The tailored latissimus dorsi free flap

A technique is described for dissection of the latissimus dorsi free flap which yields musculocutaneous cover accurately tailored to the primary defect. It involves exposure high into the axilla, early transverse incision of the muscle to enhance visualization of the pedicle, and transection of the muscle close to the point at which the thoracodorsal artery enters. This last step eliminates the bulky portion of the muscle between this point of vascular supply and its insertion.     

Autologous breast reconstruction with the extended latissimus dorsi flap

The extended latissimus dorsi myocutaneous flap can provide autogenous tissue replacement of breast volume without an implant. Nevertheless, experience with the extended latissimus dorsi flap for breast reconstruction is relatively limited. In this study, the authors evaluated their experience with the extended latissimus dorsi flap for breast reconstruction to better understand its indications, limitations, complications, and clinical outcomes. All patients who underwent breast reconstruction with extended latissimus dorsi flaps at the authors' institution between January of 1990 and December of 2000 were reviewed. During the study period, 75 extended latissimus dorsi flap breast reconstructions were performed in 67 patients. Bilateral breast reconstructions were performed in eight patients, and 59 patients underwent unilateral breast reconstruction. There were 45 immediate and 30 delayed reconstructions. Mean patient age was 51.5 years. Mean body mass index was 31.8 kg/m2. Flap complications developed in 21 of 75 flaps (28.0 percent), and donor-site complications developed in 29 of 75 donor sites (38.7 percent). Mastectomy skin flap necrosis (17.3 percent) and donor-site seroma (25.3 percent) were found to be the most common complications. There were no flap losses. Patients aged 65 years or older had higher odds of developing flap complications compared with those 45 years or younger (p = 0.03). Patients with size D reconstructed breasts had significantly higher odds of flap complications compared with those with size A or B reconstructed breasts (p = 0.05). Obesity (body mass index greater than or equal to 30 kg/m2) was associated with a 2.15-fold increase in the odds of developing donor-site complications compared with patients with a body mass index less than 30 kg/m2 (p = 0.01). No other studied factors had a significant relationship with flap or donor-site complications. In most patients, the extended latissimus dorsi flap alone, without an implant, can provide good to excellent autologous reconstruction of small to medium sized breasts. In selected patients, larger breasts may be reconstructed with the extended latissimus dorsi flap alone. This flap's main disadvantage is donor-site morbidity with prolonged drainage and risk of seroma. Patients who are obese are at higher risk of developing these donor-site complications. In conclusion, the extended latissimus dorsi flap is a reliable method for total autologous breast reconstruction in most patients and should be considered more often as a primary choice for breast reconstruction.     

Lumbar hernia after latissimus dorsi flap

The authors present what they believe to be the first recorded case of a lumbar hernia following latissimus dorsi myocutaneous flap procedure. The authors discuss the diagnosis by physical examination and x-ray confirmation, pointing out the importance of not mistaking the hernia for a seroma. Suggestions for avoiding the problem are given, relating primarily to preservation of the fascia underlying the distal latissimus aponeurosis.     

Immediate closure of traumatic upper arm and forearm injuries with the latissimus dorsi island myocutaneous pedicle flap

This paper reports the authors' experience with latissimus dorsi island pedicle flaps in the acute treatment of massive arm injuries. Seven patients with upper arm injuries and four patients with forearm injuries were treated with latissimus dorsi pedicle flaps. All cases involved massive soft-tissue loss and open fractures. Primary healing of wounds occurred without complications in 10 of 11 patients; the eleventh developed a wound infection. There were no instances of flap loss or vascular complications. This report compares and discusses surgical management options and details the importance of robust, immediate soft-tissue coverage for optimal functional recovery. Contrary to traditional thought, delay in definitive wound closure may be unnecessary when aggressive debridement is followed by acute flap closure.     

Sensitivity of breasts reconstructed with the autologous latissimus dorsi flap

The purpose of this study was to measure, both objectively and subjectively, the sensitivity of breasts reconstructed with the autologous latissimus dorsi flap and to compare these results with those of other reconstruction techniques, especially the transverse rectus abdominis myocutaneous flap. The study population included 50 patients with autologous latissimus dorsi flap breast reconstruction; these patients had an average age of 51 years and an average follow-up of 27 months. Patients answered a seven-item questionnaire that attempted to define the sensitivity of the reconstructed and opposite breasts. This sensitivity was then measured objectively using standard techniques for heat, cold, and tactile sensations. After statistical analysis, these results were compared with those published for other reconstruction techniques. Overall results were comparable or superior to those published for other techniques for autologous breast reconstruction. A total of 56 percent of patients had fine or very fine sensitivity, but 70 percent deemed this sensitivity to be less than that of the opposite breast. A total of 94 percent of patients perceived the reconstructed breast as integral to their body image. The superior medial part of the breast had the greatest sensitivity, both objectively and subjectively. Autologous latissimus dorsi breast reconstruction, a good technique with excellent aesthetic results, affords satisfactory sensitivity. This is yet another advantage of the technique.     

