Refined harvest technique for a segmental latissimus dorsi muscle flap with a lengthened pedicle

The latissimus dorsi (LD) muscle flap is one of the most versatile flaps used for reconstruction of soft tissue defects. With knowledge of its anatomy, harvest of the segmental LD muscle has been introduced as a reliable technique with the advantage of muscle preservation. We devised a new harvest technique for the segmental LD flap using a limited transverse incision to elevate a less bulky distal segment of the muscle with a sufficient pedicle length obtained by intramuscular dissection of the vascular pedicle. Two cases, in which this technique was effectively applied to reconstruct plantar defects after wide excision of malignant melanoma with a maximally efficient use of donor and recipient tissues, are presented. Satisfactory results were gained with stability in walking. When the defect size permits use of a segmental muscle and the long pedicle is needed, this pedicle‐lengthened segmental LD muscle harvest technique would be a valuable method. © 2013 Wiley Periodicals, Inc. Microsurgery 33:491–495, 2013.     

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.     

The rectus abdominis free flap for lower extremity reconstruction

The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction--the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.     

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.     

Segmentally split pectoral girdle muscle flaps for chest-wall and intrathoracic reconstruction

The latissimus dorsi, pectoralis major, and serratus anterior provide the principal flaps for major chest-wall and intrathoracic reconstructions. Each of these muscles shows a philogenetically preserved internal metamerism that is expressed by a segmental morphology and neurovascular supply. This segmental anatomy creates multiple independent subunits in each muscle that can be surgically split and independently used. Surgically splitting these muscles permits flap refinements such as creating two flaps from one donor muscle and leaving independent subunits in situ to preserve donor motor function after flap transfer. The latissimus dorsi has a consistent proximal bifurcation of its neurovascular supply into a medial and lateral branch that permits dividing the muscle or skin-muscle unit into two independent flaps. The pectoralis major has three segmental neurovascular subunits, the clavicular, the sternocostal, and the external. These can be surgically split and independently transferred on vascular pedicles from the thoracoacromial, internal mammary, and lateral thoracic vessels. This provides a substantial degree of donor motor preservation, as shown by the pectoralis V-Y myoplasty for mediastinal reconstruction. The serratus arterial has a highly segmental morphology with multiple subunits corresponding to each of the first nine costovertebral units; it also can be surgically split. The resultant upper and lower groups can be further subdivided if needed. These flaps provide useful intrathoracic reconstruction with a substantial degree of donor motor preservation. Such technical refinements substantially increase each flap's versatility and lessens the donor cost for thoracic reconstruction.     

Differences in intramuscular vascular connections of human and dog latissimus dorsi muscles

BACKGROUND: Distal ischemia and necrosis of the dog latissimus dorsi muscle flap used in experimental cardiomyoplasty have been reported. However, little information on the intramuscular vascular anatomy of the dog latissimus dorsi is available. It is unclear whether there are any anatomic factors relating to the muscle flap ischemia and necrosis, and whether the dog latissimus dorsi is a suitable experimental model. METHODS: To study the intramuscular vascular territories in the dog latissimus dorsi muscle, and to compare the intramuscular vasculature of the dog with that of the human, 5 fresh dog cadavers and 7 fresh human cadavers were injected with a mixture of lead oxide, gelatin, and water (200 mL/kg) through the carotid artery. Both the dog and the human latissimus dorsi muscles and neurovascular pedicles were dissected and radiographed. The intramuscular vascular anatomy of the latissimus dorsi muscles was compared. RESULTS: Radiographs demonstrate clearly that the pattern of latissimus dorsi intramuscular anastomoses between branches of the thoracodorsal artery and the perforators of posterior intercostal arteries in the proximal half of the muscle are different between the dog and the human. In the dog muscle, vascular connections between the thoracodorsal artery and the posterior intercostal arteries are formed by reduced-caliber choke arteries, whereas four to six true anastomoses without a change in caliber between them are found in the human muscle. The portion of the latissimus dorsi muscle supplied by the dominant thoracodorsal vascular territory was 25.9% +/- 0.3% in the dog and 23.9% +/- 0.5% in the human. For further comparison, an extended vascular territory in the latissimus dorsi muscle was demonstrated, including both the thoracodorsal territory and the posterior intercostal territories. The area of the extended vascular territory was 52% +/- 0.5% of the total muscle. CONCLUSIONS: The dog latissimus dorsi model may not be a perfect predictor of the behavior of the human latissimus dorsi muscle flap in cardiomyoplasty.     

Free flap transfer of the cutaneous maximus muscle in the rat: comparison to the latissimus dorsi muscle flap.

