Use of the free latissimus dorsi flap in the reconstruction of extensive orbital exenterations]

The authors present the use of a free latissimus dorsi myocutaneous flap for closure of large orbital exenterations. Five cases illustrate different tumor involvements and coverage possibilities. Several technical details are studied. The vascular anastomoses are performed on cervical vessels: external carotid artery internal jugular vein. The latissimus dorsi myocutaneous flap is particularly suited for reconstruction of large facial soft tissue defects around the orbit when obliteration of the orbital cavity and restoration of deficient facial skin are necessary with correct morphological results.     

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.     

Microvascular surgery as an adjunct to craniomaxillofacial reconstruction

Fifteen patients (8 female and 7 male) age 4 to 57 years underwent microsurgical free tissue transfers as a component of a craniomaxillofacial reconstruction. In 12 patients the free flap was performed simultaneously with the bony procedure and in three it was a secondary procedure. The patients included two craniosynostosis, four craniofacial tumours, five hemicraniofacial microsomias, one facial and skull base arteriovenous malformation, one orbitofacial neurofibromatosis and two hemifacial atrophies with extensive facial skeletal involvement. The rectus abdominis free flap was used in 9 patients, the latissimus dorsi in two, the omentum in three, and the first web-space in one. The choice of tissue varied according to the size of the defect and its location. The rectus abdominis musculofasciocutaneous flap was the most frequent source of tissue for contour restoration, and the omentum was used to fill intracranial spaces. One flap failed intraoperatively in a patient with hemifacial microsomia and inadequate and abnormal recipient vessels. One patient had an injury to the temporal branch of the facial nerve, with spontaneous recovery. In 13 patients the free tissue transfer was for soft tissue fill with cover of facial bone or skull base; secondary procedures were frequently required in these patients. In two patients with intracranial free flaps, no further procedures were necessary. In selected cases the association of microvascular techniques with craniomaxillofacial surgery can facilitate reconstruction and improve results.     

Scapular free flap for repair of massive lower facial composite defects

The scapular osteocutaneous free flap provides excellent tissue for reconstruction of massive lower facial defects. Five cases of full-thickness cheek and lip defects associated with mandibular loss were successfully repaired with sandwiched osteocutaneous scapular flaps plus a parascapular or latissimus dorsi flap. In two instances the osteocutaneous scapular flap was harvested along with a parascapular skin paddle. The other three patients had latissimus dorsi myocutaneous units taken with the scapular osteocutaneous flap from the same subscapular pedicle.     

Scalp reconstruction by microvascular free tissue transfer

We report on a series of patients with scalp defects who have been treated with a variety of free flaps, spanning the era of microvascular free tissue transfer from its incipient stages to the present. Between 1971 and 1987, 18 patients underwent scalp reconstruction with 21 free flaps: 11 latissimus dorsi, 3 scalp transfers between identical twins, 3 groin, one combined latissimus dorsi and serratus anterior, two serratus anterior, and one omentum. These flaps were used to cover scalp defects resulting from burns, trauma, radiation, and tumors in patients ranging from 7 to 79 years of age. Follow-up has ranged from 3 weeks to 7 years. All of our flaps survived and covered complex defects, many of which had failed more conservative attempts at cover. One patient received radiation therapy to his flap without unfavorable sequelae. This experience began with a pioneering omental flap and includes cutaneous and muscle flaps. The latissimus dorsi is our first choice for free flap reconstruction of extensive, complicated scalp wounds because of its large size, predictable blood supply, ease of harvesting, and provision of excellent vascularity to compromised beds.     

Restoration of finger extension and forearm contour utilizing a neurovascular latissimus dorsi free flap

The use of a free neurovascular latissimus dorsi flap for restoration of wrist and finger extension and forearm contour is described in a burn patient. Wound coverage is the prime need of the extensive tissue loss in the upper limb, and a muscle or musculocutaneous flap is necessary to cover the exposed bone and muscles for infection control. Furthermore, restoration of the limb function as well as aesthetic flap donor and recipient site contour are needed. The case presented is the extremely rare patient in whom restoration of finger extension was achieved after the nearly total loss of the extensor forearm muscles.     

