Primary one-stage reconstruction of cheek defect after a shotgun blast to the face: use of the latissimus dorsi musculocutaneous free flap for soft-tissue repair and facial reanimation

The authors describe a case of a shotgun blast injury to the face in which early definitive repair of both facial soft tissues and facial reanimation was accomplished in one stage using a free flap. The trauma occurred 2 days before presentation via a hunting rifle fired at a short range. On examination, a 8 x 5-cm cheek defect was evident, involving the full thickness of the perioral facial mimetic muscles as well. A free latissimus dorsi musculocutaneous flap was transferred to the defect, with the thoracodorsal nerve coapted to an ipsilateral, severed buccal branch of the facial nerve. Postoperatively, the flap survived completely, with its skin paddle excised subsequently in two stages. Good muscle movement was obtained, providing resting symmetry and a pleasant smile. Other than soft-tissue and bony defects resulting from shotgun injuries, ablation of the facial nerve or facial mimetic muscles may be an important component of the defect that needs further consideration. The authors conclude that the current technique of one-stage, early definitive repair of soft tissues and facial reanimation in such cases of facial shotgun blast injury offers the advantages of achieving both goals with one flap and accomplishing the procedure primarily in one stage.     

One-stage reconstruction of facial paralysis associated with skin/soft tissue defects using latissimus dorsi compound flap.

Neurovascular free muscle transfer is now the mainstay for smile reconstruction in the treatment of established facial paralysis. Since facial paralysis due to ablative surgery or some specific disease sometimes accompanies defects of the facial skin and soft tissue, simultaneous reconstruction of defective tissues with facial reanimation is required. The present paper reports results for 16 patients who underwent reconstruction by simultaneous soft tissue flap transfer with latissimus dorsi muscle for smile reconstruction of the paralysed face. Soft tissue flaps comprised skin paddle overlying the latissimus dorsi muscle (n=6), serratus anterior musculocutaneous flap (n=5), serratus anterior muscle flap (n=2), and latissimus dorsi perforator-based flap with a small muscle cuff (n=3). The latissimus dorsi muscle can be elevated as a compound flap of various types, and thus offers the best option as a donor muscle for facial reanimation when soft tissue defects require simultaneous reconstruction.     

背阔肌功能恢复后再移位重建屈肘屈指功能

[目的]探讨利用经神经移位修复胸背神经而恢复的背阔肌作为动力肌再移位重建屈肘、屈指功能的疗效。[方法]2000年3月~2003年6月,共有全臂丛根性撕脱伤患者经多组神经移位术后屈肘功能无恢复而背阔肌恢复良好者5例,屈指功能无恢复,背阔肌功能良好者3例,均采用恢复的背阔肌再移位重建屈肘、屈指功能。[结果]术后随访1 a~3 a 6个月,移位背阔肌皮瓣全部成活,肘关节活动度为伸肘10°~25,°屈肘100°以上,肌力达Ⅲ~Ⅳ级。手指可抓握,各指屈距掌纹2 cm左右,肌力达Ⅲ级。[结论]利用经神经移位恢复的背阔肌作为动力肌再移位重建屈肘、屈指功能疗效可靠,因此在治疗全臂丛根性撕脱伤患者时应常规修复胸背神经以恢复背阔肌功能。     

Transfer of pedicled musculocutaneous latissimus dorsi flap for restoration of shoulder contour after neurogenic atrophy

Neurogenic atrophy of the deltoid muscle due to brachial plexus injury will lead to a disfiguring deformity of the shoulder contour, apart from the functional deficit. When there is no possibility for functional restoration of the shoulder movement, this contour defect will become the patient's major concern. We present a new method in which the ipsilateral latissimus dorsi muscle was used as a pedicled musculocutaneous flap to augment the shoulder contour in 3 patients. In all patients, there was a concomitant lesion to the thoracodorsal nerve, with subsequent palsy of the latissimus dorsi muscle. Therefore, donor-site morbidity was minimal. The final esthetic appearance was pleasing, and the patient satisfaction was quite high.     

The anatomy of the thoracodorsal artery within the latissimus dorsi muscle

This paper reports the findings of an anatomical study of the primary and secondary muscular branches of the thoracodorsal artery within the latissimus dorsi muscle. Twenty latissimus dorsi muscles were studied, harvested from 13 fresh cadavers and the findings support the hypothesis that it is possible to thin safely a latissimus dorsi muscle flap at the time of flap transfer.     

