Pedicled Latissimus Dorsi Research Articles

Versatility of the Pedicled Latissimus Dorsi Myocutaneous Flap in Reconstruction of Upper Limb and Trunk Soft Tissue Defects

Purpose The purpose of the study was to share our indications, technique, outcome, and complications associated with the pedicled latissimus dorsi myocutaneous flap (LDMF) for reconstructing various upper limb and trunk soft tissue defects.Patients and Methods We reviewed the prospectively collected data of the patients who underwent reconstruction of upper limb/trunk soft tissue defects with pedicled LDMF between January 2016 and March 2019. By analyzing the clinical scenarios, the location of flap inset, the arc of rotation, reach of the flap, and associated complications, we put forward few significant findings from our experience.Results Thirty-four patients were included in the study: 13 of them underwent LDMF for coverage of upper limb defects, 12 of them for postradical mastectomy soft tissue defects, 8 for posterior trunk reconstruction, and 1 for sternal wound infection. LDMF was successfully used to cover the scapula, anterior and posterior arms, axilla, cubital fossa, mid-forearm, breast, sternum, and midline dorsal wounds. When used reversely, the flap could cover the exposed spine in the midline dorsum. Three patients (9%) had major complications (two patients had partial flap necrosis which required additional debridement and skin grafting, and one patient required an additional transpositional flap). Three patients had minor complications (managed nonoperatively).Conclusion Pedicled LDMF is a straightforward and versatile option for reconstruction of the varied upper limb and trunk soft tissue defects with minimal complications.Level of Evidence This is a level IV, therapeutic, retrospective study.

Comparison of the Pedicled Latissimus Dorsi Flap With Immediate Fat Transfer Versus Abdominal-based Free Flaps for Breast Reconstruction

PURPOSE: Abdominally based free flaps and the latissimus dorsi and immediate fat transfer (LIFT) procedure are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique while the LIFT combines a common set of techniques familiar with all plastic surgeons. Comparison of the 2 methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making. METHODS: A retrospective review was performed to analyze outcomes of both patients who underwent the LIFT procedure and patients who underwent abdominal-based flaps between March 2017 and July 2018 by the senior surgeon. Data were analyzed per breast. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat grafting procedures. Continuous variables between the 2 groups were compared using the 2-sample t test. Categorical variables were compared using Pearson’s chi-square and Fischer’s exact tests as appropriate. RESULTS: Sixty-five breasts were identified as having undergone abdominal-based flap procedures, and 31 breasts underwent the LIFT procedure. Average follow-up time was 8 months (± 4.6 months) for the abdominal-based flap patients and 7.9 months (± 4.2 months) for the LIFT patients (P > 0.05). Demographics were not statistically different between the 2 flap cohorts (P > 0.05). This includes age, body mass index (abdominal-based flaps, 29.9 ± 4.76; LIFT, 28.2 ± 6.2 kg/m2), diabetes mellitus, hypertension, connective tissue disease, and current tobacco use. Additionally, the use of neoadjuvant chemotherapy and adjuvant radiation was not statistically different between the 2 groups (P > 0.05). The LIFT procedure cohort had a shorter length of operation time (375 ± 136 minutes) as compared to the abdominal-based flap cohort (514 ± 136 minutes) (P < 0.001). Similarly, the LIFT cohort had a shorter length of hospital stay (1.65 ± 0.85) than the abdominal-based flap cohort (3.83 ± 1.65) (P < 0.001). However, the average abdominal-based flap procedure had a shorter time until drain removal (13.3 ± 4.3 days) as compared to the LIFT (24.0 ± 11.2 days). The number of overall, major (requiring operation), and minor complications including infection/cellulitis, seroma, dehiscence, hematoma, and flap issues and/or failure were also not statistically different (abdominal-based flaps: major 20.0%, minor 27.7%; LIFT: major 12.9%, minor 19.35%). Similarly, the need for reoperations for revisions (abdominal-based flaps 0.80 ± 0.71 versus LIFT 0.87 ± 0.71) and fat grafting (abdominal-based flaps 41.54% versus LIFT 58.8%) was not statistically different. CONCLUSIONS: Both the LIFT versus abdominally based free flaps have similar outcomes and complication rates. However, the LIFT may be preferred in patients that require shorter operation times due to comorbid medical conditions or with severe obesity which may result in abdominal donor site problems. Furthermore, the LIFT may be the fully autologous breast reconstruction choice for nonmicrosurgeons.

