstruction using a pedicled latissimus dorsi muscle flap. Successful reconstructions were achieved and primary healing of wounds occurred in all patients, with minor complications. The donor site morbidity was minimal. At a mean of 3.6 years' follow-up (range: 1.5-6 years), all functional results were good and the patients were satisfied with their outcomes.

Reconstruction of the shoulder region using a pedicled latissimus dorsi flap after resection of soft tissue due to sarcoma

Six patients underwent reconstruction of soft tissue using a pedicled latissimus dorsi flap after tumour resection of the shoulder region. Successful flap healing was observed in all patients. One flap exhibited partial skin necrosis, which healed after conservative treatment. The pedicled latissimus dorsi flap is a safe, easy, and reliable technique for reconstruction of the shoulder region.