Pedicled Latissimus Dorsi Musculocutaneous Flap Research Articles

The Use of the Deep Brachial Artery as the Recipient Artery for Free Perforator Flap Transfer: An Anatomic Study and Clinical Applications.

Background and Objectives: Soft tissue reconstruction after sarcoma ablation in the posterior aspect of the upper arm has been commonly addressed using the pedicled latissimus dorsi musculo-cutaneous flap. The use of a free flap for coverage of this region has not been reported in detail. The goal of this study was to characterize the anatomical configuration of the deep brachial artery in the posterior upper arm and assess its clinical utility as a recipient artery for free-flap transfers. Materials and Methods: In total, 18 upper arms from 9 cadavers were used for anatomical study to identify the deep brachial artery's origin and point of crossing the x-axis, which was set from the acromion to the medial epicondyle of the humerus. Measurements of the diameter were taken at each point. The anatomic findings of the deep brachial artery were employed clinically in the reconstruction of the posterior upper arm after sarcoma resection using free flaps in 6 patients. Results: The deep brachial artery was found in all specimens between the long head and the lateral head of the triceps brachii muscle, and it crossed the x-axis at an average distance of 13.2 ± 2.9 cm from the acromion, with an average diameter of 1.9 ± 0.49 mm. In all 6 clinical cases, the superficial circumflex iliac perforator flap was transferred to cover the defect. The average size of the recipient artery, the deep brachial artery, was 1.8 mm (range, from 1.2 to 2.0 mm). The average diameter of the pedicle artery, the superficial circumflex iliac artery, was 1.5 mm (range, from 1.2 to 1.8 mm). All flaps survived completely with no postoperative complications. Conclusions: The deep brachial artery can be a reliable recipient artery in free-flap transfers for posterior upper arm reconstruction, given its anatomical consistency and sufficient diameter.

Key to the Success of a Pedicled Latissimus Dorsi Musculocutaneous Flap in Patients with Soft Tissue Defects Around the Elbow Complicated by Trauma

Key to the Success of a Pedicled Latissimus Dorsi Musculocutaneous Flap in Patients with Soft Tissue Defects Around the Elbow Complicated by Trauma

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

Sternal resection and reconstruction for metastasis due to breast cancer: the Marlex sandwich technique and implantation of a pedicled latissimus dorsi musculocutaneous flap

BackgroundThe treatment of hemotogenous solitary sternal metastases by breast cancer remains a controversial issue. Sternal resection for select patients might provide good long-term local control.Case presentationA 63-year-old woman was admitted to our hospital with a mass at the sternum and right second to third costochondral cartilage. She had undergone bilateral mastectomy for breast cancer 13 years earlier. A percutaneous biopsy was performed, and the mass was diagnosed as solitary metastasis due to breast cancer. She received two courses of weekly paclitaxel and bevacizumab, and computed tomography (CT) revealed shrinking of the mass in the sternum. We performed surgical resection with curative intent for a multimodality approach. Parasternectomy and removal of the right second and third costochondral cartilage was performed. A prosthesis was created to fill the defect by sandwiching molded methylmethacrylate between polypropylene mesh. The prosthesis was fixed to the cut ends of the costochondral cartilage and the residual sternum. Finally, a harvested latissimus dorsi myoctaneous flap was transpositioned to cover the chest midline wound. Negative surgical margins at the stump of the sternum and costochondral cartilage were revealed.ConclusionParasternal resection and reconstruction by the Marlex sandwich technique and implantation of a pedicled latissimus dorsi myocutaneous flap for metastasis due to breast cancer was safely performed.

Hinge Flap with Triangular Extension for Reconstruction of Pharyngocutaneous and Laryngocutaneous Fistulas.