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.

Salvage of the failed implant-based breast reconstruction using the Deep Inferior Epigastric Perforator Flap: A single centre experience with tertiary breast reconstruction

The longevity and durability of implant-based reconstruction is limited and many patients who develop complications seek alternative reconstruction. Recent studies have shown tertiary reconstruction with autologous tissue to be safe in the short term. But no study has looked in-depth at the motivation for seeking referral and its long-term outcome. This was a retrospective study using patient case-notes and a prospectively-collated database. One hundred and fifteen patients underwent tertiary breast reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap between 1998 and 2016. Mean age was 49 (23-67). The predominant initial reconstruction was expander (71%). Twenty nine percent received a definitive reconstruction (implant with acellular dermal matrix or pedicled latissimus dorsi). The proportion of patients who received post-mastectomy radiotherapy (PMRT) to their implant was 72%. Thirty four percent underwent surgical salvage prior to referral for autologous tissue and this was significantly higher in the group that did not receive PMRT (29% vs 40, p = 0.04). Predominant motivation for autologous reconstruction was poor cosmesis (62%) and/or grade III/IV capsular contracture (27%). Mean time from implant to DIEP was 4 years 5 months. Ten percent had complications requiring re-operation. Flap loss was 0.7%. Fifty five percent required an additional ipsilateral procedure and 47% required symmetrization. Median follow-up was 20-months (6-months to 7-years). We present the largest UK series of tertiary breast reconstruction. Tertiary reconstruction is safe with a surgical outcome comparable to delayed autologous reconstruction. Patients with implant complications often had multiple failed attempts at salvage prior to referral. We advocate careful consideration of implants in the setting of PMRT and early referral for autologous tissue once complications become apparent.

Video-assisted thoracic surgery for pleuroperitoneal communication

BackgroundHydrothorax due to pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD). Approximately 50% of the patients need to convert to hemodialysis.Case presentationA 65-year-old man with chronic renal failure due to membranoproliferative glomerulonephritis underwent CAPD. Seven months after starting CAPD, a chest X-ray showed a right hydrothorax. For performing radioscintigraphy, 99mTc-macro-aggregated albumin was administered into the peritoneal cavity with dialysate, and a leakage point of the dialysate into the right pleural cavity was detected. He was diagnosed with PPC and underwent video-assisted thoracic surgery (VATS). The hole was closed by direct suturing and reinforced by a pedicled latissimus dorsi muscle flap (LDM). The patient resumed CAPD 7 weeks later and had no recurrence of the right hydrothorax.ConclusionsVATS was a useful method for treating PPC. A pedicled LDM flap is an effective material for preventing the recurrence of PPC.

Latissimus Dorsi Flap for Functional Reconstruction of the Deltoid: A Descriptive and Illustrated Surgical Technique Guide

Loss of deltoid function due to irreversible damage to the muscle or its innervation results in severe disability and affects the remainder of the upper extremity even if the elbow, wrist, and fingers remain functional. The pedicled latissimus dorsi flap is our preferred method for restoring shoulder motion in well-selected patients with loss of deltoid function and an at least partially functional rotator cuff. The flap’s inherent biomechanical advantages enable superior shoulder flexion and abduction compared with other local muscle transfer techniques described for this condition. Moreover, minimal donor-site morbidity is associated with this procedure, and the flap’s ample size is capable of restoring normal shoulder contour in cases of large soft tissue defects. Herein is a descriptive and illustrated surgical technique for performing a functional reconstruction of the deltoid using a pedicled latissimus dorsi flap. Also included is a review of the pertinent anatomy, indications/contraindications, and the outcomes and complications of this procedure.

