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.     

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.     

The 2 key muscles in thoracotomy for excision of the lung. The latissimus dorsi and the levator scapulae muscles

Anatomical data related to the thoracotomies performed most frequently in lung surgery are described in some detail: continuity between serratus anterior and levator scapulae as a vide muscular sheet possessing a common deep aponeurosis (thoracolumbar fascia) extending Gilis' space to the vertebral column as the levator scapulae-thoraci space; presence of a "composite aponeurosis" in the posterior angle between serratus anterior and levator scapulae, covering the 8th rib triangle or triangle of auscultation; long costal insertion area and presence of two differently orientated muscle layers for the digitations, particularly of apical bundle. Supplied by a rich vascularization of multiple sources, the serratus anterior and latissimus dorsi are two muscles with single longitudinal nerve pedicles derived from brachial plexus. It is certainly the denervation which is responsible for the distal atrophy of these muscles "sectioned on the right of the selected ribs" following conventional thoracotomy. To avoid esthetic and functional sequelae this innervation must be preserved as far as possible by: interrupting division of serratus anterior anterior to long thoracic nerve and avoiding inclusion of axillary border of latissimus dorsi during lateral thoracotomy; sectioning the latissimus dorsi as low as possible--the other muscles being simply freed and inclined--during lateral thoracotomy.     

Potential excursion and relative tension of muscles in the shoulder girdle: relevance to tendon transfers.

Muscles used for transfer ought to have adequate structural properties. The purpose of this study was to provide a database of potential excursion (muscle excursion without reference to connective tissue restraints) and relative tension (muscle physiologic cross-sectional area in percentage among a group) in shoulder girdle muscles. Thirteen muscles in 13 human cadavers aged 17 to 89 years at death were studied. Potential excursion ranged from 6.7 cm (supraspinatus) to 33. 9 cm (latissimus dorsi). Relative tension ranged from 1.7% (levator scapulae) to 20.9% (deltoid). Significant discrepancies were found between the properties of some of the muscles used as transfers around the shoulder and the properties of the muscles for which they are commonly used as substitutes. Despite the limitations of cadaveric studies and the fact that many other factors are involved in muscle transfers, this database of structural properties of shoulder girdle muscles may help when planning tendon transfers around the shoulder.     

Pedicle or free musculocutaneous flaps for shoulder defects after oncological resection

Management of soft-tissue defects of the shoulder is described. Extensive defects of soft tissues with or without overlying skin were created after resection of sarcomas in five patients. Reconstruction was performed using musculocutaneous flaps, which included three pedicle latissimus dorsi and two free tensor fascia lata flaps. Simultaneous functioning replacement of the defects of the trapezius and deltoid muscles were each achieved in two patients. Primary wound healing was achieved, and each patient recovered good contour of the shoulder. Functional results were satisfactory in all patients with an average score of 93.4% (range, 83%-100%) using the system of the Musculoskeletal Tumor Society. The four functioning muscles recovered active contraction in the transferred position. The shoulder elevation was normal in three patients, and was 90 degrees and 30 degrees in one patient each. All patients remained disease-free at the time of latest follow-up. Thus, shoulder defects of the soft tissues can be managed appropriately with the two representative musculocutaneous flaps.     

The Pedicled Latissimus Dorsi Flap for Shoulder Reconstruction After Sarcoma Resection

Background Tumor extirpation around the shoulder can result in large defects requiring coverage of allograft-alloprosthetic constructs and vital neurovascular structures. This study examined a single institution’s experience with the pedicled latissimus dorsi flap in reconstructing large shoulder defects after oncologic resection. Methods Using a prospectively maintained database, 33 consecutive patients were reviewed who had undergone a pedicled latissimus dorsi flap to reconstruct oncologic shoulder defects between 1994 and 2004. Wide excision or radical en-bloc resection of shoulder tissues was performed with defects often extending intra-articularly and to the level of the mid-arm. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were evaluated. Outcome variables included major and minor complications, patient survival, and limb viability. Results Adjuvant therapy included chemotherapy in 18 patients, radiation therapy in 12 patients, and brachytherapy in 2 patients. Defects averaged 280.1 cm² (range 18–1,225 cm²). Mean skin paddle surface area was 118.9 cm² (range 21–350 cm²). There were 28 myocutaneous flaps and 5 muscle flaps. Materials for bony reconstruction included 13 allograft and alloprosthetic composites, 6 metallic prostheses, and 3 reconstructions using allograft alone. Two patients experienced partial skin flap necrosis. One patient developed local recurrence. Two patients required combined flaps. Conclusions Use of the pedicled latissimus dorsi flap in complex shoulder reconstructions provided ample well-vascularized soft tissue, minimized risk of infection, and maximized limb salvage. In our experience, the pedicled latissimus dorsi flap is an excellent choice for reconstruction of defects around the shoulder after tumor extirpation.     

