部分背阔肌皮瓣游离移植修复前臂背侧组织缺损并重建伸指功能

目的 报告应用部分背阔肌皮瓣游离移植修复前臂背侧复合组织缺损,并重建伸指功能的手术方法.方法 对11例因外伤致前臂背侧大面积复合组织缺损的患者,采用保留内侧部分背阔肌及胸背神经内侧支的部分背阔肌皮瓣游离移植修复,将皮瓣中胸背神经近端与受区桡神经深支或指总伸肌肌支缝合,背阔肌远端腱膜修复2～4指指总伸肌.皮瓣切取面积为21 cm×9 cm-27 cm×13 cm.结果 术后11例肌皮瓣全部存活,3例因皮瓣臃肿再次行皮瓣、肌皮瓣修整术,2例指伸肌腱松弛再次行肌腱紧缩术.术后2例失访,9例获得6个月至3年的随访,其中指伸肌力恢复至Ⅲ级2例、Ⅳ级6例、V级1例,肢体功能大部分恢复且外形满意.按中华医学会手外科学会上肢功能评定标准评定:优2例,良5例,可2例;优良率为77.8%.结论 应用游离部分背阔肌皮瓣修复前臂背侧复合组织缺损并重建伸指功能可取得较好的临床疗效,同时供区保留了部分背阔肌的功能.     

Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.     

Repair of bilateral lower limb injuries using a free latissimus dorsi cross-leg flap

Current microsurgical techniques are used in single stage repair of distal lower limb defects. The previously popular cutaneous and fasciocutaneous flaps have been practically shelved. However, in selected cases, the vessels of a lower limb can still be employed to vascularize a harvested flap for the repair of a contralateral defect. In cases where the vessels of a traumatized leg are severely damaged or jeopardized, vascular components of the opposite limb can be exploited to provide the blood supply for the flap chosen to cover the defect. There are times when trauma to both legs may require a single large flap (latissimus dorsi) which if properly vascularized can bridge a bilateral defect. This could bring about the revival of the cross-leg flaps. Four cases are reported: in one, the flap was vascularized from a healthy limb to cover a contralateral exposed fracture and an avulsed heel. In three other cases, the latissimus dorsi was utilized to fill large post-traumatic bilateral defects at the distal lower limb level. In these cases the limb with the best vascular system was chosen for flap anastomoses and fixation was then applied. Received: 2 June 1998 / Accepted: 12 August 1998     

Free latissimus dorsi and deep epigastric vessels —a good combination for lower abdominal defects

Summary Two cases of extensive loss of the lower abdominal wall, in patients with cutaneous stomas and large surgical wounds, are reported. Local flaps (i.e., rectus abdominis or TFL flaps) were not available or sufficient to repair the defects, therefore a free latissimus dorsi myocutaneous flap was used for the reconstruction in both cases.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of seven cases

The purpose of this paper is to review the results of free latissimus dorsi transfer for scalp and cranial reconstruction in the case of large defects with exposed brain tissue, cranial bone without periosteal cover, and dura, which cannot be reconstructed with local flaps or skin grafts. Free latissimus dorsi transfer was carried out in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after long-standing osteitis, two tissue breakdown after irradiation, one defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was performed with a muscle flap (1) or a myocutaneous flap (6) in combination with a split-thickness skin mesh (1:1.5) graft in a single-stage procedure. In a retrospective clinical study, the following criteria were evaluated: (1) flap healing, (2) aesthetic result, and (3) complications. All flaps healed primarily, and all wounds remained closed without any signs of infection. Complete wound healing was achieved after 4 to 8 weeks, depending on the “take” of the skin grafts. Secondary skin grafting was necessary in two patients, while revision of the donor site was necessary in two patients. From an aesthetic point of view, four patients complained about the appearance of the retroauricular skin island. After removal of the skin island 6 months after the initial operation, all patients judged the result as good or acceptable. Besides the free omentum flap, the free latissimus dorsi transfer is the only option for cover of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression, we use a myocutaneous flap. The skin island must be removed secondarily. In patients where no bone reconstruction is possible or planned, the de-epithelialized skin paddle can be used for correction of a contour defect.This work was presented at the Spring Meeting of the Belgian Society for Plastic, Reconstructive and Aesthetic Surgery, May 8, 2004 in Ghent, Belgium.     

