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.     

The subscapular approach in head and neck reconstruction with the pedicled latissimus dorsi myocutaneous flap.

We have devised a new approach for transferring the pedicled latissimus dorsi myocutaneous flap to the head and neck region, and have applied it successfully in several patients. Our approach is rapid and increases the arc of rotation in order to cover defects of the lower lateral and posterior aspects of the head and neck. The vascular pedicle is protected between the scapula and the rib cage. We have used this approach in 15 patients over the last 9 years with good results.     

Use of the latissimus dorsi flap in head and neck reconstructive microsurgery

Reconstructive surgery of the head and neck has particularly benefited from the rapid developments in microsurgery. Resection of tumours from the head and neck which are associated with serious physical and psychological problems, or which often require multiple reconstructive procedures, can now be performed as a single-stage procedure with good oncological and functional results. The present series reports on the treatment of 12 primary or recurrent malignant tumours of the head and neck using the latissimus dorsi musculocutaneous free flap. Complications consisted of two venous thromboses which required revision of the anastomoses. The oncological and functional results were good, while the aesthetic outcome was fair. We conclude that the latissimus dorsi muscle or musculocutaneous free flap is the method of choice to repair wide defects of the head and neck following the resection of malignant tumours. © 1994 Wiley-Liss, Inc.     

Autologous breast reconstruction with latissimus dorsi flap

The gold standard technique for autologous breast reconstruction is the transverse rectus abdominis flap (TRAM). Recently, techniques of harvesting a latissimus dorsi flap have been modified in such a way as to increase the flap and allow breast reconstruction without an associated implant. The aim of this study was to evaluate aesthetic results obtained with this method and to assess early morbidity related to the changes in the technique. Between January 1994 and August 1998, 43 patients underwent breast reconstruction with an autologous latissimus dorsi flap. Their postoperative outcome was compared to that of 30 patients who underwent reconstruction with a latissimus dorsi flap associated with an implant. These 43 patients were asked to come back for aesthetic evaluation by a physician and to answer a questionnaire about cosmetic results. Mean duration of follow-up was 18.6 months (range 8 to 60). Mean size of the breast reconstructed with this technique was 340 g (up to 835 g). Dorsal seroma was the most frequent complication (72%), followed by delayed dorsal healing (19%). The frequency of seroma was significantly increased when compared to a classic latissimus dorsi flap (P = 0.003), but frequency of skin slough was not. The aesthetic result was considered satisfactory in 93% of the cases by the patient and 77% of the cases by the physician. In conclusion, the extended latissimus dorsi flap allows reconstruction of small and medium size breasts, with a good aesthetic result. This flap appears to be an interesting alternative to the TRAM flap for autologous reconstruction in selected patients.     

The latissimus dorsi flap for breast reconstruction

The major factor limiting reconstruction of major postmastectomy deformities (especially after a radical mastectomy, such as that of Halsted) has been the lack of a satisfactory flap operation. The latissimus dorsal flap fills this need, as it allows a safe one-stage breast reconstruction, with an improved aesthetic result. It should be considered whenever insufficient chest wall skin remains for a satisfactory reconstruction. The author's technique for performing this flap operation is described, having evolved from cadaver dissections and eight clinical cases.     

Oblique latissimus dorsi myocutaneous flap in breast reconstruction

Breast reconstruction with latissimus dorsi myocutaneous flap is a reliable technique. Its width is limited to between 10 and 12 cm if direct closure of the donor site defect is required. We report a study with assessment of the dorsal skin laxity in 25 women, simulating vertical, horizontal and reverse oblique flap. The average width was 12.5 cm (11.6 to 14 cm) for reverse oblique flap, 9.4 cm (8 to 11 cm) for vertical and 9.2 cm (8 to 10.6 cm) for horizontal flap. Our study suggests that the reverse-oblique flap provides a wider flap and reduces the donor site morbidity.     

Intraoral reconstruction with latissimus dorsi myocutaneous island flap

Summary Intraoral reconstruction for large defects using a latissimus dorsi myocutaneous island flap in ten patients is presented. All flaps were transferred successfully in one stage and provided adequate flap tissue for the intraoral defect. Five cases involved hemiglossectomy. The postoperative atrophy of the flap was minor and the intraoral defects were adequately resurfaced. The postoperative function of the remaining tongue was satisfactory. The latissimus dorsai myocutaneous flap was found to be reliable and useful for intraoral reconstruction.     