Pedicled Latissimus Dorsi Flap for Complex Arm Defects: A Report of Twenty Cases from Two Centers

Introduction: The reconstruction of extensive defects ofthe upper limb are challenging regarding both coverage andfunction. Latissimus dorsi is a suitably located muscle forresurfacing defects in the arm, elbow and forearm especiallywith exposure of the vital structures. It is a large flap, witha long pedicle and can be used as a muscle or musculocutaneousflap.Aim of the Work: Evaluate the role of pedicled latissimusdorsi flap in reconstruction of complex posttraumatic armdefects.Patients and Methods: Pedicled Latissimus dorsi flapswith split thickness skin graft were used to reconstruct 20arm defects. The study were performed in two plastic surgeryunits in Egypt and Kuwait. Overall flap survival and postoperativecomplications were used as outcome measures.Results: None of our flap was totally necrosed. Two cases(10%) developed partial necrosis and partial graft loss occurredin 2 cases (10%). Donor site seroma formation was seen in4 cases (20%). Four cases developed stretching of the scar.Followup ranged from (6-24 months), in which Latissimusdorsi healed perfectly, atrophied and contoured well with acosmetically satisfactory result. No functional deficit developedfrom the loss of the latissimus dorsi.Conclusion: Pedicled latissimus dorsi flap is reliable,versatile, and could be the primary choice for reconstructionof post traumatic large complex arm defects.

Different modalities for correction of breast asymmetry

Objective The aim of this study was to evaluate the different types of breast asymmetry and choice of the suitable approaches for each type of deformity. Background Naturally, there is asymmetry in female normal breast. When the difference in the site, size, shape, or volume of the breast, nipple–areola complex, and inframammary crease position is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Patients and methods The study included 29 female patients presented by breast asymmetry aged 14–43 years in the period from September 2016 till September 2018 at the Department of Plastic and Reconstructive Surgery of Menoufia University Hospitals. All patients were evaluated by history, physical examination, investigations, and photography. Surgical methods used for correction of breast asymmetries include: reduction mammoplasty, mastopexy, breast lipofilling, silicone gel implant and reconstruction of the missing breast, nipple–areola complex, and inframammary fold using different methods including pedicled latissimus dorsi, free transverse rectus abdominis myocutaneous, deep inferior epigastric artery perforator as well as a combination of the mentioned techniques. Results Most of the breast asymmetries were corrected by a combination of surgical procedures. Having combined different surgical procedures achieve satisfactory results. Conclusion The key to successful treatment is to define the nature of the breast asymmetry, respecting the patient's esthetic goals. It is critical to grasp the concept that the more similar the procedures performed on each breast, the more likely there will be symmetry over time.

Technique and Outcomes of Pedicled Latissimus Dorsi Myocutaneous Flap for Oncologic Defects Around the Clavicle

The authors present a retrospective review of 7 patients who underwent wide excision of the malignant tumors around the clavicle. Patient demographics, clinical details, the arc of rotation, outcome, and complications were analyzed.

A RARE CASE OF TRAUMATIC PENETRATING CHEST INJURY WITH HEMOPNEUMOTHORAX

Thoracic trauma contributes to one-quarter of trauma deaths. Traumatic hemothorax is commonly associated with organ damage, such as rib fracture, lung injury, and diaphragm rupture and usually occurs immediately after trauma. Here, we report the case of an 18-year-old male patient of a road traffic accident. He was admitted with an open chest wound and fractured ribs with exposed heart, left hemidiaphragm, left lung, and left thoracic cavity. He had fractured lower ribs with the contusion of intercostal and pectoral muscles. The wound was explored proper toileting of the wound, and the left chest cavity was done. A tear in the left lung was repaired, ribs were positioned, and the chest wall was reconstructed without using any prosthesis. In the post-operative period, the patient developed partial flap necrosis and so he was referred to plastic surgery where debridement and pedicled latissimus dorsi flap were applied. The patient got discharge after about 1 month of the post-operative period.

Cutaneous Breast Radiation-associated Angiosarcoma: Anterior Chest Wall Reconstruction Options Following Extra-radical Resection.