The free latissimus dorsi myocutaneous flap.

The general anatomy and the detailed vascular anatomy of the latissimus dorsi myocutaneous flap is described, and its use as a free flap is illustrated. The speed and ease with which it can be raised, its long vascular pedicle, the large diameter of the donor vessels, and the potentially large size of the flap are emphasized.     

Breast reconstruction using the sensate latissimus dorsi musculocutaneous flap

The authors performed immediate breast reconstruction on four patients using a sensate latissimus dorsi musculocutaneous flap accompanied by neurorrhaphy during the past 6 years. In the neurorrhaphy, the lateral cutaneous branch of the dorsal primary divisions of the seventh thoracic nerve, which controls the sensation of the myocutaneous flap, was anastomosed to the lateral cutaneous branch of the fourth intercostal nerve, which controls the sensation of the breast. The subjects consisted of four patients whose postoperative follow-up period was 14 to 29 months, with an average of 19.3 months. The control subjects consisted of 10 cases with a latissimus dorsi musculocutaneous flap whose sensory nerve had not been reconstructed (postoperative follow-up period, 15 to 49 months; average, 26.9 months). The sensory examination included tests of touch, pain, and temperature. The innervated musculocutaneous flap sensation showed gradual recovery at about 6 months after surgery and reached the value of the normal side after about 1 year. In the control subjects, the recovery was gradual after more than 1 year and reached the value of the normal side in only some of the control subjects. On the basis of these findings, the authors consider the present technique to be useful for the recovery of sensation in immediate breast reconstruction.     

The "reduced" latissimus dorsi musculocutaneous flap

This report introduces a new device among latissimus dorsi flaps: the "reduced" latissimus dorsi musculocutaneous flap. This flap consists of a proximal musculocutaneous unit and a distal, thin fasciocutaneous unit (the "reduced" portion). The former unit carries a reliable blood supply from the thoracodorsal artery and is able to cover deeper recipient defects, while the latter provides a well-contoured reconstruction of the defect. If needed, an extended portion and/or a thin cutaneous flap can be carried along with the flap according to the defect. In our clinic, we have so far used four pedicled and one free reduced latissimus dorsi musculocutaneous flap in the repair of a variety of defects. All flaps survived, and satisfactory contour of the recipient site was achieved in each case. These clinical experiences clarify that a reduced portion 10 cm in length can be safely carried, and it is suggested that survival of this flap does not depend on its width-to-length ratio.     

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.     

Bilobed latissimus dorsi flap for a decubitus ulcer

A case is presented of a bilobed latissimus dorsi flap. The advantage of this flap is to close a large defect without having to resort to a skin graft for closure of the donor-site defect. The advantages of this procedure are as follows: Well-vascularized, stable coverage for decubitus ulcers. Acceptable cosmetic deformity. Avoidance of a skin graft. Decreasing the length of hospitalization.     

Simultaneous reconstruction of the Achilles tendon and soft-tissue defect using only a latissimus dorsi muscle free flap

The combined loss of the Achilles tendon and the overlying soft tissue in the young ambulant patient with expectations of a normal life is a challenging problem. These patients need not only soft tissue but also dynamic and functional reconstruction. Four cases of major defects of the Achilles tendon and overlying soft tissue after trauma are presented. In each case, the tendon and the overlying soft tissues were reconstructed using only a latissimus dorsi muscle free flap and overlying split-thickness skin graft. In conventional methods, evolved in the reconstruction of the Achilles tendon and soft tissue, the size of the defect was a limit. However, this technique can be used to reconstruct an extensive defect, including distal calf muscle to the plantar metatarsal area. In one case, the flap was harvested in a myocutaneous unit, and the skin portion was deepithelialized for the coverage and enough padding on the bony exposure area in reverse position. The purpose of the present study was to reevaluate the potential of denervated muscle flap for a force-bearing conduit as an alternative reconstructive method of the Achilles tendon. The denervated latissimus dorsi muscle in this study eventually experienced the process of atrophy and fibrosis but maintained its original length. Although there remained some atrophic muscle fibers, a fibrosis of the muscle fibers formed a tendon-like fibrous band, and so the action of the posterior calf muscle could be transmitted through the tendon-like fibrotic change of the denervated latissimus dorsi muscle. The advantages of this technique are that (1) it is a single procedure, (2) it is adaptable to a wide range of defect sizes, (3) it allows faster wound healing supported by well-vascularized tissues, (4) it produces satisfactory function of the ankle joint and a padding effect, and (5) it produces good contour of the posterior calf to the sole and an acceptable donor-site morbidity.