背阔肌节段肌瓣一期修复晚期面瘫的应用解剖

目的 为联合应用背阔肌两块节段肌瓣一期动力矫正晚期面瘫表情肌功能提供解剖学依据.方法 解剖20具10%福尔马林固定的成人尸体共40侧背阔肌标本,醋酸乙酯血管灌注2具新鲜成人尸体共3侧背阔肌标本,观察肌外、肌内神经血管的分布特点.结果 ①92.5%的胸背神经分为内、外侧支;7.5%的胸背神经分为内、中、外侧支.胸背神经内、外侧支分叉点的坐标为(7.94±1.23)em、(3.71±1.68)cm,在该交角的中线区域,神经血管的数量相对较少.②背阔肌外侧肌瓣可以分为3～5个亚单位,内侧肌瓣可以分为2～4个亚单位.③肌内神经血管分支排列关系(由内向外),内侧节段100%为NVAV(神经、静脉、动脉、静脉),外侧节段85.0%为VAVN,其余15.0%为NVAV.④在神经蒂分支点外侧切断,第三段内侧肌瓣神经蒂平均达16 cm,第三或四段外侧肌瓣神经蒂平均达12 cm.结论 吻合血管神经的背阔肌双节段肌瓣移植可一期跨面修复晚期面瘫.     

A novel reconstruction of 2 distinct defects: concomitant use of a thoracodorsal artery perforator flap and its corresponding muscle flap

A perforator flap completely spares the underlying muscle, so the muscle tissue can now be used as a second flap for the reconstruction of another defect after the harvest of the overlying perforator flap as long as sufficient nutritive branches to the muscle remain. The authors describe here the creation of 2 independent free flaps from a single donor site, the latissimus dorsi musculocutaneous unit. The 2 flaps, thoracodorsal artery perforator and its corresponding muscle flap, were created and transferred to 2 distinct defects. Using this technique, we could avoid creation of double donor sites and so minimize the donor morbidity to that associated with the traditional single musculocutaneous flap. This technique was employed by us for treating 2 patients who presented with 2 separate defects.     

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.     

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face.

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.     

Free thoracodorsal artery perforator flap in extremity reconstruction: 12 cases.

The need for thin flap coverage has increased, especially for contouring or covering shallow defects of extremities. The free thoracodorsal artery perforator flap harvested from the upper lateral back can be useful for this purpose. The thoracodorsal artery supplies the latissimus dorsi muscle and supplies perforating branches to the overlying skin. The flap is based upon the proximal perforator of the thoracodorsal artery, which usually emerges in an area approximately 8-10 cm below the posterior axillary fold and 2-3 cm posterior to the lateral border of the latissimus dorsi muscle. Between February of 2001 and April of 2003, we used the free thoracodorsal artery perforator flap for distal limbs reconstruction in 12 clinical cases, including three hands, two forearms and seven feet. The soft tissue defects resulted from trauma, scar release, chronic ulcer, or tumour ablation. The main advantages of the thoracodorsal artery perforator flap are that it contains no muscle, allowing more reconstructive precision, and morbidity is minimised by preserving the function of the latissimus dorsi muscle and hiding the donor scar. However, meticulous intra-muscular retrograde dissection of the perforator, to the thoracodorsal artery, is necessary in order to obtain suitable pedicle length and vessel diameter. The authors conclude that the free thoracodorsal artery perforator flap has greater potential for resurfacing large defects of distal limbs, because of its suitable thickness and hidden donor site.     

背阔肌解剖分区及其肌电研究

目的 明确背阔肌的解剖分区及各区在肩关节运动中的肌电表现。方法 对10具成人尸体背岂进行血管、神经解剖并按主要血管、神经的分支、分布将背阔肌分区、。利用体表电极记录13例（25侧）健康成人背阔肌不同区在肩关节运动中的肌电表现，并将记录结果进行统计学处理、分析。结果 背阔肌的主要血管、神经来自胸痛血管、神经及其内、外侧分支，部分来自肋间血管、神经，胸背血管、神经分支及肋间血管、神经分支间有广泛的吻合，胸背血管、神经内、外侧支及其延长线将背阔肌分成三个区域。三区在肩关节6种运动中的肌电表现不同。结论 背阔肌内不同区域肌纤维在肩关节运动中的作用不同。     

Latissimus dorsi musculocutaneous flap based on the serratus branch with microvascular venous augmentation

The authors report a case of a latissimus dorsi musculocutaneous flap with microvascular venous supercharging in the setting of an acute ligation of the thoracodorsal vascular pedicle. Through their experience with this case, they have questioned a common belief that the flap will survive without the thoracodorsal vessels intact. They accept that risk is minimized when rotation of the flap takes place several weeks after ligation of the vessels. However, they do not believe it is prudent to transfer a latissimus flap of significant size immediately after ligation of the thoracodorsal vessels, unless the vascular supply is enhanced.     

The serratus anterior/rib composite flap in mandibular reconstruction

A flap comprising the serratus anterior muscle and the underlying rib, based on the serratus branches of the thoracodorsal artery has been developed. In addition to the rib the potential exists to include a cartilaginous growth centre, a functional muscle and/or overlying skin. A latissimus dorsi musculocutaneous unit can be included on a common pedicle. This paper describes its use as both a free and a pedicled composite unit in mandibular reconstruction. The surgical anatomy of the flap is reviewed and cases are shown to illustrate its use in the treatment of congenital, malignant and post-traumatic conditions where reconstruction of the lower jaw is required.     

One‐stage reconstruction by dual‐innervated double muscle flap transplantation with the neural interconnection between the ipsilateral masseter and contralateral facial nerve for reanimating established facial paralysis: A report of 2 cases

The authors developed a one‐stage double‐muscle reconstruction technique for facial paralysis using a latissimus dorsi (LD) flap and a serratus anterior (SA) flap, which were dually reinnervated by the contralateral facial nerve (FN) and ipsilateral masseter nerve (MN). The procedure was performed for 61‐year‐old man 3‐years after resection of a malignant tumor and a 24‐year‐old woman 10‐years after temporal fracture with facial paralysis. A double‐muscle flap comprising left LD and SA flaps was harvested, a 15‐cm thoracodorsal nerve (TN) section was attached to the LD flap, and 5‐cm and 1‐cm sections of the long thoracic nerve (LTN) were attached to the proximal and distal sides of SA flap. The LD flap and SA flap were sutured along the direction of motion of the zygomaticus major and risorius muscles, respectively. The contralateral FN and ipsilateral MN were interconnected by nerve suturing: the medial branch of TN to the distal end of LTN, the proximal end of LTN to the ipsilateral MN, and the buccal branch of contralateral FN to the main trunk of TN. After surgery, good contraction of the transferred flaps resulted in reanimation of a natural symmetrical smile; no complications were observed during the 12‐month follow‐up period.     

Latissimus dorsi muscle and its short perforator-based skin compound free flap

Some authors have described the latissimus dorsi muscle and its short perforator-based skin compound flap based on the same thoracodorsal vessels. This flap procedure involves separating the skin island from the underlying latissimus dorsi muscle and rotating the skin island over the musculocutaneous perforator emerging from the latissimus dorsi muscle. As with all surgical procedures, there are various advantages and disadvantages. However, to the best of the authors' knowledge, there are no reports on the use of the flap in a consecutive series.Between 1997 and 2005, the flap was used to reconstruct below-knee structures in 26 patients (23 males and 3 females) by the 2 senior authors at the Chonnam National University Medical School. The clinical outcomes of this procedure were evaluated.Satisfactory results were obtained in most patients. However, there were 2 marginal necroses in the excessively large skin flaps, 1 partial necrosis over the distal edge of a skin flap, and 1 total flap failure caused by infection. The marginally and partially necrotized skin flaps were treated successfully with split-thickness skin grafts. However, another flap procedure was required to cover the defect in the case of flap failure. The donor sites were closed primarily in all patients, and the skin flaps were rotated between 40 degrees and 180 degrees. This flap allows the surface of the latissimus dorsi musculocutaneous flap to be expanded without additional donor morbidity. In addition, the flap procedure is safe and easy to perform. Moreover, the flap provides sufficient flexibility, even though it has less independent flap mobility than the chimeric flap. Therefore, the flap may be a convenient and reliable alternative for the reconstruction of large and irregular-shaped wounds.     

Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction

Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the routine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidentally injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction.     