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.     

带蒂背阔肌皮瓣修复锁骨区恶性肿瘤切除术后皮肤软组织缺损

目的 探讨带蒂背阔肌皮瓣在修复锁骨区恶性肿瘤切除术后皮肤软组织巨大缺损的疗效.方法 对2015年11月-2018年1月收治的9例锁骨区恶性肿瘤患者,术前常规穿刺病检,病检结果证实后手术扩大切除,切除后所形成的巨大缺损创面采用带蒂背阔肌皮瓣进行修复.结果 术后经15～24个月随访,皮瓣全部成活,供区均一期愈合.近、远期随...     

Anomalous blood supply to the serratus anterior/rib composite flap

The serratus anterior muscle and rib composite flap has been well described for oral and mandibular reconstruction. The flap may also be used in combination with the latissimus dorsi flap based on the common thoracodorsal vascular pedicle, a blood supply which has hitherto been proven to be reliable. This case demonstrates a totally independent arterial supply to the serratus anterior and latissimus dorsi muscles.     

背阔肌肌皮瓣在前胸部肿瘤切除后皮肤缺损中的应用

目的探讨应用背阔肌肌皮瓣修复前胸部肿瘤切除后皮肤缺损的临床疗效。方法对28例前胸部皮肤肿瘤患者根据其性质切除肿瘤后,按皮肤肌肉缺损面积,设计背阔肌肌皮瓣转移至缺损区修复。结果28例患者相应的局部皮瓣转移修复至缺损区,术后皮瓣均全部成活,供受区切口均Ⅰ期愈合,随访3～24个月,效果满意。结论背阔肌肌皮瓣是临床上修复胸部肿瘤切除后皮肤缺损的实用而有效的方法。     

Shoulder arthrodesis

Current indications for shoulder arthrodesis include posttraumatic brachial plexus injuries, paralysis of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. The trapezius, levator scapulae, serratus anterior, and rhomboid muscles must be functional to optimize the functional result following shoulder arthrodesis. A consensus has not been reached concerning the ideal position of the shoulder arthrodesis, although excessive abduction or flexion has been associated with chronic postoperative pain. Decortication of both the acromiohumeral and the glenohumeral surfaces to increase the surface area available for arthrodesis is the most common means for obtaining successful fusion. Although there are numerous methods for stabilization of a shoulder arthrodesis, the most popular method today is probably the AO technique with either a single plate or double plates.     

Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction

Breast reconstruction utilizing the latissimus dorsi musculocutaneous flap with an underlying breast implant is a well-established technique. Postoperative shoulder limitation is usually limited if at all noticeable. The muscle itself may, however, remain active in the new anterior position. Many patients find the muscle twitches with extension of the humerus, despite the anterior translocation of the muscle. This leads to a disturbing contraction, superolaterally, of the entire reconstruction. In addition, the resting tone can lead to a sense of tightness, despite a lack of clinically obvious capsular contracture. Division of the thoracodorsal nerve during initial flap elevation can prevent this problem. When raising the routine flap however, the pedicle itself is often not visualized and there is anxiety related to dividing the nerve and accidentally injuring the vascular pedicle. In addition, many of the transferred muscles atrophy, thereby avoiding this potential problem. When the muscle remains active, delayed division of the thoracodorsal nerve via a 2.5-cm axillary incision will stop the active twitching, decrease the resting tone of the muscle, and in most patients offer significant relief from symptoms of tightness. During the past 2 1/2 years, 100 latissimus dorsi flap breast reconstructions in 80 patients were performed. Forty-one nerves in 28 patients have been divided, with successful denervation in 37 of the 41 reconstructions, for a success rate of 90%. Delayed division of the thoracodorsal nerve can offer relief to patients complaining of tightness and muscle activity post-latissimus flap breast reconstruction.     

