Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited

Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.     

Full thickness chest wall reconstruction after tumor resection by myocutaneous flap

Full thickness chest wall defects result when a chest wall tumor resection is necessary. The feasibility of a reconstruction is sometimes unfamiliar to the oncologist or thoracic surgeon; this can be the reason for refusing the possibility of surgical resection or inappropriate coverage of the defect. Our experiences over the last 7 years in collaboration between plastic the thoracic surgical services, shows that it is generally possible to utilize a myocutaneous flap for reconstruction of even extensive full thickness chest wall defects. The reconstruction of any full thickness chest wall defect after tumor resection by myocutaneous flaps is almost always possible with low mortality, acceptable morbidity and good results, mechanically and aesthetically. The experience with the different reconstruction techniques clearly shows the preference for the latissimus dorsi myocutaneous flap, but also emphazises that the other kinds of reconstruction must be kept in mind for special indications.     

Using the costal muscle flap with latissimus dorsi muscle to repair full-thickness anterior chest wall defects

Musculoosseous flaps with latissimus dorsi muscle are used for reconstruction of full-thickness anterior chest wall defects. The 11th and 12th ribs and the posterior parietal pleura are elevated with the latissimus dorsi muscle. The blood supply of the compound flap comes from the thoracodorsal pedicle and from perforating segmental vessels. The posterior thoracic wall island is transferred to the anterior chest wall defect to restore a skeletal plane and the transposed latissimus dorsi obliterates all the dead spaces that cannot be collapsed. The latissimus dorsi compound flap with the 11th and 12th ribs appears to be a "safe" procedure to reconstruct full-thickness anterior chest wall defects.     

Transposition of modified latissimus dorsi musculocutaneous flap in the treatment of persistent bronchopleural fistula after posterolateral incision

The condition of a 51-year-old man was complicated with empyema and bronchopleural fistula (BPF) after left upper lobectomy and thoracoplasty for pulmonary aspergillosis. On the postoperative day (POD) 12, the opened bronchial stump was directly closed and covered with a pedicled pectoralis major muscle flap. On POD 66, an open-window thoracostomy was done, because of empyema with Pseudomonas aeruginosa. Two years later, we could fill the empyema cavity, and close the multiple BPFs with the transposition of a modified pedicled musculocutaneous (MC) flap and the additional thoracoplasty to gain good quality of life. Although the MC flap was a proximal part of the latissimus dorsi muscle, which was dissected along the posterolateral incision of the first operation, it could be successfully transplanted to cover the BPFs in the open-window. In some patients with a small open-window on the upper anterior chest wall, the pedicled proximal latissimus dorsi MC flap may be very useful for treating persistent BPFs even after a standard posterolateral incision.     

The use of tissue expansion to elongate the latissimus dorsi myocutaneous flap in the pig model

The latissimus dorsi myocutaneous pedicled flap is a reliable and versatile flap frequently used in reconstructive procedures. However, due to its fixed axial length, the use of this flap is limited to coverage of adjacent defects. In this study we present the use tissue expansion as a means to elongate the latissimus dorsi myocutaneous pedicled flap for coverage at distal sites in the pig model.     

应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

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.     

Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Limitations and refinements in 56 cases

The transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Fifty-six transaxillary latissimus dorsi musculocutaneous flap reconstructions were performed in 55 patients. There were two cases of complete flap necrosis and eight cases of partial flap necrosis. The latissimus dorsi vascular pedicle is separate from the irradiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicled latissimus dorsi flap does not reach far enough cephalad, the nutrient vessels may be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, mandibulofacial region, and neck may be reconstructed with a single large latissimus dorsi flap. Hairless skin particularly suitable for oral cavity reconstruction is usually available. Aesthetic and functional deficits are minimal after latissimus dorsi reconstruction. Disadvantages of this technique include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury may occur. The latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed by simpler methods.     

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 of post-upper lobectomy empyema treated by serratus anterior muscle and pedicled latissimus dorsi musculocutaneous flaps plombage via open-window thoracostomy.