Donor site morbidity: standard versus partial latissimus dorsi free flap

Over the last 7 years 128 latissimus dorsi free flaps have been performed at the BG Unfallklinik in Murnau. Since 1995, the use of a partial latissimus dorsi, sized according to the defect that has to be covered, leaving a functional remnant has continuously increased. We compared the donor site morbidity after standard and after partial latissimus dorsi flap in a small group of 10 patients each (n=20). The mean follow-up time was 18 and 24 months, the mean age of the patient 42.5 and 43.6 years. The evaluation included complaints, subjective loss of strength, scar length, ROM of the shoulder, and measured loss of strength, taking into account the patient’s dominant side. The acceptance of the donor area by the patients was very good in both groups. It was found that the loss of strength after partial latissimus dorsi is less evident than after standard latissimus dorsi. The scar length was independent of the type of flap chosen. There was no loss in range of movement. In both groups it was found that if the flap was taken from the non-dominant side the difference in strength to the dominant side was more than if the flap was taken from the dominant side. We could not see a causal relationship between age and the amount of strength lost. Because of the decreased donor site morbidity we think the partial latissimus dorsi flap should be used instead of the standard latissimus whenever possible. Received: 9 March 1998 / Accepted: 3 June 1999     

背阔肌肌皮瓣移植修复严重深度烧伤

目的总结高压电烧伤、热压伤创面适用背阔肌肌皮瓣进行修复的经验。方法26例严重深度烧伤创面,应用背阔肌肌皮瓣移植,其中岛状转位25例,游离移植1例。对上肢广泛电击伤及热压伤创面采用该肌皮瓣与侧胸皮瓣及髂腰部皮瓣联合移植修复,全跟腱坏死应用游离背阔肌肌皮瓣修复。结果皮瓣面积最大40cm×20cm,除1例皮瓣尖端坏死2cm,其余全部成活。跟腱的功能恢复满意。结论背阔肌肌皮瓣修复严重深度烧伤是一种理想的方法。     

背阔肌游离肌皮瓣用于颅颌面部缺损重建

目的　提高颅颌面部组织缺损的修复水平。方法　本组 8例颅颌面部组织缺损患者 ,皮肤和黏膜缺损面积最小 10cm× 8cm ,最大 30cm× 12cm ,应用背阔肌游离肌皮瓣移植修复 ,所有皮瓣的神经均与受区神经吻合。 7例患者一期手术完成 ,另 1例分 3次手术完成 :第 1次行皮瓣延迟 ,第 2次手术行游离皮瓣移植 ,第 3次手术行口角成形术。肌皮瓣面积最小 12cm× 10cm ,最大 32cm× 16cm。结果　术后随访 6个月～ 4年 ,所有患者功能和形态满意 ,感觉恢复良好 ,无皮瓣发生坏死和溃疡。结论　背阔肌游离肌皮瓣移植是一种修复严重颅颌面部组织缺损的较为理想的方法 ,具有血供可靠、抗感染力强、供瓣面积大、供区隐蔽、可重建运动和感觉功能等优点。     

One stage reconstruction of the skull defect following chronic osteomyelitis using a serratus anterior muscle rib osteomyocutaneous free flap

Summary In two cases of chronic osteomyelitis following craniotomy, removal of the bone flaps and debridement were performed. The defects in the calvarial bone and the scalp were immediately reconstructed in a one-stage operation using an osteomyocutaneous free flap consisting of the serratus anterior muscle and rib.     

Correction of pectus excavatum with free latissimus dorsi musculocutaneous flap

The treatment of pectus excavatum in an adult patient using a free de-epithelialized latissimus dorsi myocutaneous flap is described. While sternal elevation has been a standard method for the treatment of pectus excavatum, the procedure proposed herein is an appropriate option for patients with mild pectus excavatum who want to avoid invasive surgery and return to daily activities as soon as possible. Received: 24 June 1998 / Accepted: 8 December 1998     

Mucosal prelamination of a radial forearm flap for intraoral reconstruction

Until now the microvascular fasciocutaneous radial forearm flap has been one of several methods favoured for reconstruction of intraoral soft tissue defects after radical resection of squamous cell carcinoma. Mucosal reconstruction and lining has been performed by a skin island, this is epidermis and cannot produce mucus. In order to provide mucosal properties and allow mucus production, a distal radial forarm flap has been successfully prelaminated with buccal mucosa in five patients. By this method thin, pliable and resistant flaps have been produced. Due to mucosal spreading, the mucosa lined area was 30–50% larger than the originally inserted mucosal grafts. Preservation of skin and subcutaneous tisssue lowered donor site morbidity. This technique has also been performed in axial pattern flaps; two osteofasciomucosal fibulae and three myomucosal pectoralis major flaps. Received: 17 July 1997 / Accepted: 15 October 1997     

Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap

We present a surgical treatment for bladder reconstruction in a case of chronic vesicocutaneous radiation‐induced fistula and reconstruction of the abdominal wall after resection of a liposarcoma in the rectus abdominis muscle. Fistulas are sequelae after radiotherapy. To regain bladder function and reconstitute abdominal wall stability, a microsurgical flap approach should be considered. A male patient underwent resection of a liposarcoma in the rectus abdominis muscle with adjuvant radiotherapy, suffering from a chronic vesicocutaneous fistula. A bipedicled combined latissimus dorsi and serratus anterior flap was carried out after resection of the fistula for reconstruction of the urine bladder and the abdominal wall. Ascending urethrography 4 weeks postoperatively showed no leakage. In the 4‐month follow‐up period, no signs of recurrence of the fistula or herniation occurred. A bipedicled flap allowed reconstruction of the urine bladder and the abdominal wall. Using non‐irradiated, well‐perfused intra‐abdominal muscle tissue over the urine bladder prevented recurrence of the fistula.     

Incidence of shoulder functional morbidity following ipsilateral mastectomy and latissimus dorsi flap reconstruction

IntroductionThe aim of this study was to investigate the incidence of shoulder morbidity in our cohort of patients with latissimus dorsi flap reconstruction after mastectomy.MethodsThis is a retrospective study of prospectively collected data of 72 patients using validate Oxford shoulder score for function and quickDASH score for disability. Scores were collected preoperatively and at time of final review or study. We also reviewed patient records for patients who had a formal diagnosis of shoulder pathology. Results were analysed with student t-test.ResultsAnalysis of scores showed a statistically significant worsening of both oxford shoulder score (p < 0.005) and quickDASH score (p < 0.005), when pre and post-operative scores were compared. Seven patients had a formal diagnosis of shoulder pathology, and all of them recovered well. There was no significant difference in oxford shoulder score or quickDASH scores between patients with or without shoulder pathology. About 40% patients had some functional loss or disability at 4 years after the surgery.ConclusionOur study shows a high incidence of significant shoulder functional morbidity following latissimus dorsi flap reconstruction but number of patients requiring specific treatment is low.Level of evidenceLevel IV, therapeutic study.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation

One of the significant reconstructive challenges is closure of large soft tissue defects of the lower extremity. A patient with a large traumatic defect in the lower extremity was treated with a cross-leg free latissimus dorsi myocutaneous flap. The size of the flap was 32×12 cm. The pedicle was divided 22 days after the initial operation. The result was satisfactory after a 2-year follow-up. This technique allows the transfer of large flaps to cover compromised wounds, with the advantage of using suitable recipient vessels. Received: 4 March 1998 / Accepted: 25 March 1999     

背阔肌肌皮瓣移植修复上肢大面积复合组织缺损

目的　探讨应用背阔肌肌皮瓣修复上肢大面积复合组织缺损的疗效。方法　用带蒂背阔肌肌皮瓣修复上肢皮肤肌肉缺损 3例 ,并重建肱二头肌和肱三头肌功能 ;游离背阔肌肌皮瓣修复上肢皮肤肌肉缺损 9例 ,其中 3例将胸背神经与桡神经缝合 ,另 6例将胸背神经与正中神经缝合。皮瓣切取面积为 7～ 15cm× 18～ 42cm。结果　 12例皮瓣全部存活 ,4例肌力恢复至M4,6例恢复到M3 ,2例为M3 -。结论　应用背阔肌肌皮瓣修复上肢大面积皮肤、肌肉缺损时 ,能恢复伸屈肘关节的功能及大部分伸屈手指的功能。     