Latissimus dorsi musculocutaneous flap model in the rabbit: a hemodynamic and anatomical study

The rabbit island and peninsular axial pattern latissimus dorsi musculocutaneous (LDM) flaps were assessed for their appropriate use as experimental musculocutaneous flap models. Contralateral island and peninsular LDM flaps (10 X 20 cm) were constructed on rabbits, and their vascular anatomy, hemodynamics, and viability were compared. Anatomical dissections and fluorescein dye studies revealed that the skin overlying the latissimus dorsi muscle received its blood supply mainly from a direct cutaneous branch of the thoracodorsal artery before its entry to the latissimus dorsi muscle. A few small musculocutaneous arteries (perforators) were seen in the proximal portion of the latissimus dorsi muscle, but these perforators provided very little blood supply to the overlying skin. Results from hemodynamic and viability studies with rabbit peninsular and island LDM flaps also indicated that the blood supply from the musculocutaneous arteries to the overlying skin paddle was small and could not reliably support the survival of the cutaneous portion of these musculocutaneous flaps. We conclude that rabbit LDM flaps are different in vascular structure and blood supply compared with the human LDM flaps. Thus, discretion should be advised in applying the rabbit peninsular or island LDM flaps as experimental flap models for the study of the pathophysiology and pharmacology of the musculocutaneous flaps relevant to the clinical situation.     

Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

ObjectiveTo investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest.MethodsThe function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery. The entire treatment period was divided into two stages, during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II.During stage I, the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively; the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch; and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months.In stage II, the chest scars were excised, and breast tissues were repositioned; the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery.ResultsFrom October 2010 to October 2019, 21 patients (on 24 sides) underwent reconstructive procedures for extensive scar contractures on the anterior chest. All flaps survived, and their donor sites were sutured directly. During a follow-up of 3 months to 8 years, the flaps became soft and exhibited color similar to that of the adjacent tissues. The limited neck and shoulder movements improved, and postoperatively, all female patients were satisfied with the shape of their breasts. Additionally, neither apparent weakening on the adduction, internal rotation, or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed.ConclusionPre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.     

面神经瘫痪外科治疗301例回顾

１９８２年２月至１９９６年６月，共收治各类面瘫病人３０１例。其中采用神经、肌肉移植修复１５７例，筋膜悬吊１１９例，其他２５例。包括：①神经、肌肉移植，Ⅰ期带血管神经肌瓣移植，Ⅱ期带血管、神经肌肉移植；②损伤面神经修复，面神经残端肌肉内种植以及舌下—面神经吻接；③动力性或静力性筋膜悬吊；④其他：面部畸形整形及其他肌肉移植等。认为：早期损伤的面神经吻接，舌下—面神经吻接等是早期外伤性面瘫治疗的最佳选择。Ⅰ期节段性断层背阔肌肌瓣移植是晚期面瘫的最佳选择，６８例中６６例取得了术后动静态平衡。腹内斜肌肌瓣移植是有前途的术式，Ⅱ期胸小肌移植及筋膜悬吊仍是晚期面瘫治疗中可选择的术式。讨论了手术时机的选择和适应证，着重提出带有靶器官的神经移植的生长不是爬行生长，而是逐步的能量积累，由量变到质变的飞跃。     

胸背神经双分支的解剖研究与临床应用

目的 对胸背神经的外侧束和腋神经穿越四边孔后支配的三角肌肌支进行显微解剖研究,并应用于临床,为臂丛神经损伤后功能重建提供新的方法。方法 取17具成人尸体,在手术显微镜下对31侧胸背神经外侧束和液神经三角肌肌支进行解剖,观察其可应用长度、直径及分支情况,并取神经标本经HE染色、石蜡切片,对有髓神经纤维进行计数。临床上进行3例手术。例1钭胸背神经外侧束与四边孔内切断的腋神经三角肌肌支吻合,例2在例1休式基础上,用胸背神经内侧束支配的部分背阔肌重建屈肘功能,例3将背阔肌按内、外侧束的支配区域,剪切成两部分,移位的同时重建屈肘、屈指功能,结果 胸背神经在人背阔肌处开始分为内、外侧束,外侧束明显较内侧束粗大,外侧束在背阔肌内可利用的长度平均为58.2mm直径平均为1.46mm,有髓纤维数平均为1519根,90.4%的外侧束可再分为2支或3支,腋神经三角肌肌支直径平均为2.31mm,有髓纤维数 平均为2341根,61.3%的三角肌肌支可再分为3支,32.3%的三角肌肌支可再分为2支,3例术后情况：例1三角肌肌力为4级;例2三角肌肌力为4级,屈肘时肌力为4级;例3屈肘、指时肌力均达到4级。结论 应用胸背双分支的解剖基础。将胸背神经外侧束与腋神经三角肌肌支相吻合恢复三角肌的功能,从理论和[实践上是统一的,是行这有效的方法,充分利用胸背神经双分支的原理可以重建两块失神经支配的肌群功能。