A new rat model of free muscle flap transfer is presented. Microvascular transplantation of the cutaneous maximus muscle flap is performed at the groin site, with anastomosis of the axillary vessels to the appropriate femoral vessels. This muscle flap has many useful attributes for experimental manipulation. It has a high success rate following transplantation, the anatomy is consistent, the dissection is straightforward, the length of pedicle is relatively long (10 mm), the vessels for repair are of sufficient size (1.0-1.35 mm diameter), and the microsurgical procedure can be performed in a relatively short period. The donor site deficit causes minimal impairment to animal mobility, and no evidence of limb ischemia is noted after ligation of the axillary vessels. The cutaneous area adjacent to the muscle is perfused by muscular perforators supplied by the flap pedicle; thus a skin island may be used to monitor the flap or to create a composite myocutaneous transfer. The cutaneous maximus muscle has mixed muscle types and anatomic dimensions similar to those of the latissimus dorsi muscle, and it provides ample tissue for pharmacological and biochemical studies, yet it presents easier dissection and microanastomoses than the latissimus flap, with more potential for versatility in application. The advantages of this muscle flap make it a very useful experimental model for flap transfer research.     

The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopedic surgery

The latissimus dorsi was transferred as a pedicle flap in ten patients and as a free vascular flap in ten others for extremity reconstruction. Group I comprised ten patients in whom the transfer was used solely to cover a skin or soft-tissue defect. Although there was partial necrosis of the transferred skin in one patient, the remaining nine patients obtained complete coverage without further reconstructive surgery. Group II comprised five patients in whom transfer of the latissimus dorsi was performed for active flexion or extension of the elbow or for abduction of the shoulder. Postoperatively, muscle strength obtained was classified from Grades 0 to 5 according to the muscle testing method. Three patients obtained muscle strength of Grade 3, while two obtained Grade 2. Group III comprised five patients who had brachial plexus palsy after high-dose irradiation. Coverage of the skin and soft tissue was performed after neurolysis of the brachial plexus palsy to free the tissue bed of scarred tissue. Postoperatively, sensory and motor disturbances were alleviated in four of five patients.     

Functional units within the latissimus dorsi muscle based on Sihler technique

The latissimus dorsi is the largest dorsally located pectoral girdle muscle. The anatomic basis for splitting this muscle is based on dissection studies. These dissection studies have outlined the extramuscular innervation of the muscle. The intramuscular innervation, on the other hand, has been studied by using radiographs of intramuscular nerves labeled by fine wire. This technique, however, is limited by the level of microdissection that can be performed. Sihler staining technique renders the muscle translucent, stains the myelin in the nerve a dark blue and the hemoglobin in the vessels a dark brown. The intramuscular course and branching of the nerve and vessels is thus revealed without any surgical disruption of the anatomy. We use this technique to study the intramuscular neurovascular anatomy of the latissimus dorsi flap in 6 fresh human cadavers to determine the degree to which the muscle could be separated for functional muscle transfer.     

Use of the latissimus dorsi and the serratus anterior muscles as a combined flap

Flaps composed of the latissimus dorsi and the serratus anterior muscles have been used to repair extensive defects in 10 patients with no remarkable disabilities of shoulder function. The latissimus dorsi and serratus anterior muscles are consistently nourished through the subscapular-thoracodorsal vessels. Thus, the 2 flaps can be based on 1 vascular pedicle. If required, the ribs beneath the serratus anterior muscle, which are vascularized by the periosteal circulation, can be transferred with the muscle. The vascular pedicle of this flap is long and anatomically reliable. Care must be taken to avoid tension or torsion of the pedicle when positioning the flap.     

Use of the pedicled latissimus muscle flap for upper-extremity reconstruction

Tissue with a blood supply derived from a single constant vascular pedicle may be raised as a flap and rotated within the reach of its blood supply to cover and reconstruct a variety of complex wounds. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilization, and expendability. It can be rotated, with or without overlying skin, to cover soft-tissue defects involving the shoulder, arm, and elbow, or it can be transferred as an innervated muscle to improve shoulder abduction as well as elbow flexion and extension. The major clinical applications of the pedicled latissimus dorsi muscle flap for upper-extremity reconstruction include use as a bipolar transfer to improve elbow flexion after trauma or brachial plexus injury and as a nonfunctioning myocutaneous transfer for coverage of nerves, bones, and joints after soft-tissue loss due to trauma, tumors, infection, or irradiation.     

背阔肌双极移位重建产瘫儿童屈肘肌功能

目的：介绍和评价背阔肌双极移位重建臂丛神经产伤后屈肘肌功能障碍的手术方法和结果。方法：从1992年6月-2002年6月，本科共收治分娩性臂丛神经损伤病人36例，其中采取背阔肌双极移位治疗臂丛神经产伤后屈肘肌功能障碍10例，男4例，女6例，手术时平均年龄为7(5—12)岁，2例息儿在术后1年因肩关节连枷而行肩关节固定术。结果：本组10例病人术后平均随访3(1．5—6)年，肘关节屈曲肌力达到4级以上，手触嘴的功能均恢复，无神经血管束损伤等手术并发症。结论：臂丛神经产伤引起的屈肘肌功能障碍严重影响患儿的生活和学习能力，需要手术治疗。本组选择的背阔肌双极移位，具有操作相对简便、符合生物力学、并发症少和结果确实的优点，因此是一种值得推荐的手术方法。     

Alternative techniques for pedicle transfer of an island flap and a free flap

Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Exteriorization of the vascular pedicle of a reverse radial forearm flap allows a greater arc of movement of the flap for more distal coverage, and avoids the potential vascular compromise of tunnelling under a tight skin bridge. Two-stage transfer of a latissimus dorsi myocutaneous free flap on a wrist carrier pedicle may be useful in circumstances when local recipient vessels are inadequate for free flap transfer. Although both of these vascular pedicle modifications have drawbacks, they may be of value in limited circumstances. Their advantages and limitations are discussed.     