部分背阔肌皮瓣游离移植修复前臂背侧组织缺损并重建伸指功能

Objective To report the operative methods and clinical effects of free transfer of part of the latissinus dorsi flap for coverage of dorsal forearm composite tissue defects and reconstruction of extensor function. Methods Eleven cases of large-scale composite tissue defects of the dorsal forearm as a result of trauma were treated with partial latissimus dorsi flap The medial portion of the myoeutaneou flap containing the medial thoracodorsal nerve branch Was transferred to the defect on dorsal forearm.The thoracodorsal nerve in the flap was sutured either to the radial nerve deep branch or to the extensor comnunis muscle branch.The distal aponeurosis of the latissimus dorsi woven to the tendons of the 2nd to 4th digit extertsors.The size of the harvested flaps ranged from 21 cm×9 cm to 27 cm×13 cm. Results Postoperatively all 11 myocutaneous flaps survived.Three cases underwent trimming of the cutaneous flap or myocutaneous flap due to bulkiness.Two cases had tendon tighteing procedures due to laxity of the extensor tendon.Nine eases were followed up for 6 months to 3 years,while 2 cases were lost to follow up.The extensor strength returned grade Ⅲ in 2 cases,grade Ⅳ in 6 cases grade Ⅴ in 1 case.The limb function was mostly restored and the appearance was satisfactory.According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of Chinese Medical Association the results were rated as excellent in 2 cases,good in 5 cases,and fair in 2 cases.The overall excellent and good rate was 77.8%. Conclusion Partial transfer of the latissimus dorsi myocutaneous flap for coverage of dorearm forearm composite tissue defects and reconstruction of extensor function can not only achieve good treatment outcomes,but retain some of the latissimus dorsi function as well.     

The value of latissimus dorsi flap with implant reconstruction for total mastectomy after conservative breast cancer surgery recurrence

Total mastectomy is usually indicated after breast conservative treatment cancer recurrence. Breast reconstruction in this group can be performed with many options. We did 63 latissimus dorsi flap with implants reconstructions between 2001-2007. All of them were performed in breast cancer recurrence cases after breast conservative treatment and preceded for total mastectomy. The patient age range from 31 to 71 years old (50.1 ± 7.3 years). The follow-up was 36.5 ± 14.9 months (22-141 months). Neither flap loss nor significant major donor-site complication was recorded. The capsular contraction Baker’s grade III was observed in 2 cases (3.1%). The rest were grade I-II and there was no grade IV contracture. We purpose that LD flap with implant can be performed in irradiated breast with low capsular contracture rate. It is suitable in total mastectomy reconstruction after conservative breast cancer surgery recurrence.     

胸廓内动脉穿支皮瓣修复气管造瘘口和颈前皮肤缺损

目的 探索带蒂胸廓内动脉穿支皮瓣修复气管造瘘口和颈前皮肤缺损的临床效果.方法 2009年4月至12月应用带蒂胸廓内动脉穿支皮瓣修复颈部皮肤缺损共4例,其中气管造瘘口周围缺损2例,颈部手术后皮肤缺损2例.4例均选择第2肋间穿支血管供血,皮瓣面积(4～7)cm×(10～13)cm.结果 3例皮瓣全部存活,1例发生部分坏死.供区缺损均直接拉拢关闭且无并发症.结论 带蒂胸廓内动脉穿支皮瓣是头颈部缺损修复的新技术,供区并发症低,主要适用于气管造瘘口和颈部手术后皮肤缺损.

Abstract：

Objective To investigate the application of pedicled internal mammary artery perforator(IMAP) flap for tracheostoma and anterior cervical defect. Methods From April to December 2009, 4 IMAP flaps, based on the second internal mammary artery perforator, were used for two cases of tracheostoma and two cases of anterior cervical skin defect. The flap size was (4-7) cm× ( 10-13 )cm.Results 3 of 4 flaps survived completely. Partial necrosis happened in one flap. The defects at donor sites were closed directly. Conclusions The IMAP flap is a new method for head and neck defect. It is very suitable for tracheostoma and cervical skin defect, with less morbidity at donor site.