Hinge flaps are commonly used for closure of a pharyngocutaneous fistula (PCF) or laryngocutaneous fistula. These flaps are employed to augment the wall of the pharynx or larynx, but the junction between the reconstructed and native lumens can eventually become narrow and irregular after reconstruction with standard hinge flaps. We devised a method of adding a triangular extension to the end of either or both flaps and used it to treat 3 patients. In 1 patient who developed a PCF (4 × 10 cm) after laryngectomy followed by radiotherapy, the fistula was closed with 2 hinge flaps. One flap had a caudal triangular extension. The residual skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. Another patient who developed a PCF (2.5 × 3 cm) after laryngectomy underwent 2-stage reconstruction using a buccal mucosal graft with a triangular extension, followed by 2 hinge flaps. A patient who developed an laryngocutaneous fistula (1 × 2 cm) after radiotherapy and subsequent partial laryngectomy underwent reconstruction using 2 hinge flaps, each of which had a triangular extension. The skin defect was covered by another flap. Postoperative CT or video fluoroscopic examination of swallowing showed a smooth lumen with no strictures in all 3 patients. The triangular extension of the hinge flap supplements the pharyngeal/laryngeal wall at the junction between the reconstructed and intact regions, thus avoiding postoperative stricture. Especially with PCF reconstruction, restoration of a smooth luminal surface minimizes dysphagia.

Proprioceptive Neuromuscular Facilitation Approach for Functioning Muscle Transfer: A Case Report

Background: This case report of a patient with a an avulsion brachial plexus injury demonstrates the effectiveness of proprioceptive neuromuscular facilitation (PNF) integrated into hand therapy following a pedicled latissimus dorsi (LD) musculocutaneous flap transfer for elbow and fingers extension. Methods: A 29-year-old right-hand dominant male suffered from high-energy crushing and avulsion injury at the workplace. He presented with pain (5/10), numbness over right upper limb, shoulder strength weakness (2/5), and brachial plexus injury including median, radial and ulnar nerve palsies. A pedicled LD musculocutaneous flap was performed to reconstruct the elbow and hand function simultaneously in the primary stage. The treatment program was divided into three phases: (1) immobilization phase (within 4 weeks after surgery), (2) facilitation phase (4 to 8 weeks after surgery), (3) strengthening phase (8 weeks after surgery). Application of PNF principles (manual contact, visual input and verbal instructions) and techniques (rhythmic initiation, repeated stretch, combination of isotonics and irradiation with D1 extension) were guided in the facilitation phase and early stage of strengthening phase to facilitate active control of elbow and finger extension. Results: The patient could actively move the elbow and finger extensors after 2-weeks of PNF therapy. Up to 4 months after reconstructive surgery, the patient's elbow and fingers extensor reached strength of M4 and M3. In the next months, several palliative surgeries (e.g. elbow joint arthroplasty, thumb and wrist extension reconstruction) were performed. The patient returned to his original job as a manufactory worker 2 years after the accident. Conclusion: PNF may be an effective and specific component of rehabilitation in the recovery of function in the early phase post injury for a patient with a major upper arm traction avulsion amputation reconstructed by a pedicled latissimus dorsi muscle.

Pedicled latissimus dorsi flap for arm defects: A report of twenty-three cases

Background: The latissimusdorsi muscle or myocutaneous flap is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and post mastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck and upper limb either as a pedicled flap or as a free flap. It has been described for reconstruction of hand and foot defects as microvascular flap and functional reconstruction of elbow in brachial plexus injuries. Aim: Evaluate its role in reconstruction of arm defects. Patient and Methods: Twenty three cases of pedicled Latissimus dorsi flaps for arm defects are enrolled into the study. The cause of the defect, the site and size of the defect, associated injuries and timing of flap cover are also noted. Observaion and Result: Out of 23 cases majority of defects are from trauma (19 cases) and rest from neoplastic resection (4 cases) all belonging to the age group of 15-45 years with defect size ranging from 10 × 15 cm 2 to 15 × 25 cm 2 . The average duration of follow up was 6 months to 1 year. All the flaps survived without partial loss. Six patients developed seroma at flap donor site which settled with multiple aspirations. Two patient developed hyper trophy at the borders at the donor site scar. Three patients had stretching of the scar. There were no other donor site complications at the flap or skin graft sites. All patients have cosmetically satisfactory result. Conclusion: Pedicled Latissimus dorsi muscle and musculocutaneous flap with a split thickness skin graft is the primary choice for reconstruction of large complex arm defects.

