The extended latissimus dorsi flap in repair of anterior abdominal wall defects

Large abdominal wall defects (ventral hernias) can be difficult to repair. Some defects are not amenable to primary repair or the use of synthetic mesh because of repeated recurrence or wound infection. In complicated situations such as that mentioned above, the extended latissimus dorsi muscle flap has been used to repair upper and middle abdominal wall defects. This method has been utilized in six patients, and there has been no recurrence of the defect or evidence of a lumbar hernia. The follow-up has been from 7 to 66 months. The extended latissimus dorsi muscle flap has proven to be an excellent alternative in the repair of complicated abdominal wall defects.     

Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap

To avoid a more proximal amputation at the distal part of the thigh, and when the knee joint is preserved, it is possible to lengthen short lower leg stumps. The authors report five cases in which the latissimus dorsi-rib flap was used to achieve a satisfactory functional prosthetic result. The bone segment is long enough to both lengthen the stump and allow its extremities to be firmly fixed to the tibia. Depending on the remaining tibia length, one or two ribs were included in the flap. The procedure allowed achievement of a 5-cm to 9-cm lengthening of the tibia. Bone healing time was 5 to 6 months and allowed prosthetic rehabilitation and ambulating 5 to 7 months after surgery. Final range of motion of the knee joint is compatible with normal ambulating, and the prosthesis is well tolerated. This procedure, which provides a large amount of skin, muscle, and bone, is very effective for reconstruction of short lower leg stumps.     

Flow-through thin latissimus dorsi perforator flap for repair of soft-tissue defects in the legs

Flow-through thin latissimus dorsi perforator flaps were used in six cases with complicated defects of the legs. This flap has a small amount of latissimus dorsi muscle with a considerable amount of fatty tissue removed to make a thin flap. In addition, the flap has several branches of the subscapular vessel, which are interposed to the recipient vessels of the legs. The advantages of this thin flap are: (1) flow-through vascular reconstruction can preserve the main vessels of the damaged legs; (2) the double arterial inflows and venous drainage systems of the flap ensure safe vascularization of the flap; (3) a flow-through venous drainage system from the distal extremities can also be established to prevent congestion of the affected legs; (4) this flap is versatile (it can be either thin or large); and (5) even in emergent ischemic legs, simultaneous elevation of the flap is possible with preparation of the legs. This flow-through flap is indicated for: (1) cases with a large skin defect and obstruction of the main vessels in the leg; (2) cases with a possibility of tumor recurrence in the legs; and (3) young women or girls with a large defect in the legs, rather than the rectus abdominis musculocutaneous flap.     

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.     

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.     

Shoulder defect correction with the island latissimus dorsi flap

Reconstruction of normal shoulder contour is possible utilizing a latissimus dorsi musculocutaneous flap at the end of a long neurovascular pedicle. The thoracodorsal vessels and their lateral divisions form the basis of the pedicle. The nerve in the pedicle is left intact if maintenance of muscle bulk is desired and sectioned if atrophy is preferred. The amount of muscle taken in conjunction with the skin island is determined by the nature of the defect to be corrected. The twin goals of a single-stage reconstruction and a satisfactory aesthetic result are achieved with this method.     

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.     

Treatment of chronic radiation injury over the shoulder with a latissimus dorsi myocutaneous flap.

We report our experiences in treating chronic radiation injury about the shoulder, a complication of radiation after mastectomy. Left untreated, these can result in chronic infection and/or amputation. The coverage of a large shoulder area presents certain unique problems, which severely limit the usefulness of traditional procedures. We have found that the remarkable size and versatility of the latissimus dorsi myocutaneous flap enables one to use it with relative simplicity and safety. A further great advantage is that it brings new permanent blood supply into this ischemic area, thus favoring rapid healing and durable coverage.     

Distal arteriovenous fistula to maintain patency of the venous drainage of a latissimus dorsi flap following subclavian vein repair

Successful reconstructive surgery with muscle flaps depends on adequate arterial supply and undisturbed venous drainage. Combining such surgery with reconstructive vascular surgery of a large-caliber vein that is responsible for the venous drainage of the flap poses an additional challenge--the repaired vein's susceptibility to thrombosis. Every attempt must be made to prevent venous outflow obstruction following muscle flap surgery. Data from the vascular surgery literature demonstrate a low success rate for subclavian vein repair. The success rate with venous reconstructive surgery has been greater when a distal arteriovenous fistula accompanied the repair. The present case described the use of a temporary distal cephalic-brachial arteriovenous fistula to maintain the patency of the venous drainage of a pedicled latissimus dorsi muscle flap, following subclavian vein repair, for one-stage coverage of a large chest wall defect.     

Treatment of total sternal necrosis using the latissimus dorsi muscle flap

Complications after a median sternotomy incision, which is used currently in most cardiac and mediastinal surgical procedures, although infrequent, are serious. If sternal dehiscence follows median sternotomy, infection extends to vital underlying structures, exposing the anterior part of the heart and ascending aorta. Permanent hemorrhage, septic thrombosis, or septic perforation of prosthetic material demand soft-tissue coverage. In 5 patients with total sternum necrosis the retrosternal space was covered with a latissimus dorsi muscle flap in order to achieve stable protection of the exposed mediastinal organs.     

Free latissimus dorsi muscle flap with skin graft for treatment of traumatic chronic bony wounds

Based on this review of 35 cases of chronic bony wounds, it would appear that the free-muscle flap method of wound closure and nourishment after thorough dead bone debridement is an attractive and successful alternative to local skin flaps, staged skin flaps, or extend skin-muscle flaps in areas where reliable muscle flaps are not available. It would also seem that the latissimus dorsi muscle flap with skin graft is an ideal donor-muscle transfer with features allowing a favorable and contoured surface in the recipient site and minimal aesthetic and functional deformity in the donor site.     

The reverse latissimus dorsi muscle flap for closure of meningomyelocele

Closure of the meningomyelocele wound requires stable coverage of the dural repair. In the case presented, multiple conventional attempts at reconstruction failed. A modification of the "reverse" latissimus dorsi flap is presented that successfully managed this low lumbar defect.     

The value of angiography prior to use of the latissimus dorsi myocutaneous flap.

In 5 patients studied, preoperative angiography showed the thoracodorsal artery to be patent in two--both of them then had successful transfers of latissimus dorsi myocutaneous flaps. Obliteration of this artery was apparent in 3 patients, precluding the operation. We suggest that selective preoperative angiography be performed in all patients in whom a latissimus dorsi myocutaneous flap transfer is being considered, as a patent thoracodorsal artery is essential to the success of this procedure.     

Latissimus dorsi free flaps for total repair of extensive lower leg injuries in children

A well-established belief is that with crushed and contaminated wounds closure should be delayed. However, an emergency procedure involving very thorough debridement, complete reconstruction of all injured tissues, and cover by a latissimus dorsi free flap in the same operation is evaluated in 15 children presenting with severe injuries to the lower limb. It is felt that the procedure is superior to the established method because it is a one-stage procedure that minimizes the danger of infection, prevents growth impairment, shortens hospitalization, and allows early mobilization, thus being, in some cases, a limb-saving procedure.