A 62-year-old male was admitted to our hospital for operation for Aspergillus empyema with a fungus ball in the right upper lobe. We performed a right upper lobectomy and decortication of the middle and lower lobes through a standard posterolateral thoracotomy with dissection of the latissimus dorsi and serratus anterior muscles, in October 2000. Twenty-one days postoperatively (POD), he developed an empyema and a bronchopleural fistula. We performed open-window thoracostomy through the axilla with removal of the third and fourth ribs at 41 POD, and sterilized the open drainage cavity in the out-patient clinic 11 months after discharge. Although the condition of the bronchopleural fistulas was not improved, and methicillin-resistant Staphylococcus aureus (MRSA) was found in the purulent discharge, the discharge decreased. Finally, a pedicled latissimus dorsi musculocutaneous and serratus anterior muscle flap plombage was performed 11 months after initial operation. The patient is now well and works as a driver 21 months after discharge. We conclude that muscle flaps of the pedicled latissimus dorsi and serratus anterior muscles can be useful for plombage of the cavity in cases of post-standard thoracotomy.     

Chest wall reconstruction for recurrent breast cancer

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).     

Chest wall reconstruction in thoracoabdominal ectopia cordis: using the pedicled osteomuscular latissimus dorsi composite flap

Ectopia cordis is a rare congenital defect characterized by complete or partial displacement of the heart outside the thoracic cavity. Repair of ectopia cordis can present a reconstructive challenge often requiring a staged approach. Ideally, structural integrity and protection of the heart are restored using autologous tissues capable of growth. In addition, reconstruction of the thorax must proceed without compromise to pulmonary or cardiovascular stability. The following article describes repair of thoracoabdominal ectopia cordis in a patient with pentalogy of Cantrell. Reconstruction of the chest wall was accomplished using a musculoosseus composite flap involving segments of the 9th and 10th ribs and overlying pedicled latissimus dorsi muscle. This is the first report known to the authors of such a repair.     

Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps--technique illustration and clinical outcomes

SUMMARY: Reconstruction of large soft-tissue defects of an upper extremity is very challenging due to the unavailability of expendable local muscle. Appropriate soft-tissue restoration is an essential component of such reconstruction treatment protocols, and often requires a vascularised flap to protect the exposed neurovascular and musculotendinous structures. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilisation and expendability. Moreover, the flap provides well-vascularised tissue from a region far from the area of injury. This paper describes the technique for pedicle latissimus dorsi flap transfer and also reports the authors' experience of its application for the acute treatment of massive upper-extremity soft-tissue injuries. 20 patients with large soft-tissue defects over the upper extremity caused by trauma and infection underwent aggressive debridements and immediate soft-tissue reconstruction using a pedicled latissimus dorsi muscle flap. Successful reconstructions were achieved and primary healing of wounds occurred in all patients, with minor complications. The donor site morbidity was minimal. At a mean of 3.6 years' follow-up (range: 1.5-6 years), all functional results were good and the patients were satisfied with their outcomes.     

Latissimus dorsi-scapula free flap for reconstruction of defects following radical maxillectomy with orbital exenteration.

A total of 21 patients with latissimus dorsi-scapula free flap reconstruction immediately following radical maxillectomy together with orbital exenteration are presented. Orbital exenteration was performed in all patients due to tumour invasion at the time of diagnosis. There was no total flap failure. Two tissue components subdivided into separate flap units with individual vascular pedicles linked by a single vascular source provide an ideal reconstructive solution for massive defects of the mid-face and orbit. Separate arcs of rotation of each flap unit permit greater mobility necessary for complex three-dimensional reconstruction. A vertically positioned angle of the scapula enables simultaneous reconstruction of the malar eminence and alveolar ridge whereas spontaneous intraoral epithelialisation of the latissimus dorsi muscle requires no additional procedure. For these reasons, in our opinion, combined latissimus dorsi-scapula free flap should be considered the first choice in reconstruction of defects following total maxillectomy with orbital exenteration.     

Full thickness thoracic wall reconstruction after oncologic surgery

Objectives

Thoracic wall reconstruction after oncologic resection remains a complex form of surgery that implies a multidisciplinary approach. The purpose of this study is to present our experience in full thickness thoracic wall reconstruction after tumor resection.

Methods

A retrospective study, including patients who were operated for full thickness thoracic wall defects after tumor resection, was undertaken. The type of bone and soft tissue reconstruction and the patient outcome was evaluated.

Results

Between 1998 and 2011, a total of ten patients underwent full thickness thoracic wall resection and reconstruction. All patients were reconstructed during a single-stage surgery. In all cases, bone reconstruction was accomplished by a polytetrafluoroethylene patch (Gore-Tex), while soft tissue reconstruction required either muscle or musculocutaneous pedicled flaps such as latissimus dorsi, rectus abdominis, or pectoralis major flaps. In this series, no major complications (infection, respiratory or cardiac failure, or deaths) were detected.

Conclusions

Usually treated as palliative surgery, thoracic wall resection and immediate reconstruction allows large wall resection which, in association with adjuvant therapy, can potentially cure patients who have had a primary tumor or a unique metastasis. Level of Evidence: Level IV, therapeutic study.     

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.     

Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow

Sixteen consecutive patients who were treated with a pedicled latissimus dorsi flap for complex soft tissue defects about the elbow were reviewed. The average defect size was 100 cm2. Thirteen of the 16 patients achieved stable wound healing with a single procedure. Three patients had partial necrosis of the latissimus and required additional coverage procedures. We recommend that the latissimus dorsi flap should not be routinely used to cover defects more than 8 cm distal to the olecranon. The flap should be closely monitored in the first 48 hours, drains should be routinely used at the recipient and donor sites, and the elbow should be maintained in an extended position for the first 5 days after the procedure. The latissimus dorsi flap may also have a prophylactic role in selected patients with compromised soft tissue coverage about the elbow. The pedicled latissimus flap can be performed under loupe magnification and requires no microsurgical skills or equipment.     

Versatility of the pedicled thoracodorsal artery perforator (TDAP) flap in soft tissue reconstruction

For the last decades, the latissimus dorsi skin-muscle flap has contributed to the efficient reconstruction of the loss of skin cover (especially in breast surgery) and in long-distance tissue defects. Unfortunately, the nonuse of such an important muscle as the latissimus dorsi for the patient, as well as the resulting thickness of the flap after reconstruction, has turned it into a second choice flap. However, this flap is still indicated in the reconstruction of areas which need a great amount of cutaneous and muscular tissue. The appearance of the perforator flaps and, specifically, thoracodorsal artery perforator (TDAP) flap, has meant a radical change in relation to lower morbidity of the donor site, thus highly ranking the use of these flaps in the reconstruction for similar defects. The aim of this publication is to present our experience with the pedicled TDAP flap in a series of 17 different cases. Of those, there were 14 cases of mammary reconstruction after sparing surgery, 2 cases of axillary reconstruction following severe recurrent hidradenitis, and a case of extensive substance loss in a patient's upper limb following a severe crush injury.     

Versatile use of the muscle and nerve sparing latissimus dorsi flap

In this report, we describe the technique of muscle and nerve sparing latissimus dorsi (LD) flap and evaluate the outcomes of reconstruction of various defects with 12 free and 2 pedicled muscle and nerve sparing LD flaps in 14 patients. The LD muscle functions at operated and nonoperated muscles were evaluated clinically and with electroneuromyography. All flaps survived completely but one which had a partial necrosis. The mean follow-up time was 12.3 months. Adduction and extention ranges of the shoulders were the same bilaterally in all patients. In electroneuromyography, no significant difference was available statistically between the sides. This muscle and nerve sparing latissimus dorsi flap has advantages of thinness, muscle preservation and reliability, and thus can be a good option to other fasciocutaneous flaps in reconstruction surgery.