Causes of failure in the use of a pedicled latissimus dorsi musculocutaneous flap in delayed reconstruction of a scalp and facial defect: a case report

Background: To prevent failure of a pedicled latissimus dorsi musculocutaneous axial flap in high facial reconstruction, it is advisable that the blood flow and extent of reach of the thoracodorsal vessel must be ascertained during preoperative assessment using Laser Doppler perfusion imaging. The aim of this report was to document possible causes of failure and necessary precautions that will enhance the take of this flap in the repair of scalp and high level facial defects. Methods: A 19-year-old female patient was brought into the casualty department of our hospital with a history of extensive injury to the left side of the scalp and face due to a road traffic accident. A delayed reconstruction of the defect using a pedicled latissimus dorsi musculocutaneous flap was performed two weeks following admission. Results: On the sixth post-operative day, a blister appeared on the flap and the color of the flap skin had turned black, there was a persistent purulent discharge, her vital signs had deteriorated by the 8th postoperative day, fever and vomiting had persisted. Conclusion: Although latissimus dorsi island or axial musculocutaneous flap offers sufficient tissue of compatible skin color and thickness, it may be necessary to avoid tunneling of the axial flap and ensure that adequate assessment and precautions are done before embarking on this time consuming reconstructive surgery.Keywords: flap failure, latissimus dorsi flap, scalp and facial trauma

Transaxillary-Subclavian Transfer of Pedicled Latissimus Dorsi Musculocutaneous Flap to Head and Neck Region

Free-tissue transfer is the reconstruction of choice for most head and neck defects. However, pedicled flaps are also used, especially in high-risk patients and after failure of a free flap. The aim of this study was to compare transaxillary-subclavian pedicled latissimus dorsi musculocutaneous (PLDMC) flap, pectoralis major musculocutaneous flap, and free-tissue transfer for head and neck reconstruction in American Society of Anesthesiologists grades II and III patients. During the last 4 years, PLDMC flap with a modified transaxillary-subclavian route for transfer to the neck was used in 8 patients, pectoralis major musculocutaneous flap was used in 7 patients, and free flaps were used in 12 patients for head and neck reconstructions. These 3 methods were compared regarding the flap dimensions, complications, flap outcome scores, hospitalization time, and cost of the treatment. Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regarding the operation time, flap complications, outcomes, and cost of total treatment, although statistically not significant, PLDMC group offered the fastest reconstruction with highest flap outcome scores and minimum cost. Free-tissue transfer is the procedure of choice especially for functional reconstruction of head and neck region. Occasionally, there exist cases in whom a pedicled flap could offer a safer option. The PLDMC flap transferred via the transaxillary-subclavian route may be preferred than, with advantages including increased arc of rotation, safer pedicle location, shorter duration of the procedure, and reduced complication rates and costs.

Vakuumtherapie bei sternaler Wundinfektion - Initiale Therapie zur Infektkontrolle und Überbrückung zur plastisch chirurgischen Rekonstruktion

Vacuum Assisted Closure (V.A.C.) is a sound strategy to control severe post-sternotomy infection. Secondary re-wiring of the sternal bone or reconstructive surgery may be required later to achieve complete wound closure. Ten patients with severe sternal bone infection underwent initial V.A.C. therapy and delayed surgery for wound closure. Complete wound healing was achieved in all cases. As a case report we describe a patient with right-sided mastectomy and irradiation for breast cancer, who developed severe post-sternotomy infection and sternal bone necrosis following CABG. A combination of V.A.C. therapy and surgical reconstruction using a pedicled latissimus dorsi musculocutaneous flap led to complete wound closure.