Free flaps for type III complex pharyngoesophageal defects after enlarged ablative surgery for advanced cancer of larynx and hypopharynx

Free tissue transfer has become a useful technique for reconstruction of type III complex pharyngoesophageal defects after enlarged laryngectomy and partial or total pharyngoesophageal resection. We present a retrospective analysis of our experience with 36 patients who received free flaps for reconstruction of complex pharyngoesophageal defects associated with skin and soft-tissue defects. Free fasciocutaneous flaps and jejunum combined with a deltopectoral flap and musculocutaneous pectoralis major flap, gastro-omental flap, and combined latissimus dorsi musculocutaneous and cutaneous scapular flaps were used for reconstruction. Adjuvant therapy included preoperative or postoperative radiotherapy. Free flap failure occurred in 2 of 36 patients. Twenty-eight patients had good swallowing function. Better results with fewer complications in reconstruction of type III complex pharyngoesophageal defects were obtained with the use of a combined latissimus dorsi and scapular flap.     

Expanded reduced latissimus dorsi flap

The reduced latissimus dorsi musculocutaneous flap is a recently reported flap, consisting of a proximal musculocutaneous unit and a distal, thin fasciocutaneous or cutaneous unit. It can be used to obtain satisfactory contour of the recipient site. In cases where a larger and thinner flap is required, we employ pretransfer tissue expansion of the reduced latissimus dorsi flap. Application of the tissue expander appears to increase both the area and the vascularity of the flap. We have so far employed two pedicled and four free-expanded reduced latissimus dorsi flaps in the repair of a variety of defects. All of these flaps survived, and suitable contour, along with primary closure of the donor site, was obtained.     

Use of pedicled latissimus dorsi myocutaneous flap to reconstruct the upper limb with large soft tissue defects

ObjectiveTo report the technique of reconstruction of large skin and soft tissue defects in the upper extremity using pedicled latissimus dorsi myocu-taneous flaps.MethodsSix patients with large skin and soft tissue defects were included in this report. There were 5 trauma patients and the rest one needed to receive plastic surgery for his extremity scar. All wounds were in the upper extremity. The sizes of defects ranged from 15 cmx6 cm to 30 cmx18 cm. Pedicled latissimus dorsi myocutaneous flaps were designed according to the defect area and raised with part of latissi-mus dorsi. The thoracodorsal artery and its perforators were carefully protected during surgery.ResultsAll flaps healed primarily without flap congestion, margin necrosis or infection. The skin donor sites either received split-thickness skin graft (3 cases, mostly from the anterior thigh) or was closed primarily (3 cases) and had minimal morbidity. Follow-up of 6-12 months showed that the contour of flap was aesthetic and the function of limb was excellent.ConclusionOur experience indicates that the pedicled latissimus dorsi myocutaneous flap is favorable for reconstruction of large skin and soft tissue defects in the upper extremity.     

Use of free flaps in the aesthetic reconstruction of face and neck deformities.

Three cases of face and neck deformities, reconstructed with free flaps in order to obtain better aesthetic results, are presented here. Nasal tip, cartilage, and soft tissue defects as well as facial burn contractures were reconstructed with a free radial forearm flap, latissimus dorsi myocutaneous flap, and groin flap, respectively. Case specifics are discussed.     

Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases

OBJECT: The purpose of the paper is to review the results of free latissimus dorsi transfer for scalp and cranium reconstruction in case of large defects with exposed brain tissue, deperiosted cranial bone, and dura that cannot be reconstructed with local flaps or skin grafts. METHODS: Free latissimus dorsi transfer was carried out in an interdisciplinary approach involving neurosurgery and plastic surgery in seven patients with subtotal and total scalp defects (two reconstruction after tumor removal, two reconstructions after longstanding osteitis, 2x tissue break down after irradiation, 1x defect reconstruction after high voltage injury). There were three male and four female patients. The age ranged from 36 to 72 years. Reconstruction was carried out with a muscle flap (1x) or a myo-cutaneous flap (6x) in combination with a split thickness skin mesh (1:1.5) graft, done in a single-stage procedure. In a retrospective clinical study the following criteria were evaluated: 1) flap healing, 2) esthetic result, and 3) complications. All flaps healed primarily, and all wound remained closed without any signs of infection. Complete wound healing was achieved after 4-8 weeks, depending on the healing of the skin grafts. Secondary skin grafting was necessary in two patients, revision of the donor site in two patients. From an esthetic 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 patient judged the result as good or acceptable. CONCLUSION: Besides the free omentum flap, the free latissimus dorsi transfer is the only option for coverage 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 are using a myo-cutaneous flap. The skin island must be removed secondarily. In patients were no bone reconstruction is possible or planned, the deepithelialized skin paddle can be used for correction of a contour defect.     