The latissimus dorsi myo-cutaneous flap for breast reconstruction

Summary The authors present a method of breast reconstruction after mastectomy making use of the versatile latissimus dorsi myo-cutaneous flap. Two different flap designs are proposed. A fish-shaped flap for reconstruction after mastectomy without irradiation damage and a tennis rackuet type flap for the replacement of irradiated skin, breast and pectoralis muscle. This axial pattern innervated composite flap enables a safe 2-stage breast reconstruction.     

Toxic shock syndrome following latissimus dorsi musculocutaneous flap breast reconstruction.

Acute toxic shock syndrome (TSS) not related to menstruation has comprised an increasing proportion of cases reported to the Center for Disease Control in recent years. We report a patient with TSS resulting from a postoperative donor site infection after bilateral breast reconstruction with latissimus dorsi musculocutaneous flaps. The diagnosis, management, and outcome of TSS are reviewed. The plastic surgeon should be aware of TSS as a potential postoperative complication of routine procedures in plastic surgery.     

腹直肌-背阔肌肌皮瓣联合应用乳房再造术

目的　探索一种同时修复乳房和胸壁缺损的手术方法。方法　利用下腹部横行腹直肌肌皮瓣 (下简称TRAM皮瓣 )和部分背阔肌肌皮瓣 ,为乳癌术后患者行乳房再造及胸壁缺损修复。结果　 4例 8个皮瓣全部成活 ,再造乳房及胸壁缺损修复效果满意。结论　联合应用腹直肌—背阔肌肌皮瓣 ,可以同时完成乳房再造及胸壁缺损的修复 ,效果满意。     

Entire pharyngoesophageal reconstruction with latissimus dorsi myocutaneous island flap

The entire pharynx and cervical esophagus were reconstructed after total laryngectomy and pharyngoesophagectomy for advanced cancer in 14 patients with the use of a pedicled latissimus dorsi myocutaneous island flap. All flaps were transferred successfully in one stage. The reliability of the flap and postoperative state of food passage were studied. Repair was confirmed by roentgenographic examination 6 months after surgery. A slight narrowness was noted at the portion anastomosed with the esophagus, with dilatation of the reconstructed segment. All patients in our study have been able to resume normal oral feeding. The pedicled latissimus dorsi myocutaneous island flap is reliable and useful for the reconstruction of the pharynx and cervical esophagus.     

Lymphatic drainage study after latissimus dorsi flap breast reconstruction

Background

Recurrence of breast cancer to latissimus dorsi (LD) flap donor site is a very rare condition, and as a result, few data are currently available on its possible causes. The aim of the study was to investigate the role of LD flap transfer in lymphangiogenesis and connection to the preexisting lymphatic network after mastectomy and axillary lymph node dissection and the lymphatic drainage involvement in local relapse to flap donor site.

Methods

Lymphoscintigraphy was performed on subgroup of ten patients who had previously undergone modified radical mastectomy, axillary lymph node dissection, and pedicled LD flap reconstruction. Lymphatic drainage was imaged by static gamma camera acquisitions after two intradermal injections of 37 MBq ^99mTc-Nanocoll® on residual breast skin and LD skin paddle, respectively.

Results

In eight cases (80 %), the residual breast skin showed fast lymphatic drainage directed only toward the ipsilateral axilla, while in two cases (20 %), it was also seen to the internal mammary nodes. LD skin paddle showed slower drainage in all cases but 1, where no visible drainage was observed within 2 h after injection.

Conclusions

Although a small case series is the study limitation, our findings suggested that the LD flap harvest can promote a preferential route of lymphatic drainage in the axillary region and could be involved in a metastatic spread to the dorsum because of the new tissue plane opening. The direct communication created between recipient and donor sites could have lead to cell cancer transfer to the donor site either by lymphatic or a contiguity pathway. Level of Evidence: Level V, diagnostic study.     

Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap

ObjectiveTo analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction.Patients and methodsProspective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months.ResultsThe reconstructed and healthy breasts decreased in volume in group 1 (?45.85 cm³ ± 48.41 cm³, p = 0.0004; ?29.13 cm³ ± 14.98 cm³, p = 0.0009) and in group 2 (?31.5 cm³ ± 25.35 cm³, p = 0.0001; ?15.4 cm³ ± 21.96 cm³, p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05).Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001).ConclusionWe suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast.