Reverse-flow latissimus dorsi myocutaneous flap in a multi-step approach for complex back defect reconstruction: A case report

Reconstruction of complex back defects is challenging for reconstructive surgeons, as it should preserve function, provide adequate coverage, and minimize morbidity. We present a case of multiple-step reconstruction after resection of a large squamous cell carcinoma recurrence in a 68-year-old man, with local perforator flaps and a reverse-flow latissimus dorsi myocutaneous flap. After radical excision, four propeller perforator flaps were harvested to cover a 30 × 25 cm defect, based on the dorsal branch of the fifth posterior intercostal arteries (right 20 × 9 cm, left 17 × 9 cm) and on the superior gluteal arteries (right 20 × 11 cm, left 21 × 12 cm) bilaterally. In the second step, bilateral propeller perforator flaps based on the fourth lumbar arteries (right 18 × 13 cm, left 23 × 11 cm) were transposed to cover the residual loss of tissues. After 5 months, a recurrence occurred on the left midback. A wide en bloc excision of the last three ribs and pulmonary pleura was performed, and the synthetic mesh used for thoracic wall reconstruction was covered with an ipsilateral 20 × 10 cm reverse-flow latissimus dorsi myocutaneous flap based on the serratus anterior branch. All the flaps healed uneventfully and there were no donor-site complications. Two years postoperatively, the patient had a cosmetically acceptable result without any functional impairment. The reverse-flow latissimus dorsi myocutaneous flap can represent a salvage procedure in back complex defects reconstruction, especially when other local flaps have already been harvested in previous reconstructive procedures.     

The distally based,venous supercharged anterolateral thigh flap

The distally‐based anterolateral thigh flap is an attractive option for proximal leg and knee coverage but venous congestion is common. Restoration of antegrade venous drainage via great saphenous vein supercharge to the proximal flap vein is proposed. The purpose of this study was to evaluate and compare outcomes of 18 large, distally‐based anterolateral thigh flaps with and without venous augmentation on the basis of flap size, venous congestion, and clinical course. The average age of 12 men and 6 women was 35.9‐year old (range, 16–50 years old). Wounds resulting from trauma, burn sequela, sarcoma, and infection were localized to the knee, proximal leg, knee stump and popliteal fossa. The mean defect was 17.6 × 9.4 cm² (range, 6 × 7 cm² to 22 × 20 cm²). The mean flap size was 21.4 × 8.8 cm² (range, 12 × 6 to 27 × 12 cm²). There were 14 cases in the venous supercharged group and 4 cases in the group without supercharge. The mean size of flaps in the venous supercharged group was significantly larger than that in the group without supercharge (22.6 ± 3.8 × 9.1 ± 1.7 cm vs. 17.5 ± 4.4 × 7.8 ± 1.7 cm, P = 0.03). Venous congestion occurred in all four flaps without supercharge that lasted 3–7 days and partial flap loss occurred in two cases. There was no early venous congestion and partial flap loss in supercharged flaps but venous congestion secondary to anastomotic occlusion developed in two cases. Early exploration with vein grafting resolved venous congestion in one case. Late exploration in the other resulted in flap loss. Preventive venous supercharge is suggested for the large, distally‐based anterolateral thigh flap. © 2015 Wiley Periodicals, Inc. Microsurgery 36:20–28, 2016.     

A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation

One of the significant reconstructive challenges is closure of large soft tissue defects of the lower extremity. A patient with a large traumatic defect in the lower extremity was treated with a cross-leg free latissimus dorsi myocutaneous flap. The size of the flap was 32×12 cm. The pedicle was divided 22 days after the initial operation. The result was satisfactory after a 2-year follow-up. This technique allows the transfer of large flaps to cover compromised wounds, with the advantage of using suitable recipient vessels. Received: 4 March 1998 / Accepted: 25 March 1999     

Free latissimus dorsi perforator flap for reconstruction of hemifacial atrophy: case report

Progressive hemifacial atrophy (PHA) is characterized by slow and progressive atrophy usually of one side of the face. PHA affects primarily the subcutaneous fat and muscle tissues, but may involve the bone. The cause is unknown. The treatment is symptomatic and directed at augmentation of the deficient soft-tissue volume. The reconstructive procedures may combine fat grafts, dermis fat grafts, pedicle flaps, bone grafts, microvascular free flaps, and alloplastic implants. We report a patient with of PHA whose condition was treated with a free latissimus dorsi (LD) perforator flap. The LD perforator flap was suitable for the large defect of the patient. It could easily be tailored and thinned to follow the facial contour. Minor revisions were needed for esthetic reasons. There was neither significant downward gravitation nor wasting of the flap. 23 months later, the natural appearance of the face was maintained.     