Poland's Syndrome: Improved Surgical Management

Single-stage reconstruction of the chest wall combined with simultaneous augmentation mammoplasty and transfer of an island pedicle myocutaneous flap of latissimus dorsi muscle are major improvements over previous multiple-stage procedures that provide less satisfactory cosmetic results in management of patients with Poland's syndrome. Utilization of the single-stage technique in 2 patients demonstrated its efficacy as proven by excellent cosmetic results. In 1 patient with absent second, third, and fourth costal cartilages and ribs, Marlex mesh covered with a synthetic dura mater graft was employed to stabilize the chest wall. Simultaneously, an island pedicle myocutaneous flap of latissimus dorsi with its neurovascular bundle preserved was transferred to cover the prosthesis. The other patient had a coexistent pectus carinatum defect, which was repaired by resection of the costal cartilages and osteotomy of the sternum without use of Marlex. The breast implant was covered concomitantly with the myocutaneous flap of latissimus dorsi. No morbidity or mortality occurred. The cosmetic and functional results are superior to those obtained with standard techniques.     

Bilobed monobloc transfer including parascapular and neurovascular latissimus dorsi muscle flap for functional lower leg repair following muscle group resection for synovial sarcoma

Summary A 34-year-old female presented with a recurrent synovial sarcoma of the heel region. This necessitated ablative surgery of the soft tissues of the flexor side of the distal lower leg including tibial nerve, and posterior tibial artery down to the crural interosseous membrane. A fasciocutaneous parascapular flap, together with an ipsilateral latissimus dorsi muscle flap, was harvested with a common pedicle. The vessels of the monobloc transfer served as segmental interposition to restore the arterial continuity: proximally, the subscapular artery and distally, the thoracodorsal artery were used to bridge the tibial artery defect. To achieve achilles tendon motor function, the latissimus dorsi muscle flap was reinnervated from the tibial nerve stump. This procedure permitted the conservation of the lower leg, in spite of the extensive resection to obtain tumorfree margins in three dimensions and a simultaneous functional repair in one stage. Following this, combined oncological therapy could be rapidly instituted.     

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.     

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.     

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.     

The use of latissimus dorsi muscle flap in the aesthetical reconstruction of heat-press injury of the hand

We present a successful case of aesthetic reconstruction utilizing free latissimus dorsi muscle flap transfer. A large quantity of skin of the dorsum of hand and finger was lost. The dorsum of the index, long and ring fingers was severely damaged, such that extensor tendons were necrotic and all digital bones and the second metatarsal bone were exposed with partial necrosis. In addition, the proximal interphalangeal joints (PIP) were also exposed. To cover exposed bones and the tendons of dorsum of the hand, a free latissimus dorsi muscle flap was transferred, and then meshed skin covered the muscle, resulting in a mitten-like condition. After cutting the grafted muscle and skin to divide fingers, the grafted muscle was shaved to create the contour of fingers and dorsum of the hand, and then sheet grafting was performed. Six years after the operation, although the movement of fingers was restricted, an acceptable contour of the hand was obtained. The patient is satisfied with the result and does not desire any further surgery. In conclusion, the use of latissimus dorsi muscle flap is a method of choice not only to cover damaged hand but also to give contour in the aesthetic reconstruction of a hand presenting after heat-press injury.     

Coverage of complex defects of the shoulder girdle and posterior neck triangle following tumor resection

IntroductionNumerous pedicle and free flaps have been used to cover complex defects of the shoulder girdle and posterior neck triangle following tumor resection. We describe our choice of flap selection in these patients with case examples.Presentation of casesThree cases examples demonstrate our choice of flap selection. In the first case, an anterior shoulder girdle defect is covered by an anteriorly transposed latissimus dorsi muscle flap. The second case demonstrates the coverage of a posterior shoulder girdle defect by a posteriorly transposed latissimus dorsi muscle flap. Finally, the third case demonstrates the coverage of a posterior triangle neck defect using a superiorly transposed pectoralis major muscle flap. All reconstructions utilize muscle flaps (covered by split-thickness skin grafts) and not myocutaneous flaps.DiscussionWe demonstrate that these two pedicle muscle flaps are adequate for coverage of large complex defects of the shoulder girdle and posterior neck triangle. We also demonstrate the advantages of using muscle rather than myocutaneous flaps.ConclusionPedicle latissimus dorsi and pectoralis major muscle flaps are simpler and preferred over free flaps for coverage of complex defects of the shoulder girdle and posterior neck triangle. The use of muscle rather than myocutaneous flaps will reduce the size of the original defect, make flap design easier and reduce donor site morbidity.