Radiation-associated angiosarcoma (RAAS) of the breast is a rare complication following breast irradiation with high rates of recurrence and death. To improve survival, we have advocated for an extra-radical resection where the entire irradiated skin and subcutaneous tissue is excised. This results in very large chest defects for which we describe our reconstructive experience. We performed a retrospective review of patients diagnosed with RAAS and treated with extra-radical resection followed by immediate reconstruction between 1999 and 2017. We analyzed reconstructive options, complications rates, length of stay, and operative times. Extra-radical resections were performed in 35 patients. We reconstructed these large defects with abdominal advancement flaps with split-thickness skin grafting in 25 patients and added a pedicled latissimus dorsi or omental flap in the 10 other patients. Skin grafts took well over the irradiated pectoralis major muscle with a median take rate of over 90%. Average operative times were 150 minutes for those treated with an abdominal advancement flap and skin grafting with a median length of stay of 5 days for all patients. Large anterior chest soft-tissue defects caused by extra-radical resections leaves defects too large to be covered by traditional breast reconstruction flaps. Abdominal advancement, latissimus dorsi muscle, and omental flaps along with skin grafts can be safely performed while leaving other traditional options open for future breast reconstruction.

Volume Change of Pedicled Latissimus Dorsi Muscle Flap after Partial Breast Reconstruction.

Despite successful breast reconstruction with oversized latissimus dorsi muscle flap after breast-conserving surgery for breast cancer, esthetic problems continue to exist due to flap shrinkage. The purpose of this study was to evaluate the objective volume change of pedicled latissimus dorsi muscle flap when it is used in breast reconstruction. Patients who were diagnosed with breast cancer and underwent a breast-conserving surgery with immediate breast reconstruction with pedicled latissimus dorsi myocutaneous flap between October 2009 and November 2015 were studied. Eleven patients who were followed up for more than 1 year after operation were included in the study. We evaluated the volume of muscle portion of the latissimus dorsi myocutaneous flap with computed tomography (CT) scan. We analyzed the rate of volume change of the latissimus dorsi muscle every year until 5 years after the operation. The latissimus dorsi muscle flaps of all 11 patients showed a volume decrease over time. The rate of volume change of the latissimus dorsi muscle flaps decreased 8.04% in the first year, 6.36% in the second year, 5.05% in the third year, 2.88% in the fourth year, and 2.56% in the fifth year after operation in average. This research shows the possibility of objectively evaluating the volume change of pedicled latissimus dorsi muscle flaps after breast reconstruction. The findings will be helpful in designing the size of the flaps to use on defects after breast-conserving surgery.

Quantitative analysis of shoulder function and strength after breast reconstruction: A retrospective cohort study.

Immediate breast reconstruction (IBR) after mastectomy has been proven to affect patient quality of life, psychological well-being, and functional capacities. In the present study, we aimed to investigate the effect of breast reconstruction on postoperative shoulder function and muscle performance by evaluating isokinetic muscle performance tests.A retrospective chart review to collect data on shoulder function analysis with isokinetic muscle performance testing was performed among patients who received mastectomy with IBR from July 2013 to March 2015. Patients were categorized into 4 groups: a control group that underwent mastectomy without reconstruction, a tissue expander/implant insertion group, a pedicled latissimus dorsi (LD) flap group, and a free transverse rectus abdominis muscle (TRAM) flap group.Analysis of the groups at 1 to 3, 4 to 6, 7 to 9, 10 to 12, and 13 to 15 months postoperatively showed significant shoulder function improvement in the tissue expander/implant and TRAM groups as measured by linear regression analysis. Compared with the control group, patients who received immediate reconstruction with tissue expander/implant insertion or a TRAM flap showed statistically significant improvement in shoulder function after mastectomy.IBR with a TRAM flap or tissue expander/implant insertion were more beneficial for shoulder rehabilitation and for regaining function compared to mastectomy alone and breast reconstruction with a LD flap.

Autologous reconstruction following nipple sparing mastectomy: a comprehensive review of the current literature.