Chimeric partial scapula and latissimus dorsi muscle flap for midfoot reconstruction: A case report

Free muscular, osteomuscular, and fasciocutaneous flaps are widely used for midfoot reconstruction. The latissimus dorsi (LD) flap is rich in muscle mass, but the weight‐bearing ability of the reconstruction with its combination with a scapula or rib has not been evaluated. Here, we report a case of reconstruction of the right midfoot with the trauma‐related osteomyelitis using a free chimeric scapula and LD muscle flap in a 59‐year‐old woman with diabetes mellitus. After radical debridement and sequestrectomy, a 7 × 3 cm² wound with a 5 × 3 cm² bony defect was reconstructed with the chimeric scapula and LD muscle flap. The postoperative course was uneventful. The bony union was achieved 6 months after surgery. In 14 months follow‐up, no clinical complications including a new ulcer or stress fracture were noted. At the end of follow‐up, the gait analysis showed an unbalanced stress distribution on the right foot and a valgus gait. We suggest that this chimeric scapula and LD muscle flap may be an alternative option for midfoot reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

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.     

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.     

Bipedicled distally based medial plantar artery perforator flap for forefoot reconstruction: A case report

Reconstruction of soft-tissue defects in the foot weight-bearing area should encompass sensate and robust skin. Regarding forefoot defects, distally based medial plantar artery (MPA) flap is an ideal option. However, considering variation of the terminal branches of the MPA, reverse flow flaps can be unreliable with an increasing risk of venous congestion or insufficient arterial flow. In this report, we present a case of the use of reverse flow MPA flaps with dual flow vascularization. The patient was a 37-year-old female who presented a 7 × 3 cm soft-tissue defect of the right forefoot after wide local excision following melanoma. Reconstruction happened with a perforator distally based bipedicled flap (8 × 4 cm) on the MPA though keeping an enhanced vascularization through both superficial (sMPA) and deep (dMPA) medial plantar arteries. Donor site was closed with skin graft. Patient was discharged from hospital at postoperative Day 10 and healed uneventfully with progressive start walk was possible again. A full weight bearing with normal shoes was possible after 8 weeks. Good healing and no functional impairment were present after 9 months of follow-up. We believe this dual vascularization concept may be adopted when possible to improve the overall circulation of the flap and to prevent risks of vascular insufficiency or vein congestion.     

Composite skull and dura defect reconstruction using combined latissimus dorsi musculocutaneous and serratus anterior muscle‐rib free flap coupled with vascularized galea transfer: A case report

Recalcitrant epidural abscess following cranioplasty is a complicated problem, which becomes even more trying when large span of dura and skull bone are being replaced by alloplastic materials. A 22‐year‐old male underwent right fronto‐temporo‐parietal craniectomy and duroplasty with artificial dura graft after traumatic brain injury. Epidural abscesses recurred after cranioplasty with autologous bone graft as well as with a methyl methacrylate bone plate. The massive defects of both the dura and skull bone (15 × 9 cm) caused by radical debridement were reconstructed successfully with a combined free latissimus dorsi and serratus anterior myo‐osseous flap transfer plus galea flap transposition. Proper contour and adequate stability of the construct were maintained during 2‐year follow up without episodes of relapsing infection. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Transplantation of a latissimus dorsi flap after nearly 6 hr of extracorporal perfusion: A case report

Prolonged ischemia of tissues inevitably leads to their necrosis. This is especially relevant in the case of transplantation or replantation. In such situations, reperfusion in a timely manner might not be possible due to transportation times or other unforeseen complications. Therefore, a readily available and simple method to oxygenate the tissue and thus widen the time frame to reperfusion seems desirable. Here, we present the case of extracorporal perfusion of a latissimus dorsi (LD) flap that was successfully transplanted after nearly 6 hr of ischemia. A 41‐year‐old patient suffered multiple injuries including complete severance of the popliteal artery requiring emergency bypass. After stabilization of the patient and subsequent debridement, a LD flap was performed for soft tissue coverage. However, there was an acute occlusion of the bypass during flap inset. To salvage the free flap, a one‐way extracorporal perfusion of the flap with heparinized isotonic saline solution was performed for a total of 5 hr and 47 min. The flap survived with minimal tip necrosis. This case report describes the application of a simple extracorporal perfusion technique for salvage of a free flap over a prolonged ischemia time and discusses the relevant literature. Due to its ease and quickness of application as well as ubiquitous availability, it might serve as a valuable tool in cases of acute problems with the recipient vessels or other incidents where several hours of ischemia time are to be anticipated.     

The reverse turnover latissimus dorsi flap for closure of midline lumbar defects.