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.     

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.     

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.     

Physiological studies using laser Doppler flowmetry to compare blood flow to the zones of the free TRAM flap

The latissimus dorsi musculocutaneous island flap was once the standard for breast reconstruction. With the increased use of tissue expanders and the development of the transverse rectus abdominis musculocutaneous flap for autologous tissue breast reconstruction, use of the latissimus dorsi has decreased. To reassess the role of the latissimus dorsi musculocutaneous flap in breast reconstruction, a retrospective review was performed to evaluate women who had skin-sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and permanent implants. The postoperative aesthetic results and donor site morbidity, including contour deformity and scarring, were examined. Satisfactory results were obtained in 17 of 18 patients. Complications were noted in 5 patients, and all were minor. Using the latissimus dorsi musculocutaneous flap and a permanent breast prosthesis for immediate reconstruction is successful because it provides sufficient muscular coverage of the implant. In addition, it provides a good aesthetic result using a single-stage procedure. Illustrative cases are presented.     

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.     

New options in breast reconstructive surgery: alternatives to the latissimus dorsi musculocutaneous flap

Transposition of the latissimus dorsi musculocutaneous flap is still considered by most authors a first-choice technique for breast reconstruction. However, the aesthetic drawbacks of the technique are significant: In our experience the posterior scar and the "patchlike" skin island are of concern to more than 30% of patients. Recent alternatives have sharply reduced the use of the latissimus dorsi myocutaneous flap as our first-choice technique. The utilization of a latissimus dorsi muscular flap in association with submuscular placement of a tissue expander is now our favorite technique for the majority of patients: Residual scarring is insignificant since the whole muscle can be raised through a 5-7-cm-long, S-shaped incision placed along the anterior border of the latissimus dorsi. The results obtained in a group of 35 patients demonstrate that the final results of the procedure in terms of shape and projection of the reconstructed breasts are absolutely similar to those obtained using the latissimus dorsi musculocutaneous flap. However, in patients with heavy body structure and large contralateral breast, satisfactory symmetry and a natural-looking reconstructed breast are obtained more effectively by transposition of a rectus abdominis myocutaneous flap. The precautions to be taken in order to make the procedure suitable for over-weight patients are described and the results are discussed.     

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.     

Simultaneous reconstruction of both feet with a vascularized latissimus dorsi free flap

Simultaneous reconstruction of both feet with a single vascularized latissimus dorsi free flap is reported. The authors describe the repair of extensive dorsal and plantar defects, as well as of heel lesions secondary to osteitis of the calcanei. The latissimus dorsi free flap serves well in combining the classic cross-leg procedure with microsurgical techniques.     

Free composite osseomyocutaneous flap of latissimus dorsi, serratus anterior and rib for oromandibular reconstruction

A wide variety of osseomyocutaneous free flaps for mandibular reconstruction has been described. The flap made up of latissimus dorsi, serratus anterior and rib (LSRF), , can provide vascularized skin, muscle, bone and cartilage on a single thoracodorsal vascular pedicle and is useful in some circumstances, i.e., large soft tissues defects. In this paper, we describe two cases in which the flap was chosen for reconstruction of the mandible, cheek and intraoral mucosa, following major ablation of malignant tumours. In our experience, this flap is excellent for soft tissue repair and fulfils the basic requirements of bony restoration. Moreover, the donor site morbidity is minimal and its dissection is rather easy. The LSRF may be the first choice in certain reconstructive circumstances. Received: 12 July 1999 / Accepted: 31 January 2000