Functional evaluation of latissimus dorsi donor site

A study was undertaken to determine the cosmetic and functional problems associated with the latissimus dorsi muscle donor site. Twenty-four patients undergoing both free and pedicle muscle and myocutaneous flap procedures for a wide variety of reconstructive problems were studied. All patients had a contour defect at the donor site, a scar which varied with the patient's age and whether overlying skin had been taken with the muscle flap. Mild to moderate shoulder weakness and some loss of motion were noted in most patients which improved over the course of several months. An upper extremity disability in strength and shoulder motion should be anticipated following latissimus dorsi transfer, which in most cases is minimized by the recruitment of synergistic muscle units. Vigorous range-of-motion exercises following surgery should be encouraged to minimize adhesions and joint capsule stiffness. Social changes in occupation and daily living activities were noted which were not a problem for most patients. Twenty-three of 24 patients were pleased with the overall outcome of their surgery and would recommend the procedure to others. A prospective study before and after latissimus dorsi transfer followed by a second evaluation 2 to 3 years postoperatively would help to clarify the role synergistic muscle units play in "taking over" latissimus dorsi function.     

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.     

Vascularization of the myocutaneous latissimus dorsi flap. Injection study on the thoracodorsal artery

This study reports on investigations of the thoracodorsal artery by injection studies. This artery has a long proximal extramuscular course before it enters the muscle. A consistent neurovascular hilum was found at a considerably constant location on the inferior muscle surface, 2-3 cm medial to its lateral edge and about 5 cm distal to the inferior scapular border. A constant branching pattern of the thoracodorsal artery into a lateral and a medial vessel stem was found. A high number of muscle-perforating arteries from a dense network in the cutaneous and subcutaneous layer. The thoracodorsal artery supplies the whole cutaneous area adjacent to the latissimus dorsi muscle plus a streak of about 2 cm at the medial and distal muscle borders. The presented anatomical landmarks are useful for locating the neurovascular hilum, and the intramuscular course of the thoracodorsal artery for exploration of the vessel by Doppler sonography or dissection. The length of the pedicle and the relatively big vessel gauge are good anatomical markers for the free transfer of a latissimus dorsi flap.     

Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap.

The latissimus dorsi myocutaneous flap is a remarkably durable and versatile flap. Flap necrosis did not occur in any of our patients. One can safely carry with it skin segments as narrow as 3 cm, or as wide as 30 cm. In addition to the 5 cases presented, we have used the flap to repair axillary burn contractures, for breast reconstruction after a transverse incision, and for coverage of the upper arm and shoulder. The applications of this flap challenge the creative imagination of the surgeon and allow a simplified reconstruction, compared to other good methods. The newly described posterior advancement of a latissimus dorsi myocutaneous flap is suggested as the preferred method to repair meningomyelocele defects.     

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.     

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.     

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.     

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.     

Staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts

The use of long vein grafts in the axilla adds a new dimension to the versatility of the latissimus dorsi myocutaneous flap. When suitable recipient vessels are not available for a microvascular anastomosis, long vein grafts can be used in the axilla to double the arc of rotation of the flap, allowing it to cover the buttocks, lower torso, and scalp (Fig. 8). A case is presented in which the latissimus dorsi myocutaneous flap was transferred in stages to cover a large radiation ulcer of the right buttock.     

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.     

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.     

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.