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。     

肩胛带巨大软组织肉瘤的外科治疗

目的 探讨肩胛带巨大软组织肉瘤的外科治疗特点和影响治疗效果的各种因素.方法 2005-2009年我科治疗7例肩胛带巨大软组织肉瘤患者,男性4例,女性3例.7例均为术后复发患者.年龄14 ～75岁,平均43.8岁.肿瘤最大径10～ 16 cm.所有患者均行手术治疗,其中广泛切除4例,边缘切除3例.5例患者行肿物局部切除背阔肌肌瓣转移取皮植皮术,1例患者行局部推进皮瓣术,另1例患者行肿物局切取皮植皮术.术后病理:3例恶性纤维组织细胞瘤、1例低度恶性黏液性纤维肉瘤、1例原始神经外胚层瘤、1例腺泡状横纹肌肉瘤、1例皮肤隆突性纤维肉瘤.术后采用国际肌肉骨骼系统肿瘤协会(MSTS)标准进行肩关节功能评分.结果 7例患者得到长期随访,平均随访时间29个月(10 ～46个月).2例患者有局部复发,其中1例再次术后6个月肺转移死亡;1例患者有肺转移;其余4例患者无复发及肺转移.术后患者肩关节功能满意,MSTS评分28分.结论 肩胛带软组织肉瘤在早期常被误诊误治,广泛的外科边界是控制局部复发的主要因素.外科边界和病变的侵袭性是肩胛带软组织肉瘤预后的主要影响因素.手术造成的巨大软组织缺损常需局部肌瓣或皮瓣转移来修补,常用背阔肌肌瓣转移.     

Recurrent tuberculous abscess in the chest wall; report of a case

A case of recurrent tuberculous abscess in the chest wall which was successfully treated by resection of the rib and transposition with a latissimus dorsi muscle flap is reported. A 70-year-old man was admitted to the hospital for the purpose of receiving tuberculostatic treatment after an operation for tuberculous abscess in the chest wall at another hospital. When he first visited the another hospital, he had complained of a left chest wall tumor and Mycobacterium tuberculosis was isolated from the pus. After admission to the hospital, tuberculous abscess recurrenced in the left chest wall 2 months after the operation. We performed resection of the abscess, 5th and 6th ribs, as well as transposition of the latissimus dorsi muscle flap. There have been no signs of recurrence and is followed in the clinic, as of 4 months after the operation. We think that resection of the abscess, ribs, and, transposition of the muscle flap are useful methods for tuberculous abscess in the chest wall.     

Single pedicle microvascular transfers of the serratus anterior and latissimus dorsi muscles in rats

In the rat, the serratus anterior and latissimus dorsi muscles receive axial vascular pedicles from the thoracodorsal artery. This anatomy was confirmed by dissections, and 10 microvascular transfers of the latissimus-serratus flap on a common pedicle were performed with a 90% success rate. The flaps had an average weight of 1.8 g. This flap is a reliable small animal model for microvascular muscle transplants and contains sufficient tissue to be used in multiple biochemical assays.     

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.     

Clinical studies on reconstruction procedure of total layer chest wall resection

The results of clinical studies on 16 reconstruction procedure after total layer chest wall resection in 14 cases of malignant tumor of the chest wall were reported. The 14 cases consisted of two cases with recurrent primary chest wall tumor, two cases of primary breast cancer, seven cases of recurrent breast cancer, and others. The reconstruction procedure after total layer chest wall resection was conducted using only various myocutaneous flaps (eight cases using latissimus dorsi of the resected side, three cases using the abdominitis of the resected side, three cases using latissimus dorsi of the non-resected side, and two cases using a pectoralis major myocutaneous flap of the non-resected side). reconstruction only using a myocutaneous flap proved to be satisfactory for preventing early stage postoperative respiratory distress and maintaining the stability of the chest wall and respiratory function during prolonged observation. Namely, use of myocutaneous flap is the best approach of reconstruction the chest wall after total layer chest wall resection. We confirmed that reconstruction with latissimus dorsi myocutaneous free flap of the non-resected side with microvascular anastomosis of thoracodorsal vessels was useful for posterior chest wall tumors invading the latissimus dorsi muscle. Also, our results demonstrated the insertion of an omental flap under the myocutaneous flap was useful for cases with secondary chest wall infection or vascular damage caused by preoperative high dose irradiation.     

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.     

Anatomy of the scapulothoracic articulation

Four fresh frozen human cadavers (eight extremities) consisting of the head, neck, thorax, and entire upper extremities were used for dissection of the scapulothoracic articulation. In each specimen, the spinal accessory nerve, all relevant muscle insertions, and bursae were identified and measured. The structures of the scapulothoracic articulation can be divided into superficial, intermediate, and deep layers. The superficial layer consists of the trapezius, latissimus dorsi, and an inconsistent bursa between the inferior angle of the scapula and the latissimus dorsi. The intermediate layer consists of the levator scapulae, rhomboid minor and major, spinal accessory nerve, and scapulotrapezial bursa located between the superomedial scapula and the overlying trapezius. In all specimens, the spinal accessory nerve traveled intimately along the wall of the scapulotrapezial bursa, an average of 2.7 cm lateral to the superomedial angle of the scapula. The deep layer consists of the serratus anterior, subscapularis, and two bursae: one between the serratus and the thorax, the scapulothoracic bursa; and one between the subscapularis and the serratus, the subscapularis bursa.