The surgical treatment of wounds located in the median lumbar area is difficult. When occurring after neurosurgical procedures, they may display a high level of complexity because of dural exposure, deep irregular three-dimensional contours, and bacterial contamination of the wound. The difficulty of reconstruction in that region of the body is made greater by the few possible regional flaps available in the vicinity. In order to obtain well-vascularised tissue, with good resistance to bacterial contamination and easy to shape into such defects, the reverse turnover latissimus dorsi flap is a useful surgical option. Between 1998 and 2003, four patients presented with complex lumbar wounds in our department. Three patients were adults (mean age: 63 years) and one patient was 1 year old. In all cases, reconstruction was needed in the lumbar area after surgery on the spine. All wounds presented with bacterial contamination. In three cases, dural exposure was present, while in the fourth case, a small remnant of the posterior vertebral bony lamina was still present after debridement. In all four cases, the reconstruction was successfully achieved by turning over the latissimus dorsi to reach the lumbar midline defect. In one case, the adult paraplegic patient, only the inferior part of the muscle was harvested, to preserve an innervated upper part of the muscle for upper limb function. In the four cases, long term results were excellent (the mean follow up was 3.5 years), with no residual infection.     

Reconstruction of posterior compartment of lower extremity using a functional latissimus dorsi free flap: A case report

We present an unusual case in an 8‐year‐old male that presented with a severe crushing injury to the right lower extremity with grade IIIB open tibia/fibula fracture and composite loss of the majority of the posterior muscle compartments and overlying skin and segmental loss of the tibial nerve. Composite reconstruction was performed with internal fixation, cable autografting of the tibial nerve, and a functional latissimus dorsi musculocutaneous flap. A motor branch of the tibial nerve to the soleus was used as the donor motor nerve. The patient achieved a bony union and began ambulating at 8 weeks postoperatively. At 24 months, the patient was running and jumping with plantar push‐off. Recovery of plantar flexion was to the M5 level. Static and moving 2‐point discrimination of the plantar foot was 8 mm and 6 mm, respectively. Functioning muscle transfer in a child with a severe lower extremity injury with composite tissue loss may provide soft tissue and motor‐unit defect reconstruction with an acceptable functional restoration. © 2015 Wiley Periodicals, Inc. Microsurgery 36:77–80, 2016.     

Extra-abdominal desmoid tumor in a scar of donor-site of a latissimus dorsi flap: case report

Tumefaction arising lately after latissimus dorsi flap harvest are rare and observed in 1 or 2% of the cases. These lesions are frequently related to kystic sero-hematoma and are easily and efficiently treated with surgical excision. In some rare circumstances, a tumoral evolution can mimic a kystic sero-hematoma. We will discuss one case of desmoid tumor arising from a latissimus dorsi flap donor-site scar. The subject was a 45 years old woman who had a breast reconstruction following mastectomy. A dorsal tumefaction, with a benign aspect, was observed during the follow-up period. The biopsy showed an extra-abdominal desmoid tumor. The patient was treated with a large excision of the lesion and reconstructed using two opposing local cutaneous advancing flaps. No radicalization was necessary. No sign of recurrence has been observed at 4 years follow-up.     

Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: Case report and literature review

Perineal wound complications following abdominoperineal resection (APR) are still frequent and most troublesome complications. We report the case of a 79‐year‐old male found to have the huge precoccygeal defect with infection after APR for rectal carcinoma. Before surgery, the patient received a complete course of chemoradiation therapy to treat for downgrade staging of the rectal malignancy. Extensive debridement of the perianal wound was performed for three times, followed by perianal reconstruction and packing and augmentation of the precoccygeal dead space with free latissimus dorsi (LD) muscle flap. Although persisted wound infection was still observed after reconstruction, the patient still led a good result after one time of further debridement and split‐thickness skin graft. We selected free LD muscle flap to fill and seal off the large pelvic dead space without the needs to change the jackknife position of the patient after debridement. To the best of our knowledge, this is the first case reported in the literature with the radiation‐associated perianal wound infection after APR reconstructed successfully by free LD muscle flap. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011.     

A latissimus dorsi muscle flap used for repair of the esophagus after enucleation of a giant leiomyoma--a case report

A giant leiomyoma of the esophagus, 11.5 X 5.0 cm in size, which occupied half of the esophageal circumference, was surgically enucleated. A small epithelial defect caused by the enucleation of the tumor was directly closed, and a large muscular defect was covered with a latissimus dorsi muscle flap, introduced into the thoracic cavity through the space where the second rib had been resected. Postoperatively, a leakage at the epithelial suture line was noted, however, it was localized by the muscle flap coverage and spontaneously healed two weeks postoperatively. During the follow-up period of 1.5 years, no diverticle formation or stenosis occurred, and the patient had no complaints. The present clinical experience indicates that this procedure may be a useful method of grafting after excision of giant leiomyoma of the esophagus.