Delayed breast reconstruction with a pedicled contralateral latissimus dorsi musculocutaneous flap.

Use of the pedicled contralateral latissimus dorsi musculocutaneous flap is a safe and valuable option in delayed breast reconstruction. This flap also can create an anterior axillary fold by including fat from the lumbosacral fascia.     

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.     

Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction

Patients presenting advanced breast tumors are usually subject to major resections of the anterior chest wall tissue. Flaps taken from the abdominal wall, such as the TRAM, the external oblique flap, and the thoracoabdominal flap are frequently used for closure of this type of lesion. In this study, a different shape was planned for the skin island from the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall after mastectomies occasioned by advanced breast cancer. The technique was used on eight female patients, between November of 1998 and July of 1999, victims of advanced breast cancer, who had been submitted to radical mastectomies with major resections of the cutaneous tegument. It was possible to make primary closure of lesions in the anterior chest wall, the preoperative areas of which varied between 15 x 15 and 29 x 14 cm (vertical x horizontal). This technical variant permitted use of the flap without the need to create tunnels for its advancement and rotation. It also proved to be easy to perform and presented a low morbidity rate, with three patients presenting minor complications that did not require correction through any further surgical intervention. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. According to the authors, this procedure is a viable alternative in repairing large defects in the anterior chest wall.     

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.     

Bilateral latissimus dorsi V-Y musculocutaneous flap for closure of a large meningomyelocele

Reconstruction of a large meningomyelocele defect with bilateral latissimus dorsi V-Y musculocutaneous flaps is reported. This procedure provides a reliable, well-vascularized soft-tissue coverage over the neural repair with minimum donor-site morbidity.     

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.     

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.     

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.     

Donor site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap

The indications for autologous reconstruction are increasing. The standard procedure is the transverse rectus abdominis muscle flap; however, this flap has contraindications and drawbacks. The latissimus dorsi muscle flap is simple and reliable. Hokin et al. demonstrated in 1983 that this flap can be extended and used for breast reconstruction without an implant. Since then, it has been widely studied in this setting and is known to provide good aesthetic results. Dorsal sequelae, conversely, were not appraised. The aim of this study was to assess objective and subjective dorsal sequelae after the harvest of an extended flap. Forty-three consecutive patients who had had breast reconstruction with an autologous latissimus dorsi flap were assessed by a surgeon and a physiotherapist for muscular strength and shoulder mobility. Patient opinion was studied through a questionnaire. Mean delay between the operation and the evaluation was 19 months. Early complications, mainly dorsal seromas, were frequent after the harvest of an extended flap (72 percent). There was no late morbidity and, especially, no flap loss or partial necrosis. As for functional results, 37 percent of the patients had complete adjustment and 70 to 87 percent demonstrated no change in shoulder strength. Sixty percent of the patients experienced no limitation in everyday life, and 90 percent said they would undergo this procedure again. The authors show that dorsal sequelae after an extended latissimus dorsi flap are minimal and that this technique compares favorably with the transverse rectus abdominis muscle flap.