Large Chest Wall Reconstruction Using Titanium Micromesh and a Pedicled Latissimus Dorsi Musculocutaneous Flap: Report of a Case

The patient was a 54-year-old woman with a dermatopleural fistula and necrosis of the third to the fifth anterior ribs after postoperative adjuvant radiation for right breast cancer. After resection of the chest wall and combined partial resection of the right upper and middle lobes of the lung, the thoracic cage defect was stabilized by titanium micromesh and the soft tissue defect was covered by an ipsilateral pedicled latissimus dorsi musculocutaneous flap. The dorsal skin defect was covered by split-thickness skin grafts 3 weeks later. The advantages of titanium micromesh lie not only in its good biocompatibility and mechanical strength, but also in its light weight and low radiological interference. No paradoxical movement or other prosthesis-related complications occurred during the follow-up period. Thus, we consider that titanium micromesh is a suitable material to use in the reconstruction of a large chest wall defect.

The creation of new rotation arc to the rat latissimus dorsi musculo-cutaneous flap with delay procedures.

BackgroundLatissimus dorsi musculocutaneous flap is one of the most frequently performed reconstructive techniques in surgery. Latissimus dorsi muscle has two arcs of rotation. It is classified as type V muscle. This muscle can be elevated on the thoracodorsal artery to cover large defects in the anterior chest and also, the muscle can be elevated on the segmental vessels to cover midline defects posteriorly. The aim of this study was to create a new arc of rotation on a vertical axis for the muscle and investigate effectiveness of vascular and chemical delays on the latissimus dorsi muscle flap with an inferior pedicle in an experimental rat model. We hypothesized that the latissimus dorsi muscle would be based on inferior pedicle by delay procedures.MethodsWe tested two different types of delay: vascular and combination of vascular and chemical. We also tried to determine how many days of "delay" can elicit beneficial effects of vascular and combination delays in an inferior pedicled latissimus dorsi musculocutaneous flap. To accomplish this, 48 male Sprague-Dawley rats were randomly subjected to vascular or combination delay (vascular and chemical). In addition, one ear of each rat was assigned into a delay procedure and the other ear was used as a control. Results were evaluated macroscopically, and micro-angiography and histological examinations were also performed. As a result, there was a significant difference in viable flap areas between vascular delay alone and control groups (p < 0.05).ResultsThe higher rate of flap viability was obtained in seven-day vascular delay alone. However, there was no significant difference in the viability between seven-day vascular delay and five-day vascular delay (p < 0.05), so the earliest time when the flap viability could be obtained was at five days. The rate of flap viability was significantly higher in the vascular delay combined with chemical delay than the control group (p < 0.05).ConclusionThe combination of vascular and chemical delays increased the rate of viability. Nevertheless, there was no significant difference between vascular delay alone and combination of vascular and chemical delays. Chemical delay did not significantly decrease the delay period. Better histological and microangiographical results were achieved in delay groups compared to control groups. We concluded that the arch of the latissimus dorsi musculocutaneous flap can be changed and the flap can be used for various purposes with the delay procedures.

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis.

Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

Technical modifications of the latissimus dorsi pedicled flap to increase versatility and viability.