As surgical methods continue to evolve and patients become more educated consumers of their medical care, both oncologic breast surgeons and reconstructive plastic surgeons should understand the current options for surgical management of breast cancer. This review evaluates the current autologous breast reconstruction options following nipple sparing mastectomy (NSM). A comprehensive review of the current literature discussing autologous reconstruction after NSM was performed. Fat grafting alone has been used to reconstruct small to medium sized-breasts over multiple injection sessions. Goldilocks mastectomy-like reconstructions can be used for larger, more ptotic breasts. Pedicled latissimus dorsi (LD) flaps can be used, but usually need to be modified to ensure sufficient breast volume. While the lower abdominal tissue remains the most common donor site in free tissue transfer, other donor sites can be used if there is insufficient volume or inadequate perforators. Periareolar incisions are associated with the highest rates of overall complications and nipple areola complex necrosis. It has not been determined whether implant-based or autologous reconstructions have lower complication rates. Both prior radiation and large, ptotic breasts present unique challenges during reconstruction. Overall, there is a high rate of patient satisfaction with breast reconstruction following NSM. Autologous breast reconstruction after NSM is a safe method of breast cancer surgical management with aesthetically excellent results. Multiple techniques have been described along the reconstructive ladder. Special consideration should be given to choices of incision, previously irradiated breasts, and large, ptotic breasts.

The anatomy of the thoracodorsal artery in pedicled breast reconstruction

Background: Many women undergo partial or total mastectomy for the surgical resection of breast cancer. The pedicled latissimus dorsi myocutaneous flap has been an important surgical option for breast reconstruction after mastectomy for over a century. This flap is supplied by the thoracodorsal artery, a branch of the subscapular artery.

Salvage of an Exposed Axillo-profunda Bypass Graft and Discussion of Reconstructive Options on the Torso

IntroductionA case of salvage of an exposed axillo-profunda bypass graft is presented.ReportRobust coverage of the graft was achieved with a pedicled latissimus dorsi muscle flap and overlying bi-pedicled cutaneous flap.DiscussionReconstructive options to salvage an exposed prosthetic graft will depend on the position on the trunk but can be successful if a reconstructive plastic surgery algorithm is followed. The options are discussed within this report. Exposed axillo-profunda graft can be salvaged successfully through a variety of reconstructive techniques. Close cooperation between vascular and plastic surgeons is vital for a successful outcome.

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.

Pedicled latissimus dorsi myocutaneous flap in the reconstruction of the head and neck region: Experience with 17 patients

Pedicled latissimus dorsi myocutaneous flap in the reconstruction of the head and neck region: Experience with 17 patients

The anatomy of the thoracodorsal artery in pedicled breast reconstruction

Background: Many women undergo partial or total mastectomy for the surgical resection of breast cancer. The pedicled latissimus dorsi myocutaneous flap has been an important surgical option for breast reconstruction after mastectomy for over a century. This flap is supplied by the thoracodorsal artery, a branch of the subscapular artery.

Basal cell carcinoma of the scalp with destruction and invasion into the calvarium and dura mater: Report of 7 cases and review of literature

Basal cell carcinoma (BCC) is the most common skin malignancy in humans. Giant BCC is a rarer entity that is characterised by aggressive biological behaviour. Intracranial invasion by a BCC on the scalp is extremely rare. The gold standard treatment of BCCs is represented by surgical excision with a wide variety of reconstructive techniques. In this paper, we describe the largest series to date of recurrent BCCs with intracranial extension involving the dura mater. We report recurrent giant BCC of the scalp with dura mater invasion in 7 patients. All patients in this series previously had more than 2 operations. Gadolinium-enhanced MRI revealed neoplastic invasion of the meninges and brain tissues. All patients had a multi-disciplinary team approach with the surgical margins ranging between 1 and 2 cm depending on the location and the size of the tumour. 5 of the patients underwent reconstruction of the skin defect by antero-lateral thigh flap, 1 patient underwent reconstruction with pedicled myocutaneous (trapezius) flap, and 1 with a pedicled myocutaneous latissimus dorsi flap. There was a mean follow-up of 5.3 years. 2 patients died due to cardio-pulmonary complications in the neuro-intensive care unit. A multi-disciplinary team approach and early aggressive tumour resection followed by sophisticated reconstructive and aesthetic procedures appears to be a reliable and realistic treatment modality for invasive BCC.