Describe the elevation and insetting of the pedicled latissimus dorsi musculocutaneous flap. Review history of this flap's evolution and personal series of 68 consecutive cases since 1984. Retrospective review. Tertiary, referral, academic center. Retrospective review of 68 consecutive patient records in which the pedicled latissimus dorsi musculocutaneous flap was used to reconstruct head and neck defects. Overall flap survival and postoperative complications were used as outcome measures. Thirty-one women and 37 men underwent reconstruction with the latissimus dorsi pedicled flap between 1984 to 1998. The mean age was 61 years. Sixty-three cases followed postoncologic ablation and 5 cases addressed traumatic tissue loss. Forty-three patients had prior radiotherapy and 26 patients had undergone prior reconstructive surgery. The overall flap survival rate was 67/68 (98.5%), with one case of complete flap necrosis. Six cases of partial flap necrosis occurred. There were 8 other minor complications including fistula, wound dehiscence, hematoma and cerebrospinal fluid accumulation. Fifty-six donor sites were closed primarily resulting in 2 dehiscences and 17 seromatas. Three of 12 skin grafts to the donor sites were compromised. The excellent flap survival rate (98.5%) is the result of proper patient selection and adherence to three technical fundamentals: skin paddle design, pedicle dissection, and pedicle stabilization. The minimal donor site morbidity also demonstrated in this series supports the continued use of the latissimus dorsi pedicled flap for reconstruction of head and neck defects.

Improving the donor site cosmesis of the latissimus dorsi flap.

A modification in the design of the pedicled latissimus dorsi musculocutaneous flap is described that aims to minimize the cosmetic morbidity of its donor site. The implications of this variation are discussed with particular reference to use of the flap in postmastectomy reconstruction.

Salvage of extensively burned upper limbs by a pedicled latissimus dorsi flap

Very deep burns of the arm and elbow lead to soft tissue necrosis and infection with exposure of important structures. Aggressive debridement should be performed as early as possible to cut the vicious circle, and the defect, which may be extensive, should be covered by well-vascularized tissues. The reliability and versatility of the pedicled latissimus dorsi muscle or musculocutaneous flap make it our first choice in the management of this problem. A retrospective study of three patients for whom salvage of the upper limb has been achieved by the use of a pedicled latissimus dorsi flap is presented, illustrating the advantages of this technique.

The pedicled latissimus dorsi musculocutaneous flap

The pedicled latissimus dorsi musculocutaneous flap (PLDMCF) is one of the most reliable and versatile flap of which head and neck surgeons must learn about the operative technique. We have performed 10 head and neck reconstruction using PLDMCF for the reconstruction of 4 intraoral, one intraoral and extraoral defects combined, 2 mesopharyngeal, one hypopharyngeal, 2 anterior chest wall (mediastinal tracheostomy) defects. There has been no flap loss, but two minor leakage. Although PLDMCF elevation required that the patient be placed in a lateral position, it was thought the first choice reconstructive procedure for the cases which require the plural skin flaps, for women and for the mediastinal tracheostomy.

Delayed Breast Reconstruction with a Pedicled Contralateral Latissimus Dorsi Musculocutaneous Flap

Use of the pedicled contralateral latissimus dorsi musculocutaneous flap is a safe and valuable option in delayed breast reconstruction. This flap also can create an anterior axillary fold by including fat from the lumbosacral fascia.

Subclavicular approach in head and neck reconstruction with the latissimus dorsi musculocutaneous flap

As an alternative procedure in transferring the pedicled latissimus dorsi musculocutaneous flap to the head and neck, we have devised a subclavicular approach and applied it successfully in our clinic. This approach reduces the distance of the transfer and leaves no bulkiness over the clavicle. The subclavian vessels, the brachial plexus and the cervical pleura are retracted safely beyond the periosteum during the procedure, and the pedicle of the flap is protected under the clavicle postoperatively.

Reconstruction of breast after super-radical mastectomy with a pedicled latissimus dorsi flap and a free TRAM flap

Reconstruction of the breast after super-radical mastectomy is difficult because not only a breast mound but also the subclavicular and anterior axillary regions must be reconstructed simultaneously. If a defect is extremely large a single flap cannot fulfil these two purposes. For this goal we use two flaps, an ipsilateral pedicled latissimus dorsi musculocutaneous flap and a free TRAM flap pedicled on the inferior epigastric vessels. A latissimus dorsi flap along with a silicone gel prosthesis is used to reconstruct a breast mound and the free TRAM flap is transferred to augment the subclavicular and anterior axillary regions. We have used this technique successfully in three cases.